Efficacy Of Diaphragm Biofeedback Training In The Maintenance Therapy Of Reflux Esophagitis And Exploration Of The Machenisms

Part1Exploration and Evaluation on Methodology of Autonomic Nerve Function in Ggastrointestinal DiseaseBackground and AimIf cardiac autonomic function test could be suitable for gastrointestinal disease was still to be determined. This study aimed to explore and evaluate autonomic nerve function tests in gastrointestinal disease.MethodsFive, ten, twenty and thirty mins of ECG was recorded in both healthy subject (HS, n=18, M/F=16:2,42.2±8.3y) and reflux esophagitis (RE, n=20, M/F=17:3,44.8±10.5y). Heart rate variability (HRV) indexes derived from these time spans were compared, seperately. Both HSand RE had standard cardiac autonomic test in fasting state and later post-prandial state, the indexes from these states were also compared, separately.Results(1) Evaluation of length of ECG recorded on HRV results:The indexes (from all the length of ECG recorded) indictive of sympathic nerve activity increased (p<0.05), and those of vagal activity decreased (p<0.05) after meal in both groups. Compared with HS, HRV indexes in fasting state and those indictive of the influences of test meal on autonomic nerves, from different length of ECG recorded, were different (p<0.05; p<0.05).(2) Evaluation of test meal on standard cardiac autonomic test:There was no difficiences between prepandial and postprandial indexes in HS. Difficiently, the HRin-HRex increased significantly after test meal in RE patients (p<0.05).ConclusionsThe change of autonomic function induced by test meal could reflect the characteristics of autonomic nerver function of digestive system. It was reasonable to have test meal in the autonomic test of digestieve diseases. Shortended length of ECG recorded, might simplify the HRV analysis in gastrointestinal diasease, but still to be studied. Part2Autonomic Nerve Function of Reflux EsophagitisBackground and AimReflux esophagitis (RE) is often accompanied by autonomic nerve dysfunction, but if the autonomic dysfunction was preliminary to RE was yet to be discovered. This research was focused on the characteristics of autonomic nerve dysfunction in RE, and the causal relationship between RE and autonomic dysfunction was also discussed.MethodsRE (n=42, M:F=31:11,44.8±10.5y) and healthy subject (HS, n=18, M:F=16:2,42.2±8.3y) were enrolled in our research, all of them had Heart rate variability (HRV) analysis in fasting state and later post-prandial state. The correlationship was evaluated between HRV indexes and clinical features of RE (RE-LA stage, GERD symptom score, GERD-HRQL score, SAS and SDS).14RE patients had HRV analysis before and after treatment.ResultsCompared with HS, RE patients had a higher (p<0.05) sympathetic activity and a lower (p<0.05) vagal activity in fasting state. Pre-prandial P2/(P1+P2+P3)(indicative of vagal tongue) negatively correlated with RE-LA stage (r=-0.42, p=0.014), which was magnificient in30, and not in20RE patients. Post-prandial P1/(P1+P2)(indicative of sympathic activity) correlated negatively (r=-0.43, p=0.038) and P2/(P1+P2)(indicative of vagal tongue) positively(r=0.43, p=0.038) with GERD symptom score. The ratio of post-prandial P1/P2to pre-prandial P1/P2(indicative of the influence of test meal on sympathy-vagal balance) correlated negatively (r=-0.48, p=0.012), while the ratio of post-prandial P2/(P1+P2) to pre-prandial P2/(P1+P2)(indicative of the influence of test meal on vagal tongue) positively with GERD symptom score. Pre-prandial P2/(P1+P2+P3) derived from5min ECG recorded was negatively correlated with gastroesophageal junction incompetencs, and those from10,20,30min could not. There was no improvement of autonomic dysfunction after treatment of RE for2to4months.ConclusionsAutonomic nerve dysfunction, manifested as higher sympathic activity and lower vagal activity in fasting state, was the characteristics of RE. Pre and post prandial autonomic function test might reveal the relationship between RE-LA stage, GERD symptom smptom score and autonomic nerve dysfunction seperately.5minutes of recording might help in reflecting autonomic nerve dysfunction of RE patients. This research suspected that the damaged autonomic nerve function of digestive system might be the cause of RE Part3Efficacy of Diaphragm Biofeedback Training in the Maintenance Therapy for Patients with Reflux EsophagitisBackground and AimRelapse is the main problem of PPIs in the maintenance therapy of Reflux esophagitis (RE). This research was to explore the effect of diaphragm biofeedback training (DBT) in the maintenance therapy of RE.Methods49RE patients were enrolled in this stuty, from September2009to April2010, who were randomly divided to two groups, that is, PPI with DBT group (n=27, M:F=17:10,47.8±10.7y) and PPI group (n=22, M:F=18:4,49.1±11.1y). The treatment course was4moths, the first2months patients in both groups were treated with double doses of PPIs, and in the next2months, with PPIs on demand therapy. Meanwhile, hydrotalcite chewable tablets (Bayer Co. Ltd.) were taken on demand in4months periods of treatment. Patients in PPI with DBT group were asked to have DBT regularly during the treatment period. GERD symptom score, HRQL score were recorded at the baseline, and every one month during the treatment period, the amounts of PPIs and hydrotalcite chewable tablets consumed were recorded every1month, and SAS, SDS were recorded every2months. The data from both groups on different time point were analyzed separately between and within groups.Results(1) Influence of DBT on symptoms of GERD:Compared with baseline, the GERD symptom score and HRQL score in both groups decreased significantly (p<0.05) in the first2months. During the maintenance therapy, the GERD symptom score in the third month in both groups increased compared with that of the second month (p<0.05; p<0.05), but it dropped again to the level of that of the second month in PPI wih DBT group (p>0.05). The GERD symptom score of RE patients in PPI with DBT group was significantly lower than that of PPI group in the first2months (p<0.05; p<0.05). The HRQL score were lower in PPI with DBT group in the second and third month (p<0.01; p<0.05).(2) Influence of DBT on amounts of PPIs and hydrotalcite chewable tablets:In maintenance therapy, the amounts of PPIs consumed were less than the first2months in both groups (p<0.01; p<0.01). The amount of PPIs and hydrotalcite chewable tablets consumed were less in PPI with DBT group in the first, second and third month of therapy (p<0.05, p<0.01, p<0.01) compared with PPI group.(3) Influence of DBT on psychological state of RE:After the end of the first2months of therapy, the SAS and SDS score dropped significantly in both groups (p<0.05, p<0.05), and the SAS score of PPI with DBT group was lower than that of PPI group in the second month (p<0.05). (4) Influence of DBT on gastroesophageal junction incompetence:The degree of dropping HRQL score in patients of PPI with DBT group with gastroesophageal junction incompetence (GEJI)(n=12) was more than that of patients without GEJI (n=15) in the first2months of therapy (p<0.01; p<0.05), while the PPIs and hydrotalcite chewable tablets consumed were the same. In the third and forth month, those patients with GEJI consumed more PPIs than those without (p<0.05; p<0.05).ConclusionsPPI with DBT therapy showed more effective than PPIs therapy alone in the treatment of RE, which was more prominent in the maintenance therapy. It seemed that PPI with DBT therapy was more helpful in control of anxiety of RE patients. Oure research suspected that DBT was effective in the maintenance therapy of RE patients. Part4Machenism of Diaphragm Biofeedback Training in the Maintenance Therapy of Reflux EsophagitisBackground and AimThe impaired gastroesophageal junction, chearance of esophagus and the delayed gastric emptying were three components of defensive mechanism in RE. This stuty was to explore the influence of diaphragm biofeedback training (DBT) on esophageal motility and gastric emptying of RE patients.MethodsIn our study above (Part3),49RE patients were enrolled and divided randomly into PPI group and PPI with DBT group. Patients in PPI with DBT group had DBT during PPIs treatment. Ten patients of them (M:F=7:3,50.3±10.2y) received esophageal manometry15min before and1h after a test meal at baseline, and at2to4months of treatment. Six patients from PPI with DBT group and5from PPI group underwent radionuclide gastric emptying at baseline and2-4months after therapy. Health subjects (HS, n=9) got gastric emptying only at baseline.Results(1) Influence of DBT on esophageal motility:The gastroesophago-gastric juncture pressure (EGJP) and crural diaphragm pressure (CDP) increased significantly (p<0.05; p<0.05) after2to4months of treatment, meanwhile, evens of transient lower esophageal sphincter relaxations (TLESRs) after meal decreased (p<0.05) significantly. There was no improvement on the chearance of esophagus.(2)Influence of DBT on gastric emptying:The overall and proximal gastric emptying were both delayed in RE patients (p<0.01; p<0.01). The gastric emptying velocity (%/min) was slower in patients from PPI with DBT group than from PPI group at base line (p<0.05), but, interestingly, after2to4months the difference was not significant.Conclusions2to4months of PPIs with DBT treatment could enhance the function of anti reflux barrier of gastroesophageal junction, reduce events of TLESRs after the meal. The proximal gastric emptying was delayed in RE patients, which could be improved by2to4months of DBT.