A characteristic symptom for herb on x-ray examination. Gastroesophageal reflux disease (GERD) (help for doctors). Treatment of reflux disease

S.S. Vyalov, S.A. Chorbinskaya

Reviewers:
Doctor of Medical Sciences, Professor Lyashchenko Yu.N.
Doctor of Medical Sciences, Professor Kapustin G.M.

The costs of socio-economic and political change in the world are the problems of human nutrition and lifestyle that result from this among the population. This is especially noticeable in the health of young people, in particular students.
To determine the effective tactics of managing such patients, general practitioners and therapists have developed these guidelines.

The issues of diagnosis and treatment of gastroesophageal reflux disease (GERD) in young people remain very relevant, despite significant advances in endoscopy and pharmacotherapy.

The main reasons for the unfavorable course of GERD in outpatient settings are frequent relapses and, as a result, the development of complications. According to domestic and foreign authors, complications are observed in 74.3% of cases.

Analysis of the course of GERD in young people on an outpatient basis revealed frequent recurrences of the disease in 61.3% of cases, and complications occurred in 56.2% of cases.

Analysis of treatment showed insufficient effectiveness associated with violation of the outpatient treatment regimen by patients - in 72.4% of cases (non-attendance for repeated appointments, non-systemic medication, non-compliance with diet, etc.), insufficient effectiveness of prescribed drugs - in 36 .2% of cases, non-attendance of patients for preventive (dispensary) observation - 34.2% of cases.

A detailed clinical-diagnostic and treatment-and-prophylactic analysis was carried out during the observation of 220 young patients at the clinical bases of the Department of General Medical Practice of the Peoples' Friendship University of Russia within the framework of the Health Program.

We see the significance of this analysis in the development of early and correct diagnosis of various forms of GERD, subject to successive stages of treatment and dispensary (preventive) observation. It is on this that the choice of method of treatment and the outcome of the disease largely depend.

Gastroesophageal reflux disease (GERD) is a symptom complex formed by a pathological increase in the duration of contact of the esophageal mucosa with acidic gastric contents, which is a consequence of a defect in the motility of the esophagus and stomach, and not an increase in the acidity of gastric juice. Definition of GERD (Genval, 1999).

According to a number of authors, the prevalence of GERD in Russia among the adult population ranges from 40 to 75%, and esophagitis is found in 45-80% of people with GERD. The incidence of severe esophagitis is 5 cases per 100,000 population per year. In Western Europe and the USA, up to 40-50% of people constantly experience heartburn; among those who underwent endoscopy: esophagitis was detected in 12-16% of cases, esophageal strictures in 7-23% of cases, and bleeding in 2% of cases. 20% of patients with GERD seek medical help.

The prevalence of Barrett's esophagus (BE) among individuals with esophagitis is about 3%. In the last five years, there has been a marked increase in the incidence of esophageal adenocarcinoma (AKA) and its detection rate is currently estimated at 6-8 new cases per 100,000 population per year. Adenocarcinoma of the esophagus develops in 0.5% of patients with Barrett's esophagus per year with a low degree of epithelial dysplasia, in 6% per year with high degree of dysplasia. The incidence of adenocarcinoma of the esophagus in patients with Barrett's esophagus rises to 800 cases per 100,000 population per year. Thus, the presence of Barrett's esophagus increases the risk of subsequent development of AKP tenfold (Ivashkin V.T., Sheptulin A.A., 2003).

In pathogenesis, 2 groups of factors are considered: predisposing and resolving.

Predisposing factors:

hiatal hernia;

obesity;

alcohol consumption;

medicines (drugs with anticholinergic properties, tricyclic antidepressants, H2-blockers, phenothiazines, nitrates, universal antispasmodics, opiates, etc.)

Resolving factors:

dysfunction of the lower esophageal sphincter;

decreased esophageal clearance; slow gastric emptying

involutional changes in the esophagus in old age (replacement of muscle fibers with connective tissue, a decrease in the number of secretory cells, a decrease in the protective properties of the mucosa and a delay in reflux in the esophagus).

GERD classifications

Various classifications are currently in use. Modification of the classification proposed in Genval suggests the allocation of at least two types of disease:

1. GERD with reflux esophagitis, which is characterized by the presence of certain damage to the mucosa of the esophagus, identified during endoscopy (erosion and ulcers);

2. GERD without esophagitis or endoscopically negative reflux disease, or non-erosive reflux disease, in which lesions of the esophageal mucosa (erosions and ulcers, as well as Barrett's esophagus) are not detected. The so-called "small signs" - edema, hyperemia of the mucous membrane of the esophagus - are not regarded by the participants of the Genval conference as unambiguous signs of esophagitis.

Based on the semantic meaning of the classification, which allows diagnosing the disease, as well as determining the treatment, its intensity and duration, as well as the tactics of managing the patient, it is advisable to single out another type of GERD.

3. Complicated GERD (recurrent ulcer, stricture, bleeding, Barrett's esophagus, adenocarcinoma of the esophagus). Isolation of this type of disease involves the participation of the surgeon in the treatment and increased activity of pharmacotherapy. In the case of conservative management of the patient, the intensity of endoscopic control increases.

Classification of GERD by severity(according to Savary M., Miller G., 1993, modified by Sheptulina A.A., 2001)

RE I degree of severity. Endoscopically, a picture of catarrhal esophagitis is detected, and single erosions capture less than 10% of the surface of the mucous membrane of the distal esophagus.

RE II degree of severity. Erosions become confluent and capture up to 50% of the surface of the mucous membrane of the distal esophagus.

RE III severity. Circularly located confluent erosion, occupying almost the entire surface of the mucous membrane of the esophagus.

RE IV severity. The formation of peptic ulcers and strictures of the esophagus, the development of small intestinal metaplasia of the mucous membrane of the esophagus (Barrett's syndrome).

Clinical and endoscopic classification

Of interest is a new clinical and endoscopic classification adopted at the IX European Gastroenterological Week in Amsterdam, which divides GERD into three groups:

1. Non-erosive GERD - the most common form (60% of all cases of GERD), which includes GERD without signs of esophagitis and catarrhal esophagitis - the most favorable form;

2. Erosive and ulcerative form of GERD (34%) and its complications: ulcer and stricture of the esophagus;

3. Barrett's esophagus (6%) - metaplasia of stratified squamous epithelium into a cylindrical one in the distal esophagus as a result of GERD. The isolation of PB is due to the fact that the cylindrical epithelium of a specialized intestinal type is considered as a precancerous condition.

At the same time, the modification of the Genval classification, which in practical terms is the most promising and convenient, has the greatest practical meaning.

Classification of endoscopically positive GERD

(Los Angeles, 1995):

Grade A. One or more mucosal defects, less than 5 mm in size.
Grade B. A mucosal defect larger than 5 mm, not extending beyond 2 folds of the esophageal mucosa (ESM).
Grade C. Mucosal defects extending beyond two folds of the SOP but involving< 75% окружности.
Grade D. Mucosal defects involving 75% or more of the SOP circumference.

Complications: ulcers, strictures, bleeding, Barrett's esophagus, laryngitis, bronchial asthma, aspiration pneumonia.

Classification of endoscopically negative GERD:

symptomatic, without mucosal injury.

Complaints

I. Esophageal complaints

painful swallowing (odynophagia);

sensation of "coma" in the throat;

sensation of a large amount of liquid in the mouth;

pain in the epigastric region, in the projection of the xiphoid process, occurs after eating, with torso bending and at night;

dysphagia;

heartburn, aggravated by errors in diet, alcohol intake, carbonated drinks, slopes; in a horizontal position;

belching food, aggravated after eating, taking carbonated drinks;

regurgitation of food is aggravated by physical exertion.

II. Extraesophageal complaints

retrosternal pain that mimics angina pectoris (cardialgia) is associated with food intake and the physical properties of food, body position, and is stopped by taking alkaline mineral waters or antacids;

chronic cough, shortness of breath, often occurring in the supine position;

hoarseness of voice, salivation;

erosion on the gums;

bloating, nausea, vomiting.

Despite all the variety of clinical manifestations, it should be recognized that heartburn is the main, and in many cases the only symptom of the disease. It mainly affects the quality of life, both in the presence and in the absence of esophagitis.

It is important to remember that in order to consider heartburn as a symptom of GERD, it is necessary to be sure that the patient correctly understands the definition of this sensation, in any case, understands it in the same way as the attending physician.

The interpretation of the word "heartburn" by patients (and by the doctor) is often unreliable. Therefore, in order to avoid misunderstanding in a conversation with a patient, it is recommended not just to use the word "heartburn", but to define it - "a burning sensation rising from the stomach or lower chest up to the neck." This allows more patients with heartburn to be identified and ensures the correct diagnosis of GERD. It was found that with this description of heartburn, the questionnaire is a more sensitive diagnostic method for GERD (92% sensitivity) than endoscopy and pH monitoring (Carlsson R., et all, 1998).

Other clinical manifestations are less common and are associated, as a rule, either with emerging complications or the severity of functional disorders.

Extraesophageal manifestations are important because their differential diagnosis is carried out with coronary syndrome, which is more gloomy prognostically. It is necessary to exclude coronary pathology (repeated ECG, stress tests, coronary angiography).

It should be remembered that a combination of these diseases is possible and then esophageal pain can be a trigger for coronary pain.

In such a situation, coronary disease determines the prognosis, but GERD should be treated with maximum intensity.

Of the extraesophageal manifestations in GERD, the respiratory system is in the first place. The first description of attacks of suffocation caused by overflowing of the stomach was made by W.B. Osier, 1892, thereby laying the foundation for the study of the relationship between bouts of bronchial obstruction and changes in the esophagus.

Gastroesophageal reflux can provoke cough, dyspnea, wheezing in patients with bronchial asthma (BA). With a combination of GERD and BA, its course is severe, progressive and requires early use of glucocorticoid hormones.

Very important with this combination is that patients have "pulmonary manifestations", which are the only equivalent of GERD.

Anamnesis

duration of complaints and their dynamics;
survey being carried out;
established diagnosis, newly diagnosed or already known chronic disease;
ongoing treatment (under the supervision of a doctor, by the type of self-treatment, haphazardly), basic therapy;
effect (with temporary effect, stable remission);
active surveillance (on or off).
allergies: none or multiple drug, food, household, or specifically to what.

Objectively

The skin is clean. Peripheral lymph nodes are not enlarged. Tongue wet, coated with white, with imprints of teeth on the sides. The abdomen is soft, moderately painful in the epigastric region. The liver along the edge of the right costal arch, painless. There is no muscle tension in the abdominal wall.

Formulation of the diagnosis

GERD. Endoscopically positive form (EPF). Acute erosion of the esophagus.
GERD. Endoscopically negative form (ENF), subcompensation stage.
GERD. Endoscopically negative form (ENF), compensation stage (after treatment).

Differential Diagnosis

Bronchial asthma and other bronchopulmonary diseases.
Hiatus hernia (HH)
Sliding hiatal hernia (SHH)
Peptic ulcer of the stomach with localization in the cardiac region

Diagnostics (examination)

I. Basic diagnostic methods

II. Additional diagnostic methods

EGDS: reflux esophagitis; hyperemia and edema of the esophageal mucosa; erosion of the distal esophagus, HH.

VEGDS: reflux esophagitis; hyperemia and edema of the esophageal mucosa; erosion of the distal esophagus, HH.

X-ray of the esophagus and stomach: HH, esophageal strictures, esophagospasm, erosive and ulcerative changes, reflux.

Daily pH monitoring: frequency and duration of refluxes, individual selection of drugs.

Manometry: indicators of the movement of the esophageal wall and the function of its sphincters.

Esophageal scintigraphy with technetium.

Chromoendoscopy: detection of metaplastic and dysplastic changes in the esophagus.

Bilimetry: verification of alkaline and bile reflux; spectrophotometry of refluxate containing bilirubin.

Endoscopic ultrasound: detection of endophytic growing tumor.

omeprazole test.

This order of distribution of research methods is due to the fact that more than 60% of patients with GERD are beyond the capabilities of the endoscopic method and their diagnosis is based on a thorough analysis of clinical manifestations.

The participants of the Genvala conference agreed that the presence of GERD can be assumed if heartburn occurs on two or more days per week.

Thus, the main method allows only to assume GERD, and then it should be carried out: firstly, an endoscopic examination, which should exclude a life-threatening pathology (oncological, in the first place) and establish the type of GERD: the presence of reflux esophagitis and endoscopically negative / positive form.

General principles of treatment

Elimination of the symptoms of the disease
Reflux Prevention
Reducing the damaging properties of refluxate
Improved esophageal clearance
Increased resistance of the esophageal mucosa
Treatment of esophagitis
Prevention of complications and exacerbations of the disease
Conservative treatment should be comprehensive and include both medication and lifestyle changes.

1. Lifestyle change

after eating, avoid tilting, do not lie down (within 1.5 hours); sleep on a bed with a head end raised by at least 15 cm;

do not wear tight clothes and tight belts, corsets, bandages,

avoid work in an incline (leading to an increase in intra-abdominal pressure);

stop smoking and drinking alcohol.

2. Changing the diet

avoid heavy meals, do not eat too hot food, do not eat at night (3-4 hours before bedtime);

limit the consumption of fats, alcohol, coffee, chocolate, citrus fruits, green onions, garlic, avoid the use of acidic fruit juices, products that increase gas formation (irritate the mucous membrane);

avoid weight gain, reduce body weight in obesity.

3. Restriction of taking medicines

avoid taking drugs that cause reflux: nitrates, anticholinergics, antispasmodics, sedatives, hypnotics, tranquilizers, calcium antagonists, beta-blockers, theophylline, as well as drugs that damage the esophagus - aspirin, non-steroidal anti-inflammatory drugs.

Medical therapy

Drug treatment includes the following groups of drugs: alginates; antacids; prokinetics; antisecretory drugs.

Antacids and alginates should be used frequently, depending on the severity of the symptoms.

ranitidine 150 mg 2 times a day, or 300 mg at night;
famotidine 20 mg twice a day, or 40 mg at night.

2.2. Proton pump inhibitors (PPIs) - acting intracellularly on the enzyme H + K + ATPase, drugs inhibit the proton pump, thereby providing a pronounced and long-term suppression of acid production:

omeprazole
lansoprazole 30 mg 2 times a day (daily dose 60 mg);
pantoprazole 20 mg 2 times a day (40 mg daily dose);
esomeprazole 20 mg 2 times a day (40 mg daily dose);
rabeprazole (daily dose 20 mg).

Effective therapy for GERD, especially given the wide spread of its endoscopically negative form, should be recognized as the treatment that most adequately relieves the decisive symptom. In this regard, proton pump inhibitors (PPIs) are recognized as the most advantageous class of drugs used in the management of patients with GERD.

Evidence-based medicine studies have demonstrated that PPIs are superior to histamine H2 receptor blockers and prokinetics in relieving heartburn.

In terms of drug choice, rabeprazole is currently the most effective, which is characterized by a rapid onset of action, a fairly uniform distribution of the effective dose throughout the day, and a smaller arsenal of side effects (since only 30% is metabolized in the liver). In addition, rabeprazole is in the form of tablets with 10 mg of active ingredient, which is important for maintenance treatment.

It seems that non-erosive GERD, despite a significant negative impact on the quality of life, progresses to erosive esophagitis in a small percentage of cases, and from this point of view, its prognosis is relatively favorable. This fact has led to the formation of a new therapeutic approach to the treatment of endoscopically negative GERD - "on demand" therapy, when taking a proton pump inhibitor is prescribed only when heartburn occurs. Tactically, GERD treatment with full therapeutic doses is carried out until clinical and endoscopic remission (with reflux esophagitis) or until stable clinical remission (with non-erosive form) is obtained. Of the proton pump inhibitors, rabeprazole is the best in this clinical situation.

Most patients with GERD require long-term therapy, and PPIs are currently the preferred therapy due to their high efficacy, especially for grade II-III reflux esophagitis. It is they who are able to create optimal conditions under which erosive or erosive-ulcerative lesions heal (i.e., maintain the pH in the stomach above 4 for 20 hours). When clinical and endoscopic remission is achieved, it is necessary to continue therapy with maintenance doses of drugs (half doses daily, for a long time, or at the initial dose, every other day), at which control of symptoms is possible. Histamine H2 receptor blockers in combination with prokinetics can be used as maintenance therapy.

In the negative form of GERD, taking into account the economic possibilities of the patient, therapy can be carried out with histamine H2-receptor blockers as monotherapy or in combination with prokinetics, and antacids and alginates can be used for maintenance therapy. The latter is preferable.

For the negative form of GERD, the most optimal form of follow-up therapy is on-demand treatment, i.e. when the drug is used only when symptoms appear (heartburn). Maintenance therapy schemes are different: from 2 to 4 weeks or intermittent courses.

Patients with endoscopically positive GERD should be actively monitored with endoscopic control once a year. In the absence of the effect of conservative treatment of patients with GERD (5-10% of cases), in the event of complications, it is necessary to make a decision on the advisability of surgical treatment.

3. Prokinetics- have anti-reflux action:

metoclopramide: raglan, cerucal 10 mg 3 times a day 15-20 minutes before meals;
domperidone: motilium 10 mg 3 times a day 15-20 minutes before meals.

Prokinetics lead to the restoration of the physiological state of the esophagus, increase its contractility, increase the tone of the lower esophageal sphincter. Motilium is considered the most effective (with fewer side effects), which is also convenient because it has two forms, including lingual, convenient for stopping unexpectedly developed heartburn in patients on bed rest.

Treatment regimens depending on the degree of reflux esophagitis:

Alginates or antacids: Gaviscon 10 ml 3 times a day 1 hour after meals and at bedtime for any degree. The course of treatment is 4-6 weeks.
Reflux esophagitis grade A: domperidone or cisapride 10 mg 2-4 times a day; H2 blockers - histamine receptors or rabeprazole 20 mg, omeprazole 20-40 mg. The course of treatment is 4-6 weeks.
Reflux esophagitis grade B-D: rabeprazole 20-40 mg per day; omeprazole 20-40 mg per day; lansoprazole 30-60 mg per day; domperidone 10 mg 4 times a day. The course of treatment is 6-12 weeks.

Active Surveillance

GERD without esophagitis (there are symptoms, but there are no visible changes in the mucosa of the esophagus).

Diet number 1. Domperidone or cisapride 10 mg 3 times a day + antacids 15 mg 1 hour after meals 3 times a day and at bedtime for 10 days.
Reflux esophagitis of the 1st degree of severity: diet No. 1, histamine H2 receptor blockers - ranitidine 150 mg 2 times a day or famotidine 20 mg 2 times a day. After 6-8 weeks, treatment is gradually completed, subject to the onset of remission.
Reflux esophagitis 2nd degree severity: ranitidine 300 mg 2 times a day or famotidine 40 mg 2 times a day (morning, evening). With the disappearance of symptoms, reduce the dose of the drug by 2 times and continue treatment with one drug: ranitidine 300 mg (famotidine 40 mg at 20:00) or omeprozole 20 mg or lansoprazole 30 mg, once at 15:00. After 6-8 weeks, stop treatment with remission.
Reflux esophagitis grade 3: omeprazole or rabeprazole 20 mg 2 times a day with an interval of 12 hours, and then, in the absence of symptoms, continue taking omeprazole or rabeprazole 20 mg per day or lansoprazole 30 mg at 15 hours until 8 weeks. Then ranitidine 150 mg or famotidine 20 mg for a year.
Reflux esophagitis grade 4: omeprazole or rabeprazole 20 mg 2 times a day or lansoprazole 30 mg 2 times a day for 8 weeks and, if remission occurs, switch to constant intake of ranitidine or famotidine.
Preventive courses of drug therapy are carried out on demand (when clinical symptoms appear).
Treatment on demand includes the above option or a single dose of omeprazole 20 mg (lansoprazole 30 mg) and motilium 10 mg 3 times a day for 2 weeks.
Patients with Barrett's syndrome require special monitoring: dynamic endoscopic control with biopsy and histological assessment of the degree of dysplasia. With a low degree of epithelial dysplasia, long-term PPIs are prescribed with histological examination after 3 and 6 months, and then, in the absence of negative dynamics, annually. With high-grade epithelial dysplasia - surgical treatment (endoscopic).

Indications for surgical treatment

Lack of effect from conservative therapy
The development of complications of GERD (ulcers, repeated bleeding, strictures, Barrett's esophagus with the presence of histologically confirmed high-grade dysplasia.
The need for constant antireflux therapy in young streets.
Frequent aspiration pneumonia.
Combination of GERD with HH.

In recent years, laparoscopic fundoplication has been introduced, which provides lower mortality rates and earlier rehabilitation periods.

Complications

Peptic ulcers of the esophagus
Esophageal strictures
Bleeding from esophageal ulcers
Barrett's syndrome is a precancer, the risk of developing adenocarcinoma in patients increases by 30-125 times.
Adenocarcinoma of the esophagus (cancer).

Barrett's esophagus

Barrett's esophagus is a pathological condition in which cylindric intestinal metaplasia of the stratified squamous epithelium of the esophagus occurs, i.e., it is replaced by a specialized small intestinal (with the presence of goblet cells) cylindrical epithelium - a potentially precancerous condition. The prevalence of the disease is in 1 out of 10 patients with esophagitis.

Management of patients with Barrett's esophagus

Active dispensary observation of patients with Barrett's esophagus can prevent the development of esophageal adenocarcinoma in cases of early diagnosis of epithelial dysplasia. Verification of the diagnosis of Barrett's esophagus and the establishment of the degree of dysplasia is carried out using a histological examination. The intensity of observation (endoscopic) 1 time per quarter.

Histological examination: low-grade dysplasia - at least 20 mg of rabeprazole with repeated histological examination after 3 months.
If low-grade dysplasia persists, a constant intake of rabeprazole 20 mg with repeated histological examination after 3-6 months, then annually.
High-grade dysplasia - at least 20 mg of rabeprazole, followed by an assessment of the results of histological examination and a decision on endoscopic or surgical treatment.

The following endoscopic techniques are used:

laparoscopic fundoplication;
laser destruction;
electrocoagulation;
photodynamic destruction (48-72 hours before the procedure, photosensitizing drugs are administered, then they are treated with a laser);
endoscopic local resection of the mucosa of the esophagus.

Thus, the results of the study conducted within the framework of the "Health" program showed that a methodically correct outpatient stage of diagnosis and treatment of patients with GERD can prevent the development of complications, as well as timely identify various complications in young people, which makes it possible to proceed to early pathogenetic treatment.

Gastroesophageal reflux disease (GERD) is a chronic, recurring, multi-symptom disease that is caused by a sudden, constantly observed reflux of contents from the stomach into the esophagus.

It causes damage to the lower esophagus. Many people try to do without the use of medications in the treatment of GERD.

However, there are diseases when it is not possible to do without drugs, and their absence in the treatment regimen threatens the patient with dangerous consequences.

For example, drugs for GERD are certain preventive measures of surgical (surgical) therapy and oncology.

Medical treatment for GERD

To effectively combat esophagitis, you should consult with your doctor about possible contraindications when using medications.

Drug therapy for GERD is carried out by a gastroenterologist. The process lasts from 1 to 2 months (in some cases, the course of treatment lasts about six months).

The use of such groups of medicines is carried out: antacids, H2-histamine blockers, proton pump inhibitors, prokinetics and cytoprotectors.

In a situation where conservative therapy for GERD has not been successful (approximately 5-10% of cases), or in the process of developing adverse effects or diaphragmatic hernia, surgical treatment is performed.

The most important in the treatment of GERD is:

complete diagnostics;
consultation with a doctor;
strict observance of all instructions of the specialist.

Anyone who really wants to get well should strictly follow all the doctor's recommendations, and if adverse effects appear, you need to find out how to eliminate them.

If you are allergic to any drug, you should not replace such drugs with others. This is done only with the permission of a specialist.

Many people wonder what medications should be used in the treatment of GERD. General approaches to the use of such funds are as follows:

Long course of treatment. In accordance with the latest prescriptions, certain groups of medications (normalize the acidity inside the stomach) should be taken from 2 to 6 months. It is necessary to change drugs to others only with personal hypersensitivity.
Drug treatment of GERD involves the complex use of medications. There is no special monotherapy in order to completely eliminate all symptoms at once. Therefore, several subgroups of medications are prescribed that affect each of the symptoms of the disease.
Gradual administration of substances. To date, a “phasing down” treatment regimen has been successfully applied. Initially, it involves a therapeutic dosage of proton pump blockers. Further, people suffering from GERD are transferred to a maintenance dose of the same medication or to the use of H2-blockers.

The duration of treatment and the number of medications used varies depending on the degree of inflammation. Basically prescribe drugs from various groups. For example, Motilium with Almagel or Omeprazole in combination with Motilium.

Treatment should continue for at least 6 weeks. In severe inflammatory processes in the esophagus, all 3 subgroups of drugs are used. They are taken for more than 8 weeks.

Similar drugs have specific differences.

The main ones are different mechanisms of action, the rate of onset of positive changes, the duration of the effect on the damaged area, different effects depending on the time of use, the cost of the drug.

Proton pump inhibitors (blockers)

Proton pump inhibitors are currently the most effective medication for GERD. Their advantages when used during this pathological process:

modern proton pump blockers rather eliminate pain near the chest;
normalize the degree of acidity of gastric juice, and can also maintain these indicators throughout the day;
prolonged use of blockers favorably affects the healing of esophageal erosions in the vast majority of situations;
with proper continuous use of such medications, it is possible to count on a long-term stable remission (no exacerbations).

Because of these positive characteristics, experts prefer this drug directly. Representatives of this subgroup of medicines include:

"Omeprazole";
"Rabeprazole";
"Lansoprazole";
"Esomeprazole";
"Pantoprazole".

The dosage of medications is regulated taking into account the stage of development of GERD or the presence of adverse effects.

Antacids and alginates

Such drugs reduce the degree of acid and protect the mucous membrane of the digestive organs. They are available as tablets or suspensions.

Representatives of this subgroup have a fast action (within 10-15 minutes from the moment of administration), therefore they are prescribed in the first 10 days of the course of treatment.

The main reasons for prescribing medicines from this subgroup:

speed of action;
the fitness of some during pregnancy.

However, this treatment of GERD has a number of its own disadvantages:

antacids include aluminum, magnesium or calcium, with an increase in the dose, an imbalance of trace elements occurs, therefore they are used in small courses;
short-term effect of drugs, they must be used frequently (3-6 times a day), which causes discomfort.

The most common representatives of this group are:

"Phosphalugel";
"Renny";
"Almagel", Almagel-Neo";
"Maalox";
"Gastal".

Alginates are similar in effect to antacids, but in contrast to the former, they do not have contraindications and side effects. Therefore, they are prescribed for a long course.

A similar medicine for GERD, such as Gaviscon or Laminal, is not recommended for use only in children under 6 years of age.

H2-histamine receptor blockers

These drugs also lower the degree of stomach acid. Their influence and effect is similar to the action of representatives of proton pump blockers.

Recently, however, such funds have faded into the background. H2-histamine receptor blockers are used to a lesser extent due to the fact that:

The therapy regimen involves 2 and 3-fold use of H2-histamine receptor blockers, which causes some discomfort to patients who are undergoing a long course of treatment.
A greater number of contraindications and side effects in comparison with representatives of the omeprazole subgroup.
Drug treatment of GERD with these drugs is less effective because after their use, the proper pH level inside the esophagus is maintained for a short time (less than 16 hours).

To date, Ranitidine and Famotidine are often prescribed.

Prokinetics

These drugs are another equally important subgroup of drugs in counteracting GERD. Their advantages include:

improvement of gastrointestinal motility.
increased tone of the lower esophageal sphincter.
ridding a person of constant nausea.

The most common representatives of prokinetics:

"Metoclopramide";
"Domperidone";
"Itoprid";
"Cisapride".

Drug treatment of GERD involves the use of such drugs in short courses as an addition to the main means or after prolonged use of blockers.

Cytoprotectors

The most popular representative of this subgroup is Misoprostol (Cytotec, Cytotec). It is a synthetic analogue of PG E2.

It is characterized by a wide range of protective effects on the mucous membrane of the gastrointestinal tract:

lowers the degree of acidity of gastric juice;
promotes increased secretion of mucus and bicarbonates;
increases the protective characteristics of mucus;
improves the blood flow of the esophageal mucosa.

This drug is prescribed 2 g 4 times a day, mainly with 3 degrees of GERD.

Venter (Sucralphate) is the ammonium salt of sulfated sucrose.

It helps to accelerate the recovery of ulcerative defects in the gastrointestinal mucosa through the formation of a chemical complex that prevents the influence of pepsin, acid and bile.

It has astringent properties. It is prescribed 1 g 4 times a day between meals. The use of Sucralfate and antacids should be timed.

With GERD, which is caused by reflux of stomach contents into the esophagus, which is noted mainly during cholelithiasis, Ursofalk 250 mg at bedtime (combined with Coordinax) will be effective.

The use of cholestyramine will be justified. Used 12-16 g per day.

Dynamic monitoring of detectable secretory, morphological and microcirculatory failures in GERD can confirm the various schemes for GERD drug correction proposed to date.

Possible schemes

The first treatment regimen with the same medication. The severity of symptoms, the degree of soft tissue hyperemia, the presence of adverse effects are not taken into account.

Such an approach is not considered effective, and in certain situations it can harm health.

The second treatment regimen is an intensifying treatment. It involves the use of agents of different aggressiveness at different stages of inflammation.

Treatment consists of following a diet and taking antacids. When the effect has not been achieved, the specialist may prescribe a combination of similar medications, but more intense in effect.

The third regimen, during which the patient takes strong proton pump blockers. When the severity of symptoms subsides, weak prokinetic drugs are used.

Such a measure has a positive effect on the health of patients suffering from severe GERD.

Standard 4-stage scheme

With a weak manifestation of GERD (stage 1), it is necessary to maintain lifelong use of medications (antacids and prokinetic drugs).

The average severity of inflammatory processes (stage 2) involves constant adherence to the correct diet. You also need to use blockers that normalize acidity.

During severe inflammation (stage 3), the patient is prescribed receptor blockers, inhibitors in combination with prokinetic agents.

At the last stage, the drugs will be powerless, therefore, surgical intervention and a course of maintenance therapy are necessary.

Important milestones

Treatment with medications involves 2 stages. The first allows you to heal and normalize the mucous membrane of the esophagus.

The second stage of therapy contributes to the achievement of sustainable remission. In this scheme, there are 3 approaches, selected only in combination with the patient according to his personal desire.

The use of proton pump inhibitors for a long period of time in large quantities helps to prevent relapses.

On demand. Inhibitors are used in full dose. The course is small - 5 days. By means of these medications, unpleasant symptoms are quickly eliminated.

In the third approach, drugs are used only during the formation of symptoms. It is recommended to take the required dosage 1 time in 7 days.

Prevention

Primary preventive measures for GERD consist in following the instructions of a specialist regarding an active lifestyle (refusal of smoking, drinking alcohol).

It is forbidden to use medications that disrupt the functioning of the esophagus and that reduce the protective characteristics of its mucosa.

Secondary preventive measures are to reduce the frequency of relapses and prevent the progression of the disease.

A mandatory component of secondary preventive measures for GERD is the following of the above instructions for primary prevention and non-drug therapy of such a disease.

In order to prevent exacerbations, if there is no esophagitis or a mild form of esophagitis is observed, timely treatment “on demand” will retain its value.

Although some drugs can exacerbate the symptoms of GERD, due to the use of others, drug-induced esophagitis occurs, during which the same symptoms appear as in GERD, but not due to reflux.

Drug-induced esophagitis occurs when a pill is swallowed but does not reach the stomach because it sticks to the wall of the esophagus.

If GERD is not eliminated in a timely manner, then this is fraught with the appearance of adverse consequences. In this regard, it is necessary to consult a doctor and choose the optimal treatment.

Useful video

GASTROESOPHAGEAL REFLUX DISEASE

Gastroesophageal reflux disease(GERD) is a chronic relapsing disease caused by spontaneous, regularly repeated reflux of gastric and / or duodenal contents into the esophagus, leading to damage to the lower esophagus.

Reflux esophagitis- an inflammatory process in the distal part of the esophagus, caused by the action of gastric juice, bile, as well as enzymes of pancreatic and intestinal secretions on the mucous membrane of the organ in gastroesophageal reflux. Depending on the severity and prevalence of inflammation, five degrees of RE are distinguished, but they are differentiated only on the basis of the results of endoscopic examination.

Epidemiology. The prevalence of GERD reaches 50% among the adult population. In Western Europe and the United States, extensive epidemiological studies indicate that 40-50% of people constantly (with varying frequency) experience heartburn, the main symptom of GERD.
Among those who underwent endoscopic examination of the upper digestive tract, esophagitis of varying severity was detected in 12-16% of cases. The development of strictures of the esophagus was noted in 7-23%, bleeding - in 2% of cases of erosive-ulcerative esophagitis.
Among persons over 80 years of age with gastrointestinal bleeding, erosion and ulcers of the esophagus were their cause in 21% of cases, among patients in intensive care units who underwent surgery, in ~ 25% of cases.
Barrett's esophagus develops in 15-20% of patients with esophagitis. Adenocarcinoma - in 0.5% of patients with Barrett's esophagus per year with a low degree of epithelial dysplasia, in 6% per year - with high degree of dysplasia.

Etiology, pathogenesis. Essentially, GERD is a kind of polyetiological syndrome, it can be associated with peptic ulcer, diabetes mellitus, chronic constipation, occur against the background of ascites and obesity, complicate the course of pregnancy, etc.

GERD develops due to a decrease in the function of the antireflux barrier, which can occur in three ways:
a) primary decrease in pressure in the lower esophageal sphincter;
b) an increase in the number of episodes of his transient relaxation;
c) its complete or partial destructuring, for example, with a hernia of the esophageal opening of the diaphragm.

In healthy people, the lower esophageal sphincter, consisting of smooth muscles, has a tonic pressure of 10-30 mm Hg. Art.
Approximately 20-30 times a day, transient spontaneous relaxation of the esophagus occurs, which is not always accompanied by reflux, while in patients with GERD, with each relaxation, refluxate is thrown into the lumen of the esophagus.
The determining factor for the occurrence of GERD is the ratio of protective and aggressive factors.
Protective measures include anti-reflux function of the lower esophageal sphincter, esophageal clearance (clearance), resistance of the esophageal mucosa, and timely removal of gastric contents.

Factors of aggression - gastroesophageal reflux with reflux of acid, pepsin, bile, pancreatic enzymes into the esophagus; increased intragastric and intra-abdominal pressure; smoking, alcohol; drugs containing caffeine, anticholinergics, antispasmodics; mint; fatty, fried, spicy food; binge eating; peptic ulcer, diaphragmatic hernia.

The most important role in the development of RE is played by the irritating nature of the fluid - refluxate.
There are three main mechanisms of reflux:
1) transient complete relaxation of the sphincter;
2) transient increase in intra-abdominal pressure (constipation, pregnancy, obesity, flatulence, etc.);
3) spontaneously occurring "free reflux" associated with low residual sphincter pressure.

The severity of RE is determined by:
1) the duration of contact of the refluxate with the wall of the esophagus;
2) the damaging ability of the acidic or alkaline material that has entered it;
3) the degree of resistance of the esophageal tissues. Most recently, when discussing the pathogenesis of the disease, the importance of the full functional activity of the crura of the diaphragm began to be discussed more often.

The frequency of hiatal hernia increases with age and after 50 years it occurs in every second.

Morphological changes.
Endoscopically, RE is divided into 5 stages (classification by Savary and Miller):
I - erythema of the distal esophagus, erosions are either absent or single, non-merging;
II - erosions occupy 20% of the circumference of the esophagus;
III - erosion or ulcers of 50% of the circumference of the esophagus;
IV - multiple confluent erosion, filling up to 100% of the circumference of the esophagus;
V - development of complications (ulcer of the esophagus, stricture and fibrosis of its walls, short esophagus, Barrett's esophagus).

The latter option is considered by many as pre-cancer.
More often you have to deal with the initial manifestations of esophagitis.
clinical picture. The main symptoms are heartburn, retrosternal pain, dysphagia, odynophagia (painful swallowing or pain when food passes through the esophagus) and regurgitation (the appearance of the contents of the esophagus or stomach in the oral cavity).
Heartburn can serve as an evident sign of RE when it is more or less permanent and depends on the position of the body, sharply intensifying or even appearing when bending over and in a horizontal position, especially at night.
Such heartburn may be associated with sour belching, a “stake” sensation behind the sternum, the appearance of a salty fluid in the mouth associated with reflex hypersalivation in response to reflux.

The contents of the stomach can flow into the larynx at night, which is accompanied by the appearance of a rough, barking, unproductive cough, a feeling of irritation in the throat and a hoarse voice.
Along with heartburn, RE can cause pain in the lower third of the sternum. They are caused by esophagospasm, dyskinesia of the esophagus, or mechanical compression of the organ and the area of the hernial opening when combined with diaphragmatic hernias.
Pain in nature and irradiation can resemble angina pectoris, stop with nitrates.
However, they are not associated with physical and emotional stress, they increase during swallowing, appear after eating and with sharp torso bends, and are also stopped by antacids.
Dysphagia is a relatively rare symptom in GERD.
Its appearance requires differential diagnosis with other diseases of the esophagus.
Pulmonary manifestations of GERD are possible.
In these cases, some patients wake up at night with a sudden attack of coughing, which begins simultaneously with regurgitation of gastric contents and is accompanied by heartburn.

A number of patients may develop chronic bronchitis, often obstructive, recurrent, difficult to treat pneumonia caused by aspiration of gastric contents (Mendelssohn's syndrome), bronchial asthma.

Complications: strictures of the esophagus, bleeding from ulcers of the esophagus. The most significant complication of RE is Barrett's esophagus, which involves the appearance of small intestinal metaplastic epithelium in the esophageal mucosa. Barrett's esophagus is a precancerous condition.

Rapidly progressive dysphagia and weight loss may indicate the development of adenocarcinoma, but these symptoms appear only in the advanced stages of the disease, so the clinical diagnosis of esophageal cancer is usually delayed.

Therefore, the main way of prevention and early diagnosis of esophageal cancer is the diagnosis and treatment of Barrett's esophagus.

Diagnostics. It is carried out mainly with the use of instrumental research methods.
Of particular importance is daily intraesophageal pH monitoring with computer processing of the results.
Distinguish between endoscopically positive and negative forms of GERD.
At the first diagnosis, it must be detailed and include a description of the morphological changes in the mucosa of the esophagus during endoscopy (esophagitis, erosion, etc.) and possible complications.
Mandatory laboratory tests: complete blood count (if there is a deviation from the norm, repeat the study once every 10 days), once: blood type, Rh factor, fecal occult blood test, urinalysis, serum iron. Mandatory instrumental studies: once: electrocardiography, twice: esophagogastroduodenoscopy (before and after treatment).

Additional instrumental and laboratory studies are carried out depending on concomitant diseases and the severity of the underlying disease. It is necessary to remember about the fluoroscopy of the stomach with the mandatory inclusion of research in the Trendelenburg position.

In patients with erosive reflux esophagitis, almost 100% of cases have a positive Bernstein test. To detect it, the mucous membrane of the esophagus is irrigated with a 0.1 M hydrochloric acid solution through a nasogastric catheter at a rate of 5 ml/min.
Within 10-15 minutes, with a positive test, patients develop a distinct burning sensation behind the sternum.

Consultations of experts according to indications.

Histological examination. Atrophy of the epithelium, thinning of the epithelial layer is more often detected, but occasionally, along with atrophy, areas of hypertrophy of the epithelial layer can be detected.
Along with pronounced dystrophic-necrotic changes in the epithelium, hyperemia of the vessels is noted.
In all cases, the number of papillae is significantly increased.
In patients with a long history, the number of papillae is increased in direct proportion to the duration of the disease.
In the thickness of the epithelium and in the subepithelial layer, focal (usually perivascular) and in some places diffuse lymphoplasmacytic infiltrates with an admixture of single eosinophils and polynuclear neutrophils are detected.

With active current esophagitis, the number of neutrophils is significant, while some of the neutrophils are found in the thickness of the epithelial layer inside the cells (epithelial leukopedesis).
This picture can be observed mainly in the lower third of the epithelial layer.
In isolated cases, along with neutrophils, interepithelial lymphocytes and erythrocytes are found. Some new diagnostic methods for R. E.
Identification of the pathology of the p53 gene and signs of a structural disorder in the DNA structure of Barrett's esophageal epithelium cells will in the future become a method of genetic screening for the development of esophageal adenocarcinoma.

The method of fluorescent cytometry will possibly reveal aneuploidy of cell populations of the metaplastic epithelium of the esophagus, as well as the ratio of diploid and tetraploid cells.

The widespread introduction of chromoendoscopy (a relatively inexpensive method) will make it possible to identify metaplastic and dysplastic changes in the esophageal epithelium by applying substances to the mucous membrane that stain healthy and affected tissues in different ways.

Flow. GERD is a chronic, often relapsing disease that lasts for years.

In the absence of supportive treatment, 80% of patients experience relapses of the disease within six months.
Spontaneous recovery from GERD is extremely rare.

Treatment. Timely diagnosis of HEBR during its initial clinical manifestations, without signs of esophagitis and erosions, allows timely treatment.

Among many functional diseases, it is with GERD that the “palette” of medical care is actually quite wide - from simple useful tips on regulating nutrition and lifestyle to using the most modern pharmacological agents for many months and even years.

Dietary recommendations. Pisha should not be too high in calories, it is necessary to exclude overeating, nightly "snacking".
It is advisable to eat in small portions, 15-20-minute intervals should be made between meals.
After eating, you should not lie down.
It is best to walk for 20-30 minutes.
The last meal should be at least 3-4 hours before bedtime.

Foods rich in fats should be excluded from the diet (whole milk, cream, fatty fish, goose, duck, pork, fatty lamb and beef, cakes and pastries), coffee, strong tea, Coca-Cola, chocolate, foods that reduce the tone of the lower esophageal sphincter (peppermint, pepper), citrus fruits, tomatoes, onions, garlic.
Fried foods have a direct irritating effect on the mucosa of the esophagus.
Do not drink beer, any carbonated drinks, champagne (they increase intragastric pressure, stimulate acid formation in the stomach).

You should limit the use of butter, margarine.
The main measures: the exclusion of a strictly horizontal position during sleep, with a low headboard (and it is important not to add extra pillows, but actually raise the head end of the bed by 15-20 cm).
This reduces the number and duration of reflux episodes as effective esophageal clearance is increased by gravity.
It is necessary to monitor body weight, stop smoking, which reduces the tone of the lower esophageal sphincter, and alcohol abuse. Avoid wearing corsets, bandages, tight belts that increase intra-abdominal pressure.

It is undesirable to take drugs that reduce the tone of the lower esophageal sphincter: antispasmodics (papaverine, no-shpa), prolonged nitrates (nitrosorbide, etc.), calcium channel inhibitors (nifedipine, verapamil, etc.), theophylline and its analogues, anticholinergics, sedatives , tranquilizers, b-blockers, hypnotics and a number of others, as well as agents that damage the esophageal mucosa, especially when taken on an empty stomach (aspirin and other non-steroidal anti-inflammatory drugs; paracetamol and ibuprofen are less dangerous from this group).

It is recommended to start treatment with a "two options" scheme.
The first is step-up therapy (step-up - “step up” the stairs).
The second is to prescribe a gradually decreasing therapy (step-down - “step down” the stairs).

Complex, step-up therapy is the main treatment for GERD at the stage of the onset of the initial symptoms of this disease, when there are no signs of esophagitis, i.e., with an endoscopically negative form of the disease.

In this case, treatment should begin with non-drug measures, “on-demand therapy” (see above).
Moreover, the whole complex of drug-free therapy is preserved in any form of GERD as a mandatory permanent "background".
In cases of episodic heartburn (with an endoscopically negative form), treatment is limited to episodic (“on demand”) administration of non-absorbable antacids (Maalox, Almagel, Phosphalugel, etc.) in the amount of 1-2 doses when heartburn occurs, which immediately stops it.
If the effect of taking antacids does not occur, you should resort to topalkan or motilium tablets once (you can take the sublingual form of motilium), or an H2 blocker (ranitidine - 1 tablet 150 mg or famotidine 1 tablet 20 or 40 mg).

With frequent heartburn, a variant of the course step-up therapy is used. The drugs of choice are antacids or topalcan in usual doses 45 min-1 h after meals, usually 3-6 times a day and at bedtime, and/or motilium.
The course of treatment is 7-10 days, and it is necessary to combine an antacid and a prokinetic.

In most cases, with GERD without esophagitis, topalkan or motilium monotherapy is sufficient for 3-4 weeks (I stage of treatment).

In cases of inefficiency, a combination of two drugs is used for another 3-4 weeks (stage II).

If after discontinuation of the drugs any clinical manifestations of GERD reappear, however, much less pronounced than before the start of treatment, it should be continued for 7-10 days in the form of a combination of 2 drugs: antacid (preferably topalkan) - prokinetic (motilium) .

If, after discontinuation of therapy, subjective symptoms resume to the same extent as before the start of therapy, or the full clinical effect does not occur during treatment, one should proceed to the next stage of GERD therapy, which requires the use of H2-blockers.

In real life, the main treatment for this category of GERD patients is on-demand therapy, which most often uses antacids, alginates (topalkan) and prokinetics (motilium).

Abroad, in accordance with the Ghent Agreements (1998), there is a slightly different tactical scheme for the treatment of patients with endoscopically negative form of GERD.
There are two options for treating this form of GERD; the first (traditional) includes H2-blockers or/and prokinetics, the second involves the early administration of proton pump blockers (omeprazole - 40 mg 2 times a day).

At present, the appearance on the pharmaceutical market of a more potent analogue of omeprazole - pariet - will probably allow one to limit oneself to a single dose of 20 mg.
An important detail of the management of patients with GERD according to an alternative scheme is the fact that after a course of treatment, in cases of need ("on demand") or lack of effect, patients should be prescribed only representatives of proton pump blockers in lower or higher doses.
In other words, in this case, the principle of treatment according to the “step down” scheme is obviously violated (with a gradual transition to “lighter” drugs - antacid, prokinetic, H2-blockers).

With endoscopically positive form of GERD, the selection of pharmacological agents, their possible combinations and tactical treatment regimens are strictly regulated in the "Diagnostic Standards ...".

In case of reflux esophagitis I and II severity for 6 weeks, prescribe:
- ranitidine (Zantac and other analogues) - 150 - 300 mg 2 times a day or famotidine (gastrosidin, kvamatel, ulfamide, famocide and other analogues) - 20-40 mg 2 times a day, for each drug taken in the morning and evening with a mandatory interval of 12 hours;
- maalox (remagel and other analogues) - 15 ml 1 hour after meals and at bedtime, i.e. 4 times a day for the period of symptoms.
After 6 weeks, drug treatment is stopped if remission occurs.

With reflux esophagitis III and IV severity, prescribe:
- omeprazole (zerocide, omez and other analogues) - 20 mg 2 times a day in the morning and evening, with a mandatory interval of 12 hours for 3 weeks (for a total of 8 weeks);
- at the same time, sucralfate (venter, sukrat gel, and other analogues) is administered orally, 1 g 30 minutes before meals 3 times a day for 4 weeks, and cisapride (coordinax, peristylus) or domperidone (motilium) 10 mg 4 times a day for 15 minutes before meals for 4 weeks.
After 8 weeks, switch to a single dose in the evening of ranitidine 150 mg or famotidine 20 mg and periodic administration (for heartburn, feeling of heaviness in the epigastric region) of Maalox in the form of a gel (15 ml) or 2 tablets.
The highest percentage of cure and maintenance of remission is achieved with combined treatment with proton pump inhibitors (pariet 20 mg per day) and prokinetics (motilium 40 mg per day).

With reflux esophagitis of the V degree of severity - surgery.

With pain syndrome associated not with esophagitis, but with spasm of the esophagus or compression of the hernial sac, the use of antispasmodics and analgesics is indicated.

Papaverine, platifillin, baralgin, atropine, etc. are used in usual doses.
Surgical treatment is performed for complicated variants of diaphragmatic hernias: severe peptic esophagitis, bleeding, hernia incarceration with the development of gastric gangrene or intestinal loops, intrathoracic expansion of the stomach, esophageal strictures, etc.

The main types of operations are closure of the hernial orifice and strengthening of the esophagophrenic ligament, various types of gastropexy, restoration of the acute angle of His, fundoplasty, etc.

Recently, methods of endoscopic plastic surgery of the esophagus (according to Nissen) have been very effective.

The duration of inpatient treatment with I-II severity is 8-10 days, with III-IV severity - 2-4 weeks.

Patients with HEBR are subject to dispensary observation with a complex of instrumental and laboratory examinations at each exacerbation.

Prevention. The primary prevention of GERD is to follow the recommendations for a healthy lifestyle (the exclusion of smoking, especially "malicious", on an empty stomach, taking strong alcoholic beverages).
You should refrain from taking medications that disrupt the function of the esophagus and reduce the protective properties of its mucosa.
Secondary prevention aims to reduce the frequency of relapses and prevent the progression of the disease.
An obligatory component of secondary prevention of GERD is compliance with the above recommendations for primary prevention and non-drug treatment of this disease.
For the prevention of exacerbations in the absence of esophagitis or in mild esophagitis, timely therapy "on demand" remains important.

What causes GERD? Symptoms of uncomplicated GERD Complications of GERD How is GERD treated? Appropriate approach to GERD treatment Who is eligible for GERD surgery? Unresolved problems associated with GERD

How is GERD diagnosed?

1) Symptoms and response to treatment

A common sign of GERD is the presence of the characteristic symptom, heartburn. In most cases, heartburn is described as a burning sensation in the chest area, which occurs mainly after eating, and often worsens when a person is in a horizontal position. To confirm the diagnosis, specialists often treat patients with medications to suppress stomach acid production. If heartburn decreases, then the diagnosis of GERD can be considered confirmed.

However, there are problems with this approach, primarily because this approach does not include diagnostic studies. Patients whose condition closely resembles that of a patient with GERD, such as duodenal ulcers or gastric ulcers, may also have a reaction to such treatment. In this situation, peptic ulcer should be excluded. For example, infection with Helicobacter pylori or non-steroidal anti-inflammatory drugs (such as ibuprofen) can cause ulcers, and patients with this condition should be treated differently than those with GERD.

Moreover, as with any type of treatment, there is a 20% placebo effect, which means that 20% of patients will respond to any drug or treatment. This means that in 20% of patients whose symptoms were caused by other diseases, the symptoms improve after treatment for GERD. Thus, based on their response to treatment, such patients will continue treatment for GERD even if they do not have GERD. Moreover, the cause of such symptoms will not appear in the future.

2) Endoscopy

Endoscopy of the upper gastrointestinal tract (esophagogastroduodenoscopy or EFGDS) is the usual way to diagnose GERD. EFGDS is a procedure in which a tube with an optical system for observation is swallowed by the patient. As the tube progresses towards the lower gastrointestinal tract, the lining of the esophagus, stomach, and duodenum can be examined.

The esophagus of most patients with reflux symptoms appears completely normal. Therefore, for most patients, endoscopy will not help in the diagnosis of GERD. However, sometimes the lining of the esophagus looks inflamed (presence of esophagitis). Moreover, if there are erosions (shallow tears in the esophageal mucosa) or ulcers (deeper tears), the diagnosis of GERD can be made with certainty. Endoscopy can also reveal some complications of GERD, especially ulcers, stenosis, and Barrett's esophagus. You can also do a biopsy.

Finally, other pathologies that may cause symptoms similar to GERD (eg, ulcers, inflammation, stomach or duodenal cancers) may be identified.

3) Biopsy

A biopsy of the esophagus, which is obtained through an endoscope, is considered very informative in the diagnosis of GERD. A biopsy is important in diagnosing cancerous tumors or identifying cases of inflammation of the esophagus not associated with acid reflux, such as infections of the esophagus. Moreover, a biopsy is the only way to detect cellular changes in Barrett's esophagus. It has recently been suggested that even in GERD patients whose esophagus appears normal at first glance, a biopsy will show cellular changes.

4) X-ray studies

Before the advent of endoscopy, an x-ray of the esophagus (called an esophagogram) was the only way to diagnose GERD. Patients are given barium (a contrast material) and then an x-ray of the barium-filled esophagus is taken. The problem with the esophagogram was that it was a non-responsive test in the diagnosis of GERD. This means that the esophagogram could not detect signs of GERD in many patients, because the esophageal mucosa in such patients was slightly damaged or not damaged at all. X-rays revealed only infrequent complications of GERD, such as ulcers and stenosis. Over time, X-rays were abandoned and stopped being used in the diagnosis of GERD, despite the fact that it can still be used, along with endoscopy, in detecting complications.

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

General information

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

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

Causes of GERD

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

Pathogenesis

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

Symptoms of GERD

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

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

Complications

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

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

Diagnostics

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

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

Treatment for GERD

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

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

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

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

Forecast and prevention

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

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