Gastroesophageal disease. Gerb symptoms, diagnosis and treatment

Gastroesophageal reflux- a disease in which there is a reverse movement of the contents of the stomach, through the lower esophageal sphincter, into the esophagus.

Incorrect names: esophageal reflux, gastroesophageal reflux, gastroesophageal reflux. Sometimes, based on English-speaking traditions, gastroesophageal reflux is called gastroesophageal reflux disease (GERD).

According to the results of special studies, signs of gastroesophageal reflux are detected in 20-40% of the inhabitants of developed countries (according to some reports, in almost half of the adult population).

Daily signs of gastroesophageal reflux disease experience up to 10% of the population, weekly - 30%, monthly - 50% of the adult population.

Causes of reflux

A decrease in the tone of the lower esophageal sphincter occurs due to:

External stimuli

• the use of drinks containing caffeine (coffee, strong tea, Coca-Cola);
• taking medications, such as: calcium antagonists - verapamil, antispasmodics - papaverine, nitrates, analgesics, theophylline, etc .;
• smoking (toxic effect of nicotine on muscle tone);
• alcohol consumption (in this case, damage to the mucous membrane of the esophagus occurs);
• pregnancy (hypotension of the lower esophageal sphincter is due to the influence of hormonal factors).

Internal stimuli

• Increased intra-abdominal pressure. Occurs with obesity, ascites, bloating (flatulence), pregnancy.
• Diaphragmatic hernia. This creates conditions for reflux - there is a decrease in pressure on the lower part of the esophagus in the chest. A hernia of the esophageal opening of the diaphragm occurs in approximately 1/2 of people over 50 years of age.
• Hasty and plentiful consumption of food, during which a large amount of air is swallowed, which leads to an increase in intragastric pressure, and the reflux of stomach contents into the esophagus.
• Peptic ulcer of the duodenum.
• Excess consumption of foods rich in animal fats, foods containing peppermint, fried foods, spicy spices, carbonated mineral water. All these products lead to a long delay of food masses in the stomach, an increase in intragastric pressure.

Symptoms of gastroesophageal reflux

Manifestations of gastroesophageal reflux are characterized by a variety of signs that can be observed in isolation and in combinations.

The most characteristic manifestations include:

• heartburn;
• regurgitation;
• pain behind the sternum and in the left half of the chest;
• painful swallowing;
• prolonged cough, hoarseness of voice;
• destruction of tooth enamel

Unfortunately, the severity of clinical manifestations does not fully reflect the severity of reflux. In more than 85% of cases, episodes of a decrease in intraesophageal acidity below 4 are not accompanied by any sensations.

Diet for gastroesophageal reflux

Proper nutrition with gastroesophageal reflux is an important part in the treatment of this disease, because frequent heartburn occurs in case of malnutrition, especially at night, and in the event that a person is convinced that his pain in the sternum is not caused by heart disease, then measures must be taken to elimination of gastroesophageal reflux.

It should also be borne in mind that the development of gastroesophageal reflux disease is primarily affected by malnutrition, when a person eats too much fatty, fried and smoked food, also when he drinks a lot of coffee, eats spicy food, abuses alcoholic beverages, smokes.

In addition, gastroesophageal reflux can develop with obesity, pregnancy, with frequent torso bending, especially after eating, and this disease can also appear during stress and heavy physical exertion.

Treatment of gastroesophageal reflux

Treatment begins with general rules for all patients suffering from this disease.

Firstly, it is recommended to eat small portions, but more often. This will prevent the overflow of the stomach, and its contents will be more quickly excreted into the duodenum. The fact is that a full stomach stimulates the formation of more gastric juice.

Secondly, do not lie down in a horizontal position after eating. The contents of the stomach increase pressure on the sphincter, which leaves it open. Therefore, during the day you should not go to bed, but dinner should take place at least 2 hours before bedtime. You should sleep on a high pillow, and you should not sleep on your stomach. Even during sleep, you need to betray the body to a semi-sitting position, as pressure shifts from the sphincter to the abdominal cavity. Also, you can not wear clothes that are tight at the waist, again due to increased pressure in the abdominal cavity.

Non-drug therapeutic measures

• normalization of body weight, compliance with the diet (in small portions every 3-4 hours, eating no later than 3 hours before bedtime), avoidance of foods that help relax the esophageal sphincter (fatty food, chocolate, spices, coffee, oranges, tomato juice, onion, mint, alcoholic drinks), increasing the amount of animal protein in the diet, avoiding hot food and alcohol;
• tight clothing that pinches the body should be avoided;
• recommended to sleep on a bed with a headboard raised by 15 centimeters;
• to give up smoking;
• it is necessary to avoid prolonged work in an inclined state, heavy physical exertion;
• drugs that negatively affect esophageal motility (nitrates, anticholinergics, beta-blockers, progesterone, antidepressants, calcium channel blockers), as well as non-steroidal anti-inflammatory drugs that are toxic to the esophageal mucosa, are contraindicated.

Medical treatment

Drug treatment of gastroesophageal reflux disease is carried out by a gastroenterologist. Therapy takes from 5 to 8 weeks (sometimes the course of treatment reaches a duration of up to 26 weeks), is carried out using the following groups of drugs: antacids (maalox, rennie, phosphalugel, almagel, gastal), H2-histamine blockers (ranitidine, famotidine), inhibitors of proton pumps (omeprazole, rebeprazole, esomeprazole).

In cases where conservative therapy for GERD does not work (about 5-10% of cases), or with the development of complications or diaphragmatic hernia, surgical treatment is performed.

Surgical intervention

• endoscopic plication of the gastroesophageal junction (sutures are placed on the cardia),
• radiofrequency ablation of the esophagus (damage to the muscular layer of the cardia and gastroesophageal junction, in order to scar and reduce reflux),
• gastrocardiopexy and laparoscopic Nissen fundoplication.

This is an inflammation of the walls of the lower esophagus that occurs as a result of regular reflux (reverse movement) of gastric or duodenal contents into the esophagus. Manifested by heartburn, belching with a sour or bitter taste, pain and difficulty in swallowing food, dyspepsia, chest pain and other symptoms that worsen after eating and physical exertion. Diagnosis includes FGDS, intraesophageal pH-metry, manometry, radiography of the esophagus and stomach. Treatment involves non-drug measures, the appointment of symptomatic therapy. In some cases, surgical interventions are recommended.

General information

Gastroesophageal reflux disease (GERD) - morphological changes and symptom complex that develop as a result of the reflux of the contents of the stomach and duodenum into the esophagus. It is one of the most common pathologies of the digestive system, with a tendency to develop numerous complications. The high prevalence, severe clinic, which significantly worsens the quality of life of patients, the tendency to develop life-threatening complications, and the frequent atypical clinical course make GERD one of the most urgent problems of modern gastroenterology. The constant increase in the incidence requires a thorough study of the mechanisms of GERD development, improvement of early diagnosis methods and the development of effective pathogenetic treatment measures.

Subjectively, reflux is felt as the occurrence of heartburn - a burning sensation behind the sternum - and belching. If heartburn occurs regularly (more than 2 times a week), it is suggestive of GERD and requires a medical examination. Chronic reflux that occurs for a long time leads to chronic esophagitis, and later a change in the morphological structure of the mucosa of the lower esophagus and the formation of Barrett's esophagus.

Causes of GERD

Factors contributing to the development of pathology are violations of the motor functions of the upper digestive tract, hyperacidotic conditions, reduced protective function of the mucous membrane of the esophagus. Most often, in GERD, there is a violation of two natural mechanisms for protecting the esophagus from the aggressive environment of the stomach: esophageal clearance (the ability of the esophagus to evacuate the contents into the stomach) and resistance of the mucosal wall of the esophagus. The likelihood of developing the disease is increased by stress, smoking, obesity, frequent pregnancies, diaphragmatic hernia, medications (beta-blockers, calcium channel blockers, anticholinergics, nitrates).

Pathogenesis

The main factor in the development of gastroesophageal reflux disease is insufficiency of the lower esophageal sphincter. In healthy people, this muscular circular formation in the normal state keeps the opening between the esophagus and stomach closed and prevents the reverse movement of the food bolus (reflux). In case of insufficiency of the sphincter, the opening is open and when the stomach contracts, its contents are thrown back into the esophagus. Aggressive gastric environment causes irritation of the walls of the esophagus and pathological disorders in the mucosa up to its deep ulceration. In healthy people, reflux can occur when bending over, exercising, or at night.

Symptoms of GERD

A typical clinical picture of the disease is characterized by heartburn, which is aggravated by bending over, physical exertion, after heavy meals and in the supine position, belching with a sour or bitter taste. May be accompanied by nausea and vomiting. Depending on the severity of the course, dysphagia is noted - a swallowing disorder, which can be primary (as a result of impaired motor skills) or be a consequence of the development of strictures (narrowings) of the esophagus.

GERD often occurs with atypical clinical manifestations: chest pain (usually after eating, aggravated by bending over), heaviness in the abdomen after eating, hypersalivation (excessive salivation) during sleep, bad breath, hoarseness. Indirect signs indicating a possible pathology are frequent pneumonia and bronchospasm, idiopathic pulmonary fibrosis, a tendency to laryngitis and otitis media, damage to tooth enamel. Of particular danger in terms of the development of severe complications is GERD, which occurs without severe symptoms.

Complications

The most common (in 30-45% of cases) complication of GERD is the development of reflux esophagitis - inflammation of the mucous membrane of the lower esophagus, resulting from regular irritation of the walls by gastric contents. In the event of ulcerative-erosive lesions of the mucosa and their subsequent healing, the remaining scars can lead to strictures - narrowing of the lumen of the esophagus. Reduced patency of the esophagus is manifested by developing dysphagia, combined with heartburn and belching.

Prolonged inflammation of the esophageal wall can lead to the formation of an ulcer - a defect that damages the wall up to the submucosal layers. An esophageal ulcer often contributes to bleeding. Long-term gastroesophageal reflux and chronic esophagitis provoke the epithelium normal for the lower esophagus to gastric or intestinal. This degeneration is called Barrett's disease. This is a precancerous condition, which in 2-5% of patients transforms into adenocarcinoma (cancer of the esophagus) - a malignant epithelial tumor.

Diagnostics

The main diagnostic method for detecting GERD and determining the severity and morphological changes in the wall of the esophagus is esophagogastroduodenoscopy. It is carried out after consultation with an endoscopist. During this study, a biopsy sample is also taken to study the histological picture of the condition of the mucosa and diagnose Barrett's esophagus.

For early detection of mucosal changes in the type of Barrett's disease, all patients suffering from chronic heartburn are recommended endoscopic examination (gastroscopy) with a biopsy of the esophageal mucosa. Often, patients report coughing, hoarseness. In such cases, it is necessary to consult an otolaryngologist to identify inflammation of the larynx and pharynx. If the cause of laryngitis and pharyngitis is reflux, antacids are prescribed. After that, the signs of inflammation subside.

Treatment for GERD

Non-drug therapeutic measures for gastroesophageal disease include the normalization of body weight, adherence to a diet (in small portions every 3-4 hours, eating no later than 3 hours before bedtime), avoiding foods that help relax the esophageal sphincter (fatty food, chocolate, spices, coffee, oranges, tomato juice, onions, mint, alcoholic drinks), increasing the amount of animal protein in the diet, avoiding hot food and alcohol. Tight clothing that constricts the body should be avoided.

It is recommended to sleep on a bed with a headboard raised by 15 centimeters, smoking cessation. It is necessary to avoid prolonged work in an inclined state, heavy physical exertion. Drugs that negatively affect esophageal motility (nitrates, anticholinergics, beta-blockers, progesterone, antidepressants, calcium channel blockers), as well as non-steroidal anti-inflammatory drugs that are toxic to the mucous membrane of the organ, are contraindicated.

Drug treatment of gastroesophageal reflux disease is carried out by a gastroenterologist. Therapy takes from 5 to 8 weeks (sometimes the course of treatment reaches a duration of up to 26 weeks), is carried out using the following groups of drugs: antacids (aluminum phosphate, aluminum hydroxide, magnesium carbonate, magnesium oxide), H2-histamine blockers (ranitidine, famotidine), proton pump inhibitors (omeprazole, rebeprazole, esomeprazole).

In cases where conservative therapy for GERD does not work (about 5-10% of cases), with the development of complications or diaphragmatic hernia, surgical treatment is performed. The following surgical interventions are used: endoscopic plication of the gastroesophageal junction (sutures are placed on the cardia), radiofrequency ablation of the esophagus (damage to the muscular layer of the cardia and gastroesophageal junction, in order to scar and reduce reflux), gastrocardiopexy and laparoscopic Nissen fundoplication.

Forecast and prevention

Prevention of the development of GERD is the maintenance of a healthy lifestyle with the exclusion of risk factors that contribute to the onset of the disease (smoking cessation, alcohol abuse, fatty and spicy foods, overeating, weight lifting, prolonged inclination, etc.). Timely measures are recommended to identify violations of the motility of the upper digestive tract and treatment of diaphragmatic hernia.

With timely identification and adherence to lifestyle recommendations (non-drug measures for the treatment of GERD), the outcome is favorable. In the case of a prolonged, often recurrent course with regular refluxes, the development of complications, and the formation of Barrett's esophagus, the prognosis worsens markedly.

The term "gastroesophageal reflux" refers to the reverse movement of the contents of the stomach, through the lower esophageal sphincter, into the esophagus.

The acidity index of the contents of the stomach is normally 1.5-2.0 (low acidity is due to the secretion of hydrochloric acid). In contrast, the contents of the esophagus have acidity values ​​close to neutral (6.0-7.0).

With the development of gastroesophageal reflux, the acidity in the esophagus is significantly shifted towards low values ​​due to the ingress of acidic stomach contents. Prolonged contact of the mucous membrane of the esophagus with the acidic contents of the stomach, in addition, containing digestive enzymes, contributes to the development of its inflammation.

Bile acids, enzymes, bicarbonates, which are part of the contents of the duodenum, can also have a strong damaging effect on the esophageal mucosa. When these substances are thrown into the stomach, they may also move into the esophagus.

Gastroesophageal reflux is a normal physiological manifestation if it meets the following criteria:

• develops mainly after eating;
• not accompanied by discomfort;
• the duration of refluxes and their frequency during the day is small;
• at night, the frequency of reflux is small.

Gastroesophageal reflux should be considered painful if it has the following characteristics:

• frequent and/or prolonged episodes of reflux;
• reflux episodes are recorded during the day and / or at night;
• the reflux of gastric contents into the esophagus is accompanied by the development of clinical symptoms, inflammation / damage to the mucosa of the esophagus.

The reasons

A number of factors contribute to the development of reflux of gastric contents into the esophagus. Among them:

• failure of the lower esophageal sphincter;
• transient episodes of relaxation of the lower esophageal sphincter;
• insufficiency of esophageal clearance;
• painful changes in the stomach, which increase the severity of physiological reflux.

The protective, "anti-reflux" function of the lower esophageal sphincter is ensured by maintaining the tone of its muscles, the sufficient length of the sphincter zone and the location of a part of the sphincter zone in the abdominal cavity. In a sufficiently large proportion of patients, a decrease in pressure in the lower esophageal sphincter is detected; in other cases, episodes of transient relaxation of his muscles are observed.

It has been established that hormonal factors play a role in maintaining the tone of the lower esophageal sphincter. A number of medications and some foods help reduce pressure in the lower esophageal sphincter and cause or maintain reflux.

The location of part of the sphincter zone in the abdominal cavity, below the diaphragm, serves as a wise adaptive mechanism to prevent the reflux of gastric contents into the esophagus at the height of inhalation, at a time when increasing intra-abdominal pressure contributes to this.

At the height of inhalation under normal conditions, the lower segment of the esophagus is “clamped” between the crura of the diaphragm. In cases of formation of a hernia of the esophageal opening of the diaphragm, the final segment of the esophagus is displaced above the diaphragm. "Clamping" of the upper part of the stomach by the legs of the diaphragm disrupts the evacuation of acidic contents from the esophagus.

Due to the contraction of the esophagus, the natural cleansing of the esophagus from acidic contents is maintained, and normally the intraesophageal acidity index does not exceed 4. The natural mechanisms by which cleansing is carried out are as follows:

• motor activity of the esophagus;
• salivation; bicarbonates contained in saliva neutralize the acid content.

Violations of these links contribute to a decrease in the "cleansing" of the esophagus from acidic or alkaline contents that have entered it.

Reflux Symptoms

Manifestations of gastroesophageal reflux are characterized by a variety of signs that can be observed in isolation and in combinations. According to the results of special studies, signs of gastroesophageal reflux are detected in 20-40% of the inhabitants of developed countries (according to some reports, in almost half of the adult population). Daily signs of gastroesophageal reflux disease experience up to 10% of the population, weekly - 30%, monthly - 50% of the adult population.

The most characteristic manifestations include:

• heartburn;
• regurgitation;
• pain behind the sternum and in the left half of the chest;
• painful swallowing;
• prolonged cough, hoarseness of voice;
• destruction of tooth enamel

Unfortunately, the severity of clinical manifestations does not fully reflect the severity of reflux. In more than 85% of cases, episodes of a decrease in intraesophageal acidity below 4 are not accompanied by any sensations.

Diagnostics

Evaluation of changes in the esophagus in gastroesophageal reflux disease through esophagoscopy with biopsy allows not only to assess the degree of damage to the esophagus, but also to make a differential diagnosis with esophagitis.

X-ray examination of the esophagus with barium reveals anatomical disorders of the esophagus and stomach, which contribute to the formation of gastroesophageal reflux (hiatal hernia).

24-hour monitoring of intraesophageal acidity plays an important role in confirming the presence of gastroesophageal reflux.

Treatment of gastroesophageal reflux

Therapeutic measures for gastroesophageal reflux disease should be aimed at reducing the severity of reflux, reducing the damaging properties of gastric contents, increasing esophageal cleansing, and protecting the esophageal mucosa.

It is important to follow general measures that help reduce the severity of reflux of gastric contents into the esophagus. These include:

• normalization of body weight (in overweight patients, this measure reduces the severity of the degree of insufficiency of the lower esophageal sphincter);
• avoiding smoking, reducing alcohol consumption, limiting the consumption of fatty foods, coffee, chocolate (these effects help reduce the tone of the lower esophageal sphincter, fatty foods slow down the activity of the stomach);
• the exclusion of acidic foods, which, as a rule, provokes the appearance of heartburn;
• eating in small portions, regularly;
• eating no later than 2 hours before bedtime;
• avoidance of stress associated with increased intra-abdominal pressure;
• sleep on a bed, the head end of which is raised by 10-15 cm.

About the diet for esophagitis

With the ineffectiveness of such measures, antacids are prescribed. Antacids are a group of drugs containing aluminum, magnesium, and calcium salts that neutralize hydrochloric acid. In addition, antacids are able to bind and reduce the activity of the digestive enzyme of gastric juice, bile acids and lysolecithin - which are part of bile and have a damaging effect on the mucous membrane of the stomach and esophagus.

It is preferable to take antacid preparations in the form of gels. In the lumen of the esophagus and stomach, the gels form small drops, which enhances their effect. Currently, Almagel, Phosphalugel, Maalox, Remagel are produced in the form of gels. These preparations contain aluminum salts, or salts of aluminum and magnesium in various proportions.

Antacids are taken 30 minutes before meals and at night (if possible, it is advisable to take the drug in the supine position, in small sips).

In the absence of the effect of taking antacids, as well as in the presence of endoscopic signs of esophagitis, it is necessary to prescribe prokinetics and / or antisecretory drugs.

As a prokinetic, patients with gastroesophageal reflux disease are shown to prescribe dopridone due to the presence of systemic side effects in metoclopramide. Domperidone is prescribed 10 mg 4 times a day.

If the patient has erosive esophagitis, additional administration of proton pump inhibitors (rabeprazole 20 mg at night, omeprazole 20 mg 2-3 times a day) is necessary.

The duration of treatment for erosive esophagitis should be at least 8 weeks; when healing erosions, it is necessary to carry out maintenance therapy with domperidone (20 mg / day), proton pump inhibitors (rabeprazole 10-20 mg / day, omeprazole 20 mg / day) or their combination.

Forecast

Complications of gastroesophageal reflux disease are observed in 10-15% of patients and determine the prognosis of the course of the disease. In severe reflux esophagitis, ulcers and narrowing of the esophagus, esophageal bleeding may develop.

Gastroesophageal reflux disease (GERD) is a chronic relapsing disease caused by spontaneous, regularly repeated reflux of gastric and/or duodenal contents into the esophagus. Duodenal contents - the contents of the lumen of the duodenum, consisting of digestive juices secreted by the mucous membrane of the duodenum and pancreas, as well as bile, mucus, impurities of gastric juice and saliva, digested food, etc.
leading to damage to the lower esophagus.
Often accompanied by the development of inflammation of the mucosa of the distal esophagus - reflux esophagitis, and (or) the formation of a peptic ulcer and peptic stricture of the esophagus Peptic stricture of the esophagus is a type of cicatricial narrowing of the esophagus that develops as a complication of severe reflux esophagitis as a result of the direct damaging effect of hydrochloric acid and bile on the esophageal mucosa.
, esophageal-gastric bleeding and other complications.

GERD is one of the most common diseases of the esophagus.

Classification

A. Distinguish two clinical variants of GERD:

1. Gastroesophageal reflux without signs of esophagitis. Nonerosive reflux disease (endoscopically negative reflux disease).
This clinical variant accounts for about 60-65% of cases ("Gastroesophageal reflux without esophagitis" - K21.9).

2. Gastroesophageal reflux, accompanied by endoscopic signs of reflux esophagitis. Reflux esophagitis (endoscopically positive reflux disease) occurs in 30-35% of cases (Gastroesophageal reflux with esophagitis - K21.0).

For reflux esophagitis, the recommended classification adopted at the 10th World Congress of Gastroenterology (Los Angeles, 1994):
- Grade A: One or more mucosal lesions (erosion or ulceration) less than 5 mm in length, limited to the mucosal fold.
- Degree B: One or more mucosal lesions (erosion or ulceration) greater than 5 mm in length, limited to the mucosal fold.
- Grade C: The mucosal lesion extends to two or more folds of the mucosa, but occupies less than 75% of the circumference of the esophagus.
- Grade D: The mucosal lesion extends to 75% or more of the circumference of the esophagus.

In the United States, the following classification, which is simpler for everyday use, is also common:
- Degree 0: There are no macroscopic changes in the esophagus; signs of GERD are detected only by histological examination.
- Degree 1: Above the esophageal-gastric junction, one or more delimited foci of inflammation of the mucous membrane with hyperemia or exudate are detected.
- Degree 2: Merging erosive and exudative foci of inflammation of the mucous membrane, not covering the entire circumference of the esophagus.
- Degree 3: Errosive-exudative inflammation of the esophagus along its entire circumference.
- Degree 4: Signs of chronic inflammation of the esophageal mucosa (peptic ulcers, esophageal strictures, Barrett's esophagus).

The severity of GERD does not always depend on the type of endoscopic picture.

B. Classification of GERD according to international evidence-based agreement(Montreal, 2005)

Etiology and pathogenesis

The following causes contribute to the development of gastroesophageal reflux disease:

I. Decreased tone of the lower esophageal sphincter (LES). There are three mechanisms for its occurrence:

1. Occurring from time to time NPS relaxation in the absence of anatomical abnormalities.

2. Sudden increased intra-abdominal and intragastric pressure above the pressure in the LPS area.
Causes and factors: concomitant PUD (gastric ulcer), PUD (duodenal ulcer), impaired motor functions of the stomach and duodenum, pylorospasm Pylorospasm is a spasm of the muscles of the pylorus of the stomach, causing the absence or difficulty in emptying the stomach.
, pyloric stenosis Pyloric stenosis - narrowing of the pylorus of the stomach, making it difficult to empty it
, flatulence, constipation, ascites Ascites - accumulation of transudate in the abdominal cavity
, pregnancy, wearing tight belts and corsets, excruciating cough, heavy lifting.

3. Significant decrease in the basal tone of the LES and equalization of pressures in the stomach and esophagus.
Causes and factors: hiatal hernia; operations for diaphragmatic hernias; resection Resection - a surgical operation to remove part of an organ or anatomical formation, usually with the connection of its preserved parts.
stomach; vagotomy Vagotomy - a surgical operation of crossing the vagus nerve or its individual branches; used to treat peptic ulcer
; long-term use of drugs: nitrates, β-blockers, anticholinergics, slow calcium channel blockers, theophylline; scleroderma Scleroderma is a skin lesion characterized by its diffuse or limited compaction, followed by the development of fibrosis and atrophy of the affected areas.
; obesity; exogenous intoxications (smoking, alcohol); congenital anatomical disorders in the LES area.

Also, reduction of additional mechanical support from the diaphragm (dilation of the esophagus) helps to reduce the basal tone of the LES.

II. Decreased ability of the esophagus to self-cleanse.
Prolongation of esophageal clearance (the time required to clear the esophagus of acid) leads to increased exposure to hydrochloric acid, pepsin and other aggressive factors, which increases the risk of esophagitis.

Esophageal clearance is determined by two protective mechanisms:
- normal peristalsis of the esophagus (liberation from the trapped aggressive environment);
- normal functioning of the salivary glands (dilution of the contents of the esophagus and neutralization of hydrochloric acid).

The damaging properties of the refluxant, that is, the contents of the stomach and / or duodenum, thrown into the esophagus:
- mucosal resistance (inability of the mucosa to resist the damaging effect of the refluxant);
- violation of gastric emptying;
- increased intra-abdominal pressure;
- drug damage to the esophagus.

There is evidence of induction of GERD (when taking theophylline or anticholinergic drugs).

Epidemiology

There is no exact information on the prevalence of GERD, which is associated with a large variability in clinical symptoms.
According to studies conducted in Europe and the United States, 20-25% of the population suffers from GERD symptoms, and 7% have symptoms on a daily basis.
25-40% of patients with GERD have esophagitis on endoscopic examinations, but most people with GERD have no endoscopic manifestations.
Symptoms appear equally in men and women.
The true prevalence of the disease is greater, since less than one third of patients with GERD consult a doctor.

Factors and risk groups

It should be remembered that the following factors and lifestyle features influence the development of gastroesophageal reflux disease:
- stress;
- work associated with the inclined position of the body;
- obesity;
- pregnancy;
- smoking;
- nutritional factors (fatty foods, chocolate, coffee, fruit juices, alcohol, spicy foods);
- taking drugs that increase the peripheral concentration of dopamine (phenamine, pervitin, other derivatives of phenylethylamine).

Clinical picture

Clinical Criteria for Diagnosis

Heartburn, belching, dysphagia, odynophagia, regurgitation, regurgitation, cough, hoarseness, kyphosis

Symptoms, course

The main clinical manifestations of GERD are heartburn, belching, regurgitation, dysphagia, and odynophagia.

Heartburn
Heartburn is the most characteristic symptom of GERD. Occurs in at least 75% of patients; its cause is prolonged contact with the acidic contents of the stomach (pH<4) со слизистой пищевода.
Heartburn is perceived as a burning sensation or sensation of heat in the xiphoid process, behind the sternum (usually in the lower third of the esophagus). Most often appears after eating (especially spicy, fatty foods, chocolate, alcohol, coffee, carbonated drinks). The occurrence is facilitated by physical activity, weight lifting, torso forward bending, horizontal position of the patient, as well as wearing tight belts and corsets.
Heartburn is usually treated with antacids.

Belching
Belching sour or bitter, occurs as a result of the entry of gastric and (or) duodenal contents into the esophagus, and then into the oral cavity.
As a rule, it occurs after eating, taking carbonated drinks, and also in a horizontal position. May be exacerbated by exercise after meals.

Dysphagia andodynophagy
They are observed less frequently, usually with a complicated course of GERD. Rapid progression of dysphagia and weight loss may indicate the development of adenocarcinoma. Dysphagia in patients with GERD often occurs when eating liquid food (paradoxical dysphagia Dysphagia is a general name for swallowing disorders
).
Odynophagia - pain that occurs when swallowing and passing food through the esophagus; usually localized behind the sternum or in the interscapular space, may radiate Irradiation - the spread of pain outside the affected area or organ.
in the shoulder blade, neck, lower jaw. Starting, for example, in the interscapular region, it spreads to the left and right along the intercostal space, and then appears behind the sternum (inverted dynamics of pain development). Pain often mimics angina pectoris. Esophageal pain is characterized by a connection with food intake, body position and their relief by the use of alkaline mineral waters and antacids.

Regurgitation(regurgitation, esophageal vomiting)
It occurs, as a rule, with congestive esophagitis, manifested by the passive flow of the contents of the esophagus into the oral cavity.
In severe cases of GERD, heartburn is accompanied by dysphagia. Dysphagia is a general name for swallowing disorders
, odynophagia, belching and regurgitation, and also (as a result of microaspiration of the airways by the contents of the esophagus) the development of aspiration pneumonia is possible. In addition, with inflammation of the mucosa with acidic contents, a vagal reflex may occur between the esophagus and other organs, which can manifest itself as chronic cough, dysphonia Dysphonia - a disorder of voice formation in which the voice is preserved, but becomes hoarse, weak, vibrating
, asthma attacks, pharyngitis Pharyngitis - inflammation of the mucous membrane and lymphoid tissue of the pharynx
, laryngitis Laryngitis - inflammation of the larynx
, sinusitis Sinusitis - inflammation of the mucous membrane of one or more paranasal sinuses
, coronary spasm.

Extraesophageal symptoms of GERD

1. Bronchopulmonary: cough, asthma attacks. Episodes of nocturnal suffocation or respiratory discomfort may indicate the occurrence of a special form of bronchial asthma pathogenetically associated with gastroesophageal reflux.

2. Otorhinolaryngological: hoarseness of voice, symptoms of pharyngitis.

3. Dental: caries, thinning and/or erosion of tooth enamel.

4. Severe kyphosis Kyphosis - curvature of the spine in the sagittal plane with the formation of a bulge facing backwards.
, especially if you need to wear a corset (often combined with hiatal hernia and GERD).

Diagnostics

Required Research

Single shot:

1.X-ray examination chest, esophagus, stomach.
It is necessary to detect signs of reflux esophagitis, other complications of GERD, accompanied by significant organic changes in the esophagus (peptic ulcer, stricture, hiatal hernia, and others).

2. Esophagoscopy(esophagogastroduodenoscopy, endoscopic examination).
It is necessary to identify the degree of development of reflux esophagitis; the presence of complications of GERD (peptic ulcer of the esophagus, stricture of the esophagus, Barrett's esophagus, Shatzky rings); exclusion of a tumor of the esophagus.

3.24-hour intraesophageal pH-metry(intraesophageal pH-metry).
One of the most informative methods for diagnosing GERD. Allows you to evaluate the dynamics of the pH level in the esophagus, the relationship with subjective symptoms (eating, horizontal position), the number and duration of episodes with pH below 4.0 (reflux episodes over 5 minutes), the ratio of reflux time (for GERD pH<4.0 более чем 5% в течение суток).

(Note: the normal pH of the esophagus is 7.0-8.0. When acidic gastric contents are thrown into the esophagus, the pH drops below 4.0)

4. Intraesophageal manometry(esophagomanometry).
Allows you to identify changes in the tone of the lower esophageal sphincter (LES), the motor function of the esophagus (peristalsis of the body, resting pressure and relaxation of the lower and upper esophageal sphincters).

Normally, the pressure of the LES is 10-30 mm Hg. Reflux esophagitis is characterized by a decrease to less than 10 M Hg.

It is also used for differential diagnosis with primary (achalasia) and secondary (scleroderma) lesions of the esophagus. Manometry helps to correctly position the probe for pH monitoring of the esophagus (5 cm above the proximal edge of the LES).
The most informative and physiological is the combination of 24-hour esophageal manometry with esophageal and gastric pH monitoring.

5.ultrasound abdominal organs to determine the concomitant pathology of the abdominal organs.

6. Electrocardiographic study, bicycle ergometry for the differential diagnosis with CAD. GERD does not show any changes. When extraesophageal syndromes are detected and when indications for surgical treatment of GERD are determined, consultations of specialists (cardiologist, pulmonologist, ENT, dentist, psychiatrist, etc.) are indicated.

Provocative Tests

1. Standard acid test for GERD.
The test is carried out by placing the pH electrode 5 cm above the upper edge of the LES. With the help of a catheter, 300 ml is injected into the stomach. 0.1 N HCl solution, after which the pH of the esophagus is monitored. The patient is asked to breathe deeply, cough, perform Valsalva and Müller maneuvers. Research is carried out by changing the position of the body (lying on the back, on the right, on the left side, lying with the head down).
Patients with GERD have a pH drop below 4.0. In patients with severe reflux and impaired esophageal motility, the decrease in pH persists for a long time.
The sensitivity of this test is 60%, the specificity is 98%.

2.Acid perfusion test Bernstein.
Used to indirectly determine the sensitivity of the esophageal mucosa to acid. A decrease in the threshold of acid sensitivity is typical for patients with GERD complicated by reflux esophagitis. Using a thin probe, a 0.1 N hydrochloric acid solution is injected into the esophagus at a rate of 6-8 ml per minute.
The test is considered positive and indicates the presence of esophagitis if, 10-20 minutes after the end of the HCl administration, the patient develops symptoms characteristic of GERD (heartburn, chest pain, etc.), which disappear after perfusion into the esophagus of isotonic sodium chloride solution or taking antacids.
The test is highly sensitive and specific (from 50 to 90%) and in the presence of esophagitis may be positive even with negative results of endoscopy and pH-metry.

3. Inflatable balloon test.
The inflatable balloon is placed 10 cm above the LES and gradually inflated with air, in 1 ml portions. The test is considered positive when the typical symptoms of GERD appear simultaneously with the gradual distension of the balloon. The tests induce spastic motor activity of the esophagus and reproduce chest pain.

4. Therapeutic test with one of the proton pump inhibitors in standard dosages, for 5-10 days.

Also, according to some sources, the following methods are used as diagnostics:
1. Scintigraphy of the esophagus - a method of functional imaging, which consists in introducing radioactive isotopes into the body and obtaining an image by determining the radiation emitted by them. Allows you to evaluate the esophageal clearance (time to clear the esophagus).

2. Impedancemetry of the esophagus - allows you to explore the normal and retrograde peristalsis of the esophagus and refluxes of various origins (acid, alkaline, gas).

3. According to indications - assessment of violations of the evacuation function of the stomach (electrogastrography and other methods).

Laboratory diagnostics

There are no laboratory signs pathognomic for GERD.

GERD and Helicobacter pylori infection
Currently, it is believed that H. pylori infection is not the cause of GERD, however, against the background of a significant and prolonged suppression of acid production, Helicobacter spreads from the antrum to the body of the stomach (translocation). In this case, it is possible to accelerate the loss of specialized glands of the stomach, which leads to the development of atrophic gastritis and, possibly, stomach cancer. In this regard, those patients with GERD who require long-term antisecretory therapy should be diagnosed with Helicobacter pylori, and eradication is indicated if an infection is detected.

Differential Diagnosis

In the presence of extraesophageal symptoms, GERD should be differentiated from coronary heart disease, bronchopulmonary pathology (bronchial asthma, etc.), esophageal cancer, gastric ulcer, diseases of the bile ducts, and esophageal motility disorders.

For a differential diagnosis with esophagitis of a different etiology (infectious, drug, chemical burns), endoscopy, histological examination of biopsy specimens and other research methods (manometry, impedancemetry, pH monitoring, etc.) are performed, as well as the diagnosis of alleged infectious pathogens by methods adopted for this.

Complications

One of the serious complications of GERD is Barrett's esophagus, which develops in patients with GERD and complicates the course of this disease in 10-20% of cases. The clinical significance of Barrett's esophagus is determined by the very high risk of developing adenocarcinoma of the esophagus. In this regard, Barrett's esophagus is classified as a precancerous condition.
GERD can be complicated by stridor breathing, fibrosing alveolitis, due to the frequent development of regurgitation Regurgitation is the movement of the contents of a hollow organ in the direction opposite to the physiological one as a result of contraction of its muscles.
after eating or during sleep and subsequent aspiration.

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Treatment

Non-drug treatment

Patients with GERD are advised to:
- weight loss;
- smoking cessation;
- refusal to wear tight belts, corsets;
- sleep with the head end of the bed raised;
- exclusion of excessive load on the abdominal press and work (exercises) associated with forward bending of the torso;
- refrain from taking drugs that contribute to the occurrence of reflux (sedatives and tranquilizers, calcium channel inhibitors, alpha or beta-blockers, theophylline, prostaglandins, nitrates).

Reducing or avoiding foods that weaken LES tone: spicy and fatty foods (including whole milk, cream, cakes, pastries, fatty fish, goose, duck, pork, lamb, fatty beef), coffee, strong tea, orange and tomato juice, carbonated drinks, alcohol, chocolate, onions, garlic, spices, food that is too hot or too cold.
- fractional meals in small portions and refusal to eat at least 3 hours before bedtime.

However, as a rule, the implementation of these recommendations is not enough for complete relief of symptoms and complete healing of erosions and ulcers of the esophageal mucosa.

Medical treatment

The goal of drug treatment is the rapid relief of the main symptoms, the healing of esophagitis, the prevention of relapses of the disease and its complications.

1. Antisecretory therapy
The goal is to reduce the damaging effect of acidic gastric contents on the esophageal mucosa. The drugs of choice are proton pump blockers (PPIs).
Assign once a day:
- omeprazole: 20 mg (in some cases up to 60 mg / day);
- or lansoprazole: 30 mg;
- or pantoprazole: 40 mg;
- or rabeprazole: 20 mg;
- or esomeprazole: 20 mg before breakfast.
Treatment is continued for 4-6 weeks with non-erosive reflux disease. In erosive forms of GERD, treatment is prescribed for a period of 4 weeks (single erosion) to 8 weeks (multiple erosions).
In case of insufficiently rapid dynamics of erosion healing or in the presence of extraesophageal manifestations of GERD, a double dose of proton pump blockers should be prescribed and the duration of treatment should be increased to 12 weeks or more.
The criterion for the effectiveness of therapy is the persistent elimination of symptoms.
Subsequent maintenance therapy is carried out in a standard or half dose on an "on demand" basis when symptoms appear (average 1 time in 3 days).

Notes.
Rabeprazole (pariet) has the most powerful and long-lasting antisecretory effect, which is currently considered the "gold standard" of drug treatment for GERD.
The use of histamine H2 receptor blockers as antisecretory drugs is possible, but their effect is lower than that of proton pump inhibitors. The combined use of proton pump blockers and histamine H2 receptor blockers is not advisable. Histamine receptor blockers are justified in PPI intolerance.

2. Antacids. Combination of PPIs with antacids is recommended at the beginning of GERD therapy until stable control of symptoms (heartburn and regurgitation) is achieved. Antacids can be used as a symptomatic remedy for infrequent heartburn, but preference should be given to taking proton pump inhibitors, incl. "on demand". Antacids are prescribed 3 times a day 40-60 minutes after meals, when heartburn and chest pain most often occur, as well as at night.

3. Prokinetics improve the function of the LES, stimulate gastric emptying, but are most effective only as part of combination therapy.
Preferably use:
- domperidone: 10 mg 3-4 times / day;
- metoclopramide 10 mg 3 times a day or at bedtime - less preferred, as it has more side effects;
- bethanechol 10-25 mg 4 times / day and cesapride 10-20 mg 3 times / day are also less preferred due to side effects, although they are used in some cases.

4. With reflux esophagitis caused by the reflux of duodenal contents (primarily bile acids) into the esophagus, a good effect is achieved by taking ursodeoxycholic acid at a dose of 250-350 mg per day. In this case, it is advisable to combine the drug with prokinetics in the usual dose.

Surgery
Indications for antireflux surgery for GERD:
- young age;
- absence of other severe chronic diseases;
- failure of adequate drug therapy or the need for lifelong PPI therapy;
- complications of GERD (esophageal stricture, bleeding);
- Barrett's esophagus with the presence of high-grade epithelial dysplasia - obligate precancer;
- GERD with extraesophageal manifestations (bronchial asthma, hoarseness, cough).

Contraindications for antireflux surgery for GERD:
- elderly age;
- the presence of severe chronic diseases;
- severe esophageal motility disorders.

An operation aimed at eliminating reflux is a fundoplication, including endoscopic.

The choice between conservative and operative tactics depends on the patient's state of health and his suggestions, the cost of treatment, the likelihood of complications, the experience and equipment of the clinic, and a number of other factors. Non-drug therapy is considered strictly mandatory for any treatment tactics. In routine practice, with moderate heartburn without signs of complications, complex and expensive methods are hardly justified and trial therapy with H2-blockers is sufficient. Some experts still recommend starting treatment with radical lifestyle changes and PPIs until endoscopic symptoms are relieved, then switching to H2-blockers with the consent of the patient.

Forecast

GERD is a chronic disease; 80% of patients relapse after discontinuation of drugs, so many patients require long-term drug treatment.
Non-erosive reflux disease and mild reflux esophagitis usually have a stable course and a favorable prognosis.
The disease does not affect life expectancy.

Patients with severe forms may develop complications such as esophageal stricture Esophageal stricture - narrowing, reduction of the lumen of the esophagus of various nature.
or Barrett's esophagus.
The prognosis worsens with a long duration of the disease, combined with frequent long-term relapses, with complicated forms of GERD, especially with the development of Barrett's esophagus due to an increased risk of developing adenocarcinoma Adenocarcinoma is a malignant tumor originating and built from glandular epithelium.
esophagus.

Hospitalization

Indications for hospitalization:
- with a complicated course of the disease;
- with the ineffectiveness of adequate drug therapy;
- carrying out endoscopic or surgical intervention in case of ineffectiveness of drug therapy, in the presence of complications of esophagitis (stricture of the esophagus, Barrett's esophagus, bleeding).

Prevention

The patient should be explained that GERD is a chronic disease, usually requiring long-term maintenance therapy.
It is advisable to follow the recommendations for lifestyle changes (see section "Treatment", paragraph "Non-drug treatment").
Patients should be informed about the possible complications of GERD and advised to consult a doctor if symptoms of the disease occur.

Information

Sources and literature

1. Ivashkin V.T., Lapina T.L. Gastroenterology. National leadership. Scientific and practical publication, 2008
   1. pp 404-411
2. McNally Peter R. Secrets of gastroenterology / translation from English. edited by prof. Aprosina Z.G., Binom, 2005
   1. page 52
3. Roitberg G.E., Strutynsky A.V. Internal illnesses. The digestive system. Study guide, 2nd edition, 2011
4. wikipedia.org (Wikipedia)
   1. http://ru.wikipedia.org/wiki/Gastroesophageal_reflux_disease
   2. Maev I. V., Vyuchnova E. S., Shchekina M. I. Gastroesophageal reflux disease M. Journal "Attending Doctor", No. 04, 2004 - -
   3. Rapoport S. I. Gastroesophageal reflux disease. (Manual for doctors). - M.: ID "MEDPRAKTIKA-M". - 2009 ISBN 978-5-98803-157-4 - page 12
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GERD (gastroesophageal reflux disease) is one of the most common chronic diseases of the upper digestive system due to gastroesophageal reflux. Reflux is the retrograde reflux of stomach and duodenal contents into the esophagus. Gastric juice, enzymes damage its mucous membrane, and sometimes overlying organs (trachea, bronchi, pharynx, larynx).

The causes of reflux can be very diverse. The most common causes of GERD are:

• decreased tone of the lower esophageal sphincter;
• increased pressure in the abdominal cavity (during pregnancy, obesity, ascites);
• diaphragmatic hernia;
• overeating or hasty eating, as a result of which a large amount of air is swallowed;
• eating foods that take longer to digest and, as a result, linger in the stomach.

Symptoms of GERD

1. - a burning sensation behind the sternum that appears 1-1.5 hours after eating or at night. Burning can rise to the epigastric region, give to the neck and to the interscapular region. Discomfort may increase after exercise, overeating, drinking carbonated drinks, strong coffee.
2. Belching is a phenomenon caused by the flow of stomach contents through the lower esophageal sphincter directly into the esophagus, and then into the oral cavity. As a result of belching, a sour taste appears in the mouth. Belching most often appears in a horizontal position, torso tilts.
3. Pain and feeling of difficulty in swallowing food. These symptoms often appear with the development of complications of the disease (narrowing or swelling of the esophagus) and are due to the presence of persistent inflammation in the damaged mucosa of the esophagus.
4. Esophageal vomiting is a sign of GERD, which also appears with the development of complications. Vomit is undigested food eaten shortly before the onset of vomiting.
5. Hiccups are a sign of a disease, the development of which is caused by irritation of the phrenic nerve, causing frequent contraction of the diaphragm.

GERD is characterized by an increase in the above-described esophageal symptoms in a horizontal position of the body, with forward bending and physical exertion. These manifestations can be reduced by taking alkaline mineral waters or milk.

In some patients, extraesophageal symptoms of the disease are also observed. Patients may experience pain behind the sternum, which can be regarded as signs of heart disease (acute coronary syndrome). When the contents of the stomach enter the larynx, especially at night, patients begin to be disturbed by a dry cough, sore throat, and hoarseness. Throwing of gastric contents into the trachea and bronchi may occur, resulting in the development of obstructive bronchitis and aspiration pneumonia.

Signs of gastroesophageal reflux can also be observed in absolutely healthy people, in this case, reflux does not cause the development of pathological changes in the mucous membrane of the esophagus and other organs. However, if the above symptoms occur more than 2 times a week for 2 months, you should consult a doctor for an examination.

Diagnosis of GERD

The doctor makes a preliminary diagnosis of GERD based on the patient's complaints. To clarify the diagnosis, the following studies are carried out:

1. Daily intraesophageal pH-monitoring is the main research method confirming GERD in a patient. This study determines the number and duration of refluxes during the day, as well as the length of time during which the pH level falls below 4.
2. Proton pump inhibitor test. The patient is prescribed a drug from the group of proton pump inhibitors (omez, nexium) in a standard dose for 2 weeks. The effectiveness of therapy is a confirmation of the disease.

In addition to these diagnostic methods, other studies may be prescribed to the patient. Usually they are necessary to assess the condition of the esophagus and other organs of the digestive system, identify concomitant diseases, and also to exclude diseases with a similar clinical picture:

• FEGDS (fibroesophagogastroduodenoscopy) with urease test;
• chromendoscopy of the esophagus;
• x-ray studies of the esophagus and stomach using contrast;
• ECG and daily ECG monitoring;
• ultrasound examination of the abdominal organs.

Treatment for GERD

1. First of all, the patient needs to change his lifestyle, namely, to give up such a bad habit as smoking, and from drinking alcoholic beverages. These factors contribute to the occurrence of reflux. Obese people need to normalize body weight with the help of a specially selected diet and a set of physical exercises.
2. Compliance with diet and diet. Food should be taken in small portions 5-6 times a day, avoid overeating. After eating, it is recommended to avoid physical exertion and a horizontal position of the body for several hours. Strong coffee and tea, carbonated drinks, chocolate, citrus fruits, spicy dishes and spices, as well as foods that promote gas formation (legumes, cabbage, fresh black bread) should be excluded from the diet.
3. Drug therapy is aimed at stopping the symptoms of the disease and preventing complications. Patients are prescribed proton pump inhibitors (omez, nexium), H2-histamine receptor blockers (ranitidine, famotidine). For bile reflux, ursodeoxycholic acid (ursofalk) and prokinetics (trimedat) are prescribed. Occasionally, antacids (almagel, phosphalugel, gaviscon) can be used to get rid of heartburn.

The appointment of therapy must be entrusted to the doctor, you should not self-medicate, as this can lead to the development of complications.

Which doctor to contact

If heartburn and other signs of GERD appear, you should contact a gastroenterologist. The role of the endoscopist is important in diagnosis. A nutritionist is involved in the treatment of the disease. In addition, a consultation with a cardiologist is required to rule out coronary pathology.