Impaired Esophageal Mucosal Integrity and the Related Motility Factors in Refractory Gastroesophageal Reflux Disease

Abstract

\n Backgrounds. Research on esophageal mucosal integrity in gastro-oesophageal reflux disease (GERD) has been taken seriously in recent years, especially in refractory GERD. Mean nocturnal baseline impedance (MNBI) is proposed as an indicator of impaired mucosal integrity. We aimed to compare the MNBI value and investigate the impact of esophageal motility on MNBI in different subtypes of refractory GERD. Methods. Endoscopy, high-resolution manometry, and 24h impedance-pH monitoring were performed in 412 refractory GERD patients. From these patients, 94 erosive esophagitis (EE), 52 non-erosive reflux disease (NERD), and 31 Barrett s esophagus (BE) patients were enrolled in the study. EE group 54 included Los Angeles (LA) Grade-A/B and 40 LA Grade-C/D patients. 52 functional heartburn (FH) patients were used as the control. MNBI was acquired at 3 and 5 cm above lower esophageal sphincter (LES) and was compared between groups. Parameters of esophagogastric junction (EGJ) and LES, along with esophageal peristaltic sequences were recorded. Univariate and multivariate regression analysis were performed to determine the impact of these motility factors on MNBI in different subtypes of refractory GERD. Results. MNBI values were signifiantly lower in all subgroups of refractory GERD patients than in FH patients. MNBI in NERD patients was similar with LA-A/B and LA-C/D patients. MNBI in NERD and LA-C/D patients was signifiantly lower than in BE patients. No difference in MNBI was found between LA-A/B and BE patients. Ineffective esophageal motility and absent contractility were the risk factor for decreased MNBI in LA-A/B and LA-C/D patients, respectively. Type III EGJ (hiatus hernias) and decreased LES length were the risk factor for decreased MNBI in NERD and BE patients, respectively. Conclusions. Impaired mucosal integrity of NERD patients was as severe as that of EE patients and hiatus hernias were the risk factor, therefore, mucosal protections and explorations of hiatus hernias should be emphasized in refractory NERD patients. Weakened esophageal body peristalsis and decreased LES length were the risk factor for the impaired mucosal integrity of refractory EE patients and BE patients, respectively, and thus the therapy on peristaltic disorders and LES function was recommended for them. These results provided new ideas for optimizing the treatment of refractory GERD.