基于罗马Ⅳ标准的内镜阴性胃灼热患者食管运动和抗反流屏障功能研究

Study on esophageal motility and anti-reflux barrier function in patients with heartburn symptom and negative endoscopic findings based on RomeⅣcriteria

目的评估基于罗马Ⅳ标准分类的不同表型内镜阴性胃灼热患者食管运动和抗反流屏障功能。方法回顾性分析2011年3月至2018年11月有胃灼热症状且内镜阴性的患者136例。联合食管高分辨率压力测定(HRM)、24 h pH值监测和PPI试验,按照罗马Ⅳ标准和新的诊断流程,分为非糜烂性反流病(NERD)组、反流高敏感组、功能性胃灼热组和未分类组;同时选择20名健康志愿者作为健康对照组。分析比较不同组间食管动力类型和食管HRM参数变化。采用单因素方差分析、Kruskal-Wallis H检验和卡方检验进行统计学分析。结果基于罗马Ⅳ标准,NERD组35例,反流高敏感组43例,功能性胃灼热组48例,未分类组10例。在下食管括约肌(LES)长度、呼气末下食管括约肌静息压(LESP)、LESP平均值、4 s完整松弛压力(4 s-IRP)、远端收缩延迟时间(DL)、上食管括约肌静息压残余压(UESRP)、上食管括约肌(UES)松弛至最低点时间、UES恢复时间和食管胃连接部收缩积分(EGJ-CI)方面,NERD组、反流高敏感组、功能性胃灼热组、未分类组间及其与健康对照组间的差异均无统计学意义(P均>0.05);NERD组和未分类组远端收缩积分(DCI)均低于健康对照组[919.7 mmHg·s·cm(411.7,1417.9)mmHg·s·cm(1 mmHg=0.133 kPa)、535.6 mmHg·s·cm(321.4,1513.4)mmHg·s·cm比1322.1 mmHg·s·cm(841.6,1918.5)mmHg·s·cm],差异均有统计学意义(Z=-2.62、-2.20,P=0.01、0.03);未分类组上食管括约肌静息压(UESP)低于健康对照组[57.0 mmHg(31.3,77.8)mmHg比70.4 mmHg(49.4,97.8)mmHg],差异有统计学意义(Z=-2.64,P=0.02);NERD组、反流高敏感组、功能性胃灼热组、未分类组间食管胃连接部(EGJ)分型的差异有统计学意(χ^2=10.85,P=0.02),未分类组EGJⅢ型患者比例最高,其次为NERD组,均高于反流高敏感组和功能性胃灼热组。在食管动力类型方面,NERD组、反流高敏感组、功能性胃灼热组、未分类组间食管动力类型构成的差异无统计学意义(P>0.05)。结论不同表型内镜阴性的胃灼热患者,应遵循罗马Ⅳ标准,按照有效的诊断流程,联合HRM、24 h pH值监测和PPI试验正确分类,特别是对PPI试验有效且pH值监测阴性的未分类患者须进一步评估;采用HRM评估内镜阴性胃灼热患者的抗反流屏障功能存在一定的局限性。

Objective To evaluate esophageal motility and anti-reflux barrier function in patients with different phenotypes of heartburn and negative endoscopic findings based on the RomeⅣcriteria.Methods From March 2011 to November 2018,136 patients with heartburn and negative endoscopic findings were retrospectively analyzed.The patients underwent high-resolution manometry(HRM),24-hour pH monitoring and proton pump inhibitor(PPI)test and according to the RomeⅣcriteria and new diagnostic procedures,they were divided into non-erosive reflux disease(NERD)group,reflux hypersensitivity(RH)group,functional heartburn(FH)group and unclassified group.During the same period,20 healthy volunteers were selected as healthy control group.The changes of esophageal motility and HRM were analyzed among different groups.Statistical analysis was performed using one-way analysis of variance,Kruskal-Wallis H test and chi-square test.Results According to RomeⅣcriteria,35 patients were enrolled into the NERD group,43 patients were enrolled into the RH group,48 patients were included in the FH group,and 10 patients were enrolled into unclassified group.There were no significant differences between the NERD group,the RH group,the FH group,the unclassified group and healthy control group in the length of the lower esophageal sphincter(LES),end lower esophageal sphincter resting pressure(LESP),mean LESP,4-second-integrated relaxation pressure(4 s-IRP),distal latency(DL),upper esophageal sphincter residual pressure(UES-RP),upper esophageal sphincter relaxation time to nadir,upper esophageal sphincter(UES)recovery time and esophagogastric junction contractile integral(EGJ-CI,all P>0.05).The distal contractile integral(DCI)of NERD group and unclassified group were both lower than that of healthy control group(919.7 mmHg·s·cm(411.7,1417.9)mmHg·s·cm(1 mmHg=0.133 kPa),535.6 mmHg·s·cm(321.4,1513.4)mmHg·s·cm vs.1322.1 mmHg·s·cm(841.6,1918.5)mmHg·s·cm),and the differences were statistically significant(Z=-2.62 and-2.20,P=0.01 and 0.03).The upper esophageal sphincter pressure(UESP)of the unclassified group was lower than that of the healthy control group(57.0 mmHg(31.3,77.8)mmHg vs.70.4 mmHg(49.4,97.8)mmHg),and the difference was statistically significant(Z=-2.64,P=0.02).There was significant difference in esophagogastric junction(EGJ)subtypes between the NERD group,the RH group,the FH group and the unclassified group(χ^2=10.85,P=0.02);the proportion of typeⅢpatients was highest in unclassified group,followed by NERD group,which were both higher than those of RH group and FH group.There was no significant difference in the proportion of esophageal motility subtypes between NERD group,RH group,FH group and unclassified group(P>0.05).Conclusions Patients with different phenotypes of heartburn and negative endoscopy finding should be classified by efficient diagnostic procedure according to the RomeⅣcriteria combined with HRM,24-hour pH monitoring and PPI test.The unclassified patients need further evaluation,especially for those with effective PPI test and negative pH monitoring.However,the evaluation of anti-reflux barrier function by the HRM parameters in patients with heartburn and negative endoscopic findings has certain limitations.