摘要目的:探讨GERD合并食管胃连接部流出道梗阻(EGJOO)在动力学特征、相关临床症状、食管24 h pH-阻抗测定中的特点和临床意义。方法:纳入2014年8月至2019年8月在珠海市人民医院就诊的512例GERD患者。依据患者是否合并EGJOO分为EGJOO组(85例)和非EGJOO组(427例)，根据内镜检查是否合并食管糜烂分为非糜烂性反流病(NERD)组(393例)和反流性食管炎(RE)组(119例)。分析各组患者的食管高分辨率测压(HRM)动力特征、相关临床症状和食管24 h pH-阻抗检测结果。组间比较采用Fisher确切概率法、Wilcoxon秩和检验，配对资料比较采用McNemar检验。结果:EGJOO组患者下食管括约肌(LES)静息压、整合松弛压(IRP)、远端收缩积分(DCI)、食团内部压力(IBP)、IBP最大值均高于非EGJOO组[分别为30.70 mmHg(22.50 mmHg，40.75 mmHg)(1 mmHg＝0.133 kPa)比19.90 mmHg(14.50 mmHg，26.20 mmHg)、17.80 mmHg(16.20 mmHg，22.85 mmHg)比7.80 mmHg(5.20 mmHg，10.20 mmHg)、1 282.80 mmHg·s·cm(654.55 mmHg·s·cm，2 563.20 mmHg·s·cm)比818.90 mmHg·s·cm(495.10 mmHg·s·cm，1 365.10 mmHg·s·cm)、7.00 mmHg(4.40 mmHg，11.65 mmHg)比3.60 mmHg(1.10 mmHg，5.80 mmHg)、14.90 mmHg(11.50 mmHg，18.80 mmHg)比10.40 mmHg(8.10 mmHg，13.10 mmHg)]，差异均有统计学意义( Z＝-7.82、-14.57、-4.25、-7.16、-6.27， P均<0.01)。NERD组患者LES静息压高于RE组[21.70 mmHg(15.65 mmHg，29.40 mmHg)比19.40 mmHg(13.60 mmHg，25.10 mmHg)]，差异有统计学意义( Z＝-2.47， P＝0.014)。EGJOO组患者的DeMeester评分、长反流(>5 min)次数、最长反流持续时间、pH值<4时间百分比均高于非EGJOO组[分别为6.60分(2.70分，11.20分)比3.25分(1.30分，9.18分)、1.00次(0.00次，1.00次)比0.00次(0.00次，0.00次)、6.50 s(2.00 s，15.00 s)比1.00 s(0.00 s，5.00 s)、1.70%(0.30%，2.30%)比0.30%(0.00%，1.63%)]，差异均有统计学意义( Z＝-2.04、-2.94、-3.98、-2.42， P均<0.05)。EGJOO组治疗前吞咽困难的比例高于非EGJOO组[9.4%(8/85)比2.1%(9/427)]，差异有统计学意义(Fisher确切概率法， P＝0.01)。EGJOO组和非EGJOO组治疗后烧心、嗳气、腹痛、腹胀、胸痛比例均低于治疗前[EGJOO组：11.8%(10/85)比34.1%(29/85)、34.1%(29/85)比51.8%(44/85)、4.7%(4/85)比20.0%(17/85)、3.5%(3/85)比22.4%(19/85)、4.7%(4/85)比21.2%(18/85)。非EGJOO组：14.8%(63/427)比33.0%(141/427)、36.8%(157/427)比51.5%(220/427)、5.4%(23/427)比26.5%(113/427)、6.6%(28/427)比21.1%(90/427)、2.8%(12/427)比18.3%(78/427)]，差异均有统计学意义(均McNemar检验， P均<0.05)。 结论:EGJOO患者LES舒缩功能障碍引起的症状更严重，酸反流更明显，且常规促动力药物对其治疗效果欠佳。食管糜烂的发生不仅与酸反流和酸暴露时间的增加有关，还与食管动力障碍、局部黏膜屏障功能等的影响有关。

abstractsObjective:To explore features and clinical significance of motility characteristics, related clinical symptoms, 24-hour esophageal impedance-pH monitoring in patients with gastroesophageal reflux disease (GERD) complicated with esophagogastric junction outflow obstruction (EGJOO).Methods:From August 2014 to August 2019, a total of 512 GERD patients visited Zhuhai People′s Hospital were enrolled. All patients were divided into EGJOO group (85 cases) and non-EGJOO group (427 cases) according to the presence or absence of EGJOO. The patients were also divided into non-erosive reflux disease (NERD) group (393 cases) and reflux esophagitis (RE) group (119 cases) based on the endoscopic findings. The esophageal high resolution manometry (HRM) motility characterisrics, clinical symptoms, results of 24-hour esophageal impedance-pH monitoring of each group were analyzed. Fisher exact probability method, Wilcoxon rank sum test for comparison among groups and McNemar test for comparison of paired data were used for statistical analysis.Results:The lower esophageal sphincter (LES) resting pressure, integrated relaxation pressure (IRP), distal contractile integral (DCI), intrabolus pressure (IBP) and maximum IBP of EGJOO group were all higher than those of non-EGJOO group (30.70 mmHg, 22.50 mmHg to 40.75 mmHg (1 mmHg=0.133 kPa) vs. 19.90 mmHg, 14.50 mmHg to 26.20 mmHg; 17.80 mmHg, 16.20 mmHg to 22.85 mmHg vs. 7.80 mmHg, 5.20 mmHg to 10.20 mmHg; 1 282.80 mmHg·s·cm, 654.55 mmHg·s·cm to 2 563.20 mmHg·s·cm vs. 818.90 mmHg·s·cm, 495.10 mmHg·s·cm to 1 365.10 mmHg·s·cm; 7.00 mmHg, 4.40 mmHg to 11.65 mmHg vs. 3.60 mmHg, 1.10 mmHg to 5.80 mmHg; 14.90 mmHg, 11.50 mmHg to 18.80 mmHg vs. 10.40 mmHg, 8.10 mmHg to 13.10 mmHg, respectively), and the differences were statistically significant ( Z=-7.82, -14.57, -4.25, -7.16, and -6.27, all P<0.01). The LES resting pressure of NRED group was higher than that of RE group (21.70 mmHg, 15.65 mmHg to 29.40 mmHg vs. 19.40 mmHg, 13.60 mmHg to 25.10 mmHg), and the difference was statistically significant ( Z=-2.47, P=0.014). The DeMeeste score, episodes of long time (more than five minutes) acid reflux, the longest duration of reflux and the percentage of time pH<4 of EGJOO group were all higher than those of non-EGJOO group (6.60 points, 2.70 points to 11.20 points vs. 3.25 points, 1.30 points to 9.18 points; 1.00 times, 0.00 times to 1.00 times vs. 0.00 times, 0.00 times to 0.00 times; 6.50 s, 2.00 s to 15.00 s vs. 1.00 s, 0.00 s to 5.00 s; 1.70%, 0.30% to 2.30% vs. 0.30%, 0.00% to 1.63%, respectively), and the differences were statistically significant ( Z=-2.04, -2.94, -3.98 and -2.42, all P<0.05). Before treatment, the percentage of dysphagia of EGJOO group was higher than that of non-EGJOO group (9.4%, 8/85 vs. 2.1%, 9/427), and the difference was statistically significant (Fisher exact test, P=0.01). The percentage of heartburn, belching, abdominal pain, abdominal distention and chest pain of EGJOO group and non-EGJOO group after treatment were all significantly lower than those before treatment (EGJOO group: 11.8%, 10/85 vs. 34.1%, 29/85; 34.1%, 29/85 vs. 51.8%, 44/85; 4.7%, 4/85 vs. 20.0%, 17/85; 3.5%, 3/85 vs. 22.4%, 19/85; 4.7%, 4/85 vs. 21.2%, 18/85. Non-EGJOO group: 14.8%, 63/427 vs. 33.0%, 141/427; 36.8%, 157/427 vs. 51.5%, 220/427; 5.4%, 23/427 vs. 26.5%, 113/427; 6.6%, 28/427 vs. 21.1%, 90/427; 2.8%, 12/427 vs. 18.3%, 78/427), and the differences were statistically significant (all McNemar test, all P<0.05). Conclusions:In EGJOO patients with LES dysfunction, the symptoms are more severe, acid reflux is more obvious, and the efficacy of conventional prokinetic therapy is poor. The occurrence of esophageal erosion is not only due to acid reflux and acid exposure time, but also to esophageal motility disorder and local mucosal barrier function.