胃食管反流病相关非心源性胸痛诊断的探讨

Diagnosis of gastroesophageal reflux disease-related noncardiac chest pain

目的评价内镜、24h食管pH监测、症状指数、24h食管胆汁监测和质子泵抑制剂（PPI）试验等方法对胃食管反流病（GERD）相关非心源性胸痛（NCCP）的诊断价值。方法因胸痛而接受冠状动脉造影的连续病例共255例中，符合本研究标准的NCCP患者27例纳入研究，对这些患者行问卷调查、内镜、24h食管pH和胆汁监测后，予埃索美拉唑20mg，2次／d，试验14d。结果27例NCCP中，若仅以存在糜烂性食管炎和（或）病理性酸反流诊断GERD相关NCCP有9例（33％）；若以存在糜烂性食管炎和（或）病理性酸反流、症状指数阳性、病理性胆汁反流之其中1项诊断为GERD相关NCCP则有20例（74％）。以后者为GERD相关NCCP的诊断标准，PPI试验的诊断敏感性75％、特异性86％，反流性疾病问卷（RDQ）敏感性35％、特异性86％。结论结合内镜、24h食管pH监测、症状指数、24h食管胆汁监测等检查可提高GERD相关NCCP的诊断，PPI试验是临床上诊断GERD相关NCCP的首选方法。

Objective To assess the values of endoscopy, 24-hour esophageal pH monitoring, symptom index, 24-hour esophageal bile monitoring, and proton pump inhibitor （PPI） trail in the diagnosis of gastroesophgeal reflux disease （GERD）-related noncardiac chest pain （NCCP）. Methods 27 NCCP patients, selected from a consecutive sample of 255 patients who had received coronary angiography owing to chest pain, underwent upper endoscopy, and 24-hour esophageal pH and bile monitoring, then they took esomeprazole 20 mg orally twice daily for 14 days. Symptom score （SI） was used to measure the severity and frequency of chest pain before and after treatment. The patients also underwent an initial questionnaire survey including the general personal data and symptom characters, reflux diagnostic questionnaire （RDQ）, self-rating anxiety scale （SAS） survey, and self-rating depression scale （SDS） survey. Results If only based on erosive esophagitis and/or abnormal 24-hour esophageal pH monitoring, 9 of the 27 patients （33%） were classified as GERD-related NCCP. Otherwise, 74% （20 of the 27 patients were classified as GERD-related NCCP based on erosive esophagitis and/or abnormal 24-hour esophageal pH monitoring, or positive SI or abnormal bile monitoring. 15 of the 20 GERD patients （ 75% ） had a significant symptom improvement on PPI compared with 14% （ 1/7 ） of non-GERD patients （ P = 0. 009 ）. The calculated sensitivity and specificity of the PPI trail was 75% and 86% respectively. The typical reflux symptoms presented more frequently among GERD patients than non-GERD patients [65% （13/20） vs 29% （2/7）, P =0. 185]. There was no significant RDQ score difference between the 2 groups （10±4 vs 8±4, P = 0. 411 ）. The sensitivity and specificity of RDQ to GERD-related NCCP were 35% and 86% respectively. The SAS scores of GERD and non-GERD-related NCCP patients were both significantly higher than that of the normal controls （P = 0.008 and P = 0.011 ）, while the SDS scores of the GERD and non-GERD-related NCCP patients were both similar to that of the normal controls （P =0. 090 and P =0. 113）. Conclusion Combination of endoscopy, 24-hour esophageal pH monitoring, SI, and 24-hour esophageal bile monitoring helped to improve the diagnosis of GERD-related NCCP. PPI trail is the first clinical diagnostic tool in the evaluation of GERD-related NCCP.