劉均平， 戚燕云， 魏紅山

首都醫(yī)科大學附屬北京地壇醫(yī)院 1.消化內科；2.神經內科，北京 100015

論著·胃相關疾病

胃食管反流病合并焦慮及抑郁狀態(tài)初步臨床評估

劉均平1， 戚燕云2， 魏紅山1

首都醫(yī)科大學附屬北京地壇醫(yī)院 1.消化內科；2.神經內科，北京 100015

目的比較胃食管反流病(gastroesophageal reflux disease, GERD)中非糜爛性反流病(non-erosive reflux disease, NERD)與反流性食管炎(reflux esophagitis, RE)患者精神心理異常癥狀表現，為其有效治療提供依據。方法選擇反酸、燒心、胸骨后疼痛為主訴，伴焦慮和(或)抑郁癥狀的患者，經胃食管反流病問卷(Gred Q)調查確定為GERD者為研究對象，依據胃鏡檢查結果分為RE組和NERD組。兩組均進行漢密爾頓焦慮、抑郁量表問卷調查。結果GERD伴焦慮和(或)抑郁患者共52例，其中NERD患者32例、RE患者20例。年齡、病程、文化程度及Gred Q評分等兩組比較，差異無統(tǒng)計學意義(P<0.05)；抑郁狀態(tài)患者中NERD組27例(84.4%)，RE組19例(95.0%)，抑郁量表評分兩組比較，差異無統(tǒng)計學意義(P>0.05)；焦慮狀態(tài)患者中NERD組32例(100%)，以女性為主(84.4%)，RE組 20例(100%)，女性7例(35.0%)，焦慮量表評分兩組比較，差異有統(tǒng)計學意義(P<0.05)；焦慮合并抑郁狀態(tài)患者中NERD組27例(84.4%)，RE組19例(95.0%)，兩組比較，差異無統(tǒng)計學意義(P>0.05)。結論GERD合并精神心理異常癥狀的患者中，NERD患者呈焦慮狀態(tài)比例較RE高，且女性患病率高。漢密爾頓焦慮、抑郁量表測評有助于GERD伴有精神心理異常癥狀患者心理干預和(或)藥物治療的選擇。

胃食管反流??；非糜爛性反流??；反流性食管炎；焦慮；抑郁

胃食管反流病(gastroesophageal reflux disease, GERD)包括非糜爛性反流病(non-erosive reflux disease, NERD)、反流性食管炎(reflux esophagitis, RE)和Barrett’s食管(Barrett’s esophagus, BE)，其發(fā)病機制有所不同。目前臨床專家普遍認為，GERD是指胃內容物反流入食管引起不適癥狀和(或)并發(fā)癥的一種疾病[1]。本研究擬通過比較NERD和RE患者精神心理評分狀況， 探討精神心理因素與NERD和RE發(fā)病的相關性，為NERD和RE的有效治療提供臨床循證醫(yī)學的證據。

1 資料與方法

1.1 一般資料選取2013年12月-2015年6月就診于首都醫(yī)科大學附屬北京地壇醫(yī)院消化科門診，以反酸、燒心、胸骨后疼痛為主要癥狀，伴有焦慮和(或)抑郁，經胃食管反流病問卷(Gred Q)調查[2]診斷為GERD的患者為研究對象，評分值10分作為GERD的診斷標準[6]。入選病例經檢查排除伴隨疾?。?1)肝、膽、胰、甲狀腺疾病；(2)消化性潰瘍、消化道惡性腫瘤；(3)肝硬化；(4)腹部重大手術；(5)糖尿??；(6)其他部位腫瘤；(7)心臟疾?。?8)2周內未使用過抗焦慮、抑郁藥物。

1.2 分組經胃鏡檢查將入選病例分為NERD組與GERD組，食管下段黏膜破損者為RE，黏膜正常者為NERD。胃鏡檢查由消化科醫(yī)師完成。應用漢密爾頓焦慮、抑郁量表采用他評方法問卷調查，焦慮評分>7分和抑郁評分>7分患者納入研究。漢密爾頓焦慮、抑郁量表問卷調查均由神經內科專職心理醫(yī)師完成。

1.3 漢密爾頓焦慮量表調查測評項目焦慮共14項，包括焦慮心境、緊張、害怕、失眠、認知功能、抑郁心境、軀體性焦慮感覺系統(tǒng)、軀體性焦慮肌肉系統(tǒng)、心血管系統(tǒng)癥狀、呼吸系統(tǒng)癥狀、胃腸道癥狀、生殖系統(tǒng)癥狀、植物神經系統(tǒng)癥狀、會談時行為表現。焦慮狀態(tài)判定標準：7分以下者為無，7～14分者為輕度，15～21分者為中度，22～29分者為重度，>29分者為嚴重。

1.4 漢密爾頓評抑郁量表調查測評項目共17項，包括抑郁情緒、有罪感、自殺、入睡困難、睡眠不深、早醒、工作和興趣、遲緩、激越、精神性焦慮、軀體性焦慮、胃腸道癥狀、全身癥狀、性癥狀、疑病、體質量減輕、自知力。抑郁狀態(tài)判定標準： 7分以下無，7～17分者為輕度，18～24分者為輕-中度，>24分者為重度。

2 結果

2.1 患者人口學資料GERD伴焦慮及/或抑郁患者52例。其中NERD患者32例、RE患者20例?；颊叩哪挲g、病程、文化程度及Gred Q評分等兩組比較，差異無統(tǒng)計學意義(P>0.05)，性別差異有統(tǒng)計學意義(P<0.05，見表1)。

表1 兩組患者一般資料比較

Tab 1 Comparison of base data between two groups

組別例數性別[n(%)]男女年齡(x±s,歲)病程(x±s,年)文化程度中學及以下大專及以上GredQ評分(x±s)NERD組325(15.6)*27(84.4)*45.2±6.11.8±0.124811.8±1.1RE組2013(65.0)7(35.0)47.6±5.72.0±0.416412.5±1.7

注：與RE組比較，*P<0.05。

2.2 NERD 和RE患者焦慮狀態(tài)合并焦慮狀態(tài)的患者中NERD組32例(100%)，以女性為主(84.4%)，RE組 20例(100%)，女性7例(35.0%)，焦慮量表評分兩組比較，差異有統(tǒng)計學意義(P<0.05，見表2)。

表2 兩組患者焦慮狀態(tài)分布的比較 [例數(%)]

Tab 2 Comparison of anxiety state distribution between two groups [n(%)]

組別例數7～14分男女15～21分男女>21分男女NERD組322(6.2)13(40.6)3(9.4)8(25.0)06(18.8)RE組2012(60.0)4(20.0)1(5.0)3(15.0)00

注：NERD組與RE組患者比較，P=0.005；NERD組與RE組的男女比例比較，P=0.001。

2.3 NERD 和RE患者抑郁狀態(tài)抑郁狀態(tài)者中NERD組27例(84.4%)，RE組19例(95.0%)，抑郁量表評分兩組比較,差異無統(tǒng)計學意義(見表3)。焦慮合并抑郁狀態(tài)者中NERD組27例(84.4%)，RE組19例(95.0%)，兩組比較,差異無統(tǒng)計學意義(見表4)。

表3 兩組患者抑郁狀態(tài)分布的比較[例數(%)]

Tab 3 Comparison of the distribution of depression between two groups [n(%)]

分組例數<7分男女7～17分男女18～24分男女NERD組3205(15.6)5(15.6)17(53.1)05(15.6)RE組2001(5.0) 12(60.0)5(25.0)1(5.0)1(5.0)

注：NERD組與RE組抑郁評分比較，P=0.703；NERD組與RE組的男女比例比較，P=0.003。

表4 兩組患者焦慮合并抑郁狀態(tài)比較 [例數(%)]

Tab 4 Comparison of anxiety combined with depression between two groups [n(%)]

組別例數男女合計NERD組275(18.5)22(81.5)27(84.4)RE組1913(68.4)6(31.6)19(95.0)

注：NERD組與RE組患者焦慮合并抑郁發(fā)生率比較，P=0.243；NERD組與RE組患者焦慮合并抑郁男女比例，P=0.001。

3 討論

GERD包括RE、NERD及Barrett’s食管。目前多數學者傾向RE、NERD及Barrett’s食管屬三種獨立的疾病，但其各自的發(fā)病機制及三者之間的關系，目前仍不明確。RE與NERD患者常合并精神心理異常，近年來引起國內外學者關注[3]。臨床發(fā)現，RE、NERD患者中有部分存在焦慮、抑郁等心理異常，且NERD患者對抑酸劑治療效果較差[4]。本研究顯示，NERD組患者中女性比例顯著高于RE組，與近期報道結果類似[5]。NERD女性患者焦慮狀態(tài)、抑郁狀態(tài)、焦慮合并抑郁狀態(tài)發(fā)生率顯著高于RE組。NERD組焦慮狀態(tài)程度顯著高于RE組， 提示NERD患者較RE有更明顯的焦慮傾向，更易合并焦慮狀態(tài)。NERD患者焦慮狀態(tài)與反酸、燒心、胸骨后疼痛等癥狀關系密切，焦慮狀態(tài)與反酸、燒心、胸骨后疼痛癥狀間可能存在因果關系。目前已證實，各種應激、精神心理異常等因素均與燒心癥狀密切相關。有研究顯示，心理異常和神經質是NERD的危險因素，但不能預測內鏡下食管黏膜損傷[6]。

精神心理異常與NERD相互影響，反流癥狀困擾產生焦慮和或抑郁情緒，精神心理異常，可能引發(fā)或加重反流癥狀，精神心理異常在其發(fā)病機制中起一定作用。已有研究證實，精神心理因素通過腦-腸軸引起食管內臟高敏感性，導致食管內微小刺激就會誘發(fā)燒心、反酸等癥狀，表現為患者對常規(guī)抑酸藥治療反應差[7-8]。本研究顯示，NERD和RE患者的精神心理異常表現程度有一定差異，焦慮癥狀在NERD患者中更為突出，但限于樣本量較小，有待更大樣本進一步觀察。本研究病例經抑酸劑、黏膜保護劑、安慰劑、心理疏導、抗焦慮、抑郁藥物等治療效果較好。因此，建議對RE和NERD患者應注意其是否合并有精神心理異常，對合并精神心理異常者應予個體化治療，必要時給予心理治療和(或)抗焦慮、抑郁藥物治療，以改善患者癥狀。

[1]Vakil N, van Zanten SV, Kahrilas P, et al. The Montreal definition and classification of gastroesophageal reflux disease：a global evidence-based consensus [J]. Am J Gastroenterol, 2006, 10l (8): 1900-1920．

[2]Dent J, Jones R, Vakil N, et al. A management strategy for GERD based on the gastroesophageal reflux disease questionnaire (GerdQ) [J]. Gut, 2007, 56(43): 34-35．

[3]張艷麗, 孫曉紅, 陳春曉, 等. 反流性食管炎和非糜爛性反流病患者癥狀譜、生活質量和精神心理狀態(tài)調查[J]. 胃腸病學, 2008, 13(2): 82-86. Zhang YL, Sun XH, Chen CX, et al. Clinical survey of symptom spectrum, quality of life and psychological status in patients with reflux disease [J]. Chin J Gastroenterol, 2008, 13(2): 82-86.

[4]Kimura Y, Kamiya T, Senoo K, et al. Persistent reflux symptoms cause anxiety, depression, and mental health and sleep disorders in gastroesophageal reflux disease patients [J]. J Clin Biochem Nutr, 2016, 59(1): 71-77.

[5]Lee SW, Chang CS, Lien HC, et al. Impact of overlapping functional gastrointestinal disorders on the presentation and quality of life of patients with erosive esophagitis and nonerosive reflux disease [J]. Med Princ Pract, 2015, 24(5): 491-495.

[6]Lee YC, Wang HP, Chiu HM, et al. Comparative analysisbetween psychological and endoscopic profiles in patientswith gastroesophageal reflux disease: a prospective studybased on screening endoscopy [J]．J Gastroentcrol Hepatol, 2006, 21(5): 798-804．

[7]Fass R, Tougas G. Functional heartbum：the stimulus, the pain, and the brain [J]. Gut, 2002, 51(6): 885-892．

[8]GerdQ研究協(xié)作組. 胃食管反流病問卷對胃食管反流病的診斷價值[J]. 中華消化雜志, 2009, 29(12): 793-798. GerdQ Research Collaboration. Evaluation of gastroesophageal reflux disease questionnaire in diagnosis of gastroesophageal reflux disease [J]. Chin J Dig, 2009, 29 (12): 793-798.

(責任編輯：陳香宇)

Initial clinical evaluation of the states of anxiety and depression in gastroesophageal reflux disease patients

LIU Junping1, QI Yanyun2, WEI Hongshan1

1.Department of Gastroenterology; 2.Department of Neurology, Beijing Ditan Hospital Affiliated to Capital Medical University, Beijing 100015, China

Objective To compare abnormal psychological symptoms among non-erosive reflux disease (NERD) and reflux esophagitis (RE) patients in gastroesophageal reflux disease (GERD), and to provide the evidence for the effective treatment. Methods Acid reflux, heartburn, retrosternal pain as chief complaint, while patients with anxiety and (or) depression symptoms, the gastroesophageal reflux disease questionnaire (Gred Q) survey identified GERD were chosen as the research object. Gastroscopy indicated that the patients whose lower esophageal mucosa being damaged were enrolled as RE.The rest were enrolled the NERD. Both of two groups were adopted depression scale questionnaire and Hamilton anxiety. Results Depression and/or anxiety were found in total of 52 GERD patients, including 32 NERD patients and 20 RE patients. There were no significant differences in age， course of disease, culture degree and the Gred Q score, etc between two groups (P>0.05). There were 27 NERD patients with depression (84.4%) and the same condition in RE were 19 patients (95.0%). Symptom scores had no significant difference between the two groups (P>0.05). There were 32 cases in NERD patients with anxiety (100%), female cases were 27, which occupied for 84.4% of total. There were 20 RE patients with anxiety (100%), female were 7 patients (35.0%). Symptom scores was significantly different between two groups (P<0.05); the NERD patients with depression and anxiety was in 27 patients (84.4%) and the same conditions was seen in RE patients (95.0%), and there was no significant difference between two groups (P>0.05). Conclusion In the patients who suffer from GRED and psychological anomaly, NERD patients show more anxiety than RE patients, and the female patients have high prevalence rate. The methods of Hamilton anxiety and depression scale assessment are helpful to GERD patients with mental abnormality providing information for medication.

Gastroesophageal reflux disease; Non erosive reflux disease; Reflux esophagitis; Anxiety; Depression

10.3969/j.issn.1006-5709.2017.02.012

劉均平，副主任醫(yī)師，副教授。研究方向：胃食管反流病的防治研究。E-mail：dtljp171@126.com

魏紅山，主任醫(yī)師，教授，博士生導師，研究方向：肝癌預警及早期診斷標志物研究。 E-mail：drwei@ccmu.edu.cn

R57

A 文章編號：1006-5709(2017)02-0161-03

2016-09-04