无效食管动力在非糜烂性反流病中的作用及其与酸暴露的相关性

The role of ineffective esophageal motility in non-erosive reflux disease and its correlation with acid exposure

目的探讨无效食管动力(IEM)在非糜烂性反流病(NERD)诊断中的作用及其与酸暴露的关系。方法回顾性选择2013年3月至2019年5月于吉林大学第一医院行胃镜、食管高分辨率测压(HRM)、24 h pH值监测的具有GERD样症状,且胃镜检查无食管黏膜和结构异常改变的患者,基于罗马Ⅳ诊断标准重新评估,诊断分型为NERD、反流高敏感(RH)、功能性烧心(FH)。分析比较IEM患者食管HRM和酸反流相关参数的变化。统计学方法采用采用独立样本t检验、非参数检验和卡方检验。结果共收集228例患者资料,排除食管胃连接部(EGJ)流出道梗阻和重度食管动力障碍患者37例(8例贲门失弛缓症、9例EGJ流出道梗阻、4例远端食管痉挛、14例无效收缩、2例高收缩食管)、内镜下反流性食管炎53例(洛杉矶分级A级20例、B级15例、C级13例、D级5例)。最终138例患者入组,男60例,女78例,年龄为(50.1±14.1)岁,包括NERD 36例,RH 44例,FH 58例。按照食管HRM芝加哥分类标准将138例患者分为IEM组(46例,其中NERD 15例,RH 12例,FH 19例)和测压正常组(92例,其中NERD 21例,RH 32例,FH 39例)。两组诊断为NERD、RH和FH的患者比例比较,差异无统计学意义(P>0.05)。IEM组下食管括约肌(LES)长度[2.70(2.40,3.00)cm比3.00(2.70,3.20)cm]、LES静息压呼吸平均值[16.55(7.98,22.95)mmHg比19.10(14.15,25.68)mmHg,1 mmHg=0.133 kPa]、远端收缩积分[417.90(279.08,584.45)mmHg·s·cm比1429.40(994.38,1852.80)mmHg·s·cm]和EGJ收缩积分[37.86(26.97,46.78)mmHg·cm比45.19(35.39,58.20)mmHg·cm]均低于测压正常组,差异均有统计学意义(Z=3.33、2.09、8.09、2.90,P均<0.05);两组的呼气末LES静息压、4 s完整松弛压、远端收缩延迟、上食管括约肌(UES)静息压、UES残余压、UES基线松弛时间、UES恢复时间、EGJ分型和食管酸反流相关参数[总酸暴露时间(AET)、立位AET、卧位AET、反流事件和Demeester评分]比较,差异均无统计学意义(P均>0.05)。将36例NERD患者分为IEM组(15例)和测压正常组(21例)。IEM组远端收缩积分低于测压正常组[401.10(276.60,555.60)mmHg·s·cm比1135.00(903.20,1537.65)mmHg·s·cm],差异有统计学意义(Z=3.93,P<0.01);两组的EGJ分型、其他HRM相关参数和酸反流相关参数比较,差异均无统计学意义(P均>0.05)。结论IEM与NERD的诊断无关;表现为IEM的胃镜阴性GERD样症状患者或NERD患者除食管体部动力减弱外,评价抗反流屏障功能的EGJ形态分型与IEM也无关;在NERD患者,IEM与食管酸暴露的关系还需要进一步研究。

Objective To investigate the role of ineffective esophageal motility(IEM)in the diagnosis of non-erosive reflux disease(NERD)and its relationship with acid exposure.Methods From March 2013 to May 2019,in First Hospital Affiliated to Jilin University,patients who underwent gastroendoscopy exam,esophageal high-resolution manometry(HRM),24-h pH monitoring and had gastroesophageal reflux symptoms,and without mucosal or structural abnormal changes under gastroendoscopy were retrospectively selected.Based on RomeⅣcriteria,the patients were reevaluated and the diagnostic types were NERD,reflux hypersensitivity(RH)and functional heartburn(FH).The changes of esophageal HRM metrics and acid reflux-related parameters of patients with IEM were analyzed and compared.Independent sample t-test,nonparametric test and chi-square test were used for statistical analysis.Results The data of 228 patients were collected.Thirty-seven cases with esophageal gastric junction(EGJ)outflow obstruction and severe esophageal motility disorder(8 cases of achalasia,9 cases of EGJ outflow obstruction,4 cases of distal esophageal spasm,14 cases of absent contractility and 2 cases of hypercontractile esophagus)and fifty-three cases with endoscopic reflux esophagitis under endoscopy(20 cases of Los Angeles grade A,15 cases of grade B,13 cases of grade C,and 5 cases of grade D)were excluded.In the end 138 patients were enrolled,including 60 males and 78 females,with a mean age of(50.1±14.1)years,including 36 cases of NERD,44 cases of RH and 58 cases of FH.According to esophageal HRM Chicago classification standard,138 patients with gastroesophageal reflux symptoms were divided into IEM group(46 cases,including 15 cases of NERD,12 cases of RH,and 19 cases of FH)and normal manometry group(92 cases,including 21 cases of NERD,32 cases of RH,and 39 cases of FH).There was no statistically significant difference in the proportion of patients diagnosed as NERD,RH and FH between the two groups(P>0.05).The length of lower esophageal sphincter(LES)(2.70 cm,2.40 to 3.00 cm vs.3.00 cm,2.70 to 3.20 cm),the average value of LES resting breathing pressure(16.55 mmHg,7.98 to 22.95 mmHg vs.19.10 mmHg,14.15 to 25.68 mmHg,1 mmHg=0.133 kPa),the distal contractile integral(DCI)(417.90 mmHg·s·cm,279.08 to 584.45 mmHg·s·cm vs.1429.40 mmHg·s·cm,994.38 to 1852.80 mmHg·s·cm)and EGJ contractile integral(37.86 mmHg·cm,26.97 to 46.78 mmHg·cm vs.45.19 mmHg·cm,35.39 to 58.20 mmHg·cm)of IEM group were all lower than those of normal manometry group,(Z=3.33,2.09,8.09,and 2.90,all P<0.05).There were no statistically significant differences in LES resting pressure at the end of the breath,4 s-intergrated reloxation pressure,distal latency,upper esophageal sphincter(UES)resting pressure(UESP),UES residual pressure,UES baseline relaxation time,UES recovery time,EGJ type,acid reflux related parameters(total acid exposure time(AET),AET in upright position,AET in supine position,and Demeester score)between the two groups(all P>0.05).The 36 NERD patients were divided into IEM group(15 cases)and normal manometry group(21 cases).The distal contractile integral was lower in IEM group than that in normal manometry group(401.10 mmHg·s·cm,276.60 to 555.60 mmHg·s·cm vs.1135.00 mmHg·s·cm,903.20 to 1537.65 mmHg·s·cm),the difference was statistically significant(Z=3.93,P<0.01).There was no statistically significant difference in EGJ type,other HRM parameters or acid reflux-related parameters between IEM group and normal manometry group(all P>0.05).Conclusions IEM is not related with the diagnosis of NERD.In patients with gastroscopy-negative gastroesophageal reflux symptoms or NERD with IEM,except for weakened peristaltic function,the EGJ morphological evaluation of the anti-reflux barrier function has nothing to do with IEM.In NERD patients,the relationship between IEM and acid exposure needs further study.