消化系统学习资料胃食管反流病20163八年制课件

胃食管反流病 Gastroesophageal Reflux Disease (GERD) 讲者：谢艳 副教授 博士 医院：四川大学华西医院 Which of the following statements is true? A. GERD is one of the least common conditions affecting the GI system. B. All GERD patients will require medication to control their symptoms. C. 50% of adults experience reflux at least once a month. D. GERD symptoms generally occur before meals. Regarding the symptoms of GERD, which one is false? A. Heartburn is a common manifestation of GERD B. Dysphagia is associated with GERD or esophageal cancer C. Symptoms of GERD are usually worse with lying down D. A glass of wine can frequently help with the symptoms of GERD What is the most common condition associated with GERD? A. Scleroderma B. Type 2 Diabetes Mellitus C. Pregnancy D. Peptic ulcer disease E. Hypertension Which of the following usually raise the incidence of GERD? A. Cigarette smoking B. Alcohol C. Calcium channel blockers D. Fatty foods E. Dr. Places lectures F.All of the above When should a patient consider surgery for GERD? A. Symptoms are unresolved with maximum medical therapy. B. GERD is complicated by hiatus hernia and continues to interfere with quality of life. C. Does not desire or is unable to to take any more medications. D. All of the above GERD Definition (Gastroesophageal Reflux Disease) A condition which develops when the reflux of stomach contents causes troublesome symptoms or complications. -The Montreal definition and classification of GERD -The Montreal definition and classification of GERD 20062006 Pepsin Bile Pathogenesis - Anti-Reflux Barrier - Esophageal Contact Time - Gastric contents Anti-Reflux Barrier Transient LES Relaxation Esophageal Acid Contact 1.Impaired esophageal motility - Dysfunctional peristalsis (aging) - Poor emptying (hiatal hernia) 2. Salivary function - Decreased salivation in sleep - Cigarette use 0.05 咽 痛21（15%）32（19%）0.05 恶 心44（32%）63（38%）0.05 嗳 气55（40%）81（49%）0.05 上腹痛73（53%）90（54%）0.05 胸骨后疼痛84（61%）95（57%）0.05 反 流66（48%）100（60%）4.0 烧心/反流 减轻/消失 提示症状与 酸反流相关 PPI试验方法及作用 烧心/反流 内镜阴性 怀疑NERD 症状减轻 50%以上 PPI试验 阳性 确诊NERD 标准剂量 PPI bid 1-2周 1. 2014 胃食管反流病共识意见草案. 2. Bredenoord AJ, et al. Lancet 2013; 381(9881):1933-1942. PPI试验的敏感性和特异性 奥美拉唑试验对GERD 诊断价值的随机、双盲 、安慰剂对照的多中心 研究： 敏感性为88.1% 特异性为44.4% PPI试验敏感性高，但特异性低 1. Numans ME, et al. Ann intern Med 2004;140:518-27. 2. 许国铭, et al. Chin J Dig 2002; 22:7-10. 食管反流监测是GERD的有效检查方法。未使用质子泵 抑制剂者可选择单纯pH监测，若正在使用质子泵 抑制剂则需加阻抗监测以检测非酸反流。 推荐级别：A+级证据等级：中等质量 食管pH监测 Bravo 胶囊pH探头 pH-阻抗监测 1. 2014 胃食管反流病共识意见草案. 2. Bredenoord AJ, et al. Lancet 2013; 381(9881):1933-1942. 食管反流监测的意义和指征 食管pH监测监测 l难难治性GERD评评估 lGERD诊诊断有疑问问 lGERD手术术治疗疗前评评估 食管pH/阻抗检测检测 pH 7.0 非酸反流 应应用指征 1. Numans ME, et al. Ann intern Med 2004;140:518-27. 2. 许国铭, et al. Chin J Dig 2002; 22:7-10. 胃食管反流病 非糜烂性反流病 non-erosive reflux disease, NERD 糜烂性食管炎 erosive esophagitis, EE Barrett食管 Barretts esophagitis, BE 内镜检查 对具有反流症状的初诊患者建议行内镜检查 推荐级别：A级证据等级：中等质量 胃内容物反流 不适症状 并发症 烧心 反流 糜烂性食管炎 Barrett食管 和/或 pH监测 pH阻抗监测 质子泵抑制剂试验 内镜活检 病史 是GERD典型症状， 但不是特异症状 食管癌/胃癌 消化性溃疡 贲门失弛缓 功能性烧心 明确烧心/反流病因 确定GERD类型 推荐是基于我国内镜检查费用低、普及率高，上消化道肿瘤 发病率高这一现实。 Bredenoord AJ, et al. Lancet 2013; 381(9881):1933-1942. Prompt Upper Endoscopy Is an Appropriate Initial Management in Uninvestigated Chinese Patients with Typical Reflux Symptoms 有典型反流症状尚未经调查者的恰当的初始处理是立即内镜检查 Peng S, et al. Am J Gastroenterol 2010;105:1947-52. 内镜检查正常的患者其检查过程中 不推荐常规进行食管活检 推荐级别：A级证据等级：中等质量 食管活检主要在难治性NERD处理中有作用 内镜正常， 食管活检 NERD与 功能性烧心 鉴别 排除嗜酸性 粒细胞性 食管炎 基底细胞增生乳头延长细胞间隙扩大炎症细胞浸润 轻度嗜酸性粒细胞性食管 炎内镜观察可接近正常 显微镜下见显著的嗜酸性 粒细胞浸润 2014 胃食管反流病共识意见草案. Los Angeles Classification A级: 1条或多条粘膜损伤长度不超过 5 mm Los Angeles Classification B级: 至少1处5mm且互不融合 Los Angeles Classification C级: 黏膜破损融合不超过 75% Los Angeles Classification D级: 黏膜破损融合超过 75% Complications of GERD- Barretts Esophagus 10% 的GERD患者 食 管 远 端 柱 状 上 皮 肠上皮化生 GI Motility online (May 2006)GI Motility online (May 2006) Barretts 食管 Adenocarcinom 食管钡剂造影不推荐为GERD的诊断方法 推荐级别：A+级证据等级：中等质量 弥漫性食管痉挛食管环贲门失弛缓症 评估烧心/反流评估吞咽困难 作用有限，已被 内镜检查替代内镜检查难以替代或难以完全替代 2014 胃食管反流病共识意见草案. 食管测压可了解食管动力状态，用于术前评估， 不能作为GERD的诊断手段。 推荐级别：A+级证据等级：中等质量 l 贲门失弛缓症 l 硬皮病样食管 抗反流手术前 必须排除 可以表现为GERD 食管测压有 诊断作用 食管pH监测前的定位 胃内容物反流 监测反流 不适症状 并发症 烧心 反流 询问症状 糜烂性食管炎 Barrett食管 内镜检查 和/或 GERD诊断中不需要食管压力参数 2014 胃食管反流病共识意见草案. 胃食管反流病诊断和鉴别诊断流程 烧心/反流 内镜检查 糜烂性食管炎 /Barrett食管 内镜阴性 PPI试验试验 阳 性 PPI试验试验 阴 性 非糜烂烂性反 流病(NERD) 其他器质 性疾病 食管癌 胃癌 l功能性烧心 l其它 非酸反流 胃食管 反流病 24小时时食管 pH-阻抗检测检测 l消化不良 l体检 消化性 溃疡 是GERD典型症状， 但不是特异症状 糜烂性食管炎 /Barrett食管可 无典型症状或 甚至无症状 检查费用/ 可获得性不一 烧心/反流者中 如不内镜检查 存在漏检风险 PPI治疗疗 有显显效 Treatment 中国胃食管反流病共识意见. 胃肠病学2007年 第12卷第4期第233-239页 GERD How is GERD treated? Lifestyle Changes Medications Surgery Endoscopic options Lifestyle Changes If you smoke, stop Do not drink alcohol Lose weight if needed Eat small meals Wear loose-fitting clothes Avoid lying down for 3 hours after a meal Raise the head of your bed 6 to 8 inches by putting blocks of wood under the bedposts-just using extra pillows will not help. Medications Antacids: Aluminium hydroxide Hydrotalcite(达喜) Pepto-Bismol Rolaids H2 blockers Cimetidine Famotidine Nizatidine Ranitidine Magnesium salt can lead to diarrhea, and aluminum salts can cause constipation Medications Proton pump inhibitors omeprazole (奥美拉唑) lansoprazole (兰索拉唑) pantoprazole (泮托拉唑) rabeprazole (雷贝拉唑) esomeprazole (埃索美拉唑) Prokinetics Mosapride(莫沙必利) Metoclopramide (胃复安) Domperidone (吗丁啉) 胃酸是导致烧心等症状的关键因素 Data on file 胃食管反流病（GERD）症状产生的主要机制： (b)细胞连接 削弱 (c)细胞间隙扩 大，更多胃酸 和蛋白酶渗入 (d) 胃酸 直接接触 神经末梢 (e)细胞破 裂，黏膜 损伤 （a）胃酸和 胃蛋白酶接 触食管黏膜 Efficacy of proton pump inhibitors in decreasing intragastric pH. Therapy% Time pH 4.0aNo. Hours pH 4.0bMean pH Esomeprazole, 40 mg Rabeprazole, 20 mg Omeprazole, 20 mg Lansoprazole, 30 mg Pantoprazole, 40 mg 58.43 50.53 49.16 47.98 41.94 14.0 12.1 11.8 11.5 10.1 4.04 3.70 3.54 3.56 3.33 a Percentage of time that intragastric pH was 4.0. b Mean 24-h intragastric pH on day 5 by treatment group (n = 34). Miner P Jr, Katz PO, Chen Y, et al. Gastric acid control with esomeprazole, lansoprazole, omeprazole, pantoprazole, and rabeprazole: a five-way crossover study. Am J Gastroenterol. 2003;98:2616-2620. GERD TREATMENT ALGORITHM Maintenance Therapy On Demand Treatment Begin PPI and Titrate Up to b.i.d. if Needed Frequent Relapses Occasional Symptoms Good ResponseSuboptimal Response or Initiate b.i.d. H2RA Heartburn GERD TREATMENT ALGORITHM Good ResponseSuboptimal Response Begin PPI and Titrate Up to b.i.d. if Needed Maintenance with Lowest Effective Dose of H2RA or PPI or Surgery Confirm Diagnosis (24 Hr. pH, Endoscopy) No GERD Consider Other Diagnosis GERD Surgery Nissen Fundoplication Endoscopic view of Nissen Fundoplication Complications of Surgery Injury to an abdominal organ or to the bowel, stomach, or esophagus Bleeding Failure to completely relieve reflux symptoms Difficulty swallowing Inability to vomit Diarrhea Distended abdomen Vagus nerve injury Overview Definition Pathophysiology Incidence and Background Symptoms Other conditions associated with GERD Complications Diagnostic Tests Treatment Which of the following statements is true? A. GERD is one of the least common conditions affecting the GI system. B. All GERD patients will require medication to control their symptoms. C. 50% of adults experience reflux at least once a month. D. GERD symptoms generally occur before meals. Regarding the symptoms of GERD, which one is false? A. Heartburn is a common manifestation of GERD B. Dysphagia is associated with GERD and esoph