基于高分辨食管压力测定及阻抗-pH监测的难治性烧心患者食管动力特点

Esophageal motility characteristics of refractory heartburn： a study based on high resolution manometry and 24 hour pH-impedance monitoring

目的 分析不同反流特点的难治性烧心患者食管动力特点,初步阐述食管动力异常在难治性烧心中所起的作用.方法 回顾性分析2009至2013年北京大学第三医院消化科就诊的难治性烧心患者资料,根据胃镜检查及24h阻抗-pH联合监测将患者分为反流性食管炎（RE）组、非糜烂性胃食管反流病（NERD）-酸反流组、NERD-弱酸反流组及非反流烧心组.所有受试者接受食管高分辨率压力测定（HRM）,按照2012年发布的芝加哥分型标准对食管动力障碍进行分析.结果 共纳入难治性烧心患者176例.其中RE组29例,NERD-酸反流组51例,NERD-弱酸反流组51例,非反流烧心组45例.前3组又为胃食管反流病（GERD）组.（1）HRM结果显示,60.23％ （106/176）的难治性烧心患者存在符合芝加哥分型诊断的动力障碍.其中42.61％ （75/176）患者诊断为食管蠕动弱,7.39％ （13/176）呈远端食管痉挛,4.55％ （8/176）为快速收缩,3.98％ （7/176）为流出道梗阻,食管裂孔疝为1.14％ （2/176）,并有1例Jackhammer食管.（2）不同反流特点组患者总体动力障碍检出率近似,且均以食管体部蠕动弱伴蠕动中断最多见,RE组为41.38％ （12/29）,NERD-酸反流组为37.25％ （19/51）,NERD-弱酸反流组为54.90％ （28/51）,非反流烧心组为35.56％（16/45）;非反流烧心组患者高动力障碍总体检出率为31.11％ （14/45）,高于GERD组的11.45％ （15/131） （P＜0.05）.（3）GERD各组下食管括约肌（LES）松弛率高于非反流烧心组,其中NERD-弱酸反流组显著高于非反流烧心组[65％（50％～80％）比58％（42％～67％）,P＜0.05],非反流烧心组患者4秒综合松弛压（IRP4s）较GERD各组略高,但差异无统计学意义（P＞0.05）.结论 食管蠕动弱是难治性烧心尤其是GERD患者中最常见的动力障碍类型,而食管高动力障碍在非反流相关烧心患者中常见.食管动力功能检查有利于难治性烧心患者的诊断分型及进一步治疗.

Objective To analyze the esophageal motility characteristics of refractory heartburn with different reflux patterns and preliminarily clarify the roles of esophageal disorder in refractory heartburn.Methods A total of 176 refractory heartburn patients were enrolled from 2009 to 2013.After gastroscopy and 24 hour pH-impedance monitoring,they were divided into 4 groups of reflux esophagitis （RE,n =29）,non-erosive reflux disease with acid reflux （NERD-acid,n =51）,NERD with weakly acidic reflux （NERD-weakly acid,n =51） and non-reflux associated heartburn （n =45）.All subjects undertake high resolution manometry test and their esophageal motility functions were analyzed by the Chicago classification criteria 2012.Results Among them,60.23％ （106/176） patients presented esophageal motility disorders.And 42.61％ （75/176） fulfilled the criteria of weak peristalsis,7.39％ （13/176） distal esophageal spasm,4.55％ （8/176） rapid contraction,3.98％ （7/176） EGJ outflow obstruction,1.14％ （2/176） hiatus hernia and 1 Jackhammer esophagus.The detection rates of esophageal motility disorder were similar among 4 groups and weak peristalsis was the most common disorder in all groups （41.38％ in RE,37.25％ in NERD-acid patients,54.90％ in NERD-weakly acid and 35.56％ in non-reflux associated heartburn patients）.However,hypertensive motility disorders in non-reflux associated heartburn group （31.11％,14/ 45） were more than GERD subgroups （11.45％,15/131） （P ＜ 0.05）.The relax ratio of low esophagus sphincter （LES） in GERD subgroups were higher than that in non-reflux associated heartburn patients.And the relax ratio of NERD-weakly acid was significantly higher than that in non-reflux associated heartburn patients （65％ （50％-80％） vs 58％ （42％-67％）,P ＜ 0.05）.The integrated relaxation pressure in GERD subgroups were lower than that of non-reflux associated heartburn patients without significant differences （P ＞ 0.05）.Conclusions Esophageal weak peristalsis is one of the most common motility disorders in refractory heartburn patients,and esophageal hypertensive motility disorders are common in nonreflux associated heartburn patients.Esophageal manometry is necessary for the diagnosis and treatment of refractory heartburn.