为什么用阻抗技术检测胃食管反流课件.ppt

1、作者使用作者使用Sandhill公司产品公司产品阻抗-pH 检测VS单纯pH检测单纯pH阻抗-pH酸反流YesYes非酸反流NoYes餐后反流50%100%酸性症状YesYes非酸性症状NoYes单纯单纯pH检测是以病人主诉为基础的检查方法。有主观性。检测是以病人主诉为基础的检查方法。有主观性。联合阻抗联合阻抗-pH检测的意义是可以客观确诊各种反流。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 2019;50:1916

2、食物食物最低最低pH值值Cola1.9Lemonade2.0Strawberry2.3White Wine2.6Red Wine2.8Ketchup2.9Apple Juice3.1Orange Juice3.4Coffee3.8Tea3.9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。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。An Analysis of Persistent Symptoms in Acid-Suppressed Patients

3、 Undergoing Impedance-pH Monitoring;Sharma,Agrawal,Freeman,Vela&Castell;Clinical Gastroenterology and Hepatology 2019;6:xxx阻抗的作用：阻抗的作用：全面监测反流全面监测反流抗反流治疗寻找其它原因抑酸治疗58%35%7%Impedance at 17 cmImpedance at 15 cmImpedance at 9 cmImpedance at 7 cmImpedance at 5 cmImpedance at 3 cmpH at 5 cm阻抗-pH 导管监测原理利用阻抗

4、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（pH 50%218名PPI治疗后症状持续的患者An Analysis of Persistent Symptoms in Acid-Suppressed Patients Undergoing Impedance-pH Monitoring;Sharma,Agrawal,Freeman,Vela&Castell;Clinical Ga

5、stroenterology and Hepatology 2019;6:xxx24%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非酸性反流36%(36 patients)没有反流57%(58 patients)101 例病人在研究期间有症状酸性反流7%(7 patients)Inder Mainie,R.Tutuian&D.O.Castell;Medical College of SC;Symptoms on PPI Therapy Associated with Nonacid,Acid or No Reflux;A

6、CG Presentation;October 2019pH-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。最佳 GERD 治疗方案 可能有 GERD 症状症状缓解抗酸治疗Acid Reduction Therapy服药期间做联合阻抗-pH检测症状持续寻找最佳抗酸治疗严重酸反流抗反流治疗非酸性反流找其它原因不是反流 Donald O.Castell,MD;Medi

7、cal University of South Carolina 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&Therapeutics 26,13551360服用PPI期间持续有烧心反胃的病人 N=1

8、43PPI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食管括约肌定位器对研究结果至关重要儿童阻抗儿童阻抗pH 导管导管5 cm above LES3 cm above LES7 cm above LES9 cm above LES11 cm above LES13 cm above LES6 Impedance

9、Sensors1 pH Sensor成人阻抗成人阻抗pH 导管导管5 cm above LES3 cm above LES7 cm above LES9 cm above LES15 cm above LES17 cm above LES6 Impedance Sensors1 pH Sensor成人阻抗成人阻抗pH+胃胃 pH导管导管5 cm above LES3 cm above LES7 cm above LES9 cm above LES15 cm above LES17 cm above LES6 Impedance SensorsEsophageal pH SensorGastri

10、c pH Sensor成人咽喉反流成人咽喉反流-胃食胃食管反流导管管反流导管5 cm above LES3 cm above LES7 cm above LES9 cm above LES15 cm above LES17 cm above LES6 Impedance Sensors1 pH Sensor1 cm above UES1 pH Sensor单支咽喉返流监测导管5 cm above LES3 cm above LES7 cm above LES9 cm above LES15 cm above LES17 cm above LES6 Impedance SensorsEsopha

11、geal pH SensorNonaAcidAcid1 cm above UESPharyngeal pH SensorAcidLPR Monitoring Probe-1123456-13-12-11-10-9-8-7-6-5-41718190-2-3-2-1016-3-7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：优点：可以分别精确定位上、下食管括约肌可以同时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30Acid GER Episode30酸性非酸性pH 4.0 是阈值酸性和非酸性反流Acid RefluxNonacid Reflux快速

12、鉴别酸性和非酸性反流 3 cm 5 cm 7 cm 9 cm 15 cm 17 cm4pHEsophagealGastric4 Clearance Swallows阻抗随食团变化pH下降典型酸性胃食管反流33Acid GER Episode食团从下向上反向运动食团进入后pH低于4酸性胃食管反流pH 4.0 为阈值Impedance 17 cmImpedance 15 cmImpedance 3 cmImpedance 5 cmImpedance 7 cmImpedance 9 cmpH 5 cm33酸性胃食管反流显示方式Impedance 17 cmImpedance 15 cmImpedan

13、ce 3 cmImpedance 5 cmImpedance 7 cmImpedance 9 cmpH 5 cm酸性反流物清除食团清除10秒Impedance 17 cmImpedance 15 cmImpedance 3 cmImpedance 5 cmImpedance 7 cmImpedance 9 cmpH 5 cmAcid GER Clearance PhasesAcid Clearance 38 secondsImpedance 17 cmImpedance 15 cmImpedance 3 cmImpedance 5 cmImpedance 7 cmImpedance 9 cmp

14、H 5 cmAcid GERClearance SwallowClearance SwallowDistal Esophageal GERProximal Esophageal GERLPR酸性胃食管反流和咽喉反流酸性胃食管反流和咽喉反流39Retrograde Bolus MovementpH Remains Above 4.0Nonacid GER EpisodepH 4.0 threshold39Impedance 17 cmImpedance 15 cmImpedance 3 cmImpedance 5 cmImpedance 7 cmImpedance 9 cmpH 5 cm非酸性胃

15、食管反流显示方式智能建立分析模型 PPI模板 Joshson-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 未用未用PPI在用在用PPI非酸非酸 酸酸(Zapata C et al:MUSC,Charleston

16、,SC)据MII-pH监测指导治疗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&Therapeutics 26,13551360PPI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-p

17、H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非酸反流(14)酸反流(4)与反流无关(1)19 名症状指数阳性的患者(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

18、;2019烧心-2反流-3咳嗽-7清喉-1声嘶-1烧心-1烧心-3恶心-1Hoarseness?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-pH 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 RecumbentAcid ExposureUprightNormalRecumbent Normal TotalTime2.1 min0

19、.0 min 2.1 minPercent Time0.4%(6.3%)0.0%(1.2%)0.2%Acid Reflux Composite Score Analysis(DeMeester)(pH)Patient ValuePatient ScoreNormal ThresholdUpright Time In Reflux0.4%0.2 8.4Recumbent Time In Reflux0.0%0.4 3.5Total Time In Reflux0.2%0.1 4.5Episodes Over 5 min.0.00.3 3.5Longest Episode1.1 min0.3 19

20、.8Total Episodes6.80.0 46.9Composite Score1.2 14.7NOTE:Composite Score Normalized for 24 Hours.Impedance-pH Monitoring Data Summary(page 2)Reflux Episode ActivityUprightRecumbent Total Total NormalAcid50 5Nonacid421 43All Reflux471 48 (73)Symptom Correlation to RefluxAcidNonacidAll RefluxSymptomOccu

21、rrencesRelatedRelatedRelatedUnrelatedHeartburn32130Regurgitate17016161Reflux Symptom IndexSymptomAcidNonacidAll RefluxHeartburn66.67%33.33%100.00%Regurgitate0.00%94.12%94.12%Reflux Symptom Association ProbabilitySymptomAcidNonacidAll RefluxHeartburn99.93%66.51%99.72%Regurgitate0.00%99.75%99.46%Imped

22、ance-pH Monitoring Data SummaryAcid Exposure(pH)Upright Recumbent TotalAcid Exposure Upright NormalRecumbent Normal TotalNormalTime 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 sec0 sec 20 secAcid Reflux Composite Score Analysis

23、(DeMeester)(pH)Patient ValuePatient Score Normal ThresholdUpright Time In Reflux 0.2%0.1 8.4Recumbent Time In Reflux 0.0%0.4 3.5Total Time In Reflux 0.1%0.0 4.5Episodes Over 5 min.0.00.3 3.5Longest Episode 0.6 min0.2 19.8Total Episodes 5.10.0 46.9Composite Score1.0 14.7NOTE:Composite Score Normalize

24、d for 24 Hours.Acid(chemical)Exposure DataFrom pH SensorAdult or Pediatric Composite Score From pH SensorImpedance-pH Monitoring Data SummaryReflux Episode Acidity(Impedance)UprightRecumbentTotal Total NormalAcid303 (on PPI)Nonacid454085All Reflux484088 (48)Symptom Association Data AcidNonacid All R

25、efluxSymptom Occurrences RelatedRelated Related UnrelatedHeartburn 3 2 1 3 0Regurgitate 17 0 16 16 1Reflux Symptom IndexSymptomAcidNonacidAll RefluxHeartburn67%33%100Regurgitate0%94%94%Reflux Symptom Association ProbabilitySymptomAcidNonacidAll RefluxHeartburn99%66%99%Regurgitate0%99%99%Number of Ac

26、id&Nonacid Reflux EpisodesSymptom Association to RefluxPreliminary DataPatient Name:Acid GERDPatient Number:123456NormalAcid Exposure Percent Time Upright39.3%(6.3%)Acid Exposure Percent Time Recumbent5.6%(1.2%)Reflux Symptom IndexSymptomAcidNonacidAll RefluxNormalHeartburn93%15%98%(50.00%)Regurgita

27、te17%68%85%(50.00%)_Suggested Editing RequirementsAbnormal acid exposure:No EditingAbnormal acid symptom index:No EditingAll Reflux symptom index 75%:No Editing related to that specific symptomAll Reflux symptom index 50-75%for a symptom:Edit as follows1.Review impedance reflux episodes preceding sy

28、mptoms(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 measurement areasAdult Editing Guideline;Donald Castell,MD;Me

29、dical University of South Carolina Data and page formatting are examplesExample OnePreliminary DataPatient Name:Acid GERDPatient Number:123456NormalAcid Exposure Percent Time Upright39.3%(6.3%)Acid Exposure Percent Time Recumbent5.6%(1.2%)Reflux Symptom IndexSymptomAcidNonacidAll RefluxNormalHeartbu

30、rn93%15%98%(50.00%)Regurgitate17%68%85%(50.00%)_Suggested Editing RequirementsAbnormal acid exposure:No EditingAbnormal acid symptom index:No EditingAll Reflux symptom index 75%:No Editing related to that specific symptomAll Reflux symptom index 50-75%for a symptom:Edit as follows1.Review impedance

31、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 measurement areasAdult Editing Gu

32、ideline;Donald Castell,MD;Medical University of South CarolinaData and page formatting are examplesAbnormal Acid ExposureExample OnePreliminary DataPatient Name:Acid GERDPatient Number:123456NormalAcid Exposure Percent Time Upright39.3%(6.3%)Acid Exposure Percent Time Recumbent5.6%(1.2%)Reflux Sympt

33、om IndexSymptomAcidNonacidAll RefluxNormalHeartburn93%15%98%(50.00%)Regurgitate17%68%85%(50.00%)_Suggested Editing RequirementsAbnormal acid exposure:No EditingAbnormal acid symptom index:No EditingAll Reflux symptom index 75%:No Editing related to that specific symptomAll Reflux symptom index 50-75

34、%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 movement(i.e.not impedance reflux)3.Delete any pH measurement areas corresponding to the de

35、leted impedance measurement areasAdult Editing Guideline;Donald Castell,MD;Medical University of South CarolinaData and page formatting are examplesAbnormal Heartburn Symptom IndexExample OnePreliminary DataPatient Name:Acid GERDPatient Number:123456NormalAcid Exposure Percent Time Upright39.3%(6.3%

36、)Acid Exposure Percent Time Recumbent5.6%(1.2%)Reflux Symptom IndexSymptomAcidNonacidAll RefluxNormalHeartburn93%15%98%(50.00%)Regurgitate17%68%85%(50.00%)_Suggested Editing RequirementsAbnormal acid exposure:No EditingAbnormal acid symptom index:No EditingAll Reflux symptom index 75%:No Editing rel

37、ated to that specific symptomAll 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 movement(i.e.not impedance reflu

38、x)3.Delete any pH measurement areas corresponding to the deleted impedance measurement areasAdult Editing Guideline;Donald Castell,MD;Medical University of South CarolinaData and page formatting are examplesExample OneAbnormal Heartburn All Symptom IndexAbnormal Regurgitate All Symptom IndexReflux-S

39、ymptom Temporal Associations19:4520:0020:1520:301357pH7Z6Z5Z4Z3Z2Z1HeartburnRegurgMealRecumbAmbulatory Impedance-pH-ManometryReflux-Cough1A 7440.93S 5576.542A 2697.40S 796.223A 5086.31S 1484.974A 2660.49S 796.915A 1782.45S 817.316A 1769.27S 354.599A-15.00S 21.4610A-10.00S 14.2911A 181.00S 34.8012A 2

40、7.00S 10.7314A 6.78S 2.0315A 5.08S 2.09Nonacid Reflux(pH 5.6)Cough EventMedian time 44 secondsImpedancepHManometry7711Weakly Acidic Reflux in Patients with Chronic Unexplained Cough During 24 Hour Pressure,pH and Impedance Monitoring;D.Sifrim et al;GUT;2019;54;449-454(Range 41-51 seconds)阻抗-pH 检测反流与

41、症状的关系Chronic Cough Data SummaryWeakly Acidic Reflux in Patients with Chronic Unexplained Cough During 24 Hour Pressure,pH and Impedance Monitoring;D.Sifrim et al;GUT;2019;54;449-4543 Nonacid Associated2 Acid&Nonacid Associated5 Acid Associated10 SAP+Reflux-Cough22 PatientsNO!Its a Coke swallowImpedance/pH tracing Thank you