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ObjectiveTo evaluate the clinical efficacy and adverse effects of Shugan Hewei prescription combined with vonoprazan in the treatment of refractory gastroesophageal reflux disease （RGERD） due to qi depression and phlegm obstruction. MethodEighty RGERD patients who met the inclusion criteria underwent 24-hour pH impedance and high-resolution esophageal manometry and electronic gastroscopy. The 80 patients were randomly assigned to an observation group （Shugan Hewei prescription， one bag each time， twice a day + vonoprazan， 20 mg each time， once a day） and a control group （vonoprazan， 20 mg each time， once a day） by the random number table method. The treatment in both groups lasted for 4 weeks. The clinical efficacy was examined. The scores of TCM symptoms （pharyngeal discomforts such as phlegm obstruction， retrosternal discomfort， and belching）， somatic symptoms， quality of life， and improvement of esophageal mucosa under gastroscopy were observed in both groups before treatment and after treatment for 2 and 4 weeks. ResultSeventy-five patients completed the trial were included in this study， including 38 patients in the observation group and 37 patients in the control group. The total response rate in the observation group was 89.47%（34/38）， which was higher than that （62.16%，23/37） in the control group （χ2=13.014， P<0.01）. After treatment， the scores of esophageal mucous membrane， reflux disease symptoms， TCM symptoms， gastroesophageal reflux disease health-related quality of life scale （GERD-HRQL）， and somatic self-rating scale （SSS） decreased in both groups（P<0.05）. Moreover， the observation group outperformed the control group in alleviating heartburn， acid reflux， throat discomforts， midnight coughing， nausea and dry vomiting， mucousy mouth， and insomnia in the patients with GERD （P<0.05，P<0.01）. However， the two groups showed no statistically significant differences in the improvement of esophageal mucosa after treatment. ConclusionThe combination of Shugan Hewei prescription with vonoprazan was superior to vonoprazan alone in treating RGERD regarding clinical symptoms， physical signs， quality of life， and somatic symptoms， without causing obvious adverse effects.
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@#Objective To investigate the short-term effects of Da Vinci robot-assisted Nissen fundoplication in the treatment of refractory gastroesophageal reflux disease (rGERD), and to evaluate the safety and efficacy of its surgical treatment. Methods A total of 40 patients with rGERD treated by Da Vinci robot-assisted surgery from October 2016 to November 2019 in our hospital were collected. There were 23 males and 17 females at age of 34-76 (61±23) years. The related clinical data were retrospectively analyzed, and the operation skills of Da Vinci robot-assisted Nissen fundoplication with rGERD were summarized. Results There was no perioperative death or serious complication such as esophagogastric fistula. Postoperative reflux symptoms were significantly improved. DeMeester scores after surgery (39.79±35.01 points vs. 2.61±2.40 points, P=0.029), lower esophageal sphincter pressure (8.74±7.21 mm Hg vs. 24.56±8.76 mm Hg, P=0.020), integrated relaxation pressure (7.29±7.21 mm Hg vs. 16.49±9.99 mm Hg, P=0.023), distal contractile integral (600.49 ± 665.30 mm Hg·s·m vs. 510.99 ± 580.60 mm Hg·s·m, P=0.042), GERD-Q scale score (12.98±2.39 points vs. 7.59±1.11 points, P=0.033) were significantly improved compared with those before surgery. Postoperative dysphagia was found in 2 patients. And dysphagia was alleviated after diet adjustment and other treatments. Conclusion Da Vinci robot-assisted Nissen fundoplication is a safe and effective treatment for rGERD.
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ABSTRACT BACKGROUND: Gastroesophageal reflux disease (GERD) is a clinical condition that develops when the reflux of stomach contents causes troublesome symptoms and/or complications. Transient lower esophageal sphincter relaxation is the main pathophysiological mechanism of GERD. Symptoms and complications can be related to the reflux of gastric contents into the esophagus, oral cavity, larynx and/or the lung. Symptoms and other possible manifestations of GERD are heartburn, regurgitation, dysphagia, non-cardiac chest pain, chronic cough, chronic laryngitis, asthma and dental erosions. The proton pump inhibitor (PPI) is the first-choice drug and the most commonly medication used for the treatment of GERD. The most widespread definition of Refractory GERD is the clinical condition that presents symptoms with partial or absent response to twice-daily PPI therapy. Persistence of symptoms occurs in 25% to 42% of patients who use PPI once-daily and in 10% to 20% who use PPI twice-daily. OBJECTIVE: The objective is to describe a review of the current literature, highlighting the causes, diagnostic aspects and therapeutic approach of the cases with suspected reflux symptoms and unresponsive to PPI. CONCLUSION: Initially, the management of PPI refractoriness consists in correcting low adherence to PPI therapy, adjusting the PPI dosage and emphasizing the recommendations on lifestyle modification change, avoiding food and activities that trigger symptoms. PPI decreases the number of episodes of acid reflux; however, the number of "non-acid" reflux increases and the patient continues to have reflux despite PPI. In this way, it is possible to greatly reduce greatly the occurrence of symptoms, especially those dependent on the acidity of the refluxed material. Response to PPI therapy can be evaluated through clinical, endoscopic, and reflux monitoring parameters. In the persistence of the symptoms and/or complications, other causes of Refractory GERD should be suspected. Then, diagnostic investigation must be initiated, which is supported by clinical parameters and complementary exams such as upper digestive endoscopy, esophageal manometry and ambulatory reflux monitoring (esophageal pH monitoring or esophageal impedance-pH monitoring). Causes of refractoriness to PPI therapy may be due to the true Refractory GERD, or even to other non-reflux diseases, which can generate symptoms similar to GERD. There are several causes contributing to PPI refractoriness, such as inappropriate use of the drug (lack of patient adherence to PPI therapy, inadequate dosage of PPI), residual acid reflux due to inadequate acid suppression, nocturnal acid escape, "non-acid" reflux, rapid metabolism of PPI, slow gastric emptying, and misdiagnosis of GERD. This is a common cause of failure of the clinical treatment and, in this case, the problem is not the treatment but the diagnosis. Causes of misdiagnosis of GERD are functional heartburn, achalasia, megaesophagus, eosinophilic esophagitis, other types of esophagitis, and other causes. The diagnosis and treatment are specific to each of these causes of refractoriness to clinical therapy with PPI.
RESUMO CONTEXTO: A doença do refluxo gastroesofágico (DRGE) é a condição clínica que se desenvolve quando o refluxo do conteúdo gástrico provoca sintomas incômodos e/ou complicações. O relaxamento transitório do esfíncter inferior do esôfago é o principal mecanismo fisiopatológico da DRGE. Os sintomas e complicações podem estar relacionados ao refluxo do conteúdo gástrico para o esôfago, cavidade oral, laringe e/ou pulmão. Os sintomas e outras possíveis manifestações da DRGE são pirose, regurgitação, disfagia, dor torácica não-cardíaca, tosse crônica, laringite crônica, asma e erosões dentárias. O inibidor da bomba de prótons (IBP) é o medicamento de primeira escolha e o mais comumente utilizado para o tratamento da DRGE. A definição mais difundida de DRGE Refratária é a condição clínica que apresenta sintomas com resposta parcial ou ausente ao tratamento com IBP duas vezes ao dia. A persistência dos sintomas ocorre em 25% a 42% dos pacientes que utilizam IBP uma vez ao dia e em 10% a 20% dos que utilizam IBP duas vezes ao dia. OBJETIVO: O objetivo é apresentar uma revisão da literatura atual, salientando as causas, aspectos diagnósticos e abordagem terapêutica dos casos com sintomas suspeitos de refluxo e não responsivos ao IBP. CONCLUSÃO - Inicialmente, o manejo da refratariedade ao IBP consiste em corrigir a baixa aderência à terapia com IBP, ajustar a dosagem do IBP e reforçar as recomendações sobre modificação do estilo de vida, evitando alimentos e atividades que desencadeiem os sintomas. O IBP diminui o número de episódios de refluxo ácido, no entanto o número de refluxos "não-ácidos" aumenta e o paciente continua apresentando refluxo apesar do IBP. Desta forma, é possível reduzir consideravelmente a ocorrência de sintomas, especialmente aqueles dependentes da acidez do material refluído. A resposta à terapia com IBP pode ser avaliada através de parâmetros clínicos, endoscópicos e de monitorização do refluxo. Na persistência dos sintomas, outras causas de DRGE Refratária devem ser suspeitadas. Em seguida, deve ser iniciada a investigação diagnóstica, que é apoiada por parâmetros clínicos e exames complementares, como endoscopia digestiva alta, manometria esofágica e monitorização ambulatorial do refluxo (pHmetria esofágica ou impedancio-pHmetria esofágica). As causas de refratariedade à terapia com IBP podem ser devidas à DRGE Refratária verdadeira ou mesmo a outras doenças não relacionadas ao refluxo, que podem gerar sintomas semelhantes à DRGE. Existem várias causas de refratariedade ao IBP, como uso inadequado da droga (falta de aderência do paciente à terapia com IBP, dosagem inadequada de IBP), refluxo ácido residual devido à supressão ácida inadequada, escape ácido noturno, refluxo "não-ácido", metabolismo rápido do IBP, esvaziamento gástrico lento e diagnóstico equivocado de DRGE. Este representa uma causa frequente de insucesso do tratamento clínico e neste caso, o problema não é o tratamento, mas sim o diagnóstico. As causas de diagnóstico equivocado da DRGE são pirose funcional, acalásia, megaesôfago, esofagite eosinofílica, outros tipos de esofagite e outras causas. O diagnóstico e o tratamento são específicos para cada uma dessas causas de refratariedade ao tratamento clínico com IBP.
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Humans , Gastroesophageal Reflux/drug therapy , Proton Pump Inhibitors/administration & dosage , Drug Resistance , Gastroesophageal Reflux/complications , Treatment Failure , Proton Pump Inhibitors/adverse effects , Symptom AssessmentABSTRACT
Objective To investigate the correlation between esophageal motility abnormalities and the characteristics of gastroesophageal reflux in patients with different subtypes of refractory gastroesophageal reflux disease (rGERD).Methods From September 2015 to May 2016,a total of 100 rGERD patients were collected,all of whom received gastroendoscopy examination,high resolution manometry (HRM) and 24 h impedance-pH monitoring.According to the results of gastroendoscopy examination,the patients were divided into refractory non-erosive reflux disease (NERD) group and refractory reflux esophagitis (RE) group.Abnormal esophageal motility and pathological gastroesophageal reflux of each group were analyzed.Chi-square test,t test and sum-rank test were performed for comparison,the correlation factors were analyzed by multivariate unconditional Logistic regression.Results Among the 100 patients with rGERD,there were 83 cases in refractory NERD group and 17 in refractory RE group.The episodes of weak acid and gas-liquid mixed reflux of refractory NERD group were both significantly higher than those of refractory RE group (80.2±56.9 vs 44.8± 13.7,56.0± 25.6 vs 25.2±16.1);and the differences were statistically significant (t=3.202 and 2.229,both P＜ 0.05).The DeMeester score,acid reflux episodes and the percentage of reflux time of refractory NERD group were all significantly lower than those of refractory RE group (24.2±8.5 vs 56.8±3.0,21.4± 11.8 vs 35.9 ± 32.6,(7.1 ± 1.6) ％ vs (16.2 ± 8.8) ％),and the differences were statistically significant (t=-2.820,-2.230 and-2.604;all P＜0.05).However,the average resting pressure of lower esophageal sphincter was higher than that of refractory RE group ((7.9±5.6) mmHg (1 mmHg=0.133 kPa) vs (4.5±2.2) mmHg),and the difference was statistically significant (t=2.443,P＜0.05).Patients with esophageal motility disorders of refractory NERD group and refractory RE group were 58 cases (69.9 ％) and 12 cases (12/17),respectively,and the difference was not significant (P＞0.05).Compared with refractory RE group,the ratio of intermittent contraction was higher (1/17 vs 26.5％,22/83) and the peristaltic contraction disorder was lower in refractory NERD group (11/17 vs 43.4％,36/83);and the differences were statistically significant (x2 =3.389 and 2.587,both P ＜ 0.05).The results of multivariate non-conditional Logistic regression analysis showed that intermittent contraction and gas reflux were risk factors of the incidence of pathological weak acid reflux (odd ratio (OR) =3.139 and 1.254,both P＜0.05),while body mass index and gas-liquid mixed reflux were the risk factors of the occurrence of pathological acid reflux (OR =1.302 and 1.026,both P＜ 0.05),whereas the distal contractile integral was a protective factor (OR=0.998,P＜0.05).Conclusion Esophageal dysmotility is common in patients with rGERD,and the dysmotility disorders are different in patients with different subtypes,which may be related to the different reflux characteristics.
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Gastroesophageal reflux disease (GERD) is a common gastrointestinal disease and its incidence is increased in recent years in China.As the main treatment of GERD, proton pump inhibitors (PPI) has stable effects and high safety in long-term application.However, around 30% GERD patients had poor symptom control under standard PPI treatment, even developed into refractory GERD, seriously affecting the quality of life.Therefore, the treatment of GERD is a difficult clinical problem and multiple therapeutic modalities have emerged, including drug therapy, endoscopic treatment and surgery.In this paper, we reviewed the advances in study on treatment of refractory GERD.
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Objective To investigate the effects of transcutaneous electro acupuncture stimulation (TEA) on esophageal motility of patients with refractory gastroesophageal reflux disease (RGERD) by high resolution manometry (HRM),and to provide a new treatment option for RGERD.Methods From February 2014 to June 2015,a total of 45 patients with RGERD were enrolled.TEA instrument was used for electro acupuncture stimulation at the points of Zusanli and Neiguan.HRM was carried out before and after treatment.The changes of HRM parameters such as lower esophageal sphincter pressure (LESP),distal contractile integral (DCI),and amplitude of 3 cm,7 cm above lower esophageal sphincter (LES),esophageal body velocity and contractile front velocity (CFV) were also compared.The paired-samples t test was performed for statistical analysis.Results According to LESP value,45 patients were divided into low LESP group (10 patients) and normal LESP group (35 patients).According to parameter of esophageal motility function,patients were divided into esophageal dysmotility group (25 patients) and normal esophageal motility group (20 patients).After TEA treatment,the LESP of lower LESP group was (14.83± 4.17) mmHg (1 mmHg =0.133 kPa),which was higher than that before treatment ((9.54 ±2.42) mmHg),and the difference was statistically significant (t=4.92,P=0.001).LESP of esophageal dysmotility group was (19.04±5.91) mmHg,which was higher than that before treatment ((16.20±6.09) mmHg),and the difference was statistically significant (t=4.92,P=0.001).There was no statistically significant difference in LESP of normal LESP group and normal esophageal motility group before and after treatment (both P＞0.05).After treatment,DCI of esophageal dysmotility group was (530.76±215.53) mmHg· cm· s,which was higher than that before treatment ((363.92 ± 279.17) mmHg · cm · s),and the difference was statistically significant (t=2.86,P＜0.05).There was no statistically significant difference in esophageal body velocity,amplitude of 3 cm,7 cm above LES andCFV before and after treatment (all P＞0.05).There was no statistically significant difference in all of the esophageal motility parameters in normal esophageal motility group before and after treatment (all P＞0.05).Conclusion TEA can increase LESP and DCI in RGERD patients with esophageal motility dysfunction,improve contraction of entire esophagus and raise esophageal clearance capacity.
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Background:Gastroesophageal reflux disease( GERD)that does not respond satisfactorily to standard proton pump inhibitor is defined as refractory gastroesophageal reflux disease( rGERD). Combined therapy is used to treat rGERD, however,the addition of baclofen is rarely studied. Aims:To investigate the efficacy of baclofen combined with esomeprazole and mosapride on rGERD. Methods:Seventy-two patients with rGERD from March 2013 to April 2014 at the First Hospital of Putian City were enrolled and randomly divided into group A and group B. Patients in group A were orally administrated with esomeprazole 20 mg bid + mosapride 5 mg tid + baclofen 5 mg tid. Patients in group B were treated with esomeprazole 20 mg bid + mosapride 5 mg tid. The treatment course was 8 weeks. The efficacy on symptoms, esophagitis under endoscopy and adverse effects were compared between the two groups. Results:After 8-week treatment, score of heartburn,regurgitation,retrosternal pain,dysphagia and overall symptom were significantly decreased in the two groups than before the treatment. The overall symptom alleviating rate was significantly higher in group A than in group B (90. 6% us. 70. 0%;χ2 =4. 585,P=0. 032). Esophagitis under endoscopy in the two groups was significantly improved, the effective rate was significantly higher in group A than in group B(93. 8% us. 75. 0%;χ2 =4. 500,P=0. 034). The main adverse effects of baclofen were somnolence,dizziness and fatigue,all the patients were well tolerated. Conclusions:Baclofen combined with esomeprazole and mosapride is an efficient option for rGERD.
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Objective To investigate the effects of acupuncture on the improvement of esophageal motility disorder in patients with refractory gastroesophageal reflux disease (GERD).Methods From September 2012 to March 2014,40 patients with refractory GERD were enrolled and evenly divided into the treatment group and the control group. High resolution esophageal impedance manometry was conducted in patients.After the first examination,patients of the control group lay down for 30 minutes, and patients of the treatment group received acupuncture treatment at Neiguan,Gongsun and Zusanli points for 30 minutes.Then all the patients underwent high resolution esophageal impedance manometry again.ManoView ESO 3.0 software was used for analysis.The parameters included swallowing peristalsis defect,lower esophageal sphincter (LES)pressure,LES residual pressure,LES length,upper esophageal sphincter (UES)pressure,distal wave amplitude,peristalsis duration time,starting speed of peristalsis wave,speed of edge contraction and integration of the peristaltic waves.Chi-square test or t test was performed for data analysis.Results The percentage of normal swallows of the treatment group before and after treatment was 56.0% (112/200)and 74.0% (148/200),the percentage of delayed esophageal emptying was 31 .5 % (63/200 )and 11 .5 % (23/200 ),and the differences were statistically significant (χ2 =14.242 and 23.700,both P 0.05 ).The LES resting pressure of the treatment group before and after treatment was (20.2 ±18.8)mmHg (1 mmHg=0.133 kPa)and (26.3±10.1)mmHg,the length of LES was (2.2 ±0.6 )cm and (3.3 ±0.8)cm,the distal esophageal peristaltic amplitude was (60.2 ± 21 .9)mmHg and (41 .1 ± 16.8 )mmHg,and the differences were statistically significant (t = 5 .519, 6.580 and 6.881 ,all P 0.05 ).There as no significant difference in LES resting pressure and LES residual pressure of the control group before and after lying down (both P >0.05 ).However,before and after lying down,there were significant differences in the length of LES ((2.3 ±0.6)cm vs (2.5 ±0.6)cm) and UES resting pressure ((67.4 ±21 .2 )mmHg vs (53.5 ±18.1 )mmHg)in the control group (t =2.530 and 6.652,both P 0.05).Before and after lying down,there was no significant difference in distal wave amplitude,duration of peristalsis,the beginning speed of the peristaltic wave and CFV of the control group (all P >0.05 ).Conclusion Acupuncture can help increase the LES resting pressure,extend the length of LES,improve the overall peristaltic pressure and completeness of esophageal somatic part,meanwhile,it increases the percentage of normal swallows of patients with refractory GERD.
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BACKGROUND: TREATMEN The contribution of eosinophilic esophagitis (EoE) to refractory gastroesophageal reflux disease (GERD) remains unknown. When EoE and GERD overlap, the clinical, endoscopic and histological findings are nonspecific and cannot be used to distinguish between the two disorders. Limited data are available on this topic, and the interaction between EoE and GERD is a matter of debate. AIM: We have conducted a prospective study of adult patients with refractory GERD to evaluate the overlap of reflux and EoE. METHODS: Between July 2006 and June 2008, we consecutively and prospectively enrolled 130 male and female patients aged 18 to 70 years old who experienced persistent heartburn and/or regurgitation more than twice a week over the last 30 days while undergoing at least six consecutive weeks of omeprazole treatment (at least 40 mg once a day). The patients underwent an upper digestive endoscopy with esophageal biopsy, and intraepithelial eosinophils were counted after hematoxylin/eosin staining. The diagnosis of EoE was based on the presence of 20 or more eosinophils per high-power field (eo/HPF) in esophageal biopsies. RESULTS: Among the 103 studied patients, 79 (76.7 percent) were females. The patients had a mean age of 45.5 years and a median age of 47 years. Endoscopy was normal in 83.5 percent of patients, and erosive esophagitis was found in 12.6 percent. Only one patient presented lesions suggestive of EoE. Histological examination revealed >20 eo/HPF in this patient. CONCLUSION: Our results demonstrated a low prevalence of EoE among patients with refractory GERD undergoing omeprazole treatment.