臺灣博碩士論文加值系統

依據2006年Montreal會議對於胃食道逆流疾病之定義(Gastroesophageal reflux disease,GERD)，是指病患因胃內容物不正常逆流至食道所形成之不舒服感覺。主要症狀，以心灼熱感和胃酸逆流來表現。一般而言，西方國家的盛行率比東方國家高，但在台灣胃食道逆流疾病的人數與比率有逐年增加之趨勢，不但對病患造成生活的困擾、影響生活品質、減低工作生產力，更會造成醫療資源的過度使用及浪費。
胃食道逆流疾病之診斷主要是以病患症狀表現為主，在國外有諸多研究有效地證實運用問卷可診斷及評估胃食道逆流的嚴重程度，不同國家或地區也發展出不同的問卷。診斷胃食道逆流疾病後，質子幫浦抑制劑是標準的治療藥物。反觀國內，根據中央健康保險局條文的給付規範，質子幫浦抑制劑的給付是以上消化道內視鏡檢查結果為準則，然而內視鏡為侵襲性診斷的工具，病患會在檢查的過程中有不同程度的不適感，時常導致病患精神及體力的消耗。
國內外有許多關於胃食道逆流問卷方面的研究，有的研究使用較為繁複的問卷進行分析，有的研究使用內容較為簡單的問卷進行分析，不同的問卷呈現不同的結果與結論。
本研究使用中文化RDQ(Reflux disease questionnaire)問卷和GerdQ(Gatroesophageal reflux disease questionnaire)問卷來進行比較，於台灣中部一所醫學中心消化系內科門診進行收案。從西元2009年4月至2010年3月，總計一年的時間中，2306例患者於門診經消化系內科專科醫師依症狀診斷為胃食道逆流疾病，給予兩份問卷讓病患填寫，大部份病患選擇接受上消化道內視鏡檢查，由消化系內科專科醫師逐一回溯性檢視其內視鏡檢查之影像檔案，透過收案標準及排除標準之篩選，總計有1018位病患納入本研究之統計與分析。
本研究收案之1018位病患中，總共有915位病患經由上消化道內視鏡檢查確定診斷為胃食道逆流疾病，佔本研究總人數之89.9 %；而消化性潰瘍患者總計有103位，佔本研究總人數之10.1 %。於本研究中，RDQ問卷量表之效度和信度皆優於GerdQ問卷量表。RDQ問卷量表對於鑑別診斷胃食道逆流疾病、鑑別診斷輕微或嚴重之糜爛性食道炎，其特異性和敏感性皆優於GerdQ問卷量表。另外，在這兩份問卷中，非糜爛性逆流疾病(Non-erosive reflux disease，NERD)患者之分數並非為最低分的組別，其分數皆介於輕微與嚴重的糜爛性食道炎之間，而平均分數略高於輕微的糜爛性食道炎；顯示有部份非糜爛性逆流疾病患者，儘管在上消化道內視鏡檢查下無黏膜缺損之食道炎證據，其症狀表現依然造成很大之困擾，而反映於問卷。
將704位糜爛性食道炎病患之基本資料分成輕微與嚴重兩組，經由單變項分析方式，得到抽菸、喝酒、喝咖啡、胃食道辦閥(Gastroesophageal flap valve，GEFV)嚴重度、橫膈膜裂孔疝氣(Hiatal hernia，HH)、體重、身體質量指數(Body mass index，BMI)、RDQ問卷分數(以本研究分析取得之22.5分為切點)皆達到統計學上之意義，P值小於0.05。顯示上述各項目的嚴重程度，對應糜爛性食道炎之嚴重程度，具有顯著之臨床意義。再由多變項分析發現，橫膈膜裂孔疝氣(HH)、胃食道辦閥(GEFV)嚴重度、RDQ問卷分數(以22.5分為切點)等總共三項達到P<0.05之數值，具有明顯的臨床意義。
結論：於本研究中，中文化RDQ問卷之效度和信度皆優於GerdQ問卷，運用中文化RDQ問卷相對於GerdQ問卷來診斷國人胃食道逆流疾病具有較高的敏感性和精確性，中文化RDQ問卷對於鑑別診斷糜爛性食道炎之嚴重度亦優於GerdQ。消化系內科專科醫師對於胃食道逆流疾病之高診斷率，以及兩份問卷內容不同的設計項目，應是造成這些結果的因素。另外，此為回溯性研究之設計，未來應有大型的前瞻性研究來做更深入之探討，以獲得更明確之結論。

According to Montreal definition, gastroesophageal reflux disease (GERD) is defined as patients with abnormal reflux of gastric contents to their esophagus. The most common symptoms are heart burn and acid regurgitation. Although such symptoms are relatively more popular in western countries, there is a rising trend in Taiwan. These symptoms not only bother our people, impair their quality of life and work, but also hugely waste our medical resources.
The diagnosis of GERD is based on patient''s symptoms. GERD is a patient-centered disease. In European and America area etc, many studies are validated the role of different questionnaires to diagnose or evaluate GERD. However, the study and clinical use of questionnaire of GERD is relative lack in our country. According to our National Health Insurance, the standard paid of proton pump inhibitor (PPI) to treat GERD is based on the finding of mucosal injury of esophagus by esophagogastroduodenoscopy (EGD). Indeed, endoscopy is still an invasive diagnostic procedure. Patients in the process of EGD may result in some discomfort, depletion of mental and physical condition.
There are many literatures about questionnaires of GERD. Some studies use complex-item questionnaire, while others use relatively simple-item questionnaires. Different questionnaires show different results and conclusions.
In our research, we compare the Chinese version of RDQ (Reflux disease questionnaire) with GerdQ (Gastroesophageal reflux disease questionnaire). This study was proceeded in the clinic of gastroenterology in a medical center in central Taiwan. From April 2009 to March 2010, a total of 2306 patients were diagnosed GERD by gastroenterologists through our clinic. Partial patient underwent EGD, and we retrospectively reviewed their images of EGD in detail. Then, according to inclusion and exclusion criteria, totally 1018 patients were included to this study.
Among the 1018 patients, totally 915 (89.9%) were diagnosed GERD by EGD. Other 103 (10.1%) patients were diagnosed peptic ulcer disease (PUD). In our study, the validity and reliability of RDQ are better than GerdQ. To diagnose GERD and differentiate mild to severe erosive esophagitis (EE), RDQ are also better than GerdQ. Besides, the scores of non-erosive reflux disease (NERD)are not the lowest group. The average score of NERD is between mild to severe EE. It is a little higher than mild EE. It shows that some people without the evidence of mucosa break in EGD also present troublesome and intolerable symptoms.
We divided 704 EE patients to two groups as mild versus severe EE group. Patients with male gender, obesity, consumption of tobacco, alcohol and tea, presence of hiatal hernia (HH), severe gastroesophageal flap valve (grade III+IV GEFV), and higher RDQ scores were more significant to be severe EE than mild. While multivariable analysis, HH, severe GEFV, and higher RDQ scores achieve significance (P<0.05).
In conclusion, RDQ is better than GerdQ in clinical use of GERD in our study. The higher percentage of the diagnosis rate by our gastroenterologist and different design of the two questionnaires would be the principal reasons. Besides, this retrospective study contains its defect such as selection bias or recall bias etc. Larger and prospective study in the future would be need to confirm the role of these questionnaires of GERD.

致謝 ………………………………………………………… i
中文摘要 ………………………………………………………… ii
英文摘要 ………………………………………………………… v
目錄 ………………………………………………………… viii
表格索引 ………………………………………………………… x
圖目索引 ………………………………………………………… xi
第一章 緒論 ………………………………………………… 1
第一節 本研究之背景…………………………………………… 1
第二節 本研究之目的和動機 …………………………………… 2
第二章 文獻之探討 ……………………………………………… 3
第一節 胃食道逆流疾病 …………………………………… 3
2.1.1. 胃食道逆流疾病 ………………………………… 3
2.1.2. 胃食道逆流疾病之定義……………………………… 3
2.1.3. 胃食道逆流疾病的流行病學及盛行率………………… 3
2.1.4. 胃食道逆流之成因及機轉 ……………………… 5
2.1.5 胃食道逆流疾病常見的症狀及導致之合併症 ……… 6
2.1.6. 胃食道逆流疾病危險因子………………………… 7
2.1.7. 胃食道逆流疾病之分類……………………………… 8
第二節 胃食道逆流的問卷 …………………………………… 9
2.2.1. 關於胃食道逆流的問卷 ………………………………… 9
2.2.2. GerdQ問卷量表發展 …………………………………… 10
第三章 研究方法和步驟 …………………………………… 12
第一節 收案之對象 ……………………………………………… 12
第二節 研究之設計 ……………………………………………… 12
第三節 研究之工具 ……………………………………………… 13
3.3.1. 個人基本資料和生活習慣 ……………………… 13
3.3.2. GerdQ問卷量表 ……………………………………… 14
3.3.3. RDQ問卷量表 …………………………… 14
3.3.4. 上消化道之內視鏡 …………………………………… 15
3.3.5. 資料處理與分析方法 ……………………………… 16
第四章 研究之結果 ……………………………………………… 18
第一節 回溯統計一年度胃食道逆流疾病的盛行率 ……………… 18
第二節 分析RDQ和GerdQ問卷與胃食道逆流性疾病關係 …… 18
第三節 RDQ問卷GerdQ問卷之信度和效度分析 …… 20
第四節 ROC curve曲線下之面積 …………………… 24
第五節 RDQ問卷分數越高與上消化道內視鏡檢查比較 …… 25
第六節 RDQ問卷分數越高與上消化道內視鏡比較 …… 27
第五章 討論 ……………………………………………………… 29
第六章 結論 ……………………………………………………… 34
參考文獻 …………………………………………………………… 36
圖與表 …………………………………………………………… 43
附錄 …………………………………………………………… 61

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