难治性胃食管反流病RGERD-参考幻灯片
合集下载
相关主题
- 1、下载文档前请自行甄别文档内容的完整性，平台不提供额外的编辑、内容补充、找答案等附加服务。
- 2、"仅部分预览"的文档,不可在线预览部分如存在完整性等问题,可反馈申请退款(可完整预览的文档不适用该条件!)。
- 3、如文档侵犯您的权益，请联系客服反馈,我们会尽快为您处理(人工客服工作时间：9:00-18:30)。
? Esophageal distension
? Persistent impaired mucosal integrity
? Esophageal hypersensitivity
2020/2/14
Gut,2004,53:1024-18031
Esophageal Hypersensitivity
Physiological stressors, sensitization of spinal sensory neurons
AM J Gastroenterol ,2012, 107, 89-15.
Gastropareห้องสมุดไป่ตู้is
Delayed gastric emptying (gastroparesis) may be a factor associated with severe reflux, dyspepsia, or both.
Potential factors contributing to the spectrum of reflux perception in patients with GERD
2020/2/14
Esophageal receptor upregulation and/ or enhanced signaling
Patients dosed suboptimally the PPIs(%)
>60 min before meals 39%
after meals
30%
at bedtime
28%
as-needed
4%
2020/2/14
—Richter JE Natl Clin Gastroenterol 2007;4:658
? Others suggest that lack of satisfactory symptomatic response to PPI once a day is suf?cient to consider patients as PPI failures.
Failure on PPI qd 6-15%
Barrett′s oesophagus 6-10%
Failure on PPI qd 20%
2020/2/14
——Fass et al. Aliment Pharmacol Ther 2005; 22(2):739-94.
30%NERD fail to PPI treatment
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”.
Remains an area of controversy
2020/2/14
2
PPI failed in Each of the Gastrooesophageal Re?ux Disease (GERD) Groups
GERD
NERD 60-70%
EE 20-30%
Failure on PPI qd 40-50%
2020/2/14
4
NERD-acid,visceral sensitivity
2020/2/14
5
Potential causes of PPI refractoriness in GERD
2020/2/14
Neurogastroenterol Motil (2012) 24, 697–704 6
ef?cacy of the medication.
PPI dosing situation in 100 patients with persistent GERD symptoms
Patients dosed
Proper dosing timing 46%
optimally the PPIs(%)
Psychological
Weakly acid ref lux
Poor compliance
with PPI treatment
Mechanism
NAB
Dilated intercellular
spaces
Gastroparesis
Esophageal hypersensitivity
DGER
7
? Any attempt to narrow the de?nition of refractory GERD might exclude many true sufferers.
——Hershcovici T et al. Best Practice& Research Clinical Gastroenterology 2010 (24)923-936
Gastroparesis, concomitant in 25% of patients with gastroesophageal reflux disease (GERD), has been shown to improve after Nissen fundoplication.
2020/2/14
1
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.
SURGICAL ENDOSCOPY AND OTHER INTERVENTIONAL TECHNIQUES ，2008，22 （11） 2440-2444
10
Poor Compliance with PPI Treatment
?Compliance to treatment and proper dosing are important. ?Timing and frequency of dosing are critical for maximum
? Persistent impaired mucosal integrity
? Esophageal hypersensitivity
2020/2/14
Gut,2004,53:1024-18031
Esophageal Hypersensitivity
Physiological stressors, sensitization of spinal sensory neurons
AM J Gastroenterol ,2012, 107, 89-15.
Gastropareห้องสมุดไป่ตู้is
Delayed gastric emptying (gastroparesis) may be a factor associated with severe reflux, dyspepsia, or both.
Potential factors contributing to the spectrum of reflux perception in patients with GERD
2020/2/14
Esophageal receptor upregulation and/ or enhanced signaling
Patients dosed suboptimally the PPIs(%)
>60 min before meals 39%
after meals
30%
at bedtime
28%
as-needed
4%
2020/2/14
—Richter JE Natl Clin Gastroenterol 2007;4:658
? Others suggest that lack of satisfactory symptomatic response to PPI once a day is suf?cient to consider patients as PPI failures.
Failure on PPI qd 6-15%
Barrett′s oesophagus 6-10%
Failure on PPI qd 20%
2020/2/14
——Fass et al. Aliment Pharmacol Ther 2005; 22(2):739-94.
30%NERD fail to PPI treatment
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”.
Remains an area of controversy
2020/2/14
2
PPI failed in Each of the Gastrooesophageal Re?ux Disease (GERD) Groups
GERD
NERD 60-70%
EE 20-30%
Failure on PPI qd 40-50%
2020/2/14
4
NERD-acid,visceral sensitivity
2020/2/14
5
Potential causes of PPI refractoriness in GERD
2020/2/14
Neurogastroenterol Motil (2012) 24, 697–704 6
ef?cacy of the medication.
PPI dosing situation in 100 patients with persistent GERD symptoms
Patients dosed
Proper dosing timing 46%
optimally the PPIs(%)
Psychological
Weakly acid ref lux
Poor compliance
with PPI treatment
Mechanism
NAB
Dilated intercellular
spaces
Gastroparesis
Esophageal hypersensitivity
DGER
7
? Any attempt to narrow the de?nition of refractory GERD might exclude many true sufferers.
——Hershcovici T et al. Best Practice& Research Clinical Gastroenterology 2010 (24)923-936
Gastroparesis, concomitant in 25% of patients with gastroesophageal reflux disease (GERD), has been shown to improve after Nissen fundoplication.
2020/2/14
1
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.
SURGICAL ENDOSCOPY AND OTHER INTERVENTIONAL TECHNIQUES ，2008，22 （11） 2440-2444
10
Poor Compliance with PPI Treatment
?Compliance to treatment and proper dosing are important. ?Timing and frequency of dosing are critical for maximum