Clinical Observation On The Efficacy Of Acupuncture In Refractory Gastroesophageal Reflux Disease

Background:Gastroesophageal reflux disease(GERD)is characterized by symptoms of heart bum and acid regurgitation.The definition of refractory GERD remains controversial.Because refractory GERD is a patient-driven phenomenon,PPI failure in patients who seek medical attention will exhibit different frequency and/or severity of GERD-related symptoms.GERD is the most common digestive disease,affecting one third of the world's population,the most common reason that outpatients refer to gastrointestinal clinics and also the most common indication for upper endoscopy.GERD has a prevalence from 10 to 20%in the western world and less than 5%in Asia.Although the prevalence of GERD in China is lower than that in the western countries,but appears to be increasing.Gastro esophageal reflux occurs normally during transient lower esophageal sphincter relaxation,but it does not cause esophagitis,because it needs excessive reflux,often accompanied by impaired clearance of the refluxed gastric juice.Three main mechanism is known that lead to incompetence of this sphincter,Transient lower esophageal sphincter(LES)relaxation,LES h,ypotension.Anatomic distortion of the esophago-gastric junction because of hiatus hernia.Impaired peristalsis and reduced salivation are two causes of prolonged acid-esophageal contact time.More attention must be paid to bile because it persists in refluxate even when acidity is decreased.There is no single entity as GERD in Chinese medicine,but there are some entities that overlap xwith it as follow;Cao Za(Gnawing Hunger).Fan Wei(Regurgitation of food),Ye Ge(Dysphagia and Blockage),E Ni(Hiccup),Tun Suan(Sour Regurgitation),Tu Suan(Sour Vomiting).Elements of what mentioned above may be seen in GERD.therefor to treat GERD,we should notice treatment of all the above conditions.The main organ in GERD is the stomach.When we talk about gastroesophageal reflux,there is always a pathological Qi in stomach that moves upward instead of its normal direction downward.Objectives:To evaluate the efficacy of acupuncture as a treatment for Refractory gastroesophageal reflux disease(R-GERD)Methods and materials:A case series study was performed in Guangji Traditional Chinese medicine(TCM)hospital in Beijing,China,from June 2017 to March 2018.After summon people with main symptoms of GERD,only patients who have had diagnosis of GERD were chosen.Those who had a course of unsatisfied standard Proton pump inhibitor(PPI)treatment,were adapted to exclusion and inclusion criteria.Twenty patients completed the study and collected data from these patients was analyzed.Because patient's satisfaction of treatment is the main tool to evaluate outcome,two standard questionnaires,Chinese gastroesophageal reflux disease questionnaire(CGERD-Q)and Visual analogue scale(VAS)questionnaires were used.This study aims to detect effectiveness of Acupuncture in decreasing frequency of symptoms that are noticed in CGERD-Q.Beside this evaluation by using a VAS questionnaire effect of treatment on severity also was evaluated.Data were fed into a computer spreadsheet for statistical analysis.Final data were imported and analyzed by a medical expert statistician who was blinded to study grouping and only analyzed presented data.Statistical analysis was performed by using the SPSS version 18.0 for Windows.The Friedman non-parametric test was used to detect differences in treatments across multiple test attempts.Schedule for acupuncture treatment was as follow.First step:Screening consist of standard interview,taking history and physical examination and then filling in CGERD-Q and VAS questionnaires by patient.Second step:Treatment initiation,patient was received 4 sessions of acupuncture treatment,one another day.Third step:At 5th session of treatment and before needling,the patient fill in the same CGERD-Q and VAS questionnaires and again insist on avoiding any thing that may interfere with results,and then acupuncture treatment was done.Fourth step:After 8th session of acupuncture,patient fill in the same CGERD-Q and VAS questionnaires.Patients received acupuncture treatment three times a week,totally 8 sessions.The acupuncture treatment was conducted by Professor Bai Xinhua PHD of TCM.Two group of points were used in the study.One group that located on DU meridian,all located on depression beneath spinous process of vertebrae,consist of points beneath T4 and T12 and also DU6(ji zhong)beneath T11,DU7(zhong shu)beneath T10,DU8(jin suo)beneath T9,DU9(zhi yang)beneath T7,DU 10(ling tai)beneath T6,DU11(shen zhu)beneath T5,and DU12(shen zhu)beneath T3.Among these points,tender points were determined and used for needling.Second group of used points are not located on Du meridian and consist of LI4(he gu),LI10(shou san li),SP6(san yin jiao)and KI3(tai xi).The usual patient care education such as avoiding foods that may trigger or make worsen symptoms or over eating and late night dinner,avoiding smoking and alcohol drinking was provided during every session.Results presented in the text and tables are means plus and minus standard deviation of the mean(mean± standard deviation);P-value<0.050 was considered to be statistically significant.Results:Twenty participants completed the study.Seven(34%)participants in the study were male and 13(66%)were female,with an average age of 47.11 years.Average BMI of participants was 22 which is not out of normal range.Friedman test for acid regurgitation symptom in different times relate to CGERD-Q showed statistically significant difference(P-VALUE=0.000).Belching symptom in different times related to CGERD-Q(P-VALUE= 0.000)and for severity of belching symptom in different times related to VAS questionnaire showed statistically significant difference(P-VALUE= 0.000).Feeling of acidity in the stomach symptom in different times related to CGERD-Q showed statistically significant difference(P-VALUE= 0.001).Epigastric pain in different times related to CGERD-Q(P-VALUE= 0.003)and for epigastric pain in different times related to VAS questionnaire showed statistically significant difference(P-VALUE= 0.009).Friedman test for severity of acid regurgitation in different times related to VAS questionnaire,with this sample size,could not show statistically significant difference(P-VALUE= 0.320).Severity of feeling acidity in the stomach in different times related to VAS questionnaire,with this sample size,could not show statistically significant difference(P-VALUE= 0.262).Chest pain syndrome in different times related to CGERD-Q(P-VALUE=0.263)and for severity of chest pain in different times related to VAS questionnaire,with this sample size,could not show statistically significant difference(P-VALUE=0.400).Conclusion:Totally this study showed acupuncture is effective in relieving some symptoms of R-GERD,So that,Acupuncture was effective in treating acid regurgitation,belching,severity of belching,heart burn,epigastric pain and severity of epigastric pain but not on severity of acid regurgitation,severity of heart burn and severity of chest pain;Of course by enlarging sample size and treating according to Chinese medicine syndrome differentiation,results will be more reliable.Therefore by precise case selection,acupuncture can be used alone to treat R-GERD patients.