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Mémoire de Maîtrise
DOI
10.11606/D.5.2009.tde-06112009-145113
Document
Auteur
Nom complet
Cláudia Cristina de Sá
Adresse Mail
Unité de l'USP
Domain de Connaissance
Date de Soutenance
Editeur
São Paulo, 2009
Directeur
Jury
Rodriguez, Tomás Navarro (Président)
Barbuti, Ricardo Corrêa
Eisig, Jaime Natan
Titre en portugais
Persistência dos sintomas típicos de doença do refluxo gastroesofágico na vigência de inibidor da bomba de próton: características clínicas, endoscópicas, manométricas e de pH-metria de 24 horas
Mots-clés en portugais
Eosinófilos
Falha terapêutica
Refluxo gastroesofágico
Sinais e sintomas
Resumé en portugais
I NTRODUÇÃO: A refratariedade aos inibidores da bomba de prótons (IBP) tem sido o grande desafio dos gastroenterologistas. Este trabalho visa caracterizar os pacientes que persistem com sintomas típicos de doença do refluxo gastroesofágico (DRGE), em uso de inibidores de bomba de prótons em doses de, pelo menos 40mg/dia, quanto aos aspectos demográficos, clínicos e laboratoriais, determinando-se a freqüência da persistência de refluxo ácido pela pH-metria esofágica de 24h. Secundariamente procurouse determinar a freqüência da esofagite eosinofílica nessa população. MÉTODO: Foram entrevistados 110 pacientes que apresentavam persistência de sintomas de pirose e/ou regurgitação em uso de pelo menos 40 mg de IBP por pelo menos 6 semanas. Os mesmos foram submetidos à endoscopia digestiva alta (EDA) com biópsia esofágica, manometria, pHmetria esofágica de duplo canal e exames laboratoriais. RESULTADOS: Dos pacientes avaliados, 77,3% eram do sexo feminino, com média de 46 anos e predomínio de baixa escolaridade. Apenas 10,9% eram tabagistas, 55% apresentavam índice de massa corpórea (IMC) acima de 25Kg/m2, sendo o IMC médio de 27Kg/m2. Entre as comorbidades, as mais freqüentes foram: alergias (72,7%); hipertensão arterial (34,5%), asma (18,2%), depressão (29,1%) e fibromialgia (8,2%), sendo estas duas últimas maiores que a encontrada na população geral. Observou-se freqüência elevada de sintomas dispépticos (70% dos pacientes relataram epigastralgia e 70% plenitude pós-prandial), disfagia (60,9%); globus (37,3%), tosse (37,3%) e dor torácia não cardíaca (30,9%). Apenas 16,4% evidenciavam à endoscopia, lesão em corpo esofágico e 23,6% hérnia de hiato. A maioria dos pacientes (61,8%) apresentava alguma alteração à manometria esofágica. Encontrou-se, entre os pacientes estudados, 24,6% com pHmetria positiva (8,1% no canal distal e 16,45% no proximal) e 75,4% com pH-metria normal. Comparando-se os resultados desses dois grupos de pacientes (pH-metria positiva e normal), segundo as variáveis estudadas, apenas a presença de lesão no corpo esofágico à endoscopia e a elevada escolaridade evidenciaram associação com persistência de pH-metria positiva (p: 0,0061 OR: 4,11 IC: 1,43:11,84 e p: 0,0237 OR: 2,74 IC: 1,13: 6,67 respectivamente). Ao se comparar presença de sintomas atípicos com a presença de refluxo ácido (no esôfago proximal versus distal), apenas globus apresentou associação com pH-metria positiva no canal proximal. Foi diagnosticado um único caso de esofagite eosinofílica entre os pacientes com sintomas típicos de DRGE refratários ao IBP. CONCLUSÃO: DRGE refratária predomina em mulheres de meia idade, associada à alta freqüência de história de alergia, depressão, fibromialgia e sintomas dispépticos. Segundo os resultados da pH-metria, a presença de esofagite erosiva em uso do IBP ou elevada escolaridade foram os únicos fatores de risco para a persistência de refluxo ácido nos dois canais, e globus no canal proximal. Não se observou diferença entre os pacientes com pH-metria positiva ou normal quanto às demais variáveis, até mesmo sintomas dispépticos. É baixa a freqüência de esofagite eosinofílica entre pacientes com pirose e/ou regurgitação refratários ao inibidor da bomba de próton
Titre en anglais
Persistent typical symptoms of gastroesophageal reflux disease on proton pump inhibitor treatment. Clinical, endoscopic, manometric and 24- hour pH-metry characteristics
Mots-clés en anglais
Eosinophils
Gastroesophageal reflux disease
Signals and symptoms
Treatment failure
Resumé en anglais
BACKGROUND: Proton pump inhibitor (PPI) refractory patients have been a big challenge to gastroenterologists. The aim of this study was to characterize the patients that had gastroesophageal reflux disease (GERD) persistent typical symptoms, undergoing PPI medication, administered at a dose of at least 40 mg/day, according to demographic, clinical and laboratory aspects. The primary outcome was to determine the frequency of acid reflux persistence based on the 24-hour esophageal pH-metry result. The secondary outcome was to determine, the frequency of eosinophilic esophagitis in the same population. METHODS: We interviewed 110 patients that presented persistence of heartburn and/or regurgitation symptoms and were undergoing treatment with PPI at a minimum dose of 40 mg/day for at least six weeks. They underwent upper gastrointestinal endoscopy with esophageal mucosa biopsy, esophageal manometry and double probe 24- hour esophageal pH-metry, as well as laboratory tests. RESULTS: 77.3% of the evaluated patients were female, with mean age of 46 years old, and most of them with low educational level. Only 10.9% were tobacco smokers and 55% had body mass index (BMI) greater than 25Kg/m2, showing mean BMI of 27Kg/m2. The most frequent comorbidities were allergy (72.7%), arterial systemic hypertension (34.5%), asthma (18.2%), depression (29.1%) and fibromyalgia (8.2%). Comparing the general population and the group of patients, a higher frequency of depression and fibromyalgia was observed. Some symptoms were found in high frequency: dyspeptic symptoms (70% associated with epigastric pain and 70% with postprandial fullness), dysphagia (60.9%), globus and cough (37.3% each) and no-cardiac chest pain (30.9%). By endoscopy, only 16.4% showed esophageal body lesion and 23.6% hiatal hernia. Most patients (61.8%) presented some alteration in esophageal manometry. Among studied patients, 24.6% had abnormal pHmetry (8.1% in distal probe and 16.45% in the upper probe) and 75.4%, a normal result. When comparing normal to abnormal pH-metry patients according to studied variables only the presence of esophageal body lesion, observed by endoscopy, and high educational level were associated to the persistence of abnormal pH-metry (p: 0.0061; OR: 4.11; IC: 1.43:11.84; and p: 0.0237; OR: 2.74; IC: 1.13: 6.67; respectively). When comparing atypical symptoms with the presence of acid reflux (proximal versus distal esophagus) only globus was associated with abnormal upper probe pHmetry. Only one patient was diagnosed with eosinophilic esophagitis among the total sample with typical gastroesophageal reflux symptoms refractory to PPI treatment. CONCLUSION: Refractory GERD was predominant in middleaged females, associated with high frequency of previous allergy, depression, fibromyalgia and dyspeptics symptoms. The risk factors to the persistence of acid reflux in the two pH-metry probes and to the symptom of globus in the upper pH-metry probe were the persistence of erosive esophagitis in patients undergoing treatment with PPI an a higher educational level. No differences between abnormal or normal pH-metry results patients were found regarding the other variables, such as dyspeptic symptoms. The frequency of eosinophilic esophagitis was low in heartburn and/or regurgitation in PPI refractory patients
 
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ClaudiaCristinaSa.pdf (861.16 Kbytes)
Date de Publication
2009-11-09
 
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