Characteristics of reflux and manifestation under probe-based confocal laser endoscopy in patients with endoscopic negative heartburn / 中华消化内镜杂志

Objective:To study reflux characteristics of patients with endoscopic negative heartburn and their manifestation under probe-based confocal laser endoscopy (pCLE) based on the Rome Ⅳ standard.Methods:Thirty-six endoscopic negative outpatients with typical heartburn at the Department of Gastroenterology of the Second Affiliated Hospital of Baotou Medical College from September 2020 to March 2021 were included, and underwent 24-hour multichannel intraluminal impedance-pH monitor and pCLE. According to Rome Ⅳ diagnostic process, patients were divided into non-erosive reflux disease (NERD) group ( n=16), reflux hypersensitivity (RH) group ( n=8) and functional heartburn (FH) group ( n=12). The Gerd-Q scale score, 24-hour pH monitoring results and microstructure changes under pCLE were compared among the three groups. Results:There was no significant difference in the total score, positive symptom score, negative symptom score or positive influence score of Gerd-Q scale among the three groups ( P>0.05). DeMeester score [28.45 (20.08, 34.53)] and acid reflux times (24.88±9.05) in the NERD group were significantly higher than those in the RH group [7.30 (3.90, 11.38), P<0.001; 13.63±5.76, P=0.003] and FH group [6.90 (4.80, 9.73), P<0.001; 7.42±8.32, P<0.001]. But there was no significant difference between the RH group and the FH group ( P>0.05). The diameter of intra-papillary capillary loop (IPCL) (18.68±2.12 μm) and dilation of intercellular space (3.95±0.97 μm) in the NERD group were significantly higher than those in the RH group (13.91±1.99 μm, P<0.001; 2.97±0.55 μm, P=0.006) and FH group (13.83±2.00 μm, P<0.001; 2.31±0.54 μm, P<0.001), but there was no significant difference between the RH group and the FH group ( P>0.05). The number of IPCL in the NERD group, RH group and FH group were 2.0 (1.00, 2.75), 2.0 (1.00, 2.75) and 1.5 (1.00, 2.00), respectively with no significant difference ( P=0.697). Conclusion:Gerd-Q scale is not suitable for differential diagnosis of patients with endoscopic negative heartburn. Compared with functional esophageal diseases (RH and FH), acid reflux and mucosal microstructure changes are of more important pathogenic significance in NERD.

Clinical significance of ineffective esophageal motility in non-erosive acid reflux diseases / 中华消化内镜杂志

Objective:To investigate the role of ineffective esophageal motility (IEM) in non-erosive acid reflux related diseases, and the influence of the fourth edition Chicago classification (CC v4.0) on the diagnosis of IEM.Methods:From January 2018 to January 2020, 63 patients with acid reflux related symptoms who underwent gastroscopy and showed no abnormal changes in esophageal mucosa or structure, and underwent high resolution esophageal manometry (HRM) and 24-hour esophageal pH monitoring in the Department of Gastroenterology of Beijing Friendship Hospital were included in the case-control study. According to the HRM results, the third edition Chicago classification standard (CC v3.0) and CC v4.0 were used to divided patients into IEM group and normal dynamic group. The HRM results, 24-hour esophageal pH monitoring results and final diagnosis of the two groups under the two editions of Chicago classification standard were mainly compared and analyzed.Results:Among the 63 patients, there were 14 cases of non-erosive gastroesophageal reflux disease (NERD), 19 cases of reflux hypersensitivity (RH), and 30 cases of functional heartburn (FH). When using CC v3.0, there were 20 cases in the IEM group, including 9 cases of NERD, 5 cases of RH and 6 cases of FH, and 43 cases in the normal dynamic group, including 5 cases of NERD, 14 cases of RH and 24 cases of FH. When using CC v4.0, there were 16 cases in the IEM group, including 7 cases of NERD, 4 cases of RH and 5 cases of FH, and 47 cases in the normal dynamic group, including 7 cases of NERD, 15 cases of RH and 25 cases of FH. When using CC v3.0, compared with the normal dynamic group, the acid exposure time (AET) of the IEM group was significantly higher [3.45 (1.55, 6.40)% VS 1.20 (0.40, 2.30)%, Z=-2.940, P=0.003], the DeMeester score was also significantly higher [13.8 (5.8, 21.4) VS 5.3 (2.9, 10.0), Z=-2.851, P=0.004], the lower esophageal sphincter pressure (LESP) [10.15 (7.52, 13.65) mmHg (1 mmHg=0.133 kPa) VS 15.40 (11.20, 21.60) mmHg, Z=-3.241, P=0.001], 4-second integrated relaxation pressure (4sIRP) (3.79±0.57 mmHg VS 6.05±0.50 mmHg, t=2.727, P=0.008), and distal contraction integral (DCI) [334.65 (208.25, 438.92) mmHg·s·cm VS 1 258.70 (919.00, 1 750.10) mmHg·s·cm, Z=-6.305, P<0.001] were significantly lower than those of the normal dynamic group. When using CC v4.0, AET and Demeester scores in the IEM group were also significantly higher than those in the normal dynamic group (both P<0.05), and LESP, 4sIRP and DCI were also significantly lower than those in the normal dynamic group (all P<0.05). In addition, upper esophageal sphincter pressure was significantly lower than that in normal dynamic group [34.60 (21.50, 48.05) mmHg VS 49.67 (36.75, 61.10) mmHg, Z=-2.140, P=0.032]. Conclusion:IEM is associated with impaired anti-reflux barrier function and esophageal acid exposure in patients with non-erosive acid reflux related diseases. Compared with CC v3.0, CC v4.0 can reduce the heterogeneity of IEM patients to some extent.

Comparison of esophageal motility and reflux characteristics of patients with endoscopic-negative heartburn based on the Lyon Consensus / 西安交通大学学报(医学版)

【Objective】 To explore the characteristics of esophageal motility and reflux of endoscopic-negative heartburn patients based on the Lyon Consensus Diagnostic Criteria and discuss the differential diagnosis value of the mean nocturnal baseline impedance （MNBI） and the postreflux swallow-induced peristaltic wave （PSPW） index for reflux hypersensitivity （RH） and functional heartburn （FH） patients. 【Methods】 We enrolled 132 patients with heartburn as the main symptom who visited the Gastroenterology Department of our hospital from January 2017 to June 2021， including 24 in the non-erosive reflux disease （NERD） group， 24 in the RH group， and 84 in the FH group. All the patients completed gastroscopy， esophageal high-resolution manometry and 24h-pH impedance monitoring. We analyzed and compared the related indexes of esophageal motility and reflux. The receiver operating characteristic （ROC） curve was used to analyze the esophageal proximal MNBI， distal MNBI， and PSPW indexes for the differential diagnosis of RH and FH. 【Results】 The lower esophageal sphincter （LES） average resting pressure， LES residual pressure and intact relaxation pressure （IRP） in NERD were lower than those in RH and FH （P0.05）. When the proximal MNBI， distal MNBI， and PSPW indexes were used alone respectively to diagnose RH， the area under the ROC curve was 0.480， 0.810， 0.682， respectively， with the sensitivities being 87.5%， 100% and 91.7%， and the specificities being 26.2%， 66.7% and 51.2%， respectively. 【Conclusion】 NERD patients have obvious abnormal esophageal dynamics， mainly manifested as LES relaxation， which further aggravates the pathological acid reflux， while patients with RH and FH are mainly exposed to physiological acid or non-acid reflux. In patients with endoscopic negative heartburn， distal MNBI value can improve the clinical diagnosis rate of RH and help distinguish RH from FH.

Esophageal pH-impedance monitoring of reflux patterns in non-erosive reflux disease, reflux hypersensitivity and functional heartburn / 南方医科大学学报

OBJECTIVE@#To analyze the differences in reflux patterns in 24-hour esophageal pH-impedance monitoring in patients with non-erosive reflux disease (NERD), reflux hypersensitivity (RH) and functional heartburn (FH) and explore the possible mechanism of symptoms in patients with heartburn and negative endoscopic findings.@*METHODS@#Seventy-nine patients with heartburn as the main symptoms but negative endoscopic findings, including 35 with NERD, 16 with RH and 28 with FH, were enrolled in this study.All the patients underwent 24-h esophageal pH-impedance monitoring and esophagogastroscopy, and the results were compared among the 3 groups.@*RESULTS@#Acid reflux episode was significantly increased and weakly alkaline reflux episode was significantly decreased in NERD group in comparison with RH group and FH group (@*CONCLUSIONS@#Patients with NERD, RH and FH had different reflux patterns.Acid reflux is predominant in the NERD, while weakly alkaline reflux is significantly increased RH and FH.In patients with normal esophageal acid exposure but without symptoms or without recorded symptoms during esophageal pH-impedance monitoring, analysis of the total reflux episode, mixed reflux episode, proximal acid reflux episode and percentage can help in the differential diagnosis between RH and FH.

Understanding the Rome IV: Esophageal Disorders / 대한내과학회지

The Rome IV criteria, published in 2016, encompass upper gastrointestinal lesions of functional esophageal disorders and functional gastroduodenal disorders. Functional esophageal disorders include functional chest pain, functional heartburn, reflux hypersensitivity, globus, and functional dysphagia. Patients with functional esophageal disorders typically have esophageal symptoms that are not associated with structural, inflammatory, or major esophageal motor disorders. Although the mechanisms of symptom generation in functional esophageal disorders are unclear, visceral hypersensitivity and hypervigilance may play a role. Therefore, treatment options include drugs and modalities that affect peripheral triggering and central perception. Further well-designed studies are needed to identify the mechanisms of symptom generation in, and to develop appropriate therapies for, functional esophageal disorders.

A analysis on the monitoring results of high resolution esophageal manometry and 24-Hour impedance-pH for the patients with functional heartburn and non-erosive reflux disease / 中国医学装备

Objective:To analyze the monitoring results of high resolution esophageal manometry (HRM) and 24-Hour impedance-pH for the patients with functional heartburn (FH)and non-erosive reflux disease(NERD), and explore the effect of Gastroesophageal junction morphology, transient lower esophageal sphincter relaxation and regurgitation of gastric acid in FH and NERD.Methods: 86 patients with continuous heartburn who were negative under endoscope were divided into FH group(38cases) and NERD group(48cases), and gastrointestinal symptom rating scales (GSRS), the results of HRM and 24h pH/impedance monitoring of the two groups were compared and analyzed.Results: The GSRS of sour regurgitation, abdominal distension, diarrhea and constipation of FH group were significantly higher than that of NERD group, respectively(t=-4.45,t=3.83,t=3.07,t=4.58,P<0.05). The ratio of esophagogastric junction-III(EGJ-III)of FH group was significantly lower than that of NERD group (Z=-3.27,P<0.05). And the ratio of esophageal hiatus hernia of FH group was significantly lower than that of NERD group(x2=16.01,P<0.05). In HRM parameters, the differences of lower esophageal sphincter pressure (LESP), upper esophageal sphincter pressure(UESP), distal contractile integral(DCI)and esophagogastric junction- contractile integral (EGJ-CI) between FH group and NERD group were statistically significant(t=6.99,t=-4.51,t=-2.91,t=-3.72;P<0.05), respectively. On the other hand, the times of sour regurgitation in erect position, the ratio of fluid regurgitation, exposed time of erect position and clinostatism, and DeMeester integral of NERD group was statistically significant higher than that of FH group(t=-9.48,t=-13.00,t=-13.56,t=-18.31;P<0.05).Conclusion:There are esophageal dysfunction in a certain degree and obvious regurgitation in both of two groups, and the detections of HRM and 24h-impedance pH contribute to differential diagnosis for NERG. Besides, the symptom of patients with FH may be relative with regurgitation of non-acidic material, especially may be relative with regurgitation of air.

The characteristics of esophagogastric junction contractile index in patients with gastroesophageal reflux disease or functional heartburn / 中华内科杂志

Objective To study the role of esophagogastric junction contractile index (EGJ-CI) in evaluating the function of anti-reflux barrier,and in differentiating patients with gastroesophageal reflux disease (GERD) from those with functional heartburn (FH).Methods A total of 115 patients presenting heartburn were enrolled in the study from January 2012 to June 2015.All subjects had completed Gerd-Q questionnaire and undergone gastroscopy,24-hour pH-impedance monitoring and esophageal high-resolution manometry.GERD patients were divided into as reflux esophagitis,acid-nonerosive reflux disease (NERD) and weakly acid-NERD groups.Patients with normal esophageal mucosa,normal acid exposure and negative proton pump inhibitor test were enrolled in FH group.EGJ-CI (mmHg · cm) as well as EGJ rest pressure and 4s integrated relaxation pressure (IRP 4s) were measured.Results Among the 115 patients,18 were reflux esophagitis [(49.0 ± 18.9) years,M ∶ F =10 ∶ 8],25 were acid-NERD [(48.7 ± 14.4) years,M∶F=13∶ 12],37 were weakly acid-NERD [(52.0 ±14.8) years,M∶F=15∶22] and 35 were FH [(53.6 ± 14.8),M∶ F =8∶27].No differences of Gerd-Q scores were noticed between the four groups.(1) Negative correlations were demonstrated between EGJ-CI and esophageal acid exposure time (r =-0.283,P =0.002),EGJ-CI and acid reflux events (r =-0.233,P =0.012),EGJ-CI and weakly acid reflux events (r =-0.213,P =0.022),EGJ-CI and non-acid reflux events (r =-0.200,P =0.032).(2)The value of EGJ-CI was significantly higher in FH patients than in the three subgroups of GERD(all P ＜ 0.01).EGJ rest pressure of FH group was higher than that of acid-NERD (P ＜ 0.01).IRP 4s in acid-NERD group was lower than that of FH and weakly acid-NERD (P ＜ 0.05).(3) The area under curve (AUC) of EGJ-CI was higher than that of EGJ-CIT,EGJ rest pressure or IRP 4s (0.686 vs 0.678,0.641 and 0.578).The cut-off value of EGJ-CI to differentiate GERD from FH was 9.74 mmHg · cm with sensitivity 82.86％ and specificity 51.52％.Conclusions The EGJ-CI values are negatively correlated with esophageal acid exposure time,weakly acid reflux events and non-acid reflux events.Thus it might be used as a metric to reflect the anti-reflux function of EGJ.According to the cut-off value of EGJ-CI 9.74 mmHg · cm,patients with GERD can be sensitively differentiated from patients with FH.

Efficacy Observation of Mosapride Combined with Flupentixol Melitracen in the Treatment of Elderly Func-tional Heartburn / 中国药房

OBJECTIVE:To observe clinical efficacy and safety of mosapride combined with flupentixol melitracen in the treat-ment of elderly functional heartburn. METHODS:106 elderly patients with functional heartburn in accordance with Rome IIIstan-dard were randomly divided into control group(52 cases)and treatment group(54 cases). The control group was treated with Mo-sapride dispersible tablets 5mg,tid,orally;the treatment group was additionally given Flupentixol melitracen tablets(containing flu-pentixol 0.5 mg and melitracen 10 mg),qd,on the basis of control group. Therapeutic efficacy of 2 groups were observed after 4 weeks. Hamilton anxiety scale(HAMA),Hamilton depressive scale(HAMD) and symptom score were conducted before and after treatment. RESULTS:The total effective rate of treatment group and control group were 87.0%and 53.8%;with statistical signifi-cance(P<0.05);there was statistical significance in symptom score,HAMA score and HAMD score between 2 groups after treatment (P<0.01). No severe ADR was found in 2 groups. CONCLUSIONS:Mosapride combined with flupentixol melitracen is safe and ef-fective in the treatment of elderly functional heartburn.

Comparison of Gastroesophageal Reflux Disease Symptoms and Proton Pump Inhibitor Response Using Gastroesophageal Reflux Disease Impact Scale Questionnaire

BACKGROUND/AIMS: To compare gastroesophageal reflux disease (GERD) symptoms and response to proton pump inhibitor (PPI) in patients with erosive esophagitis (EE), non-erosive reflux disease (NERD) or functional heartburn (FH) using GERD impact scale (GIS) questionnaire. METHODS: Total 126 patients with GERD symptoms were diagnosed as EE (n = 62), NERD (n = 34) and FH (n = 30) by endoscopy, 24-hour esophageal pH testing and Bernstein test, prospectively. Analysis of risk factors and GIS questionnaire for GERD symptoms and quality of life were performed before and 8 weeks after PPI treatment. RESULTS: EE group had a higher proportion of men, frequent alcohol consumption, smoking, hiatal hernia, body mass index > or = 25 kg/m2 and triglyceride levels (> or = 150 mg/dL) than the other groups (all P < 0.05). On the other hand, both psychiatric treatment and psychopharmacotherapy were more frequent in patients with FH than in those with EE and NERD (both P < 0.05). Among GERD symptoms, chest pain was more frequent in FH group than in EE and NERD groups (P < 0.05). Eating problems and limitation of productive daily activities occurred frequently in FH group and NERD group, respectively. GIS after 8 week PPI treatment showed improvement in all of the GERD symptoms in EE (all P < 0.05) and in acid regurgitation, epigastric pain and hoarseness in NERD group (all P < 0.05). In terms of quality of life, PPI treatment improved sleep disturbance in EE (P = 0.031) and limitation of productive activity in the NERD group (P = 0.001). CONCLUSIONS: GIS questionnaire showed that different characteristics and symptoms improved after PPI therapy among patients with EE, NERD and FH, demonstrating the usefulness of the GIS questionnaire.