胃食管反流病-内科学课件

讲题：胃食管反流病

（GastroesophagelRefluxDisease）讲题：胃食管反流病

（GastroesophagelRef1定义分类临床表现诊断治疗胃食管反流病病因并发症定义分类临床诊断治疗胃食管反流病病因并发症2胃食管反流病-内科学课件3胃食管反流病的定义胃食管反流病的定义4反流性食管炎正常ErosionsNormalsuqmo-columnarjunctionEsophagusScopeview反流性食管炎正常ErosionsNormalEsophagu5胃食管反流病（GERD）

100%反流性食管炎（RE）

40%非糜烂性反流病（NERD）60%无并发症

35%伴有并发症

5%胃食管反流病的分类胃食管反流病（GERD）

100%反流性食管炎（RE）

46食管下段括约肌(LES)异常食管裂孔疝食管收缩胃排空其它食管裂孔疝食管收缩食管裂孔疝胃排空食管收缩食管裂孔疝其它胃排空延迟食管收缩异常His角减弱或消失食管裂孔疝胃食管反流病的病因食管下段括约肌(LES)异常食管裂孔疝食管收缩胃排空其它食管7胃食管反流病-内科学课件8

LES异常LES异常LES异常LES异常LES异常LES异常一过性食管下段括约肌松弛tLESR一过性食管下段括约肌松弛tLESR一过性食管下段括约肌松弛tLESR一过性食管下段括约肌松弛tLESRLES压力降低LES压力降低LES压力降低LES异常LES异常LES异常LES异常LES异常LES异常LES异9食管下段括约肌(LES)异常His角减弱或消失食管裂孔疝食管收缩异常胃排空延迟其它胃食管反流病的病因食管下段括约肌(LES)异常His角减弱或消失食管裂孔疝食管10NormalGERDNormalGERD11食管下段括约肌(LES)异常His角减弱或消失食管裂孔疝食管收缩异常胃排空延迟其它胃食管反流病的病因食管下段括约肌(LES)异常His角减弱或消失食管裂孔疝食管12胃食管反流病-内科学课件13食管下段括约肌(LES)异常His角减弱或消失食管裂孔疝食管收缩异常胃排空延迟其它胃食管反流病的病因食管下段括约肌(LES)异常His角减弱或消失食管裂孔疝食管14胃食管反流病-内科学课件15胃食管反流病-内科学课件16食管下段括约肌(LES)异常His角减弱或消失食管裂孔疝食管收缩异常胃排空延迟其它胃食管反流病的病因食管下段括约肌(LES)异常His角减弱或消失食管裂孔疝食管17胃食管反流病-内科学课件18食管下段括约肌(LES)异常His角减弱或消失食管裂孔疝食管收缩异常胃排空延迟其它胃食管反流病的病因食管下段括约肌(LES)异常His角减弱或消失食管裂孔疝食管19妊娠、腹腔积液唾液分泌不足胃酸、胃蛋白酶、胆汁、胰酶食管黏膜防御作用减弱妊娠、腹腔积液20食管下段括约肌(LES)异常His角减弱或消失食管裂孔疝食管收缩异常胃排空延长其它胃食管反流病的病因食管下段括约肌(LES)异常胃食管反流病的病因21烧心(Heartburn)反流(Regurgitation)胃食管反流病临床表现烧心反流胃食管反流病临床表现22胃食管反流病食管症状食管外症状VakilNetal.AmJGastroenterol,2006;101:1900－20症状综合征伴食管破损的综合征典型反流综合征反流胸痛综合征反流性食管炎反流性狭窄Barrett食管食管腺癌已证实相关反流性咳嗽综合征反流性喉炎综合征反流性哮喘综合征反流性蛀牙综合征可能相关咽炎鼻窦炎特发性肺纤维化复发性中耳炎胃食管反流病食管症状食管外症状VakilNetal.23胃食管反流病引起哮喘原因：胃食管反流病引起哮喘原因：24上消化道出血食管狭窄Barrett食管胃食管反流病的并发症上消化道出血胃食管反流病的并发症25上消化道出血上消化道出血26食管狭窄食管狭窄27Barrett食管Barrett食管28Barrett食管Barrett食管29内镜（Endoscopy）食管X线钡餐（Bariumswallow）24小时食管pH监测（AmbulatorypHmonitoring）食管测压（Esophagealmanometry）实验室及其他检查内镜（Endoscopy）实验室及其他检查30EndoscopyEndoscopy31IllustrationdepictingvariousgradesofesophagitisaccordingtothemodifiedLosAngelesclassification(1999).LAClassificationofEsophagitiscIllustrationdepictingvarious32One(ormore)mucosalbreaknolongerthan5mmthatdoesnotextendbetweenthetopsoftwomucosalfolds.LAGradeAOne(ormore)mucosalbreakno33One(ormore)mucosalbreakmorethan5mmlongthatdoesnotextendbetweenthetopsoftwomucosalfolds.LAGradeBOne(ormore)mucosalbreakmo34One(ormore)mucosalbreakthatiscontinuousbetweenthetopsoftwoormoremucosalfoldsbutthatinvolveslessthan75%ofthecircumference.LAGradeCOne(ormore)mucosalbreakth35One(ormore)mucosalbreakthatinvolvesatleast75%oftheesophagealcircumference.LAGradeDOne(ormore)mucosalbreakth36LAGradeBisthemost

prevalentgradeofesophagitis34%39%20%7%GradeAGradeBGradeCGradeDLAGradeBisthemost

preval37UsefulfirstdiagnostictestforpatientswithdysphagiaStricture(location,length)Mass(location,length)Bird’sbeakHiatalhernia(size,type)LimitationsDetailedmucosalexamforerosiveesophagitis,Barrett’sesophagusBariumSwallowUsefulfirstdiagnostictestf38Ambulatory24hr.pHMonitoringNormalGERDAmbulatory24hr.pHMonitorin39Wireless,Catheter-FreeEsophagealpHMonitoring

ImprovedpatientcomfortandacceptanceContinuednormalwork,activitiesanddietstudyLongerreportingperiodspossible(48hours)MaintainconstantprobepositionrelativetoSCJPotentialAdvantagesWireless,Catheter-FreeEsopha40AssessLESpressure,locationandrelaxationAssistplacementof24hr.pHcatheterAssessperistalsisPriortoantirefluxsurgeryEsophagealManometryLimitedroleinGERDAssessLESpressure,location41Symptomsandresponsetotreatment(therapeutictrial)

Endoscopy

Biopsies

EsophagealacidtestingEsophagealmotilitytesting诊断与鉴别诊断Symptomsandresponsetotreat42PPI试验简便有效，可作为GERD酸反流的诊断试验1推荐级别：A+级证据等级：高质量PPI试验原理质子泵抑制剂抑制胃酸分泌反流物pH>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PPIbid1-2周1.2014胃食管反流病共识意见草案.2.BredenoordAJ,etal.Lancet2013;381(9881):1933-1942.PPI试验简便有效，可作为GERD酸反流的诊断试验1推荐级别43控制症状治愈食管炎减少复发防治并发症胃食管反流病的治疗目标控制症状胃食管反流病的治疗目标44一般治疗药物治疗维持治疗手术治疗内镜治疗并发症治疗胃食管反流病的治疗一般治疗胃食管反流病的治疗45LifestyleModificationsareCornerstoneofGERDTherapyElevateheadofbed15-20cmAvoideatingwithin2-3hoursofbedtimeLoseweightifoverweightStopsmokingModifydietEatmorefrequentbutsmallermealsAvoidfatty/friedfood,peppermint,chocolate,alcohol,coffeeandteaOTCmedicationsprn一般治疗LifestyleModificationsareCo46胃食管反流病-内科学课件47药物治疗Pro-motilitydrugsAntacidsHistamineantagonistsProtonpumpinhibitorsFoambarriers药物治疗Pro-motilitydrugs48AntacidsAntacids49AGENTEQUIVALENTDOSAGEDOSAGESCimetadine400mgtwicedaily400-800mgtwicedailyTagametFamotidine20mgtwicedaily20-40mgtwicedailyPepcidNizatidine150mgtwicedaily150mgtwicedailyAxidRanitidine150mgtwicedaily150mgtwicedailyzantac

HistamineantagonistsAGENTEQUIVAL50ProtonpumpinhibitorsAGENTEQUIVALENTDOSAGEDOSAGESEsomeprazole40mgtwicedaily20-40mgtwicedailyNexiumOmeprazole20mgtwicedaily20mgtwicedailyPrilosecLansoprazole30mgtwicedaily15-10mdtwicedailyPrevacidPantoprazole40mgtwicedaily40mgtwicedailyProtonixRabeprazole20mgtwicedaily20mgtwicedailyAciphexProtonpumpinhibitorsAGENT51FoambarriersFoambarriers52停药后很快复发且症状持续者有食管炎并发症——PPI长程维持治疗对于无食管炎的患者，按需维持治疗。维持治疗停药后很快复发且症状持续者维持治疗53抗反流手术治疗抗反流手术治疗54胃食管反流病-内科学课件55EndoscopicantirefluxtherapiesRadiofrequencyenergydeliveredtotheLESStrettaprocedureSutureligationofthecardiaEndoscopicplicationSubmucosalimplantationofinertmaterialintheregionoftheloweresophagealsphincterEnteryx内镜治疗Endoscopicantirefluxtherapie56TreatmentwithendoscopyTreatmentwithendoscopy57胃食管反流病-内科学课件58BeforetreatmentAftertreatmentBeforetreatmentAftertreatmen59胃食管反流病-内科学课件601、食管狭窄2、Barrett食管治疗并发症1、食管狭窄治疗并发症61EsophagealStricture:DilatingDevicesEsophagealStricture:Dilating62TTSBalloonDilationofaPepticStrictureTTSBalloonDilationofaPept63讲题：胃食管反流病

（GastroesophagelRefluxDisease）讲题：胃食管反流病

（GastroesophagelRef64定义分类临床表现诊断治疗胃食管反流病病因并发症定义分类临床诊断治疗胃食管反流病病因并发症65胃食管反流病-内科学课件66胃食管反流病的定义胃食管反流病的定义67反流性食管炎正常ErosionsNormalsuqmo-columnarjunctionEsophagusScopeview反流性食管炎正常ErosionsNormalEsophagu68胃食管反流病（GERD）

100%反流性食管炎（RE）

40%非糜烂性反流病（NERD）60%无并发症

35%伴有并发症

5%胃食管反流病的分类胃食管反流病（GERD）

100%反流性食管炎（RE）

469食管下段括约肌(LES)异常食管裂孔疝食管收缩胃排空其它食管裂孔疝食管收缩食管裂孔疝胃排空食管收缩食管裂孔疝其它胃排空延迟食管收缩异常His角减弱或消失食管裂孔疝胃食管反流病的病因食管下段括约肌(LES)异常食管裂孔疝食管收缩胃排空其它食管70胃食管反流病-内科学课件71

LES异常LES异常LES异常LES异常LES异常LES异常一过性食管下段括约肌松弛tLESR一过性食管下段括约肌松弛tLESR一过性食管下段括约肌松弛tLESR一过性食管下段括约肌松弛tLESRLES压力降低LES压力降低LES压力降低LES异常LES异常LES异常LES异常LES异常LES异常LES异72食管下段括约肌(LES)异常His角减弱或消失食管裂孔疝食管收缩异常胃排空延迟其它胃食管反流病的病因食管下段括约肌(LES)异常His角减弱或消失食管裂孔疝食管73NormalGERDNormalGERD74食管下段括约肌(LES)异常His角减弱或消失食管裂孔疝食管收缩异常胃排空延迟其它胃食管反流病的病因食管下段括约肌(LES)异常His角减弱或消失食管裂孔疝食管75胃食管反流病-内科学课件76食管下段括约肌(LES)异常His角减弱或消失食管裂孔疝食管收缩异常胃排空延迟其它胃食管反流病的病因食管下段括约肌(LES)异常His角减弱或消失食管裂孔疝食管77胃食管反流病-内科学课件78胃食管反流病-内科学课件79食管下段括约肌(LES)异常His角减弱或消失食管裂孔疝食管收缩异常胃排空延迟其它胃食管反流病的病因食管下段括约肌(LES)异常His角减弱或消失食管裂孔疝食管80胃食管反流病-内科学课件81食管下段括约肌(LES)异常His角减弱或消失食管裂孔疝食管收缩异常胃排空延迟其它胃食管反流病的病因食管下段括约肌(LES)异常His角减弱或消失食管裂孔疝食管82妊娠、腹腔积液唾液分泌不足胃酸、胃蛋白酶、胆汁、胰酶食管黏膜防御作用减弱妊娠、腹腔积液83食管下段括约肌(LES)异常His角减弱或消失食管裂孔疝食管收缩异常胃排空延长其它胃食管反流病的病因食管下段括约肌(LES)异常胃食管反流病的病因84烧心(Heartburn)反流(Regurgitation)胃食管反流病临床表现烧心反流胃食管反流病临床表现85胃食管反流病食管症状食管外症状VakilNetal.AmJGastroenterol,2006;101:1900－20症状综合征伴食管破损的综合征典型反流综合征反流胸痛综合征反流性食管炎反流性狭窄Barrett食管食管腺癌已证实相关反流性咳嗽综合征反流性喉炎综合征反流性哮喘综合征反流性蛀牙综合征可能相关咽炎鼻窦炎特发性肺纤维化复发性中耳炎胃食管反流病食管症状食管外症状VakilNetal.86胃食管反流病引起哮喘原因：胃食管反流病引起哮喘原因：87上消化道出血食管狭窄Barrett食管胃食管反流病的并发症上消化道出血胃食管反流病的并发症88上消化道出血上消化道出血89食管狭窄食管狭窄90Barrett食管Barrett食管91Barrett食管Barrett食管92内镜（Endoscopy）食管X线钡餐（Bariumswallow）24小时食管pH监测（AmbulatorypHmonitoring）食管测压（Esophagealmanometry）实验室及其他检查内镜（Endoscopy）实验室及其他检查93EndoscopyEndoscopy94IllustrationdepictingvariousgradesofesophagitisaccordingtothemodifiedLosAngelesclassification(1999).LAClassificationofEsophagitiscIllustrationdepictingvarious95One(ormore)mucosalbreaknolongerthan5mmthatdoesnotextendbetweenthetopsoftwomucosalfolds.LAGradeAOne(ormore)mucosalbreakno96One(ormore)mucosalbreakmorethan5mmlongthatdoesnotextendbetweenthetopsoftwomucosalfolds.LAGradeBOne(ormore)mucosalbreakmo97One(ormore)mucosalbreakthatiscontinuousbetweenthetopsoftwoormoremucosalfoldsbutthatinvolveslessthan75%ofthecircumference.LAGradeCOne(ormore)mucosalbreakth98One(ormore)mucosalbreakthatinvolvesatleast75%oftheesophagealcircumference.LAGradeDOne(ormore)mucosalbreakth99LAGradeBisthemost

prevalentgradeofesophagitis34%39%20%7%GradeAGradeBGradeCGradeDLAGradeBisthemost

preval100UsefulfirstdiagnostictestforpatientswithdysphagiaStricture(location,length)Mass(location,length)Bird’sbeakHiatalhernia(size,type)LimitationsDetailedmucosalexamforerosiveesophagitis,Barrett’sesophagusBariumSwallowUsefulfirstdiagnostictestf101Ambulatory24hr.pHMonitoringNormalGERDAmbulatory24hr.pHMonitorin102Wireless,Catheter-FreeEsophagealpHMonitoring

ImprovedpatientcomfortandacceptanceContinuednormalwork,activitiesanddietstudyLongerreportingperiodspossible(48hours)MaintainconstantprobepositionrelativetoSCJPotentialAdvantagesWireless,Catheter-FreeEsopha103AssessLESpressure,locationandrelaxationAssistplacementof24hr.pHcatheterAssessperistalsisPriortoantirefluxsurgeryEsophagealManometryLimitedroleinGERDAssessLESpressure,location104Symptomsandresponsetotreatment(therapeutictrial)

Endoscopy

Biopsies

EsophagealacidtestingEsophagealmotilitytesting诊断与鉴别诊断Symptomsandresponsetotreat105PPI试验简便有效，可作为GERD酸反流的诊断试验1推荐级别：A+级证据等级：高质量PPI试验原理质子泵抑制剂抑制胃酸分泌反流物pH>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PPIbid1-2周1.2014胃食管反流病共识意见草案.2.BredenoordAJ,etal.Lancet2013;381(9881):1933-1942.PPI试验简便有效，可作为GERD酸反流的诊断试验1推荐级别106控制症状治愈食管炎减少复发防治并发症胃食管反流病的治疗目标控制症状胃食管反流病的治疗目标107一般治疗药物治疗维持治疗手术治疗内镜治疗并发症治疗胃食管反流病的治疗一般治疗胃食管反流病的治疗108LifestyleModificationsareCornerstoneofGERDTherapyElevateheadofbed15-20cmAvoideatingwithin2-3hoursofbedtimeLoseweightifoverweightStopsmokingModifydietEatmorefrequentbutsmallermealsAvoidfatty/friedfood,peppermint,chocolate,alcohol,coffeeandteaOTCmedicationsprn一般治疗LifestyleModificationsareCo109胃食管反流病-内科学课件110药物治疗Pro-motilitydrugsAntacidsHistamineantagonistsProtonpumpinhibitorsFoambarriers药物治疗Pro-motilitydrugs111AntacidsAntacids112AGENTEQUIVALENTDOSAGEDOSAGESCimetadine400mgtwicedaily400-800mgtwicedailyTagametFamotidine20mgtwicedaily20-40mgtwicedailyPepcidNizatidine150mgtwicedaily150mgtwicedailyAxidRanitidine150mgtwicedaily150mgtwicedailyzantac

HistamineantagonistsAGENTEQUIV