下食管括约肌与膈肌分离对食管裂孔疝患者的诊断价值

Diagnostic value of lower esophageal sphincter and diaphragm separation in patients with hiatus hernia

目的 分析下食管括约肌（LES）与膈肌分离患者的胃镜表现,探究其在诊断食管裂孔疝（HH）中的意义.方法 回顾性分析2011年1月至2012年6月的高分辨率食管测压（HRM）患者资料,从中筛选提示LES与膈肌分离的患者,排除上消化道手术史及缺乏完整胃镜资料的病例,共93例纳入分析.按芝加哥标准分成3组,Ⅰ型组（LES与膈肌分离＜1 cm）21例；Ⅱ型组（LES与膈肌分离1～＜2 cm）37例；Ⅲ型组（LES与膈肌分离≥2 cm） 35例.分析各组间胃镜表现差异.以HRM为金标准,计算胃镜诊断HH的敏感度、特异度.计量资料以（-x）±s表示,多组间均数比较采用单因素方差分析,两两比较采用LSD法或Dunnett T3检验.两组间率的比较采用卡方检验或Fisher确切概率法.结果 3组间胃食管连接部（EGJ）与门齿的距离差异无统计学意义（P＞0.05）,而EGJ与膈食管裂孔压迹的距离：Ⅲ型组[（3.57±0.78） cm]＞Ⅱ型组[（1.89±0.81） cm]＞Ⅰ型组[（1.14±0.67） cm],差异均有统计学意义LSD-t=9.26、11.44、3.57,P均＜0.05].贲门久开和胃囊上压迹出现率：Ⅲ型组＞Ⅱ型组＞Ⅰ型组（80.0％、40.5％、4.8％,x2=11.64、29.76、8.59,P均＜0.05；91.4％、27.1％、4.8％,x2=30.69、40.73、4.32,P均＜0.05）.His角变钝（可从食管看到胃体）和疝囊出现率：Ⅲ型组大于Ⅰ型组和Ⅱ型组（分别为74.3％和77.1％,24.3％和24.3％,4.8％和4.8％;x2=17.97、25.41,P均＜0.05）,Ⅰ型组和Ⅱ型组差异均无统计学意义（P均＞0.05）.食管炎发生率：Ⅲ型组和Ⅱ型组皆大于Ⅰ型组（71.4％,59.5％,14.3％；x2=17.14、11.15,P均＜0.05）,Ⅲ型组和Ⅱ型组差异无统计学意义（P＞0.05）.Barrett食管在：3组各1例.胃镜诊断HH敏感度为91.4％,特异度为81.0％.结论 HH的胃镜表现中,EGJ与膈食管裂孔压迹距离、贲门久开、His角变钝、胃囊上压迹及疝囊是比较重要的指标.胃镜诊断HH敏感度较高,特异度偏低.

Objective To analyze the endoscopic features of patients with the lower esophageal sphincter （LES） and crural diaphragm （CD） separation and explore its significance in hiatus hernia （HH） diagnosis.Methods From January 2011 to June 2012,the data of patients underwent esophagus high resolution manometry （HRM） examination were retrospectively analyzed and of which the patients with LES-CD separation were selected.Patients who received digestive tracts operation or lack of complete endoscopic date were excluded.A total of 93 cases were enrolled for analysis.According to Chicago Criteria,the cases were divided into three groups.There were 21 cases in type Ⅰ group （LES-CD separation〈1 cm）,37 cases in type Ⅱ group （LES-CD separation≥l cm and 〈2 cm）,35 cases in type Ⅲ group （LES-CD separation≥2 cm）.The differences among groups in endoscopic features were analyzed.HRM were taken as golden standard,the sensitivity and specificity of endoscopy in HH diagnosis were analyzed.Measurement data were expressed as x ± s,one-way ANOVA was performed for multi-groups comparisons,LSD method or Dunnett T3 test for pairwise comparisons and chi-square test or Fisher＇s exact test for two groups＇ comparisons.Results There were no significant differences in the distance between esophagus gastric junction （EGJ） and foreteeth of the three groups （P〉0.05）.Distances between EGJ and diaphragmatic HH pressure impression in type Ⅲ group,type Ⅱ group and type Ⅰ group were （3.57±0.78） cm,（1.89±0.81） cm and （1.14±0.67） cm,respectively and the differences were significant （LSDt=9.26,11.44,3.57; all P〈0.05）.The percentage of continuously-open cardia and showing pressure impression of the gastric pouch of type Ⅲ group was higher than that of type Ⅱ group and the percentage of continuously-open cardia and showing pressure impression of gastric poach of type Ⅱ group was higher than that of type Ⅰ group （80.0%,40.5% and 4.8%,x2 =11.64,29.76 and 8.59; 91.4%,27.0% and 4.8%,x2 =30.69,40.73 and 4.32＇ all P〈0.05）.The occurrence rates of the His angle blunting and sac of type Ⅲ group were higher than those of typeⅡ group and type Ⅰ group （74.3% and 77.1%,24.3% and 24.3%,4.8% and 4.8%,x2 =17.97 and 25.41,both P〈0.05）,there was no significant difference between type Ⅱ group and type Ⅰ group （P〉0.05）.The rates of esophagitis of type Ⅲ group and type Ⅱ group were higher than that of type Ⅰ group （71.4%,59.5% and 14.3%,x2 =17.14 and 11.15,both P〈0.05）,there was no significant difference between type Ⅲ group and type Ⅱ group （P〉0.05）.There was one case of Barrett＇s esophagus in each group.The sensitivity and specificity of endoscopy in HH diagnosis were 91.4% and 81.0%,respectively.Conclusions The distance between EGJ and hiatal pressure impression,continuously-open cardia,the His angle blunting,hiatal pressure impression of the gastric pouch and hernia sac were important indicators of HH endoscopic features.The sensitivity of endosocopy is higher than the spcificity of endosocopy in HH diagnosis.