胃食管反流病不同亚型食管酸暴露及发病机制的差异

Differences of esophageal acid exposure and pathogenesis for different subtypes of gastroesophageal reflux disease

目的比较反流性食管炎(reflux esophagitis,RE)和非糜烂性反流病(nonerosive reflux disease,NERD)不同亚型食管酸暴露情况,探讨其发病机制的差异。方法 115例具有典型反流症状的患者进行胃镜及24小时食管pH监测。结果①115例中26例(22.6%)为RE,89例(77.4%)为NERD,RE中pH监测阳性率高于NERD92.3%(24/26)vs 74.2%(66/89)(P<0.05),包括DeMeester积分[64.55(128.28)vs 26.60(59.11)]在内的全部pH监测指标均高于NERD(P<0.05或<0.01)。②RE pH监测阳性组(RE+)与NERD pH监测阳性组(NERD+)的24小时pH<4时间百分比[17.6%(38.8%)vs 9.0%(20.3%)],卧位pH<4时间百分比[18.3%(49.3%)vs6.5%(18.4%)],pH<4长于5分钟的次数[15.00(19.00)次vs 5.00(8.25)次]及DeMeester积分[69.70(120.47)分vs 35.58(64.97)分],(P<0.05或<0.01)。③中重度RE包括DeMeester积分[151.70(124.24)分vs 49.93(57.92)分]在内的多项pH监测指标均高于轻度RE(P<0.05或<0.01)。轻度RE多项pH值监测指标的中位数比NERD+高。④NERD pH监测阴性组(NERD-)症状的发生与病理性酸反流无关。结论病理性酸反流是导致RE黏膜损害的主要因素,食管酸暴露程度越重,食管炎症越重。NERD+症状发生与病理性酸反流相关。NERD+和RE可能为同一疾病谱中程度递增的病变。在NERD-组中,内脏高敏感是症状指数(symptom index,SI)阳性组症状发生的主要机制,而SI阴性组症状的发生与酸无关。

Objective To compare the characteristics esophagitis（RE） and non-erosive reflux disease（NERD） and of esophageal acid exposure among subtypes of reflux to explore their pathogenesis. Methods A total of 115 patients with typical reflux symptoms underwent gastroscopy and esophageal pH monitoring. Results （1） 26 cases （22.6%） of 115 patients were RE, the other 89 cases were NERD. The abnormal pH monitoring rate （92.3% vs 74.2%） and all parameters of pH monitoring including DeMeester score （64. 55[128.28] vs 26.60[59.11]） in the RE group were significantly higher than those in the NERD group （ P 〈 0.05 or 〈 0.01）. （2） RE with positive pH monitoring（RE＋） subgroup had more the percentage of time that pH〈4 in 24 hours（17.6%[38.8%] vs 9.0% [20.3%]） ,the percentage of time that pHi4 in recumbent position（18.3%[49.3%] vs 6.5%[18.4%]） ,long reflux episodes（15. 00119.00] times vs 5.00[8.25] times） and DeMeester score（69.70[120.47] marks vs 35.58[64.97] marks） compared to NERD with positive pH monitoring（NERD＋） subgroup（ P〈0.05 or 〈0.01）. （3）The majority of parameters of pH monitoring in the moderate and severe RE were significantly higher than those in the mild（ P 0.05 or 〈0.01）. The medians of most parameters of pH monitoring in the mild RE were higher than those in the NERD＋ subgroup, though without significant difference. （4）Reflux symptoms were unrelated to abnormal acid reflux in the NERD with negative pH monitoring（NERD--） subgroup. Conclusion Abnormal acid reflux is a major factor in the mucosaI injury of RE. The acid exposure of esophagus is heavier, the inflammation is more severe. Reflux symptoms are related to abnormal acid reflux in NERD＋ subgroup. NERD＋ may be a milder form,while RE may be a more severe one in the same spectrum of disease. Visceral hypersensitivity plays a primary role in the pathogenesis of NERD--SI＋ subgroup. Reflux symptoms are unrelated to acid in the NERD- SI- subgroup.