非梗阻性吞咽困难高分辨率食管测压分析

Analysis of non-obstructive dysphagia with esophageal high-resolution manometry

目的 分析非梗阻性吞咽困难（NOD）患者的疾病分布和食管动力特点.方法 选取2010年6月至2012年6月97例吞咽时有胸骨后梗阻感的患者,经内镜和上消化道造影排除食管器质性狭窄.另选取同期健康志愿者9名为健康对照组.采用荷兰CTDSynectics高分辨率多通道胃肠功能监测系统（Pcpolygraf多导记录系统）和MMS消化道动力检测系统进行高分辨率食管测压,观察指标包括上食管括约肌压力（UESP）、上食管括约肌松弛率（UESRR）、下食管括约肌长度（LESL）、下食管括约肌压力（LESP）、完整松弛压（IRP）、下食管括约肌松弛率（LESRR）、食管体部下段压力、食管体部有效蠕动比例.组间比较行秩和检验.结果 97例NOD患者中贲门失弛缓症、非特异性食管动力异常、胃食管反流病（GERD）者分别占41.2％（40/97）、39.2％ （38/97）、19.6％（19/97）.非特异性食管动力异常者中蠕动异常、蠕动缺失、测压正常、远端食管痉挛者分别占39.5％ （15/38）、36.8％（14/38）、15.8％（6/38）、7.9％（3/38）.贲门失弛缓症组、GERD组、非特异性食管动力异常组、健康对照组间比较,LESL、LESP、LESRR、食管体部下段压力、有效蠕动比例差异均有统计学意义（F=6.143、57.490、50.559、10.155、22.046,P均＜0.05）.贲门失弛缓症组的LESP大于健康对照组,LESRR、食管体部下段压力、有效蠕动比例则均小于健康对照组,差异均有统计学意义（F=2.276、-11.113、-8.036、-14.663,P均＜0.05）.贲门失弛缓症组的LESL和LESP均大于GERD组,LESRR、食管体部下段压力、有效蠕动比例则均小于GERD组,差异均有统计学意义（F=4.325、15.983、-19.235、-3.410、-4.351,P均＜0.05）.贲门失弛缓症组的LESL和LESP均大于非特异性食管动力异常组,LESRR和有效蠕动比例则均小于GERD组,差异均有统计学意义（F=2.376、7.668、-2.873、-3.873,P均＜0.05）.GERD组的LESRR大于健康对照组,LESL、LESP、食管体部下段压力、有效蠕动比例则均小于健康对照组,差异均有统计学意义（F=5.931、-2.483、-14.618、-3.071、4.516,P均＜0.05）.GERD组的LESL和LESP均小于非特异性食管动力异常组,LESRR则大于非特异性食管动力异常组,差异均有统计学意义（F=-2.113、-6.578、10.979,P均＜0.05）.非特异性食管动力异常组的LESP、LESRR、食管体部下段压力、有效蠕动比例均小于健康对照组,差异均有统计学意义（F=-6.313、-3.580、-3.511、8.150,P均＜0.05）.所有40例贲门失弛缓症患者的IRP均高于正常范围.结论 NOD的疾病分布主要为贲门失弛缓症、非特异性食管动力异常和GERD.食管体部有效蠕动减少可能是NOD的重要病理生理机制.

Objective To analyze the distribution and esophageal motility characteristics of patients with non-obstructive dysphagia （NOD）. Methods From June 2010 to June 2012, ninety seven patients with a sense of obstruction when swallowing were selected and patients with esophagealorganic stenosis was excluded through endoscopic examination and upper gastrointestinal radiography. While nine healthy volunteers were recruited as healthy control. High-resolution esophageal manometry was performed with high-resolution multi-channel Netherlands CTD Synectics gastrointestinal function monitoring system （Pcpolygraf polysomnography recording system） and MMS digestive power detection system. The observation parameter included upper esophageal sphincter pressure （UESP）, upper esophageal sphincter relaxation rate （UESRR）, the length of the lower esophageal sphincter （LESL）, lower esophageal sphincter pressure （LESP）, intergrated relaxation pressure （IRP）, lower esophageal sphincter relaxation rate （LESRR）, esophageal subordinate segments pressure and esophageal effective peristalsis ratio. The rank sum test was performed for comparison between groups. Results Among 97 patients with NOD, the percentage of achalasia, nonspecific esophageal motor disorder and gastroesophageal reflux disease （GERD） was 41.2%（40/97）, 39. 2% （38/97） and 19.6% （19/97）, respectively. Among patients with nonspecific esophageal motor disorder, the percentage of abnormal peristalsis, absent peristalsis, normal pressure and distal esophegesl spasm was 39.5%（15/38）, 36.8%（14/38）, 15.8%（6/38） and 7.9%（3/38）, respectively. The differences in LESL, LESP, LESRR, esophageal subordinate segments pressure and esophageal effective peristalsis ratio among achalasia, GERD, nonspecific esophageal motor disorder and healthy control were statistically significant （F=6.143, 57. 490, 50. 559, 10. 155 and 22.046,all P〈0.05）. LESP of patients with achalasia was higher than that of healthy control, however LESRR, esophageal subordinate segments pressure and esophageal effective peristalsis ratio were all lower than those of healthy control and the differences were statistically significant （F= 2. 276, -11. 113, -8. 036 and -14. 663, all P〈0.05）. LESL and LESP of achalasia were both higher than those of GERD group, LESRR, esophageal subordinate segments pressure and esophageal effective peristalsis ratio were all lower than those of GERD group and the differences were statistically significant （F=4. 325, 15. 983, - 19. 235, -3. 410 and -4. 351, all P〈0.05）. LESL and LESP of achalasia group both were higher than those of nonspecific esophageal motor disorder group, LESRR and esophageal effective peristalsis ratio were both lower than those of GERD group and the differences were statistically significant （F= 2. 376, 7. 668, 2. 873 and -3. 873, all P〈0.05）. LESRR of GERD group was higher than that of healthy control group, LESL, LESP, esophageal subordinate segments pressure and esophageal effective peristalsis ratio were all lower than those of healthy control group and the differences were statistically significant （F=5.931, -2. 483,-14. 618, -3. 071 and --4. 516, all P〈0. 05）. LESL and LESP of GERD group were both lower than those of nonspecific esophageal motor disorder group, LESRR was higher than that of nonspecific esophageal motor disorder group and the differences were statistically significant （F= --2.113, -6.578 and 10.979, all P〈0. 05）. LESP, LESRR, esophageal subordinate segments pressure and esophageal effective peristalsis ratio of nonspecific esophageal motor disorder group were all lower than those of healthy control group and the differences were statistically significant （F=-6. 313, -3. 580, -3. 511 and -8. 150, all P〈0.05）. IRP of 40 patients with achalasia were all beyond the normal range. Conclusions NOD mainly included achalasia, nonspecific esophageal motor disorder and GERD. The reduction of effective esophageal peristalsis may be an important pathophysiological mechanism of NOD.