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如何处理内镜检查阴性的吞咽困难?

发布日期:2015-4-28 14:20:54 文章来源:医脉通 作者次数:956

    吞咽苦难是一种临床常见症状,普通人群的发病率约3%[1,2]。上消化道内镜检查是作为初始评估的常规检查方法[3,5],食管胃十二指肠镜(EGD)检查在吞咽困难的评估中会产生较高获益;在一项涉及1649例吞咽困难患者的研究中,所有患者均行EGD检查,其中约有70%患者有检测到异常,而这些发现中有近一半被认为具有临床意义[6]。医脉通整理如下:


    从经济方面考虑,相对于钡餐食管造影而言,上消化道内镜检查更具有成本效益[7]。然而,有近1/3吞咽困难患者在行EGD检查时未发现异常[6]。因此,在患者被确诊“内镜检查结果阴性”之前应行食管近端或远端病理检查,以排除反流性食管炎和嗜酸性食管炎可能,这两种疾病在内镜检查过程中都可以呈现粘膜正常表现(例如,内镜检查嗜酸性食管炎的敏感性只有15%~48%)[8,9]。内镜检查阴性的吞咽困难提示了内镜检查的限制性,而众所周知内镜检查在确诊细微结构方面上存在不准确性以及不能准确排除食管动力障碍的问题[10,11]


    一旦吞咽困难患者内镜检查提示阴性结果,下一步需要行食管钡餐检查以评估食管结构性病变,例如,隐匿性食管狭窄,环绕样食管,以及网格样食管。荧光内镜检查通过评估患者吞咽功能来诊断是否有食管动力障碍。同时可以加用一个13mm钡片来增加对微小病变检查的敏感性,因为通常液态钡剂敏感性没有这么高。在适当的条件下,横断面成像检查(CT或MRI)检查可以排除或确诊食管外病变(例如,肿块,肿大淋巴结及血管压迫)。高分辨率的测压检查可以用来评估食管动力障碍疾病。理想情况下,测压试验应该与阻抗试验相结合,这样可以清楚记录固态及液态食团通过食管的全过程,从而能够发现高分辨率测压试验未能发现的食管微小运动异常[12]


    如果上述评估检查后吞咽困难仍然存在,应该行经验性治疗,内镜下食管扩张术是常用的治疗手段,尽管目前关于内镜下食管扩张术疗效的评估是相互矛盾的[13-16]。食管高敏感性可能是食管功能性吞咽困难重要原因,但是目前仅有有限的数据支持使用抗抑郁药物及其他神经调节药物;在临床实践中,这种治疗方法是有效的,因此可能同时伴有其他食管功能症状[17-19]。如果患者有GERD症状,应该给予PPI治疗[5]。对于伴有吞咽困难的患者,在针对食管体部检查没有明确病因时,应该再次检查患者口咽部以排除口咽部病变的肯能性。除此之外,吞咽困难的诊断及治疗方案仍有局限性,应重点加强患者适当饮食及咀嚼技巧方面的教育[19,20]。下图列举关于内镜检查阴性的吞咽困难处理方法。


     

    总之,对内镜检查阴性吞咽困难患者的有效管理取决于诊断性检查方案优势和局限性的理解,以及治疗性干预策略实施的理解。

     

    参考文献:


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    [8]Gentile N, Katzka D, Ravi K, et al. Oesophageal narrowing is common and frequently under-appreciated at endoscopy in patients with oesophageal eosinophilia. Aliment Pharmacol Ther. 2014;40(11-12):1333-1340.


    [9]Kim HP, Vance RB, Shaheen NJ, Dellon ES. The prevalence and diagnostic utility of endoscopic features of eosinophilic esophagitis: a meta-analysis. Clin Gastroenterol Hepatol. 2012;10(9):988-996 e5.


    [10]Halpert RD, Feczko PJ, Spickler EM, Ackerman LV. Radiological assessment of dysphagia with endoscopic correlation. Radiology. 1985;157(3):599-602.


    [11]Ott DJ, Gelfand DW, Wu WC, Chen YM. Radiological evaluation of dysphagia. JAMA. 1986;256(19):2718-2721.


    [12]Conchillo JM, Nguyen NQ, Samsom M, et al. Multichannel intraluminal impedance monitoring in the evaluation of patients with non-obstructive Dysphagia. Am J Gastroenterol. 2005;100(12):2624-2632.


    [13]Olson JS, Lieberman DA, Sonnenberg A. Empiric dilation in non-obstructive dysphagia. Dig Dis Sci. 2008;53(5):1192-1197.


    [14]Colon VJ, Young MA, Ramirez FC. The short- and long-term efficacy of empirical esophageal dilation in patients with nonobstructive dysphagia: a prospective, randomized study. Am J Gastroenterol. 2000;95(4):910-913.


    [15]Scolapio JS, Gostout CJ, Schroeder KW, et al.Dysphagia without endoscopically evident disease: to dilate or not? Am J Gastroenterol. 2001;96(2):327-330.


    [16]Lavu K, Mathew TP, Minocha A. Effectiveness of esophageal dilation in relieving nonobstructive esophageal dysphagia and improving quality of life. South Med J. 2004;97(2):137-140.


    [17]Deschner WK, Maher KA, Cattau EL, Benjamin SB. Manometric responses to balloon distention in patients with nonobstructive dysphagia. Gastroenterology. 1989;97(5):1181-1185.


    [18]Weijenborg PW, de Schepper HS, Smout AJ, Bredenoord AJ. Effects of Antidepressants in Patients With Functional Esophageal Disorders or Gastroesophageal Reflux Disease: A Systematic Review. Clin Gastroenterol Hepatol. 2015;13(2):251-259.e1


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    [20]Galmiche JP, Clouse RE, Balint A, et al. Functional esophageal disorders. Gastroenterology. 2006;130(5):1459-1465.


    医脉通编译自:MY APPROACH to Endoscopy-Negative Dysphagia,PracticeUpdate, March 31, 2015

     

     

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