膈肌生物反馈训练治疗胃食管反流病疗效及机理研究
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摘要
摘要一GERD患者不良生活方式、既往诊治及疾病认知的调查
背景和目的
不良的生活方式、饮食习惯及焦虑抑郁的心理状态可能会导致食管及胃食管交界处的功能障碍,降低食管的感觉阈值,从而引发反流症状的出现。而对疾病的错误认知,往往造成患者反复就医、治疗不规范,既影响治疗效果,又浪费了医疗资源。本研究目的：通过对GERD患者进行问卷调查,了解与GERD发病相关的危险因素,以便有效治疗GERD。
对象和方法
2008年8月至2009年6月就诊于我院消化科门诊的122名GERD患者连续入组,填写GERD问卷。入选标准：1.年龄18～75岁；2.典型的反流症状,评分≥6分；3.慢性咳嗽、喘息、咽喉炎、咽部异物感,考虑可能为GERD伴随的食管外症状,经24小时食管pH监测检查证实存在异常酸反流；4.排除大的滑动型食管裂孔疝,排除其他消化系统疾病、胃肠道手术病史、继发性胃食管反流病及其它系统严重器质性疾病。问卷内容包括：一般人口学特征、胃食管反流及相关症状、生活方式、既往检查治疗情况、疾病认知、生活质量、精神心理状态。
结果
1.一般情况：共纳入122例GERD患者,其中男75例(61.5%),年龄49.1±12.5岁；女47例(38.5%),年龄54.5±13.0岁；大学以上学历者50.8%；轻体力劳动者占80.3%；33.6%的患者存在长期腹压增加的危险因素。2.症状分布：32.8%的患者以烧心为最难受的症状,而胸痛、反酸分列第2、3位。3.危险因素：至少存在一项GERD相关危险因素的占79.5%；按照不同的危险因素进行分类,以超重／肥胖(45.1%)、经常饱餐(39.3%)及伴随焦虑抑郁状态(31.1%)最多见；29.5%的患者对于罹患本病比较或非常担心、紧张,因担心得肿瘤就诊的患者占27.9%,担心本病会发展为食管癌占50.8%。4.既往检查治疗：18%的患者接受过5次及5次以上的胃镜检查,最多者达到20余次(77个月)；51.6%的患者曾经坚持一种非药物治疗,避免饱餐、抬高床头、戒烟戒酒是有效的前三位非药物治疗方式；患者服用过多种药物治疗；检查费超过1万元的占20.5%,药品费用超过1万元的占24.6%,36.9%的患者总花费达到数万元以上。
结论
GERD患者最难受症状是烧心、胸痛、反酸,多出现于餐后,饮食、体位、情绪与最难受症状出现有关。多数患者存在GERD相关的危险因素。患者因对本病认知有限,接受过反复检查及多种药物治疗,既浪费了医疗资源,同时患者本人也承担了巨大的经济和精神负担。接近1／3的患者对罹患本病比较或非常担心、紧张,约半数患者担心本病会发展为食管癌。在GERD患者的治疗中,强调改变不良生活方式及饮食习惯以及对疾病认知误区的患者的解释非常重要。
摘要二膈肌生物反馈训练治疗GERD患者的长期疗效观察
背景与目的
本研究中心已观察到膈肌生物反馈训练(DBT)对GERD患者的疗效,本研究的目的是观察DBT对GERD的维持治疗的疗效。
对象和方法
连续入组GERD患者123例,入选标准：1.年龄18～75岁；2.具有烧心、反酸、反食、胸骨后疼痛等典型的反流症状,反流症状评分≥6分；3.反流症状评分<6分但怀疑为胃食管反流病,且食管24小时pH监测阳性和／或PPI试验治疗有效；4.排除心肺疾病的胸痛、慢性咳嗽、哮喘的患者,食管24小时pH监测阳性和／或PPI试验治疗有效。患者在填写GERD问卷后根据意愿被分入两组,即DBT组(N=84)和PPI组(N=39)。分为两期：(1)初始治疗期(0-8周)：DBT组的患者每日进行DBT,同时服用PPI(单剂量,2次／日),记录日记,PPI组的患者仅服用PPI,入组后第2、4、6周,通过电话了解患者症状变化(DBT组的患者应每2周至医院随访1次,在医生指导下训练1次),第8周患者至门诊复诊并填写随访问卷；(2)维持治疗期(9周-6月),DBT组的患者继续每日进行DBT,两组患者均可按需服用PPI,记录PPI的用药量及症状变化,每月1次通过电话了解患者情况,要求患者于随访的第4、6个月至门诊复诊,填写随访问卷。不能来门诊随访的患者,通过邮寄随访问卷的形式来了解其情况。
结果
1.DBT组与PPI组患者,入组时在性别构成、年龄、BMI、腹围、反流症状总评分、PPI用量、精神心理状态上均无显著性差异。DBT组中有54人(64.3%)能坚持规律训练,其余30人训练欠规律或者未训练(35.7%),根据训练情况分为规律DBT组与不规律DBT组。在入组时及随访的各个时间点,三组患者的反流症状总评分(total reflux symptom score, TRSS)、PPI消耗量、SAS、SDS评分无显著性差异。
2.规律DBT组患者的反流症状在随访的第2、4、6、8周及第4、6月末,均较入组时显著下降(3.1、3.0、2.2、1.9、2.8、2.9 vs 8.5,p<0.05)；PPI用量与入组时比较无显著性差异(入组时已服用PPI)；规律DBT组患者在第4、6月末的SAS、SDS评分均较入组时显著降低。
3.不规律DBT组的患者,除第2、4、6、8周末TRSS较入组时比较有显著改善外,第4、6月末的TRSS以及随访过程中的PPI用量、精神心理状态均较入组时比较无显著差异。
4.PPI组患者在维持治疗随访过程中,除反流症状评分显著下降外,PPI用量及精神心理状态均与入组时比较无显著性差异。
结论
4个月及6个月规律的DBT能够改善GERD患者的精神心理状态。
摘要三膈肌生物反馈训练对以呼吸道症状为突出表现的GERD患者的治疗观察
背景和目的
本论文第二部分的结果提示,规律DBT联合药物治疗有助于减少患者反流症状的出现,改善患者异常的精神心理状态。本研究目的旨在观察DBT在以呼吸道症状为主要表现的GERD患者中的治疗效果。
对象和方法
本研究共纳入14例GERD患者,入组条件：1.年龄18～75岁；2.咳嗽和／或哮喘病程≥8周,除外肺部占位性病变及急性感染性病变；3.反流症状评分≥6分,或症状评分<6分但24小时食管pH监测阳性,或症状评分<6分、24小时食管pH监测(—),但PPI试验治疗2周有效；4.排除消化性溃疡、既往胃肠道手术史及全身疾病史的患者。患者填写GERD问卷后,学习DBT方法,在接受药物治疗同时进行规律的DBT,每2周电话或者门诊随访1次,了解症状变化,第8周末填写随访问卷。第8周后每月电话或门诊随访1次。
结果
1.共纳入14例GERD患者,其中RE 4例,NERD10例；男性9例；超重者5例；年龄50.9±12.9岁。2.咳嗽病程在10年以上的有5例,占35.7%,中位病程51月。3.以咳嗽为首发症状的有6例(42.9%),为最难受症状的有9例(64.3%)；42.9%的患者咳嗽症状最常出现在睡眠过程中以及晨起空腹时；症状的诱因依次为体位相关(50%)、受凉(35.7%)及进食(28.6%)；精神心理呈异常状态2例。4.DBT联合药物治疗2周后,患者的TRSS较最严重时显著下降,而咳嗽的评分较最严重时及入组时比较均出现显著下降,药物消耗量、精神心理状态在第8周末时与入组时比较无显著性差异。随访3个月,症状的改善可以维持,药物消耗量有减少趋势但未出现显著性差异。
结论
1. NERD(71.4%)患者与RE患者比较伴有更显著的呼吸道症状。
2.咳嗽可能与夜间酸反流显著有关。
3.DBT联合PPI治疗伴有呼吸道症状的GERD患者,短期内(2周)能显著改善患者的反流和咳嗽症状,并可能减少维持治疗期PPI的消耗量,为反流病合并的咳嗽患者治疗提供一种新的治疗途径。
摘要四膈肌生物反馈训练对GERD患者治疗的作用机制探讨
背景和目的
本研究第二、三部分研究结果提示DBT有助于改善GERD患者的反流症状,也有相关文献表明DBT可以改善EGJ抗反流屏障功能。本部分研究目的在于观察DBT对GERD患者食管酸暴露、胃排空及食管动力的影响。
对象和方法
入组条件：同论文的第二部分。
1.DBT对食管酸暴露的影响：7例GERD患者,入组前1周禁止服用PPI,规律训练2周后复查食管pH监测,训练期间避免服用抑酸药物及影响胃肠道动力药物。
2.DBT对胃排空的影响：16例GERD患者,入组时进行1次核素胃排空检查,RE患者如果入组时已经服用PPI,则研究期间不更改PPI剂量。患者规律训练2周后需复查核素胃排空。另外,入组13名HS。患者与HS均签署知情同意书。
3.DBT对食管动力的影响：入组32名GERD患者。重点观察DBT前后TLESR发生次数、TLESR总时间。
结果
1. GERD患者在2周规律的DBT后反酸评分(2.34±0.9 vs 1.3±0.4)、TRSS(7.7±2.9 vs 3.5±1.3)均较入组时显著下降,食管pH监测结果提示酸反流次数也明显减少(138.7±79.71 vs 79.3±92.5)(p<0.05)。
2.入组时与HS比较,GERD患者2h全胃排空率(%)、2h近端胃排空率(%)、全胃排空速率(%／min)及近端胃排空速率(%／min)均显著降低(39.1±13.3 vs 57±18.4,49.4±13.5 vs 63.8±18.4,0.3±0.1 vs 0.4±0.1，0.4±0.1 vs 0.5±0.2),半排时间(min)明显延长(186.0±86.4 vs 119.9±40.1)。经过规律的2周DBT后,2h全胃排空率(%)仍显著低于HS组(40.6±16.5 vs 57±18.4),全胃半排时间(min)仍长于HS组(181.2±79.0 vs 119.9，40.1),但全胃排空速率、近端胃2小时排空率、近端胃半排时间、近端胃排空速率与HS组的差异不显著。
3.6例患者经过DBT治疗后复查食管压力测定,TLESR发生次数、TLESR总时间变化不显著。
结论
1.2周的规律DBT能显著改善GERD患者的症状及食管酸暴露情况；
2. GERD患者的胃排空明显较HS延缓,2周的DBT可能改善GERD患者近端胃排空功能；
3.8周内的DBT尚不能减少GERD患者TLESR的发生。
Abstract I Investigation of unhealthy lifestyle, previous status of examination and treatment and disease recognition in gastroesophageal reflux disease patients
Background and Objectives
Unheathy lifestyle and eating habits and abnormal psychological status may affect the function of EGJ, reduce the sensation threshold of the esophagus, and cause reflux symptoms. Wrong recognition to GERD induces patients going to hospitals repeatedly and receiving unregular treatment, all of these impact therapeutic effect, cause waste of medical resource, cause economic and psychological burden on these patients. This study aimed to investigate risk factors related to GERD for improvement of therapeutic effect.
Subjects and Methods
We recruited consecutively 122 GERD patients. They were all between 18-65 years old, who had typical symptoms of reflux (such as heartburn, acid reflux, regurgitation or chest pain), or those who were believed to have extra-esophageal symptoms of GERD such as chronic cough, asthma, pharyngitis, et al, and 24h pH monitoring positive. Those who had slide hiatus hernia, history of gastrointestinal operation or systemic diseases which may cause secondary gastric esophageal reflux should be excluded. All patients were asked to complete a questionnaire on GERD, including demographic status, reflux related symptoms, lifestyle, previous status of examination, and treatment, their disease recognition, SF-36 questionnaire and questionnaire of psychological status(SAS and SDS).
Results
1.122 GERD patients were investigated,75 male,mean age 49.1 years,47 female, mean age 54.5 years, patients who at least had a bachelor's degree account for 50.8%, 80.3%had mild physical labour,33.6%had risk factors for increase of abdominal pressure.
2. Symptoms:32.8%of patients reported heartburn to be the most troublesome symptom, followed by chest pain and acid reguitation as the second and third troublesome symptom.
3. Risk factors:patients who had at least one of the risk factors related to GERD account for 79.5%, and the most common risk factors were over weight or obesity (45.1%), often taking large meals (39.3%) and abnormal psychological status (31.1%), 29.5%of GERD patients were very anxious about this disease,27.9%came to see the doctor because they were afraid of cancer and 50.8%were worried about progressing to esophageal cancer.
4. Previous status of examination and treatment,18%(22/122) had received gastric endoscopy at least 5 times or more, the most frequent one had more than 20 times(in a period of 77 months),51.6%had tried one of non-drug therapy, avoidance of large meals, elevation of head of bed and absence of cigarettes and alchohol were the first three which may be effective, patients had ever taken different kinds of drugs to treat this disease,20.5%and 24.6%complained the cost of examinaiton and medicine over RMB 1,0000,36.9%had total cost over tens of thousands.
Conclusions
1. The most troublesome symptom of GERD is heartburn and quite often occurred postprandially.The second and third troublesome symptom are chest pain and acid regurgitation. Diet, posture and emotion are related to occurrence of the most troublesome symptoms. Large part of patients had at least one of the risk factors related to GERD.
2. Patients had received different kinds of drugs and cost a lot on examinaiton and medicine. Nearly one third of patients were very anxious about GERD, about one half were afraid of progressing to esophageal cancer. In clinical practice, disease education to change unhealthy lifestyle and eating habits, and explanation to those who had wrong recognition of GERD are very important.
Abstract II Investigation of long term effect of diaphragm biofeedback training in GERD patients
Background and aims
Our research center have applied DBT in GERD therapy and found it effective. The aim of this study was to investigate the effect of DBT in maintenance therapy in patients with GERD.
Subjects and methods
123 GERD patients were enrolled continously in this study (male 76, female 47). They were all between 18-75 years old, had typical reflux symptoms, total reflux symptom score(TRSS)≥6, or TRSS<6 but still suspected to be GERD and 24h pH monitoring were positive and/or response to PPI treatment.Patients who had chest pain, chronic cough or asthma, heart disease and pulmonary disease should be firstly excluded, and they also must have 24h pH monitoring positive and/or response to PPI treatment.
After completing the GERD questionnaire, they were distributed into two groups-group DBT (N=84) or group PPI (N=39) according to their willingness. Both groups were asked to take PPI regularly (single dose, twice daily) in the first 8 weeks, and patients in group DBT must also receive DBT 4 times daily. In this period, we made telephone call to these patients every two weeks to monitor whether their symptoms were relieved, and asked patients in group DBT come back to hospital to check their DBT was correct or not. At the end of this period, they were asked to come back to GI clinic and complete a follow-up questionnaire. Then in the maintenance treatment period (from 9th week to 6th month), both groups took PPI only when needed, and group DBT were asked to continue to apply DBT 4 times daily.Both of the two groups should record their symptoms and PPI consumption, and came to hospital for a countercheck and completed the follow-up questionnaire at the end of 4th and 6th month. Patients who was not able to come to GI clinic received a letter for follow-up questionnaire.
Results
1. There were no statistical differences in all these aspects as follows, female proportion, age, BMI, TRSS, dosage of PPI, psychological status, between group DBT and group PPI at baseline. There were 54 patients (64.3%) in group DBT who could insist on regular DBT, the other 30 patients could not insist on or even stopped it, so patients in group DBT were divided into regular DBT group and un-regular DBT group. TRSS, consumption of PPI and psychological status were not significantly different within these three groups at baseline and during the period of follow-up.
2. Patients in regular DBT group showed significant decrease of TRSS at the end of 2nd,4th,6th,8th week and 4th,6th month compared with baseline (3.1,3.0,2.2,1.9,2.8,2.9 vs 8.5, p<0.05), PPI consumption was not different from baseline (because all patients took PPI when they were enrolled), SAS and SDS score were improved distinctly at the end of 4th and 6th month.
3. Patients who did not receive DBT regularly only had significant reduction of TRSS at the end of 2nd,4th,6th,8th week (3.8,2.2,1.6,2.2 vs 9.8, p<0.05), TRSS at the end of 4th and 6th month were not significantly different from baseline, the same as the PPI consumption, SAS and SDS score during the period of follow-up. 4. In group PPI, TRSS decreased significantly but dosage of PPI and psychological status were all similar to baseline throughout the follow-up period.
Conclusions
4-month and 6-month regular DBT could improve psychological status in GERD patients.
Abstract III Effect of diaphragm biofeedback training in GERD patients with distinct respiratory tract symptoms
Backgrounds and aims
In the second part of this study, we found that regular DBT could reduce reflux symptoms and improve psychological status of GERD patients. The aim of this study was to observe effect of DBT in GERD patients who have distinct respiratory tract symptoms.
Subjects and methods
14 GERD patients were enrolled, they were all between 18～75 years old, had chronic cough and/or asthma for over 8 weeks,excluded for pulmonary mass or acute infection. They had a TRSS≥6, or if TRSS<6 but positive 24h esophageal pH monitoring, or good response to 2-week PPI therapy.Gastric or duodenal ulcer, past history of operation on gastrointestinal tract and systemic disease should also be excluded. Patients completed the GERD questionnaire and learned how to do DBT, then they applied regular DBT (4 times daily) at home besides taking drugs. We made telephone call to monitor their symptoms and asked them come back to GI clinic every two weeks in the first eight weeks. At the end of 8th week, they were asked to fill in the follow-up questionnaire. After that, they were followed up each month by telephone or coming to clinic.
Results
1. In these 14 patients, there were 4 RE patients and 10 NERD patients,9 male, average age was 50.9±12.9 years, and 5 patients were overweight (BMI≥24 kg/m2).
2.5 patients had course of disease over 10 years, accouted for 35.7%, and median course of disease was 51 months.
3.6 patients (42.9%) complained of cough as the first occurring symptom, and 9 (64.3%)took it as the most troublesome symptom,42.9%of the 14 patients had cough during sleep or just when they woke up in the morning, provocative factors of symptoms were posture (50%), catching cold (35.7%) and eating food (28.6%).2 patients had abnormal psychological status(14.3%).
4.2-week therapy combined DBT with PPI could significantly reduce the TRSS of GERD patients compared with that in the worst status, and make score of cough much lower than that at baseline and in the worst status.
5. PPI consumption and psychological status didn't change statistically at the end of 8th week, improvement of symptoms lasted to the 3rd month, and PPI comsumption in the 3 rd month had a tentancy to decrease but did not reach a statistical significance.
Conclusions
1. NERD patients(71.4%) had more respiratory tract symptoms than RE patients.
2. Cough induced by GERD may be related to more nocturnal reflux.
3. DBT combined with PPI therapy in GERD patients with distinct respiratory tract symptoms may significantly reduce their symptoms in a short period (2 weeks) and maybe can reduce the PPI consumption during maintenance therapy. DBT may become a new way to control chronic cough related to GERD.
Abstract IV Investigation of mechanism of DBT in GERD therapy Background and aims
The second and third part of the study have shown that DBT could relieve the reflux symptoms in GERD patients. Aims of this part were to investigate the mechanism of DBT in GERD therapy, including effect of DBT on acid exposure of esophagus, gastric emptying and TLESR.
Subjects and methods
Enrolling standards:the same to that in abstractⅡ.
1. Effect of DBT on acid exposure of esophagus of GERD patients:7 GERD patients were enrolled. Acid inhibitors and gastrointestinal prokinetic-agents should be avoided at least 7 days before 24h esophagus pH monitoring. Patients repeated 24h esophagus monitoring after 2-week regular DBT.
2. Effect of DBT on gastric emptying in GERD patients:16 GERD patients, received the first nuclide gastric emptying inspection when enrolled, then repeated it after 2-week regular DBT. If patients had PPI at baseline, they did not change the dosage during the first two weeks. Another 13 healthy subjects were also enrolled. All subjects were well informed about the examination.
3. Effect of DBT on TLESR:32 GERD patients were enrolled.We compared the parameters of esophagus manometry before and after DBT. Times of TLESR, total duration of TLESR were what we are concerned.
Results
1. Score of acid regurgitation and TRSS decreased significantly after 2-week regular DBT (2.34±0.9 vs 1.3±0.4,7.7±2.9 vs 3.5±1.3, p<0.05), episodes of acid reflux recorded by pH monitoring was also reduced (138.7±79.71 vs 79.3±92.5, p<0.05).
2.2h total gastric emptying%, velocity of total gastric emptying,2h proximal gastric emptying%and velocity of proximal gastric emptying was much lower in GERD patients than HS (39.1±13.3 vs 57±18.4,49.4±13.5 vs 63.8±18.4,0.3±0.1 vs 0.4±0.1,0.4±0.1 vs 0.5±0.2), T1/2 of total and proximal gastric emptying was also much longer than HS (186.0±86.4 vs 119.9±40.1,141.0±53.4 vs 103.5±30.7, p<0.05). After 2-week regular DBT,2h total gastric emptying%was still much lower than HS (40.6±16.5%vs 57±18.4%, p<0.05), T1/2 of total gastric emptying still longer than HS (181.2±79.0 min vs 119.9±40.1min, p<0.05), however, velocity of total gastric emptying, T1/2 of total gastric emptying,2h proximal gastric emptying%and velocity of proximal gastric emptying were not significantly different from those in HS.
3.6 of 32 GERD patients repeated EM after regular DBT, times of TLESR, total duration of TLESR didn't change obviously.
Conclusions
1.2-week regular DBT could improve reflux symptoms and acid exposure of esophagus in GERD patients.
2. Gastric emptying in GERD patients was much lower than HS,2-week regular DBT maybe can improve 2h proximal gastric emptying.
3.8-week DBT could not reduce the TLESR significantly.
背景和目的
不良的生活方式、饮食习惯及焦虑抑郁的心理状态可能会导致食管及胃食管交界处的功能障碍,降低食管的感觉阈值,从而引发反流症状的出现。而对疾病的错误认知,往往造成患者反复就医、治疗不规范,既影响治疗效果,又浪费了医疗资源。本研究目的：通过对GERD患者进行问卷调查,了解与GERD发病相关的危险因素,以便有效治疗GERD。
对象和方法
2008年8月至2009年6月就诊于我院消化科门诊的122名GERD患者连续入组,填写GERD问卷。入选标准：1.年龄18～75岁；2.典型的反流症状,评分≥6分；3.慢性咳嗽、喘息、咽喉炎、咽部异物感,考虑可能为GERD伴随的食管外症状,经24小时食管pH监测检查证实存在异常酸反流；4.排除大的滑动型食管裂孔疝,排除其他消化系统疾病、胃肠道手术病史、继发性胃食管反流病及其它系统严重器质性疾病。问卷内容包括：一般人口学特征、胃食管反流及相关症状、生活方式、既往检查治疗情况、疾病认知、生活质量、精神心理状态。
结果
1.一般情况：共纳入122例GERD患者,其中男75例(61.5%),年龄49.1±12.5岁；女47例(38.5%),年龄54.5±13.0岁；大学以上学历者50.8%；轻体力劳动者占80.3%；33.6%的患者存在长期腹压增加的危险因素。2.症状分布：32.8%的患者以烧心为最难受的症状,而胸痛、反酸分列第2、3位。3.危险因素：至少存在一项GERD相关危险因素的占79.5%；按照不同的危险因素进行分类,以超重／肥胖(45.1%)、经常饱餐(39.3%)及伴随焦虑抑郁状态(31.1%)最多见；29.5%的患者对于罹患本病比较或非常担心、紧张,因担心得肿瘤就诊的患者占27.9%,担心本病会发展为食管癌占50.8%。4.既往检查治疗：18%的患者接受过5次及5次以上的胃镜检查,最多者达到20余次(77个月)；51.6%的患者曾经坚持一种非药物治疗,避免饱餐、抬高床头、戒烟戒酒是有效的前三位非药物治疗方式；患者服用过多种药物治疗；检查费超过1万元的占20.5%,药品费用超过1万元的占24.6%,36.9%的患者总花费达到数万元以上。
结论
GERD患者最难受症状是烧心、胸痛、反酸,多出现于餐后,饮食、体位、情绪与最难受症状出现有关。多数患者存在GERD相关的危险因素。患者因对本病认知有限,接受过反复检查及多种药物治疗,既浪费了医疗资源,同时患者本人也承担了巨大的经济和精神负担。接近1／3的患者对罹患本病比较或非常担心、紧张,约半数患者担心本病会发展为食管癌。在GERD患者的治疗中,强调改变不良生活方式及饮食习惯以及对疾病认知误区的患者的解释非常重要。
摘要二膈肌生物反馈训练治疗GERD患者的长期疗效观察
背景与目的
本研究中心已观察到膈肌生物反馈训练(DBT)对GERD患者的疗效,本研究的目的是观察DBT对GERD的维持治疗的疗效。
对象和方法
连续入组GERD患者123例,入选标准：1.年龄18～75岁；2.具有烧心、反酸、反食、胸骨后疼痛等典型的反流症状,反流症状评分≥6分；3.反流症状评分<6分但怀疑为胃食管反流病,且食管24小时pH监测阳性和／或PPI试验治疗有效；4.排除心肺疾病的胸痛、慢性咳嗽、哮喘的患者,食管24小时pH监测阳性和／或PPI试验治疗有效。患者在填写GERD问卷后根据意愿被分入两组,即DBT组(N=84)和PPI组(N=39)。分为两期：(1)初始治疗期(0-8周)：DBT组的患者每日进行DBT,同时服用PPI(单剂量,2次／日),记录日记,PPI组的患者仅服用PPI,入组后第2、4、6周,通过电话了解患者症状变化(DBT组的患者应每2周至医院随访1次,在医生指导下训练1次),第8周患者至门诊复诊并填写随访问卷；(2)维持治疗期(9周-6月),DBT组的患者继续每日进行DBT,两组患者均可按需服用PPI,记录PPI的用药量及症状变化,每月1次通过电话了解患者情况,要求患者于随访的第4、6个月至门诊复诊,填写随访问卷。不能来门诊随访的患者,通过邮寄随访问卷的形式来了解其情况。
结果
1.DBT组与PPI组患者,入组时在性别构成、年龄、BMI、腹围、反流症状总评分、PPI用量、精神心理状态上均无显著性差异。DBT组中有54人(64.3%)能坚持规律训练,其余30人训练欠规律或者未训练(35.7%),根据训练情况分为规律DBT组与不规律DBT组。在入组时及随访的各个时间点,三组患者的反流症状总评分(total reflux symptom score, TRSS)、PPI消耗量、SAS、SDS评分无显著性差异。
2.规律DBT组患者的反流症状在随访的第2、4、6、8周及第4、6月末,均较入组时显著下降(3.1、3.0、2.2、1.9、2.8、2.9 vs 8.5,p<0.05)；PPI用量与入组时比较无显著性差异(入组时已服用PPI)；规律DBT组患者在第4、6月末的SAS、SDS评分均较入组时显著降低。
3.不规律DBT组的患者,除第2、4、6、8周末TRSS较入组时比较有显著改善外,第4、6月末的TRSS以及随访过程中的PPI用量、精神心理状态均较入组时比较无显著差异。
4.PPI组患者在维持治疗随访过程中,除反流症状评分显著下降外,PPI用量及精神心理状态均与入组时比较无显著性差异。
结论
4个月及6个月规律的DBT能够改善GERD患者的精神心理状态。
摘要三膈肌生物反馈训练对以呼吸道症状为突出表现的GERD患者的治疗观察
背景和目的
本论文第二部分的结果提示,规律DBT联合药物治疗有助于减少患者反流症状的出现,改善患者异常的精神心理状态。本研究目的旨在观察DBT在以呼吸道症状为主要表现的GERD患者中的治疗效果。
对象和方法
本研究共纳入14例GERD患者,入组条件：1.年龄18～75岁；2.咳嗽和／或哮喘病程≥8周,除外肺部占位性病变及急性感染性病变；3.反流症状评分≥6分,或症状评分<6分但24小时食管pH监测阳性,或症状评分<6分、24小时食管pH监测(—),但PPI试验治疗2周有效；4.排除消化性溃疡、既往胃肠道手术史及全身疾病史的患者。患者填写GERD问卷后,学习DBT方法,在接受药物治疗同时进行规律的DBT,每2周电话或者门诊随访1次,了解症状变化,第8周末填写随访问卷。第8周后每月电话或门诊随访1次。
结果
1.共纳入14例GERD患者,其中RE 4例,NERD10例；男性9例；超重者5例；年龄50.9±12.9岁。2.咳嗽病程在10年以上的有5例,占35.7%,中位病程51月。3.以咳嗽为首发症状的有6例(42.9%),为最难受症状的有9例(64.3%)；42.9%的患者咳嗽症状最常出现在睡眠过程中以及晨起空腹时；症状的诱因依次为体位相关(50%)、受凉(35.7%)及进食(28.6%)；精神心理呈异常状态2例。4.DBT联合药物治疗2周后,患者的TRSS较最严重时显著下降,而咳嗽的评分较最严重时及入组时比较均出现显著下降,药物消耗量、精神心理状态在第8周末时与入组时比较无显著性差异。随访3个月,症状的改善可以维持,药物消耗量有减少趋势但未出现显著性差异。
结论
1. NERD(71.4%)患者与RE患者比较伴有更显著的呼吸道症状。
2.咳嗽可能与夜间酸反流显著有关。
3.DBT联合PPI治疗伴有呼吸道症状的GERD患者,短期内(2周)能显著改善患者的反流和咳嗽症状,并可能减少维持治疗期PPI的消耗量,为反流病合并的咳嗽患者治疗提供一种新的治疗途径。
摘要四膈肌生物反馈训练对GERD患者治疗的作用机制探讨
背景和目的
本研究第二、三部分研究结果提示DBT有助于改善GERD患者的反流症状,也有相关文献表明DBT可以改善EGJ抗反流屏障功能。本部分研究目的在于观察DBT对GERD患者食管酸暴露、胃排空及食管动力的影响。
对象和方法
入组条件：同论文的第二部分。
1.DBT对食管酸暴露的影响：7例GERD患者,入组前1周禁止服用PPI,规律训练2周后复查食管pH监测,训练期间避免服用抑酸药物及影响胃肠道动力药物。
2.DBT对胃排空的影响：16例GERD患者,入组时进行1次核素胃排空检查,RE患者如果入组时已经服用PPI,则研究期间不更改PPI剂量。患者规律训练2周后需复查核素胃排空。另外,入组13名HS。患者与HS均签署知情同意书。
3.DBT对食管动力的影响：入组32名GERD患者。重点观察DBT前后TLESR发生次数、TLESR总时间。
结果
1. GERD患者在2周规律的DBT后反酸评分(2.34±0.9 vs 1.3±0.4)、TRSS(7.7±2.9 vs 3.5±1.3)均较入组时显著下降,食管pH监测结果提示酸反流次数也明显减少(138.7±79.71 vs 79.3±92.5)(p<0.05)。
2.入组时与HS比较,GERD患者2h全胃排空率(%)、2h近端胃排空率(%)、全胃排空速率(%／min)及近端胃排空速率(%／min)均显著降低(39.1±13.3 vs 57±18.4,49.4±13.5 vs 63.8±18.4,0.3±0.1 vs 0.4±0.1，0.4±0.1 vs 0.5±0.2),半排时间(min)明显延长(186.0±86.4 vs 119.9±40.1)。经过规律的2周DBT后,2h全胃排空率(%)仍显著低于HS组(40.6±16.5 vs 57±18.4),全胃半排时间(min)仍长于HS组(181.2±79.0 vs 119.9，40.1),但全胃排空速率、近端胃2小时排空率、近端胃半排时间、近端胃排空速率与HS组的差异不显著。
3.6例患者经过DBT治疗后复查食管压力测定,TLESR发生次数、TLESR总时间变化不显著。
结论
1.2周的规律DBT能显著改善GERD患者的症状及食管酸暴露情况；
2. GERD患者的胃排空明显较HS延缓,2周的DBT可能改善GERD患者近端胃排空功能；
3.8周内的DBT尚不能减少GERD患者TLESR的发生。
Abstract I Investigation of unhealthy lifestyle, previous status of examination and treatment and disease recognition in gastroesophageal reflux disease patients
Background and Objectives
Unheathy lifestyle and eating habits and abnormal psychological status may affect the function of EGJ, reduce the sensation threshold of the esophagus, and cause reflux symptoms. Wrong recognition to GERD induces patients going to hospitals repeatedly and receiving unregular treatment, all of these impact therapeutic effect, cause waste of medical resource, cause economic and psychological burden on these patients. This study aimed to investigate risk factors related to GERD for improvement of therapeutic effect.
Subjects and Methods
We recruited consecutively 122 GERD patients. They were all between 18-65 years old, who had typical symptoms of reflux (such as heartburn, acid reflux, regurgitation or chest pain), or those who were believed to have extra-esophageal symptoms of GERD such as chronic cough, asthma, pharyngitis, et al, and 24h pH monitoring positive. Those who had slide hiatus hernia, history of gastrointestinal operation or systemic diseases which may cause secondary gastric esophageal reflux should be excluded. All patients were asked to complete a questionnaire on GERD, including demographic status, reflux related symptoms, lifestyle, previous status of examination, and treatment, their disease recognition, SF-36 questionnaire and questionnaire of psychological status(SAS and SDS).
Results
1.122 GERD patients were investigated,75 male,mean age 49.1 years,47 female, mean age 54.5 years, patients who at least had a bachelor's degree account for 50.8%, 80.3%had mild physical labour,33.6%had risk factors for increase of abdominal pressure.
2. Symptoms:32.8%of patients reported heartburn to be the most troublesome symptom, followed by chest pain and acid reguitation as the second and third troublesome symptom.
3. Risk factors:patients who had at least one of the risk factors related to GERD account for 79.5%, and the most common risk factors were over weight or obesity (45.1%), often taking large meals (39.3%) and abnormal psychological status (31.1%), 29.5%of GERD patients were very anxious about this disease,27.9%came to see the doctor because they were afraid of cancer and 50.8%were worried about progressing to esophageal cancer.
4. Previous status of examination and treatment,18%(22/122) had received gastric endoscopy at least 5 times or more, the most frequent one had more than 20 times(in a period of 77 months),51.6%had tried one of non-drug therapy, avoidance of large meals, elevation of head of bed and absence of cigarettes and alchohol were the first three which may be effective, patients had ever taken different kinds of drugs to treat this disease,20.5%and 24.6%complained the cost of examinaiton and medicine over RMB 1,0000,36.9%had total cost over tens of thousands.
Conclusions
1. The most troublesome symptom of GERD is heartburn and quite often occurred postprandially.The second and third troublesome symptom are chest pain and acid regurgitation. Diet, posture and emotion are related to occurrence of the most troublesome symptoms. Large part of patients had at least one of the risk factors related to GERD.
2. Patients had received different kinds of drugs and cost a lot on examinaiton and medicine. Nearly one third of patients were very anxious about GERD, about one half were afraid of progressing to esophageal cancer. In clinical practice, disease education to change unhealthy lifestyle and eating habits, and explanation to those who had wrong recognition of GERD are very important.
Abstract II Investigation of long term effect of diaphragm biofeedback training in GERD patients
Background and aims
Our research center have applied DBT in GERD therapy and found it effective. The aim of this study was to investigate the effect of DBT in maintenance therapy in patients with GERD.
Subjects and methods
123 GERD patients were enrolled continously in this study (male 76, female 47). They were all between 18-75 years old, had typical reflux symptoms, total reflux symptom score(TRSS)≥6, or TRSS<6 but still suspected to be GERD and 24h pH monitoring were positive and/or response to PPI treatment.Patients who had chest pain, chronic cough or asthma, heart disease and pulmonary disease should be firstly excluded, and they also must have 24h pH monitoring positive and/or response to PPI treatment.
After completing the GERD questionnaire, they were distributed into two groups-group DBT (N=84) or group PPI (N=39) according to their willingness. Both groups were asked to take PPI regularly (single dose, twice daily) in the first 8 weeks, and patients in group DBT must also receive DBT 4 times daily. In this period, we made telephone call to these patients every two weeks to monitor whether their symptoms were relieved, and asked patients in group DBT come back to hospital to check their DBT was correct or not. At the end of this period, they were asked to come back to GI clinic and complete a follow-up questionnaire. Then in the maintenance treatment period (from 9th week to 6th month), both groups took PPI only when needed, and group DBT were asked to continue to apply DBT 4 times daily.Both of the two groups should record their symptoms and PPI consumption, and came to hospital for a countercheck and completed the follow-up questionnaire at the end of 4th and 6th month. Patients who was not able to come to GI clinic received a letter for follow-up questionnaire.
Results
1. There were no statistical differences in all these aspects as follows, female proportion, age, BMI, TRSS, dosage of PPI, psychological status, between group DBT and group PPI at baseline. There were 54 patients (64.3%) in group DBT who could insist on regular DBT, the other 30 patients could not insist on or even stopped it, so patients in group DBT were divided into regular DBT group and un-regular DBT group. TRSS, consumption of PPI and psychological status were not significantly different within these three groups at baseline and during the period of follow-up.
2. Patients in regular DBT group showed significant decrease of TRSS at the end of 2nd,4th,6th,8th week and 4th,6th month compared with baseline (3.1,3.0,2.2,1.9,2.8,2.9 vs 8.5, p<0.05), PPI consumption was not different from baseline (because all patients took PPI when they were enrolled), SAS and SDS score were improved distinctly at the end of 4th and 6th month.
3. Patients who did not receive DBT regularly only had significant reduction of TRSS at the end of 2nd,4th,6th,8th week (3.8,2.2,1.6,2.2 vs 9.8, p<0.05), TRSS at the end of 4th and 6th month were not significantly different from baseline, the same as the PPI consumption, SAS and SDS score during the period of follow-up. 4. In group PPI, TRSS decreased significantly but dosage of PPI and psychological status were all similar to baseline throughout the follow-up period.
Conclusions
4-month and 6-month regular DBT could improve psychological status in GERD patients.
Abstract III Effect of diaphragm biofeedback training in GERD patients with distinct respiratory tract symptoms
Backgrounds and aims
In the second part of this study, we found that regular DBT could reduce reflux symptoms and improve psychological status of GERD patients. The aim of this study was to observe effect of DBT in GERD patients who have distinct respiratory tract symptoms.
Subjects and methods
14 GERD patients were enrolled, they were all between 18～75 years old, had chronic cough and/or asthma for over 8 weeks,excluded for pulmonary mass or acute infection. They had a TRSS≥6, or if TRSS<6 but positive 24h esophageal pH monitoring, or good response to 2-week PPI therapy.Gastric or duodenal ulcer, past history of operation on gastrointestinal tract and systemic disease should also be excluded. Patients completed the GERD questionnaire and learned how to do DBT, then they applied regular DBT (4 times daily) at home besides taking drugs. We made telephone call to monitor their symptoms and asked them come back to GI clinic every two weeks in the first eight weeks. At the end of 8th week, they were asked to fill in the follow-up questionnaire. After that, they were followed up each month by telephone or coming to clinic.
Results
1. In these 14 patients, there were 4 RE patients and 10 NERD patients,9 male, average age was 50.9±12.9 years, and 5 patients were overweight (BMI≥24 kg/m2).
2.5 patients had course of disease over 10 years, accouted for 35.7%, and median course of disease was 51 months.
3.6 patients (42.9%) complained of cough as the first occurring symptom, and 9 (64.3%)took it as the most troublesome symptom,42.9%of the 14 patients had cough during sleep or just when they woke up in the morning, provocative factors of symptoms were posture (50%), catching cold (35.7%) and eating food (28.6%).2 patients had abnormal psychological status(14.3%).
4.2-week therapy combined DBT with PPI could significantly reduce the TRSS of GERD patients compared with that in the worst status, and make score of cough much lower than that at baseline and in the worst status.
5. PPI consumption and psychological status didn't change statistically at the end of 8th week, improvement of symptoms lasted to the 3rd month, and PPI comsumption in the 3 rd month had a tentancy to decrease but did not reach a statistical significance.
Conclusions
1. NERD patients(71.4%) had more respiratory tract symptoms than RE patients.
2. Cough induced by GERD may be related to more nocturnal reflux.
3. DBT combined with PPI therapy in GERD patients with distinct respiratory tract symptoms may significantly reduce their symptoms in a short period (2 weeks) and maybe can reduce the PPI consumption during maintenance therapy. DBT may become a new way to control chronic cough related to GERD.
Abstract IV Investigation of mechanism of DBT in GERD therapy Background and aims
The second and third part of the study have shown that DBT could relieve the reflux symptoms in GERD patients. Aims of this part were to investigate the mechanism of DBT in GERD therapy, including effect of DBT on acid exposure of esophagus, gastric emptying and TLESR.
Subjects and methods
Enrolling standards:the same to that in abstractⅡ.
1. Effect of DBT on acid exposure of esophagus of GERD patients:7 GERD patients were enrolled. Acid inhibitors and gastrointestinal prokinetic-agents should be avoided at least 7 days before 24h esophagus pH monitoring. Patients repeated 24h esophagus monitoring after 2-week regular DBT.
2. Effect of DBT on gastric emptying in GERD patients:16 GERD patients, received the first nuclide gastric emptying inspection when enrolled, then repeated it after 2-week regular DBT. If patients had PPI at baseline, they did not change the dosage during the first two weeks. Another 13 healthy subjects were also enrolled. All subjects were well informed about the examination.
3. Effect of DBT on TLESR:32 GERD patients were enrolled.We compared the parameters of esophagus manometry before and after DBT. Times of TLESR, total duration of TLESR were what we are concerned.
Results
1. Score of acid regurgitation and TRSS decreased significantly after 2-week regular DBT (2.34±0.9 vs 1.3±0.4,7.7±2.9 vs 3.5±1.3, p<0.05), episodes of acid reflux recorded by pH monitoring was also reduced (138.7±79.71 vs 79.3±92.5, p<0.05).
2.2h total gastric emptying%, velocity of total gastric emptying,2h proximal gastric emptying%and velocity of proximal gastric emptying was much lower in GERD patients than HS (39.1±13.3 vs 57±18.4,49.4±13.5 vs 63.8±18.4,0.3±0.1 vs 0.4±0.1,0.4±0.1 vs 0.5±0.2), T1/2 of total and proximal gastric emptying was also much longer than HS (186.0±86.4 vs 119.9±40.1,141.0±53.4 vs 103.5±30.7, p<0.05). After 2-week regular DBT,2h total gastric emptying%was still much lower than HS (40.6±16.5%vs 57±18.4%, p<0.05), T1/2 of total gastric emptying still longer than HS (181.2±79.0 min vs 119.9±40.1min, p<0.05), however, velocity of total gastric emptying, T1/2 of total gastric emptying,2h proximal gastric emptying%and velocity of proximal gastric emptying were not significantly different from those in HS.
3.6 of 32 GERD patients repeated EM after regular DBT, times of TLESR, total duration of TLESR didn't change obviously.
Conclusions
1.2-week regular DBT could improve reflux symptoms and acid exposure of esophagus in GERD patients.
2. Gastric emptying in GERD patients was much lower than HS,2-week regular DBT maybe can improve 2h proximal gastric emptying.
3.8-week DBT could not reduce the TLESR significantly.
引文
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[5]陈春明,国际生命科学学会中国办事处中国肥胖问题工作组联合数据汇总分析协作组.中国成人体质指数分类的推荐意见简介[J].2001：35,349-350.
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