[Therapeutic mechanism of diaphragm training at different periods in patients with gastroesophageal reflux disease].

OBJECTIVE: To explore the effects of postprandial diaphragm training (DT) on esophageal acid exposure, esophageal motility and proximal gastric volume at different postprandial periods in patients with gastroesophageal reflux disease (GERD). METHODS: Thirty GERD patients and 9 healthy subjects (HS) with matched demographic characteristics were enrolled from June 2005 to June 2006 at Peking Union Medical College Hospital. Esophageal manometry with a Dent sleeve catheter and simultaneous esophageal pH monitoring were recorded in a 30-min fasting period and a 120-min postprandial period. The GERD patients were divided into 3 groups: 9 patients received diaphragm training at 1(st) hour after meal (group DT1 h) and another 10 at 2(nd) hour after meal (group DT2 h) whereas no diaphragm training after meal in 11 (group NDT). Ultrasonic imaging of proximal gastric volume was undertaken at 0, 30, 60, 90 and 120 min after meal. RESULTS: (1) The percentage time with pH<4 in group DT1 h was lower than that in group NDT in the 120-min postprandial period (0.2% (0-4.1%), 6.6% (2.2%-18.2%), P < 0.05) and no significant difference of esophageal acid exposure was observed between groups DT2 h and NDT (3.7% (0.1%-17.8%), 6.6% (2.2%-18.2%), P > 0.05) . (2) Esophagogastric junction (EGJ) and crural diaphragm pressures at the 1(st) hour after meal in group DT1 h were both significantly higher than those in group NDT during diaphragm training ((44.4 ± 8.1) vs(16.2 ± 4.5) mm Hg, (38.2 ± 4.2) vs (9.8 ± 4.5) mm Hg, 1 mm Hg = 0.133 kPa, both P < 0.05). EGJ and crural diaphragm pressures at the 2(nd) hour after meal in group DT2 h were significantly higher than those in group N-DT during diaphragm training ((53.2 ± 7.5) vs (14.0 ± 3.7) mm Hg, (48.2 ± 6.3) vs (8.9 ± 2.7) mm Hg, both P < 0.05). There was no change of lower esophageal sphincter pressure (all P > 0.05). (3) After test meal, the groups DT1 h, DT2 h and N-DT had similar proximal stomach volume (all P > 0.05). CONCLUSIONS: Diaphragm training at the 1(st) hour after meal might reduce the 120-min postprandial esophageal acid exposure in GERD patients. The reduction in esophageal acid exposure may result from enhanced antireflux barrier of EGJ function. Therefore postprandial diaphragm training provides a new approach to conservative treatment of GERD.

[Follow-up of pediatric inflammatory bowel disease].

OBJECTIVE: To analyze the clinical characteristics and prognosis of pediatric inflammatory bowel disease (IBD) through a long-term follow-up so as to improve the diagnosis and management of IBD in children. METHODS: Seventy-three IBD patients admitted into our hospital from May 2000 to September 2010 were re-evaluated with the uniform diagnostic criteria proposed by the 2010 consensus diagnostic criteria for pediatric IBD. All patients were followed up by questionnaire, telephone and face-to-face interview. RESULTS: Among them, 56 cases (76.7%) (ulcerative colitis (UC): n = 34, Crohn's disease (CD): n = 22) were available for follow-up study. Among 34 UC cases, 13 cases had their diagnosis confirmed and 21 cases were diagnosed as probable UC. Meanwhile, among 22 CD cases, 14 and 8 had definite and probable diagnoses respectively. At diagnosis, 46.9% (15/32) of UC patients had extensive colitis, 40.6% (13/32) left-sided colitis while 72.7% (16/22) of CD patients with had ileocolonic. And 28 cases (82.4%) of UC patients and 20 cases (90.9%) of CD patients fulfilled the criteria for moderate to severe grade. Among 56 IBD cases, there was no death for CD, but 5 died for UC (14.7%). In the remaining 29 UC and 22 CD patients, 16 cases (55.2%) and 15 cases (68.2%) stayed symptom-free (P > 0.05). Moreover, 8 cases (27.6%) of UC and 3 cases (13.6%) of CD patients belonged to chronic relapsing type while 16 cases (55.2%) of UC and 15 cases (68.2%) of CD patients were of chronic persistent type. The physical activities of most IBD patients (n = 49) were unrestricted. The surgical rate for IBD was 19.6% (n = 11), 8.8% for UC (n = 3) and 36.4% for CD (n = 8) (P < 0.05). The incidences of surgical complications such as intestinal obstruction, intestinal perforation and hemorrhage of gastrointestinal tract were 7.1% (n = 4), 7.1% (n = 4) and 1.8% (n = 1). And it was more common in the CD group. CONCLUSIONS: Most IBD patients belong to chronic persistent type and then chronic relapsing type. Their physical activities are unrestricted. The surgical rate for CD is significantly higher than UC. And surgical complications such as intestinal obstruction, intestinal perforation and hemorrhage of gastrointestinal tract occur more frequently in the CD group.

[Diagnostic value of reflux disease questionnaires in children with gastroesophageal reflux disease].

OBJECTIVE: To evaluate the value of reflux diagnostic questionnaire in the diagnosis of children with gastroesophageal reflux disease (GERD). METHODS: Forty-five children aged 7-16 years old referred for suspected GERD with vomiting/regurgitation, nausea, heartburn/retrosternal pain, abdominal pain, epigastric pain, acid regurgitation and pain while swallowing were assessed. Each symptom was rated from 0 to 3 according to its severity and frequency. The items of questionnaire were validated against the results from upper gastrointestinal endoscopy and esophageal 24 h pH monitoring. And the results were compared with symptom scores to determine the threshold value for GERD. RESULTS: In 45 patients, the ratio of male to female was 1.37:1 and the mean age (11.1±2.6) years old. Composite score in 23 patients with GERD (20±10) was significantly higher than that in 22 patients without GERD (13±4) (P<0.05). There was no significant difference of composite scores among patients with grades 0, I, II and III according to upper gastrointestinal endoscopy (P>0.05). With 13.0 as threshold score for GERD, the sum of sensitivity and specificity was maximal. The area under the receiver operating characteristic curve (ROC) was 0.79 while true positive diagnostic rate 72.0% and true negative diagnostic rate 75.0% with a sensitivity of 78.3%, a specificity of 68.2% and an accuracy of 73.3%. CONCLUSION: Reflux diagnostic questionnaire is a suitable method in initial diagnosis of GERD. It may serve as a screening test for GERD in 7-16-year-old children.

[Multi-channel electrogastrography and autonomic nervous system function in patients with non-erosive reflux disease and reflux esophagitis].

OBJECTIVE: To investigate the gastric myoelectrical activity and autonomic nervous system (ANS) function in patients with non-erosive reflux disease (NERD) and reflux esophagitis (RE). METHODS: 42 patients with gastroesophageal reflux disease (GERD), 21 with NERD and 21 with RE, and 20 healthy volunteers (controls) underwent multi-channel electrogastrography (MEGG) and electrocardiography simultaneously for 30 min in the fasting state and 60 min after a standard test meal. The MEGG parameters included dominant frequency (DF), dominant power (DP), normal percentage of 2 - 4 times/min gastric slow waves (N%), and percentage of slow wave coupling (%SWC). ANS was determined according to power spectra analysis of heart rate variability (HRV) which was conducted by using electrocardiogram recording, including the parameters of sympathetic activity, vagal activity, and sympathovagal balance ratio so as to evaluate the ANS function. RESULTS: The DF levels of the NERD and RE patients and healthy volunteers after test meal were all significantly higher than those in fasting state (all P < 0.05). The %SWC levels of the 3 groups after test meal were all significantly lower than those when fasting (all P < 0.05), and the %SWC level of the NERD patients was significantly lower than that of the healthy volunteers in fasting state [70.5% (40.6% - 81.9%, 76.3% (66.4% - 91.4%), P < 0.05]. Test meal significantly increased the sympathetic activity and sympathovagal balance ratio of the NERD and RE patients and healthy volunteers (all P < 0.05), and the vagal activity levels of the 3 groups after test meal were all significantly lower than those when fasting (all P < 0.01). The sympathovagal balance ratio of the NERD group was significantly lower than that of RE group after meal [1.4 (0.8 - 2.5), 2.2 (1.3 - 4.4), P < 0.05]. CONCLUSION: The spatial regularity of gastric slow waves and ANS function in NERD patients are significantly different from those in RE patients.

[Effect of combined drug treatment on megacolon with severe constipation].

OBJECTIVE: To assess the effectiveness of combined drug treatment on megacolon complicated by severe constipation. METHODS: Ten patients with megacolon confirmed by barium enema examination, 4 males and 6 females, aged 38 (15 - 66), with a mean course of 10 years (2 weeks - 23 years), all complicated by severe constipation and 5 cases with colonic obstruction confirmed by X-ray examination, 1 being diagnosed as with Hirschsprung' disease, 3 secondary to chronic constipation, 1 with diabetes mellitus, 1 with a history of anorectal malformation, 4 with colonic pseudo-obstruction, and 4 with colonic pseudo-obstruction, were treated with combined conservative therapy including tegaserod (6 mg 2/d), polyethylene glycol (PEG) 4000 (20 - 40 g/d), and liuweianxiao (traditional Chinese medicine, 5 # 3/d). Colon enema was used in the first week if necessary. Follow-up was conducted for 1 - 7 months. The major clinical data included bowel symptoms, complications and adverse effects. RESULTS: After 1 - 2 weeks of treatment, properties of feces, defecation times, defecation difficulty, and abdominal symptoms, and X-ray findings were all notably improved. No relapse of colonic obstruction was found. The 5 patients with colonic obstruction all showed release. Regarding adverse effect, mild diarrhea was found in 2 cases and was relieved when the dosage was decreased. CONCLUSION: Combined drug treatment including tegaserod, PEG 4000 and traditional Chinese medicine is effective in treating megacolon with severe constipation and may help avoid surgical treatment.

[Barrier function of esophagogastric junction in patients with gastroesophageal reflux disease].

OBJECTIVE: To investigate the barrier function of esophagogastric junction (EGJ) in the patients with gastroesophageal reflux diseases (GERD). METHODS: Ninety-six GERD patients and 18 healthy subjects (HSs) underwent esophageal manometry. Forty-two of the 96 patients were with reflux esophagitis (RE) and were divided into 2 subgroups according to the LA typing: 31 subgroup of LA-A or B (n = 31), and subgroup of LA-C or D (n = 11). Fifty-four of the 96 patients suffered from non-erosive reflux disease (NERD) and were divided into 2 subgroups based on 24 h esophageal pH monitoring: 31 patients with normal acid exposure (pH < 14.72 according to DeMeester scoring) and 23 with excessive acid exposure (pH > 14.72). The EGJ functions, including lower esophageal sphincter pressure (LESP), crura of diaphragm pressure (CDP), esophagogastric junction pressure (EGJP, sum of LESP and CDP), and post-lower esophageal sphincter relaxation pressure (post-LESRP), and the contractive pressure of esophageal body, including proximal esophageal contractive pressure (PECP) and distal esophageal contractive pressure (DECP), were measured. RESULTS: The levels of LESP, CDP, EGJP, and post-LESRP of the RE patients were (8 +/- 3), (13 +/- 7), (20 +/- 9), and (31 +/- 13) mm Hg respectively, all significantly lower than those of the NERD patients [(9 +/- 3), (18 +/- 6), (28 +/- 8), and (39 +/- 15) mm Hg, all P < 0.05]. The levels of LESP and post-LESRP of the NERD patients were significantly lower than those of the HSs [(32 +/- 7) and (50 +/- 15) mm Hg, both P < 0.05], however, the levels of CDP and EGJP of the NERD patients were both not significantly different from those of the HSs [(16 +/- 6) and (32 +/- 7) mm Hg, both P > 0.05]. The PECP and DECP of the RE and NERD patients were all significantly lower than those of the HSs (all P < 0.05), however, there were not significant differences in DECP and PECP between the RE and NERD patients (both P > 0.05). Among the NERD patients there were not significant differences in the PECP and DECP between the LA-A and B subgroup and RE LA-C and D subgroup, and among the NERD patients there were not significant differences in PECP and DECP between the subgroups with and without excessive esophageal acid exposure (all P > 0.05). CONCLUSION: The EGF anti-reflux function of the GERD patients is impaired. The function of crura of diaphragm of the NERD patients is almost normal, however, that of the RE patients is impaired. NERD and RE have different path physiological basis.