| Background and ObjectiveGastroesophageal reflux disease(GERD)is one of the most common and frequent diseases in digestive system caused by stomach contents refluxing into the esophagus,and triggering symptoms or complications.The incidence rate of GERD showed an upward trend with the speeding up of social work and the pace of life.The clinical manifestation forms of GERD are classified as typical symptoms of regurgitation,heartburn,chest pain and extraesophageal symptoms of chronic cough,asthma,laryngitis,laryngeal itching.And extraesophageal symptoms are as the main clinical manifestations of a part of GERD patients.Current research suggested that extraesophageal symptoms-were caused by many factors,and gastroesophageal reflux was one of the aggravating factors,the possible mechanisms included immediate stimulation and neutrally mediated.Proton pump inhibitor,which has a strong anti-secretory and mucosa healing action,is considered the mainstay pharmacologic management for GERD,and improves the symptoms of GERD patients.However,there are still some patients with GERD who have poor or no-response to PPI.The PPI refractory GERD,of which the pathogenesis,diagnosis and treatment is not clearly,attracts attention from worldwide gastroenterologist and scholars.This rearch compared the different esophageal manometry and reflux characteristics of refractory GERD patients esophageal symptoms and refractory GERD patients with extraesophageal symptoms,and explore the possible pathogenesis of refractory GERD with extraesophageal symptoms,to conduct the clinical treatment.Subjects and Methods1.Subjects A total of 298 refractory GERD patients admitted to the First Affiliated Hospital of Zhengzhou University from November 2017 to March 2019 were selected as the subjects of this research,and all of them complete the personal information and reflux symptoms score questionnaire,and all performed the 24 hours pH-impedance and high resolution manometry examination.According to the type of manifestation,the subjects were divided into the esophageal symptom group(100 cases were included),the extraesophageal symptom group(198 cases were included),which included the otolaryngological symptom group(99 cases were included)and the respiratory symptom group(99 cases were included).2.Methods The general information,24 hours pH-impedance and esophageal high resolution manometry results of patients in three groups were collected and analyzed,including gender,age,height,weight,upper esophageal sphincter(UES)resting and residual pressure,lower esophageal sphincter(LES)resting and residual pressure,intra-abdominal LES length,LES-PIP distance,distal contractile integral(DCI),incidence of ineffective contraction,DeMeester score,PH<4 time percentage,the number and longest duration of long acid reflux,the incidence of weak acid and non-acid reflux events,etc.All data above were compared between the esophageal group and the extraesophageal group,and were compared among the esophageal group,otolaryngological group and the respiratory group.3.Statistical methods The SPSS 24.0 software was selected for data statistics and analysis.For the two groups of design,the normal distribution quantitative variables were expressed as mean ± standard deviation(x±s)and compared by Student t-test,the non-normal distribution quantitative variables were expressed as the median and interquartile range[M(P25,P75)],and were compared by non-parametric test(Mann-Whitney U test),and the qualitative variables were expressed as rate[n(n%)],and were compared by ?2 test.For the three groups of design,the normal distribution quantitative variables were compared by ANAVO,and the non-normal distribution quantitative variables were compared by Kruskal-Wallis-test,the qualitative variables were compared by R*2 contingency table ?2 test.All statistics were analyzed by two-side test,and the difference was statistically significant when the P<0.05.Results1.General information A total of 298 cases of patients were selected as the subjects of this research,including 100 patients with esophageal symptoms,198 patients with extraesophageal symptoms,which included 99 patients with otolaryngological symptom symptoms and 99 patients with respiratory symptoms.The otolaryngological group manifestations included foreign body sensation(52 cases),dry throat(27 cases),sore throat(12 cases),rhinitis(24 cases),and hoarseness(15 cases).The respiratory group manifestations included cough(38 cases),chest stuffiness(49 cases),asthma(8 cases),and suppress awake(13 cases).There was no statistically significant difference in age,sex composition ratio and BMI between the typical group and the two extraesophageal group(P>0.05).2.HRM results There was no statistically significant difference in upper esophageal sphincter(UES)resting and residual pressure,lower esophageal sphincter(LES)resting and residual pressure,intra-abdominal LES length,LES-PIP distance,distal contractile integral(DCI)and incidence of ineffective contraction between the esophageal group and extraesophageal group(P>0.05),and there was also no statistically significant difference in above results among esophageal group,otolaryngological group and respiratory group(P>0.05).3.24 hours pH-impedance results There was no statistically significant difference in DeMeester score,PH<4 time percentage,the number and longest duration of long acid reflux between the esophageal group and extraesophageal group(P>0.05).The incidence rate of weak-acid reflux events in extraesophageal group[108(54.5%)]was high than esophageal group[39(39.0%)](P<0.05).The incidence rate of non-acid reflux events in extraesophageal group[41(20.7%)]was high than esophageal group[9(9.0%)](P<0.05).There was no statistically significant difference in DeMeester score,PH<4 time percentage,the number and longest duration of long acid reflux among the esophageal group and the two extraesophageal group(P>0.05).There was statistically significant difference among the there study groups in the incidence rate of weak-acid reflux events(P<0.05),through comparing the two groups between the three groups,the otolaryngological group[57(57.5%)]has a high incidence rate of weak-acid reflux events than esophageal group[39(39.0%)](P<0.05),there was no statistically significant difference between respiratory group[51(51.5%)]and esophageal group or otolaryngological group(P>0.05).There was statistically significant difference among the there study groups in the incidence rate of non-acid reflux events(P<0.05),through comparing the two groups between the three groups,the otolaryngological group[22(22.2%)]and the respiratory group[19(19%)]has a high incidence rate of non-acid reflux events than esophageal group[9(9.0%)](P<0.05),there was no statistically significant difference between respiratory group otolaryngological group(P>0.05).Conclusions1.There was no significant difference among types of refractory GERD clinical manifestations in the esophageal dynamic abnormalities and acid exposure.2.Weak-acid and non-acid reflux are more likely to occur in refractory GERD patients with extraesophageal symptoms than in refractory GERD patients with esophageal symptoms.Weak-acid and non-acid reflux may be important pathogenesis of refractory GERD with extraesophageal symptoms. |
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