胃食管反流病临床诊断中检查方法应用策略

doi:10.16150/j.1671-2870.2025.04.001

摘要/Abstract

摘要：

胃食管反流病（gastroesophageal reflux disease， GERD）是一种常见的消化系统疾病，流行病学调查显示，欧美国家的发病率在10%~30%之间，而中国的发病率相对较低，约为10%。近年我国的GERD发病率呈上升趋势。不同检查方法包括pH监测及pH阻抗、内镜检查、高分辨率食管测压、质子泵抑制剂（proton pump inhibitor，PPI）试验简及唾液胃蛋白酶检测。内镜能直观观察病变，但灵敏度稍差；PPI试验简便易行但不能确诊；问卷调查主观性强；唾液胃蛋白酶检测可评估喉咽反流，但受限于酶降解。以上各项方法的灵敏度和特异度各有不同。问卷调查在诊断DERD方面表现良好，灵敏度为77.50%，特异度为87.31%；唾液胃蛋白酶检测诊断GERD的灵敏度为73.0%，特异度为88.3%；PPI试验适用于有典型反流症状患者，但非典型症状患者的应答率显著下降。反流、烧心并非GERD所特有的症状，其他疾病也可有这2个症状，如贲门失弛缓症、功能性烧心、反流高敏感、嗜酸性食管炎等，有时会被误诊。同时，GERD是一项涉及多种致病因素、病理生理机制的复杂的综合征，临床医师在制定治疗策略时，也应该针对不同表现类型患者的病理、生理机制进行个体化精准治疗。未来，随着研究的进一步深入和新技术的应用，个体化精准治疗将成为GERD管理的核心，目标是改善患者的生活质量并降低复发率。

关键词: 胃食管反流病, 临床诊断, pH监测, 内镜

Abstract:

Gastroesophageal reflux disease (GERD) is a common digestive system disease. Epidemiological studies show that the incidence of GERD ranges from 10% to 30% in Europe and the United States, while the incidence in China is relatively lower, at approximately 10%. In recent years, the incidence of GERD in China has shown an increasing trend. Different diagnostic methods include pH monitoring and pH-impedance testing, endoscopy, high-resolution esophageal manometry, proton pump inhibitor (PPI) test, and salivary pepsin testing. Endoscopy enables direct observation of lesions but exhibits relatively low sensitivity. PPI tests are simple and practical but cannot provide a definitive diagnosis. Questionnaires are highly subjective. Salivary pepsin testing can evaluate laryngopharyngeal reflux, but its accuracy is limited by enzyme degradation. The sensitivity and specificity of these diagnostic methods differ. Among them, questionnaires demonstrate good performance in GERD diagnosis, with a sensitivity of 77.50% and a specificity of 87.31%. Salivary pepsin tes-ting in GERD diagnosis shows a sensitivity of 73.0% and specificity of 88.3%. The PPI test is suitable for patients with typical reflux symptoms, but the response rate significantly decreases in patients with atypical symptoms. Reflux and heartburn are not exclusive to GERD. These two symptoms may also occur in other conditions, such as achalasia, functional heartburn, reflux hypersensitivity, and eosinophilic esophagitis, potentially leading to misdiagnosis in some cases. Meanwhile, GERD is a complex syndrome involving multiple pathogenic factors and pathophysiological mechanisms. When formulating treatment strategies, clinicians should adopt individualized and precision treatment tailored to the pathological and physio-logical mechanisms of patients with different clinical manifestations. In the future, with further research and the application of new technologies, individualized precision treatment will become the core of GERD management, aiming to improve patients' quality of life and reduce the recurrence rate.

Key words: Gastroesophageal reflux disease, Clinical diagnosis, pH monitoring, Endoscopy

中图分类号:

张玲, 姚玮艳, 邹多武. 胃食管反流病临床诊断中检查方法应用策略[J]. 诊断学理论与实践, 2025, 24(04): 359-364.

ZHANG Ling, YAO Weiyan, ZOU Duowu. Application strategies of examination methods in clinical diagnosis of gastroesophageal reflux disease[J]. Journal of Diagnostics Concepts & Practice, 2025, 24(04): 359-364.

图/表 1

表1

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项目	优点	局限
pH监测及pH阻抗监测	操作简单；相对无创；可进行准确的自动分析	导管置入引起的鼻喉不适；可能会改变日常生活习惯；导管位置不正确导管移位等均影响其准确性
内镜检查	直视下观察，可诊断反流性食管炎、巴雷特食管、并发症等；对反流性食管炎可进行分级；可活检，有助于鉴别诊断；有助于评估阀瓣功能	灵敏度略差；大部分病人内镜下阴性；有创检查
高分辨率食管测压	指导抗反流手术的决策和类型；精准定位LES，辅助放置pH/阻抗监测导管；评估EGJ及食管体部功能；有助于排除与GERD症状相似的食管动力疾病	不能直接诊断GERD；有创性；操作相对复杂；无法评估食管黏膜损伤
PPI试验	无报警症状的典型反流症状患者；简便易行；具有治疗和诊断双重价值；适用于基层医疗和初步筛查	消化性溃疡及功能性消化不良也可能是阳性；不能确诊；非典型症状患者应答率显著下降；部分患者改善是因为降低了食管高敏感；受剂量、疗程影响；结果判读存在主观性；可能带来GERD过度诊断和PPIs过度使用
问卷调查	简单方便；可操作性强；非侵入性检测方法；可评估生活质量	主观性强；特异度较低；对食管外症状诊断价值有限
唾液胃蛋白酶检测	非侵入性检测方法；可用于喉咽反流的评估；采样方便、可及性强；可方便地在治疗前、治疗中和治疗后多次采样，用于评估治疗效果和疾病活动度的变化	敏感性有限；不能反映反流的频率、酸度或持续时间；受口腔环境及pH影响；不能评估食管损伤