1、5-06-08 2008,阻抗技术用于胃食管反流,丁文京博士 北美医学基金会 www.ast-,作者使用Sandhill公司产品,阻抗-pH 检测VS单纯pH检测,单纯pH检测是以病人主诉为基础的检查方法。有主观性。 联合阻抗- pH检测的意义是可以客观确诊各种反流。,单纯pH检测不能辨别酸性食物造成的假象。 单纯pH检测不能发现非酸性反流。 单纯pH检测不能发现不是反流。 单纯pH检测不能评判胃底折叠术效果。,Agrawal et al: Dig Dis Sci 2005; 50: 1916,阻抗可以通过食团运动反向辨别酸性食物造成的假象。 阻抗可以发现非酸反流。 阻抗可以发现不是反流的病人
2、。 阻抗可以评判胃底折叠术效果。,阻抗-pH 检测VS单纯pH检测,联合阻抗-pH检测,单纯pH检测,联合阻抗-pH检测可以客观和准确提供更多信息。,阻抗的作用：全面监测反流,58%,35%,7 %,阻抗-pH 导管,监测原理,利用阻抗检测反流 利用pH区分酸碱度,24小时pH-阻抗检测系统,重要意义 利用阻抗检测反流 利用pH区分酸碱度 判定是否发生返流 鉴别返流性质（酸性或非酸性返流） 返流高度 检测食团和化学物质的排空情况,检测内容 返流时间、返流次数 最长返流持续时间 酸清除时间（pH4的时间） 酸返流时间、返流时间百分比 返流性质（气体返流/液体返流/混合性返流） 返流高度 综合评分
3、,为什么要联合使用pH-阻抗？,99例持续典型症状的病人,在99例有典型胃食管反流症状的病人中，经检测发现48%没有反流，41%为非酸性反流，只用11%为酸性反流。,服药期间做联合阻抗-pH 检测,有典型症状的病人 N=58,45 %,45 %,10 %,No Reflux Association,Nonacid Association,Acid Association,Inder Mainie, R. Tutuian October 2004,典型症状: 烧心、打嗝、胸痛,非典型症状的病人 N=43,2 %,23 %,75 %,Acid Association,Nonacid Associa
4、tion,No Reflux Association,Inder Mainie, R. Tutuian October 2004,非典型症状:Cough咳嗽声嘶打嗝, 吞咽困难, globus, 腹部症状 & acid taste,联合阻抗-pH检测期间有症状的病人 N=200,An Analysis of Persistent Symptoms in Acid-Suppressed Patients Undergoing Impedance-pH Monitoring; Sharma, Agrawal, Freeman, Vela 6:xxx,35 %,3.5 %,3.5 %,58 %,在服
5、抗酸药期间做联合阻抗-pH检测,An Analysis of Persistent Symptoms in Acid-Suppressed Patients Undergoing Impedance-pH Monitoring; Sharma, Agrawal, Freeman, Vela 6:xxx,42 %,58 %,症状指数阳性,症状指数阴性,42 %,58 %,200例病人在检测期间有症状,症状指数 50%,218名PPI治疗后症状持续的患者,An Analysis of Persistent Symptoms in Acid-Suppressed Patients Undergoin
6、g Impedance-pH Monitoring; Sharma, Agrawal, Freeman, Vela 6:xxx,24 %,17 %,16%,13 %,10 %,9 %,7 %,4 %,症状发作,成人病人,服药期间做联合阻抗-pH检测,125 例在服药期间有持续症状的病人,101 例病人在研究期间有症状,酸性反流 7 % (7 patients),Inder Mainie, R. Tutuian October 2004,pH-阻抗联合测试的意义,可以鉴别反酸性和非反酸性胃食管返流性疾病，排除有反流症状的非反流病人。 可以测量返流性质和返流高度。 可以检测咽喉反流。 可以测量食团
7、和化学物排空，可以测量食团上下运动。 可以检查反流物的性质：液体、气体、混合等。 结合阻抗和压力波以动画技术动态显示食团传送和食管蠕动。,联合阻抗-pH指导治疗,Clinical Trial: Persistent Gastro-Oesophageal Reflux Symptoms Despite Standard Therapy with Proton Pump Inhibitors A Follow-up Study of Intraluminal-Impedance Guided Therapy; Becker et al; Alimentary Pharmacology & Ther
8、apeutics 26, 13551360,服用PPI期间持续有烧心反胃的病人 N=143,PPI治疗期间用联合阻抗-pH检测,联合阻抗-pH检测39 % 的病人有病理性变化,调整PPI用量或做胃底折叠术,91 % 的病人症状消失,阻抗-pH 检测系统构成,3-20-09 2009,性能齐全的记录器,功能强大的软件,种类丰富的固态导管,独特的食管括约肌定位器,确保导管放置位置，保证检查结果的准确性、一致性、可重复性。,食管括约肌定位器对研究结果至关重要,单支咽喉返流监测导管,双分支咽喉返流监测导管,左侧分支检测咽喉反流,右侧分支检测胃食管反流,优点： 可以分别精确定位上、下食管括约肌 可以同时
9、监测咽喉反流和胃食管反流 可以准确放置导管,阻抗-pH 客观评价反流,酸性,非酸性,pH 4.0 是阈值,酸性和非酸性反流,Acid Reflux,Nonacid Reflux,快速鉴别酸性和非酸性反流,阻抗随食团变化,pH下降,典型酸性胃食管反流,34,Acid GER Episode,酸性胃食管反流,pH 4.0 为阈值,34,酸性胃食管反流显示方式,酸性反流物清除,Acid GER Clearance Phases,酸性胃食管反流和咽喉反流,40,Nonacid GER Episode,pH 4.0 threshold,40,非酸性胃食管反流显示方式,智能建立分析模型,PPI模板 Jos
10、hson-DeMeester pH评分模板 Joshson-DeMeester阻抗-pH评分模板 Joshson-DeMeester/PPI阻抗-pH评分模板 Biox-Ochoa阻抗-pH评分模板 Biox-Ochoa pH评分模板 Vandenplas评分模板,结论,大量临床研究证明，只有联合pH阻抗技术才能真正快速鉴别胃食管反流患者。,进行监测的目的 是否有效抑酸？ 症状与反流的关系：酸、弱酸、非酸、弱碱、碱 反流频率 反流高度,每小时总反流次数,据MII-pH监测指导治疗,Clinical Trial: Persistent Gastro-Oesophageal Reflux Symp
11、toms Despite Standard Therapy with Proton Pump Inhibitors A Follow-up Study of Intraluminal-Impedance Guided Therapy; Becker et al; Alimentary Pharmacology & Therapeutics 26, 13551360,PPI治疗中烧心/反流症状持续的患者 N=143,行治疗过程中的MII-pH监测,39 %患者在MII-pH监测中存在病理性反流,治疗升级 PPI 剂量调整或胃底折叠术,91 % 患者症状缓解,胃底折叠术结果,19 名症状指数阳性的
12、患者 ( 50%),Combined MultiChannel Intraluminal Impedance-pH Monitoring to Select Patients with Persistent Gastro-oesophageal Reflux for Laparoscopic Nissen Fundoplication; Mainie et al; British Journal of Surgery; 10.1002/bjs.5493; 2006,需要考虑的问题,病人有无 GERD? 症状的原因是什么?,适当的抗酸治疗 与症状相关因素 酸性反流 非酸性反流 反流频率,阻抗-p
13、H 检测报告,pH 反酸时间 酸反流成分评分阻抗 反流性质：酸反流、非酸反流 反流次数,选择合适的报告格式,打印报告,自动分析 自动出报告,Impedance-pH Monitoring Data SummaryAcid Exposure (pH)Upright Recumbent Acid Exposure Upright Normal Recumbent Normal TotalTime 2.1 min 0.0 min 2.1 minPercent Time 0.4% ( 6.3 %) 0.0% ( 1.2 %) 0.2%Acid Reflux Composite Score Analys
14、is (DeMeester) (pH)Patient Value Patient Score Normal ThresholdUpright Time In Reflux 0.4% 0.2 8.4 Recumbent Time In Reflux 0.0% 0.4 3.5 Total Time In Reflux 0.2% 0.1 4.5 Episodes Over 5 min. 0.0 0.3 3.5 Longest Episode 1.1 min 0.3 19.8 Total Episodes 6.8 0.0 46.9 Composite Score 1.2 14.7NOTE: Compo
15、site Score Normalized for 24 Hours.,Impedance-pH Monitoring Data Summary (page 2)Reflux Episode ActivityUpright Recumbent Total Total NormalAcid 5 0 5 Nonacid 42 1 43 All Reflux 47 1 48 ( 73)Symptom Correlation to RefluxAcid Nonacid All Reflux Symptom Occurrences Related Related Related UnrelatedHea
16、rtburn 3 2 1 3 0 Regurgitate 17 0 16 16 1Reflux Symptom Index Symptom Acid Nonacid All RefluxHeartburn 66.67% 33.33% 100.00% Regurgitate 0.00% 94.12% 94.12%Reflux Symptom Association Probability Symptom Acid Nonacid All RefluxHeartburn 99.93% 66.51% 99.72% Regurgitate 0.00% 99.75% 99.46%,Impedance-p
17、H Monitoring Data SummaryAcid Exposure (pH)Upright Recumbent Total Acid Exposure Upright Normal Recumbent Normal Total Normal Time 1.0 min (on PPI) 0.0 min (on PPI) 1.0 min (on PPI) Percent Time 0.2% ( 1.5 %) 0.0% ( 0.5 %) 0.1% (1.3%) Mean Acid Clearance Time 20 sec 0 sec 20 sec Acid Reflux Composit
18、e Score Analysis (DeMeester) (pH)Patient Value Patient Score Normal Threshold Upright Time In Reflux 0.2% 0.1 8.4 Recumbent Time In Reflux 0.0% 0.4 3.5 Total Time In Reflux 0.1% 0.0 4.5 Episodes Over 5 min. 0.0 0.3 3.5 Longest Episode 0.6 min 0.2 19.8 Total Episodes 5.1 0.0 46.9 Composite Score 1.0
19、14.7NOTE: Composite Score Normalized for 24 Hours.,Acid (chemical) Exposure Data From pH Sensor,Adult or Pediatric Composite Score From pH Sensor,Impedance-pH Monitoring Data SummaryReflux Episode Acidity (Impedance)Upright Recumbent Total Total Normal Acid 3 0 3 (on PPI) Nonacid 45 40 85 All Reflux
20、 48 40 88 ( 48)Symptom Association Data Acid Nonacid All Reflux Symptom Occurrences Related Related Related UnrelatedHeartburn 3 2 1 3 0 Regurgitate 17 0 16 16 1Reflux Symptom IndexSymptom Acid Nonacid All RefluxHeartburn 67% 33% 100 Regurgitate 0% 94% 94%Reflux Symptom Association ProbabilitySympto
21、m Acid Nonacid All RefluxHeartburn 99% 66% 99% Regurgitate 0% 99% 99%,Number of Acid & Nonacid Reflux Episodes,Symptom Association to Reflux,Preliminary DataPatient Name: Acid GERD Patient Number: 123456Normal Acid Exposure Percent Time Upright 39.3% (6.3%) Acid Exposure Percent Time Recumbent 5.6%
22、(1.2%)Reflux Symptom Index Symptom Acid Nonacid All Reflux NormalHeartburn 93 % 15 % 98 % ( 75 %: No Editing related to that specific symptom All Reflux symptom index 50-75% for a symptom: Edit as follows1. Review impedance reflux episodes preceding symptoms (5 min. prior to symptom event) 2. Delete
23、 any impedance measurement areas preceding symptoms which are not true retrograde bolus movement (i.e. not impedance reflux) 3. Delete any pH measurement areas corresponding to the deleted impedance measurement areasAdult Editing Guideline; Donald Castell, MD; Medical University of South CarolinaDat
24、a and page formatting are examples,Example One,Preliminary DataPatient Name: Acid GERD Patient Number: 123456Normal Acid Exposure Percent Time Upright 39.3% (6.3%) Acid Exposure Percent Time Recumbent 5.6% (1.2%)Reflux Symptom Index Symptom Acid Nonacid All Reflux NormalHeartburn 93 % 15 % 98 % ( 75
25、 %: No Editing related to that specific symptom All Reflux symptom index 50-75% for a symptom: Edit as follows1. Review impedance reflux episodes preceding symptoms (5 min. prior to symptom event) 2. Delete any impedance measurement areas preceding symptoms which are not true retrograde bolus moveme
26、nt (i.e. not impedance reflux) 3. Delete any pH measurement areas corresponding to the deleted impedance measurement areasAdult Editing Guideline; Donald Castell, MD; Medical University of South Carolina Data and page formatting are examples,Preliminary DataPatient Name: Acid GERD Patient Number: 12
27、3456Normal Acid Exposure Percent Time Upright 39.3% (6.3%) Acid Exposure Percent Time Recumbent 5.6% (1.2%)Reflux Symptom Index Symptom Acid Nonacid All Reflux NormalHeartburn 93 % 15 % 98 % ( 75 %: No Editing related to that specific symptom All Reflux symptom index 50 -75% for a symptom: Edit as f
28、ollows1. Review impedance reflux episodes preceding symptoms (5 min. prior to symptom event) 2. Delete any impedance measurement areas preceding symptoms which are not true retrograde bolus movement (i.e. not impedance reflux) 3. Delete any pH measurement areas corresponding to the deleted impedance
29、 measurement areasAdult Editing Guideline; Donald Castell, MD; Medical University of South Carolina Data and page formatting are examples,Reflux-Symptom Temporal Associations,Ambulatory Impedance-pH-Manometry Reflux - Cough,阻抗-pH 检测反流与症状的关系,Chronic Cough Data Summary,Weakly Acidic Reflux in Patients with Chronic Unexplained Cough During 24 Hour Pressure, pH and Impedance Monitoring; D. Sifrim et al; GUT; 2005; 54;449-454,NO! Its a Coke swallow,Impedance/pH tracing,
