难治性胃食管反流病RGERD.ppt

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1、RefractoryGastroesophagealrefluxdiseaseDefinitionofRGERDRGERD:Patientswhoareunresponsiveto4-8weeks'treatmentwithPPIstwicedailyoresophagealinjurycausedbyREcan’ttobehealing.—RichterJENatlClinGastroenterol2007;4:658OtherssuggestthatlackofsatisfactorysymptomaticresponsetoPPIonceaday

2、issufficienttoconsiderpatientsasPPIfailures.AnyattempttonarrowthedefinitionofrefractoryGERDmightexcludemanytruesufferers.——HershcoviciTetal.BestPractice&ResearchClinicalGastroenterology2010(24)923-936RemainsanareaofcontroversyPPIfailedinEachoftheGastrooesophagealRefluxDisease(GERD)

3、GroupsGERDNERD60-70%EE20-30%Barrett′soesophagus6-10%PPIfailurepatientsFailureonPPIqd40-50%FailureonPPIqd6-15%FailureonPPIqd20%——Fassetal.AlimentPharmacolTher2005;22(2):79-94.30%NERDfailtoPPItreatmentNERD-acid,visceralsensitivityPotentialcausesofPPIrefractorinessinGERDNeurogastro

4、enterolMotil(2012)24,697–704MechanismWeaklyacidrefluxNABDilatedintercellularspacesDGEREsophagealhypersensitivityGastroparesisPoorcompliancewithPPItreatmentPsychologicalWeaklyAcidRefluxTheprevalenceofweaklyacidicrefluxinrefractoryGERDis30-40%.WhentheesophagealpHfallsby≥1unit,butr

5、emains＞4,itisconsidered“weaklyacidicreflux”.Gut,2004,53:1024-1031EsophagealdistensionPersistentimpairedmucosalintegrityEsophagealhypersensitivityEsophagealHypersensitivityAMJGastroenterol,2012,107,8-15.Esophagealreceptorupregulationand/orenhancedsignalingPhysiologicalstressors,s

6、ensitizationofspinalsensoryneurons.PotentialfactorscontributingtothespectrumofrefluxperceptioninpatientswithGERDGastroparesisDelayedgastricemptying(gastroparesis)maybeafactorassociatedwithseverereflux,dyspepsia,orboth.Gastroparesis,concomitantin25%ofpatientswithgastroesophagealr

7、efluxdisease(GERD),hasbeenshowntoimproveafterNissenfundoplication.SURGICALENDOSCOPYANDOTHERINTERVENTIONALTECHNIQUES，2008，22（11）:2440-2444PoorCompliancewithPPITreatmentCompliancetotreatmentandproperdosingareimportant.Timingandfrequencyofdosingarecriticalformaximumefficacyofthemedi

8、cation.PatientsdosedoptimallythePPIs(%)Properdo