【医学英语第9期】临床篇之消化内科（一）

本期为消化系统疾病的第一讲，主要讨论食管贲门失迟缓症和胃食管反流症这两种常见上消化道疾病。

食管贲门失弛缓症是因食管神经肌肉运动功能障碍，下段食管括约肌呈失驰缓状态，食物无法顺利通过，滞留于食管，逐渐导致食管张力减退、蠕动消失及食管扩张的一种疾病，临床上以吞咽困难，胸骨后疼痛及食物反流为最常见的症状。

胃食管反流性疾病(GERD)是一种食管胃动力性疾病。存在生理反流和病理性反流两种。生理性反流是由LES自发性松弛引起，正常情况下不造成食管粘膜损伤。病理性反流是多种因素引起的胃食管抗反流功能不全，所造成的一种病理现象，常合并食管炎，人群中约10%-20%有胃食管反流症状，持续发展可导致严重并发症，如：食管狭窄、溃疡、出血及巴瑞特(Barrett)食管，后者为癌前期病变。

案例分析

Case 1：A 50-year-old man presents to his physician complaining of problems swallowing for the past several months. Solid foods have been most difficult for him to swallow but recently liquids have also become problematic. He often has chest discomfort after eating and occasionally regurgitates bits of undigested food. His physical examination is unremarkable.

案例1：50岁患者自诉过去几月中有吞咽困难。固体食物吞咽最为困难，后发展为吞咽液体亦然。常有餐后胸部不适，偶尔出现未消化食物反流。体检无异常。

1 What is the most likely diagnosis?

Achalasia (an esophageal motility disorder that results in dysphagia)

食管贲门失迟缓症

诊断特点：题干示典型的进行性吞咽困难（固体→液体）+进食后胸部不适+食物反流

2 What is the pathophysiology of this condition?

Achalasia is an idiopathic motility disorder caused by impaired relaxation of the lower esophageal sphincter (LES) and loss of smooth muscle peristalsis in the lower tow thirds of the esophagus. It is thought that nitric oxide-producing inhibitory neurons are lost in the myenteric plexus.

病理生理表现：

自发性的食管下段迟缓功能异常，下2/3平滑肌蠕动功能丧失。与肠道神经丛产NO抑制性神经元丢失有关。

3 What other imaging or testing can help confirm this diagnosis?

a. A barium esophagram demonstrates a “bird’s beak” appearance of the esophagus.

b. Esophageal manometry reveals complete absence of peristalsis and failure of the LES to relax after swallowing to confirm the diagnosis.

诊断：钡餐检查可见食管贲门结合部经典“鸟喙样”缩窄，食管测压法可见LES蠕动完全消失。

4 What is the appropriate treatment for this condition?

Pneumatic dilation of the LES provides effective but temporary relief in most patients and may need to be repeated. Surgical myotomy is also effective. In nonsurgical candidates, trials of calcium channel blockers and multiple injections of botulinum toxin in the LES are also used.

治疗措施: 充气扩张可以暂时缓解症状，但需重复治疗；外科括约肌切开；非手术治疗包括CCB类和肉毒碱局部注射。

Case 2: A 55-year-old man presents to his physician complaining of burning chest pain that typically occurs after eating and radiates to the neck. Occasionally, the pain and a slight cough awaken him from sleep. He also complains of difficulty swallowing, particularly solid foods. The patient has had these symptoms for several years, but they seem to be worsening.

案例2：55岁男性主诉用餐后烧灼样胸痛，向颈部放射。有时夜间咳嗽影响睡眠。有吞咽困难，尤其是固体食物。病史多年，近期有加重。

1 What is the most likely diagnosis?

Gastroesophageal reflux disease (GERD), complicated by Barrett esophagus.

胃食管反流性疾病

诊断：题干可知有典型的进食后胸骨后烧灼感，夜间有反流引发咳嗽并伴有吞咽困难。

2 What are the common treatments for uncomplicated cases of this condition?

a. Proton pump inhibitor (PPIs) trial

b. Testing for Helicobacter pylori (HP) is appropriate in patients not responsive to PPIs.

c. Lifestyle modifications including elevation of the head of the bed, dietary restrictions, and weight loss are often used in conjunction with medical therapy.

治疗方法：

a. 质子泵抑制剂（PPI）

b. 如PPI无效→查幽门螺旋杆菌（HP），如阳性则三联疗法先治疗

c. 生活方式改变：抬高床头防止反流、限制饮食（忌辛辣）、减肥等

3 Patients with this condition are at greatly increased risk for what other condition?

Patients with Barrett esophagus are 30 times more likely to develop esophageal adenocarcinoma.

Barrett食管：为癌前病变，为胃食管移行部位肠上皮化生，易发展为食管腺癌。

4 What factors increase the risk of developing esophageal cancer?

Barrett esophagus is the major risk factor for adenocarcinoma. Alcohol and cigarette smoking are major risk factors for esophageal squamous cell carcinoma. The risk factors for esophageal cancer can be remembered by ABCEDF: Achalasia, Barrette esophagus, Corrosive esophagitis/Cigarettes, Diverticula (Zucker diverticulum), Esophageal web/EtOH and Familial.

食管癌危险因素：记忆法ABCDEF

A. 食管贲门失弛缓

B. Barrette食管→多为腺癌

C. 腐蚀性食管炎/吸烟→多为鳞癌

D. 食管憩室（Zucker憩室）

E. 食管蹼/饮酒

F. 家族性遗传