内科学教学课件：胃食管反流病

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1、讲题：胃食管反流病（Gastroesophagel Reflux Disease）定义定义分类分类临床临床表现表现诊断诊断治疗治疗胃食管反流病胃食管反流病病因病因并发症并发症胃食管反流病的定义反流性食管炎反流性食管炎正常正常ErosionsNormalsuqmo-columnarjunctionEsophagusScope view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 食管下段括约肌食管下段括约肌(LES)异常异常 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

2、 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 LES异常异常LES异常异常LES异常异常LES异常异常LES异常异常LES异常异常一过性一过性食管下段括约肌松弛食管下段括约肌松弛tLESR一过性一过性食管下段括约肌松弛食管下段括约肌松弛tLESR一过性一过性食管下段括约肌松弛食管下段括约肌松弛tLESR一过性一过性食管下段括约肌松弛食管下段括约肌松弛tLESRLES压力降低压力降低LES压力降低压力降低LES压力降低压力降低LES异常异常 食管下段括约肌食管下段括约肌(LES)异常异常 His角减弱或消失 食管裂孔疝 食管收缩异常 胃

3、排空延迟 其它胃食管反流病的病因NormalGERD 食管下段括约肌食管下段括约肌(LES)异常异常 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 食管下段括约肌食管下段括约肌(LES)异常异常 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 食管下段括约肌食管下段括约肌(LES)异常异常 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 食管下段括约肌食管下段括约肌(LES)异常异常 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妊娠、腹腔积液唾液分泌不足胃

4、酸、胃蛋白酶、胆汁、胰酶食管黏膜防御作用减弱 食管下段括约肌食管下段括约肌(LES)异常异常 His角减弱或消失角减弱或消失 食管裂孔疝食管裂孔疝 食管收缩异常食管收缩异常 胃排空延长胃排空延长 其它其它胃食管反流病的病因烧心烧心(Heartburn)反流反流(Regurgitation)胃食管反流病临床表现胃食管反流病胃食管反流病食管症状食管症状食管外症状食管外症状Vakil N et al.Am J Gastroenterol,2006;101:190020症状综合征症状综合征伴食管破损伴食管破损的综合征的综合征典型反流综合征典型反流综合征反流胸痛综合征反流胸痛综合征反流性食管炎反流性食管

5、炎反流性狭窄反流性狭窄Barrett食管食管食管腺癌食管腺癌已证实相关已证实相关反流性咳嗽综合征反流性咳嗽综合征反流性喉炎综合征反流性喉炎综合征反流性哮喘综合征反流性哮喘综合征反流性蛀牙综合征反流性蛀牙综合征可能相关可能相关咽炎咽炎鼻窦炎鼻窦炎特发性肺纤维化特发性肺纤维化复发性中耳炎复发性中耳炎胃食管反流病引起哮喘原因：胃食管反流病引起哮喘原因：上消化道出血上消化道出血 食管狭窄食管狭窄 Barrett食管食管胃食管反流病的并发症上消化道出血上消化道出血食管狭窄食管狭窄Barrett食管食管Barrett食管食管l内镜（Endoscopy）l食管X线钡餐（Barium swallow）l24小

6、时食管pH监测（Ambulatory pH monitoring）l食管测压（Esophageal manometry）实验室及其他检查EndoscopyIllustration depicting various grades of esophagitis according to the modified Los Angeles classification(1999).One(or more)mucosal break no longer than 5mm that does not extend between the tops of two mucosal folds.LA Grad

7、e AOne(or more)mucosal break more than 5mm long that does not extend between the tops of two mucosal folds.LA Grade BOne(or more)mucosal break that is continuous between the tops of two or more mucosal folds but that involves less than 75%of the circumference.LA Grade COne(or more)mucosal break that

8、 involves at least 75%of the esophageal circumference.LA Grade DLA Grade B is the most prevalent grade of esophagitis34%39%20%7%Grade AGrade BGrade CGrade D Useful first diagnostic test for patients with dysphagia Stricture(location,length)Mass(location,length)Birds beak Hiatal hernia(size,type)Limi

9、tations Detailed mucosal exam for erosive esophagitis,Barretts esophagusBarium SwallowAmbulatory 24 hr.pH MonitoringNormalGERDWireless,Catheter-Free Esophageal pH MonitoringImproved patient comfort and acceptance Continued normal work,activities and diet study Longer reporting periods possible(48 ho

10、urs)Maintain constant probe position relative to SCJ Assess LES pressure,location and relaxation Assist placement of 24 hr.pH catheter Assess peristalsis Prior to antireflux surgery Esophageal Manometry Symptoms and response to treatment(therapeutic trial)Endoscopy Biopsies Esophageal acid testing E

11、sophageal motility testing诊断与鉴别诊断PPI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pH4.0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.控制症状控制症状 治愈食管炎治愈食管炎 减少复发减少复发 防治并发症防治并发症胃食管

12、反流病的治疗目标 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 Lifestyle Modifications are Cornerstone of GERD Therapy Elevate head of bed 15-20 cm Avoid eating within 2-3 hours of bedtime Lose weight if overweight Stop smoking Modify diet Eat more frequent but smaller meals Avoid fatty/fried food,peppermint,choc

13、olate,alcohol,coffee and tea OTC medications prn一般治疗一般治疗药物治疗药物治疗lPro-motility drugs lAntacidslHistamine antagonistslProton pump inhibitorslFoam barriersAntacidsAGENT EQUIVALENT DOSAGE DOSAGESCimetadine 400mg twice daily 400-800mg twice dailyTagametFamotidine 20mg twice daily 20-40mg twice dailyPepci

14、dNizatidine 150mg twice daily 150mg twice dailyAxidRanitidine 150mg twice daily 150mg twice dailyzantac Histamine antagonistsProton pump inhibitorsAGENT EQUIVALENT DOSAGE DOSAGESEsomeprazole 40mg twice daily 20-40mg twice dailyNexiumOmeprazole 20mg twice daily 20mg twice daily PrilosecLansoprazole 3

15、0mg twice daily 15-10md twice daily PrevacidPantoprazole 40mg twice daily 40mg twice daily ProtonixRabeprazole 20mg twice daily 20mg twice daily AciphexFoam barriers 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。维持治疗维持治疗抗反流手术治疗抗反流手术治疗 Endoscopic antireflux therapies Radiofrequency energy delivere

16、d to the LES Stretta procedure Suture ligation of the cardia Endoscopic plication Submucosal implantation of inert material in the region of the lower esophageal sphincter Enteryx内镜治疗内镜治疗Treatment with endoscopyBefore treatmentAfter treatment 1、食管狭窄 2、Barrett食管治疗并发症治疗并发症TTS Balloon Dilation of a Peptic Stricture定义定义分类分类临床临床表现表现诊断诊断治疗治疗胃食管反流病胃食管反流病病因病因并发症并发症谢谢Thanks For Your Attention