食管胃接合处流出道梗阻与贲门失弛缓症Ⅱ型患者临床及高分辨食管测压特征比较

Comparison of clinical features and high-resolution esophageal motility characteristics between esophagogastric junction outflow obstruction and type II achalasia patients

目的研究食管胃接合处（EGJ）流出道梗阻和贲门失弛缓症Ⅱ型患者的临床特点及高分辨食管压力一阻抗特征，探讨EGJ流出道梗阻患者高分辨测压对临床诊疗的指导意义。方法纳入2011年12月至2014年12月在北京大学第三医院因吞咽困难就诊并除外食管器质性梗阻的患者以及健康志愿者。所有受试者接受食管高分辨率压力．阻抗测定，依据第二版芝加哥分型纳入诊断EGJ流出道梗阻和贲门失弛缓症的患者。分析各组的临床特征以及食管动力特征。结果共纳入EGJ流出道梗阻患者（Eoo组）23例，贲门失弛缓症Ⅱ型患者（Aeh组）24例，健康对照（Con组）20名，3组性别构成、平均年龄和体质量指数差异均无统计学意义（均P〉0．05）。（1）Eoo组反食、嗳气症状的发生率显著高于Aeh组[21．7％（5／23）比0（0／24），P=0．005；17．4％（4／23）比0（0／24），P=0．013]，而吞咽困难、呕吐的发生率显著低于Ach组[47．8％（11／23）比79．2％（19／24），P=0．025；o（o／23）比12．5％（3／24），P=0．040]，其他症状两组问差异无统计学意义（均P〉0．05）。Eoo组Eckardt评分显著低于Aeh组[1（1，2）比3（2，5）分]（P〈0．001）。（2）Eoo组下食管括约肌（LES）静息压最小值高于Con组[（26．73±2．77）比（17．16±1．76）mmHg，P〈0．05]；Eoo组综合松弛压（IRP）、IRP最大值显著低于Aeh组[（19．80±1．25）比（35．95±2．36）mmHg，（23．22±2．02）比（48．37±3．71）mmHg，均P〈0．05]，且显著高于Con组[（8．43±0．72）、（12．32±1．29）mmHg，均P〈0．05]；Eoo组LES松弛率显著高于Ach组（38．61％±3．10％比12．42％±5．66％），且显著低于Con组（64．00％±3．85％）（均P〈0．05）。（3）Eoo组在食管体部蠕动波速度、蠕动波幅、蠕动波持续时间和食团内压方面与Ach组和Con组比较差异均有统计学意义（均P〈0．05）；Eoo组的无效吞咽百分比、全段食管增压百分比、提前收缩百分比和快速收缩百分比均显著低于Aeh组（均P〈0．05），完整收缩百分比则高于Ach组（P〈0．001），但与Con组比较差异无统计学意义（均P〉0．05）。（4）Eoo组不完全食团清空比、食管传输时间显著低于Ach组[0．00％（0．00％，20．00％）比100．00％（90．00％，100．00％），（5．44±0．29）比（24．13±1．69）s，均P〈0．001]，与Con组[0．00％（0．00％，9．75％），（5．30±0．19）s，均P〉0．05]比较差异无统计学意义。结论Eoo组的临床表现和食管高分辨测压动力的改变介于Ach组和Con组之间，提示EGJ流出道梗阻可能为贲门失弛缓症Ⅱ型的前期改变，进一步研究EGJ流出道梗阻的病理生理特征可能为阐明贲门失弛缓症的发病机制提供更多依据。

Objectives To compare the clinical features and high-resolution esophageal motility- impedance characteristics among esophagogastrie junction outflow obstruction （Eoo） patients, type Ⅱ aehalasia （Ach） patients and healthy controls （Con）, in order to explore the values of esophageal high- resolution manometry （HRM） in diagnosis and treatment of Eoo patients. Methods Patients with dysphagia were enrolled from December 2011 to December 2014 at the outpatient department of Peking University Third Hospital, so were age-matched healthy volunteers. All the patients with organic obstruction were excluded. All the participants were tested with high-resolution esophageal motility-impedance measurement, the patients were diagnosed as Eoo or Ach according to the Chicago classification criteria. Clinical features and esophageal motility characteristics of Eoo, Ach and Con were analyzed. Results A total of 23 Eoo, 24 Ach and 20 Con were enrolled, whose gender ratios, average ages and body mass indexes were of no significant differences（all P〉0.05）. （1） The Eoo group had higher percentage of food reflux[21.7% （5/23） vs 0（0/24）, P =0. 005 ] and belching[ 17.4% （4/23） vs 0 （0/24）, P = 0. 013 ], but lower percentage of dysphagia[47.8% （11/23） vs 79. 2% （19/24）, P =0. 025] and vomiting[0（0/23） vs 12. 5% （3/24）, P = 0. 040 ] compared with the Ach group, with no significant differences in other symptoms （ all P 〉 0. 05 ）. Besides, the Eoo group had lower Eckardt scores than the Ach group [ 1 （ 1, 2） vs 3 （2, 5 ）, P 〈 0. 001 1. （2） The lower esophageal sphincter （LES） basal pressure-minimum in the Eoo was higher than the Con [ （26. 73 ± 2. 77 ） vs （ 17.16 ± 1.76） mmHg, P 〈 0.05 ]. The mean LES basal pressure ; and the LES integrated relaxation pressure （IRP）, IRP-maximum, and LES relaxation percentage were significantly different among Eoo, Ach and Con[ （ 19. 80 ± 1.25） vs （35.95 ±2. 36）, （8.43 ±0. 72） mmHg, both P 〈 0.05; （23.22±2.02） vs （48.37 ±3.71）,（12.32±1.29） mmHg, bothP〈0.05; 38.61% ±3.10% vs 12. 42% ±5.66% ,64. 00% ±3.85% , both P 〈0.05]. （3） There were significant differences in velocity, amplitude, and duration of esophageal peristaltic wave and intrabolus pressure （ all P 〈 0.05 ） among Eoo, Ach and Con; and failed contraction percentage, panesophageal pressurization percentage, premature contraction percentage, and rapid contraction percentage of Eoo were lower than Ach （ all P 〈 0.05 ） while complete contraction percentage of Eoo was high compared with Ach （ P 〈 0. 001 ）, but no significant differences between Eoo and Con. （4） The Eoo had significantly less incomplete bolus clearance [ 0. 00% （0. 00%, 20. 00% ） vs 100. 00% （90. 00%, 100. 00% ）, P 〈 0. 001 ] and shorter bolus transit time [ （5.44 ± 0. 29） s vs （24. 13 ± 1.69） s, P 〈 0. 001 ] than Ach, but there were no significant differences between Eoo and Con in these two indexes[0. 00% （0. 00% ,20. 00% ） vs 0. 00% （0.00%, 9. 75% ） ; （5.44 ±0. 29） s vs （5.30 ± 0. 19） s; both P 〉 0.05 ]. Conclusions The clinical manifestations and esophageal HRM characteristics of Eoo appear to be between Ach and Con, which suggests that Eoo may be an early-stage of Ach. Further study of the pathophysiological characteristics of Eoo patients may provide more evidence to elucidate the pathogenesis of achalasia.