难治性胃食管反流病课件

难治性胃食管反流病
Hale Waihona Puke Baidu
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Gut,2004,53:1024-1031
Esophageal Hypersensitivity
.
Potential factors contributing to the spectrum of reflux perception in patients with GERD
Esophageal receptor upregulation and/ or enhanced signaling
fundoplication.
INTERVENTIONAL TECHNIQUES ，2008，22 （11）:
难治性胃食管反流2病440-2444
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Poor Compliance with PPI Treatment
➢Compliance to treatment and proper dosing are important. ➢Timing and frequency of dosing are critical for maximum
Refractory Gastroesophageal reflux disease
难治性胃食管反流病
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Definition of RGERD
•RGERD:Patients who are unresponsive to 4-8 weeks' treatment with PPIs twice daily or esophageal injury caused by RE can’t to be healing.
—Richter JE Natl Clin Gastroenterol 2007;4:658
•Others suggest that lack of satisfactory symptomatic response to PPI once a day is sufficient to consider patients as PPI failures.
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难治性胃食管反流病
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Weakly Acid Reflux
• The prevalence of weakly acidic reflux in refractory GERD is 30-40%.
• When the esophageal pH falls by ≥ 1 unit, but remains ＞4, it is considered “weakly acidic reflux”.
• NAB: Gastric pH below 4 over 60 consecutive minutes at night-time in subjects who take proton pump inhibitors twice daily.
难治性胃食管反流病
Patients dosed
>60 min before meals 39%
suboptimally the PPIs(%) after meals
30%
at bedtime
28%
as-needed
4%
难治性胃食管反流病
Aliment Pharmacol Ther 2006;23:1473–7
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Nocturnal Acid Breakthrough
Gastroparesis, concomitant in
25% of patients with
gastroesophageal reflux
disease (GERD), has been
shown to improve after Nissen SURGICAL ENDOSCOPY AND OTHER
难治性胃食管反流病
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NERD-acid,visceral sensitivity
难治性胃食管反流病
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Potential causes of PPI refractoriness in GERD
难治性胃食管反流病 Neurogastroenterol Motil (2012) 24, 697–704
Barrett′s oesophagus 6-10%
Failure on PPI qd 20%
PPI failure patients
难治性胃食管—反—流F病ass et al. Aliment Pharmacol Ther 2005; 22(2):79-94.
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30%NERD fail to PPI treatment
➢ Any attempt to narrow the definition of refractory GERD might exclude many true sufferers.
——Hershcovici T et al. Best Practice& Research Clinical Gastroenterology 2010 (24)923-936
Physiological stressors, sensitization of spinal sensory neurons
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AM J Gastroenterol ,2012,107, 8-15.
Gastroparesis
Delayed gastric emptying (gastroparesis) may be a factor associated with severe reflux, dyspepsia, or both.
efficacy of the medication.
PPI dosing situation in 100 patients with persistent GERD symptoms
Patients dosed optimally Proper dosing timing
46%
the PPIs(%)
难治性胃食管反流病
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PPI failed in Each of the Gastrooesophageal Reflux Disease (GERD)
Groups
GERD
NERD 60-70%
Failure on PPI qd 40-50%
EE 20-30%
Failure on PPI qd 6-15%