胃食道逆流可能是许多患者抱怨睡眠质量不佳的原因


  Nov. 7, 2005 (檀香山) - 研究人员于第70届美国肠胃科医学年会中发表研究成果指出,抱怨有著睡眠困难的患者,可能是罹患了胃食道逆流(GERD)。
  
  首席研究员William C. Orr博士于发表演说时表示,有些患者没有明显的胃灼热症状,而是在睡眠中隐约有感到胃酸逆流;Orr博士为美国奥克拉荷马市奥克拉荷马大学健康科学中心生理学教授,同时也是美国国家睡眠基金会主席。
  
  然而,当患者深受难以解释的睡眠干扰所苦时,医师应考量到「沉默的」胃食道逆流可能会是成因。
  
  Orr博士研究团队之所以进行这项研究,是因为以前的研究已建立出某种认知架构,即为罹患胃食道逆流的患者,通常主诉为睡眠质量状况差,而睡眠警醒则是和逆流的胃酸接触到食道黏膜有关,但与胃食道逆流相关的呼吸道症状,则会在胃灼热感不再出现时发生;因此,研究团队从结论往原因推,是否睡眠质量不良的人,没有明显的胃灼热症状,却是因为「沉默的」胃食道逆流。
  
  研究团队召募了104名患者,这些患者主诉每周至少有三个晚上的睡眠质量很差,或是睡眠中断;在为期两周的实验后(期间有记录睡眠日志),研究团队找出81名患者其状况符合睡眠抱怨的标准,这些患者完成两组多重睡眠电图评估(polysomnographic sleep evaluation),包括远端食道的pH值测量;多重睡眠电图评估研究分两次进行,一次为10天,另一次为21天。
  
  在104名患者中,21名(26%)至少有一个晚上有胃酸逆流的症状,该研究将胃酸逆流定义为食道的pH值小于4,并至少在一个晚上持续发生超过30秒;在那些有逆流症状的人中,5名(21%)有超过4%的胃酸接触时间(acid contact time,ACT),另有6名(25%)则至少有一次的症状是持续超过5分钟,而这则是胃食道逆流的另一项诊断标准。
  
  夜间平均ACT是28%,而每一次胃酸逆流的症状平均持续34.4分钟,惊醒差不多发生在所有纪录的胃酸逆流症状中(94%);有趣地的是,当研究团队将这些结果对比于过去曾作过的实验,有伴随睡眠抱怨的症状性胃食道逆流(symptomatic GERD)患者,平均的ACT则低很多,少了12% (P < .05)。
  
  Edward G. Zurad医师于寻求独立意见的电话访谈中表示,这些研究发现证实一项推测,也就是许多人有著多年的无症状胃食道逆流,却抱怨有著睡眠障碍;该研究同时也增加了我们对胃食道逆流的了解程度,就是就算没有标准的胃灼热症状,也无法排除可能罹患胃食道逆流的诊断;Zurad医师为美国宾州费城谭普大学医学院家庭医学科助理教授。
  
  然而,他指出,在进行睡眠障碍评估时,医师应在不同的诊断方法中,将胃食道逆流和夜间发作的气喘、睡眠呼吸中止,以及其它会造成夜间惊醒的状况等一并纳入考量。
  
  Zurad医师表示,若是怀疑胃食道逆流的症状而需进一步确诊,相较于采取内视镜的检查,以一般经验医疗为主的两周疗程,加上氢离子阻断剂(胃酸抑制剂)(proton pump inhibitor),或许更能增加诊断的准确度;假设患者的睡眠障碍,在两周的追踪治疗后有著明显的改善,则可合理怀疑胃食道逆流可能是罪魁祸首;胃酸抑制剂的好处在于,患者能从第一次就诊后即开始服用,而不是得等耗费数周的检验报告所得出的结果。
  
  然而,他表示,如果患者有胃食道逆流的症状超过五年,或是年龄超过50岁,医师就应该施行内视镜检查。
  
  这项研究由阿斯特捷利康(AstraZeneca)所赞助,该公司产品有胃酸抑制剂Nexium和Prilosec。

Silent GERD May Underlie Many<

By Paula Moyer, MA
Medscape Medical News

Nov. 7, 2005 (Honolulu) — Patients who complain of difficulty sleeping may have gastroesophageal reflux disease (GERD) even if they deny having heartburn symptoms, according to investigators who presented their findings here at the 70th annual meeting of the American College of Gastroenterology.

"These are patients without significant heartburn symptoms who are experiencing acid reflux during sleep," said principal investigator William C. Orr, PhD, during his presentation. He is a professor of physiology at the University of Oklahoma Health Sciences Center in Oklahoma City, and director of the National Sleep Foundation. Therefore, when patients present with unexplained sleep interruptions, physicians should consider "silent GERD" as a potential cause, he added.

Dr. Orr and coinvestigators conducted the study because prior research had established that patients with GERD often reported sleeping poorly and that sleep arousals had been associated with contact of refluxed gastric acid with esophageal mucosa, but that GERD-related respiratory symptoms could occur in the absence of heartburn sensations. Therefore the investigative team wanted to know, conversely, whether people who have poor sleep but no significant heartburn are experiencing silent GERD.

Therefore, the investigators recruited 104 subjects who complained of poor sleep or sleep interruptions at least three nights per week. After a two-week run in period with recorded sleep diaries, the investigators identified 81 subjects who met the criteria for sleep complaints. These subjects completed two polysomnographic sleep evaluations that included distal esophageal pH assessment. The polysomnographic studies were separated by 10 to 21 days.

Of the 104 patients, 21 (26%) had reflux on at least one night. The study defined reflux as an esophageal pH of less than 4 and persisting for more than 30 seconds on at least one night. Among those with reflux, five (21%) had more than 4% acid contact time (ACT), and six (25%) had at least one event that lasted more than five minutes, another criteria for GERD.

The average ACT was 28% of the night, and each reflux episode lasted for an average of 34.4 minutes. Arousal or awakening occurred in virtually all of the recorded reflux events (94%). Interestingly, when the investigators compared these results to a historical comparison group of symptomatic GERD patients with concomitant sleep complaints, the average ACT was significantly less, 12% (P < .05).

"These findings confirm the suspicions that many of us have had for years regarding GERD in asymptomatic patients complaining of sleep difficulties," said Edward G. Zurad, MD, in a phone interview seeking independent comment. "The study also adds to our understanding of GERD, in that the absence of typical heartburn symptoms does not rule out a diagnosis of GERD." Dr. Zurad is a clinical assistant professor of family medicine at Temple University School of Medicine in Philadelphia, Pennsylvania.

Therefore, he said, when evaluating someone with a sleep disturbance, physicians should include GERD in the differential diagnosis, along with nocturnal asthma, sleep apnea, and other conditions that can cause nocturnal awakening.

If GERD is suspected, an empiric two-week treatment with a proton pump inhibitor may help refine the diagnosis, rather than an endoscopic study, Dr. Zurad said. "If the patient's sleep difficulties have improved significantly at the two-week follow-up, that would make one suspicious that GERD is the cause," he said. "The nice thing about proton pump inhibitors is that one can start treatment at the first visit, rather than after a study that has been scheduled several weeks out."

However, if a patient has had GERD for more than five years, or is older than 50 years, the physician should order endoscopy, he said.

The study was funded by AstraZeneca, which manufactures the proton pump inhibitors Nexium and Prilosec.

ACG 70th Annual Meeting: Abstract 308. Presented Nov. 1, 2005.

Reviewed by Gary D. Vogin, MD

    
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