The role of ineffective esophageal motility in non-erosive reflux disease and its correlation with acid exposure / 中华消化杂志

ABSTRACT

Objective:To investigate the role of ineffective esophageal motility (IEM) in the diagnosis of non-erosive reflux disease (NERD) and its relationship with acid exposure.Methods:From March 2013 to May 2019, in First Hospital Affiliated to Jilin University, patients who underwent gastroendoscopy exam, esophageal high-resolution manometry (HRM), 24-h pH monitoring and had gastroesophageal reflux symptoms, and without mucosal or structural abnormal changes under gastroendoscopy were retrospectively selected. Based on Rome Ⅳ criteria, the patients were reevaluated and the diagnostic types were NERD, reflux hypersensitivity (RH) and functional heartburn (FH). The changes of esophageal HRM metrics and acid reflux-related parameters of patients with IEM were analyzed and compared. Independent sample t-test, nonparametric test and chi-square test were used for statistical analysis. Results:The data of 228 patients were collected. Thirty-seven cases with esophageal gastric junction (EGJ) outflow obstruction and severe esophageal motility disorder (8 cases of achalasia, 9 cases of EGJ outflow obstruction, 4 cases of distal esophageal spasm, 14 cases of absent contractility and 2 cases of hypercontractile esophagus) and fifty-three cases with endoscopic reflux esophagitis under endoscopy (20 cases of Los Angeles grade A, 15 cases of grade B, 13 cases of grade C, and 5 cases of grade D) were excluded. In the end 138 patients were enrolled, including 60 males and 78 females, with a mean age of (50.1±14.1) years, including 36 cases of NERD, 44 cases of RH and 58 cases of FH. According to esophageal HRM Chicago classification standard, 138 patients with gastroesophageal reflux symptoms were divided into IEM group (46 cases, including 15 cases of NERD, 12 cases of RH, and 19 cases of FH) and normal manometry group (92 cases, including 21 cases of NERD, 32 cases of RH, and 39 cases of FH). There was no statistically significant difference in the proportion of patients diagnosed as NERD, RH and FH between the two groups ( P> 0.05). The length of lower esophageal sphincter (LES) (2.70 cm, 2.40 to 3.00 cm vs. 3.00 cm, 2.70 to 3.20 cm), the average value of LES resting breathing pressure (16.55 mmHg, 7.98 to 22.95 mmHg vs. 19.10 mmHg, 14.15 to 25.68 mmHg, 1 mmHg=0.133 kPa), the distal contractile integral (DCI)(417.90 mmHg·s·cm, 279.08 to 584.45 mmHg·s·cm vs. 1 429.40 mmHg·s·cm , 994.38 to 1 852.80 mmHg·s·cm) and EGJ contractile integral (37.86 mmHg·cm, 26.97 to 46.78 mmHg·cm vs. 45.19 mmHg·cm, 35.39 to 58.20 mmHg·cm) of IEM group were all lower than those of normal manometry group, ( Z=3.33, 2.09, 8.09, and 2.90, all P<0.05). There were no statistically significant differences in LES resting pressure at the end of the breath, 4 s-intergrated reloxation pressure, distal latency, upper esophageal sphincter (UES) resting pressure (UESP), UES residual pressure, UES baseline relaxation time, UES recovery time, EGJ type, acid reflux related parameters (total acid exposure time (AET), AET in upright position, AET in supine position, and Demeester score) between the two groups (all P>0.05). The 36 NERD patients were divided into IEM group (15 cases) and normal manometry group (21 cases). The distal contractile integral was lower in IEM group than that in normal manometry group (401.10 mmHg·s·cm, 276.60 to 555.60 mmHg·s·cm vs. 1 135.00 mmHg·s·cm, 903.20 to 1 537.65 mmHg·s·cm), the difference was statistically significant ( Z=3.93, P<0.01). There was no statistically significant difference in EGJ type, other HRM parameters or acid reflux-related parameters between IEM group and normal manometry group (all P>0.05). Conclusions:IEM is not related with the diagnosis of NERD. In patients with gastroscopy-negative gastroesophageal reflux symptoms or NERD with IEM, except for weakened peristaltic function, the EGJ morphological evaluation of the anti-reflux barrier function has nothing to do with IEM. In NERD patients, the relationship between IEM and acid exposure needs further study.