Gockel Ines, Lord Reginald V N, Bremner Cedric G, Crookes Peter F, Hamrah Pedram, DeMeester Tom R
Department of Surgery, University of Southern California Keck School of Medicine, Los Angeles, California, USA.
J Gastrointest Surg. 2003 Jul-Aug;7(5):692-700. doi: 10.1016/s1091-255x(03)00043-x.
The aim of this study was to define the clinical presentation, motility characteristics, and prevalence and patterns of gastroesophageal reflux in patients with hypertensive lower esophageal sphincter (HTLES). HTLES was defined by a resting pressure measured at the respiratory inversion point on stationary manometry of greater than 26 mm Hg (ninety-fifth percentile of normal). One hundred consecutive patients (80 women, 20 men; mean age 54.7 years, range 23 to 89 years), diagnosed with HTLES at our institution between September 1996 and October 1999, were studied. Patients with achalasia or other named esophageal motility disorders or history of foregut surgery were excluded, but patients with both HTLES and "nutcracker esophagus" were included. The most common symptoms in patients with HTLES were regurgitation (75%), heartburn (71%), dysphagia (71%), and chest pain (49%). The most common primary presenting symptoms were heartburn and dysphagia. The intrabolus pressure, which is a manometric measure of outflow obstruction, was significantly higher in patients with HTLES compared to normal volunteers. The residual pressure measured during LES relaxation induced by a water swallow was also significantly higher than in normal persons. There were no significant associations between any of the relaxation parameters studied (residual pressure, nadir pressure, duration of relaxation, time to residual pressure) and either the presence or severity of any symptoms or the presence of abnormal esophageal acid exposure. Seventy-three patients underwent 24-hour pH monitoring, and 26% had increased distal esophageal acid exposure. Compared to a cohort of patients with gastroesophageal reflux disease but no HTLES (n=300), the total and supine periods of distal esophageal acid exposure were significantly lower in the patients with HTLES and abnormal acid exposure. Patients with HTLES frequently present with moderately severe dysphagia and typical reflux symptoms. Approximately one quarter of them have abnormal esophageal acid exposure on pH monitoring. Patients with HTLES have significantly elevated intrabolus and residual relaxation pressures on liquid boluses, suggesting that outflow obstruction is present.
本研究的目的是明确高血压性食管下括约肌（HTLES）患者的临床表现、动力特征以及胃食管反流的患病率和模式。HTLES通过在静态测压的呼吸反转点测得的静息压力大于26 mmHg（正常的第95百分位数）来定义。对1996年9月至1999年10月间在我们机构被诊断为HTLES的连续100例患者（80名女性，20名男性；平均年龄54.7岁，范围23至89岁）进行了研究。排除患有贲门失弛缓症或其他明确的食管动力障碍或有前肠手术史的患者，但患有HTLES和“胡桃夹食管”的患者被纳入。HTLES患者最常见的症状是反流（75%）、烧心（71%）、吞咽困难（71%）和胸痛（49%）。最常见的主要首发症状是烧心和吞咽困难。推注内压力是流出道梗阻的一项测压指标，与正常志愿者相比，HTLES患者的推注内压力显著更高。由吞水诱发的LES松弛期间测得的残余压力也显著高于正常人。所研究的任何松弛参数（残余压力、最低点压力、松弛持续时间、达到残余压力的时间）与任何症状的存在或严重程度以及食管酸暴露异常之间均无显著关联。73例患者接受了24小时pH监测，26%的患者远端食管酸暴露增加。与一组患有胃食管反流病但无HTLES的患者（n = 300）相比，HTLES且酸暴露异常的患者远端食管酸暴露的总时长和仰卧位时长显著更低。HTLES患者常表现为中度严重的吞咽困难和典型的反流症状。其中约四分之一的患者在pH监测时存在食管酸暴露异常。HTLES患者在液体推注时推注内压力和残余松弛压力显著升高，提示存在流出道梗阻。
