胃食管反流病 .ppt

1、Gastroesophageal Reflux Disease (GERD),Prof. He Song Department of Gastroenterology and Hepatology The 2nd Affiliated Hospital of Chongqing Medical University,1.Background and definition,GERD Normal antireflux mechanism fails to protect against frequent and abnormal amounts of gastroesophageal reflu

2、x (GER), followed with reflux symptoms GER vs GERD Effortless movement of gastric contents from stomach to esophagus Normal physiological process, without reflux symptoms and damage signs of esophageal mucosa RE (reflux esophagitis）vs NERD（non-erosive reflux disease ) Visible mucosal injury at endos

3、copy in RE Abnormal mucosal structure at microscopy in NERD,Epidemiology,Its prevalence differs depending on the methods of analysis Based on reflux symptoms-Heartburn: Western countries 44%; China 9% Based on endoscopy examination-RE: Western countries 3-4%; China 2%,2.Pathophysiology,Imbalance bet

4、ween defensive factors protecting esophagus and aggressive factors from stomach contents Defensive factors: Antireflux barriers: Lower esophageal sphincter (LES), diaphragmatic crura, phrenoesophageal ligaments, sharp angle of His Esophageal acid clearance Volume clearance: esophageal peristalsis Ac

5、id clearance: saliva (weak basic salt) Tissue resistance Mucosa integrity,Mechanisms of reflux damage,Disorders of antireflux barriers Decreased esophageal acid clearance Decreased tissue resistance Increased gastric aggressive factors Associated conditions,Disorders of antireflux barriers Over freq

6、uent relaxations of LES Transient LES relaxations: 50-80% of episodes in GERD Swallow-induced LES relaxations: 5-10% of episodes in GERD Hypotensive LES pressure Uncommon and found in severe esophagitis Abnormal or destroyed GE junction: Esophageal hiatus hernia,Decreased esophageal acid clearance V

7、olume clearance: disorder of esophageal peristalsis Acid clearance: abnormal secretion of salivary and esophageal gland Decreased tissue resistance,Increased gastric aggressive factors Abnormal gastric acid secretion Duodeno-gastric-esophageal reflux Delayed gastric emptying Associated conditions Pr

8、egnancy Scleroderma Zollinger-Ellison syndrome Nasogastric tube intubation,3.Clinical manifestations,Classical reflux symptoms Extraesophageal manifestations Symptoms caused by complications,Classical reflux symptoms,Heartburn: most common Regurgitation: most common Dysphagia(吞咽困难) Water brash（反酸） O

9、dynophagia（吞咽疼痛）,Heartburn: most common Burning feeling, rising from stomach or lower chest and radiating to neck, throat, or back After large meal, spicy foods, citrus products, fats, chocolates, alcohol After recumbency and bending over Nighttime heartburn interferes with restful sleeping High spe

10、cificity and low sensitivity for diagnosis Regurgitation Feeling of effortless regurgitation of acid fliud,Dysphagia Feeling of difficult swallowing In the setting of longstanding heartburn Without weight loss and having good appetite Water brash Sudden appearance of a sour or salt fluid in the mout

11、h Not regurgitated acid fluid but secretions from salivary glands in response to acid reflux Odynophagia Pain on swallowing,Extraesophageal manifestations,Chest pain: noncardiac but GER-related Asthma and other pulmonary diseases Ear, nose, and throat diseases,Symptoms caused by complications,Hemorr

12、hage and perforation: Rare for hemorrhage: 7-18% in GERD Very rare for perforation Peptic esophageal strictures: 7-23% in untreated RE, especially in older men Related to long-term use of NSAIDs,Barrett esophagus（BE） Squamous epithelium of distal esophagus is replaced by specialized columnar epithel

13、ium resembling that of intestine and containing goblet cells. Classical or long-segment BE: Definite increased risk with becoming adeno-carcinoma Resulting from long-time reflux, most 10 ys. It is not uncommon, 10-15% in GERD. 25% of BE have no esophageal symptoms. Suspected at endoscopy and confirm

14、ed by biopsy and histological examination.,4.Diagnostic evaluation,Diagnosis can be determined based on reflux symptoms Classical symptoms of heartburn and acid regurgitation are sufficiently specific to identify reflux disease and to begin medical treatment Many further tests are available, but are

15、 often unnecessary Clinician must choose which test to use to arrive at a definite diagnosis and exclude other diseases,Tests for diagnostic evaluation,Empiric trial of acid suppression Endoscopy and esophageal biopsy Esophageal pH monitoring Esophageal manometry Barium esophagram,Empiric trial of a

16、cid suppression,The simplest and most definitive method for diagnosing GERD and has cause-and-effect relationship The first choice for patients with classical or atypical reflux symptoms without “alarm” complaints PPIs drugs trail within 7-14 days,Endoscopy and Esophageal biopsy,Upper endoscopy is c

17、urrent standard for diagnosing esophagitis and evaluating its extent and excluding other esophageal diseases 40-60% have endoscopic evidence of esophagitis Multiple classification systems to evaluate RE Los Angeles systems,Esophageal pH monitoring,Standard for establishing pathological reflux Perfor

18、med with a pH probe positioned 5 cm above LES and monitoring for 18-24 hrs Reflux episodes are detected by a pH drop below 4.0 The percentage of total time that the pH is below 4.0: upper limits of normal ranging from 4-5.5%,Esophageal manometry,Accurately assess LES pressure and relaxation An integ

19、ral component of pH testing to define the location of LES,Barium esophagram,Most useful in assessing esophageal narrowing and hiatus hernia Prone or low head and high leg position helps to assess esophagus peristalsis and identifying a weak esophageal pump Spontaneous reflux of barium into proximal

20、esophagus suggests GER but not frequent,5.Medical and surgical therapy,Rationale and goals of GERD treatment : Depending on whether with esophagitis or not With esophagitis: relieve symptoms, heal esophagitis, preventing relapses and complications Without esophagitis: relieve symptoms and preventing

21、 relapses,Therapy methods,Nonprescription therapy Prescription medicine therapy Treatment of complications Antireflux surgery or endoscpic therapy,Nonprescription therapy,Lifestyle modifications Weight loss Dietary therapy Avoiding some kinds of drugs,Lifestyle modifications: Elevating head of bed:

22、12-16cm high Refraining from lying down after meals:1hr Avoiding evening snacks before bedtime:2-3hrs Restriction of alcohol and smoking Weight loss: Reducing 10% of weight for overweight Dietary therapy: Reducing size of meal Reducing fats, carminatives, chocolate, coffee, tea Avoiding some drugs N

23、itroglycerin, nifedipine, aminophyline etc.,Prescription medicine therapy,Acid-suppressive drugs Prokinetic agents Course arrangement of treatment,Acid-suppressive drugs,Proton pump inhibitors (PPIs) Inhibit daytime, nocturnal, and meal-induced acid secretion Taken before meal Drugs: omeprazole, lansoprazole, rabeprazole, pantoprazole, esomeprazole Histamine type 2 receptor antago