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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5554_Библиотеки_им_академика_М_И_Перельмана.pdf
87
Symptoms
Never
before
The
symptoms
were not
obvious and
were found
under the
doctor’s
reminding
The
symptoms
were
between 1
and 3
The
symptoms
were obvious,
affect life,
medicine
occasionally
The
symptoms
were
between 3
and 5
The
symptoms
were
obvious,
taking
long-term
medication
After sternum
Hot heartburn
feeling
0 1 2 3 4 5
Chest pain 0 1 2 3 4 5
Sore in the mouth 0 1 2 3 4 5
An uncomfortable
sensation caused by
upwelling of
stomach contents
0 1 2 3 4 5
7.1.2 Gastroscopy
Although gastroscopy cannot directly reect the dynamic situation of the esopha-
gus, it can indirectly obtain the information of esophageal motility by observing the
size of the esophagus cavity, whether there is food reux or storage ow, the
changes of the mucosa in the lower esophagus, the resistance of the gastroscope
through the cardia, and the condition of the gastroesophageal disc by ipping
endoscopy. The endoscopic Los Angeles grade divided reux esophagitis from
light to heavy into A to D grade, and the D grade cases were mostly accompanied
by hiatal hernia. One study showed that the higher the grade, the lower the resting
pressure and the upper 3cm contraction amplitude of the esophagus, which can
reect the esophageal volume clearance rate according to the severity of the grad-
ing [10]. Some different views suggested that esophageal hiatal hernia was more
closely related to LES pressure and acid exposure, while esophageal peristalsis
suspension and esophageal motility were not statistically in patients with gastro-
esophageal reux disease [11]. The endoscopic manifestations of scleroderma after
involvement of the esophagus were esophageal wall stiffness and esophageal dila-
tation. Roman S and other studies showed that 75% of patients with systemic scle-
rosis had abnormal esophageal motility, ineffective esophageal motility or lack of
contractility, and the patients with asthenia were younger and had more severe
reux [12]. The endoscopic gastroesophageal disc (gastroesophageal ap valve,
GEFV) was divided into I–IV grades according to the degree of tissue plica wrap-
ping around the endoscope along the small bend, IV often accompanied by esopha-
geal hiatus hernia (Fig.7.1). Koch and other studies showed that the increase of
GEFV grade was positively correlated with reux, and the average LES pressure
decreased with the increase of GEFV grade [13]. This view was also supported by
7 Evaluation ofEndoscopic Treatment forGERD
88
Fig. 7.1 GEFV grade
a retrospective study of 1507 patients with GEFV abnormal group with a higher
incidence of reux symptoms than the normal group, and esophagitis was more
than GEFV normal group [14].
7.1.3 Esophageal Barium Radiography
Barium sulfate, as a contrast agent, is primarily used for esophageal barium radiog-
raphy—a diagnostic method for examining gastrointestinal tract lesions under
X-ray irradiation. Since it is insoluble in water and lipids, it is not absorbed by the
gastrointestinal mucosa, and thus is essentially non-toxic to the human body. It is of
good value to observe esophageal mucosal morphology, esophageal movement,
dysphagia, esophageal dilatation, or stenosis. Although esophageal angiography
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89
ab
Fig. 7.2 (a, b) Achalasia
cannot directly reect the dynamic state of esophagus, it can also obtain valuable
information from the side. The comparative study of 60 healthy volunteers and 218
different types of esophageal diseases by Summerton and others showed that bar-
ium angiography could detect abnormal esophageal movement, high sensitivity, and
obtain quantitative and repeatable results [15]. Barium is also a suitable tool for
screening and follow-up of patients with dysphagia and esophageal motility disor-
ders. Low and others found that through uoroscopy diagnosis of achalasia, sensi-
tivity reaches up to 95% [16] (Fig.7.2). Diffuse esophageal spasm is a rare condition,
the most common manifestations are intermittent chest pain and difculty swallow-
ing solids or liquids. Partial intermittent absence of primary peristalsis in esopha-
geal smooth muscle can be detected, and obvious dynamic abnormalities such as a
“rosary-like” or “spiral” appearance can be observed on esophageal X-ray imaging
[17]. A comparison of esophagography and manometry in patients with esophageal
dyskinesia, based on pressure measurement, x sensitivity, and specicity reached
90.4% and 92.0% [18]. At the same time, esophagography combined with pressure
measurement can complement information and improve the diagnostic titer [19].
7.1.4 Esophageal Electromyography
The circumpharyngeal muscle is the sphincter of the rhabdom is located at the
junction of the pharynx esophagus. The upper esophageal sphincter consists of
the rhabdoms and no muscle at the cricoid cartilage level. The main component is
the cricopharyngeal muscle, which adheres to the lateral margin of the anterior
side of the cricoid cartilage and surrounds the lumen. Its main function is to con-
trol the retrograde ow of contents between swallowing and pharynx and esopha-
gus. At present, the cyclopharyngeal muscle has the dual innervation of vagus
7 Evaluation ofEndoscopic Treatment forGERD
90
nerve and recurrent laryngeal nerve. By stimulating the recurrent laryngeal nerve,
a fast, large- amplitude electromyographic response of the cyclopharyngeal mus-
cle can be obtained [20]. The recurrent laryngeal nerve may increase the closure
of the proximal esophagus and avoid the gastric contents reux to the esophagus
[21]. Gastroscopy, high-resolution pressure measurement, and esophageal radio-
activity examination may only suggest a mechanical abnormality, but the effect of
nerve electromyography on esophageal function is not well explained. Therefore,
electromyography plays an important role in evaluating neurogenic esophageal
dysfunction. An electromyographic monitoring of patients with multiple lacunar
infarcts revealed hyperreexia in the cyclopharyngeal muscle of the upper esoph-
ageal sphincter during swallowing and uncoordinated with laryngeal move-
ment [22].
7.1.5 Radionuclide Esophageal Function Examination
Radionuclide esophageal function examination refers to the observation of esopha-
geal motility by radionuclide imaging after taking a certain dose of tracer, and the
reux event may be considered when the abnormal radiation curve peak appears at
the tooth line. Before the examination, the patient fasted for at least 8h, while
avoiding the menstrual cycle examination and avoiding the possible effect of hor-
mones on gastrointestinal motility. Drugs, cigarettes, and alcohol affect the results
of gastric motility tests, which need to be refrained for 24h before examination
[23]. A study of cardiac retardation shows that radionuclide esophageal emptying
test has important application value in esophageal function evaluation [24]. Arasu
etal. [25] found that the sensitivity of radionuclide studies for reux esophagitis
was 75–100%.
7.2 High-Resolution Esophageal Manometry
High-resolution esophageal manometry (HREM) determines the changes of esoph-
ageal structure and function by measuring the changes of intracavitary pressure
during esophageal rest and swallowing. Compared with the early esophageal pres-
sure measuring device, it has the advantages of wide measuring range and high
precision. By adopting the “topographic map” mode of different colors representing
the change of pressure, the change of esophageal power can be displayed more
clearly [26]. Obtaining the pressure information of upper esophageal sphincter,
esophageal body, and lower esophageal sphincter is an important basis for judging
esophageal dynamic abnormality.
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7.2.1 The Way ofMeasuring Pressure
According to the principle of pressure measurement, there are two water perfusion
modes and one solid-state pressure measurement mode. The water irrigation cathe-
ter is a bunch of ne polyethylene tubes. The distal end has different horizontal to
lateral holes. After injecting water into the catheter, it is induced by the sensor and
converted into electrical signals. When the esophageal wall shrinks and hinders the
ow of water through the lateral hole, the recorded pressure rises. Because the pres-
sure sensor may fall off from the high-pressure region in this mode, it affects the
recording results, and then improves to the recording pressure mode of the ow of
water from the catheter under the rubber lm, but its defect is that the rapid pressure
change cannot be recorded [27, 28]. Another commonly used sensing device is a
miniature solid-state pressure measuring device, which has higher frequency
response characteristics than water injection ducts, so that it can reliably record
faster pressure transients. At present, water perfusion and solid-state mode have
been used to improve the accuracy of measurement.
7.2.2 Matters Needing Attention
Considering esophageal structural and dynamic abnormalities, this examination is
feasible for denite diagnosis or next treatment; poor coagulation function, acute
myocardial infarction, poor lung function, a high risk of upper gastrointestinal
bleeding or catheter placement due to benign and malignant lesions are contraindi-
cations. There is no obvious restriction on posture when using solid catheter, but
supine position is recommended when using water perfusion mode. During catheter
placement, real-time pressure sensing images were observed to determine whether
the catheter passed through the annular pharynx muscle and the lower esophageal
sphincter, or to measure the approximate length of the esophagus matching the
depth of the tube.
7.2.3 Measurement Methods andParameters
First, the subjects need to stop swallowing for 30s to collect resting pressure. Then,
they drink 5ml of disposable drinking water 10 times in a row, with 30-s intervals
between swallows. Subjects must not swallow independently within 10s after each
of those swallows. After several rapid swallows at intervals of 2–3s (5 times, 2ml
each time), esophageal manometry data is analyzed. Using the Chicago standard v.
3.0, the parameter values included are complete relaxation pressure (integrated
7 Evaluation ofEndoscopic Treatment forGERD
92
relaxation pressure IRP), distal systolic integral (distal contractile integral DCI),
and distal latency (distal latency DL) [29]. sIRP mean pressure of the electronic
sleeve during the continuous or discontinuous time of the lowest pressure in the
relaxation window of the gastroesophageal junction (esophagogastric junction EGJ)
can exclude the effect of diaphragm contraction during breathing and more truly
reect the relaxation function of the EGJ.When IRP uses the median rather than
average, the effects of outliers such as cough can be minimized. mmHg is consid-
ered normal, and EGJ diastolic function is impaired when IRP >15mmHg. This is
used to classify the signs of cardiac retardation. Type I achalasia is characterized by
IRP >15mmHg, without esophageal peristaltic contraction, and esophageal pres-
surization; type II achalasia is characterized by IRP >15mmHg, lack of esophageal
peristalsis, and total esophageal pressurization; in type III achalasia, spastic con-
traction of the distal end of the esophagus is >20. Values above 20 need to exclude
EGJ outow obstruction or distal esophageal stenosis.
DCI is used to describe the contraction intensity of the distal esophagus. It is
calculated by collecting data on the contraction-induced esophageal pressure, dura-
tion, and length of the contraction-producing esophagus, The units for DCI are
mmHg*s*cm. Originally DCI was designed to distinguish between high shrinkage
and normal conditions, but it was later used to identify low shrinkage states.
Generally, a DCI ≥5000 is dened as a contraction anomaly. A strong spasmodic
contraction occurs at DCI ≥8000. If repeated twice or more, it is called “hand drill-
ing esophagus”. Ineffective esophageal peristalsis is dened as DCI<s 100, in more
than 50% of four sIRP measurements. A DCI between 100 and 450 indicates that
the peristalsis of the esophagus is weakened. The EGJ-CI is another measure of the
DCI of EGJ barrier function. The initial measurement used the “DCI”, at the con-
tour of the isobaric contour of 20mmHg of the EGJ complex during the 10-window
period without swallowing. A later method involved using the “DCI” value of three
consecutive respiratory cycles (at 20mmHg above gastric pressure) divided by the
total duration of three respiratory cycles in seconds. The unit for ECJ-CI is
mmHg·cm. When the EGJ-CI is low, patients are more prone to reux events.
The conduction time DL the upper esophageal sphincter (upper esophageal
sphincter, UES) begins to relax to the contraction deceleration point (contractile
deceleration point CDP). CDP refers to the inection point of the contraction wave
velocity on the isobaric line of 30mmHg, which represents the velocity of the distal
esophageal contraction front. The velocity slowed down, indicating that esophageal
peristalsis stopped. DL<value of 4.5s is dened as premature contraction.
Using the above reference data v3.0 according to the Chicago standard, the
dynamic conditions reected by the contraction force, contraction mode, esopha-
geal pressure mode, and EGJ relaxation degree of the esophagus can be analyzed
(Table7.6).
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93
Table 7.6
Characteristics of esophageal contractility
Type criteria
Shrink force
Invalid DCI <100mmHg·s·cm
Weak peristalsis DCI >100mmHg·s·cm, but <450mmHg·s·cm
Normal DCI >450mmHg·s·cm but <8000mmHg·s·cm
Spastic contraction DCI ≥8000mmHg·s·cm
Shrinkage mode
Early advance DL <4.5s
When the interrupt DCI >450mmHg·s·cm, the isobaric isoline of 20mmHg large missing
(length >5cm)
Complete Failure to meet diagnostic criteria
Esophageal internal pressure pattern (30mmHg isobaric)
Total esophageal
pressure
From UES to EGJ pressure >30
Segmental
compression
From esophageal contraction wave to EGJ compression >30
EGJ pressure Compression of LES and diaphragm when separated
Normal Boosts not exceeding 30mmHg
7.2.4 Current Research Status
HRM, as an important diagnostic method for evaluating esophageal motility pat-
terns, is widely recognized clinically [30–32]. Denaxas etal. [33] found typical
esophageal scleroderma in up to 55% of patients with systemic sclerosis; distal
esophageal peristalsis is missing or ineffective, which is accompanied by lower
esophageal sphincter pressure. Ihara etal. [34] classied achalasia by HRM and
found that endoscopic balloon dilatation or laparoscopic myotomy can be consid-
ered as a rst-line scheme for achalasia type I.Endoscopic balloon dilatation and
endoscopic tunnel technique can be considered as rst-line schemes for type 2 and
type 3 achalasia, respectively. Ding et al. [35] assessed esophageal motility by
HRM and found that the resting pressure and residual pressure of the upper sphinc-
ter (UES) of the esophagus in patients with hysteria were higher than those of the
patients with reux disease without hysteria. LPRD hysteria may be caused by
excessive UES pressure. HRM based on the Chicago criteria, however, cannot
fully explain all types of esophageal dyskinesias. It can be seen that combined pH
monitoring and bile monitoring have optimized the diagnosis and treatment
methods.
7 Evaluation ofEndoscopic Treatment forGERD
94
7.3 Esophageal andPharyngeal pH Monitoring Techniques
Esophageal and pharyngeal pH monitoring is the gold standard for the diagnosis of
throat reux disease and gastroesophageal reux disease. The initial pH monitoring
equipment, mostly single probe, was placed at 5cm above the lower esophageal
sphincter, and the data obtained only reected the reux of the lower esophagus.
With the throat reux as an external manifestation of esophageal reux or an inde-
pendent secondary disease, the monitoring method of single probe is gradually
replaced by the way of double probe pH monitoring [36]. In addition to the probe
placed 5cm above the lower esophageal sphincter, the probe placed in the pharynx
was added. At present, there is also a monitoring electrode in the middle of the
esophagus [37].
The Dx-pH monitoring system is commonly used in the United States. Compared
with the traditional pH monitoring equipment, the probe adopts the design of water
droplet antimony alloy, which increases the detectable contact area, reduces the
error, and can monitor the pH changes of liquid and gas at the same time. It has high
sensitivity. The dual probe mode allows the electrode to be placed at the same time
at 0.5cm in uvula and 5cm above the lower esophageal sphincter. Not only the
comfort is good, but also different from the probe design with multi-channel intra-
cavity impedance. The position between the two probes is adjustable and not xed.
It is suitable for people with different esophageal lengths and the positioning is
more accurate.
Stop acid suppressants for at least 7days before monitoring. Ryan index is usu-
ally used as the standard for the diagnosis of throat reux disease. The threshold
was set to stand pH <5.5, lie pH <5.0. The Ryan index is calculated by calculating
the total number of reux, the maximum reux time, the total reux time (including
straight position, recumbent reux time), the reux >5min times, and the percent-
age below baseline pH.The throat reux disease can be diagnosed by upright posi-
tion >9.41 and lying position greater than 6.79 [38]. The DeMeester index was used
as the standard for the diagnosis of gastroesophageal reux disease, with the follow-
ing parameters: a threshold of 4.0 pH< vertical, the number calculated by the param-
eters of total reux times, total time of pH <4, number of reux attacks ≥5min, and
maximum reux time. A DeMeester index >14.72 can diagnose gastroesophageal
reux disease [39].
Vailati etal. [40] predict the ability of patients with related throat symptoms to
respond to proton pump inhibitors by using Dx-pH.The conclusion is that the sen-
sitivity of Dx-pH monitoring is 69, the specicity is 100%, and the Ryan index is
consistent with the severity of symptoms. Another study with a larger sample size
similar suggested that the sensitivity and specicity of the Ryan index were 39.4%
and 100%, respectively [41]. Jamieso etal. [42] conducted a 24-h dynamic esopha-
geal pH monitoring and 25 esophageal acid exposure studies in 25 asymptomatic
healthy subjects. The results showed that the total time percentage of pH <4 was the
most effective explanation for the test. The sensitivity was 96%, the specicity of
the comprehensive score was 100%, and the accuracy was 98%. Stein etal. [43]
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found that through 24-h esophageal pH monitoring, the incidence and severity of
esophageal mucosal injury in patients with mechanical defects in the lower esopha-
geal sphincter or increased exposure to esophageal acid/alkali are higher than in
patients with normal sphincter or only esophageal acid exposure. Alkaline exposure
to esophagus is only increased in patients with gastroesophageal reux. Except for
diagnostics, 24-h monitoring can also be used to assess the accuracy of the symptom
scale and the effectiveness of anti-reux therapy. Chen etal. [44] completed a
GerdQ examination of 366 patients with gastroesophageal reux symptoms moni-
tored for 24h of esophageal pH.Conclusions: Gastroesophageal reux-like symp-
toms, nocturnal heartburn, history of hiatal hernia, and abnormal monitoring of 24-h
esophageal pH are associated. The inventor of the DeMeester index conducted a
study of 100 patients with primary Nissen gastroesophageal reux disease.
Abnormal patterns of esophageal acid exposure in all patients were monitored by
24-h esophageal pH.In 10years, an effective rate of 91% in the control of reux
symptoms were noted [45]. Dobhan etal. [46] performed dual-probe dynamic mon-
itoring of pH values in 26 normal volunteers. The study included 20 patients with
normal distal acid exposure and 23 patients with abnormal distal acid exposure. Of
the total group, 1% had mild acid exposure at the proximal end of the esophagus,
patients with abnormal distal acid exposure exhibited signicantly greater proximal
potential.
There are different views on the nal interpretation parameters of Ryan index
and DeMeester index. Wu etal. [47] monitored 590 patients with denite diagnosis
pH throat reux disease for 24h. Ryan positive rate was only 15.93%. The main
reason for the analysis may be that the parameters of upright position pH <5.5,
supine position pH <5.0 cannot contain pepsin damage to esophagus and throat,
because pepsin is inactivated at pH >6.5. Neto etal. [48] questioned the DeMeester
index because of the method itself may produce false negatives. These can be caused
by factors such as lifestyle changes during the test, excessive saliva caused by cath-
eters, and gastric alkalization caused by Helicobacter pylori infection. In addition,
DeMeester index gives different weights according to reux mode, which is also
worth discussing.
All in all, any detection method is not absolutely perfect, and 24h double probe
pH monitoring is undoubtedly an accurate monitoring method to detect reux.
Although combined with other detection methods can increase accuracy, no scheme
is obviously superior to it.
7.4 Introduction ofBile Detection
Alkaline reux is another important factor that causes gastroesophageal reux dis-
ease and reux pharyngitis-related symptoms in addition to acid reux. The main
reux is bile. Current measurement methods include direct measurement and indi-
rect measurement. One experiment showed that 1mmol/l of bile salt could cause
7 Evaluation ofEndoscopic Treatment forGERD
96
damage to the esophagus mucosa and was not by the effect of acid neutralization in
the stomach. Hence, the determination of bile in the stomach could also reect the
possible damage caused by bile salt owing back into the esophagus [49].
7.4.1 Hepatobiliary Iminodiacetic Acid Scintigraphy
Hepatobiliary iminodiacetic acid (hepatobiliary iminodiacetic acid HIDA) imaging
is a long-standing diagnostic method, which was rst used to monitor bile reux
after gastrectomy in 1979. The combination of iminodiacetic acid and
technetium- 99m (Tc-99m) was mainly injected into the vein as a radioactive tracer.
If bile reux occurs, the tracer can be shown to circulate to the liver and reux to the
stomach and esophagus after excretion into the bile duct. The repeatability of
esophageal imaging is more sensitive than gastric juice imaging [50]. Sorgi etal.
[51] compared the consistency between HIDA and gastric tube aspiration in the
detection of bile reux. Sixteen (84%) of 19 patients showed the same results.
Although this technique is non-invasive, it is not widely used because it cannot
measure the concentration, volume, and reux time of reux and needs to lie at in
radiation environment for a long time.
7.4.2 Fiber-Optic Spectrophotometric Bilirubin Monitor
Bilitec 2000 is an optical ber spectrophotometer that can be used to evaluate
dynamic reux [52]. The principle is based on the characteristic absorption of bili-
rubin and bile around 450nm. Two light-emitting diodes are used for signal pro-
cessing. One is a blue probe with a wavelength as close as possible to the 450nm
bilirubin absorption peak. The other is a green probe with a detection wavelength of
565nm as a contrast. When bile reux enters the gap, blue light is absorbed, and the
concentration of bilirubin in the reux can be determined by measuring the absorp-
tion difference between the two emission wavelengths. Similar to esophageal pH
detection, the probe was placed across the nose above the esophageal sphincter.
Fein etal. [53] conducted invitro tests by bile solution, which showed a linear
relationship with the absorbance of bilirubin and could be used as a detection
method for bile reux. At the same time, the physiological bile reux study of 27
healthy volunteers showed that the upper limit of physiological bile reux was
28.2% of the total bile reux time. Fukuhara and others measured bile reux in the
esophagus after the Roux-en Y procedure. Sixty-one percent of patients found bile
reux to the esophagus for more than 5.0% [54]. Barrett etal. [55], extracted at least
10ml of gastric juice from 32 patients; they performed quantitative analysis of total
bile acids and total bilirubin using Bilitec probes (TB) invitro and invivo. They
found that bile acids above >1mmol/l were found to be the threshold for esophageal
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