Font Size: a A A

1. Different Pattern Of Pathophysiology Between Non-Erosive Reflux Disease And Reflux Esophagitis 2. Effect Of Diaphragm Biofeedback In Patients With Gastroesophageal Reflux Disease

Posted on:2007-03-18Degree:DoctorType:Dissertation
Country:ChinaCandidate:Z L DingFull Text:PDF
GTID:1114360218456096Subject:Internal Medicine
Abstract/Summary:PDF Full Text Request
Background and ObjectivesGastroesophageal reflux disease(GERD) is a common upper gastrointestinal motility disease and studies revealed that up to 50-70% of GERD patients had non-erosive reflux disease(NERD), only 30%-50% had reflux esophagitis(RE). Recent research showed that patients rarely progressed from NERD to RE or from RE to Barrett's esophagus(BE). A new conceptual model considered GERD as three distinct groups of patients including NERD, RE and BE. Previous studies showed that exteraesophageal manifestations, duodenogastroesophageal reflux model as well as therapeutic responses were different between patients with NERD and RE. However, assessment of esophageal motility, gastric myoelectrical activity and autonomic function testing(AFT) between NERD and RE remains limited.Previous studies showed esophagogastric junction (EGJ) pressure in patients with GERD was lower than that in healthy subjects (HS). Further study showed that preprandial diaphragm biofeedback could improve EGJ pressure. Effect of postprandial diaphragm biofeedback on esophageal acid exposure should be investigated.The objectives of this study were: 1) To evaluate function of esophageal motility, especially EGJ function in patients with NERD. 2) To investigate the gastric myoelectrical activity and autonomic nervous system(ANS) function in patients with NERD and RE utilizing multi-channel electrogastrography (MEGG) and power analysis of heart rate variability(HRV). 3) To observe effect of postprandial diaphragm biofeedback training on clinical manifestations, esophageal motility, esophageal acid exposure and proximal gastric volume in patients with GERD.MethodsThe study consisted of four portions.Characteristics of esophageal motility in patients with NERD and RE. 96 GERD patients and 18 healthy subjects (HS) with matched demographic characteristics were studied. All patients underwent gastroscopy. NERD patients were divided into 2 groups based on 24-hour esophageal pH monitoring: normal acid exposure and excessive acid exposure. RE patients were divided into 2 groups according to LA criteria: LA-A or B and LA-C or D. All subjects underwent esophageal manometry and EGJ function as well as distal esophageal peristalsis amplitude (DEPA) were analyzed. The parameters of EGJ function included lower esophageal sphincter pressure (LESP), crural diaphragm pressure (CDP), EGJ pressure (EGJP) and contractive pressure of post-LES relaxation related to swallow(Post-LESRP).Characteristics of gastric myoelectrical activity and autonomic nervous system function in patients with NERD and RE. 42 patients with GERD were enrolled and divided into 2 groups based on endoscopy: 21 cases with NERD (11M, 10F, mean age: 52yrs) and 21 cases with RE (12M, 9F, mean age: 50yrs). 20 healthy volunteers matched for age and gender were recruited as control (13M, 7F, mean age: 50 yrs). The psychological inventory was evaluated with SAS and SDS. MEGG was recorded simultaneously with the electrocardiogram (ECG) recording for 30 min in fasting state and 60 min after test meal (460Kcal). MEGG parameters included dominant frequency (DF), dominant power(DP), the normal percentage of 2.0-4.0cpm gastric slow waves(N%) and the percentage of slow wave coupling(%SWC)among 4 channels(ch). ANS was determined according to the parameters of power spectra analysis of HRV which was derived from the ECG recording and the parameters included sympathovagal balance (LF/HF Ratio) , sympathetic activity (LF) and vagal activity (HF). Effect of postprandial diaphragm biofeedback on esophageal acid exposure and proximal gastric volume in patients with GERD. 30 patients with GERD and 9 HS with matched demographic characteristics were enrolled. Esophageal manometry with a Dentsleeve catheter and simultaneous esophageal pH monitoring were recorded in a 30 min fasting period and a 120 min postprandial period. GERD patients were divided into three groups: 9 patients received diaphragm biofeedback training at 1st hour after meal (The 500 kcal/500ml liquid nutrient test meal) (group DBT1st hr) and 10 patients received diaphragm biofeedback training at 2nd hour after meal (group DBT2nd hr) whereas 11 patients received no diaphragm biofeedback training after meal (group N-DBT). Ultrasonic imaging of proximal gastric volume was undertaken at at 0min, 30min, 60min, 90min and 120min after meal.Effect of 8-week postprandial diaphragm biofeedback with acid suppression on patients with GERD. 27 GERD patients were divided into two groups: 15 patients with diaphragm biofeedback combined with PPI (biofeedback group) and 12 patients with PPI (PPI group). The biofeedback group underwent diaphragm biofeedback about 20 min twice daily in the 2nd 30min after meal. All patients in both groups were required to use PPI on-demand in the 2nd month. The reflux symptoms, extraesophageal manifestations, quality of life, psychological status, esophageal motility and 24h esophageal pH monitoring were re-evaluated at the end of the 8th week and administration of PPI in the 2nd month was also compared between two groups.ResultsCharacteristics of esophageal motility in patients with NERD and RE. There were 54 NERD patients including 31 with normal acid exposure and 23 with excessive acid exposure. 42 RE patients included 31with LA-A or B and 11 with LA-C or D. LESP, EGJP and Post-LESRP in RE patients were lower than those in NERD and HS(P<0.05), but no significant difference was found in CDP. LESP and Post-LESRP in NERD patients were lower than those in HS (P<0.05), whereas CDP and EGJP were similar between NERD and HS. Lower DEPA was shown in NERD and RE patients in comparison with HS(P<0.05). There was no difference of esophageal motility between NERD patients with and without excessive esophageal acid exposure.Characteristics of gastric myoelectrical activity and autonomic nervous system function in patients with NERD and RE. Compared with fasting state: 1)Test meal significantly increased the DF but significantly decreased the N% and %SWC in both GERD patients and healthy volunteers(P<0.05) in the 60min of fed state; DP was not significantly altered by test meal in both groups in the 60min fed state. %SWC is significantly lower in NERD patients than that in healthy volunteers in in fasting and fed state. There was no significant difference between GERD patients and healthy volunteers for other parameters in fasting and fed state. 2) Test meal significantly increased the LF/HF ratio and LF but significantly decreased the HF in both groups in 60min after meal(P<0.01). The LF/HF ratio in NERD group was significantly higher than that in RE group after meal (P<0.05). No significant difference for other ANS parameters between GERD patients and healthy volunteers was found. 3) The psychological status had similar effect on myoelectrical activity in NERD and RE patients, but the effect on ANS function is different. 4) There was no correlation between MEGG parameters and ANS parameters in both fasting and fed state in both groups.Effect of postprandial diaphragm biofeedback on esophageal acid exposure and proximal gastric volume in patients with GERD. 1) Compared with group N-DBT patients, the percentage time with pH<4 in group DBT1st hr patients was reduced in the 120min postprandial period (0.2% vs. 6.6%, P<0.05) and no significant difference of esophageal acid exposure was observed between group DBT2nd hr and group N-DBT patients. 2) Crural diaphragm and EGJ pressure were significantly increased during diaphragm biofeedback training(P<0.05) and there was no change of LES pressure. 3)At 60min and 120min after the test meal, the group DBT1st hr, group DBT2nd hr and group N-DBT patients had similar proximal stomach volume, and there was significant difference between HS and GERD groups at 120min (P<0.05).Effect of 8-week postprandial diaphragm biofeedback with acid suppression on patients with GERD. 1) 12 patients with biofeedback and 10 patients with PPI completed a 8-week treatment course. 2) Reflux symptoms, quality of life, and psychological status were improved in both biofeedback and PPI groups. Regarding as extraesophageal manifestations, epigastric bloating was improved in biofeedback group whereas no changes were found in PPI group. 3) 7 of 12 patients with biofeedback and 7 of 10 patients with PPI re-evaluated esophageal manometry and 24h esophageal pH monitoring. The results showed that crural diaphragm pressure at resting state was significantly increased from 11.8±4.1mmHg to 22.7±12.9mmHg (P<0.05) in biofeedback group and EGJ pressure was also improved significantly(P<0.05), but no effect on LES pressure, peristaltic amplitude of the distal esophagus and 24h esophageal acid exposure was found (P>0.05). Esophageal motility and 24h esophageal acid exposure were not altered in PPI group. The administration of PPI in the 2nd month was significantly reduced in biofeedback group compared with PPI group(P<0.05).Conclusions(1) Less impaired EGJ function, especially normal crural diaphragm function, was found in NERD compared with RE, suggesting anti-reflux function of crural diaphragm might be important basis of pathophysiology which causes different pattern of NERD and RE.(2) GERD patients and healthy controls both have similar response to meal in MEGG and ANS test. The gastric myoelectrical activity and ANS function in NERD are different from those in RE. The psychological status has similar effect on myoelectrical activity in both NERD and RE patients whereas the effect on ANS function is different.(3) Diaphragm biofeedback at the 1st hour after test meal might reduce the 120min postprandial esophageal acid exposure in patients with GERD. The reduction in esophageal acid exposure might result from enhanced antireflux barrier of the EGJ function. Therefore, diaphragm biofeedback training after meal might provide a new approach to conservative treatment of GERD.(4) Postprandial diaphragm biofeedback for 8 weeks could reduce dosage of acid inhibiting agent and enhance antireflux barrier at EGJ by improving function of crural diaphragm. However, the effect of diaphragm biofeedback on esophageal acid exposure in GERD patients should be further investigated with a longer treatment course.
Keywords/Search Tags:Gastroesophageal
PDF Full Text Request
Related items