2000 ; 6 : , =Abstract= The Significance of Gastroesophageal Reflux Disease (GERD) Symptoms in Patients with Reflux Esophagitis Chan Hee Han, M

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1 2000 ; 6 : , =Abstract= The Significance of Gastroesophageal Reflux Disease (GERD) Symptoms in Patients with Reflux Esophagitis Chan Hee Han, M.D., Joon Seong Lee, M.D., Hee Hyuk Lim, M.D., Young Soo Oh, M.D., Young Keun Yoon, M.D., Sang Gyune Kim, M.D., Myung Soo Kim, M.D., Eun Sang Ryoo, M.D., Dong Jin Youn, M.D., In Seop Jung, M.D., Bong Min Ko, M.D., Chang Bum Yoo, M.D., Young Deok Cho, M.D., Joo Young Cho, M.D., Moon Sung Lee, M.D. and Chan Sup Shim, M.D. Institute for Digestive Research, Department of Internal Medicine, Soon Chun Hyang University College of Medicine, Seoul, Korea Background/Aims: The relationship between the symptoms and severity of GERD may be difficult to prove. The intensity and frequency of reflux induced symptoms are poor predictors of the presence or severity of an endoscopic mucosal break. The aim of this study was to determine which factors can be predicted by the presence of GERD symptoms among esophageal sensitivity to acid, abnormal acid reflux, and severity of esophagitis in pateints with reflux esophagitis. Methods: Fourty-four patients who were diagnosed with reflux esophagitis by an endoscopy at a tertiary medical facility, were given a validated questionnaire, and underwent an acid perfusion test, 24 hr ambulatory esophageal ph monitoring, and esophageal manometry. These patients were divided into a symptomatic group and asymptomatic group according to the questionaire. Comparisons between the two groups for each factor were analyzed by Chi-square. Result: Of 44 patients, 26 had symptoms and 18 did not. The positive and equivocal rates of the acid perfusion test were not different between the symptomatic and asymptomatic groups (47% vs. 39%). The abnormal reflux rate (DeMeester score >14.72) from ph monitoring was significantly higher in the symptomatic group than in the asymptomatic group (65% vs. 28%, p <0.05). The severity of esophagitis, presence of a hiatal hernia, and abnormal esophageal manometric findings were not different between the two groups. Conclusion: It would be impossible to predict esophageal sensitivity to acid, severity of the esophagitis grade, and the presence of hiatal hernia with GERD symptoms, but it could be possible to predict abnormal gastroesophageal reflux. Key Words: Gastroesophageal reflux disease, Reflux esophagitis, Esophageal sensitivity, 24 hr ambulatory esophageal ph monitoring :, 657 ( : ) Tel : (02) , Fax : (02) schidr@hosp.sch.ac.kr

2 Chan Hee Han, et al : The Significance of Gastroesophageal Reflux Disease (GERD) Symptoms in Patients with Reflux Esophagitis 197,,,.1,2 (heartburn) (acid regurgitation) ( 89%, 95%)3,,,,,,,.3-5, ( )..1,6,.8,,,.,.10, Grade (hiatal hernia),..7-9,.7, modified Salvary-Miller Ib ( ) 44.

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4 15 : grade A, 5 mm grade B, 75% Grade. C, 75% Grade D. 5 cm (sliding hernia) 7-8 ml 2~3 cm, 0.1 N HCl, 3 ~ 5 cm, 5 cm., (paraesophageal hernia), N HCl., 7., 0.1 N HCl, (equivocal). 3, ph ph 4 4, hard copy video DeMeester 2, hard copy video. DeMeester ph 4, ph 4, ph. modified Salvary- 4, Miller ( SM) Los Angeles (LA), SM Grade I( Ia, Ib Ia ), Grade II, Grade III,, Grade ph 4, ph 4 5, 6,, 90% ,,,.12,13 IV, Barrett Grade V. LA modified Salvary- 5 mm, Miller Los Angeles,

200 Korean Journal of Gastrointestinal : Vol. 6, No. 2, 2000., Chi-square test P 0.05. 1. 44 26, 18 50 15.3 ( ) 43 19.5. 17:9, 11:7, (body mass index, : 20-25 kg/m2) 23.7 2.8, 23.1 2.7 (Table 1). Fig.

5 200 Korean Journal of Gastrointestinal : Vol. 6, No. 2, 2000., Chi-square test P , ( ) :9, 11:7, (body mass index, : kg/m2) , (Table 1). Fig. 1. Esophageal sensitivity to acid between the symptomatic and asymptomatic groups in patients with reflux esophagitis. There was no significant difference between the two groups. 3. (24 ph ) 24 ph DeMeester (65%), 5 (28%) (p<0.05, Fig. 2), (odd ratio) 4.9. Table 1. Characteristics of Patients with Reflux Esophagitis. (mean SD) Symptomatic group Asymptomatic group Number Age M:F BMI* (kg/m2) : : *Body mass index (normal range:20-25kg/m2) , 25, 3, 12 (47%), 7 (9%) (Fig. 1). Fig. 2. The abnormal reflux rate in 24 hr ambulatory esophageal ph monitoring between the symptomatic and asymptomatic groups in patients with reflux esophagitis. Note that the higher rate of abnormal reflux in the symptomatic group compared to the asymptomatic group with an odd ratio of 4.9. (* p<0.05).

6 Chan Hee Han, et al : The Meaning of Gastroesophageal Reflux Disease (GERD) Symptoms in Patients with Reflux Esophagitis 201 Fig. 3. The DeMeester scores of the symptomatic and asymptomatic groups in patients with reflux esophagitis, shown as median values (bars), interquartile ranges (boxes), and ranges from 5th to 95th percentile(bar caps). Note that the higher scores in the symptomatic group compare to the asymptomatic group (* p<0.05). Fig. 4. The severity of esophagitis using the modified Savary-Miller classification (A) and Los Angeles classification (B) between the symptomatic and asymptomatic groups in patients with reflux esophagitis. There was no significant difference between the two groups. DeMeester 종합점수에 대한 차이를 보았을 때, 증상군에서 중앙값(범위)이 31.4( ), 비증 상군에서 중앙값(범위)이 13.9( )로 증상군 에서 비증상군보다 유의하게 DeMeester 종합점수 가 높은 것을 알 수 있었다(p <0.05, Fig. 3). Fig. 5. The presence of a hiatal hernia between the symptomatic and asymptomatic groups in patients with reflux esophagitis. There was no significant difference between the two groups. 4. 식도염의 중등도 및 식도 열공 헤르니아 증상군과 비증상군에서의 식도염의 정도는 SM 분류상 증상군에서 Grade I:15예(58%), Grade II:7 예(27%), Grade III:1예(4%), Grade IV:3예(12%)이 였으며 비증상군에서는 각각 11예(61%), 5예 (28%), 1예(6%), 1예(6%)이었다. LA 분류상 증상 군에서 A:19예(73%), B:6예(23%), C:1예(4%), D:0 예이였으며 비증상군에서는 각각 10예(56%), 5예 (28%), 2예(11%), 1예(6%)로 모두 두 군에서 Grade에 따른 차이는 없었다(Fig. 4). 식도열공 헤르니아가 있는 경우는 증상군에서 14예(54%), 비증상군에서 7예(40%)로 두 군간의 유의한 차이는 없었다(Fig. 5). 5. 식도 내압검사 이상소견 식도 내압검사 이상소견으로 하부식도 괄약근 압의 감소, 상부식도 괄약근압의 감소, 고압성 하 부식도 괄약근, 호두까기 식도(nutcracker esophagus), 비특이적 식도운동장애(nonspecific esophageal motility disorder) 등을 보였으며, 호두까지 식도가 2예(7.7%)로 증상군에 나타나고 하부식도 괄약근 압의 감소가 증상군에서 3예(11.5%), 비증상군에 서 1예(5.6%)로 증상군에서 많은 경향을 보였지만 전체적으로 두 군간의 식도 운동이상의 유의한 차이는 없었다(Table. 2).

7 202 : 6 2, 2000 Table 2. Abnormal Esophageal Manometric Findings according to the Patients with or without Symptoms Abnormal findings Decreased LES* pr. Decreased UES* pr. Hypertensive LES Nutcracker esophagus NEMD* Symptomatic group (%) 3/26 (11.5) 1/26 (3.8) 0/26 (0) 2/26 (7.7) 0/26 (0) Asymptomatic group (%) 1/18 (5.6) 2/18 (11.1) 1/18 (5.5) 0/18 (0) 1/18 (5.5) Total 6/26 (23) 5/18 (27.8) *LES, lower esophageal sphincter; UES, upper esophageal sphincter; NEMD, Nonspecific esophageal motility disorder ph 13, 3, 2,, 2, 1, 1. 4., ph 35-50%.14-16, Genval Genval workshop. 1,. Bremner 24 ph 160, (video esophagography),, 24 ph.17 (AFP score) ph,,,,, Grade.,, ,20, (perceptual sense)

8 15 : 203 (metaplastic columnar epithelium) 44 19, 26 (59%) 18 (41%)..20 Fass ph, 13 ph.9.,, /,.9, Cadiot 21..,,,,, 13,,,.,.,,,, 1, Helicobacter pylori,. 4., Bilitec 22,23,,.,, ph..

9 204 Korean Journal of Gastrointestinal : Vol. 6, No. 2, 2000.,,.,. 65%, 28% (p<0.05).,,. :,,. :,,, 24 ph. :,., Grade. : 44, 24 ph,,,.. : 44 26, %, 39%. 24 ph DeMeester Dent J, Brun J, Fendrick AM, et al. An evidencebased appraisal of reflux disease management: the Genval Workshop Report. Gut 1999;44(suppl 2):S1-S Devault KR, Castell DO. Guidelines for the diagnosis and treatment of gastroesophageal reflux disease. Arch Intern Med 1995;155: Klauser GK, Schindlbeck NE, Mller-Lissner SA. Symptoms in gastro-esophageal reflux disease. Lancet 1990;335: ,, ;6: ,, ;58: Smout AJPM. Endoscopy-negative acid reflux disease. Aliment Pharmacol Ther 1997;11 (suppl. 2): Trimble KC, Pryde A, Heading RC. Lowered oesophageal sensory thresholds in patients with

10 Chan Hee Han, et al : The Meaning of Gastroesophageal Reflux Disease (GERD) Symptoms in Patients with Reflux Esophagitis 205 symptomatic but not excess gastro-oesophageal reflux: evidence for a spectrum of visceral sensitivity in GORD. Gut 1995;37: Helm JF, Dodds WJ, Hogan WJ. Salivary responses to esophageal acid in normal subjects and patients with reflux esophagitis. Gastroenterology 1982;93: Fass R, Naliboff B, Higa L et al. Differential effect of long-term esophageal acid exposure on mechanosensitivity and chemosensitivity in humans. Gastroeneterology 1998;115: DeMeester TR, Peters JH, Bremner CG, Chandrasoma P. Biology of gastroesophageal reflux disease: pathophysiology relating to medical and surgical treatment. Annu Rev Med 1999;50: Jamieson JR, Stein HJ, DeMeester TR et al. Ambulatory 24-h esophageal ph monitoring: normal values, optimal thresholds, specificity, sensitivity and reproducibility. Am J Gastroenterol 1992;87: ,, ;34: ,,. 24 ph. 1998;31: Johnsson F, Joelsson B, Gudmundsson K, Grieff L. Symptom and endoscopic findings in the diagnosis of gastro-esophageal reflux disease. Scand J Gstroenterol 1987;22: Spechler SJ. Epidemiology and natural history of gastroesophageal reflux disease. Digestion 1992;51(suppl. 1): Weinbeck M, Barnet J. Epidemiology of reflux disease and reflux esophagitis. Scand J Gstroenterol 1987;24(Suppl. 156): Giuli R, Galmiche J-P, Jamieson GG, Scarpignato C. The esophagogastric junction. Paris: John L ibbey Eurotext, 1998: Winwood PJ, Mavrogiannis CC, Smith CL: Reduced sensitivity to intra-oesophageal acid in patients with reflux-induced strictures. Scand J Gastroenterol 1993; 28: Johnson DA, Winters C, Spurling TJ et al. Esophageal acid sensitivity in Barrett' s esophagus. J Clin Gastroenterol 1987; 9: Murphy PP, Johmston BT, Collins JSA. Mucosal sensitivity and salivary response to infused acid in patients with columnar-lined oesophagus. Euro J Gastroenterol Hepatol 1994;6: Cadiot G, Bruhat A, Rigaud D, et al. Multivariate analysis of pathophysiological factors in reflux esophagitis. Gut 1997;40: Grade A, Pulliam G, Johnson C et al. Reduced chemoreceptor sensitivity in patients with Barrett' s esophagus may be related to age and not to the presence of Barrett' s epithelium. Am J Gastroenterol 1997;92: Fass R, Yalam JM, Camargo L et al. Increased esophageal chemoreceptor sensitivity to acid in patients after successful reversal of Barrett' s esophagus. Dig Dis Sci 1997;42: Kern MK, Birn RM, Jaradeh S et al. Identification and characterization of cerebral cortical response to esophageal mucosal acid exposure and distension. Gastroenterology 1998;115:

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012임수진 Received : 2012. 11. 27 Reviewed : 2012. 12. 10 Accepted : 2012. 12. 12 A Clinical Study on Effect of Electro-acupuncture Treatment for Low Back Pain and Radicular Pain in Patients Diagnosed with Lumbar