为什么用阻抗技术检测胃食管反流.pptx

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,#,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,阻抗,-pH,酸反流,Yes,Yes,非酸反流,No,Yes,餐后反流,50%,100%,酸性症状,Yes,Yes,非酸性症状,No,Yes,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,食物,最低,pH,值,Cola,1.9,Lemonade,2.0,Strawberry,2.3,White Wine,2.6,Red Wine,2.8,Ketchup,2.9,Apple Juice,3.1,Orange Juice,3.4,Coffee,3.8,Tea,3.9,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 Undergoing Impedance-pH Monitoring;Sharma,Agrawal,Freeman,Vela,Clinical Gastroenterology and Hepatology 2008;6:xxx,阻抗的作用：,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 cm,Impedance at 15 cm,Impedance at 9 cm,Impedance at 7 cm,Impedance at 5 cm,Impedance at 3 cm,pH at 5 cm,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（,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,Clinical Gastroenterology and Hepatology 2008;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,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;ACG Presentation;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;Medical 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=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,儿童阻抗,pH,导管,5 cm above LES,3 cm above LES,7 cm above LES,9 cm above LES,11 cm above LES,13 cm above LES,6 Impedance Sensors,1 pH Sensor,成人阻抗,pH,导管,5 cm above LES,3 cm above LES,7 cm above LES,9 cm above LES,15 cm above LES,17 cm above LES,6 Impedance Sensors,1 pH Sensor,成人阻抗,pH+,胃,pH,导管,5 cm above LES,3 cm above LES,7 cm above LES,9 cm above LES,15 cm above LES,17 cm above LES,6 Impedance Sensors,Esophageal pH Sensor,Gastric pH Sensor,成人咽喉反流,-,胃食管反流导管,5 cm above LES,3 cm above LES,7 cm above LES,9 cm above LES,15 cm above LES,17 cm above LES,6 Impedance Sensors,1 pH Sensor,1 cm above UES,1 pH Sensor,单支咽喉返流监测导管,5 cm above LES,3 cm above LES,7 cm above LES,9 cm above LES,15 cm above LES,17 cm above LES,6 Impedance Sensors,Esophageal pH Sensor,NonaAcid,Acid,1 cm above UES,Pharyngeal pH Sensor,Acid,LPR Monitoring Probe,-1,1,2,3,4,5,6,-13,-12,-11,-10,-9,-8,-7,-6,-5,-4,17,18,19,0,-2,-3,-2,-1,0,1,6,-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：,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,31,Acid GER Episode,31,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,3 cm,5 cm,7 cm,9 cm,15 cm,17 cm,4,pH,Esophageal,Gastric,4,Clearance Swallows,阻抗随食团变化,pH,下降,典型酸性胃食管反流,34,Acid 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 cm,Impedance 15 cm,Impedance 3 cm,Impedance 5 cm,Impedance 7 cm,Impedance 9 cm,pH 5 cm,34,酸性胃食管反流显示方式,Impedance 17 cm,Impedance 15 cm,Impedance 3 cm,Impedance 5 cm,Impedance 7 cm,Impedance 9 cm,pH 5 cm,酸性反流物清除,食团清除,10,秒,Impedance 17 cm,Impedance 15 cm,Impedance 3 cm,Impedance 5 cm,Impedance 7 cm,Impedance 9 cm,pH 5 cm,Acid GER Clearance Phases,Acid Clearance 38 seconds,Impedance 17 cm,Impedance 15 cm,Impedance 3 cm,Impedance 5 cm,Impedance 7 cm,Impedance 9 cm,pH 5 cm,Acid GER,Clearance Swallow,Clearance Swallow,Distal Esophageal GER,Proximal Esophageal GER,LPR,酸性胃食管反流和咽喉反流,40,Retrograde Bolus Movement,pH Remains Above 4.0,Nonacid GER Episode,pH 4.0 threshold,40,Impedance 17 cmImpedance 15 cm,Impedance 3 cm,Impedance 5 cm,Impedance 7 cm,Impedance 9 cm,pH 5 cm,非酸性胃食管反流显示方式,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,PPI,在用,PPI,非酸,酸,(Zapata C et al:MUSC,Charleston,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 26,13551360,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,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;2006,烧心,-2,反流,-3,咳嗽,-7,清喉,-1,声嘶,-1,烧心,-1,烧心,-3,恶心,-1,Hoarseness,?,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 Summary,Acid Exposure(pH),Upright Recumbent,Acid Exposure,Upright,Normal,Recumbent,Normal,Total,Time2.1 min0.0 min 2.1 min,Percent Time0.4%(6.3%)0.0%(1.2%)0.2%,Acid Reflux Composite Score Analysis(DeMeester)(pH),Patient Value,Patient Score,Normal Threshold,Upright Time In Reflux0.4%0.2 8.4,Recumbent Time In Reflux0.0%0.4 3.5,Total Time In Reflux0.2%0.1 4.5,Episodes Over 5 min.0.00.3 3.5,Longest Episode1.1 min0.3 19.8,Total Episodes6.80.0 46.9,Composite Score1.2 14.7,NOTE:Composite Score Normalized for 24 Hours.,ImpedancepH Monitoring Data Summary,(page 2),Reflux Episode Activity,Upright,Recumbent,Total,Total Normal,Acid50 5,Nonacid421 43,All Reflux471 48 (73),Symptom Correlation to Reflux,AcidNonacidAll Reflux,Symptom,Occurrences,Related,Related,Related,Unrelated,Heartburn32130,Regurgitate17016161,Reflux Symptom Index,Symptom,Acid,Nonacid,All Reflux,Heartburn66.67%33.33%100.00%,Regurgitate0.00%94.12%94.12%,Reflux Symptom Association Probability,Symptom,Acid,Nonacid,All Reflux,Heartburn99.93%66.51%99.72%,Regurgitate0.00%99.75%99.46%,Impedance-pH Monitoring Data Summary,Acid 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 sec0 sec 20 sec,Acid Reflux Composite 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.0.00.3 3.5,Longest Episode 0.6 min0.2 19.8,Total Episodes 5.10.0 46.9,Composite Score1.0 14.7,NOTE: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 Summary,Reflux Episode Acidity(Impedance),Upright,Recumbent,Total,Total Normal,Acid303 (on PPI),Nonacid454085,All Reflux484088 (48),Symptom Association Data,AcidNonacid All Reflux,Symptom,Occurrences,Related,Related,Related,Unrelated,Heartburn 3 2 1 3 0,Regurgitate 17 0 16 16 1,Reflux Symptom Index,Symptom,Acid,Nonacid,All Reflux,Heartburn67%33%100,Regurgitate0%94%94%,Reflux Symptom Association Probability,Symptom,Acid,Nonacid,All Reflux,Heartburn99%66%99%,Regurgitate0%99%99%,Number of Acid&Nonacid Reflux Episodes,Symptom Association to Reflux,Preliminary Data,Patient Name:Acid GERD,Patient Number:123456,Normal,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,Normal,Heartburn,93%,15%,98%,(50.00%),Regurgitate17%,68%,85%,(50.00%),_,Suggested Editing Requirements,Abnormal acid exposure:,No Editing,Abnormal acid symptom index:,No Editing,All Reflux symptom index 75%:,No Editing related to that specific symptom,All Reflux symptom index 50-75%for a symptom:,Edit as follows,1.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 measurement areas,Adult Editing Guideline;Donald Castell,MD;Medical University of South Carolina,Data and page formatting are examples,Example One,Preliminary Data,Patient Name:Acid GERD,Patient Number:123456,Normal,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,Normal,Heartburn,93%,15%,98%,(50.00%),Regurgitate17%,68%,85%,(50.00%),_,Suggested Editing Requirements,Abnormal acid exposure:,No Editing,Abnormal acid symptom index:,No Editing,All Reflux symptom index 75%:,No Editing related to that specific symptom,All Reflux symptom index 50-75%for a symptom:,Edit as follows,1.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 measurement areas,Adult Editing Guideline;Donald Castell,MD;Medical University of South Carolina,Data and page formatting are examples,Abnormal Acid Exposure,Example One,Preliminary Data,Patient Name:Acid GERD,Patient Number:123456,Normal,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,Normal,Heartburn,93%,15%,98%,(50.00%),Regurgitate17%,68%,85%,(50.00%),_,Suggested Editing Requirements,Abnormal acid exposure:,No Editing,Abnormal acid symptom index:,No Editing,All Reflux symptom index 75%:,No Editing related to that specific symptom,All Reflux symptom index 50-75%for a symptom:,Edit as follows,1.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 measurement areas,Adult Editing Guideline;Donald Castell,MD;Medical University of South Carolina,Data and page formatting are examples,Abnormal Heartburn Symptom Index,Example One,Preliminary Data,Patient Name:Acid GERD,Patient Number:123456,Normal,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,Normal,Heartburn,93%,15%,98%,(50.00%),Regurgitate17%,68%,85%,(50.00%),_,Suggested Editing Requirements,Abnormal acid exposure:,No Editing,Abnormal acid symptom index:,No Editing,All Reflux symptom index 75%:,No Editing related to that specific symptom,All Reflux symptom index 50-75%for a symptom:,Edit as follows,1.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 measurement areas,Adult Editing Guideline;Donald Castell,MD;Medical University of South Carolina,Data and page formatting are examples,Example One,Abnormal Heartburn All Symptom Index,Abnormal Regurgitate All Symptom Index,Reflux-Symptom Temporal Associations,Ambulatory Impedance-pH-Manometry,Reflux-Cough,1,A 7440.93,S 5576.54,2,A 2697.40,S 796.22,3,A 5086.31,S 1484.97,4,A 266049,S 796.91,5,A 1782.45,S 817.31,6,A 1769.27,S 354.59,9,A-15.00,S 21.46,10,A-10.00,S 14.29,11,A 181.00,S 34.80,12,A 27.00,S 10.73,14,A 6.78,S 2.03,15,A 5.08,S 2.09,Nonacid Reflux,(pH 5.6),Cough Event,Median time 44 seconds,Impedance,pH,Manometry,7,7,1,1,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,(Range 41-51 seconds),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;449-454,3 Nonacid Associated,2 Acid&Nonacid Associated,5 Acid Associated,10 SAP+Reflux-Cough,22 Patients,NO!,Its a Coke swallow,Impedance/pH tracing,