Characteristics Of Ineffective Esophageal Motility In Refractory Gastroesophageal Reflux Disease And Its Relationship With Reflux Nature

Background and objectivegastroesophageal reflux disease(GERD)has become a very common digestive disease as the number of people with GERD is increasing year by year due to the changes in lifestyle and eating habits.GERD can lead to a series of intra-esophageal and extraesophageal symptoms such as heartburn,acid reflux,and retrosternal pain,however,more than 40%of patients fail to respond to proton pump inhibitor(PPI)therapy,and it is very necessary to study the mechanism and pathophysiology of these patients with refractory gastroesophageal disease(RGERD).Dysfunction of esophageal motor function is one of the common manifestations of GERD,and with the development of high-resolution esophageal manometry(HREM),esophageal motor function has been better assessed,which is conducive to the study of the relationship between esophageal dysmotility and RGERD.Ineffective esophageal motility(IEM)is the most common esophageal motility disorder,and abnormal esophageal body motility weakens the clearance of esophageal material,which in turn aggravates RGERD symptoms.In this study,HREM and 24h esophageal impedance-pH monitoring were performed in patients with RGERD,and analyzed for the characteristics of esophageal motility,characteristics and results of gastroesophageal disease questionnaire in patients with IEM.The risk factors associated with the incidence of RGERD were explored in order to guide patients to avoid these factors and prevent the occurrence of RGERD.MethodsPatients with gastroesophageal reflux disease-like symptoms who underwent HREM and 24-hour esophageal impedance-pH monitoring and completed the gastroesophageal disease questionnaire in Jinan Central Hospital Affiliated to Shandong First Medical University and Qilu Hospital of Shandong University from January 2021 to January 2022 were retrospectively selected.The basic contents of the gastroesophageal disease questionnaire include:gender,age,height,weight,BMI,history of Helicobacter pylori(HP)infection,history of HP eradication,reflux symptoms,history of other systemic diseases(including hypertension,diabetes),history of smoking,history of alcohol consumption,history of psychiatric drug use,history of prokinetic drug use,GerdQ scale,self-rating anxiety scale(SAS),self-rating depression scale(SDS),etc.The patients were grouped according to whether they were RGERD,and the differences in HREM as well as reflux related parameters between IEM and patients with essentially normal esophageal motility in each group were compared.Results1.Comparison of general conditions A total of 131 patients were included in this study,including 49 patients(37.40%)with RGERD and 82 patients(62.60%)with non-RGERD,including 77 males(58.78%)and 54 females(41.22%),aged 51.53±14.46 years.Based on the 4th edition of the HREM Chicago classification,131 patients were divided into the IEM group,49(37.40%)in total,including 19(38.78%)RGERD patients and 30(61.22%)non-RGERD patients;82(62.60%)in the essentially normal esophageal motility group,including 30(36.59%)RGERD patients and 52(63.41%)non-RGERD patients.2.Analysis of GERD questionnaire results Analysis of the questionnaire results between the two groups of RGERD and non-RGERD patients revealed that there were significant differences in the history of HP infection(57.14%vs.28.05%),HP eradication(46.94%vs.28.05%),spicy taste(26.53%vs.9.76%),a large amount of water at one time(46.94%vs.26.83%),intake of coffee(0 vs.0,Frequent:8.16%vs.3.66%,Occasional:26.53%vs.9.76%,Never:65.31%vs.86.58%),lying position after meals(daily:20.41%vs.4.88%,Regular:0.41%vs.4.88%,Occasional:57.14%vs.58.53%,Never:18.37%vs.31.71%),and walking after meals(daily:12.24%vs.15.86%,Regular:26.53%vs.40.24%,Occasional 36.74%vs.40.24%,Never:24.49%vs.3.66%)between RGERD patients and non-RGERD patients(P<0.05).3.Characteristics of HREM and 24h esophageal impedance-pH monitoring results in IEM patients Comparison of IEM group with basically normal esophageal motility showed that the mean value of LESP respiration(mmHg)[17.58(6.65,21.95)vs.19.50(12.48,23.15)]in the IEM group was lower than that in the group with basically normal esophageal motility,and the difference had statistical significance(P<0.05);the LESL(cm)[2.80(2.10,4.00)vs.3.10(2.50,4.00)],intra-abdominal LESL(cm)[1.38(0.50,2.30)vs.1.51(0.68,2.50)],and the mean values of UESP(mmHg)[44.30(31.80,79.50)vs.66.60(37.30,87.60)]in the IEM group were not significantly different from those in the group with basically normal esophageal motility(P>0.05).In the reflux monitoring,the decubitus AET(min)[10.10(1.05,11.65)vs.5.25(0.00,6.25)]and postprandial AET(min)[10.24(0.75,11.00)vs.4.17(0.00,4.73)]in the IEM group were higher than those in the basically normal esophageal motility group,and the difference had statistical significance(P<0.05).However,there was no significant difference in weak acid reflux[32.94(16.50,35.50)vs.29.96(13.50,42.50)],acid reflux[29.12(15.50,42.50)vs.26.48(13.50,37.00)],non-acid reflux[0.67(0.00,0.00)vs.0.23(0.00,0.00)],liquid reflux[45.76(26.00,60.00)vs.45.76(26.00,69.50)],mixed reflux[8.92(4.50,12.00)vs.7.98(3.00,11.50)],gas reflux[98.56(43.00,122.5)vs.79.43(32.00,102.50)],and the total numbers of reflux[58.57(34.50,73.00)vs.54.96(38.00,68.00)]to basically normal esophageal motility between the two groups(P>0.05).4.Characteristics of HREM and 24h Esophageal Impedance-pH Monitoring Results for RGERD Patients Comparison of IEM esophageal motility in RGERD patients showed that the LESL(cm)[2.61(2.00,3.00)vs.3.55(2.58,3.82)],mean LESP respiration(mmHg)[12.19(5.20,16.90)vs.18.75(11.30,24.98)],and the mean values of UESP(mmHg)[64.10(30.70,84.10)vs.73.45(45.70,92.85)]in the IEM group were lower than those in the basically normal esophageal motility group,and the difference was statistically significant(P<0.05);however,there was no significant difference in intra-abdominal LESL(cm)[1.34(0.20,2.50)vs.1.35(0.45,1.85)]compared with the basically normal esophageal motility group(P>0.05).In the reflux monitoring,the decubitus AET(min)[6.48(2.00,14.60)vs.5.51(0.10,7.73)]and postprandial AET(min)[4.66(0.70,4.60)vs.3.95(0.00,3.73)],DeMeester score[50.33(28.90,63.70)vs.19.32(6.25,26.05)]and mixed reflux number[(10.53 7.21)vs.(6.07 5.11)]in the IEM group were higher than those in the basically normal esophageal motility group,and the differences were statistically significant(P<0.05),while the total AET(min)[6.34(0.80,7.90)vs.5.16(1.05,8.82)],upright AET(min)[7.65(1.40,6.40)vs.5.36(1.13,8.98)],weak acid reflux[30.74(19.00,37.00)vs.28.66(17.00,37.00)],acid reflux[25.57(14.00,36.00)vs.20.48(6.50,31.00)],non-acid reflux[1.738(0.00,0.00)vs.0.53(0.00,0.00)],total reflux[56.94(40.00,74.00)vs.45.38(30.00,61.50)],fluid reflux[42.21(26.00,55.00)vs.42.90(27.50,54.00)],and gas reflux[117.74,10.75]were not statistically significant.5.Correlation Analysis Between Percentage of Esophageal Invalid Swallows and HREM Results in Patients with RGERD Correlation analysis between the percentage of esophageal ineffective swallowing and HREM results in RGERD patients revealed that the decubitus AET(min)and DeMeester score were positively correlated with the percentage of esophageal ineffective swallowing;while the postprandial AET(min)and mixed reflux number were not significantly correlated with the percentage of ineffective swallowing in the esophagus.6.Multivariate Analysis of RGERD Infection with HP,eradication of HP,spicy taste,drinking a lot of water at one time,and occasional or frequent decubitus position were all risk factors for RGERD,and the risk of RGERD was 3.42,2.27,3.34,2.41,6.25,and 4.54 times that of people who were not infected with HP,not eradicated HP,not spicy taste,not accustomed to drinking a lot of water and not accustomed to postprandial recumbency at one time,respectively.Conclusions1.RGERD patients with IEM are prone to LES shortening,LES low pressure,UES low pressure,pathological acid,etc.,and the decubitus AET,postprandial AET and mixed reflux number is significantly higher than that in patients with basically normal esophageal motility.2.In RGERD patients,the higher percentage of esophageal ineffective swallowing,the more severe the acid and pathological acid in the decubitus position,suggesting the importance of normal peristalsis of the esophageal body for acid clearance in RGERD patients.3.Infection and eradication of HP,spicy taste,a large amount of water at one time,and lying position may be risk factors for the incidence of RGERD and require further study.