1、胃食管反流病Gastroesophageal Reflux Disease(GERD)讲者：谢艳讲者：谢艳 副教授副教授 博士博士医院：四川大学华西医院医院：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
2、 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 GERDB.Dysphagia is associated with GERD or esophageal cancerC.Symptoms of GERD are usually worse with lying downD.A glass of wine can frequen
3、tly help with the symptoms of GERDWhat is the most common condition associated with GERD?A.SclerodermaB.Type 2 Diabetes MellitusC.PregnancyD.Peptic ulcer diseaseE.HypertensionWhich of the following usually raise the incidence of GERD?A.Cigarette smokingB.AlcoholC.Calcium channel blockersD.Fatty food
4、sE.All of the aboveWhen 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 aboveGERD Defin
5、ition(Gastroesophageal Reflux Disease)A condition which develops when the reflux of stomach contents causes troublesome symptoms or complications.PepsinBilePathogenesis-Anti-Reflux Barrier-Esophageal Contact Time-Gastric contentsAnti-Reflux BarrierTransient LES RelaxationEsophageal Acid Contact1.Imp
6、aired 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%）0.01烧 心66（48%）112
7、（68%）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 bid1-2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
8、,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l难治性GERD评估lGERD诊断有疑问lGERD手术治疗前评估 食管pH/阻抗检测pH 4.0反流lpH 4.0lpH 4.0酸反流停服
9、PPI(off PPI)服用PPI(on PPI)l酸反流:pH7.0 非酸反流 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,EEBarrett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Barr
10、ett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.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
11、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级级:1条或多条粘膜损伤长度不超过条或多条粘膜损伤长度不超过 5 mmLos Angeles Classification B级:至少1处5mm且互不融合 Los Angeles Classification C级级:黏膜破损融合不超过 75%Los Angeles ClassificationD级级:黏膜破损融合超过 75%Complications of GERD-Barretts Esophagus10%的的GERD患者患者食
12、管远端柱状上皮肠上皮化生Barretts 食管食管 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
13、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 阳 性PPI试验 阴 性非糜烂性反流病(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小时食管 pH-阻抗检测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治疗有显效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233-2
14、39页 缓解症状 治愈食管炎 提高生活质量 预防复发和并发症GERDHow is GERD treated?Lifestyle Changes Medications Surgery Endoscopic optionsLifestyle 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
15、 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 RanitidineMagnesium salt can lead to diarrhea,and aluminum salts can cause con
16、stipation胃酸是导致烧心胃酸是导致烧心等症状等症状的关键因素的关键因素Data on file胃食管反流病（胃食管反流病（GERDGERD）症状产生的主要机制症状产生的主要机制：(b)(b)细胞连接细胞连接削弱削弱(c)(c)细胞间隙扩细胞间隙扩大大，更多胃酸更多胃酸和蛋白酶渗入和蛋白酶渗入(d)(d)胃酸胃酸直接接触直接接触神经末梢神经末梢 (e)(e)细胞破细胞破裂，黏膜裂，黏膜损伤损伤（a a）胃酸和胃酸和胃蛋白酶接胃蛋白酶接触食管黏膜触食管黏膜Medications Proton pump inhibitors omeprazole(奥美拉唑)lansoprazole(兰索拉唑
17、)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)GERD TREATMENT ALGORITHMMaintenanceTherapyOn Demand TreatmentBegin PPI andTitrate Up tob.i.d.if NeededFrequentRelapsesOccasionalSymptomsGood ResponseSuboptimal ResponseorInitiate.PPIH
18、eartburnGERD TREATMENT ALGORITHMGood ResponseSuboptimal ResponseBegin PPI and Titrate Up to b.i.d.if NeededMaintenance withLowest EffectiveDose of H2RA orPPI or SurgeryConfirm Diagnosis(24 Hr.pH,Endoscopy)No GERDConsider Other DiagnosisGERDSurgeryNissen FundoplicationEndoscopic view of Nissen Fundop
19、licationComplications 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 injuryOverview Definition Pathophysiology Incidence and Background
20、 Symptoms Other conditions associated with GERD Complications Diagnostic Tests TreatmentWhich 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 reflu
21、x 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 GERDB.Dysphagia is associated with GERD and esophageal cancerC.Symptoms of GERD are usually worse with lying downD.A glass of wine can frequ
22、ently help with the symptoms of GERDWhat is the most common condition associated with GERD?A.SclerodermaB.Type 2 Diabetes MellitusC.PregnancyD.Peptic ulcer diseaseE.HypertensionWhich of the following usually raise the incidence of GERD?A.Cigarette smokingB.AlcoholC.Calcium channel blockersD.Fatty fo
23、odsE.All of the aboveWhen 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 take any more medications.D.All of the aboveReference 内科学 消化系统疾病 中国胃食管反流病共识意见-2014 2013 美国GERD指南 2016亚太共识：胃食管反流病的管理（更新版）Thank you for your attention!
