ABSTRACT
Objective:To explore features and clinical significance of motility characteristics, related clinical symptoms, 24-hour esophageal impedance-pH monitoring in patients with gastroesophageal reflux disease (GERD) complicated with esophagogastric junction outflow obstruction (EGJOO).Methods:From August 2014 to August 2019, a total of 512 GERD patients visited Zhuhai People′s Hospital were enrolled. All patients were divided into EGJOO group (85 cases) and non-EGJOO group (427 cases) according to the presence or absence of EGJOO. The patients were also divided into non-erosive reflux disease (NERD) group (393 cases) and reflux esophagitis (RE) group (119 cases) based on the endoscopic findings. The esophageal high resolution manometry (HRM) motility characterisrics, clinical symptoms, results of 24-hour esophageal impedance-pH monitoring of each group were analyzed. Fisher exact probability method, Wilcoxon rank sum test for comparison among groups and McNemar test for comparison of paired data were used for statistical analysis.Results:The lower esophageal sphincter (LES) resting pressure, integrated relaxation pressure (IRP), distal contractile integral (DCI), intrabolus pressure (IBP) and maximum IBP of EGJOO group were all higher than those of non-EGJOO group (30.70 mmHg, 22.50 mmHg to 40.75 mmHg (1 mmHg=0.133 kPa) vs. 19.90 mmHg, 14.50 mmHg to 26.20 mmHg; 17.80 mmHg, 16.20 mmHg to 22.85 mmHg vs. 7.80 mmHg, 5.20 mmHg to 10.20 mmHg; 1 282.80 mmHg·s·cm, 654.55 mmHg·s·cm to 2 563.20 mmHg·s·cm vs. 818.90 mmHg·s·cm, 495.10 mmHg·s·cm to 1 365.10 mmHg·s·cm; 7.00 mmHg, 4.40 mmHg to 11.65 mmHg vs. 3.60 mmHg, 1.10 mmHg to 5.80 mmHg; 14.90 mmHg, 11.50 mmHg to 18.80 mmHg vs. 10.40 mmHg, 8.10 mmHg to 13.10 mmHg, respectively), and the differences were statistically significant ( Z=-7.82, -14.57, -4.25, -7.16, and -6.27, all P<0.01). The LES resting pressure of NRED group was higher than that of RE group (21.70 mmHg, 15.65 mmHg to 29.40 mmHg vs. 19.40 mmHg, 13.60 mmHg to 25.10 mmHg), and the difference was statistically significant ( Z=-2.47, P=0.014). The DeMeeste score, episodes of long time (more than five minutes) acid reflux, the longest duration of reflux and the percentage of time pH<4 of EGJOO group were all higher than those of non-EGJOO group (6.60 points, 2.70 points to 11.20 points vs. 3.25 points, 1.30 points to 9.18 points; 1.00 times, 0.00 times to 1.00 times vs. 0.00 times, 0.00 times to 0.00 times; 6.50 s, 2.00 s to 15.00 s vs. 1.00 s, 0.00 s to 5.00 s; 1.70%, 0.30% to 2.30% vs. 0.30%, 0.00% to 1.63%, respectively), and the differences were statistically significant ( Z=-2.04, -2.94, -3.98 and -2.42, all P<0.05). Before treatment, the percentage of dysphagia of EGJOO group was higher than that of non-EGJOO group (9.4%, 8/85 vs. 2.1%, 9/427), and the difference was statistically significant (Fisher exact test, P=0.01). The percentage of heartburn, belching, abdominal pain, abdominal distention and chest pain of EGJOO group and non-EGJOO group after treatment were all significantly lower than those before treatment (EGJOO group: 11.8%, 10/85 vs. 34.1%, 29/85; 34.1%, 29/85 vs. 51.8%, 44/85; 4.7%, 4/85 vs. 20.0%, 17/85; 3.5%, 3/85 vs. 22.4%, 19/85; 4.7%, 4/85 vs. 21.2%, 18/85. Non-EGJOO group: 14.8%, 63/427 vs. 33.0%, 141/427; 36.8%, 157/427 vs. 51.5%, 220/427; 5.4%, 23/427 vs. 26.5%, 113/427; 6.6%, 28/427 vs. 21.1%, 90/427; 2.8%, 12/427 vs. 18.3%, 78/427), and the differences were statistically significant (all McNemar test, all P<0.05). Conclusions:In EGJOO patients with LES dysfunction, the symptoms are more severe, acid reflux is more obvious, and the efficacy of conventional prokinetic therapy is poor. The occurrence of esophageal erosion is not only due to acid reflux and acid exposure time, but also to esophageal motility disorder and local mucosal barrier function.