【讨论】内镜反转看到食管裂孔增大您怎么考虑？
常常会遇到这样的情况反转看胃底时，见到食管裂孔明显增大
在这种情况下会有几种可能
1.食管常常也有病变
比如反流性食管炎、胃底粘膜恶心时疝入食管、
贲门生理性狭窄及弯曲变小、齿状线距离门齿距离缩短等
我们会想到食管裂孔疝的诊断
（这里插一问题：内镜下您诊断过食管裂孔疝吗？依据为何？）
2.食管粘膜光滑，齿状线清晰，离门齿距离正常
单单就是见到裂孔增大
在以前俺可没注意过他，放过了
最近读到文章说食管裂孔增大和反流性食管炎有很好相关性
也听说有人诊断为：食管裂孔功能障碍
这种情况您是怎样考虑的？
裂孔增大到多少应考虑为异常呢？
比如：“黏液湖少量，稍浑浊，胃底粘膜光滑，食管裂孔增大约为2倍镜身大小”
（内镜直径为0.9cm)
其余的内镜表现无特殊，您会怎样诊断?
望大家多交流：）
转自丁香园
内镜下我们诊断过食管食管裂孔疝，分为滑动性食管裂孔疝和食管旁裂孔疝。
1 滑动性食管裂孔疝 内镜下主要识别鳞－柱接合部（齿状线）的位置
在平静呼吸时，如位于膈压迹上大于2cm，即可诊断。表现为膈压迹以上和鳞－拄接合部以下的囊样区。辅助钡餐透视胃粘膜位于膈压迹以上。
请注意与Barrett食管相鉴别，后者典型表现：食管近端粘膜正常（粉红色），齿状线位于食管上或中1/3，其下是化生的橘红色黏膜
2 食管旁裂孔疝 向上疝入胸腔的胃囊且位于食管旁测。食管内容物不能进入疝的最上部
Sorry,尚未见以裂孔的大小作为诊断标准，但的确存在其增大，可进行内镜下描述。
就知道这么多，个人体会，不知有无帮助。
如有进一步资料，我们在探讨。 我认为食管裂孔疝以钡餐造影诊断为主，内镜下观察食管裂孔大小由于受充气量多少及操作手法影响，诊断起来并不可靠。食管旁裂孔疝更是如此。 完全同意sdtzzhouyi 高见：
我认为食管裂孔疝以钡餐造影诊断为主，内镜下观察食管裂孔大小由于受充气量多少及操作手法影响，诊断起来并不可靠。食管旁裂孔疝更是如此。
食管裂孔疝是部分胃通过膈肌的食管裂孔向胸腔疝出。在内镜视野中很难明确膈肌的确切位置，因此对于诊断裂孔疝意义不大，明确诊断还须钡餐检查。仅代表个人浅见！请斧正！ 食管裂孔疝分三型：滑动性疝、食管旁疝和混合性疝
当然X线诊断目前仍是为金标准：注意检查时要做头低体位造影
但在国外用内镜诊断裂孔疝已成为内镜检查常规
国内也有相关文献的报道：
附件中为《中华内科学》的一片研究报告
内镜能比较准确的进行诊断应为无疑
我们做胃镜时脑子里要没这个醒
漏诊是有可能的
标题中所讲食管裂孔增大只是一个现象
并非表以此诊断食管裂孔疝之意
我听科里一个医生说在协和进修时见柯教授对于"单纯裂孔增大”下过食管裂孔功能障碍的诊断，只是听说，不知有没有知情者，还望指教 或跃在渊 ，你好！
我试着回答你的几个问题，大家共同探讨一下
1内镜下您诊断过食管裂孔疝吗？依据为何？应该讲现在内镜与钡餐一样可以诊断食管裂孔疝，而且有时较钡餐更准确，我们在工作中就遇到不少滑动性食管裂孔疝，依据；齿状线上移（一般小于38cm）。胃底倒镜有时在退镜到食管看的更清楚在食管裂孔与齿状线间可见有疝囊状改变（是诊断滑动性食管裂孔疝必备的重要条件，一般长度大于2cm），反转看胃底，见胃底His角变钝，食管裂孔明显增大，胃底变浅粘液湖前移，胃底粘膜皱壁逆行脱入食管可复位。其中最重要的是见疝囊状改变，食管旁疝是指胃底通过裂空疝入胸腔而食管胃连接处即我们平常所讲的贲门尚在隔裂孔之下，我还没有在实际工作中见过但在网上看到过典型的图片。
2.食管粘膜光滑，齿状线清晰，离门齿距离正常，单单就是见到裂孔增大，这种情况您是怎样考虑的？裂孔增大到多少应考虑为异常呢？在实际临床工作中单单就是见到裂孔增大我们遇见不少，是不是食管裂孔增大和反流性食管炎有很好相关性我们也没有做过相关研究，但在不少食管粘膜光滑正常的情况下可见裂孔增大，而且在胃镜退入食管下段仍可见其开放不闭合，是否与镜检时充入气体过多有关？我们还没有仔细观测。但我个人 并不认同将其归于食管裂孔功能障碍，所谓功能障碍必定伴有其动力或压力的异常，应归于贲门失弛缓症或食管下段括约肌松驰而这与反流性食管炎密切相关，同时好像也没有食管裂孔功能障碍这一临床诊断名称。裂孔增大到多少应考虑为异常呢？我想还是应结合其他内镜影像以排除裂空疝或是否出现食管下段反流性食管炎为佳。
3比如：“黏液湖少量，稍浑浊，胃底粘膜光滑，食管裂孔增大约为2倍镜身大小”（内镜直径为0.9cm)，其余的内镜表现无特殊，您会怎样诊断? 如果有上述内镜影像，我会重点观测是否有齿状线上移，是否有食管裂孔与齿状线间可见有疝囊状改变，以排除滑动性食管裂孔疝，重点观测食管下段是否有纵性红斑糜烂，以排除反流性食管炎，如无上述改变，我会在报告单中仔细描述，并结合患者是否有烧心，反酸，反食等症状建议患者行24h 食管PH值监测，以观测是否有过多酸反流情况。
上述言语仅为个人观点，与大家共同探讨。 yl720917君，食管裂孔功能障碍（gastroesophageal junction incompetence ）的概念是有的。此外，我亦同意对EGD对HH的诊断价值的看法。
需强调的是，在确诊HH的患者中，并非都合并RE，在RE患者中亦非均有HH。因此显然RE并非诊断HH的条件，RE也不必然合并HH。
以下关于HH的内镜下诊断来自
Gastrointestinal Endoscopy, 2nd edition,
1999, W. B. Saunders Company.
Endoscopic Diagnosis of Hiatus Hernia
The first step in endoscopic diagnosis of hiatus hernia is recognition of the important intraluminal landmarks used in defining this entity. Despite argument over the criteria for endoscopic diagnosis, a consensus exists concerning the major diagnostic points.
Under normal circumstances, the SCJ has been observed to migrate during swallowing and with respiration by as much as 2 cm above the diaphragmatic hiatus. Dagradi et al.,5,10 Trujillo et al.,6,7 and others agree that displacement of the SCJ more than 2 cm proximal to the diaphragmatic hiatus is abnormal. This opinion correlates well with the modern radiographic criteria for hiatus hernia as reported by Wolf.3 In patients with hiatus hernia, the diaphragmatic hiatus and cardia are often rather patulous, and the lumen opens with minimal insufflation. In many instances, this area is so widely patent that it can be seen from the proximal esophagus. The anatomic and radiologic correlation of findings at the gastroesophageal junction are demonstrated diagrammatically in Figure 44?A and B, respectively.
After the SCJ is identified, the maneuvers previously described to localize the diaphragmatic hiatus should be used. With minimal degrees of herniation, displacement of the SCJ proximal to the diaphragmatic hiatus by more than 2 cm is the primary endoscopic criterion for diagnosis of a hiatus hernia (Figure 44?). A hernia pouch is not identifiable when this minimum criterion is applied, but in a moderately sized or large hiatus hernia, the gastric mucosal folds can be seen running proximally over the hiatus margin into the bulbous cavity of the distended hernia pouch. When the patient inspires, the diaphragmatic margin moves downward to give the appearance of gastric mucosa gliding upward over this margin into the chest. If the patient sniffs, there is an abrupt, short, downward motion of the diaphragm, producing the appearance of gastric mucosa gliding over the hiatus margin into the chest.
After observing the diaphragmatic hiatus from above, the endoscope should be passed into the proximal stomach and retroverted. In most instances of hiatus hernia, the initial view from this vantage reveals a widened diaphragmatic hiatus with gastric mucosa lying loosely over the hiatus margin and gastric folds running upward into the hiatus hernia pouch (Figure 44?; see also Figure 44?). If the patient is asked to sniff or take a deep breath, the diaphragmatic margin descends as the stomach glides in a proximal direction over its edge. Several gastric folds usually can be seen running along the herniated pouch's greater curvature or posterior wall aspects to terminate just distal to the SCJ. These folds normally terminate within 5 to 10 mm of the normal location of the SCJ. This termination point can be utilized endoscopically and radiographically as a marker for the approximate location of the normal SCJ. The cephalad margin of the longitudinal gastric folds in the hernia pouch correspond to the level of the gastroesophageal muscular junction as well.
In some patients with a hiatus hernia and normal lower esophageal sphincter tone, the esophageal wall in the region of the esophageal sphincter is closed snugly around the endoscope (Figures 44? and 44?0). Some relaxation may occur with primary and secondary peristalsis or after greater degrees of air insufflation (Figure 44?1). In patients with reflux esophagitis, especially those with a columnar-lined esophagus who tend to have the lowest sphincter pressures, considerable free space exists around the endoscope in the region of the lower esophageal sphincter, just proximal to the hernia pouch.
When viewing the region of the SCJ from below in a patient with normal sphincter pressure, closure of the proximal end of the lower esophageal sphincter can be observed. The point of maximum closure is 1 to 2 cm above the SCJ (see Figure 44?). This level of closure corresponds with the so-called esophageal A ring or sphincter contraction ring in location and contour, as seen during radiography and endoscopy (see Figure 44?B).
With a hiatus hernia of moderate or larger size, the retroverted endoscope can be pulled back to the level of the diaphragmatic hiatus or even a short distance into the hernia pouch, affording a close-up view of the hernia pouch and the SCJ from below.
It is important to observe carefully and record the characteristics of the distal esophagus and proximal stomach in patients with hiatus hernia who have no gastroesophageal reflux sequelae. The location of the diaphragmatic hiatus in relation to the proximal stomach, the level of the SCJ, and the proximal extent of the gastric mucosal folds in the hernia pouch are characteristics used in the precise endoscopic diagnosis of hiatus hernia and reflux sequelae, including the earliest stages of a columnar-lined esophagus(Barrett's esophagus). The levels of these landmarks should be recorded on every esophagoscopy report.
In evaluating patients with a known or suspected hiatus hernia, it is appropriate to use more than minimal air insufflation. The radiologist makes use of changes in patient position and increased amounts of barium to demonstrate the same anatomy. Because patients with hiatus hernia tend to belch frequently, a considerable amount of insufflated air may be required to adequately demonstrate the landmarks discussed. Sliding esophageal hiatus hernias are common, particularly in older patients. Nevertheless, it is important to attempt to demonstrate this entity by radiography or endoscopy or both in all patients, especially those with upper gastrointestinal or pulmonary symptoms. If the endoscopic criteria are used with the radiographic criteria of Wolf,3 it is not difficult to recognize a sliding hiatus hernia. It is the clinician's responsibility to determine whether this finding in the individual patient is significant. If neither the radiologist nor the endoscopist diligently reports this entity, the patient's physician may not suspect a reflux-related etiology for atypical or obscure complaints. The important relationship between the anatomic defect of a hiatus hernia and gastroesophageal junction incompetence is being documented and better understood by sophisticated physiologic studies.11
The endoscopic appearance of the esophagus and proximal stomach after antireflux surgery is discussed in Chapter 52: Endoscopy in the Postoperative Upper Gastrointestinal Tract. polanyi ，你好！
你说的在确诊HH的患者中，并非都合并RE，在RE患者中亦非均有HH。因此显然RE并非诊断HH的条件，RE也不必然合并HH。我非常认同。
但你在6搂所讲的 “倘若EGD时反转观察贲门看到食管裂孔持续开放，如前面站友说的超过2个镜身，则食管裂孔功能障碍是可以成立的”，你说的理由讲 “因为正常情况下即使是内镜充气使胃扩张，诱发的食管裂孔开放也是一过性的，而不会持续开放。这是由食管裂孔本身的生理功能决定的”。 也就是说如果贲门看到食管裂孔持续开放应该是不正常的，
实际上从国内外的内镜下解剖上讲，现在多提倡“食管胃连接部（EGJ）”与食管胃粘膜交界处（SCJ）即我们常讲的齿状线，EGJ为一肌性结构，而SCJ为一粘膜结构，SCJ位于隔食管裂孔处或其略下，我们平常所讲的食管下括约肌是指内镜下所见食管下段呈菊花状皱壁收缩处至SCJ，而隔食管裂孔处结构是由于隔肌右脚与其周围的结啼组织将食管固定在隔肌上以防制其移动，当随着年纪的增大与组织的松驰，就会形成隔食管裂孔增大导至内镜下见所谓食管裂孔持续开放，我们在实际临床工作中内镜下也常常可以见到有不少老年患者出现所谓食管裂孔持续开放，也有少数年轻患者中出现，而且不少患者内镜下食管下段并没有明显异常也没有食管裂孔疝，我的确没有在教科书或文献上见到所谓食管裂孔功能障碍这一临床诊断名称（当然也可能是我看书不够），而所谓功能障碍必定应该也伴有其动力或压力的异常。单单以超过2个镜身，则食管裂孔功能障碍就可以成立好像也过于简单，同时其概念也于与我们常讲的食管下括约肌松驰有重叠，不利于我们区分，
以上接polanyi的话讲，与同道商榷。 yl720917 wrote:
polanyi ，你好！
实际上从国内外的内镜下解剖上讲，现在多提倡“食管胃连接部（EGJ）”与食管胃粘膜交界处（SCJ）即我们常讲的齿状线，EGJ为一肌性结构，而SCJ为一粘膜结构，SCJ位于隔食管裂孔处或其略下，我们平常所讲的食管下括约肌是指内镜下所见食管下段呈菊花状皱壁收缩处至SCJ，而隔食管裂孔处结构是由于隔肌右脚与其周围的结啼组织将食管固定在隔肌上以防制其移动，当随着年纪的增大与组织的松驰，就会形成隔食管裂孔增大导至内镜下见所谓食管裂孔持续开放，
我们在实际临床工作中内镜下也常常可以见到有不少老年患者出现所谓食管裂孔持续开放，也有少数年轻患者中出现，而且不少患者内镜下食管下段并没有明显异常也没有食管裂孔疝，
我的确没有在教科书或文献上见到所谓食管裂孔功能障碍这一临床诊断名称（当然也可能是我看书不够），
而所谓功能障碍必定应该也伴有其动力或压力的异常。单单以超过2个镜身，则食管裂孔功能障碍就可以成立好像也过于简单
yl720917君，关于SCJ的概念，与您有不同看法。SCJ（z line）并非在“食管裂孔处或其略下”。z line是移动的，当你在内镜下少量注气使括约肌高压带松弛，可清楚地看到z line随着呼吸在食管裂孔及其上2cm内的范围移动。如我前面转载的gastrointestinal endoscopy 2nd ed. 所述，正常情况下，SCJ移动范围在食管裂孔上2cm的距离以内。（见附图）
关于EGJ的概念也有不同看法。EGJ是一个complex。其中，下段食管平滑肌构成intrinsic sphincter、膈脚平滑肌和骨骼肌混合构成extrinc sphincter。这两个“内在”和“外在”括约肌是组成EGJ的两个最重要的解剖结构。（这个概念在九十年代后期就已确立，可参看一篇review，在Surg Clin North Am 2000;80(1):241-60）。
在食管测压时，可以看到，以食管裂孔作为分隔胸腔和腹腔的标志，EGJ的高压带实际上包括胸腔内（胸段）和腹腔内（腹段）两个部分。
镜下注气时，胃内压增加，通过神经反射，EGJ一过性开放，气体排出，随后EGJ恢复高压，食管裂孔闭合。在测压曲线上表现为一过性下食管括约肌松弛（17s(12.5-22.6)，不超过40s, 见 Holloway RH, Penagini R, Ireland AC. Criteria for objective definition of transient lower esophageal sphincter relaxation. Am J Physiol 1995;268:G128–33.），这是正常的。但如果镜下注气后看到食管裂孔持续开放，则可判定为病理性的，是EGJ功能不全的结果。故食管裂孔功能障碍是可以成立的。
至于年龄和食管裂孔功能障碍的关系，也许是可能的，不过需有研究支持。但这里要强调，食管裂孔功能障碍，乃至HH，并不必定合并RE。因此，没有RE，并不等于没有食管裂孔功能障碍或HH。
至于食管裂孔开放时的测压表现，是很容易通过测压观察到的（参看： GASTROENTEROLOGY 2000;118:688–695）。
关于食管裂孔功能障碍的概念。下面这个研究有详细叙述，不妨一看。
Sloan S, Rademaker AE, Kahrilas PJ. Determinants of gastro-esophageal junction incompetence: Hiatal hernia, lower esoph-ageal sphincter, or both?. Ann Intern Med 1992;117:977
最后，推荐一篇关于EGJ开放的近期文献，供参考。
=======================================================
Esophagogastric Junction Opening During Relaxation
Distinguishes Nonhernia Reflux Patients, Hernia Patients,
and Normal Subjects
GASTROENTEROLOGY 2003;125:1018–1024
Background & Aims: Flowacross the esophagogastric
junction (EGJ) is strongly related to opening dimensions.
This study aimed to determine whether opening of the
relaxed EGJ was altered in patients with gastroesophageal
reflux disease (GERD). Methods: Seven normal subjects
(NL), 9 GERD patients without hiatus hernia (NHH),
and 7 with hiatus hernia (HH) were studied. Cross-sectional
area (CSA) of the relaxed EGJ was measured
during low-pressure distention using a modified barostat
technique that resulted in filling a compliant bag straddling
the EGJ with renograffin to the set pressure. Swallows
were imaged fluoroscopically at distensive pressures
of 2–12 mm Hg. The diameter of the narrowest
point of the EGJ in PA and lateral projections was measured
from digitized images. CSA was determined as a
function of intrabag pressure. Results: The minimal EGJ
opening aperture occurred at the diaphragmatic hiatus
in all subjects. At pressures <0 mm Hg, EGJ opening
was observed only in HH patients, making it plausible for
these patients to reflux during deglutitive relaxation. At
pressures >0 mm Hg, there were significant increases
in EGJ CSA both for HH and NHH compared with NL (P <
0.001) and for HH compared with NHH (P < 0.005). This
difference may explain the diminished air/water discrimination
seen during transient lower esophageal
sphincter (LES) relaxation–associated reflux in GERD
patients. Conclusions: Anatomic degradation of the EGJ
distinguishes GERD patients from normal subjects, and
these changes may impact on both the observed mechanisms
of reflux and the constituents of reflux during
transient LES relaxation. Therapy focused on EGJ compliance
may benefit GERD patients. polanyi ,你好！
在这首先要谢谢你，而且我很佩服你高深的理论知识与外语水平！因为在上述理论方面国内很少文献涉及。许多人对此不是很了解，也使我收获不少！
上述我所讲的多引用gastrointestinal endosc杂志1999年的一篇综述（很遗憾现在手头没有原文，具体那期不能详细写出），你说－－“SCJ（z line）并非在“食管裂孔处或其略下”－－，正如你讲z line是移动的，但在内镜下充气后食管扩张，z line随即可以向头侧即近侧端移动约1－2cm，如你上转的图片所示。重要的是在未充气的情况下，SCJ（z line）未移位时是在食管裂孔平面或其略下，正常情况下，SCJ移动范围在食管裂孔上下而不是单单在其上2cm的距离以内（参考gastrointestinal endosc杂志1999年一篇综述）。
EGJ是一个complex，是不错。在最新一期中华消化内镜杂志（2004，12（1））报道了最新的WHO关于消化道肿瘤的分类，将 EGJ部肿瘤单独列出。其范围包括自近端胃皱壁末端至下食管括约肌近端，而食管下括约肌是指内镜下所见食管下段呈菊花状皱壁收缩处至SCJ处，其近端即呈菊花状皱壁收缩处，我们在内镜工作中也可以发现当退镜到食管下段后，可以清楚看到真正强力收缩的是在SCJ（z line）上2cm左右，当其收缩后扩张就可以看到其收缩处与SCJ（z line）有几厘米间距，而这强力收缩处即为下食管括约肌高压带，食管裂孔处隔肌右脚与其周围的结啼组织将食管固定在隔肌上以防制其移动形成低压带（参考gastrointestinal endosc杂志1999年）。假如存在滑动性食管裂孔疝那么有时更可以通过胃底倒镜看到远端是开大的裂孔处，而近端就是紧抱内镜的下食管括约肌高压带，其下低压带被充气扩张。在裂孔处下尚有几厘米腹段食管，裂孔处的结构就是防制其上下移动以及一定的压力作用。
随着年纪的增大与组织的松驰，就会不可避免形成隔食管裂孔增大导至内镜下见所谓食管裂孔持续开放，有文献报道在老年中食管裂孔疝达50％左右（我个人也感觉可能高了），但这可以说明一点即组织的松驰不可避免出现食管裂孔的增大，以至于可能难于闭合，如你所讲－－“出现食管裂孔开放测压时，是很容易通过测压观察到的”－－的确压力有可能低下，甚至24h 食管PH值监测出现酸过多现象都有可能。但由此你讲的－－“如果镜下注气后看到食管裂孔持续开放，则可判定为病理性的，是EGJ功能不全的结果，故食管裂孔功能障碍是可以成立的”－－我不敢苟同，个人感觉即使成立也应该考虑老年患者生理改变的情况。
你建议的Ann Intern Med 1992;117:977关于食管裂孔功能障碍的概念的文章有机会我会好好学习一下。
再次与polanyi主任商榷，希望多加指正，谢谢！ 1.yl720917和polanyi关于SCJ和EGJ的概念实际上是一致的，只是动态变化导致的表象差别。下面提供俩篇文献：
Gut. 1999 Apr;44(4):476-82.
The effect of hiatus hernia on gastro-oesophageal junction pressure.
BACKGROUND: Hiatus hernia and lower oesophageal sphincter hypotension are often viewed as opposing hypotheses for gastro-oesophageal junction incompetence. AIMS: To examine the interaction between hiatus hernia and lower oesophageal sphincter hypotension. METHODS: In seven normal subjects and seven patients with hiatus hernia, the squamocolumnar junction and intragastric margin of the gastro-oesophageal junction were marked with endoscopically placed clips. Axial and radial characteristics of the gastro-oesophageal junction high pressure zone were mapped relative to the hiatus and clips during concurrent fluoroscopy and manometry. Responses to inspiration and abdominal compression were also analysed. RESULTS: In normal individuals the squamocolumnar junction was 0.5 cm below the hiatus and the gastro-oesophageal junction high pressure zone extended 1.1 cm distal to that. In those with hiatus hernia, the gastro-oesophageal junction high pressure zone had two discrete segments, one proximal to the squamocolumnar junction and one distal, attributable to the extrinsic compression within the hiatal canal. Inspiration and abdominal compression mainly augmented the distal one. Simulation of hernia reduction by algebraically summing the proximal segment pressures with the hiatal canal pressures restored normal maximal pressure, radial asymmetry, and dynamic responses of the gastro-oesophageal junction. CONCLUSIONS: Hiatus hernia reduces lower oesophageal sphincter pressure and alters its dynamic responsiveness by spatially separating pressure components derived from the intrinsic lower oesophageal sphincter and the extrinsic compression of the oesophagus within the hiatal canal.
Nippon Geka Gakkai Zasshi. 1998 Sep;99(9):547-51.
[Pathology of the cardia]
[Article in Japanese]
Defining the cardia as consisting of 2 cm of the distal esophagus and 2 cm of the proximal stomach, we describe the detailed histopathological features of the cardia and esophagogastric junction (EGJ). The distance between the EGJ and the squamocolumnar junction (SCJ) was 0-10 mm (mean: 3 mm) in 50 Japanese autopsy cases, but the SCJ was not located below the EGJ. It has been reported that pancreatic metaplasia, small leiomyomas, inflammatory EGJ polyps, carditis, and Barrett's epithelium are often recognizable in the cardia, and the literature on these conditions is reviewed. The relationship between leiomyomas and gastrointestinal stromal tumors is also reviewed, and the histopathology of short-segment Barrett's esophagus is described. In biopsy specimens obtained from Barrett's esophagus, the presence of ducts of esophageal glands proper in the metaplastic mucosa as revealed by microscopy can be used to establish the diagnosis, although only in a short-segment of Barrett's esophagus less than 3 cm in length. Finally, several English and Japanese textbooks on the pathology of the digestive tract containing descriptions of normal and diseased cardia are described for the convenience of authors writing scientific papers on diseases of the cardia.
2.关于食管裂孔功能障碍（gastroesophageal junction incompetence ）这个概念也提供一篇再早些的文献。个人认为这个概念如不牵涉到NERD，目前少具临床意义
Z Gastroenterol. 1988 Apr;26(4):209-16.
[Peptone stimulation of the lower esophageal sphincter in patients with reflux disease]
[Article in German]
Twenty patients with gastroesophageal reflux disease (10 with compensated and 10 with decompensated gastroesophageal incompetence) were examined to determine if there was a correlation between the ability of physiological stimuli to tonicize the lower esophageal sphincter (LES) and the response to pentagastrin stimulation (Gastrodiagnost). The pressure of the lower esophageal sphincter as well as blood levels of the hormones/neurotransmitters gastrin, PP and VIP were determined after giving a 300 ml intragastral bolus of either 0.9% NaCl or 20% peptone solution. All patients exhibited per definitionem a positive common-cavity phenomenon on abdominal compression. Intravenous pentagastrin stimulated the LES in patients with compensated gastroesophageal incompetence (GI) but not in those with decompensated GI (p less than or equal to 0.0005). Esophagoscopy revealed a severe esophagitis in 80% of the patients with decompensated GI but in only 10% of the patients with compensated GI. Peptone stimulated the LES in patients with compensated GI (p less than or equal to 0.005) at 5, 10 and 15 minutes, pepton vs. NaCl). Neither NaCl nor peptone increased the tone of the LES in patients with decompensated GI. Peptone but not NaCl caused a significant increase of serum gastrin in all patients: there was no difference between the two groups. Neither NaCl nor peptone influenced VIP levels in peripheral blood. PP levels increased significantly in both groups following peptone. Physiological responsiveness of the LES can be inferred from the manometric data and the results of the pentagastrin test. A negative reaction to pentagastrin is associated with a loss of response to physiological stimuli.
3.老年生理是否是病理那就是另外的话题了。
4.再讨论或许又要牵涉到贲门是否先天存在的问题上了。 谢谢yl720917对SCJ位置的指正。确如所言，SCJ不仅在食管裂孔以上范围移动，其随呼吸或腹内压的改变在食管裂孔上下的一定范围内移动。
食管下段穿过食管裂孔进入腹腔，为食管腹内段，而EGJ的下缘超过Z line，止于Z line 的远端(His angle)。
(图)Esophageal anatomy and relationships with adjacent organs. Distances in centimeters are the average for an adult as measured from the incisor teeth with a flexible endoscope. LES: lower esophageal sphincter. (Gastrointestinal Endoscopy, 2nd edition, 1999, W. B. Saunders Company.)
[img]http://images.e2002.com//images/3i221326.jpg[/img] [img]http://images.e2002.com//images/ljC21341.jpg[/img] EGJ的内括约肌和外括约肌。
[img]http://images.e2002.com//images/ZI621364.jpg[/img] EGJ测压的三维图像（显示内括约肌和外括约肌成分）：
[img]http://images.e2002.com//images/5n921384.jpg[/img] 可分为三型。就 滑脱型（短食管型）说一下轻度表现为齿状线上移2-3cm。有1/3合并食管炎，食管黏膜白色浑浊，粗糙。属于色调变化型。中度齿状线上移4cm，60%合并食管炎或溃疡形成。重度齿状线上移6cm伴反流性食管炎3-4级有溃疡形成。反转内镜见贲门开大，胃黏膜集中像。食管裂孔功能障碍和林三仁教授所著（消化系统疾病电子内镜图谱）中贲门功能低下是否一致，内镜表现是一样的。怎么理解？ 最近做的胃镜，我下了滑动性食管裂孔疝的诊断。可惜没留下正面的照片，随后的钡餐也证实。
[img]http://images.e2002.com//images/lho21429.jpg[/img]
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