基于24h pH-阻抗监测的难治性胃食管反流病的病理生理分型研究

The study on the pathophysiological typing based on 24 hours pH-impedance monitoring in patients with refractory gastroesophageal reflux disease

目的建立基于24 h p H-阻抗监测的质子泵抑制剂(PPI)难治性胃食管反流病(refractory gastroesophageal reflux disease,r GERD)的病理生理分型。方法采用荷兰MMS公司开发的24 h食管多通道腔内阻抗-p H监测(multichannel intraluminal impedance-p H,MII-p H)对武警总医院GERD专病门诊2013年1月-2013年12月确诊的46例r GERD患者进行监测,并与同期就诊的50例非r GERD患者比较。根据反流参数和症状指数(symptom index,SI,≥50%为阳性),r GERD患者分为反流相关和非反流相关者。根据反流物的酸度,将反流相关者分为酸反流(p H≤4)、弱酸反流(4<p H<7)和弱碱反流(p H≥7)。结果 MII-p H监测发现,与非r GERD组相比,r GERD组患者总反流次数[76(52,114)vs 54(32,63),P=0.005]和弱酸反流次数[43(21,63)vs 22(11,34),P=0.009]均显著增多。r GERD组患者气体反流次数[37(19,52)vs 22(16,31),P=0.021]和气液混合反流次数[53(37,72)vs28(21,40),P=0.001]均显著增多。在r GERD患者记录到的1 287次液体反流中,84.6%为非酸性,15.4%为酸性;2 865次气液混合反流中73.5%为非酸性,26.5%为酸性。其中82.6%(38/46)症状与反流相关,17.4%(8/46)症状与反流无关,诊断为功能性烧心(functional heartburn,FH)。根据反流物的酸度,症状反流相关的r GERD中弱酸反流者占57.9%。与FH患者相比,r GERD患者的酸反流、弱酸反流、弱碱反流、液体反流和气液混合反流次数均增高(P均<0.05)。结论 r GERD是一种异质性疾病,MII-p H监测确定的病理生理分型包括症状反流相关因素,如残余酸反流、非酸反流、食管高敏感状态等;与症状反流无关因素,如FH等。

Objective To establish the pathophysiological typing of the patients with proton pump inhibitor （PPI）- refractory gastroesophageal reflux disease （rGERD） based on 24 hours multichannel intraluminal impedance-pH （MII- pH）. Methods MII-pH monitoring was done in 46 rGERD patients, 50 non-rGERD patients from Jan. 2013 to Dec. 2013 in the GERD clinical of General Hospital of Chinese People＇ s Armed Police Forces. The MII-pH results of both rGERD patients and non-rGERD were analyzed. According to reflux parameters and symptoms index （SI ≥ 50% posi- tive） , rGERD patients were divided into reflux stakeholders and non-reflux stakeholders. Based on acidity of refluxate, reflux stakeholders divided into acid reflux （pH ≤ 4） , weakly acidic reflux （4 〈 pH 〈 7） and weakly alkaline reflux （pH 〉17）. Results MII-pH monitoring showed that, compared with non-rGERD group, total reflux episodes [76 （52, 114） vs 54（32, 63） , P =0.005] and weakly acidic reflux episodes [43（21, 63） vs 22（11, 34） , P =0.0091 in rG- ERD patients were markedly higher. In rGERD patients, among 1 287 liquid reflux episodes recorded, 84.6% was non- acid and 15.4% was acid reflux; in 2 865 gas-liquid mixing reflux episodes, 73.5% was non-acid and 26.5% was acid reflux. Further analysis found that 3~ cases （g2. 6% ） with rGERD belonged to reflux stakeholders, and g cases （17.4%） were non-reflux stakeholders, diagnosed as functional heartburn （FH）. According to acidity of refluxate, 57.9% was weakly acidic reflux in reflux stakeholders. All mentioned-above reflux parameters in rGERD patients were higher than those in FH patients （all P 〈 0.05）. Conclusion rGERD is a heterogeneous disease, in which pathophysi- ological typing include reflux-related factors （such as residual acid reflux, non-acid reflux, esophageal hypersensitivity） and non-related factors （such as FH）.