周晓初
主任医师
科室主任
中医外科田恒宇
主任医师 副教授
3.7
中医外科蒋基令
主任医师 教授
3.6
中医外科韩炳生
主任医师 教授
3.3
中医外科赵江宁
副主任医师 讲师
3.2
中医外科李侁
医师 研究员
3.2
中医外科曾小粤
主任医师
3.2
中医外科陈洁生
主任医师
3.2
中医外科张宇光
主任医师
3.2
中医外科林欢荣
副主任医师
3.2
黄诚
副主任医师
3.2
中医外科马旭
副主任医师
3.2
中医外科姚良权
副主任医师 副教授
3.2
中医外科黎芳
主治医师 讲师
3.2
中医外科赵江宁
副主任医师
3.2
肝胆外科曾庆腾
主治医师
3.1
中医外科王亚威
主治医师
3.1
中医外科尹霖
医师
3.1
2016-09-14 火箭军总医院 马松胃食管反流病医患联盟 一、胃镜: 1)检查项目介绍:胃镜检查可以观察的范围有咽喉、食道、贲门、胃底、胃体、胃窦、十二指肠球部、十二指肠降部及十二指肠乳头;因此可以明确患者是否存在以下病变:咽喉炎、反流性食管炎、Barrett食管、食管癌、贲门口有无松弛、有无食管裂孔疝、胃炎(可以明确胃炎的严重程度,同时取活检明确有无萎缩性胃炎、有无肠化、有无不典型增生、有无癌变等,也可以同时取活检检查有无幽门螺杆菌感染)、有无胃溃疡、有无胃息肉、有无胆汁反流及有无十二指肠炎、十二指肠溃疡等病变。 2)推荐检查的对象:所有患者,胃镜检查分常规胃镜和无痛胃镜。 3)检查前注意事项:当天早晨需空腹(有吞咽困难的患者需禁食时间稍长),而且在做胃镜之前还需完善传染病(乙肝、丙肝、梅毒、艾滋)的化验,如口服由抗凝药,能否停服需咨询大夫,做无痛胃镜还需要行心电图检查和抽血化验肝功能。 二、上消化道造影(俗称:钡餐造影): 1)检查项目介绍:此项检查可以明确食道(无短食管、食管憩室、食道有无扩张或扭曲、食道有无狭窄、食道排空的快慢、贲门有无狭窄)、胃(可以明确有无胃下垂、胃动力、胃排空情况)、幽门、十二指肠(有无狭窄、扩张、排出是否顺畅,排除肠系膜上动脉压迫综合征)等病变。 2)推荐检查的对象:存在吞咽不顺畅、腹胀、呕吐症状的患者。 3)检查前注意事项:检查当天需空腹(有吞咽困难的患者需禁食时间稍长); 三、食道高分辨率测压: 1)检查项目介绍:此项检查可以明确食管动力、食管扩约肌压力、有无食管裂孔疝等。对有吞咽困难的患者可以明确吞咽困难的原因(以明确是否为贲门失弛缓症及类型、有无结蹄组织病的可能); 2)推荐检查的对象:所有患者,特别是存在吞咽、胸痛的患者; 3)检查前注意事项:检查当天需空腹(有吞咽困难的患者需禁食时间稍长),检查前需停止服用促进胃肠动力的药物和抑酸药一周左右。 四、食管测酸(食管PH-阻抗监测): 1)检查项目介绍:此项检查可以明确食管有无胃酸反流及反流的次数和严重程度, 不但可以明确是酸反流还是碱反流,并且还可以明确是气体反流还是液体反流,以及反流事件的发生与难受症状的相关性。 2)推荐检查的对象:所有患者,特别是存在烧心、胸痛、咳嗽、哮喘的患者以及服用抗反流药物效果不佳的患者。 3)检查前注意事项:检查前建议停服抗反流药物(抑酸药、促动力药及胃粘膜保护剂)1-2周以上;检查当天早晨需空腹,检查完成后可正常进食;而且之前还需完善传染病(乙肝、丙肝、梅毒、艾滋)的化验。 五、咽喉反流监测: 1)检查项目介绍:可以明确是否存在胃-食管-咽喉病理性酸反流。 2)推荐检查的对象:存在咽喉部症状(如咽痒、咳嗽、喉痉挛、咽部异物感、声音嘶哑等)的患者。 3)检查前注意事项:检查前建议停服抗反流药物(抑酸药、促动力药及胃粘膜保护剂)1-2周以上;检查当天早晨需空腹,检查完成后可正常进食;而且之前还需完善传染病(乙肝、丙肝、梅毒、艾滋)的化验。 检查当天早晨需空腹,检查做好后可正常进食;而且之前还需完善传染病(乙肝、丙肝、梅毒、艾滋)的化验。 六、胃蛋白酶检测: 1)检查项目介绍:胃蛋白酶大量存在于胃内,如在唾液、痰液及鼻部、耳部、鼻泪管等部位分泌物中检测到超过一定浓度的胃蛋白酶,均提示存在胃食管反流病。 2)推荐检查的对象:存在咽喉部症状(如咽痒、咳嗽、喉痉挛、咽部异物感、声音嘶哑等)、口腔症状、耳部症状、鼻部症状以及眼部症状的患者。 七、其他检查: 根据患者不同症状,有时候还可以行以下检查: 1)心电图、冠脉CTA、冠脉造影、心脏超声检查以排除心血管疾病; 2)行胸部CT、肺功能检查以排除胸部、肺部疾病; 3)行腹腔CT、超声以及血管CTA检查,以排除肝胆胰疾病或血管疾病; 4)焦虑、抑郁量表评估; 5)颈椎、胸椎相关影像学检查。 八、备注: 1.检查结果阴性怎么办? 建议可以行药物诊断性治疗,需足量、足量程,讲究个体化、全面治疗,我们可以给您一个最合理的建议。 2.饮食控制不容忽视 需注意少食多餐原则,避免暴饮暴食,避免睡前进食;忌烟酒、浓茶、浓咖啡;避免进食辛辣刺激食物和生、冷及不易消化的食物;进食蔬菜、水果和适当饮水十分必要,保持大便通畅和愉快的心情,适当体育锻炼均十分重要。 【汪忠镐院士领衔,吴继敏教授精英团队】 【人物】吴继敏: 吴继敏,火箭军总医院胃食管反流病科主任,主任医师,硕士研究生导师。兼任中华医学会消化病分会食管疾病协作组委员,中国医师协会外科分会疝和腹壁外科医师委员会委员,中华胃食管反流病电子杂志副主编,多家医学杂志编委。专注于胃食管反流及相关疾病的研究,参与组建国内首家胃食管反流病科,擅长腹腔镜下食管裂孔疝修补及胃底折叠术、腹腔镜heller括约肌切开术治疗贲门失弛缓症及其它腹腔镜手术,还擅长胃镜下Stretta射频治疗胃食管反流病。特别在腹腔镜抗反流手术方面积累丰富的经验,行腹腔镜胃底折叠手术2400余例,病例数居国内首位,形成规模化和专科化效应,并形成一整套针对各种类型反流采取的综合治疗模式。获军队医疗成果二等奖一项,三等奖多项。 好大夫网站(提供加号):http://wujimin.haodf.com 医院官网:http://www.hjjzyy.cn/Html/Departments/Main/Index_275.html 火箭军总医院胃食管反流病科联系方式: 咨询台:010-66343428(周一至周五上班时间) 门诊时间:专病门诊周一至周五全天,吴继敏专家门诊周一、周四上午 中心网站:http://gerd.haodf.com 中心地址:北京西城区新街口外大街16号 如果您觉得此文好,请分享到您的朋友圈,让您的朋友都可以来学习和交流。
意大利帕多瓦大学Edoardo?V.?Savarino教授 胃食管反流病(GERD)是西方国家中最常见的慢性胃肠道疾病之一,该病因广泛流行、临床表现变化多样、尚未被识别的发病率以及巨大的经济花费而引起广泛关注。抗分泌治疗,尤其是质子泵抑制剂(PPIs)是目前治疗的主要方式,因为这类药物在消除反流症状、治疗食管黏膜损伤方面效果明显。目前,有GERD症状(如烧心和/或反流)的患者首先接受4~8周的PPI试验性治疗,治疗期间,患者必须在早餐前服用PPI药物。若患者对治疗无反应(见于高达40%的患者),医生需首先确认患者的依从性,核实患者是在推荐时间服用了恰当的PPI剂量,然后更换为第二代PPI进行治疗,或者将PPI服用频率改为每日2次。如果症状仍然存在,并且不存在报警症状(否则须强制行内镜检查),这种情况下有必要进行诊断检查。 事实上,当GERD患者对内科药物治疗(8~12周PPI治疗每日1次或2次)或外科治疗无效时,或者怀疑存在并发症(难治性糜烂性食管炎、食管狭窄、Barrett食管)时,或者考虑改变治疗方案之前必须进行确诊时,必须进行诊断评价。然而,记录GERD患者反流的作用可能是一个挑战。事实上,内镜检查有一定的局限性,因为大部分患者镜下的表现是正常的。而且,上消化道内镜检查时食管活检的组织学评估还有一些弊端。因此,大多数情况下,我们主要致力于发现异常的胃食管反流。 2014年,应用于临床实践的发现胃食管反流证据的技术主要有两种:无线pH测量法和联合阻抗pH测量法。 Bravo pH监测系统使用一个无线电遥测的pH传感胶囊,行上消化道内镜检查时可以将此胶囊放置于食管远端黏膜处,一般放置于鳞柱状上皮交界以上6cm处(不使用经鼻内镜时放置在9cm处)。这个胶囊是椭圆形的,长度为25mm,可以测量pH变化,通过射频信号将数据传递到夹在患者腰带的接收器上,接收器大小与传呼机一样。多项对照试验研究已经证实了这种无导管的无线电pH电极可用于测量食管酸暴露。这种监测系统的主要优势在于,相较与导管pH测量法患者的耐受性更好,这种方法也增加了将胶囊固定于不同位置的可能。然而,此法也有许多弊端。单一传感器可能会将吞咽事件也进行测量从而导致对反流的评价过度,胶囊过早脱落也会引起监测结果变化,需要重复放置。而且,对于主诉有严重胸痛(5%),吞咽痛,或者胶囊无法脱落的患者需要行额外的内镜检查。因此,无线电pH监测系统是一种经过验证的可作为导管pH监测法的替代方法,对于不能耐受导管放置的患者或者需要长期进行pH监测的患者(例如症状一整天较少发作的患者,像非心源性胸痛)来说可能是十分有用的。 联合多通道腔内电阻抗及pH(MII-pH)通过测量与导管伴行的电阻抗的方向(逆行食团运动)和范围(食管下端括约肌以上至多17cm)变化检测反流,从而根据相关的pH变化来判定反流属于酸性(pH4.0)。与电阻抗监测系统相比,利用导管法测pH弊端很大。主要表现在电阻抗检测非酸性反流方面。因此,随着这项技术的应用,临床医生可以将更多的反流症状与反流事件相关联。这将会提高GERD的诊断率,单一pH测量会导致GERD的过低评估和功能性烧心的过度评估。但是,这种测量方法也有缺点。反流事件精确度的确认需要人工分析,因此这种技术比传统的全自动化pH测试需要花费更多时间。而且,在糜烂性食管炎,或者Barrett’s食管,或者重度动力异常疾病中,往往出现低基线电阻抗,会使电阻抗-pH追踪的分析更加费力。最后,将反流症状与反流事件关联起来的实际指数(症状指数SI和症状相关可能性SAP)有许多局限性,需要以后的结果对照研究来明确它们的效用。尽管存在这些缺点,MII-pH监测系统目前被认为是检测反流事件和评价难治性GERD内科或外科治疗效果的金标准。 反流监测能够进一步描述难治性患者的特性,因为研究可能会发现: PPI治疗失败,酸反流持续存在时,需要升级治疗或手术来控制胃酸反流。 酸性反流已被充分控制,但是非酸性反流症状仍持续存在时,需要求助于特异治疗(短效食管下端括约肌松弛抑制剂、手术、选择性5-羟色胺再摄取抑制剂或5-羟色胺-去甲肾上腺素再摄取抑制剂等抗抑郁药)。 根本无反流存在。在难治性GERD患者中,反流监测系统显示阴性,这些患者的烧心症状被归类为“功能性烧心”,那些食管外的症状(哮喘、咳嗽、喉炎)需要额外的或重复的诊断检查来明确非GERD病因(肺部、过敏、耳鼻喉)。 有两点需要考虑:①反流监测应在PPI治疗时或非治疗时实施;②应用什么技术(导管pH监测、无线电pH监测、电阻抗pH监测)。未治疗时进行反流监测可以应用任何可行的技术(无线电或电阻抗pH)。如果检测结果为阴性(食管远端酸暴露正常,阴性症状-反流相关性),患者很有可能不是GERD,PPIs治疗应当中止,需要调查非GERD病因。但是,如果检测结果是阳性的,并不能表示PPI治疗失败。治疗时进行反流检测应使用电阻抗pH监测系统,因为它能测量非酸性反流。电阻抗pH检测可以检测出所有可能的情况:持续性酸性反流、持续性非酸性反流、无反流。目前为止,电阻抗pH检测结果阴性强烈表示症状并不与反流相关。在难治性GERD患者,比较治疗存在与否时反流检测的诊断率的研究十分有限,而且结果并不统一。因此,最近的指南建议是否在PPI治疗时进行检测,应依赖GERD的预测可能性和需要解决的问题。GERD可能性很低的患者(例如,非典型临床表现,无相应典型GERD症状),pH监测最好在非治疗期间实施,因为这样可以排除GERD。GERD可能性高的患者(典型症状,至少对PPI部分有效,之前内镜检查或pH检测结果为阳性),在治疗期间进行反流监测可以找寻PPI治疗时仍存在的持续性反流。手术之前进行GERD评估,反流监测最好在无PPI治疗时进行,以便确认GERD的存在。 目前数据资料有限,关于难治性GERD患者pH测试方法的选择尚无明确的共识。检测方法的选择可能取决于患者的临床表现,GERD的预期可能性,以及技术和专业知识的可行性。 Gastroesophageal reflux disease (GERD) is one of the most common chronic gastrointestinal diseases in Western countries, notable for its prevalence, variety of clinical presentations, under-recognized morbidity, and substantial economic consequences.1?The use of anti-secretory therapy, in particular proton pump inhibitors (PPIs), represents the mainstay of its treatment given the high efficacy of these drugs in relieving reflux symptoms and healing esophageal mucosal damages. At present, patients who have GERD symptoms (ie, heartburn and/or acid regurgitation) are given a 4- to 8-week trial with a PPI to be taken in the morning before breakfast. In case of lack of response (in up to 40% of patients), the physician should confirm patient compliance, check that the patient is taking the PPI dose at the recommended time, switch to a second-generation PPI, or administer a twice-daily PPI. If symptoms still persist and alarm signs are absent (otherwise endoscopy is mandatory), a diagnostic work-up is necessary. Indeed, diagnostic evaluation in patients with GERD symptoms is typically required when patients do not respond to medical (8- to 12-week trial with a PPI given once or twice daily) or surgical therapy, complications are suspected (refractory erosive esophagitis, stenosis, Barrett’s esophagus), or the diagnosis must be confirmed before a change in treatment strategy.However, documenting the role of reflux in GERD symptoms may be challenging. Indeed, endoscopy has several limitations given that the majority of patients have a normal endoscopic findings. Moreover, histologic assessment on esophageal biopsies taken during upper endoscopy present few drawbacks. Therefore, in most cases, our efforts are focused on documenting an abnormal gastroesophageal reflux. In 2014, two different techniques are mainly used in clinical practice in order to document gastroesophageal reflux: wireless pH-metry and combined impedance-pH testing. The Bravo pH monitoring?system uses a radiotelemetry pH sensing capsule that is attached during upper endoscopy to the mucosa of the distal esophagus, commonly at 6 cm above the squamocolumnar junction (at 9 cm if a transnasal endoscopy-free approach is used). The oblong capsule is 25 mm in length and measures pH changes, thus transmitting data via a radiofrequency signal to a pager-sized receiver clipped onto the patient’s belt. The performance of the catheter-free wireless pH electrode in measuring esophageal acid exposure has been proven in several controlled trials. The main advantages of this system are the lack of a catheter with increasing tolerability when compared with catheter-based pH monitoring and the possibility of fixing the capsule in different positions.11?However, there are some drawbacks to note. A single sensor may overestimate reflux by including swallow events, and early detachment can also alter results and may require repeated placement. Furthermore, additional endoscopic procedures may be required for patients who report severe chest pain (5%), odynophagia, or failure of the capsule to detach.?Thus, wireless pH monitoring is a validated alternative to catheter-based pH monitoring and may be very helpful in patients who do not tolerate catheter placement or in whom longer-duration pH monitoring is required (for instance, in patients with symptoms less frequently reported during a single day, such as non-cardiac chest-pain). Combined multichannel intraluminal impedance and pH (MII-pH)?detects reflux by measuring the direction (retrograde bolus movement) and extent (up to 17 cm above the lower esophageal sphincter) of changes in impedance along a catheter and qualifies reflux as acid (if pH < 4.0) or nonacid (if pH >4.0) based on the concomitant pH changes. Compared with impedance monitoring, detection of reflux with catheter-based pH monitoring is clearly inferior. This is mainly related to the impedance detection of nonacid reflux. Therefore, with the use of this technique, the clinician can correlate an increased number of reflux symptoms with a reflux episode. This increases the diagnostic yield in patients with GERD and shows that the use of pH-metry alone will result in an underestimation of GERD and an overestimation of functional heartburn. However, there are some limitations to mention. Accuracy of reflux episodes identification requires manual analysis and therefore more time than does the fully automated conventional pH test. Moreover, low baseline impedance, common in patients with erosive esophagitis or Barrett’s esophagus or with severe motility disorders, can make analyzing impedance-pH tracings arduous. Finally, the actual indices used to correlate symptoms to reflux episodes (the symptom index [SI] and the symptom association probability [SAP]) present some limitations that highlight the need for future controlled outcome studies to address their validity.Thus, despite these limitations, MII-pH monitoring is currently recognized as the gold standard for the detection of reflux episodes and for the evaluation of patients with symptoms refractory to medical or surgical treatment< Reflux monitoring enables further characterization of the refractory patient, as the study may reveal: PPI failure with ongoing acid reflux, which will require escalation of therapy to control acid reflux or surgery. Adequate acid control but ongoing symptomatic nonacid reflux, which may respond to specific therapy (transient lower esophageal sphincter relaxation inhibitors, surgery, antidepressants [selective serotonin reuptake inhibitors, serotonin–norepinephrine reuptake inhibitors]). No reflux at all. Among refractory GERD patients with a negative reflux monitoring study, those with heartburn may be classified as having “functional heartburn,” while those with extra-esophageal symptoms (asthma, cough, laryngitis) will need additional or repeat work-up for non-GERD (pulmonary, allergic, ENT) etiologies. Two key issues are relevant to consider: 1) performing reflux monitoring on or off PPI therapy and 2) what technique to use (catheter-based pH, wireless pH, or impedance pH). Reflux testing off therapy can be performed with any of the available techniques (wireless pH or impedance pH). If the test is negative (normal distal esophageal acid exposure and a negative symptom–reflux association), GERD is very unlikely, PPIs can be discontinued, and non-GERD etiologies should be investigated. However, if the test is positive, it does not provide insight about the PPI failure. Reflux testing on therapy should be performed with impedance-pH monitoring to enable measurement of nonacid reflux. Impedance-pH testing may reveal all possible scenarios: ongoing acid reflux, ongoing nonacid reflux, or no reflux. So far, a negative impedance-pH test on medication strongly supports that the symptoms are not related to reflux. Studies comparing the yield of “ off vs on” therapy reflux monitoring in refractory GERD patients are limited and have provided opposing results.19,20? Recent guidelines therefore suggest that the choice of on PPI or off PPI should rely on the pretest probability of GERD and the question that needs to be answered. In patients with a low likelihood of GERD (for instance, atypical presentations without concomitant typical GERD symptoms) pH monitoring off medication may be preferred as it will enable ruling out GERD.
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