胃食管反流病患者质子泵抑制剂治疗后症状持续患者的管理选择：专家小组的建议。
Management options for patients with GERD and persistent symptoms on proton pump inhibitors: recommendations from an expert panel.
机构信息
Anschutz Medical Campus, University of Colorado, Aurora, CO, USA. Vanderbilt Medical Center, Nashville, TN, USA. Mayo Clinic, Scottsdale, AZ, USA. Baylor Health Care System, Dallas, TX, USA. University of North Carolina, Chapel Hill, NC, USA. University of South Florida, Tampa, FL, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA. Mayo Clinic, Rochester, MN, USA. Weill Cornell Medical Center, New York, NY, USA. Northwestern University, Chicago, IL, USA. Washington University, St. Louis, MO, USA. California Pacific Medical Center, San Francisco, CA, USA. Metro Health Medical Center, Cleveland, OH, USA. Medical University of South Carolina, Charleston, SC, USA. University of Wisconsin, Madison, WI, USA.
出版信息
Am J Gastroenterol. 2018 Jul;113(7):980-986. doi: 10.1038/s41395-018-0045-4. Epub 2018 Apr 24.
BACKGROUND
The aim of this study was to assess expert gastroenterologists' opinion on treatment for distinct gastroesophageal reflux disease (GERD) profiles characterized by proton pump inhibitor (PPI) unresponsive symptoms.
METHODS
Fourteen esophagologists applied the RAND/UCLA Appropriateness Method to hypothetical scenarios with previously demonstrated GERD (positive pH-metry or endoscopy) and persistent symptoms despite double-dose PPI therapy undergoing pH-impedance monitoring on therapy. A priori thresholds included: esophageal acid exposure (EAE) time >6.0%; symptom-reflux association: symptom index >50% and symptom association probability >95%; >80 reflux events; large hiatal hernia: >3 cm. Primary outcomes were appropriateness of four invasive procedures (laparoscopic fundoplication, magnetic sphincter augmentation, transoral incisionless fundoplication, radiofrequency energy delivery) and preference for pharmacologic/behavioral therapy.
RESULTS
Laparoscopic fundoplication was deemed appropriate for elevated EAE, and moderately appropriate for positive symptom-reflux association for regurgitation and a large hiatal hernia with normal EAE. Magnetic sphincter augmentation was deemed moderately appropriate for elevated EAE without a large hiatal hernia. Transoral incisionless fundoplication and radiofrequency energy delivery were not judged appropriate in any scenario. Preference for non-invasive options was as follows: H2RA for elevated EAE, transient lower esophageal sphincter relaxation inhibitors for elevated reflux episodes, and neuromodulation/behavioral therapy for positive symptom-reflux association.
CONCLUSION
For treatment of PPI unresponsive symptoms in proven GERD, expert esophagologists recommend invasive therapy only in the presence of abnormal reflux burden, with or without hiatal hernia, or regurgitation with positive symptom-reflux association and a large hiatus hernia. Non-invasive pharmacologic or behavioral therapies are preferred for all other scenarios.
背景
本研究旨在评估专家胃肠病学家对质子泵抑制剂（PPI）无反应症状的不同胃食管反流病（GERD）特征的治疗意见。
方法
14 名食管病学家应用 RAND/UCLA 适宜性方法对先前证实的 GERD（pH 监测或内镜阳性）和持续症状的假设情况进行评估，这些患者在接受双倍剂量 PPI 治疗后仍存在症状，且正在进行 pH 阻抗监测。事先设定的阈值包括：食管酸暴露（EAE）时间>6.0%；症状-反流相关性：症状指数>50%和症状关联概率>95%；>80 次反流事件；大裂孔疝：>3cm。主要结局是四种侵入性手术（腹腔镜胃底折叠术、磁括约肌增强术、经口无切口胃底折叠术、射频能量传递）的适宜性以及对药物/行为治疗的偏好。
结果
腹腔镜胃底折叠术被认为适用于 EAE 升高的情况，对反流的阳性症状-反流相关性和正常 EAE 时大裂孔疝也适度适用。磁括约肌增强术被认为适用于无大裂孔疝的 EAE 升高情况。经口无切口胃底折叠术和射频能量传递在任何情况下均不被认为是适宜的。对非侵入性选择的偏好如下：H2RA 适用于 EAE 升高，短暂性下食管括约肌松弛抑制剂适用于反流事件升高，神经调节/行为治疗适用于阳性症状-反流相关性和大裂孔疝。
结论
对于 PPI 无反应症状的治疗，在存在异常反流负担的情况下，专家食管病学家仅推荐侵入性治疗，无论是否存在裂孔疝，或存在阳性症状-反流相关性和大裂孔疝的反流。对于所有其他情况，首选非侵入性药物或行为治疗。
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