胃食管反流性咳嗽患者的食管功能及意义

Changes and implications of esophageal function in patients with chronic cough induced by gastroesophageal reflux

目的 观察胃食管反流性咳嗽患者的食管功能,探讨其临床意义.方法 选取2012年1月至2015年8月在同济大学附属同济医院确诊的135例胃食管反流性咳嗽患者（咳嗽组）,其中酸反流引起者81例,非酸反流引起者54例,标准抗反流治疗有效者88例,需要强化抗反流治疗者47例.所有患者通过食管压力检测系统测量食管下括约肌压力、长度和松弛率、食管蠕动收缩波幅、蠕动波传导速度和食管收缩时间,结合多通道食管阻抗-pH监测结果分析酸和非酸胃食管反流性咳嗽食管功能的变化差异以及对抗反流治疗反应的影响,并与26例无咳嗽的胃食管反流患者（非咳嗽组）和22名健康志愿者（对照组）相比较.结果 咳嗽组食管下括约肌压力为（11±5）mmHg（1 mmHg=0.133 kPa）,低于对照组的（15±5） mmHg（q=3.70,P=0.000）;长度为（2.2±0.5）cm,较对照组的（3.0±1.0）cm短（q=2.78,P=0.017）;但松弛率两组比较差异无统计学意义（q=1.14,P =0.258）.此外,咳嗽组的食管蠕动收缩波幅为（33±13） mmHg,小于对照组的（45±11） mmHg（q=2.19,P=0.030）;蠕动波传导速度为（2.6±0.8）cm/s,低于对照组的（3.4±0.6）cm/s（q=2.91,P =0.010）;收缩时间为（4.9±2.2）s,较对照组的（3.1±0.8）s延长（q=3.25,P=0.001）;食管蠕动波传导速度和食团清除时间存在线性负相关（r=-0.603,P=0.000）.但与非咳嗽组间差异无统计学意义（均P ＞0.05）.酸和非酸胃食管反流性咳嗽患者间的各项食管功能指标也相似,多通道食管阻抗-pH监测仅反映反流物性质的指标两者有所不同.标准抗反流治疗有效者的食管蠕动波传导速度为（2.2 ±0.6）cm/s,明显低于需要强化抗反流治疗者的（3.0±1.0） cm/s（t =2.066,P=0.041）.结论 胃食管反流性咳嗽存在食管功能障碍,其程度与反流类型无关,但可影响药物抗反流治疗的效果.

Objective To explore the changes in the esophageal function and their association with the therapeutic outcome in patients with gastroesophageal reflux-induced chronic cough （GERC）.Methods One hundred thirty-five patients with definite GERC consecutively referred to our respiratory clinic were recruited into the study between January 2012 and August 2015.Cough was due to acid reflux in 81 patients and non-acid reflux in 54 patients,with the favorable response to the standard antireflux therapy in 88 patients and to the intensified antireflux treatment in 47 patients.The control groups included 26 patients with gastroesphageal reflux disease without cough and 22 healthy volunteers.All the subjects underwent an esophageal manometry from which the parameters were recorded,including the pressure,length and relaxation rate of lower esophageal sphincter,and the peristaltic contractive amplitude,wave velocity and contractive time of esophagus.The data were combined with the results of multi-channel intraluminal impedance combined with pH monitoring to analyze the changes of esophageal function in the patients with acid or non-acid GERC and their relation to the outcomes of antireflux therapy.Results Compared withhealthy volunteers,patients with GERC presented with a lower pressure [（11 ± 5） mmHg vs （15 ± 5）mmHg （1 mmHg =0.133 kPa）,q =3.70,P =0.000],shorter overall length [（2.2 ±0.5） cm vs （3.0 ±1.0） cm,q =2.78,P =0.017] and similar relaxation rate of lower esophageal sphincter（q =1.14,P =0.258）.Furthermore,they also showed a decrease in esophageal peristaltic contractive amplitude [（33 ±13） mmHgvs （45±11） mmHg,q=2.19,P=0.030] and wave velocity [（2.6±0.8） cm/s vs （3.4±0.6） cm/s,q =2.91,P =0.010] but an increase in esophageal contractive time of esophagus [（4.9 ±2.2） s vs （3.1 ± 0.8） s,q =3.25,P =0.001] in addition to a linear negative correlation between esophageal peristaltic wave velocity and bolus clearance （r =-0.603,P =0.000）.However,these parameters were not different between patients with GERC and gastroesophageal reflux disease without cough.The patients with GERC due to acid and non-acid reflux presented with a similar esophageal dysmotility but different variables reflecting the acidity of refluxates as indicated by multi-channel intraluminal impedance combined with pH monitoring.The esophageal peristaltic wave velocity was significantly lower in the patients with GERC responsive to the standard antireflux therapy than in those responsive to the intensified antireflux therapy [（2.2±0.6） cm/s vs （3.0±1.0） cm/s,t=2.066,P=0.041].Conclusions Esophageal dysfunction is present in patients with GERC.Its characteristics and severity are not associated with the types of gastroesophageal reflux inducing cough,but may predict the efficacy of medical antireflux therapy.