胃食管反流病

1、胃食管反流病 GERD中山-10级研究生 缪青ZHONG SHAN HOSPITAL FUDAN UNIVERSITY1ContentsTitle in here4.Diagnosis2.Epidemiology3.Symptoms1.Definition5.Treatment食常见病管外表现复杂多样-涉及多个系统、器官严重生活质量，甚至危急生命误诊率高2定义 DefinitionZHONG SHAN HOSPITAL FUDAN UNIVERSITY3DefinitionGERD:由胃内容物反流 引起的不适症状和(或)并发症的一种疾病。可导致食管炎和咽、喉、气道等食管以外的组织损害镜下可表现

2、为食管黏膜糜烂、溃疡等炎症病变, 称反流性食管炎4DefinitionGERD: 也有部分患者内镜下可无反流性食管炎表现, 这类称为 内镜阴性的GERD 。5流行病学资料Epidemical dataZHONG SHAN HOSPITAL FUDAN UNIVERSITY6Epidemical features美国(unit : %)7-10%患病率7.0% -14.0%44 %的人至少每月有1次反流症状20%的人至少每周有1次反流症状44%20%西方国家十分常见：患病率为7.0% 14.0% 美国人中：20%的人至少每周有1次反流症状美国人中：44 %的人至少每月有1次反流症状美国西方7Ep

3、idemical features日本学者对1996年至2006年10年间关于GERD症状日本发病率文献进行总结发现患病率从6.6%到37.6%之间不等6.6%-37.6%？8Epidemical features北京上海江苏舟山西安安徽铜陵0% 10% 20% 30% 40% 50% 29.3%7.6% 9.5%16.9%14.6%我国,北京、上海、江苏舟山 、西安地区及安徽铜陵地区GERD症状发生率分别为29.3%、7.6%、9.5%、16.9%及14.6%。9Epidemical features中华普外科手术学杂志2010年8月第4卷第3期年龄段统计-解放军第二炮兵总医院22%17%1

4、.2%0.5%21-40岁1-20岁0.5%1.2%17%22%61-80岁81-120岁58%41-60岁58%10症状 SymptomZHONG SHAN HOSPITAL FUDAN UNIVERSITY11Symptoms症状食管刺激症状食管反流症状不典型症状 Retrosternal painHeartburn咳嗽、咳痰、喘息、憋气、胸痛、咽部异物感、吞咽困难、喉部发紧甚至窒息感等2种典型症状：食管反流症状+食管刺激症状不典型症状regurgitation12Symptoms拓展Recurrencegenerally recur once medical therapy is sto

5、ppedExaminationEndoscopic examination may or may not find esophagitisLong-term Com.long-term complications are Barretts esophagus and in some cases esophageal adenocarcinomaQuality of lifesymptoms can significantly impair the quality of life13Epidemical features中华普外科手术学杂志2010年8月第4卷第3期14Symptoms进展200

6、6年GERD蒙特利尔共识意见认为:反流性咳嗽综合征、 反流性喉炎综合征、反流性哮喘综合征和反流性牙侵蚀综合征与GERD明确相关而咽炎、鼻窦炎、特发性肺纤维化和复发性中耳炎与之可能相关。近年来很多文献报道成年人哮喘与GERD存在明显相关性,Molle等发现存在持续性哮喘的儿童和青少年胃食管反流患病47.3%,患病率显著高于正常儿童青少年。我们通过动物实验也证实:胃内容物可经咽反流至喉、气管.15诊断 DiagnosisZHONG SHAN HOSPITAL FUDAN UNIVERSITY16Diagnosis阴性阳性质子泵抑制剂试验阳性确诊胃镜检查和/或24 h pH监测应用双倍剂量PPI 7

7、 d对怀疑GERD的患者进行诊断性治疗,症状好转视为阳性17治疗 TreatmentZHONG SHAN HOSPITAL FUDAN UNIVERSITY18TreatmentLifestyle ChangeTreatment usually includes:LifestyleMedical treatmentEndoscopic treatmentTIFEndoscopetreatment腹腔镜胃底折叠术(TIF,Transoral Incisionless Fundoplication )和其他手术MedicineSurgeryEndoscope19TreatmentAdequate

8、or effective90% patients.must be maintained long term because cessation of medicine 90% recurrence of symptomslong-term drug therapy is associated with issues of cost, compliance, and long-term safetyMedicalTreatment20TreatmentEndoscopicTreatmentTo improve the antireflux barrier function injection o

9、f filler materials into the LES and cardiadelivery of radiofrequency energy to the LES and cardia creation of gastroplications 21Treatment胃底折叠术是治疗GERD的经典术式,已在国外开展50余年,被证实治疗效果满意。手术抗反流的效果在于降低酸暴露,恢复下食管括约肌的功能, 改善受损的食管蠕动功能 ,从而阻止反流,防止微吸入和迷走神经反射,这两种因素在改善GERD相关性呼吸症状中起作用。Surgerymortality rate of approximatel

10、y 0.2%, with additional morbidity including dysphagia, gas-bloat syndrome, and postprandial fullness 手术效果22other techniques (under study)His-Wiz infrasphincteric plicator ,use of magnets to augment the esophageal sphincterimplantation of an on-deman microstimulator into the LES to increase LES press

11、ure23Stretta射频治疗是一种内镜下的微创治疗,通过热能治疗后增加下食管括约肌厚度,灭活神经末梢,迷走神经受体的失活,胶原组织收缩,从而增加下食管括约肌厚度和压力,减少一过性下食管括约肌松弛,起到防止胃食管反流的效果。other techniques (under study)24此操作简捷、安全、创伤小,国外已开展约10年,多项研究已经证明其安全性,中远期效果满意。它对于药物难治性、惧怕手术或者抗反流手术后复发患者是一种有效治疗手段,但是国外仅把该项治疗用于针对反酸、烧心等消化道症状的治疗。 和腹腔镜胃底折叠术及药物治疗互相补充,极大丰富了GERD的治疗手段。other techni

12、ques (under study)25other techniques (under study)26Prospective randomized controlled trial of an injectable esophageal prosthesis versus a sham procedure for endoscopic treatment of gastroesophageal reflux diseaseendoscopic implantation of an injectable esophageal prosthesis,the Gatekeeper Reflux R

13、epair System (GK)Surg Endosc (2010) 24:13871397DOI 10.1007/s00464-009-0784-927endoscopic implantation of an injectable esophageal prosthesis,the Gatekeeper Reflux Repair System (GK)28Gatekeeper procedure:a The esophageal wall is aspirated. b Normal saline is injected into the submucosal layer. c A p

14、ocket is created into the submucosal layer. d The prosthesis is implanted in the pocket. e Hydrated prostheses in situ 24 h after implantation are shown2930not clinically meaningful. no statistically or clinically significant differences in outcomes were observed between the treatment group and the control group at 6 months compared with baseline For this reason, the study was terminated early.31The c