Division of Gastroenterology, Hepatology, Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee.
Department of Gastroenterology, Mayo Clinic, Rochester, Minnesota.
Clin Gastroenterol Hepatol. 2018 Jul;16(7):1018-1029. doi: 10.1016/j.cgh.2018.02.001. Epub 2018 Feb 7.
The purpose of this review is to outline the recent developments in the field of extraesophageal reflux disease and provide clinically relevant recommendations. The recommendations outlined in this review are based on expert opinion and on relevant publications from PubMed and EMbase. The Clinical Practice Updates Committee of the American Gastroenterological Association proposes the following recommendations: Best Practice Advice 1: The role of a gastroenterologist in patients referred for evaluation of suspected extra esophageal symptom is to assess for gastroesophageal etiologies that could contribute to the presenting symptoms. Best Practice Advice 2: Non-GI evaluations by ENT, pulmonary and/or allergy are essential and often should be performed initially in most patients as the cause of the extraesophageal symptom is commonly multifactorial or not esophageal in origin. Best Practice Advice 3: Empiric therapy with aggressive acid suppression for 6-8 weeks with special focus on response of the extraesophageal symptoms can help in assessing association between reflux and extraesophageal symptoms. Best Practice Advice 4: No single testing methodology exists to definitively identify reflux as the etiology for the suspected extra esophageal symptoms. Best Practice Advice 5: Constellation of patient presentation, diagnostic test results and response to therapy should be employed in the determination of reflux as a possible etiology in extra esophageal symptoms. Best Practice Advice 6: Testing may need to be off or on proton pump inhibitor (PPI) therapy depending on patients' presenting demographics and symptoms in assessing the likelihood of abnormal gastroesophageal reflux. A. On therapy testing may be considered in those with high probability of baseline reflux (those with previous esophagitis, Barrett's esophagus or abnormal pH). B. Off therapy testing may be considered in those with low probability of baseline reflux with the goal of identifying moderate to severe reflux at baseline. Best Practice Advice 7: Lack of response to aggressive acid suppressive therapy combined with normal pH testing off therapy or impedance-pH testing on therapy significantly reduces the likelihood that reflux is a contributing etiology in presenting extraesophageal symptoms. Best Practice Advice 8: Surgical fundoplication is discouraged in those with extra esophageal reflux symptoms unresponsive to aggressive PPI therapy. Best Practice Advice 9: Fundoplication should only be considered in those with a mechanical defect (e.g., hiatal hernia), moderate to severe reflux at baseline off PPI therapy who have continued reflux despite PPI therapy and have failed more conservative non-GI treatments.
本综述的目的是概述食管外反流病领域的最新进展，并提供临床相关建议。本综述中概述的建议基于专家意见和来自 PubMed 和 EMbase 的相关出版物。美国胃肠病学协会临床实践更新委员会提出以下建议：
最佳实践建议 1：对于因疑似食管外症状而就诊的患者，胃肠病学家的作用是评估可能导致现有症状的胃食管病因。
最佳实践建议 2：耳鼻喉科、呼吸科和/或过敏科的非胃肠科评估是必不可少的，通常应在大多数患者中首先进行，因为食管外症状的病因通常是多因素的，或者不是起源于食管。
最佳实践建议 3：经验性治疗，使用强抑酸剂治疗 6-8 周，特别关注食管外症状的反应，有助于评估反流与食管外症状之间的关联。
最佳实践建议 4：不存在单一的检测方法可以明确确定反流是疑似食管外症状的病因。
最佳实践建议 5：在确定反流是否可能是食管外症状的病因时，应采用患者表现、诊断测试结果和治疗反应的组合。
最佳实践建议 6：根据患者的表现特征和症状，在评估异常胃食管反流的可能性时，可能需要停用或继续质子泵抑制剂（PPI）治疗进行测试。A. 在基线反流可能性高的患者（有既往食管炎、巴雷特食管或异常 pH 值的患者）中，可以考虑进行治疗中测试。B. 在基线反流可能性低的患者中，可以考虑进行治疗中测试，目的是在基线时识别中度至重度反流。
最佳实践建议 7：在积极的抑酸治疗无反应且治疗中和治疗后 pH 检测正常或阻抗-pH 检测阳性的情况下，显著降低了反流是现有食管外症状病因的可能性。
最佳实践建议 8：对于食管外反流症状对积极 PPI 治疗无反应的患者，不鼓励进行外科胃底折叠术。
最佳实践建议 9：仅应考虑在以下情况下进行胃底折叠术：存在机械缺陷（例如，食管裂孔疝）、PPI 治疗后基线时存在中度至重度反流、尽管进行了 PPI 治疗仍有反流且非胃肠治疗失败的患者。
