Medical TreatmentWord下载.docx

Medical TreatmentWord下载.docx

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DeronJTessier,MD

Introduction

Gastroesophagealrefluxdisease（GERD）isoneofthemostcommongastrointestinaldiseasesfacingsocietytoday.IntheUSalone,morethan19millionpeoplehavethedisease.Approximately20%ofUSadultshaveoneepisodeofGERDinaweek,withabout7%reportingsignificantdailyheartburnsymptomsrequiringsometypeoftreatment.1MedicaltreatmentsforGERD,bothprescriptionandoverthecounter,costapproximately$19billionperyearintheUS.FortunatelythemajorityofGERDsymptomsareminorandself-limiting;

however,complications,includingesophagitis,Barrettsyndrome,andadenocarcinoma,areontheriseinWesterncountries,suggestingthatGERDdoesnothaveabenigncourseinallpatients.Thetermnonerosiverefluxdisease（NERD）hasbeenusedtodescribethemajorityofpatientsthathaveabenign,uncomplicateddiseasecourse.ThisgrouphasGERDsymptomswithoutevidenceofesophagitisonendoscopy.

TheclinicalmanagementofGERDhasevolvedrapidlysincetheearly1990swiththeintroductionofpotentmedicationsaswellaslessinvasivesurgicaltechniquestohelptreatpatientswithmedicallyrefractorydisease.Novelmedicationstohelppreventtransientloweresophagealsphincterrelaxations（tLESRs）arebeingdevelopedandmaybeaddedtothearmamentarium.2Additionally,endoscopictherapieshavegainedsomesupport,thoughlong-termdatasuggestthatthesetechniquesarenotdurable.

Thisarticlereviewsthepathophysiology,presentation,workup,treatment,andemergingtherapiesforGERDwithanemphasisonsurgicalmanagementandoutcomestohelpprimarycarephysicianshaveabetterunderstandingoftheroleofsurgeryinthiscomplexdisease.

Terminology

TheclassificationofGERDhasbeenconfusingbecauseofnumerousdefinitionsbasedonsymptomatic,physiologic,and/ordiagnosticcriteria.Insimplisticterms,GERDreferstothepathologicrefluxofgastriccontentsintotheesophagusthroughthegastroesophagealjunction.Thisrefluxatecanbeacidic,neutral,orbasic（bile）.Itcanbegas,liquid,semisolid,oracombination.Theoperativeterminthisdefinitionispathologic,inthatbelchingandvomitingwouldnotbeconsideredpathologicbecausetheyaretypicallyisolatedevents.PreviouslyGERDwasdefinedasarefluxeventresultinginadecreaseinpHof<

4,severalcentimetersabovethegastroesophagealjunction.Withintroductionofimpedancetesting（seebelow）,thisdefinitionwilllikelybeabandonedasourknowledgeofnonacidrefluxcomesintofocus.

Pathophysiology

Thenormalanatomyofthegastroesophagealjunctionallowsforrelaxationoftheloweresophagealsphincter（LES）asabolusoffoodapproachesthedistalesophagus.Oncethebolusispassedintothestomach,theLEScontractsandremainsazoneofhighpressureuntilanotherbolusisswallowed.InpatientswithGERD,thetLESRisnotcoordinatedwithaswallowandcanoccurspontaneously,allowingforgastriccontentstorefluxintothedistalesophagus.Additionally,thetLESRlastsseveralsecondsinhealthypatients,butinthosewithGERD,itcanlastmorethantenseconds,resultinginsignificantgastricreflux.StudieshavealsoshownthatpatientswithpathologicGERDhavemorefrequenttLESRsthanhealthypeopledo.3Whythisoccursinsomepeopleandnotothersiscurrentlyunderinvestigation.

Inhealthypeople,theLEShasabaselinepressurepreventingtherefluxofgastriccontentsintotheesophagus.InpatientswithGERD,thebaselineLESpressureislower,whichincreasesthelikelihoodofrefluxevents.Thisisworseinpatientswhotendtoeatalargemeal,whichincreasestheintragastricpressuremorethanthatoftheLES,resultinginGERD.EsophagealbodydysmotilitydoesnotdirectlyresultinGERD;

however;

ifapatienthaspooresophagealemptying,thiscanresultindelayedclearanceofesophagealcontentswhenarefluxeventoccurs.4Thelongerarefluxateisallowedtocomeincontactwiththeesophagealmucosa,themoredamageitcanproduce.Similarly,delayedgastricemptyingisknowntoincreasethetransittimeofgastriccontentsintotheduodenum.StasisofgastriccontentsinthestomachofpatientswithgastroparesiswhoalsohavetLESR,LEShypotension,orbothmayresultinmorefrequentandprolongedGERDevents.Finally,ahiatalherniaisstronglyassociatedwithGERDmostlikelycausedbyabreakdownintheLESmechanism,resultingindecreasedLESpressure.

RiskfactorsforGERDarenumerous,andeachlikelyplayssomeroleinincreasingthefrequencyandlengthoftLESR（Table1）.Obesity,forinstance,isknowntobeariskfactorforincreasedreflux,andtLESRislikelyduetolargermeals,whichresultingastricdistention,increasedacidproduction,increasedintra-abdominalpressurefromlargergirth,orincreasedrelaxationduetohigherlevelsofcertainhormones（eg,estrogen）thatstimulatetLESR.5FoodsandbeveragesknowntoeitherrelaxtheLESorirritatethedistalesophagusincludecitrusdrinks,spicyfood,caffeinatedbeverages（tea,cola,coffee）,chocolate,andpeppermint.PatientswhoeatlargefattymealswillalsohaveworsesymptomsmostlikelybecauseofincreasedacidproductionwithassociateddecreasedLESpressure.MedicationsknowntoexacerbateGERDbydecreasingtheLESpressureincludecalcium-channelblockers,theophylline,meperidine,someoralcontraceptives,andnitrates.

Presentation

ThepresentationofGERDisfairlycharacteristic,withthemajorityofpatientstreatingtheirconditionbeforetheycometoclinicalattention.Themostcommonpresentationisaburningpainarisingfromtheepigastriumandradiatingretrosternallytothethroatandneck.Meals（especiallythosecontainingsomeofthealready-describedfoods）,recumbency,andbendingoverworsenthesymptoms,whereasantacids,milk,andsittingorstandinguprelievethesymptoms.Patientsreportacidicfluidcominguptothemouthandattimesthesensationthatsolidmaterialiscomingbackup.FrankvomitingisrareinuncomplicatedGERDandshouldraisesuspicionforanotherunderlyingdisease.Itisnotuncommonforpatientstopresentwithchestpain;

however,allpatientsdeserveanappropriatecardiacworkupbeforetheirchestpainisattributedtoGERD.6GlobusisanothersymptomusuallyassociatedwithGERD.Dysphagia,weightloss,andhematemesisarepartofthe“alarmsymptoms”andrequireamoreaggressiveworkuptoruleoutpepticormalignantstricture,ulcerativeesophagitis,andothercausesofacuteuppergastrointestinalbleedingthatmayormaynotberelatedtoGERD.

ExtraesophagealmanifestationsofGERDhavebeenwidelystudiedanddebated.Chronicreflux–associatedcough,laryngitis,asthma,anddentalerosionshaveallbeenfoundtobeassociatedwithGERD.OtherproposedextraesophagealmanifestationsofGERDincludepharyngitis,sinusitis,idiopathicpulmonaryfibrosis,andrecurrentotitismedia.7

Evaluation

ThemainstayindiagnosingGERDinvolvessix-weektrialofempirictherapywithaprotonpumpinhibitor（PPI）.Patientsshouldbereassessedafterthetrialtodetermineimprovement.Ifsymptomshavedecreased,thennofurtherworkupisrequiredandpatientsmaycontinuetakingthePPIeithercontinuouslyorintermittentlyasneeded.If,however,thepatient’sdiseaserespondsinadequately,thenfurthertestingisnecessary.Thenextstepistoperformesophagogastroduodenoscopy（EGD）.ThisstrategyhasbeenfoundtoadequatelydiagnoseGERDwithasensitivityof75%andaspecificityof80%.8ItallowsEGDtobereservedforthosepatientswithpersistentandrefractorysymptomswhoaremorelikelytohaveadiseaseotherthanGERD.Somenotableexceptionstothisstrategyincludepatientswithalarmsymptomswhoarelikelytohaveamoreseriouslesion,patientsolderthanage55yearswhomayhaveahigherriskofaseriouslesion,andpatientstakingesophagotoxicmedicationssuchasnonsteroidalanti-inflammatorydrugsandbisphosphonateswhomayhaveacomplicationrelatedtotheirmedication.9Ifpatients’diseaserespondsminimallyornotatalltoPPIsandtheyundergoEGDandnoabnormalityisfoundtoexplaintheirsymptoms,thentheworkupshouldbedirectedatthedifferentialfordyspepsia（Table2）.

Asalreadymentioned,EGDisthestandardclinicaltestforGERDandanimportanttestinpatientswithalarmsymptoms.9ItishighlysensitiveandspecificforesophagitisandcomplicationsofGERDsuchasulcerativedisease.EGDallowstheabilitytodeterminetheexactextentofmucosalinjuryandiscapableofperformingbiopsyifnecessary.EGDallowsidentificationofBarrettesophagusbecauseofthecharacteristicsalmoncolorofthemucosaonendoscopy,andbiopsyallowspathologicstaging.

AmbulatorypHmonitoringisthemostsensitivetestforacidreflux,butitdoesnotdetectnonacidicrefluxevents.ThestandardtestrequiresplacementofanasalpHprobethatmonitorsesophagealpHfor24hourswhilethepatientresumeshisorherusualdietandactivities.Thepatientthendocumentsactivitiesandesophagealsymptomseitherinadiaryorwithanexternalmonitoringsystem.Atthecompletionofthestudy,thepatient’ssymptomsarecorrelatedwiththepHmonitoringresultsandseveralcriteriaareusedtodeterminetheextentofthepatient’srefluxdisease.10,11ThistestshouldbeusedonlytoconfirmacidrefluxifsurgeryisanticipatedortooptimizemedicaltreatmentinpatientswithcontinuedsymptomswhiletakingPPIs.Ifsurgeryisanticipated,thenthestudyshouldbeperformedwhilethepatienthasdiscontinuedPPItherapytoallowdocumentationoftheexactseverityofacidreflux.IfpatientscontinuetakingtheirPPI,