Gastroesophageal reflux disease - what is it, symptoms and treatment of herb, proper diet. Gastroesophageal reflux: symptoms, treatment and diet What is gastroesophageal reflux disease treatment

  • The date: 19.10.2019

Gastroesophageal reflux disease (GERD), often also referred to as reflux esophagitis, is characterized by recurring episodes of backflow (reflux) of acidic contents from the stomach (sometimes and/or duodenum) into the esophagus, resulting in damage to the lower esophagus by hydrochloric acid and protein-cleaving enzyme pepsin.

Causes of Reflux

The causes of reflux are damage or functional insufficiency of special locking mechanisms located at the border of the esophagus and stomach. Factors contributing to the development of the disease are stress; work associated with a constant inclination of the body down; obesity; pregnancy; as well as taking certain medications, fatty and spicy foods, coffee, alcohol and smoking. GERD often develops in people with a hernia esophageal opening diaphragm.

Reflux disease symptoms

The main symptom of GERD is heartburn, the second most common manifestation is chest pain, which radiates (radiates) to the interscapular region, neck, lower jaw, left half chest and may mimic angina pectoris. Unlike angina pectoris, pain in GERD is associated with food intake, body position and is relieved by taking alkaline mineral waters, soda or antacids. Pain can also occur in the back, in such cases they are often considered a symptom of diseases of the spine.

Complications

Regular reflux of stomach contents into the esophagus can cause erosions and peptic ulcers its mucosa, the latter can lead to perforation of the esophageal wall and bleeding (in half of the cases - severe). Another serious complication of GERD is stricture - narrowing of the lumen of the esophagus due to the formation of scar structures that disrupt the process of swallowing solid, and in severe cases even liquid food, a significant deterioration in well-being, loss of body weight. Highly dangerous complication GERD is the transformation of stratified squamous epithelium into a columnar epithelium, which is designated as Barrett's esophagus and is a precancerous condition. The frequency of adenocarcinomas in patients with Barrett's esophagus is 30-40 times higher than the average among the adult population.

In addition, GERD may be a cause of chronic inflammatory processes in the nasopharynx, leading to chronic pharyngitis or laryngitis, ulcers, granulomas and polyps of the vocal folds, stenosis of the larynx below the glottis, otitis media, rhinitis. Complications of the disease can be chronic recurrent bronchitis, aspiration pneumonia, lung abscess, hemoptysis, atelectasis of the lung or its shares, attacks of paroxysmal nocturnal cough, as well as reflux-induced bronchial asthma. GERD also causes damage to the teeth (enamel erosion, caries, periodontitis), and halitosis is often noted ( bad smell mouth) and hiccups.

Diagnostic examinations

To detect the reflux of gastric contents into the esophagus, a series of diagnostic tests. The main one is endoscopic, it allows not only to confirm the presence of reflux, but also to assess the degree of damage to the esophageal mucosa and monitor their healing during treatment. Daily (24-hour) pH-metry of the esophagus is also used, which makes it possible to determine the frequency, duration and severity of reflux, the effect of body position, food intake and drugs on it. This method allows a diagnosis to be made before damage to the esophagus occurs. Less commonly, scintigraphy of the esophagus with a radioactive isotope of technetium and esophagomanometry (to diagnose violations of peristalsis and tone of the esophagus) are performed. If Barrett's esophagus is suspected, a biopsy of the esophagus is performed, followed by a histological examination, since epithelial degeneration can only be diagnosed by this method.

Treatment and prevention of GERD

GERD is treated conservatively (with lifestyle changes and medications) or surgically. For drug treatment GERD is prescribed antacids (reduce the acidity of gastric contents); drugs that suppress the secretory function of the stomach (blockers of H2-histamine receptors and inhibitors proton pump); prokinetics, normalizing motor function gastrointestinal tract. If there is a throwing not only of gastric contents, but of the duodenum 12 (as a rule, in patients with cholelithiasis), good effect achieved by taking ursodeoxyfolic acid preparations. Patients are advised to stop taking medications that provoke reflux (anticholinergics, sedatives and tranquilizers, blockers calcium channels, β-blockers, theophylline, prostaglandins, nitrates), avoid bending forward after eating and horizontal position body; sleep with the head end of the bed raised; do not wear tight clothes and tight belts, corsets, bandages, leading to an increase in intra-abdominal pressure; stop smoking and drinking alcohol; reduce body weight in obesity. It is also important not to overeat, eat in small portions, with a break of 15-20 minutes between meals, do not eat later than 3-4 hours before bedtime. It is necessary to exclude fatty, fried, spicy foods, coffee, strong tea, Coca-Cola, chocolate, as well as beer, any carbonated drinks, champagne, citrus fruits, tomatoes, onions, garlic from your diet.

Surgical treatment is carried out in the presence of a pronounced narrowing of the lumen of the esophagus (stricture) or with severe bleeding due to perforation of its wall.

Catad_tema Heartburn and GERD - Articles

Gastroesophageal reflux disease: diagnosis, therapy and prevention

A. V. Kalinin
State Institute advanced training of doctors of the Ministry of Defense of the Russian Federation, Moscow

ESSAY

Gastroesophageal reflux disease: diagnosis, therapy and prevention

Gastroesophageal reflux disease (GERD) is a frequent illnesses. Until relatively recently, GERD seemed to practitioners to be a harmless disease with a characteristic symptom - heartburn. In the last decade, GERD has been in the zone of increased attention due to a clear trend towards an increase in the frequency of severe reflux esophagitis and an increase in cancer of the distal esophagus against the background of Barrett's esophagus. Established association with GERD lung diseases, in particular, bronchial asthma, allows you to approach their treatment in a new way. The adoption of a new classification of reflux esophagitis contributed to the unification of endoscopic conclusions. The introduction of daily pH-metry made it possible to diagnose the disease even at the endoscopically negative stage. Widespread use in clinical practice of new medicines(blockers of H 2 receptors, PPIs, prokinetics) has significantly expanded the possibilities of treating GERD, incl. and with her severe course. The pure S-isomer of omeprazole, esomeprazole (Nexium), is considered as a promising agent for the treatment and prevention of GERD.

In the last decade, gastroesophageal reflux disease (GERD) has attracted increased attention due to the following circumstances. In the developed countries of the world, there is a clear trend towards an increase in the incidence of GERD. Heartburn, the cardinal symptom of GERD, occurs in 20-40% of adults in Europe and the United States. The value of GERD is determined not only by its prevalence, but also by the severity of the course. Over the past ten years, severe reflux esophagitis (RE) has become 2-3 times more common. 10-20% of patients with EC develop pathological condition, described as "Barrett's esophagus" (BE) and is a precancerous disease. It has also been established that GERD occupies an important place in the genesis of a number of ENT and pulmonary diseases.

Significant progress has been made in the diagnosis and treatment of GERD. The introduction of daily pH-metry made it possible to diagnose the disease even at the endoscopically negative stage. The widespread use of new drugs in clinical practice (blockers of H2-reneptors, proton pump inhibitors - PPIs, prokinetics) has significantly expanded the possibilities of treatment even severe forms GERD. There are clear indications for surgical treatment RE.

At the same time, practitioners and patients themselves underestimate the significance of this disease. Patients in most cases late to see a doctor for medical care and even with severe symptoms are treated independently. Doctors, in turn, are poorly aware of this disease, underestimate its consequences, and irrationally conduct RE therapy. It is extremely rare to diagnose such a serious complication as PB.

Definition of the term "gastroesophageal reflux disease"

Attempts to define the concept of "gastroesophageal reflux disease" face significant difficulties:

  • in practically healthy individuals, reflux of gastric contents into the esophagus is observed;
  • sufficiently long acidification of the distal esophagus may not be accompanied by clinical symptoms and morphological features esophagitis;
  • often with severe symptoms of GERD are absent inflammatory changes in the esophagus.

As an independent nosological unit, GERD was officially recognized in the materials on the diagnosis and treatment of this disease, adopted in October 1997 at the interdisciplinary congress of gastroenterologists and endoscopists in Genval (Belgium). It has been proposed to distinguish between endoscopically positive and endoscopically negative GERD. The latter definition covers those cases where a patient with manifestations of the disease that meets the clinical criteria for GERD does not have damage to the esophageal mucosa. Thus, GERD is not a synonym for reflux esophagitis, the concept is broader and includes both forms with damage to the mucosa of the esophagus, and cases (more than 70%) with typical symptoms GERD, in which there are no visible changes in the esophageal mucosa during endoscopic examination.

The term GERD is used by most clinicians and researchers to designate a chronic relapsing disease caused by spontaneous, regularly recurring retrograde gastric and/or duodenal contents into the esophagus, leading to damage to the distal esophagus and/or the appearance of characteristic symptoms(heartburn, retrosternal pain, dysphagia).

Epidemiology

The true prevalence of GERD has been little studied. This is due to the high variability clinical manifestations- from episodic heartburn, in which patients rarely see a doctor, to clear signs of complicated RE, requiring hospital treatment.

As already noted, among the adult population of Europe and the United States, heartburn, the cardinal symptom of GERD, occurs in 20-40% of the population, but only 2% are treated for RE. RE is detected in 6-12% of individuals undergoing endoscopic examination.

Etiology and pathogenesis

GERD is a multifactorial disease. It is customary to single out a number of factors predisposing to its development: stress; leaning work, obesity, pregnancy, smoking, hiatal hernia, some medicines(calcium antagonists, anticholinergics, B-blockers, etc.), nutritional factors (fat, chocolate, coffee, fruit juices, alcohol, spicy foods).

The immediate cause of RE is prolonged contact of the gastric ( hydrochloric acid, pepsin) or duodenal (bile acids, lysolecithin) contents with the mucous membrane of the esophagus.

Allocate the following reasons leading to the development of GERD:

  • insufficiency of the locking mechanism of the cardia;
  • reflux of gastric and duodenal contents into the esophagus;
  • decreased esophageal clearance;
  • decrease in the resistance of the mucous membrane of the esophagus.

Insufficiency of the locking mechanism of the cardia.

Since the pressure in the stomach is higher than in chest cavity reflux of gastric contents into the esophagus should have been a permanent phenomenon. However, due to the locking mechanism of the cardia, it rarely occurs, on a short time(less than 5 minutes), and therefore is not considered as a pathology. Normal performance pH in the esophagus is 5.5-7.0. Esophageal reflux should be considered pathological if total number its episodes during the day exceeds 50 or the total time of decrease in intraesophageal pH<4 в течение суток превышает 4 ч.

The mechanisms that support the consistency of the function of the esophageal-gastric junction (the locking mechanism of the cardia) include:

  • lower esophageal sphincter (LES);
  • diaphragmatic-esophageal ligament;
  • mucous "socket";
  • acute angle of His, forming Gubarev's valve;
  • intra-abdominal location of the lower esophageal sphincter;
  • circular muscle fibers of the cardia of the stomach.

The occurrence of gastroesophageal reflux is the result of a relative or absolute insufficiency of the locking mechanism of the cardia. A significant increase in intragastric pressure with a preserved locking mechanism leads to relative insufficiency of the cardia. For example, intense contraction of the antrum of the stomach can cause gastroesophageal reflux even in individuals with normal function of the lower esophageal sphincter. Relative insufficiency of the cardiac valve occurs, according to A.L. Grebenev and V.M. Nechaeva (1995), in 9-13% of patients with GERD. Much more often there is an absolute cardiac insufficiency associated with a violation of the locking mechanism of the cardia.

The main role in the locking mechanism is assigned to the state of the LES. In healthy individuals, the pressure in this zone is 20.8 + 3 mm Hg. Art. In patients with GERD, it decreases to 8.9 + 2.3 mm Hg. Art.

The tone of the LES is under the influence of a significant number of exogenous and endogenous factors. The pressure in it decreases under the influence of a number of gastrointestinal hormones: glucagon, somatostatin, cholecystokinin, secretin, vasoactive intestinal peptide, enkephalins. Some of the widely used drugs also have a depressive effect on the obturator function of the cardia (cholinergic substances, sedatives and hypnotics, b-blockers, nitrates, etc.). Finally, the tone of the LES is reduced by some foods: fats, chocolate, citrus fruits, tomatoes, as well as alcohol and tobacco.

Direct damage to the muscle tissue of the LES (surgical interventions, prolonged presence of a nasogastric tube, bougienage of the esophagus, scleroderma) can also lead to gastroesophageal reflux.

Another important element of the locking mechanism of the cardia is the angle of His. It represents the angle of transition of one side wall of the esophagus into the greater curvature of the stomach, while the other side wall smoothly into the lesser curvature. The air bubble of the stomach and intragastric pressure contribute to the fact that the folds of the mucous membrane that forms the angle of His, fit snugly against the right wall, thereby preventing the contents of the stomach from being thrown into the esophagus (Gubarev's valve).

Often, retrograde entry of gastric or duodenal contents into the esophagus is observed in patients with hiatal hernia. Hernia is found in 50% of patients over the age of 50, and in 63-84% of these patients signs of RE are determined endoscopically.

Reflux with a hernia of the esophageal opening of the diaphragm is due to a number of reasons:

  • dystopia of the stomach into the chest cavity leads to the disappearance of the His angle and disruption of the valvular mechanism of the cardia (Gubarev's valve);
  • the presence of a hernia eliminates the locking effect of the diaphragmatic legs in relation to the cardia;
  • localization of LES in the abdominal cavity implies the impact on it of positive intra-abdominal pressure, which largely potentiates the locking mechanism of the cardia.

The role of reflux of gastric and duodenal contents in GERD.

There is a positive relationship between the likelihood of RE and the level of acidification of the esophagus. Animal studies have demonstrated the damaging effect of hydrogen ions and pepsin, as well as bile acids and trypsin, on the protective mucosal barrier of the esophagus. However, the leading role is given not to the absolute indicators of the aggressive components of the gastric and duodenal contents that enter the esophagus, but to a decrease in the clearance and resistance of the esophageal mucosa.

Clearance and resistance of the esophageal mucosa.

The esophagus is equipped with an effective mechanism to eliminate shifts in the intraesophageal pH level to the acid side. This protective mechanism is referred to as esophageal clearance and is defined as the rate of decrease of a chemical stimulus from the esophageal cavity. Esophageal clearance is provided by the active peristalsis of the organ, as well as the alkalizing properties of saliva and mucus. In GERD, there is a slowdown in esophageal clearance, primarily associated with a weakening of esophageal peristalsis and the antireflux barrier.

The resistance of the esophageal mucosa is due to preepithelial, epithelial and postepithelial factors. Damage to the epithelium begins when hydrogen ions and pepsin or bile acids overcome the aqueous layer surrounding the mucosa, the preepithelial mucus protective layer, and active bicarbonate secretion. Cellular resistance to hydrogen ions depends on the normal level of intracellular pH (7.3-7.4). Necrosis occurs when this mechanism is exhausted, and cell death occurs due to their sharp acidification. The formation of small superficial ulcerations is opposed by an increase in cell turnover due to increased reproduction of the basal cells of the esophageal mucosa. Mucosal blood supply is an effective post-epithelial defense mechanism against acid aggression.

Classification

According to the International Classification of Diseases 10th revision, GERD is classified under K21 and is subdivided into GERD with esophagitis (K21.0) and without esophagitis (K21.1).

For the classification of GERD, the severity of RE is of fundamental importance.

In 1994, a classification was adopted in Los Angeles, which distinguished the endoscopically positive and endoscopically negative stages of GERD. The term "damage to the mucous membrane of the esophagus" has replaced the concepts of "ulceration" and "erosion". One of the advantages of this classification is its relative ease of use in everyday practice. The Los Angeles classification of RE was recommended to be used when evaluating the results of endoscopic examination (Table 1).

The Los Angeles classification does not provide for the characteristics of RE complications (ulcers, strictures, metaplasia). The classification by Savary-Miller (1978) modified by Carisson et al. is now more widely used. (1996) presented in table 2.

Of interest is a new clinical and endoscopic classification, which divides GERD into three groups:

  • non-erosive, the most common form (60% of all cases of GERD), which includes GERD without signs of esophagitis and catarrhal RE;
  • erosive and ulcerative form (34%), including its complications: ulcer and stricture of the esophagus;
  • Barrett's esophagus (6%) - metaplasia of stratified squamous epithelium into a cylindrical epithelium in the distal section as a result of GERD (the isolation of this BE is due to the fact that this form of metaplasia is considered as a precancerous condition).

Clinic and diagnostics

The first stage of diagnosis is a survey of the patient. Among the symptoms of GERD, heartburn, sour belching, a burning sensation in the epigastrium and behind the sternum, which often occur after eating, when the body is tilted forward or at night, are of primary importance. The second most common manifestation of this disease is retrosternal pain, which radiates to the interscapular region, neck, lower jaw, left side of the chest and can mimic angina pectoris. For the differential diagnosis of the genesis of pain, it is important what provokes and stops them. Esophageal pain is characterized by a connection with food intake, body position and relief by taking alkaline mineral waters and soda.

Extraesophageal manifestations of the disease include pulmonary (cough, shortness of breath, often occurring in the supine position), otolaryngological (hoarseness, dry throat) and gastric (rapid satiety, bloating, nausea, vomiting) symptoms.

An x-ray examination of the esophagus can detect the ingress of contrast from the stomach into the esophagus, detect a hernia of the esophageal opening of the diaphragm, ulcers, strictures and tumors of the esophagus.

For a better detection of gastroesophageal reflux and hiatal hernia, it is necessary to conduct a polypositional study with the patient tilting forward with straining and coughing, as well as lying on his back while lowering the head end of the torso.

A more reliable method for detecting gastroesophageal reflux is daily (24-hour) pH-metry of the esophagus, which allows to assess the frequency, duration and severity of reflux, the effect of body position, food intake and drugs on it. The study of daily changes in pH and esophageal clearance allows you to identify cases of reflux before the development of esophagitis.

In recent years, esophageal scintigraphy with a radioactive isotope of technetium has been used to assess esophageal clearance. A delay of the received isotope in the esophagus for more than 10 minutes indicates a slowdown in esophageal clearance.

Esophagomanometry - measurement of pressure in the esophagus with the help of special balloon probes - can provide valuable information about the decrease in pressure in the area of ​​the LES, disturbances in peristalsis and tone of the esophagus. However, this method is rarely used in clinical practice.

The main diagnostic method for RE is endoscopic. With the help of endoscopy, it is possible to obtain confirmation of the presence of RE and to assess its severity, to monitor the healing of damage to the mucosa of the esophagus.

A biopsy of the esophagus with subsequent histological examination is performed mainly to confirm the presence of BE with a characteristic endoscopic picture, since BE can only be verified histologically.

Complications of reflux esophagitis

Peptic ulcers of the esophagus are observed in 2-7% of patients with GERD, in 15% of cases the ulcers are complicated by perforation, most often in the mediastinum. Acute and chronic blood loss of varying degrees occurs in almost all patients with peptic ulcers of the esophagus, and severe bleeding occurs in half of them.

Table 1.
Los Angeles RE classification

RE severity

Characteristics of changes

Grade A One or more lesions of the mucosa of the esophagus with a length of not more than 5 mm, limited to one mucosal fold
Grade B One or more esophageal mucosal lesions greater than 5 mm in length, limited by mucosal folds, and the lesions do not extend between two folds
Grade C One or more esophageal mucosal lesions greater than 5 mm in length, limited by mucosal folds, with lesions extending between two folds but covering less than 75% of the esophageal circumference
Grade D Damage to the mucous membrane of the esophagus, covering 75% or more of its circumference

Table 2.
RE classification according to Savary-Miller modified by Carisson et al.

Esophageal stenosis makes the disease more stable: dysphagia progresses, body weight decreases. Esophageal strictures occur in about 10% of patients with GERD. Clinical symptoms of stenosis (dysphagia) appear when the lumen of the esophagus narrows to 2 cm.

A serious complication of GERD is Barrett's esophagus, which sharply (30-40 times) increases the risk of cancer. PB is detected during endoscopy in 8-20% of patients with GERD. The prevalence of PB in the general population is much lower and amounts to 350 per 100,000 population. According to pathological statistics, for every known case, there are 20 unrecognized cases. The cause of BE is the reflux of gastric contents, and therefore BE is considered as one of the manifestations of GERD.

The mechanism of PB formation can be represented as follows. With RE, the surface layers of the epithelium are first damaged, then a mucosal defect can form. Damage stimulates local production of growth factors, which leads to increased proliferation and metaplasia of the epithelium.

Clinically, PB is manifested by the general symptoms of RE and its complications. On endoscopic examination, BE should be suspected when the bright red metaplastic epithelium in the form of finger-like protrusions rises above the Z-line (anatomical transition of the esophagus to the cardia), displacing the pale pink squamous epithelium characteristic of the esophagus. Sometimes, multiple blotches of squamous epithelium can persist in the metaplastic mucosa - this is the so-called "islet type" of metaplasia. The mucous membrane of the overlying sections may not be changed, or esophagitis of varying severity may be observed.

Rice. one
Diagnosis of atypical GERD with pulmonary manifestations

Endoscopically, two types of PB are distinguished:

  • short segment of PB - the prevalence of metaplasia is less than 3 cm;
  • long segment of PB - the prevalence of metaplasia is more than 3 cm.

In a histological study of PB, elements of three types of glands are found in place of the stratified squamous epithelium: some are similar to the fundic, others to the cardiac, and others to the intestinal. It is with the intestinal epithelium in PB that a high risk of malignant transformation is associated. Currently, almost all researchers believe that one can speak of PB only in the presence of intestinal epithelium, the marker of which is goblet cells (a specialized type of intestinal epithelium).

Assessment of the degree of metaplastic epithelial dysplasia in BE and its differentiation from malignant transformation are difficult tasks. The final judgment on malignancy in diagnostically difficult cases can be made upon detection of a mutation in the tumor suppressive p53 gene.

Extraesophageal manifestations of GERD

The following syndromes of extraesophageal manifestations of GERD can be distinguished.

    1. Oropharyngeal symptoms include inflammation of the nasopharynx and sublingual tonsil, development of tooth enamel erosion, caries, periodontitis, pharyngitis, sensation of a lump in the throat.
    2. Otolaryngological symptoms are manifested by laryngitis, ulcers, granulomas and polyps of the vocal folds, otitis media, otalgia and rhinitis.
    3. Bronchopulmonary symptoms are characterized by chronic recurrent bronchitis, the development of bronchiectasis, aspiration pneumonia, lung abscesses, paroxysmal sleep apnea and attacks of paroxysmal cough, as well as bronchial asthma.
    4. Pain in the chest associated with heart disease, manifested by reflex angina with reflux of stomach contents into the esophagus.
    5. Chest pain not associated with heart disease (non-cardiac chest pain) is a common complication of GERD that requires adequate therapy based on a thorough differential diagnosis with cardiac pain.

Establishing a link between bronchopulmonary diseases and GERD is of great clinical value, as it allows a new approach to their treatment.

Figure 1 shows the algorithm for diagnosing atypical GERD with pulmonary manifestations proposed by the American Gastroenterology Association. It is based on trial treatment with PPIs, and if a positive effect is achieved, then the connection of a chronic respiratory disease with GERD is considered proven. Further treatment should be aimed at preventing the reflux of gastric contents into the esophagus and further entry of refluxate into the bronchopulmonary system.

Great difficulties may arise in the differential diagnosis of retrosternal pain associated with heart disease (angina pectoris, cardialgia) and other diseases that cause retrosternal pain. The differential diagnosis algorithm is shown in Figure 2. 24-hour monitoring of esophageal pH can help in recognizing retrosternal pain associated with GERD (Figure 3).

Treatment

The goal of GERD treatment is to eliminate complaints, improve quality of life, fight reflux, treat esophagitis, prevent or eliminate complications. Treatment of GERD is more often conservative than surgical.

Conservative treatment includes:

  • recommendations for adherence to a certain lifestyle and diet;
  • drug therapy: antacids, antisecretory drugs (H2-receptor blockers and proton pump inhibitors), prokinetics.

The following basic rules have been developed, which the patient must constantly observe, regardless of the severity of RE:

  • after eating, avoid bending forward and do not lie down;
  • sleep with the head end of the bed raised;
  • do not wear tight clothes and tight belts, corsets, bandages, leading to an increase in intra-abdominal pressure;
  • avoid large meals; do not eat at night; limit the consumption of foods that cause a decrease in LES pressure and have an irritant effect (fats, alcohol, coffee, chocolate, citrus fruits);
  • stop smoking;
  • reduce body weight in obesity;
  • avoid taking drugs that cause reflux (anticholinergics, antispasmodics, sedatives, tranquilizers, calcium channel inhibitors, p-blockers, theophylline, prostaglandins, nitrates).

Antacids.

The goal of antacid therapy is to reduce the acid-proteolytic aggression of gastric juice. By increasing the intragastric pH level, these drugs eliminate the pathogenic effect of hydrochloric acid and pepsin on the esophageal mucosa. The arsenal of modern antacids has reached an impressive size. Currently, they are produced, as a rule, in the form of complex preparations, which are based on aluminum hydroxide, magnesium hydroxide or hydrogen carbonate, which are not absorbed in the gastrointestinal tract. Antacids are prescribed 3 times a day 40-60 minutes after meals, when heartburn most often occurs, and at night. It is recommended to adhere to the following rule: each attack of pain and heartburn should be stopped, since these symptoms indicate progressive damage to the esophageal mucosa.

Antisecretory drugs.

Antisecretory therapy for GERD is carried out in order to reduce the damaging effect of acidic gastric contents on the esophageal mucosa in gastroesophageal reflux. H2-receptor blockers (ranitidine, famotidine) have found wide application in EC. When using these drugs, the aggressiveness of the thrown gastric contents is significantly reduced, which contributes to the relief of the inflammatory and erosive-ulcerative process in the mucosa of the esophagus. Ranitidine is prescribed once at night in a daily dose of 300 mg or 150 mg 2 times a day; famotidine is used once at a dose of 40 mg or 20 mg 2 times a day.

Rice. 2.
Differential diagnosis of retrosternal pain

Rice. 3.
Episodes of recurrent chest pain correlate with episodes of reflux with pH<4 (В. Д. Пасечников, 2000).

In recent years, fundamentally new antisecretory drugs have appeared - inhibitors of H +, K + -ATPase(PPI - omeprazole, lansoprazole, rabeprazole, esomeprazole). By inhibiting the proton pump, they provide a pronounced and prolonged suppression of gastric acid secretion. PPIs are particularly effective in peptic erosive-ulcerative esophagitis, providing healing of the affected areas in 90-96% of cases after 6-8 weeks of treatment.

Omeprazole has found the widest application in our country. In terms of antisecretory effect, this drug is superior to H2 receptor blockers. Omeprazole dosage: 20 mg 2 times a day or 40 mg in the evening.

In recent years, new PPIs, rabeprazole and esomeprazole (Nexium), have been widely used in clinical practice.

Rabeprazole is converted faster than other PPIs into the active (sulfanilamide) form. Due to this, already on the first day of taking rabeprazole, such a clinical manifestation of GERD as heartburn decreases or completely disappears.

Of considerable interest is a new PPI - esomeprazole (Nexium), which is a product of a special technology. As is known, stereoisomers (substances whose molecules have the same sequence of chemical bonds of atoms, but a different arrangement of these atoms relative to each other in space) can differ in biological activity. Pairs of optical isomers that are mirror images of each other) are designated as R (from Latin rectus - straight or rota dexterior - right wheel, clockwise) and S (sinister - left or counterclockwise).

Esomeprazole (Nexium) is the S-isomer of omeprazole and is currently the first and only PPI that is a pure optical isomer. It is known that S-isomers of other PPIs are superior in pharmacokinetic parameters to their R-isomers and, accordingly, racemic mixtures, which are currently existing drugs in this group (omeprazole, lansoprazole, pantoprazole, rabeprazole). So far only omeprazole has been able to create a stable S-isomer. Studies in healthy volunteers have shown that esomeprazole is optically stable in any dosage form - both for oral and intravenous use.

The clearance of esomeprazole is lower than that of omeprazole and the R-isomer. The consequence of this is a higher bioavailability of esomeprazole compared to omeprazole. In other words, a large proportion of each dose of esomeprazole remains in the bloodstream after first pass metabolism. Thus, the amount of the drug that inhibits the proton pump of the parietal cell of the stomach increases.

The antisecretory effect of esomeprazole is dose-dependent; it increases during the first days of administration [11]. The action of esomeprazole occurs 1 hour after oral administration at a dose of 20 or 40 mg. With daily administration of the drug for 5 days at a dose of 20 mg 1 time per day, the average maximum acid concentration after stimulation with pentagastrin is reduced by 90% (measurement was carried out 6-7 hours after the last dose of the drug). In patients with symptomatic GERD, intragastric pH during daily monitoring after 5 days of taking esomeprazole at doses of 20 and 40 mg remained above 4 for an average of 13 and 17 hours, respectively. Among patients taking esomeprazole 20 mg per day, maintaining a pH level above 4 for 8, 12 and 16 hours was achieved in 76%, 54% and 24% of cases, respectively. For 40 mg esomeprazole, this ratio was 97%, 92% and 56%, respectively (p<0,0001) .

An important component that ensures the high stability of the antisecretory action of esomeprazole is its extremely predictable metabolism. Esomeprazole provides 2 times greater stability of such an indicator as individual variability in the suppression of gastric secretion stimulated by pentagastrin than omeprazole at an equivalent dose.

The efficacy of esomeprazole in GERD has been studied in several randomized, double-blind, multicenter trials. In two large studies involving more than 4000 GERD patients not infected with H. pylori, esomeprazole at daily doses of 20 or 40 mg was significantly more effective in healing erosive esophagitis than omeprazole at a dose of 20 mg. In both studies, esomeprazole was significantly superior to omeprazole after both 4 and 8 weeks of treatment.

Complete relief of heartburn (absence for 7 consecutive days) in a group of 1960 GERD patients was also achieved with esomeprazole 40 mg/day in more patients than with omeprazole, as on day 1 of dosing (30% versus 22% , R<0,001), так и к 28 дню (74% против 67%, р <0,001) . Аналогичные результаты были получены и в другом, большем по объему (п = 2425) исследовании (р <0,005) . В обоих исследованиях было показано преимущество эзомепразола над омепразолом (в эквивалентных дозах) как по среднему числу дней до наступления полного купирования изжоги, так и по суммарному проценту дней и ночей без изжоги в течение всего периода лечения. Еще в одном исследовании, включавшем 4736 больных эрозивным эзофагитом, эзомепразол в дозе 40 мг/сут достоверно превосходил омепразол в дозе 20 мг/сут по проценту ночей без изжоги (88,1%, доверительный интервал - 87,9-89,0; против 85,1%, доверительный интервал 84,2-85,9; р <0,0001) .Таким образом, наряду с известными клиническими показателями эффективности лечения ГЭРБ, указанные дополнительные критерии позволяют заключить, что эзомепразол объективно превосходит омепразол при лечении ГЭРБ. Столь высокая клиническая эффективность эзомепразола существенно повышает и его затратную эффективность. Так, например, среднее число дней до полного купирования изжоги при использовании эзомепразола в дозе 40 мг/сут составляло 5 дней, а оме-празола в дозе 20 мг/сут - 9 дней . При этом важно отметить, что омепразол в течение многих лет являлся золотым стандартом в лечении ГЭРБ, превосходя по клиническим критериям эффективности все другие ИПП, о чем свидетельствует анализ результатов более чем 150 сравнительных исследований .

Esomeprazole has also been studied as a maintenance drug for GERD. In 2 double-blind, placebo-controlled studies, including more than 300 patients with GERD with healed esophagitis, the effectiveness of three doses of esomeprazole (10, 20, and 40 mg / day) administered for 6 months was evaluated.

At all doses studied, esomeprazole was significantly superior to placebo, but the best dose/effectiveness ratio for maintenance therapy was found to be 20 mg/day. There are published data on the effectiveness of a maintenance dose of esomeprazole 40 mg / day, administered to 808 patients with GERD: remission after 6 and 12 months was maintained in 93% and 89.4% of patients, respectively.

The unique properties of esomeprazole have allowed for a completely new approach to long-term therapy for GERD - on-demand therapy, the effectiveness of which was studied in two 6-month-blind, placebo-controlled studies that included 721 and 342 patients with GERD, respectively. Esomeprazole has been used in doses of 40 mg and 20 mg. In the event of the onset of symptoms of the disease, patients were allowed to use no more than one dose (tablet) per day, and if the symptoms did not stop, then they were allowed to take antacids. When summing up, it turned out that, on average, patients took esomeprazole (regardless of dose) 1 time in 3 days, while inadequate control of symptoms (heartburn) was noted only by 9% of patients who received 40 mg of esomeprazole, 5% - 20 mg and 36 % - placebo (p<0,0001). Число больных, вынужденных дополнительно принимать антациды, оказалось в группе плацебо в 2 раза большим, чем в пациентов, получавших любую из дозировок эзомепразола .

Thus, clinical studies convincingly indicate that esomeprazole is a promising treatment for GERD, both in its most severe forms (erosive esophagitis) and in non-erosive reflux disease.

Prokinetics.

Representatives of this group of medicinal substances have an antireflux effect, and also increase the release of acetylcholine in the gastrointestinal tract, stimulating the motility of the stomach, small intestine and esophagus. They increase the tone of the LES, accelerate the evacuation from the stomach, have a positive effect on esophageal clearance and weaken gastroesophageal reflux.

Domperidone, which is a peripheral dopamine receptor antagonist, is commonly used as a prokinetic in EC. Domperidone is prescribed 10 mg (1 tablet) 3 times a day 15-20 minutes before meals.

In EC caused by reflux of duodenal contents (primarily bile acids) into the esophagus, which is usually observed in cholelithiasis, a good effect is achieved when taking non-toxic ursode-oxycholic bile acid at a dose of 5 mg/kg per day for 6-8 months .

The choice of treatment tactics.

When choosing the treatment of GERD in the stage of erosive-ulcerative RE, it should be remembered that in these cases, therapy is not an easy task. Healing of a mucosal defect occurs on average:

  • 3-4 weeks for duodenal ulcer;
  • for 4-6 weeks with a stomach ulcer;
  • for 8-12 weeks with erosive and ulcerative lesions of the esophagus.

Currently, a phased treatment scheme has been developed depending on the severity of RE. According to this scheme, it is recommended to start treatment with a full dose of PPI already in EC grade 0 and I, although the use of H2-blockers in combination with prokinetics is also allowed (Fig. 4).

The treatment regimen for patients with severe EC (II-III stage) is shown in Figure 5. The peculiarity of this regimen is longer treatment cycles and the appointment (if necessary) of high doses of PPIs. In the absence of the effect of conservative treatment in patients of this category, it is often necessary to raise the question of antireflux surgery. The expediency of surgical treatment should also be discussed in case of RE complications that are not amenable to drug therapy.

Surgery.

The goal of operations aimed at eliminating reflux is to restore the normal function of the cardia.

Indications for surgical treatment: 1) failure of conservative treatment; 2) complications of GERD (strictures, repeated bleeding); 3) frequent aspiration pneumonia; 4) PB (because of the danger of malignancy). Especially often, indications for surgery occur when GERD is combined with a hernia of the esophageal opening of the diaphragm.

The main type of surgery for reflux esophagitis is the Nissen fundoplication. Currently, methods of fundoplication performed through a laparoscope are being developed and implemented. The advantages of laparoscopic fundoplication are significantly lower rates of postoperative mortality and rapid rehabilitation of patients.

Currently, in PB, the following endoscopic techniques are used to influence the foci of incomplete intestinal metaplasia and severe epithelial dysplasia:

  • laser destruction, coagulation with argon plasma;
  • multipolar electrocoagulation;
  • photodynamic destruction (photo-sensitizing drugs are administered 48-72 hours before the procedure, then they are treated with a laser);
  • endoscopic local resection of the mucosa of the esophagus.

All of the above methods of influencing metaplasia foci are used against the background of the use of PPIs that suppress secretion and prokinetics that reduce gastroesophageal reflux.

Prevention and medical examination

Due to the widespread occurrence of GERD, which leads to a decrease in the quality of life, and the risk of complications in severe forms of RE, the prevention of this disease is a very urgent task.

The goal of primary prevention of GERD is to prevent the development of the disease. Primary prevention includes the following recommendations:

  • maintaining a healthy lifestyle (quitting smoking and drinking strong alcoholic beverages);
  • rational nutrition (avoid large meals, do not eat at night, limit the consumption of very spicy and hot foods;
  • weight loss in obesity;
  • only according to strict indications, take drugs that cause reflux (anticholinergics, antispasmodics, sedatives, tranquilizers, calcium channel inhibitors, b-blockers, prostaglandins, nitrates) and damage the mucous membrane (non-steroidal anti-inflammatory drugs).

Rice. 4.
The choice of treatment for patients with endoscopically negative or mild (0-1) degrees of reflux esophagitis

Rice. 5.
The choice of treatment for patients with severe (II-III) degrees of reflux esophagitis

The goal of secondary prevention of GERD is to reduce the frequency of relapses and prevent the progression of the disease. An obligatory component of secondary prevention is the observance of the above recommendations for primary prevention. Secondary drug prevention largely depends on the severity of RE.

"Therapy on demand" is used to prevent exacerbations in the absence of esophagitis or mild esophagitis (RE 0-1 degree). Each attack of pain and heartburn should be stopped, since this is a signal of pathological acidification of the esophagus, which contributes to progressive damage to its mucous membrane. Severe esophagitis (especially EC III-IV degree) requires long-term, sometimes permanent maintenance therapy with PPIs or H 2 receptor blockers in combination with prokinetics.

The criteria for successful secondary prevention are considered to be a decrease in the number of exacerbations of the disease, the absence of progression, a decrease in the severity of RE and the prevention of complications.

Patients with GERD in the presence of endoscopic signs of RE need dispensary observation with endoscopic control at least once every 2-3 years.

A special group should be allocated to patients diagnosed with PB. Endoscopic control with a targeted biopsy of the mucosa of the esophagus from the zone of visually altered epithelium is desirable to be carried out annually (but at least once a year), if there was no dysplasia in the previous study. When the latter is detected, endoscopic control should be carried out more often so as not to miss the moment of malignancy. The presence of low-grade dysplasia in BE requires endoscopy with biopsy every 6 months, and severe dysplasia after 3 months. In patients with confirmed severe dysplasia, surgical treatment should be considered.

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Heartburn and discomfort when eating can be signs of a disorder - reflux into the lower esophagus. You should consult a specialist for advice. In the early stages of the disease, the implementation of simple recommendations will help to regulate malfunctions in the organs and avoid possible complications.

What is gastroesophageal reflux disease?

A disorder in the digestive system, which manifests itself in the unnatural return of part of the contents of the duodenum or stomach to the lower esophagus. This situation is repeated and is spontaneous.

This phenomenon is called reflux disease, and the mass that makes its way back into the esophagus is reflux. It can have different acidity depending on which organ the return comes from.

Causes

The disease is initiated by the following disorders:

  • The esophageal sphincter of the lower section has a reduced tone.
  • The esophagus does not sufficiently cope with the function of self-cleaning.
  • The substance that returns to the lower esophagus is not characteristic of its internal membranes and has a damaging effect.
  • The stomach has problems with proper emptying.
  • The inner layer of the esophagus is not able to protect itself from the damaging effects of reflux.
  • The esophagus is narrowed in the region of the lower section.
  • Intra-abdominal pressure tends to be elevated.

Contribute to the emergence and development of the disease:

  • if professional activity often forces you to be in an inclined position,
  • experiencing stressful situations
  • taking drugs that cause a concentration of dopamine in the periphery (phenylethylamine derivatives);
  • eating:
    • spicy food,
    • fatty food,
    • alcohol,
    • coffee,
    • chocolate,
    • fruit juices;
  • smoking habit,
  • increased body weight,
  • pregnancy.

Reflux Symptoms

The fact that a person has a violation associated with the return of part of the contents from the stomach or duodenum to the lower part of the esophagus can be judged by the following signals:

  • the main manifestation of the violation is heartburn,
  • sour eructation may also be observed,
  • reflux symptoms include the circumstances that the previous two signs occur:
    • at night, especially if before that there was a hearty dinner;
    • if a person is forced to stay in an inclined position,
    • after eating.

The disease also has manifestations that affect the work of other organs:

  • otolaryngological symptoms:
    • feeling of dryness in the throat - laryngitis,
    • hoarse voice - pharyngitis;
    • rhinitis;
  • lung symptoms that most often appear when a person is lying down:
    • dyspnea,
    • cough;
  • stomach symptoms:
    • bloating,
    • fast saturation,
    • nausea;
  • as well as:
    • tooth erosion,
    • retrosternal pain that resembles angina pectoris;
    • pain in the back.

Video about the symptoms of GERD:

Signs of GERD with Esophagitis

Reflux into the esophagus can cause the following reactions in it:

  • inflammatory process,
  • damage to the walls in the form of ulcers,
  • modification of the lining layer in contact with the refluxate into a form unusual for a healthy organ;
  • narrowing of the lower esophagus.

They call the disease of the esophagus, provoked by the aggressive effect of reflux on its walls.

Inflammatory processes of the esophagus associated with reflux manifested through symptoms:

  • stomach pain,
  • heartburn,
  • nausea,
  • sour burp.

Features of GERD in children

Gastroesophageal reflux in infants is a completely normal phenomenon. The child regurgitates food due to the characteristics of this age. By the year this factor usually disappears.

In the event that reflux damages the walls of the esophagus, then it leads to illness.

Signs that the esophagus is experiencing damage to the walls:

  • regurgitation turns into intense vomiting,
  • crying child,
  • there is a cough
  • vomiting may be blood
  • no appetite,
  • child shows anxiety
  • gaining weight poorly.

Disease classification

The disease caused by reflux has two forms of manifestation:

  • Reflux esophagitis- occurs in every third patient with GERD. This form of the disease indicates that the walls of the esophagus are affected by the effects of reflux.
  • non-erosive reflux disease– 70% of people who experience reflux do not have serious damage to the walls of the esophagus.

Experts distinguish between four degrees of esophageal reflux:

  1. Linear defeat - there are separate areas of inflammation of the mucosa and foci of erosion on its surface.
  2. drain defeat - a negative process spreads to a large surface due to the merging of several foci into continuous inflamed areas, but not the entire area of ​​\u200b\u200bmucosa is still covered by the lesion.
  3. Circular defeat - zones of inflammation and foci of erosion cover the entire inner surface of the esophagus.
  4. Stenosing lesion - against the background of a complete lesion of the inner surface of the esophagus, complications already occur.

Complications

Damage to the esophageal mucosa as a result of the negative impact of reflux contents on it:

  • correspond to the state when squamous epithelial cells are reborn into another type - cylindrical cells;
  • stricture of the esophagus (reduction of the lumen).

Diagnostics

Methods that examine the disease and determine the presence of possible pathological changes associated with it:

  • Daily monitoring of acidity in the lower esophagus makes it possible to obtain information about the frequency of reflux and how long an individual reflux has. Knowledge of these data helps specialists to determine the methods of treatment.
  • Endoscopic examination provides a picture of the condition of the inner lining of the esophagus and the degree of its possible lesions.
  • X-ray examination of the esophagus provides specialists with information about specific mucosal lesions.
  • A manometric study studies the ability of sphincters to cope with their function.
  • Impedance-pH-metry of the esophagus - the study determines the degree of acidity of refluxes and how peristalsis works.
  • Gastroesophageal scintigraphy - the study examines the ability of the digestive organs to cleanse.

How to treat gastroesophageal reflux disease?

It is desirable to notice the violation as early as possible, because in the early stages the disease reacts to the patient's compliance with the rules of behavior and nutrition. The selection of drugs by a specialist can significantly alleviate the patient's condition.

Medicines

To improve the well-being of a person suffering from reflux, drugs of the following direction are used:

  • Antisecretory agents have the function of reducing the negative effect of hydrochloric acid on the surface of the esophagus. These funds include:
    • nizatidine,
    • cimetidine,
    • famotidine,
    • roxatidine.
  • Reparants - means that help restore the inner layer of the esophagus. This is:
    • misoprostol,
    • dalargin,
    • sea ​​buckthorn oil.
  • Prokinetics - funds are aimed at reducing the incidence of reflux, in connection with the correction of the sphincter. This is:
    • metoclopramide,
    • domperidone.
  • Antacids - muffle the action of hydrochloric acid, help to occur esophageal cleansing. This is:
    • maalox,
    • phosphalugel.

Operation

If other methods do not bring a positive result, then surgical intervention is recommended.

The purpose of the operation is to restore the necessary barrier so that it prevents the refluxate from entering the esophagus.

Also an indication for surgical treatment is the presence of such lesions:

  • ulcers of the superficial layer of the esophagus,
  • strictures or in other words - narrowing of the esophagus in those places where it experiences the aggressive influence of reflux;
  • Barrett's esophagus - when epithelial cells, as a result of a disease, are reborn into a cylindrical form, which is very unfavorable for health;
  • when the patient's reflux esophagitis reaches degrees three and four.

Folk remedies

To use traditional medicine, you should consult a specialist. Well proven recipes:

  • Take sea buckthorn or rosehip oil. The dose is selected individually: from a teaspoon three times a day to one serving at night;
  • Take three times a day a decoction of flax seeds, one third of a glass at a time.

Diet

To improve the patient's condition with gastroesophageal reflux disease, some rules should be followed for compiling the menu. You should refuse dishes and products:

  • chocolate,
  • fried foods,
  • radish,
  • spicy food,
  • coffee,
  • juices,
  • flour products,
  • citrus fruits,
  • alcohol.

Video on how to eat with gastroesophageal reflux disease:

Forecast

If timely measures are taken to correct behavior towards a healthy lifestyle and follow the doctor's prescriptions, then the prognosis is favorable.

If the disease is very advanced and serious damage to the esophageal mucosa is already diagnosed, then the prognosis worsens. This is especially true in cases of degeneration of the cells of the inner layer - Barrett's esophagus.

Prevention

Ways to help prevent the disease include:

  • Eat no later than two hours before going to bed.
  • Ensure that the headboard is in an elevated position during sleep.
  • Follow a diet.
  • Pick up clothes so that there is no squeezing effect on the area of ​​\u200b\u200bthe stomach and lower esophagus.
  • After eating for two hours, avoid activities that require a person to slanted postures.
  • Try to get rid of the habit of smoking, in extreme cases - avoid cases, do it on an empty stomach.
  • Make sure your weight is close to normal.
  • Meals should be organized in fractional portions, but frequent meals.

- one of the most common diseases of the digestive system. If the disease is combined with an inflammatory process that affects the lower esophagus, then gastroesophageal reflux with esophagitis develops.

A disease such as GERD with esophagitis, the treatment of which should be timely, is caused by frequently repeated reflux of the contents of the stomach, as well as enzymes involved in the digestive process into the esophagus.

If such a cast occurs after eating, then this is normal and is not a pathology. But when such reflux of stomach contents occurs, regardless of food intake, then these are already prerequisites for the disease.

The mucous membrane of the esophageal tube is susceptible to the acidic environment of the secretion of the stomach, so it becomes inflamed with the corresponding symptoms.

Gastroesophageal reflux disease is a disease of the esophagus, which is characterized by the presence of an inflammatory process in the mucosa of the distal esophageal tube. It is also called reflux esophagitis, Barrett's esophagus, gastroesophageal reflux.

Normally, there should be no gastric contents in the esophagus, as well as its secret, which has an acidic environment, negatively affects the epithelium of the esophageal tube. With frequent ingestion of these substances into the esophagus, irritation, swelling and inflammation of the mucous membrane of the organ first occurs.

With further progression of the disease on the mucous membrane erosive and ulcerative defects appear, which subsequently lead to the formation of scars and stenosis of the esophageal tube.

If such a disease is not treated for a long time, then the development of Barrett's esophagus is possible. This is a very serious complication of esophagitis, in which the stratified squamous cells of the esophageal epithelium are replaced by single-layer cylindrical ones.

Such a gullet requires serious treatment and constant monitoring, since it is considered a precancerous condition.

Frequent reflux of gastric secretions into the distal esophagus occurs as a result of insufficient function of the cardia, the muscular ring that separates the stomach from the esophageal tube. Through a not tightly closed sphincter, the secret is thrown back into the esophagus.

GERD is not an independent disease, but a consequence of other disorders in the body.

The causes of such an ailment as gastroesophageal reflux disease with esophagitis are:

  • hernia of the esophagus;
  • stomach ulcer and 12 duodenal ulcer;
  • congenital pathology of the development of the esophagus;
  • increased body weight;
  • cholecystitis;
  • surgical interventions.

The provoking factors for the development of this disease are:

  • stress;
  • work associated with a constant tilt of the body forward;
  • pregnancy;
  • spicy, fatty foods;
  • smoking;
  • pregnancy.

Gastroesophageal disease has two types of course: with and without esophagitis. Quite often, gastroesophageal reflux with esophagitis is diagnosed, which is described below.

GERD with reflux esophagitis

GERD with esophagitis: what is it, we have already figured it out. It is important to know that the disease has an acute and chronic course, accompanied by damage to the mucous membrane of the esophageal tube. There are such degrees of damage to the mucosa of the esophagus.

Degree 1- characterized by the presence of single ulcers or erosive defects. They are small and do not exceed half a centimeter in size. Only the lower part of the esophagus is affected.

Degree 2- has more extensive lesions, in which not only the upper layer of the epithelium is involved in the process, but also the tissues lying under it. Ulcerations are single or multiple, can merge. Erosions or ulcers are larger than half a centimeter. In this case, the lesion is within the same fold. Symptoms appear after eating.

Grade 3- erosive or ulcerative defects go beyond one fold, spread along the circumference of the inner wall of the esophagus, but do not affect more than 75% of the mucosa in a circle. Symptoms do not depend on whether the patient took food or not.

Degree 4- ulcers and erosions can spread around the entire circumference of the esophagus. This is a very severe degree of the disease, which causes complications in the form of stenosis, bleeding, suppuration, development of Barrett's esophagus.

Depending on the degree of pathological changes in the epithelium of the esophagus, the disease has the following classification by type.

Catarrhal view- hyperemia of the epithelium without ulcers and erosions. It develops when exposed to coarse food, spicy, hot food, strong drinks. May occur after mechanical injuries (fish and fruit bones).

Hydropic- the presence of edema of the esophagus, accompanied by a narrowing of the lumen of the organ.

erosive- on the inflamed areas of the epithelium, erosions and ulcers appear, the esophageal glands increase, cysts form. A characteristic symptom of this period is a cough with a mucous secretion.

pseudomembranous- fibrous formations appear on the mucosa. After their separation, ulcers and erosions form on the mucosa of the esophagus. A characteristic symptom: cough and vomiting with an admixture of fibrin films.

exfoliative- separation of fibrin films from the walls of the esophagus. This causes a severe cough, pain, spotting in the patient.

Necrotic- necrosis of parts of the tissues of the esophagus, a precancerous condition.

phlegmatic- purulent inflammation caused by an infectious lesion of nearby organs.

Symptoms of GERD with Esophagitis

The clinical picture of this disease is esophageal and non-esophageal symptoms. The first category includes:

  • dysphagia;
  • pain;
  • heartburn;
  • belching.

Most a characteristic manifestation of exophagitis is heartburn, which is accompanied by a painful syndrome localized behind the sternum. Such unpleasant sensations appear during physical work associated with a constant tilt of the body forward, as well as in a supine position, with reflex contraction of the esophagus, due to nerve spasm.

Soreness and burning appear as a result of the negative effect of the acidic environment on the mucosa of the esophagus when the secretion of the stomach is thrown back into the distal region of the esophageal tube.

But often patients do not pay attention to this symptom and go to the doctor. Then the disease passes into the second phase of development.

With further progression of the disease, patients may experience belching, which indicates dysfunction of the sphincter located between the stomach and esophagus. Most often it occurs during sleep.

Such a symptom is dangerous because food masses can enter the respiratory tract and lead to suffocation. Also, the ingestion of food into the respiratory tract provokes the development of aspiration pneumonia.

Dysphagia appears at later stages of the development of the disease and is characterized by a violation of the swallowing process.

Non-esophageal symptoms are the appearance of:

  • caries;
  • reflux laryngitis and pharyngitis;
  • sinusitis.

In GERD, chest pain is of a "cardiac" type and can be confused with an attack of angina pectoris, but it will not be relieved by nitroglycerin, and the appearance of pain is not associated with physical exertion or stress.

If the symptoms include shortness of breath, cough, suffocation, then the disease develops according to the bronchial type.

Treatment of GERD with Esophagitis

What is the treatment regimen for GERD with esophagitis? The treatment for this disease consists of:

  • medical treatment;
  • surgical intervention;
  • non-medical treatment.

How to treat GERD reflux esophagitis? Drug treatment is aimed at reducing the negative impact of the acidic environment on the esophageal mucosa, accelerating regenerative processes and preventing relapses of the disease.

Alginates- form a protective film on the surface of the food mass, which neutralizes hydrochloric acid, which is part of the gastric juice. With the return of food into the esophagus, there is no irritation of the epithelium by gastric contents ( gaviscon).


Prokinetics- improve the contractile function of the esophagus, promote the fastest movement of food through the esophageal tube, increase the force of contraction of the sphincter muscles, which prevents the contents of the stomach from being thrown back (cerucal, motylium).

proton pump inhibitors- reduce the production of gastric juice, which will reduce the negative impact on the mucous membrane of the esophagus (omez, omeprazole, pantoprazole).

For the speedy recovery of the affected epithelium, solcoseryl, allanton.

After the procedure, an endoscopic examination should be performed to confirm the positive effect of the therapy.

Surgical treatment

If after the treatment the symptoms persist, and there are other indications for surgical intervention, then an operation is performed.

Surgical treatment is carried out in the presence of:

  • stenosis;
  • Barrett's esophagus;
  • frequent bleeding;
  • ineffectiveness of conservative therapy;
  • frequent aspiratory pneumonia.

Surgical intervention is carried out by the classical method (the incision is made on the abdomen or chest), as well as by the laparoscopy method (a minimally invasive method that minimally affects healthy tissues).

Gastroesophageal reflux without esophagitis: what is it and how to treat it? It should be noted that a disease such as gastroesophageal reflux disease without esophagitis develops due to the reflux of the contents of the stomach into the esophagus, but there are no erosive and ulcerative lesions of the mucosa.

The clinical picture with a disease such as reflux without esophagitis is marked by the following symptoms:

The causes of GERD without esophagitis are:

  • malnutrition;
  • frequent vomiting (toxicosis, poisoning, medication);
  • obesity;
  • bad habits;
  • addiction to coffee.

The main methods of treating this disease are taking medications (antacids and alginates) and dieting.

Useful video: how to treat GERD reflux esophagitis

Basics of dietary nutrition

  • dairy products (exclude sour-milk products);
  • meat and fish are not fatty varieties;
  • boiled vegetables (exclude legumes);
  • fruit jelly (not sour).

You can not eat spicy, spicy, fatty and fried foods. It is necessary to exclude acidic foods, alcohol, strong tea and coffee.

findings

The positive effect of the treatment of GERD is achieved with the patient's steady adherence to the doctor's recommendations. With frequently recurring heartburn, you should definitely contact a gastroenterologist, because this is a symptom of developing GERD. Timely treatment will help prevent the development of complications.


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)

Esophageal syndromes Extraesophageal syndromes
Syndromes that are exclusively symptomatic (in the absence of structural damage to the esophagus) Syndromes with damage to the esophagus (complications of GERD) Syndromes associated with GERD Syndromes suspected of being associated with GERD
1. Classic reflux syndrome
2. Chest pain syndrome
1. Reflux esophagitis
2. Esophageal strictures
3. Barrett's esophagus
4. Adenocarcinoma
1. Reflux cough
2. Laryngitis of reflux nature
3. Bronchial asthma of reflux nature
4. Errosion of tooth enamel of reflux nature
1. Pharyngitis
2. Sinusitis
3. Idiopathic pulmonary fibrosis
4. Recurrent otitis media

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, forward bending of the torso, the 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 mucous membrane 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 a pH below 4.0 (reflux episodes over 5 minutes), the ratio of reflux time (with 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 identifying extraesophageal syndromes and when determining indications for surgical treatment of GERD, 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, for those patients with GERD who require long-term antisecretory therapy, it is necessary to diagnose Helicobacter pylori, if an infection is detected, eradication is indicated.

Differential Diagnosis


In the presence of extraesophageal symptoms, GERD should be differentiated from ischemic 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, medicinal, 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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