BACKGROUND Immune-mediated mechanisms are implicated in the pathogenesis of achalasia of cardia (AC), which is characterized by inflammation-driven degeneration of myenteric neurons. Circulating autoantibodies targeting the enteric nervous system may serve as potential biomarkers reflecting this underlying neurodegeneration. However, the clinical significance of anti-enteric neuronal antibodies (AENAs) in disease progression and treatment outcomes remains unexplored. AIM To evaluate the prevalence of AENA in AC and its correlation with clinical characteristics and treatment outcomes. METHODS This prospective cohort study included 97 patients with AC diagnosed according to the Chicago Classification version 4.0 and 98 age- and sex-matched healthy subjects (HS). Indirect immunofluorescence was used to detect AENA and antinuclear antibodies. Multivariable linear regression analyses were performed to explore associations between AENA intensity and clinical parameters in patients with AC. RESULTS The AENA-positive rate was significantly higher in patients with AC than HS (60.8% vs 25.5%, P < 0.001). AENA-positive patients had higher endoscopic CARS (contents, anatomy, resistance, and stasis) than AENA-negative patients (5.0 vs 4.0, P = 0.045), whereas Eckardt scores and manometric parameters did not differ between groups. Multivariable regression identified strong AENA positivity as independently associated with higher CARS (β = 0.95, 95% confidence interval: 0.37-1.53, P = 0.002), demonstrating a dose-response relationship (P for trend = 0.005). Patients with strong AENA intensity also exhibited greater barium column width and higher integrated relaxation pressure than those with moderate intensity. After peroral endoscopic myotomy and overlap weighting, AENA-positive patients had worse Eckardt scores at 1- and 6-month follow-up than AENA-negative patients (P = 0.031 and P = 0.005, respectively). CONCLUSION Serum AENA is prevalent in AC and correlates with disease severity in a dose-dependent manner and with early treatment response, potentially identifying patients with more severe disease characteristics and poorer outcomes.

Abstract Background Evidences of comparison of sex difference in Chinese irritable bowel syndrome (IBS) patients were few. We aim to compare gender difference in the biopsychosocial characteristics of Chinese patients of IBS predominant with diarrhea (IBS-D). Methods IBS-D patients meeting Rome III criteria were enrolled. We administered IBS symptom questionnaires, evaluation of psychological status (HAMD and HAMA scales) and IBS quality of life (IBS-QOL), dietary habits, healthcare seeking behaviors, and compared biopsychosocial characteristics between male and female patients. Results Four hundred and ninety patients were enrolled including 299 males and 191 females. More female patients reported abdominal pain associated with defecation (84.3% vs. 74.9%, P = 0.014) while males reported more abdominal discomfort (39.8% vs. 26.7%, P = 0.003). Females had higher IBS symptom score (9.7 ± 1.7 vs. 9.4 ± 1.4, P = 0.025) and more of females had severe abdominal pain/discomfort (17.8% vs. 12.4%, P = 0.013) while there were no significant differences of other bowel symptoms. Females reported higher incidence of comorbid anxiety state (64.9% vs. 52.8%, P = 0.008) and depression state (35.6% vs. 19.7%, P < 0.001) than males. Female patients also had lower IBS-QOL score (70.2 ± 20.4 vs. 75.1 ± 16.8, P = 0.028) and more frequent consultations, as well as less response for dietary modification than males. Conclusions Chinese female patients with IBS-D had more prominent psychosocial disorders compared to male patients and their abdominal symptoms had minor differences.

Objective: To study the alterations of p16 gene and its expression in insulinoma and to correlate the findings with clinicopathological characteristics. Methods: Expression of p16 protein was detected in 72 insulinomas and 49 para-tumoral or normal pancreatic tissues by immunohistochemical staining. Genomic DNA was isolated from 32 tumor tissue and 17 paired pancreatic tissues and bisulfite-modified. Promoter methylation status of p16 gene was detected in 32 tumor tissue and 17 paired pancreatic tissues by methylation specific PCR. The findings were correlated with the clinicopathological features. Results: There were 30 males and 42 females in all 72 patients, aged (46.5±14.0) years. Loss or reduced expression of p16 protein was found in 42 of 72 insulinomas (58.3%) while loss or reduced expression of p16 was seen in only 34.7% (17/49) of para-tumoral or normal pancreatic tissues (χ²=6.52, P=0.011). Promoter methylation of p16 gene was found in 13 of 32 insulinomas (40.6%) and only 2 of 17 (11.8%) para-tumoral tissues (χ²=4.35, P=0.037). The expression of p16 protein in insulinoma was not associated with clinicopathological features such as gender, age, tumor size and tumor grade. Conclusions: Loss or reduced expression of p16 protein was found in insulinomas, and associated with p16 gene promoter methylation.

目的 探讨PCR-Sanger测序法在幽门螺杆菌(Hp)感染个体化治疗中的应用价值.方法 选取2018年1至6月因各种消化道症状于温州市中心医院就诊且13C尿素呼气试验阳性提示存在Hp感染的患者200例,按随机数字表法分为个体化治疗组与经验治疗组,每组100例.个体化治疗组患者行胃镜检查及病理活检,并同时行Hp PCR-Sanger测序、细菌培养及药敏试验,对比分析PCR-Sanger测序法与细菌培养法检测Hp的阳性率及药敏结果;测序阳性患者予测序方案治疗(艾司奥美拉唑肠溶片+胶体果胶铋胶囊+阿莫西林胶囊+克拉霉素缓释片或左氧氟沙星片或呋喃唑酮片).经验治疗组患者给予经验方案治疗(艾司奥美拉唑肠溶片+胶体果胶铋胶囊+阿莫西林胶囊+克拉霉素缓释片).对比分析两组患者的Hp根除率,并采用Kappa检验对个体化治疗组PCR-Sanger测序与药敏试验结果进行一致性分析.结果 PCR-Sanger测序法检测Hp的阳性率为80.00％(80/100),明显高于细菌培养法的44.00％(44/100)(P<0.05).两种检测方法对克拉霉素及左氧氟沙星药敏情况诊断的Kappa值分别为0.532及0.641,提示一致性一般.按遵循研究方案分析(PP),个体化治疗组Hp根除率90.14％(64/71)明显高于经验治疗组的77.27％(68/88)(P<0.05);按意向性分析(ITT),个体化治疗组Hp根除率80.00％(64/80)与经验治疗组的68.00％(68/100)比较差异无统计学意义(P>0.05).结论 PCR-Sanger测序法检测Hp不仅灵敏度高、周期短,而且同时能检测克拉霉素与左氧氟沙星的耐药情况,根据测序结果制定的Hp感染个体化治疗方案可显著提高Hp根除率.

Diarrhea is a common digestive symptom. Here, we reported a case of young patient admitted with diarrhea caused by lead poisoning and cytomegalovirus infection. Through informative medical history and multi-disciplinary team discussion, Satoyoshi syndrome was finally diagnosed.

目的 调查腹泻型肠易激综合征(IBS-D)患者的消化道症状、精神心理状况和使用神经调节剂治疗情况,分析、探讨IBS-D患者神经调节剂选择和疗效.方法 连续纳入符合罗马Ⅲ诊断和分型标准的IBS-D患者,以面对面方式问卷调查患者消化道症状和诊疗情况,并进行汉密尔顿焦虑量表(HAMA)和抑郁量表(HAMD)测评,临床医师根据患者病情处方神经调节剂,对患者随诊记录的疗效进行评分.采用t检验、非参数检验、χ2检验和Spearman秩相关分析进行统计分析.结果 共纳入IBS-D患者410例,其中116例(28.3％)处方了神经调节剂(≥2周),19例(16.4％)未随访.神经调节剂治疗组合并中重度焦虑、抑郁比例高于常规治疗组(P=0.001;P=0.000);排便前腹痛/腹部不适频率更高(P=0.005)、排便后腹痛/腹部不适症状更难以改善(P=0.045).97.9％(95/97)患者服用神经调节剂后情绪、睡眠、腹痛/腹部不适和腹泻4种症状均有不同程度改善.用药后起效时间为(0.8±0.4)个月,最佳疗程为(3.5±2.8)个月.用药后情绪、腹痛/腹部不适、腹泻改善程度与用药疗程均呈正相关(r=0.344;r=0.322;r=0.381).最常用药为帕罗西汀和米氮平,共占78.4％(76/97);帕罗西汀治疗后情绪显著改善者基线认知障碍因子评分更低(P=0.036),腹泻显著改善者基线精神性焦虑、迟滞因子评分更高(P=0.034;P=0.028);米氮平治疗后腹痛/腹部不适和腹泻显著改善者基线睡眠障碍因子评分更高(P=0.008;P=0.003).结论 神经调节剂适用于合并中重度焦虑和/或抑郁,或肠道症状重的难治性IBS-D患者;个体化选择神经调节剂、足疗程和维持用药可明显提高整体治疗效果.

肝硬化合并肠道动静脉畸形的病例报道较为罕见,诊断及治疗困难,介入栓塞为可能的优选治疗手段.本文报道1例患者的诊治过程,为今后临床决策提供参考.

目的 通过对抗抑郁药疗效的荟萃分析来探讨抗抑郁药治疗肠易激综合征(IBS)的适应证.方法 检索MEDLINE、EMBASE和Cochrane对照研究登记库中IBS患者抗抑郁药治疗的随机对照研究(文献发表时间为2000-01-01-2018-03-31).以成年IBS患者为研究人群,将抗抑郁药与安慰剂或常规治疗进行对比.以IBS的总体症状或腹痛症状无改善为结局指标,获得抗抑郁药治疗后IBS症状无改善的相对危险度(RR)和95％可信区间(CI),并根据危险差的倒数计算出所需要治疗的患者数(NNT).对可能影响疗效的主要临床特征(即是否合并心理障碍、腹痛或腹部不适的严重程度、是否难治性IBS)和疗程进行亚组分析.结果 纳入12项高质量的随机对照研究进行荟萃分析.与安慰剂或常规治疗相比,当合并抑郁或焦虑时,抗抑郁药治疗后IBS症状无改善的相对危险度是0.45(95％CI0.26～0.80),NNT为3.7.在抑郁和焦虑未知组,难治性IBS患者抗抑郁药治疗后IBS症状无改善的相对危险度是0.58(95％CI 0.46～0.73),NNT为3.6;中-重度腹痛或腹部不适患者抗抑郁药治疗后IBS症状无改善的相对危险度是0.64(95％CI0.44～0.93),NNT为4.7.抗抑郁药疗程≥3个月时,治疗后IBS症状无改善的相对危险度是0.66(95％CI0.54～0.81).结论 IBS患者抗抑郁药治疗的适应证为合并抑郁或焦虑、难治性IBS、表现为中-重度腹痛或腹部不适的IBS患者;推荐疗程至少为3个月.

胃息肉是指胃黏膜凸出于胃腔而形成的局限性、隆起性病变.胃息肉可单发,也可有多发.胃息肉多数直径为数毫米,有时可见直径大于1厘米的息肉. 胃息肉会导致哪些不适? 事实上,大多数胃息肉患者无特殊不适症状,但因胃息肉可能会合并胃炎、幽门螺杆菌感染、胆汁反流等问题,很多患者会出现腹部不适、上腹隐痛、腹胀、恶心、消化不良等症状.罕见的息肉体积较大、较多,或位于贲门、幽门处,或表面有糜烂渗血等,在这种情况下,可能会引起患者吞咽困难、腹痛、腹泻、腹胀、黑便、贫血等症状.

Background/Aims A strong correlation between depression and irritable bowel syndrome with diarrhea (IBS-D) has been identified. The aim of this study is to identify the correlations among depression, structural factors, gastrointestinal (GI) and extra-GI symptoms, and efficacy of neuromodulators in patients with IBS-D. Methods Patients meeting the Rome III Diagnostic Criteria for IBS-D were enrolled. The intestinal symptoms and psychological states were evaluated using IBS-specific symptom questionnaires and Hamilton Depression Rating Scale. Results In total, 410 patients with IBS-D were enrolled, 28.8% (118/410) had comorbid depression. Patients with depression did not readily experience improvement in abdominal pain/discomfort after defecation, and had a higher prevalence of passing mucus, overlapping functional dyspepsia, and extra-GI symptoms. The structural factor “mental disorders” significantly correlated with main bowel symptom score and degree of pre-defecation abdominal pain/discomfort. No structural factor significantly correlated with bowel movements or stool form. Patients who had passing mucus, overlapping functional dyspepsia and extra-GI painful symptoms have higher score of “anxiety/somatization.” Patients with sexual dysfunction have higher score of “retardation symptoms.” In total, 28.3% of patients with IBS-D were prescribed neuromodulators. Baseline scores of “anxiety/somatization” and “retardation symptoms” positively correlated with improvement of diarrhea after paroxetine, and “sleep disturbances” positively correlated with improvement of abdominal pain/discomfort and diarrhea after mirtazapine. Conclusions Comorbid depression and higher scores of structural factors might aggravate GI and extra-GI symptoms other than bowel movements and stool form. Structural factors of Hamilton Depression Rating Scale correlated with efficacy of paroxetine and mirtazapine in patients with IBS-D.

Background The doctor-patient relationship in China has deteriorated in recent years, and poor doctor-patient communication is one of the main reasons. How to effectively carry out doctor-patient communication training originated from the West among Chinese medical students still to be studied. In the past decade, Peking Union Medical College has adopted clinical scenario drama to teach doctor-patient relationship and clinical communication skills. The aim of this study was to introduce clinical scenario dramas and evaluate its effectiveness in promoting doctor-patient relationships and clinical communication skills through students’ self-perceptions in Chinese medical students. Methods This study was a retrospective, self-controlled study and conducted from March 2009 to October 2018. Doctor-patient relationship and communication skills training were administered to all sixth-year medical students, which involved lectures and various clinical scenario dramas. The program totaled 24 h, of which each class session was 3 h, with 8 sessions in total. All students were requested to complete an anonymous 5 likert self-rating survey including self-confidence in using communication skills and self-perceived learning attitude and ability before and at the end of the course. In addition, they were requested to evaluate the curriculum after completion of the course. Results Clinical scenario dramas helped students improve their self-confidence in clinical communication skills except for psychosomatic history taking ( p < 0.05). The interests for participation in clinical scenario dramas were higher compared to attending lectures (4.39 ± 0.610 Vs 4.07 ± 0.831, p <0.01). Study participants were highly satisfied in the course setting, teaching instructors and content (4.61 ± 0.546, 4.65 ± 0.535, 4.63 ± 0.534). The self-evaluation results demonstrated that clinical scenario dramas improved the learning ability of medical students ( p < 0.05). Conclusion The use of clinical scenario dramas was helpful in teaching doctor-patient communication skills.

目的 通过高分辨率食管测压初步探讨非梗阻性吞咽困难(NOD)患者高分辨率食管测压(HRM)特点及病因.方法 选取48例以吞咽困难为主诉的患者,所有患者均经检查可排除食管梗阻性疾病,再行HRM检查,比较不同疾病患者食管动力各项指标的统计学差异并分析原因.结果 48例NOD患者中非特异性食管体动力异常20例、贲门失弛缓症9例、胃食管连接处流出道梗阻6例、胃食管反流病3例、食管测压正常10例.5组上食管括约肌(UES)残余压、下食管括约肌(LES)静息压、4s完整松弛压(4s IRP)、远端收缩延迟时间(DL)和远端收缩积分(DCI)差异均有统计学意义(均P＜0.05);贲门失弛缓症组、胃食管连接处流出道梗阻组UES残余压、LES静息压、4sIRP与正常组比较差异均有统计学意义(均P＜ 0.05),而DL仅在贲门失弛缓症组与正常组差异有统计学意义(P＜0.05);分析非特异性食管体动力异常组病因分布显示硬皮病5例(25.0％)、远端食管痉挛2例(10.0)、不明原因食管体动力异常13例(65.0％),均主要表现为无效蠕动.结论 NOD的病因主要为非特异性食管体动力异常,食管动力学主要特点为无效蠕动,通过HRM检查食管动力学各项参数,有助于疾病确诊.

Patients with cyclic vomiting syndrome usually have comorbid psychological disorders, the trigger and aggravating factors of gastrointestinal symptoms. It may decrease the quality of life and the response to the conventional therapies, bring the patients to seek medical care frequently and perform unnecessary examinations, result in the waste of medical resources. We reported a 20-year-old woman with complaint of recurrent vomiting since infant, and less response to symptomatic and supportive treatment. Her vomiting relieved with antidepressant after consultation with gastroenterological specialist and psychologist. Physicians should pay more attention to recognize the comorbid psychological disorders in patients with functional gastrointestinal disorders (FGIDs), including cyclic vomiting syndrome. It is important to refer the patients with refractory symptoms to the psychologists for further professional evaluation and antidepressants.

To explore the natural history of and risk factors for gastroesophageal reflux (GER) in a prospective cohort in Beijing, China. We selected adult participants using a stratified randomized method and performed initial surveys in 1996 and the current survey in 2008. Well-trained investigators administered the survey questionnaire using face-to-face interviews. Reflux symptoms were evaluated by their intensity and frequency. GER was defined as heartburn, acid reflux, and food regurgitation at least once a week, and monthly reflux was defined as at least one of the above symptoms occurring 1-3 days per month. The resurvey response rate was 47.8% (1189/2486). Over 12 years, 66.9% of the respondents remained unchanged, and one-third changed, with a GER new onset rate of 7.0 per 1000 person-years and a GER disappearance rate of 64.6 per 1000 person-years. This kept the GER prevalence stable at 8.2% to 9.5% ( P = 0.28). GER and monthly reflux exhibited significant differences in their tendency to persist or become aggravated to GER (22.4% vs 11.9%, P = 0.02). Participants who initially had single, mild to moderate, daily GER were more likely to recover from reflux over time. Participants with persistent and aggravated GER had more severe heartburn and acid reflux than those with new-onset GER in the current survey. Multiple logistic regression analysis showed that emotional depression is a risk factor for GER aggravation (odds ratio 3.52, 95% confidence interval 1.43-8.67, P = 0.006). The initial symptom profile of reflux determines the outcome of GER over time.

目的 观察高分辨率食管测压过程中上食管括约肌静息压和不同体位残余压的变化.方法 2017年1月至2018年1月该院收治的行高分辨率食管测压胃食管反流患者60例,记录仰卧位时上食管括约肌的静息压,分别比较湿咽开始前、湿咽中和湿咽结束后,以及仰卧位和坐位的上食管括约肌残余压平均值.结果 湿咽开始前上食管括约肌静息压平均63.5mmHg,湿咽中平均58.6mmHg,湿咽结束后平均53.5mmHg;且仰卧位上食管括约肌残余压高于坐位.结论 体位可影响上食管括约肌残余压,湿咽结束后获得的上食管括约肌静息压数值受干扰因素影响少,可能更具有临床相关性.

背景:肠易激综合征(IBS)患者常合并焦虑,焦虑可影响IBS症状的严重程度和治疗效果.目的:了解腹泻型IBS(IBS-D)患者的临床总体症状、精神心理状况,并探讨焦虑及其结构因子与患者症状的关系.方法:连续纳入符合罗马Ⅲ标准的IBS-D患者,以面对面问卷调查的方式评估患者症状,并进行汉密尔顿焦虑量表(HAMA)测评.分析HAMA及其结构因子与IBS-D患者肠道主要症状、排便症状、重叠上消化道症状、胃肠道外症状的相关性.结果:共纳入410例IBS-D患者,264例(64.4％)患者合并焦虑.与无焦虑患者比,合并焦虑的患者肠道主要症状评分、排便后腹痛/腹部不适评分明显升高,腹胀、排便费力、排黏液便、重叠胃食管反流病和胃肠道外症状的比例均显著升高(P＜0.05).精神性焦虑与肠道症状评分、排便后腹痛/腹部不适改善程度存在相关性(P＜0.05);躯体性焦虑与排便前腹痛/腹部不适程度相关性较强(P＜0.05);HAMA各结构因子与患者平时(非发作期)和IBS发作时排便次数和粪便性状变化无明显相关性.腹胀、排黏液便、重叠胃食管反流病、重叠胃肠道外症状者的HAMA总分、精神性焦虑和躯体性焦虑因子评分显著高于无相应症状者(P＜0.05).结论:焦虑及其结构因子主要与IBS-D患者腹痛/腹部不适严重程度有关,与排便次数和粪便性状无关.

[目的]探讨生物反馈疗法联合认知行为干预治疗功能性排便障碍的临床疗效.[方法]选取功能性排便障碍患者50例,分为治疗组26例和对照组24例.治疗组采用生物反馈疗法联合认知行为干预治疗,对照组采用单纯生物反馈治疗.比较两组治疗前后患者便秘症状积分和健康调查简表(SF-36)评分的改善结果;对两组疗效进行临床评定.[结果]治疗组便秘症状积分改善总有效率为92.3％,高于对照组的70.8％(P<0.05).治疗组健康调查简表评分(SF-36)在社会功能、 情感职能、 精神健康方面的改善优于对照组(P<0.05).[结论]生物反馈疗法联合认知行为干预治疗功能性排便障碍能显著改善患者的临床症状和提高其生活质量,值得扩大研究和初步临床推广.