食管胃流出道梗阻患者的病因及不同亚组食管动力特点分析

doi:10.19723/j.issn.1671-167X.2020.05.006

摘要/Abstract

摘要：

目的:分析食管胃流出道梗阻(esophagogastric junction outlet obstruction,EGJOO)患者的病因,探讨不同亚型EGJOO患者临床及食管动力特点。方法:回顾分析北京大学第三医院消化科因各种症状接受高分辨率食管压力测定的患者,筛选EGJOO患者。分析EGJOO患者的临床特点,探讨病因,依据病因将患者分为解剖异常性EGJOO组(anatomic EGJOO,A-EGJOO)和功能性EGJOO组(functional EGJOO,F-EGJOO)。比较两组患者间症状、食管动力参数的差异,将差异参数绘制受试者工作特征(receiver operating characteristic,ROC)曲线,分析差异参数鉴别两个亚组患者的诊断效力。结果:EGJOO患者最常见的症状为胸痛/胸骨后不适(30.63%),其次为吞咽困难(29.73%)及反酸烧心(27.03%)。原发病因中最常见的为非糜烂性反流病(36.04%),其次为反流性食管炎(17.12%),其他病因包括食管胃交界部良、恶性病变,有部分患者为结缔组织病(6.31%)及中枢神经系统疾病(2.70%), 19例患者(17.12%)经完善研究流程后未发现明确病因。A-EGJOO患者的食团内压明显高于F-EGJOO患者[6.80 (5.20, 9.20) mmHg vs. 5.10 (3.10, 7.60) mmHg, P=0.016],以食团内压为标准,ROC曲线下面积为0.637(P=0.016),当食团内压≥5.15 mmHg时,其从EGJOO中鉴别出A-EGJOO的敏感度为78.60%、特异度为50.70%。结论:EGJOO患者的常见症状为胸痛、吞咽困难,常见的病因除胃食管反流病,食管胃交界部各类良、恶性病变外,还存在食管胃交界部腔外病变及非消化道疾病等原发病因。在食管动力特点上,A-EGJOO患者的食团内压高于F-EGJOO患者,在EGJOO亚型的鉴别诊断中,食团内压具有一定的敏感度和特异度,但由于ROC曲线下面积小于0.7,作为鉴别诊断指标的意义有限。

关键词: 食道活动障碍, 食管胃接合处, 胃食管反流

Abstract:

Objective: To analyze the causes of the esophagogastric junction outlet obstruction (EGJOO) patients, to discuss the differences of the clinical manifestation and esophageal motility characteristics between the anatomic EGJOO (A-EGJOO) and functional EGJOO (F-EGJOO) subgroups, and to search the diagnostic values of the specific metrics for differentiating the subgroups of EGJOO patients. Methods: For the current retrospective study, all the patients who underwent the esophageal high resonance manometry test were retrospectively analyzed from Jan 2012 to Oct 2018 in Peking University Third Hospital. The EGJOO patients were enrolled in the following research. The clinical characteristics, such as symptoms and causes of the patients were studied. Then the patients were divided into two subgroups as A-EGJOO subgroup and F-EGJOO subgroup. The clinical symptoms and the main manometry metrics were compared between these two subgroups. The significant different metrics between the two groups were selected to draw receiver operating characteristic (ROC) curves and the diagnostic values were analyzed in differentiating the A-EGJOO and F-EGJOO subgroups. Results: The most common symptom of EGJOO was chest pain or chest discomfort (30.63%), then the dysphagia (29.73%), and acid regurgitation/heartburn (27.03%). Non-erosive reflux disease (36.04%) was the most popular cause for EGJOO, then the reflux esophagitis (17.12%). Besides the intra-EGJOO and extra-EGJOO lesions, the connective tissue disease (6.31%) and central nervous diseases (2.70%) were found to be the etiology of EGJOO. The causes of the rest 19 EGJOO were unknown. A-EGJOO patients presented significantly higher intra bolus pressure (IBP) than that of F-EGJOO [6.80 (5.20, 9.20) mmHg vs. 5.10 (3.10, 7.60) mmHg, P=0.016]. The area under curve of IBP was 0.637. When IBP≥5.15 mmHg, the sensitivity was 78.60% and specificity 50.70% to differentiate A- or F-EGJOO. Conclusion: Chest pain or chest discomfort was the most common symptom in EGJOO patients. Besides the intraluminal structural disorders, the extra-luminal causes were found in EGJOO patients. A-EGJOO presented higher IBP than that of F-EGJOO patients. The cutoff value of IBP to differentiate A-EGJOO from EGJOO was 5.15 mmHg with sensitivity 78.06% and specificity 50.70%. However for the low area under curve, the diagnostic value of IBP was limited.

Key words: Esophageal motility disorders, Esophagogastric junction, Gastroesophageal reflux

中图分类号:

R571

王琨,徐志洁,葛颖,夏志伟,段丽萍. 食管胃流出道梗阻患者的病因及不同亚组食管动力特点分析[J]. 北京大学学报（医学版）, 2020, 52(5): 828-835.

Kun WANG,Zhi-jie XU,Ying GE,Zhi-wei XIA,Li-ping DUAN. Study of etiology and esophageal motility characteristics of esophagogastric junction outlet obstruction patients[J]. Journal of Peking University (Health Sciences), 2020, 52(5): 828-835.

图/表 5

图1

表1

EGJOO患者病因分布情况"

Causes	Cases (n)	Percent (n=111)	Age/years, $x -$ ±s	Gender (Male ∶Female)
Reflux esophagitis	19	17.12%	57.42±13.35	8 ∶11
Other benign diseases in EGJ	14	12.61%	58.86±16.65	5 ∶9
Hiatus hernia	3	2.70%
Esophageal diverticulum near EGJ	3	2.70%
Esophageal venous aneurysm near EGJ	1	0.90%
Esophageal leiomyoma near EGJ	2	1.80%
Eosinophilic esophagus	1	0.90%
Severe fungous esophagitis	2	1.80%
Carditis	2	1.80%
Achalasia	4	3.60%	49.50±7.85	3 ∶1
Malignant tumor	5	4.50%	57.20±7.82	2 ∶3
Liver cancer	1	0.90%
Mediastinal mass	2	1.80%
Cardiac cancer	1	0.90%
Gastric fundus cancer	1	0.90%
NERD	40	36.04%	51.85±13.73	11 ∶29
Central nervous system disorders	3	2.70%	57.67±3.51	0 ∶3
Syringomyelia	1	0.90%
Cerebellar tonsillar hernia	2	1.80%
Connective tissue disease	7	6.31%	48.00±14.91	0 ∶7
Systemic sclerosis	5	4.50%
Dermatomyositis	1	0.90%
Undetermined type	1	0.90%
Unidentified etiology	19	17.12%	54.42±11.53	5 ∶14

表1

表2

图2

表3

RE、NERD、A-EGJOONG及F-EGJOONG组患者食管动力参数的比较"

Items	RE (r), n=19	NERD (n), n=40
LES rest pressure/mmHg	29.20 (27.6, 34.95)	30.90 (28.00, 35.80)
IRP4s/mmHg	17.10 (16.00, 18.55)	16.95 (16.00, 18.93)
Distal esophageal peristalsis amplitude/mmHg	81.10 (58.90, 117.20)	78.95 (51.95, 95.73)
Distal esophageal peristalsis duration/s	3.20 (2.75, 3.55)	3.30 (2.70, 3.50)
Peristalsis amplitude 3 cm above LES/mmHg	85.50 (65.65, 124.55)	83.05 (57.08, 113.48)
Peristalsis amplitude 7 cm above LES/mmHg	78.30 (47.70, 106.70)	60.40 (40.38, 94.25)
Peristalsis amplitude 11 cm above LES/mmHg	65.10 (47.80, 83.40)	55.90 (41.33, 81.73)
Average DCI/(mmHg·s·cm)	1 263.70 (973.25, 1 892.55)	1 181.75 (656.85, 1 710.28)
Maximum DCI/(mmHg·s·cm)	2 003.70 (1 335.60, 2 578.45)	1 613.15 (1 266.58, 2 399.05)
UES rest pressure/mmHg	58.00 (37.90, 78.50)	57.90 (37.60, 88.63)
Distal latency/s	6.00 (5.40, 6.65)	6.25 (5.80, 7.30)
Intra bolus pressure/mmHg^*	7.80 (3.70, 8.75)	4.65 (2.95, 6.73)
Items	A-EGJOO_NG (a), n=23	F-EGJOO_NG (f), n=29
LES rest pressure/mmHg	35.60 (27.25, 45.45)	31.70 (26.00, 38.00)
IRP4s/mmHg	18.60 (16.20, 30.35)	17.90 (17.20, 21.00)
Distal esophageal peristalsis amplitude/mmHg	83.00 (69.85, 121.75)	86.30 (58.10, 122.80)
Distal esophageal peristalsis duration/s	3.50 (3.00, 4.30)	3.30 (2.90, 3.70)
Peristalsis amplitude 3 cm above LES/mmHg	105.30 (64.45, 150.40)	100.40 (58.60, 138.50)
Peristalsis amplitude 7 cm above LES/mmHg	74.30 (61.75, 98.35)	79.90 (45.10, 113.10)
Peristalsis amplitude 11 cm above LES/mmHg	63.30 (50.60, 76.70)	64.40 (47.60, 91.80)
Average DCI/(mmHg·s·cm)	1 641.90 (957.25, 2 854.20)	1 443.50 (823.70, 2 168.90)
Maximum DCI/(mmHg·s·cm)	2 352.70 (1 542.20, 3 562.00)	2 141.00 (1 311.50, 2 952.90)
UES rest pressure/mmHg	50.70 (30.75, 68.90)	60.70 (45.50, 74.20)
Distal latency/s	5.70 (5.10, 6.30)	5.60 (5.00, 7.10)
Intra bolus pressure/mmHg^*	6.40 (5.50, 11.65)	5.90 (4.40, 8.10)

表3

参考文献 13

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