The Diaphragm Biofeedback Training In Treatment Of Gastroesophageal Reflux Disease, Efficacy And Mechanism Study

Abstract I Investigation of unhealthy lifestyle, previous status of examination and treatment and disease recognition in gastroesophageal reflux disease patientsBackground and ObjectivesUnheathy lifestyle and eating habits and abnormal psychological status may affect the function of EGJ, reduce the sensation threshold of the esophagus, and cause reflux symptoms. Wrong recognition to GERD induces patients going to hospitals repeatedly and receiving unregular treatment, all of these impact therapeutic effect, cause waste of medical resource, cause economic and psychological burden on these patients. This study aimed to investigate risk factors related to GERD for improvement of therapeutic effect.Subjects and MethodsWe recruited consecutively 122 GERD patients. They were all between 18-65 years old, who had typical symptoms of reflux (such as heartburn, acid reflux, regurgitation or chest pain), or those who were believed to have extra-esophageal symptoms of GERD such as chronic cough, asthma, pharyngitis, et al, and 24h pH monitoring positive. Those who had slide hiatus hernia, history of gastrointestinal operation or systemic diseases which may cause secondary gastric esophageal reflux should be excluded. All patients were asked to complete a questionnaire on GERD, including demographic status, reflux related symptoms, lifestyle, previous status of examination, and treatment, their disease recognition, SF-36 questionnaire and questionnaire of psychological status(SAS and SDS).Results1.122 GERD patients were investigated,75 male,mean age 49.1 years,47 female, mean age 54.5 years, patients who at least had a bachelor's degree account for 50.8%, 80.3%had mild physical labour,33.6%had risk factors for increase of abdominal pressure.2. Symptoms:32.8%of patients reported heartburn to be the most troublesome symptom, followed by chest pain and acid reguitation as the second and third troublesome symptom.3. Risk factors:patients who had at least one of the risk factors related to GERD account for 79.5%, and the most common risk factors were over weight or obesity (45.1%), often taking large meals (39.3%) and abnormal psychological status (31.1%), 29.5%of GERD patients were very anxious about this disease,27.9%came to see the doctor because they were afraid of cancer and 50.8%were worried about progressing to esophageal cancer.4. Previous status of examination and treatment,18%(22/122) had received gastric endoscopy at least 5 times or more, the most frequent one had more than 20 times(in a period of 77 months),51.6%had tried one of non-drug therapy, avoidance of large meals, elevation of head of bed and absence of cigarettes and alchohol were the first three which may be effective, patients had ever taken different kinds of drugs to treat this disease,20.5%and 24.6%complained the cost of examinaiton and medicine over RMB 1,0000,36.9%had total cost over tens of thousands.Conclusions1. The most troublesome symptom of GERD is heartburn and quite often occurred postprandially.The second and third troublesome symptom are chest pain and acid regurgitation. Diet, posture and emotion are related to occurrence of the most troublesome symptoms. Large part of patients had at least one of the risk factors related to GERD.2. Patients had received different kinds of drugs and cost a lot on examinaiton and medicine. Nearly one third of patients were very anxious about GERD, about one half were afraid of progressing to esophageal cancer. In clinical practice, disease education to change unhealthy lifestyle and eating habits, and explanation to those who had wrong recognition of GERD are very important.Abstract II Investigation of long term effect of diaphragm biofeedback training in GERD patientsBackground and aimsOur research center have applied DBT in GERD therapy and found it effective. The aim of this study was to investigate the effect of DBT in maintenance therapy in patients with GERD. Subjects and methods123 GERD patients were enrolled continously in this study (male 76, female 47). They were all between 18-75 years old, had typical reflux symptoms, total reflux symptom score(TRSS)≥6, or TRSS<6 but still suspected to be GERD and 24h pH monitoring were positive and/or response to PPI treatment.Patients who had chest pain, chronic cough or asthma, heart disease and pulmonary disease should be firstly excluded, and they also must have 24h pH monitoring positive and/or response to PPI treatment.After completing the GERD questionnaire, they were distributed into two groups-group DBT (N=84) or group PPI (N=39) according to their willingness. Both groups were asked to take PPI regularly (single dose, twice daily) in the first 8 weeks, and patients in group DBT must also receive DBT 4 times daily. In this period, we made telephone call to these patients every two weeks to monitor whether their symptoms were relieved, and asked patients in group DBT come back to hospital to check their DBT was correct or not. At the end of this period, they were asked to come back to GI clinic and complete a follow-up questionnaire. Then in the maintenance treatment period (from 9th week to 6th month), both groups took PPI only when needed, and group DBT were asked to continue to apply DBT 4 times daily.Both of the two groups should record their symptoms and PPI consumption, and came to hospital for a countercheck and completed the follow-up questionnaire at the end of 4th and 6th month. Patients who was not able to come to GI clinic received a letter for follow-up questionnaire.Results1. There were no statistical differences in all these aspects as follows, female proportion, age, BMI, TRSS, dosage of PPI, psychological status, between group DBT and group PPI at baseline. There were 54 patients (64.3%) in group DBT who could insist on regular DBT, the other 30 patients could not insist on or even stopped it, so patients in group DBT were divided into regular DBT group and un-regular DBT group. TRSS, consumption of PPI and psychological status were not significantly different within these three groups at baseline and during the period of follow-up.2. Patients in regular DBT group showed significant decrease of TRSS at the end of 2nd,4th,6th,8th week and 4th,6th month compared with baseline (3.1,3.0,2.2,1.9,2.8,2.9 vs 8.5, p<0.05), PPI consumption was not different from baseline (because all patients took PPI when they were enrolled), SAS and SDS score were improved distinctly at the end of 4th and 6th month.3. Patients who did not receive DBT regularly only had significant reduction of TRSS at the end of 2nd,4th,6th,8th week (3.8,2.2,1.6,2.2 vs 9.8, p<0.05), TRSS at the end of 4th and 6th month were not significantly different from baseline, the same as the PPI consumption, SAS and SDS score during the period of follow-up. 4. In group PPI, TRSS decreased significantly but dosage of PPI and psychological status were all similar to baseline throughout the follow-up period.Conclusions4-month and 6-month regular DBT could improve psychological status in GERD patients.Abstract III Effect of diaphragm biofeedback training in GERD patients with distinct respiratory tract symptomsBackgrounds and aimsIn the second part of this study, we found that regular DBT could reduce reflux symptoms and improve psychological status of GERD patients. The aim of this study was to observe effect of DBT in GERD patients who have distinct respiratory tract symptoms.Subjects and methods14 GERD patients were enrolled, they were all between 18～75 years old, had chronic cough and/or asthma for over 8 weeks,excluded for pulmonary mass or acute infection. They had a TRSS≥6, or if TRSS<6 but positive 24h esophageal pH monitoring, or good response to 2-week PPI therapy.Gastric or duodenal ulcer, past history of operation on gastrointestinal tract and systemic disease should also be excluded. Patients completed the GERD questionnaire and learned how to do DBT, then they applied regular DBT (4 times daily) at home besides taking drugs. We made telephone call to monitor their symptoms and asked them come back to GI clinic every two weeks in the first eight weeks. At the end of 8th week, they were asked to fill in the follow-up questionnaire. After that, they were followed up each month by telephone or coming to clinic. Results1. In these 14 patients, there were 4 RE patients and 10 NERD patients,9 male, average age was 50.9±12.9 years, and 5 patients were overweight (BMI≥24 kg/m2).2.5 patients had course of disease over 10 years, accouted for 35.7%, and median course of disease was 51 months.3.6 patients (42.9%) complained of cough as the first occurring symptom, and 9 (64.3%)took it as the most troublesome symptom,42.9%of the 14 patients had cough during sleep or just when they woke up in the morning, provocative factors of symptoms were posture (50%), catching cold (35.7%) and eating food (28.6%).2 patients had abnormal psychological status(14.3%).4.2-week therapy combined DBT with PPI could significantly reduce the TRSS of GERD patients compared with that in the worst status, and make score of cough much lower than that at baseline and in the worst status.5. PPI consumption and psychological status didn't change statistically at the end of 8th week, improvement of symptoms lasted to the 3rd month, and PPI comsumption in the 3 rd month had a tentancy to decrease but did not reach a statistical significance.Conclusions1. NERD patients(71.4%) had more respiratory tract symptoms than RE patients.2. Cough induced by GERD may be related to more nocturnal reflux.3. DBT combined with PPI therapy in GERD patients with distinct respiratory tract symptoms may significantly reduce their symptoms in a short period (2 weeks) and maybe can reduce the PPI consumption during maintenance therapy. DBT may become a new way to control chronic cough related to GERD.Abstract IV Investigation of mechanism of DBT in GERD therapy Background and aimsThe second and third part of the study have shown that DBT could relieve the reflux symptoms in GERD patients. Aims of this part were to investigate the mechanism of DBT in GERD therapy, including effect of DBT on acid exposure of esophagus, gastric emptying and TLESR.Subjects and methodsEnrolling standards:the same to that in abstractⅡ.1. Effect of DBT on acid exposure of esophagus of GERD patients:7 GERD patients were enrolled. Acid inhibitors and gastrointestinal prokinetic-agents should be avoided at least 7 days before 24h esophagus pH monitoring. Patients repeated 24h esophagus monitoring after 2-week regular DBT.2. Effect of DBT on gastric emptying in GERD patients:16 GERD patients, received the first nuclide gastric emptying inspection when enrolled, then repeated it after 2-week regular DBT. If patients had PPI at baseline, they did not change the dosage during the first two weeks. Another 13 healthy subjects were also enrolled. All subjects were well informed about the examination.3. Effect of DBT on TLESR:32 GERD patients were enrolled.We compared the parameters of esophagus manometry before and after DBT. Times of TLESR, total duration of TLESR were what we are concerned.Results1. Score of acid regurgitation and TRSS decreased significantly after 2-week regular DBT (2.34±0.9 vs 1.3±0.4,7.7±2.9 vs 3.5±1.3, p<0.05), episodes of acid reflux recorded by pH monitoring was also reduced (138.7±79.71 vs 79.3±92.5, p<0.05).2.2h total gastric emptying%, velocity of total gastric emptying,2h proximal gastric emptying%and velocity of proximal gastric emptying was much lower in GERD patients than HS (39.1±13.3 vs 57±18.4,49.4±13.5 vs 63.8±18.4,0.3±0.1 vs 0.4±0.1,0.4±0.1 vs 0.5±0.2), T1/2 of total and proximal gastric emptying was also much longer than HS (186.0±86.4 vs 119.9±40.1,141.0±53.4 vs 103.5±30.7, p<0.05). After 2-week regular DBT,2h total gastric emptying%was still much lower than HS (40.6±16.5%vs 57±18.4%, p<0.05), T1/2 of total gastric emptying still longer than HS (181.2±79.0 min vs 119.9±40.1min, p<0.05), however, velocity of total gastric emptying, T1/2 of total gastric emptying,2h proximal gastric emptying%and velocity of proximal gastric emptying were not significantly different from those in HS.3.6 of 32 GERD patients repeated EM after regular DBT, times of TLESR, total duration of TLESR didn't change obviously.Conclusions1.2-week regular DBT could improve reflux symptoms and acid exposure of esophagus in GERD patients.2. Gastric emptying in GERD patients was much lower than HS,2-week regular DBT maybe can improve 2h proximal gastric emptying.3.8-week DBT could not reduce the TLESR significantly.