【作者】 向雪莲；

【导师】 许军英； 侯晓华；

【作者基本信息】 华中科技大学 ， 内科学， 2012， 博士

【摘要】 第一部分不同管径高分辨率食管测压导管的测压结果一致性研究背景与目的：曾有采用传统水灌注食管测压的研究指出导管外径是影响测压结果的设备相关因素之一。高分辨率固态食管测压作为一项优于传统水灌注测压的新技术越来越多地被运用到食管动力的研究中。目前尚无研究采用高分辨率食管测压技术来验证导管外径差异对测压结果是否有影响。本研究则采用高分辨率固态食管测压技术来验证不同外径测压导管是否提供不同的测压数据而带来测压结果的不同。方法：9名无症状志愿者和9名胃食管反流病患者接受两次采用不同管径(4.2mm和2.7mm)测压导管进行的高分辨率食管测压。每次检查包括5分钟静息压测定,10次水吞咽和10次面包吞咽。分析内容包括一些涉及食管括约肌和体部的重要参数,例如括约肌的位置和静息压力、4s整合松弛压(4s IRP)、远段收缩积分(DCI)等。然后将由两条导管所得的这些参数和基于这些参数对于每口吞咽动力类型的判定结果进行对比。结果：(1)4.2mm外径的测压导管所得的上食管括约肌的静息压高于2.7mm外径的导管(59.8±21.2mmHg vs.47.2±17.7mmHg)；(2)水吞咽中,2.7mm外径的导管所得的4s IRP比4.2mm外径导管高(12.8±4.8mmHg vs.8.0±3.2mmHg)；(3)水吞咽中,粗导管所得平均DCI高于细导管(1170±728.5mmHg.cm.s vs.930.0±587.9mmHg.cm.s)；(4)粗细导管所得的LES静息压,水吞咽中IBP以及面包吞咽的所有参数均无统计学差异；(5)水吞咽中,4.2mm粗导管检测到更多的无蠕动吞咽,而2.7mm导管检测到更多的低幅蠕动型吞咽；(6)粗细两种导管对食管动力的综合评估结论存在一定的差异。结论：2.7mm粗导管采集所得数据在一定程度上与4.2mm粗导管存在差异,有必要针对不同的导管类型建立不同的正常值标准。由4.2mm外径固态测压导管所得的芝加哥标准不能直接用于采用其他外径导管的研究。第二部分110例无症状志愿者高分辨率食管测压下的下食管括约肌动力研究背景与目的：高分辨率食管测压引进入我国已四年余,现在国内医院拥有高分辨率食管测压的动力中心越来越多。目前关于高分辨率食管测压,尚无中国人食管动力的正常值,本研究则着力于完成此项工作。方法：以我科动力中心为牵头单位,联合国内其他十家医院,对110例无症状健康志愿者进行高分辨率食管测压,建立食管动力正常值数据库,统计得出食管动力正常值。参与本研究的十一家医院入组的健康志愿者来自于华北、华中、华南、华东和华西,可以反映中国不同区域人群的食管动力水平。本研究则分析胃食管结合处的参数,包括形态学参数(LES中心位置、LES上缘、LES下缘、PIP位置、食管长度、LES长度、LES腹腔内长度),LES静息压力(LES呼吸最小值、LES呼吸平均值),LES松弛相关参数(4s IRP和IBP)以了解其动力水平。结果：(1)剔除7例后,剩余103例,对水吞咽共计1017次,固体吞咽874次的测压数据进行分析。参数结果以[均数±标准差,P95]的形式展现。位置参数的值为距鼻孔的深度。(2)LES中心位置为[43.8±3.1,48.5]cm,LES上缘为[42.4±3.1,47.5]cm,LES下缘为[46.0±2.9,51.0]cm,LES长度为[3.7±0.8,5.3]cm,食管长度为[25.0±2.1,29.0]cm,PIP位置为[43.4±3.1,48.4]cm,LES腹腔内长度为[2.7±0.6,3.9]cm；(3)LES压力呼吸最小值为[12.4±6.1,23.8]mmHg,LES呼吸平均值为[20.8±7.1,34.1]mmHg;(4)水吞咽4s IRP为[10.5±4.5,18.8]mmHg,IBP为[10.3±4.7,17.8]mmHg,固体吞咽的4s IRP为[10.5±4.3,18.9]mmHg,IBP为[13.1±5.0,21.4]mmHg,水吞咽和固体吞咽的4s IRP无统计学差异(p=0.955),固体吞咽的IBP高于水吞咽(p=0.000)结论：国人高分辨率测压EGJ处压力参数的正常值较之于国外标准存在一些不同。第三部分应用高分辨率阻抗测压技术对于低压型食管动力特征的研究背景与目的：高分辨率食管测压中,对吞咽后食管低压型蠕动的判断,从最初的吞咽后食管平滑肌部分蠕动波30mmHg等压线缺损达到3cm到目前的20mmHg等压线缺损达到2cm,其标准处于变化中。某些吞咽采用不同的标准其判断结果不同。高分辨率阻抗食管测压技术可以在食管测压同时客观评价各吞咽对食团清除的结果,对低压型蠕动的判断相对客观。本研究拟以高分辨率阻抗测压技术为手段,观察食团清除失败的低压型蠕动的压力特征。方法：对5名无症状志愿者和15名胃食管反流病患者的高分辨率阻抗测压结果进行分析。依据阻抗对每次吞咽食团清除的结果将吞咽分为正常吞咽(食团清除成功)和低压型吞咽(食团清除失败),并分析各吞咽在20mmHg和30mmHg等压线的缺损情况,总结得出低压型蠕动的压力特点。结果：(1)20例受试者共行水吞咽200次,剔除掉无蠕动吞咽10次,剩下190次吞咽；(2)在190次吞咽中,采用20mmHg等压线缺损2cm作为正常吞咽与低压吞咽的临界值诊断,88.4%的吞咽与阻抗结果判断一致,采用30mmHg等压线缺损3cm作为诊断标准,87.9%的吞咽结果判断与阻抗一致,两种标准与阻抗的诊断一致率无统计学差异(p=0.874)；(3)食团清除成功的正常吞咽,20mmHg和30mmHg等压线缺损的最大值分别为5.3cm和15.2cm；食团清除失败的低压型吞咽,20mmHg和30mmHg等压线缺损的最小值分别为0.8cm和1.2cm；(4)食团清除成功的正常吞咽中,12次吞咽被20mmHg或30mmHg等压线缺损标准判断为低压型蠕动。此12次吞咽在20mmHg等压线上的缺损长度较集中,缺损长度基本在5cm以内,在30mmHg等压线上的缺损长度较离散,最大值为15.2cm,最小值为3.1cm；(5)食团情况失败的低压型吞咽中,23次吞咽被20mmHg或30mmHg等压线缺损标准判断为正常吞咽,这些缺损虽较小,仍导致了食团清空失败,而91.3%的这些缺损位于食管体部的最末端；(6)对于食管近段骨骼肌和中远段平滑肌之间蠕动的缺损而言,食团清空成功的吞咽中,20mmHg等压线间距最大为4.4cm,30mmHg等压线间距最大为9.5cm。在食团清空异常的吞咽中,20mmHg等压线间距最小为1.1cm,30mmHg等压线间距最小为4.5cm。结论：(1)单纯以等压线缺损大小为标准判断是否为低压型蠕动不合理,以高分辨率阻抗测压为工具对食管动力进行评估最准确和客观；(2)20mmHg等压线缺损标准相对比30mmHg等压线稳定,20mmHg等压线达到5cm一般食团清除失败,5cm以内的缺损食团清除结果不确定；(3)位于食管体部最末端的缺损即使长度不大也可导致食团清空失败；(4)在骨骼肌和平滑肌移行带(Transition zone, TZ)下缘不确定的情况下,以2cm作为TZ长度来判断食管远段等压线缺损长度的方法不可取。更多还原

【Abstract】 Part I Influence of the catheter diameter on the investigation of the esophageal motility through solid state high resolution manometryBackground and aims:High resolution manometry (HRM) is gradually widely used in the esophageal motility research. Besides the commonly used catheters, small diameter catheter for adult use was produced to achieve more comfort and better performance in the situations of narrow passway of esophageal manometry. There was no research to evaluate whether catheters of different diameter could provide similar data and results.Methods:Nine asymptomatic volunteers and 9 gastroesophageal reflux disease (GERD) patients accepted HRM examinations with 4.2mm and 2.7mm thick solid state catheters. Every HRM examination contained 5 min resting pressure,10 water swallows and 10 bread swallows. Some important parameters of the esophageal sphinters and esophageal body peristalsis were analyzed. For example the locations and resting pressure of sphincters, the distal contractile integral (DCI), the 4s integrated relaxation pressure (4s IRP) etc.Then these parameters and the diagnosis of each swallow based on them provided by the two different diameter catheters were compared.Results:(1) The 4.2 mm thick catheter provided higher upper esophageal sphincter (UES) resting pressure than the 2.7mm thick catheter; (2) the 2.7mm thick catheter provided higher 4s IRP than the 4.2mm thick catheter; (3) the mean DCI of the water swallows in the large diameter catheter was higher than in the small diameter catheter; (4) the 4.2mm thick catheter detected more aperistalsis swallows than the 2.7mm thick catheter in water swallows, and the 2.7mm thick catheter detected more hypotensive peristalsis swallows than the other catheter in water swallows;(5) There were some differences of the final motility assessment and diagnosis with the 4.2mm thick catheter and 2,7mm thick catheter.Conclusions:The 2.7mm thick catheter provides somewhat different data from the usually used 4.2mm thick HRM catheter. For the small diameter catheter, a new series of normative value is needed to set up for its further utilization in the research and clinic. PartⅡThe motility of esophagogastric junction under high resolution esophageal manometry in 110 Chinese asymptomatic volunteersBackground and aims:High resolution esophageal manometry was introduced to China for about 3 to 4 years, and many clinical motility centers have the expierence of using this technique. It is lack of normative values of the Chinese high reslution esophageal manomery parameters, and the aim of this study was to set up the normative value database of the high resolution manometry in Chinese asymtomatic volunteers.Methods:110 asymtomatic volunteers from different areas of China accepted high resolution esophageal manometry in 11 gastrointestinal motility centers at different hospitals. Parameters of the esophagogastric junctions including morphologic parameters (the position of the LES midpoint, upper and lower margin of the LES and pressure inverion point; the length of the esophagus, LES and intra-abdomal LES), LES resting pressure parameters (LES respiratory minimal pressrue and LES respiratory average pressure) and LES relaxation parameters (4s integrated relaxation pressure and intrabolus pressure) were analyzed. Then they were compared with the cutoff in foreign criterion especially the Chicago classification.Results:(1)Seven subjects were excluded finally and 103 subjects were left. There were totally 1017 water swallows and 874 solid swallows were analyzed. (2) All parameters were expressed as [mean±sd, P95]. The position of those EGJ anatomy structures were the depth relative to the nose. The position of the LES midpoint, upper and lower margin of the esophagogastric junction and the pressure inversion point were [43.8±3.1,48.5] cm, [42.4±3.1,47.5]cm, [46.0±2.9,51.0]cm and [43.4±3.1,48.4]cm respectively;The length of the esophagus, LES and intraabdominal LES were [25.0±2.1,29.0]cm,[3.7±0.8,5.3]cm and [2.7±0.6,3.9]cm.(3) The LES respiratory minimal pressure was[12.4±6.1,23.8] mmHg and the LES respiratory average pressure was[20.8±7.1,34.1]mmHg;(4)For water swallows the 4s IRP was [10.5±4.5,18.8] mmHg and the IBP was[10.3±4.7,17.8] mmHg; For solid swallows, the 4s IRP was[10.5±4.3,18.9] mmHg and the IBP was[13.1±5.0,21.4] mmHg.The 4s IRP between water swallows and solid swallows wasn’t different (p=0.955), but the IBP of solid swallows was higher than the water swallows(p=0.000).Conclusions:The normative values for most EGJ pressure parameters was higher than them of the foreign standards. PartⅢThe manomatric Characteristics of hypotensive swallows under high resolution impedance manometryBackground and aims:The diagnostic criterion for hypotensive swallow was changed from≥3cm defect in 30mmHg isobaric contour to≥2cm defect in 20mmHg isobaric contour. Sometimes, for one swallow, it could be diagnosed differently using different standards. High resolution impedance manometry has the ability to do manometry and reflect the results of bolus clearance simultaneously, and it is a relativley objective tool to diagnose hypotensive swallow which is with incomplete bolus clearence. The aim of this study was to observe the manometric features of the hypotensive swallows with high resolution impedance manometry.Methods:The manometric data of 5 asymptomatic volunteers and 15 gastroesophageal reflux disease patients were analyzed. Each swallow was classified as normal swallow (complete bolus clearance) and hypotensive swallow (incomplete bolus clearance), and then its peristaltic topography was analyzed with the 20mmHg and 30mmHg isobaric contour to know the information of the defects.Results:(1) There were 200 water swallows from the 20 subjects. Ten aperistalsis swallows were excluded and 190 water swallows were left for the final analysis. (2)For the 190 water swallows,88.4% of them was diagnosed correctly using the 20mmHg isobaric contour defect standard and 87.9% of them was diagnosed the same as the impedance with the 30mmHg isobaric contour defect standard. The correct diagnosis rate of both isobaric contour defect criteria wasn’t different (p=0.874). (3) For those swallows with complete bolus clearance, the maximal defect of 20mmHg and 30mmHg isobaric contour defect were 5.3cm and 15.2cm respectively; For those incomplete bolus clearance swallows the minimal defect of the two isobaric contour were 0.8cm and 1.2cm; (4) For the complete bolus clearance swallows,12 of them was misdiagnosed as hypotensive swallows with the 20mmHg or 30mmHg isobaric contour defect cutoff. The exact value of these defects in 20mmHg isobaric contour were relatively closed and they were smaller than 5cm, while the exact value of the defects in 30mmHg isobaric contour were relatively dispersed. The maximum and minimum were 15.2 cm and 3.1 cm. (5) In those incomplete bolus clearance swallows,23 of them was misdiagnosed as normal swallows with both isobaric contour defect criteria. Although these defects were small, they led to incomplete bolus clearance. 91.3% of these defects were located most distally of the esophageal body. (6) For the distance between the proximal skeletal muscle contraction and the middle and distal smooth muscle contraction, in the complete bolus clearance swallows, the maximum of the 20mmHg and 30mmHg isobaric contour were 4.4cm and 9.5cm. In incomplete bolus clearance swallows, the minimum of the 20mmHg and 30mmHg isobaric contour were 1.1cm and 4.5cm.Conclusions:(1) Defect of the isobaric contour as a standard to diagnose hypotensive swallow isn’t reasonable, and the high resolution impedance manometry is the optimal tool for the evaluation of the esophgeal motility. (2) The 20mmHg isobaric contour defect criterion is relatively stable compared with the 30mmHg isobaric contour defect criterion. Defect over 5 cm of the 20mmHg isobaric contour always predicts incomplete bolus clearance. The results of the bolus clearance of the swallows whose defects are less than 5cm are variable. (3) Defects located at the most distal part of the esophageal body always lead to failed bolus clearance even though the defect is quite small. (4) If the lower margin of the transition zone wasn’t clear, the method which was reported as setting 2cm as the TZ length to determine the defect of the isobaric contour in distal esophagus isn’t acceptable.更多还原