How to treat gastroesophageal reflux. Gastroesophageal reflux disease (GERD) - conservative treatment. Study of the evacuation function of the stomach

4. There should be practically no alcohol in the diet, and especially fizzy drinks, dry wine, and any sweet soda. These drinks increase intragastric pressure, activate the production of acid in the stomach. Certain amounts of ethanol ingested relax the lower esophageal sphincter.

5. You need to stop overeating, and long gaps between meals are also harmful. It is better to eat less, but more often, and between the first and second courses you should make a gap of five to ten minutes. Immediately after eating, you should sit quietly or walk around, but you should not lean forward. Also, you can not take a horizontal position for two hours after a meal. Do not eat with a tight belt around your stomach. Dinner should be two to three hours before going to bed. Stop chewing at night. There is an opinion that one teaspoon of refined vegetable oil right before meals can alleviate the course of the disease.

Some doctors believe that for patients suffering from gastroesophageal reflux disease, it is these dietary rules and a healthy lifestyle that are more important than the products from which the menu is composed. You should also remember that you need to approach your diet taking into account your own feelings.

The consumption of a number of foods and drinks also reduces the activity of the lower esophageal sphincter, creating favorable conditions for the disease. These foods include: cocoa, coffee, tea, carbonated sweet drinks, juices from oranges, grapefruits, lemons, citrus fruits themselves, alcohol, milk, tomatoes and all their derivatives, garlic, onions, horseradish, spicy seasonings.

In addition, people who are often in a state of nervous overstrain, who are overweight, who take a number of medications, and who smoke, are more susceptible to this disease.

So, the main factor causing this disease is increased amount of acid in the stomach.

Surgery for GERD is called fundoplication. A more advanced method of treatment is laparoscopic surgery. They make it possible to operate on a larger number of those in need. If the patient has been suffering from reflux for less than twelve months, then he has a nine out of ten chance that the operation will completely normalize his condition. If the disease is more chronic, the operation helps from sixty to eighty percent of patients. It is very important that the function of the esophagus is not impaired.

Everyone knows that you need to eat right, but they adhere to the principles of rational nutrition - only a few, the rest suffer from excess weight, digestive problems or heartburn. According to the observations of gastroenterologists, heartburn, which is often a symptom of gastroesophageal reflux disease, is now becoming one of the most common complaints in diseases of the gastrointestinal tract. Most patients do not even suspect the existence of such a disease as GERD, seizing and drinking heartburn with a variety of foods or medicines and thereby only worsening the situation, and it is not so difficult to cure gastroesophageal reflux disease, the main thing is to take up treatment in time and not let everything go to waste. gravity.

Gastroesophageal reflux disease, reflux esophagitis, or GERD is X chronic relapsing disease of the digestive system. The disease is based on functional insufficiency of the upper gastric and other valves, which must hold the contents of the stomach and prevent acid from entering the higher organs.

Classification and stages of GERD

There are two main forms of gastroesophageal reflux disease:

non-erosive (endoscopically negative) reflux disease (NERD) - occurs in 70% of cases;
reflux esophagitis (RE) - the frequency of occurrence is about 30% of the total number of GERD diagnoses.

The condition of the esophageal mucosa is assessed by stages according to the Savary-Miller classification or by degrees of the Los Angeles classification.

There are the following degrees of GERD:

zero - symptoms of reflux esophagitis are not diagnosed;
the first - non-merging areas of erosion appear, hyperemia of the mucous membrane is noted;
the total area of erosive areas is less than 10% of the total area of the distal part of the esophagus;
the second - the area of erosion is from 10 to 50% of the total surface of the mucosa;
the third - there are multiple erosive and ulcerative lesions that are located over the entire surface of the esophagus;
fourth - deep ulcers occur, Barrett's esophagus is diagnosed.

The Los Angeles classification applies only to erosive varieties of the disease:

grade A - there are no more than several mucosal defects up to 5 mm long, each of which extends to no more than two of its folds;
degree B - the length of the defects exceeds 5 mm, none of them extends to more than two folds of the mucosa;
degree C - defects are spread over more than two folds, their total area is less than 75% of the circumference of the esophageal opening;
degree D - the area of defects exceeds 75% of the circumference of the esophagus.

Causes of GERD

Most often, gastroesophageal reflux disease develops due to the influence of several factors at once. In the etiology of GERD, the cause of the development of the disease and the factors contributing to its occurrence are distinguished.

1. Decreased tone of the cardiac sphincter- the muscle ring that is supposed to hold the acidic contents of the stomach can "relax" due to overeating, the habit of drinking large amounts of caffeinated drinks, smoking, regular alcohol consumption, and also due to the long-term use of certain drugs, such as antagonists calcium, antispasmodics, NSAIDs, anticholinergics, beta-blockers, antibiotics and others. All these factors contribute to a decrease in muscle tone, and smoking and alcohol also increase the amount of acid produced;

2. Increased intra-abdominal pressure- an increase in pressure inside the abdominal cavity also leads to the fact that the sphincters open and the contents of the stomach enter the esophagus. An increase in intra-abdominal pressure occurs in people suffering from excess weight; in patients with ascites, with diseases of the kidneys or heart; with flatulence of the intestines with gases and during pregnancy;

3. Peptic ulcer of the stomach and duodenum- Helicobacter pylori, which most often provokes the onset of the disease, can also cause the development of GERD or the disease appears during the treatment of ulcers with antibiotics and drugs that reduce the acidity of gastric juice;

4. Improper diet and poor posture- Excessive consumption of fatty, fried and meat foods causes an increase in the secretion of gastric juice, and due to difficult digestion, food stagnates in the stomach. If, after eating, a person immediately lies down or his work is associated with constant inclinations, the risk of GERD increases several times. This also includes the habit of eating "on the run" and addiction to fast food - at the same time, a lot of air is swallowed, and food enters the stomach almost not chewed and not ready for digestion, as a result, due to air, the pressure in the stomach increases, and digestion is difficult. All this causes a weakening of the esophageal sphincters and GERD may gradually develop;

5. genetic predisposition- Approximately 30-40% of all cases of GERD are due to hereditary predisposition, in such patients there is a genetic weakness of muscle structures or other changes in the stomach or esophagus. Under the action of 1 or more adverse factors, such as overeating or pregnancy, they develop gastroesophageal disease;

6. Diaphragmatic hernia A hiatal hernia occurs when the upper part of the stomach gets into the hole in the membrane where the esophagus is located. In this case, the pressure in the stomach increases many times and this can provoke the development of GERD. This pathology is most often observed in older people, after 60-65 years.

Symptoms of GERD

Once in the esophagus, the contents of the stomach (food, hydrochloric acid, digestive enzymes) irritate the mucous membrane of the esophagus, leading to the development of inflammation. It manifests itself with typical esophageal (esophageal) symptoms: heartburn, sour eructation.

Heartburn is a burning sensation behind the sternum, rising from the epigastric region upwards, can be given to the neck, shoulders, usually appears 1-1.5 hours after eating or at night. It intensifies after drinking carbonated drinks, when performing physical activity. Heartburn is often combined with belching.

Belching is caused by the flow of gastric contents through the lower esophageal sphincter into the esophagus and further into the oral cavity. It is manifested by a sour taste in the mouth. Like heartburn, belching also bothers you more in the supine position, with the torso leaning forward. Quite often there is an eructation of food eaten.

Odynophagia - pain when swallowing and during the passage of food through the esophagus. Dysphagia is a feeling of difficulty or obstruction in the passage of food. They occur with the development of complications of GERD - strictures (narrowing), tumors of the esophagus. Esophageal hiccups and vomiting are less common. Hiccups are caused by irritation of the phrenic nerve and frequent contraction of the diaphragm. Vomiting occurs when GERD is combined with duodenal ulcer.

There are extraesophageal symptoms. These include pain behind the sternum, in nature reminiscent of coronary (angina pectoris, myocardial infarction), palpitations, arrhythmias. The contents of the stomach can flow into the larynx at night, resulting in a dry, frequent cough, sore throat, and hoarseness. And when gastric contents are thrown into the trachea and bronchi, the respiratory organs are affected - chronic obstructive bronchitis, aspiration pneumonia, and bronchial asthma develop.

Symptoms appear and intensify after eating, physical exertion, in a horizontal position; decrease in an upright position after taking alkaline mineral waters.

Gastroesophageal reflux can also be observed in healthy people, mainly during the day after eating, but it is not long, up to 3 minutes, and does not cause pathological changes in the body. But if the symptoms bother you with a frequency of 2 or more times a week for 4-8 weeks or more, you need to consult a general practitioner, a gastroenterologist, to undergo an examination and make a diagnosis.

Diagnosis of the disease

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 establishes the degree of acidity of refluxes and how peristalsis works;

Gastroesophageal scintigraphy - the study examines the ability of the digestive organs to cleanse.

GERD: treatment

1. Lifestyle change. Includes sleeping with a raised headboard, eating at least an hour and a half before bedtime, avoiding food that provokes heartburn (fatty, starchy foods, citrus fruits, coffee, chocolate, carbonated drinks)

2. Inhibitors (blockers) of the proton pump (abbreviated as PPI, BPP). These drugs reduce the production of hydrochloric acid by the stomach glands. PPIs are not suitable for immediate relief, as their effect develops several days after the start of use.

Currently, PPPs are considered the drug of choice in most patients with GERD. This group should be used in patients with reflux disease in a course of 6-8 weeks. All proton pump inhibitors should be taken half an hour before meals 1-2 times a day.

The IPPs include:

Omeprazole (Omez) 20 mg 1-2 r / day;
Lansoprazole (Lanzap, Acrylanz) 30 mg 1-2 r / day;
Pantoprazole (Nolpaza) 40 mg once a day;
Rabeprazole (Pariet) 20 mg once a day. If necessary, you can take a constant dose of half.
Esomeprazole (Nexium) 20-40 mg once a day. Swallow without chewing, drink water.

3. Antacids. Preparations of this group quickly neutralize hydrochloric acid, so they can be used to eliminate heartburn at the time of its occurrence. Antacids can be prescribed for GERD as the only drug in cases where there are no erosions and ulcers, or antacids are used at first in conjunction with proton pump blockers, since the latter do not begin to act immediately.

Of the medicines in this group, dispensed without a doctor's prescription, the most well-proven:

Aluminum and magnesium hydroxide in the form of gels:

Maalox - 1-2 tablets 3-4 times a day and at bedtime, take 1-2 hours after meals, chewing or sucking thoroughly.
Almagel 1-3 dosing spoons 3-4 times a day. Take half an hour before meals.
Phosphalugel 1-2 sachets (can be diluted with 100 ml of water) 2-3 times a day immediately after meals and at night.

Sucking tablets: simaldrate (Gelusil, Gelusil varnish) 1 tablet (500 mg) 3-6 times a day an hour after a meal or situationally in case of heartburn, 1 tablet.

4. Alginic acid preparations have a quick effect (heartburn stops after 3-4 minutes), and therefore can be used for "ambulance" with the first symptoms of reflux disease. This result is achieved due to the ability of alginates to interact with hydrochloric acid, turning its foam with a pH close to neutral. This foam covers the outside of the food bolus, so during reflux it is she who ends up in the esophagus, where it also neutralizes hydrochloric acid.

If a patient with GERD does not have erosions and ulcers in the esophagus according to endoscopy, alginates can be used as the only treatment for reflux disease. In this case, the course of treatment should not exceed 6 weeks.

Alginates include:

Gaviscon 2-4 tab. after meals and at bedtime, chewing thoroughly;
Gaviscon forte - 5-10 ml after each meal and at bedtime (maximum daily dose of 40 ml).

5. Blockers of H2-histamine receptors of the III generation. This group of drugs also reduces the production of hydrochloric acid, but its effectiveness is lower than that of proton pump inhibitors. For this reason, H2 blockers are a "reserve group" in the treatment of GERD. The course of treatment is 6-8 (up to 12) weeks.

Currently used for the treatment of GERD:

Famotidine 20-40 mg 2 times a day.

6. Prokinetics. Since GERD results from impaired motility of the gastrointestinal tract, in cases where the evacuation of food from the stomach is slow, drugs are used that accelerate the passage of food from the stomach into the duodenum. Means of this group are also effective in those patients who have reflux of duodenal contents into the stomach, and then into the esophagus.

The drugs in this group include:

Metoclopramide (Cerukal, Raglan) 5-10 mg 3 times a day 30 minutes before meals;
Domperidone (Motilium, Motilak) 10 mg 3-4 times a day 15-30 minutes before meals.

At the end of the 6-8-week course of treatment, those patients who have not had erosion and ulcers of the esophageal mucosa are switched to the situational intake of proton pump blockers (better), or antacids or alginates. In patients with erosive and ulcerative forms of GERD, proton pump inhibitors are prescribed for continuous use, while the minimum effective doses are selected.

Alternative methods of treatment of GERD

To eliminate the described disease, you can use folk remedies. The following effective recipes are distinguished:

A decoction of flaxseed. Such therapy with folk remedies is aimed at increasing the stability of the esophageal mucosa. It is necessary to pour 2 large spoons of ½ liter of boiling water. Infuse the drink for 8 hours, and take 0.5 cups of nitrogen 3 times a day before meals. The duration of such therapy with folk remedies is 5-6 weeks;

Potato. Such folk remedies can also achieve a positive result. You just need to peel one small potato, cut it into small pieces and chew it slowly. After a few minutes you will feel relief;

A decoction of the root of marshmallow. Therapy with folk remedies, including this drink, will help not only get rid of unpleasant manifestations, but also have a calming effect. To prepare the medicine, you need to put 6 g of crushed roots and add a glass of warm water. Infuse the drink in a water bath for about half an hour. Treatment with folk remedies, including the use of marshmallow root, includes taking a chilled decoction of ½ cup 3 times a day;

In the treatment of folk remedies, celery root juice helps effectively. It should be taken 3 times a day, 3 large spoons. Alternative medicine involves a large number of recipes, the choice of a specific one depends on the individual characteristics of the human body. But treatment with folk remedies cannot act as a separate therapy, it is included in the general complex of therapeutic measures.

Dietary nutrition for GERD

Eating fewer meals in one sitting, chewing thoroughly, and avoiding certain foods can help relieve symptoms of GERD.

If you are experiencing heartburn or other symptoms of gastroesophageal reflux disease, there is a good chance that adjusting your daily diet will help you get rid of this disease.

Certain foods tend to make GERD symptoms worse. You can eat these foods less frequently or cut them out of your diet entirely. The way you eat may also be a contributing factor to your symptoms. Changing portion sizes and timing of meals can significantly reduce heartburn, regurgitation, and other symptoms of GERD.

What foods should be excluded

Consumption of certain foods and drinks contributes to the symptoms of GERD, including heartburn and sour belching.

Here is a list of foods and drinks that people with GERD should avoid at least some of:

These foods usually worsen GERD symptoms by increasing stomach acid.

Alcoholic beverages mainly cause GERD by weakening the lower esophageal sphincter (LES). This allows stomach contents to enter the esophagus and causes heartburn.

Caffeinated beverages such as coffee and tea usually do not cause problems when consumed in moderation, such as a cup or two a day.

Carbonated drinks can increase acidity as well as increase pressure in the stomach, which allows stomach acid to travel up through the LES and into the esophagus. In addition, many types of carbonated drinks contain caffeine.

The most problematic fatty foods include dairy products, such as ice cream, as well as fatty meats: beef, pork, etc.

Chocolate is one of the worst foods for people with GERD because it is high in fat, as well as caffeine and other natural chemicals that can cause reflux esophagitis.

Different people tend to have different reactions to individual foods. Pay attention to your diet, and if a certain food or drink gives you heartburn, just avoid it.

Chewing gum can help reduce GERD symptoms.

eating habits

In addition to changing your diet, your doctor may recommend that you change the way you eat.

Eat small meals, but more often;
Eat food slowly;
Limit snacking between meals;
Do not lie down for two to three hours after eating

When your stomach is full, eating extra food can increase pressure in your stomach. This can cause the LES to relax, allowing stomach contents to flow into the esophagus.

When you are upright, gravity helps keep your stomach contents from moving upward.

When you lie down, the aggressive contents of the stomach can easily enter the esophagus.

By waiting two to three hours after eating before lying down, you can use gravity to help control GERD.

One of the most common chronic diseases of the gastrointestinal tract is gastroesophageal reflux disease. This pathology is diagnosed in about a quarter of the world's population, and every year the number of cases is growing. This is primarily due to the lifestyle of a modern person, associated with stress and bad habits, as well as poor ecology.

The essence of the disease

In fact, speaking of gastroesophageal reflux disease (GERD), they mean reflux esophagitis. These are almost synonymous terms. It's just that GERD is a newer and more complete term that covers some additional forms of the disease. So, if reflux esophagitis requires the presence of erosive lesions on the esophageal mucosa, then one of the types of pathology considered in this article is gastroesophageal reflux without esophagitis, which is not characterized by similar formations on the walls of the tubular organ.

When referring to the abbreviation GERD in medical documents, they mean a whole range of symptoms resulting from reflux - that is, the reflux of stomach contents into the lower esophagus.

Under the influence of acid, and in some cases bile, the mucous membrane of this organ is injured, which leads to the formation of various degrees of damage on it.

Classification of the disease

According to modern classification, gastroesophageal reflux disease is divided into three types.

non-erosive form. It occurs most often and is the mildest. Does not imply the presence of erosive lesions on the walls of the esophageal mucosa. Like other forms of GERD, it is a chronic disease, but it is better treated (but worse diagnosed). The chances of getting a long-term remission are quite high. Non-erosive GERD predominantly affects men over the age of 40. In fact, we are talking about the 1st stage of the pathology, the lack of treatment of which inevitably leads to an aggravation of the situation and more serious damage to the walls of the tubular organ.
Gastroesophageal reflux with esophagitis is the 2nd form of the disease, suggesting pathological formations on the esophageal mucosa of the erosive type. Sometimes at this stage the situation is aggravated by the presence of ulcers.
- the third stage of the disease. It is considered a precancerous form. It is characterized by metaplasia of the squamous epithelium of the esophagus resulting from esophagitis. Patients who ignore the treatment of GERD at stage 1 and, especially at stage 2, have a high chance of getting this severe complication.

From the point of view of the severity of damage to the esophageal mucosa as a result of reflux, a classification has been made according to the degrees of the disease:

zero degree - no erosion (GERD without esophagitis);
1 degree - there are few erosions, they are in different places and do not merge with each other;
Grade 2 - erosions merge in some places, but the area covered by them is still not significant;
Grade 3 - the esophagus is seriously affected by erosions, they occupy the mucosa of the entire distal section;
Grade 4 - Barrett's esophagus.

Causes of the disease

The causes of GERD, no matter what degree according to the above classification, may be:

increased intra-abdominal pressure, often occurring in overweight people, ascites, flatulence, or in pregnant women;
hernia of the esophagus, which occurs in many older people;
weakening of the tone of the sphincter that connects the esophagus to the stomach;
malnutrition (excess of fatty, spicy, fried and other heavy foods);
abuse of alcohol, coffee, strong tea, carbonated drinks;
gastritis;
stomach or duodenal ulcer;
sluggish work of the salivary glands;
smoking.

Symptomatic picture

It is believed that GERD without symptoms is a common occurrence. Experts confirm this fact, but only if the early stage of the disease is meant. And even then, certain signs still often take place. Further, the symptomatic picture becomes more and more distinct, and a person's life becomes less qualitative. The patient is tormented:

heartburn;
sour taste in the mouth;
belching acid or without taste;
acute sore throat;
difficulty swallowing (up to pain);
a feeling of squeezing behind the sternum after eating a "heavy" meal or alcohol;
sore throat;
dry cough, annoying at night;
urge to vomit;
nausea;
chest pain radiating to other parts of the body (neck, shoulder, arm).

Symptoms worsen, as a rule, after eating (especially plentiful and unhealthy) or physical exertion, as well as in a horizontal position of the body, when it is easiest for gastric juice to enter the esophagus.

It should be noted that some of the above signs may appear from time to time in healthy people. They are provoked by malnutrition or, for example, alcohol. If this happens less than twice a week, in principle, you should not worry. Although it would not hurt to check just in case - perhaps there is still 1 (according to the generally accepted classification) stage of GERD.

Diagnostics

Gastroesophageal reflux disease is the responsibility of a gastroenterologist. It is to him that an appointment should be made if there are suspicions and diagnostics are necessary. The doctor will conduct a conversation with the patient, during which he will ask about disturbing symptoms and other existing diseases. Next, he will schedule an examination. The usual diagnostic methods in this case are:

a test using a proton pump inhibitor;
intrafood pH monitoring;
blood, urine, stool tests;
test for Helicobacter pylori, which often causes gastritis, ulcers.

If a patient is known to have been suffering from GERD with esophagitis for a long time and extremely disturbing symptoms (weight loss, severe pain, coughing up blood) have appeared, he may be prescribed fibroesophagogastroduodenoscopy, which will help identify cancer or a precancerous condition, if any. Such patients often do chromoendoscopy of the esophagus.

As additional measures, people with a diagnosis of GERD are often prescribed ECG, ultrasound of the heart and gastrointestinal tract; as well as consultations of such specialists as a surgeon, pulmonologist, cardiologist, ENT. The need for this arises if there is reason to believe that reflux esophagitis provoked the development of other diseases.

Treatment and prospects

Without exception, all patients are interested in whether GERD can be cured completely. This is a complex question with no clear answer. On the one hand, the disease is chronic, which makes the diagnosis lifelong. On the other hand, there is still hope.

If it was possible to detect an ailment in the embryo and only GERD of the 1st degree occurs, then with an adequate treatment regimen, the chances of achieving eternal remission are quite high. And then the disease will be considered chronic only formally. If GERD with esophagitis is diagnosed, then everything is much more complicated. But the probability of the longest possible remission remains in this case. The main thing is to follow all the recommendations of the attending physician and lead a healthy lifestyle. Many diligent patients forget about unpleasant symptoms, if not forever, then for decades.

According to experts, it is best to fight the disease during an exacerbation of GERD. "Sleeping" disease responds worse to therapy.

Of the medications for GERD, as a rule, antisecretory drugs, H2-histamine receptor blockers, prokinetics (if bile enters the esophagus in addition to gastric juice), as well as antacids that relieve symptoms, are prescribed.

Perhaps with gastroesophageal reflux disease treatment and alternative methods. But it should be auxiliary, and not the main character. The doctor may advise the patient to take decoctions of flaxseed or marshmallow root, potato juice or celery root, rosehip or sea buckthorn oils, and milkshakes.

If GERD is diagnosed, surgical treatment is rare. An operation may be prescribed if conservative therapy does not give results for a long time, serious complications have arisen, or the pathology is extremely neglected. For example, surgery is usually indicated for Barrett's esophagus, since it is no longer possible to cure the disease at this stage with the usual medication.

Treatment with folk remedies

In the treatment of GERD, medicinal plants are also used, which normalize the level of acidity of gastric juice, and also relieve inflammation of the esophagus. Some effective recipes:

Centaury tincture is an anti-inflammatory agent that helps restore damaged walls of the esophagus. It is necessary to pour 1 st / l of dry raw materials into 0.5 liters of boiling water, then close it hermetically, wrap it well with a towel. The infusion should be infused for half an hour. Drink twice a day for a quarter cup.
Green drink is a vegetable drink that normalizes digestion and also restores strength. To prepare it, you need to chop carrots, cucumber, radish leaves and tomato. Put everything in a blender, add pepper, salt (to taste). Drink once a day in a glass.
Decoction of plantain - you will need 6 tablespoons of dry plantain leaves, which are mixed with 4 tablespoons of St. John's wort and tablespoons of chamomile flowers. All this is brewed in a liter of boiling water and simmered for 15 minutes. Next, the broth is removed from the stove, infused for 30 minutes, filtered through cheesecloth. Used on st / l 3 times a day.

Diet and lifestyle

Patients diagnosed with GERD during treatment must adhere to a special diet and a healthy lifestyle. They will have to say "no" to alcohol, smoking, coffee, soda, fatty, spicy, smoked, salty, sour, spicy and other "heavy" foods. In the diet, mashed cereals and soups, lean meat, fish, and dairy products are desirable. Dishes should be steamed, baked or boiled.

It is highly not recommended to lie down after a meal, absorb a large amount of food in one sitting (it is ideal to eat a little bit 6 times a day), wear tight clothes, sleep in a horizontal position, do physical exercises that consist of bending over. If there are extra pounds, it is desirable to get rid of them.

Much of the above is GERD prevention and should be adopted by healthy people. As you know, the disease is easier to prevent than to cure, so you need to make every effort to prevent the development of pathology. Proper nutrition, the rejection of bad habits significantly reduce the risk of earning an illness. It should be remembered that complications of GERD can be very serious. These are obstructive bronchitis, and bronchial asthma, and even oncological lesions of the esophagus. Do not risk your health for the sake of dubious pleasures. After all, life is one, and GERD can become truly dangerous for her.

Many are familiar with the discomfort of heartburn, belching after eating, abdominal pain or a little higher after a hearty holiday meal. Can they be ignored or are they a sign of a serious illness?

GERD - what is it?

Gastroesophageal reflux disease is a disease caused by frequent reflux (reflux) of semi-digested food from the stomach or small intestine into the esophagus. At the same time, the mucous membrane of the latter is irritated by aggressive digestive components (hydrochloric acid, enzymes, bile, pancreatic juice), inflammation and unpleasant subjective symptoms occur.

The exact prevalence of the disease has not yet been established. After all, its main manifestation - heartburn - occurs with varying frequency both among adults and children. And the severity and severity of the process do not correlate with the intensity of the symptoms. This means that a patient with severe damage to the esophagus may not experience any discomfort at all, have no complaints and not seek medical help.

Causes of gastroesophageal reflux disease

Mucosal damage occurs due to several factors:

weakening of the anatomical antireflux barrier;
a decrease in the ability of the esophagus to quickly evacuate food to the underlying sections of the gastrointestinal tract;
decrease in the protective properties of the lining of the esophagus (production of mucus, alkaline components);
this or that disease of the stomach with excessive production of hydrochloric acid, the reflux of bile from the intestines up the digestive system.

Nature has provided many devices that protect against this disease. The esophagus "flows" into the stomach at an angle, it is covered by ligaments and muscle fibers of the diaphragm so that it is tightly fixed. From the inside, the mucous membrane has a special fold that acts as a valve that does not allow gastric contents to pass upward. In addition, the gas bubble is located in the stomach in such a way that there is no reflux of food.

In a healthy person, the muscular ring surrounding the transition of the esophagus to the stomach opens only occasionally for a few seconds to release excess swallowed air. Gastroesophageal reflux is not an outflow of air, but a reflux of liquid contents, it should not be normal. Defense mechanisms fail for a variety of reasons.

Excess in the diet of foods containing caffeine (coffee, tea, chocolate, Coca-Cola), citrus fruits, tomatoes, alcoholic and carbonated drinks, fatty foods.
A hasty and plentiful meal, in which large volumes of air are swallowed.
Smoking.
Some drugs: antispasmodics (No-shpa, Papaverine), painkillers, nitrates, calcium antagonists.
Damage to the vagus nerve (for example, with diabetes mellitus or after surgical dissection).
Violation of the chemical regulation of the function of the digestive system (excessive production of glucagon, somatostatin, cholecystokinin or other substances).
Other diseases - hiatal hernia, short esophagus, scleroderma.
Conditions accompanied by an increase in intra-abdominal pressure: pregnancy, overweight, chronic constipation, flatulence, ascites, prolonged cough, regular weight lifting.

Symptoms of GERD

The sensations of the patient can vary from the complete absence of signs of the disease to excruciating pains resembling those of the heart. Any combination of symptoms is possible.

Heartburn is a burning sensation behind the sternum that occurs when the mucous membrane of the esophagus comes into contact with the acidic contents of the stomach. As a rule, it also appears in healthy people, if you lie down immediately after eating.
Belching of air and regurgitation of food, aggravated by error in diet.
Pain behind the sternum, extending to the neck, jaw, shoulder, interscapular region, left half of the chest. The sensations can be very similar to the pain of angina pectoris.
Difficult or painful swallowing of food, sensation of a "lump" in the esophagus.
Possible obsessive hiccups, occasionally vomiting, which is usually a symptom of diseases of the stomach or intestines.

The so-called extraesophageal symptoms are distinguished - signs of the disease associated with the involvement of other organs in the disease. So, the contents of the stomach can be thrown quite high, up to the oral cavity, and end up in the respiratory tract. In this case, there is dryness and sore throat, hoarseness of voice, choking cough. If during a night's sleep there is leakage of digestive juices far into the respiratory tract, bronchitis or pneumonia develops.

GERD classification

According to the results of an additional examination, there are:

non-erosive reflux disease (no visible changes in the esophagus),
GERD with esophagitis (inflammation of the lining of the esophagus caused by regular reflux from the stomach).

Depending on the volume of affected tissues, 4 degrees of the disease are distinguished, from A to D.

Confirmation of the diagnosis

To distinguish GERD from other diseases, the attending physician will prescribe an examination.

FEGDS (fibroesophagogastroduodenoscopy) - examination of the esophagus, stomach and part of the duodenum using a special camera. In this case, a biopsy of the altered areas is necessarily taken (a small piece of tissue is excised and examined under a microscope).
An X-ray examination allows a good examination of the contours of the esophagus and reveals the existing anatomical anomalies.
Daily pH-metry - 24-hour monitoring of the acidity of the esophagus. It makes it possible to judge the frequency of refluxes and their intensity.
Esophageal scintigraphy helps to assess the rate of evacuation of the contrast agent (and, accordingly, food) down the gastrointestinal tract.
Manometry measures the strength of the muscular ring that surrounds the junction of the esophagus with the stomach.
Esophageal impedancemetry allows you to assess the intensity and direction of peristalsis (pushing muscle contractions).

It is not necessary that the person who applied for help will go through all of the listed procedures. Depending on the manifestations of the disease, only a part of them and some others can be prescribed.

Should gastroesophageal reflux be treated?

Even if there are no unpleasant symptoms, the disease must be treated, as it threatens with serious complications. Peptic ulcers are large and deep defects in the wall of the esophagus that occur due to constant exposure to aggressive substances. Ulcers can penetrate the wall through and cause inflammation in the surrounding tissues. The treatment of such extensive inflammation is complex and lengthy and necessarily requires hospitalization in a hospital.

Stories from our readers

Get rid of digestive problems at home. It's been a month since I forgot about the terrible pain in my stomach and intestines. Heartburn and nausea after eating, constant diarrhea no longer bother me. Oh, how many things I tried - nothing helped. How many times I went to the clinic, but I was prescribed useless medicines again and again, and when I returned, the doctors just shrugged. I finally got over my digestive problems, and it's all thanks to this article. Anyone with digestive issues should read this!

Bleeding occurs if a blood vessel is encountered along the path of the forming ulcer, and the esophagus is surrounded by several large wide veins. Bleeding can be very intense and quickly lead to death. Strictures are strong connective tissue scars at the site of chronic inflammation. They change the shape of the esophagus, narrow its lumen, significantly complicate swallowing even liquids.

Barrett's esophagus is a disease in which the esophageal mucosa changes its epithelium to gastric or intestinal. It is a precancerous condition.

Treatment for GERD

As with any chronic disease, it is important to make lifestyle adjustments when GERD is diagnosed. Otherwise, it will not be possible to cure reflux with drugs, and the time intervals between exacerbations will be short.

Eliminate a possible increase in intra-abdominal pressure - lifting weights, tight belts, belts and corsets.
Sleep on a high headboard.
Avoid overeating, especially in the evening. The latest meal should be 3 hours before bedtime.
After a meal, do not lie down or bend over. Try to stay upright and don't slouch. Small walks of 30 minutes are ideal.
Stick to a diet for GERD. Avoid fatty foods (whole milk, cream, pork, duck, lamb). Avoid caffeinated and carbonated drinks. Don't drink alcohol. Reduce the amount of citrus fruits, tomatoes, onions, garlic and fried foods on the menu. Do not abuse legumes, white cabbage and brown bread - they increase gas formation.
Talk to your doctor about any medications you take regularly.
Quit smoking.
Control body weight.

In addition to these measures, the doctor will tell you how to treat the disease with drugs. They will help to establish the passage of food in the gastrointestinal tract from top to bottom, reduce the content of hydrochloric acid in gastric juice, and accelerate the healing of existing defects. In uncomplicated cases, surgical treatment is usually not required.

Treatment with folk remedies

As part of complex therapy, herbal treatment is used, which accelerates the healing of epithelial defects and reduces the acidity of gastric juice.

Mix 6 tbsp. dry plantain leaves, 1 tbsp. chamomile flowers and 4 tbsp. hypericum herbs. The resulting dry collection pour 1 liter of boiling water and soak on low heat for a quarter of an hour. Let the broth brew, cool and strain. Use 1 tbsp. ready-made medicine half an hour before meals three times a day.

1 tbsp 500 ml of boiling water is poured over dried centaury herb, hermetically sealed, wrapped in a towel and insisted for at least half an hour. Medicinal infusion take 1/4 cup in the morning and evening.

Do not engage in self-diagnosis and self-treatment! Without the control of a specialist, folk methods can be not only useless, but also dangerous to health!

Gastroesophageal reflux disease (GERD) is a condition that is accompanied by unpleasant symptoms (heartburn, belching, dysphagia) and / or pathological changes in the esophagus (erosions, ulcers, cylinder cell metaplasia - Barrett's esophagus), caused by gastroesophageal reflux.

In a broad sense, the term "gastroesophageal reflux disease" applies to all patients with symptoms suggestive of reflux, while "reflux esophagitis" refers to a subgroup of patients with symptoms of GERD who also have endoscopic and histological evidence of an inflammatory process in esophagus.

The socioeconomic costs of GERD are significant. From an economic point of view, the high prevalence of GERD, combined with the cost of acid-reducing drugs, is costly to the health care system. Moreover, GERD greatly affects the quality of life. Studies have shown that the quality of life, the state of health in connection with reflux disease in those suffering from this disease, compared with the general population, is significantly deteriorating. A recent systematic review concluded that patients with persistent symptoms, even despite the use of PPIs, experience significant discomfort that negatively affects the physical and mental state of the person, comparable to that felt by patients who do not receive treatment for GERD. .

Epidemiology of gastroesophageal reflux disease (GERD)

More than a third of the entire US population report symptoms of GERD once a month or more. The situation is complicated by the fact that many patients with GERD do not have a clinic. There is an increase in cases of the disease in all regions of the world, the number of complicated forms is increasing.

Epidemiologists estimate the prevalence of GERD based mainly on the registration of typical manifestations in the form of heartburn and belching. This approach has some limitations and does not reflect the true prevalence because there are patients with endoscopically confirmed GERD (eg, esophagitis and Barrett's esophagus) who have neither heartburn nor regurgitation. What's more, some people complain of both but don't have GERD.

Symptoms that make you think of GERD are noted by many people, and the older the population, the more common the manifestations. A 2005 systematic review showed that the prevalence of GERD (measured by at least weekly occurrence of heartburn and/or sour regurgitation) in the Western world is as high as 10-20%, while in Asia it is less (5%). The incidence in Western countries is about 5 cases per 1000 person-years, which seems to be lower than the prevalence, but there is a chronic process here.

Without treatment, this very common pathology can lead to many esophageal complications, including erosive esophagitis, peptic strictures, Barrett's esophagus, and esophageal adenocarcinoma. Complications of GERD are thought to be more common in white-skinned men and older adults. In patients with classic symptoms of GERD, if endoscopic examination is performed, approximately 1/3 of cases reveal erosive esophagitis, 10% have benign strictures, and 20% have Barrett's esophagus. Fortunately, adenocarcinoma of the esophagus is found only in isolated patients.

Causes of gastroesophageal reflux disease (GERD)

The main damaging factor in the pathogenesis of GERD is the entry of stomach contents into the esophagus. Normally, such aggression against the inner lining of the esophagus is prevented by several mechanical barriers and physiological mechanisms.

The role of the main barrier is assigned to the NPS. LES is a segment of smooth muscle capable of tonic contraction in the distal part of the esophagus. The sphincter relaxes during swallowing and when the stomach is stretched. In this way, it promotes the release of air. The LES occasionally relaxes outside of swallowing. These relaxations are called transient relaxations of the lower esophageal sphincter (TRNS). They are characterized by a longer duration than the relaxation of the LES due to swallowing. In patients with GERD during TRNPS, not only air, but also liquid gastric contents have time to return to the esophagus - this is how acid reflux is formed. In most patients with GERD, an increase in the incidence of TRNPS is considered as the main mechanism of pathology, and it seems that TRNPS are even more typical for patients with obesity, although the reason for this is not clear.

Another mechanism that leads to failure of the gastroesophageal junction is a decrease in the tone of the LES, although only a small proportion of patients with GERD have severe hypotension of the LES. There are many factors that weaken NPS. These include distension of the stomach, the ingestion of certain types of food (fat, chocolate, caffeine and alcohol, etc.), smoking, many drugs (CCB, nitrates, albuterol, etc.).

The third factor is a hernia of the esophageal opening of the diaphragm. There are two main mechanisms that explain why the presence of a hernia leads to the development of GERD. The first is related to the loss of influence of the diaphragm legs, that is, the gain that they provide to the LES under normal conditions. The second is implemented through a decrease in the threshold for the occurrence of TRNPS in response to gastric distension.

Other important mechanisms that deserve attention include natural mucosal factors that protect the mucosa of the esophagus from acid reflux in normal conditions (mucus on the surface and bicarbonate as its component, surface lining with stratified squamous epithelium, tight intercellular contacts, blood flow), esophageal peristalsis and neutralization of residual acid with bicarbonate-containing saliva. Any defect in these mechanisms, including motor impairment and decreased salivary flow, can lead to the development of GERD.

With regard to extraesophageal manifestations of GERD, the mechanism of their occurrence is most likely to be direct aspiration of incoming contents with damage to the airway lining and/or a vagal reflex triggered by pathological acid reflux from the mucosa of the distal esophagus.

Symptoms and signs of gastroesophageal reflux disease (GERD)

The symptoms of GERD are extensive. A typical symptom complex includes heartburn and sour belching (feeling of sour stomach contents rising up to the throat). Atypical symptoms such as feeling of fullness, heaviness, epigastric pain, nausea, bloating and belching usually indicate GERD, but they can overlap with other conditions, so there is a whole list in the differential diagnosis: peptic ulcer, achalasia, gastritis, dyspepsia , paresis of the stomach. In addition, a set of symptoms not associated with the esophagus, but characteristic of GERD, is known. These include cough, dry wheezing when breathing, hoarseness, and sore throat, but all are nonspecific for GERD.

Rarely, dysphagia and hypersalivation occur - a symptom of a "wet pillow". Among the serious complications of the disease include peptic ulcer of the esophagus. The development of stenosis of the esophagus is accompanied by the appearance of dysphagia. Bitterness in the mouth indicates duodenogastroesophageal reflux with reflux of bile and alkaline contents.

Diagnosis of gastroesophageal reflux disease (GERD)

The diagnosis of GERD is based on a combination of a specific set of patient complaints, physical examination findings, including endoscopy and esophageal pH and/or antisecretory therapy. To formulate a preliminary diagnosis, it is quite enough to register symptoms such as heartburn and regurgitation. This symptom complex is the most reliable, that is, a preliminary diagnosis is based only on anamnestic data, so in practice there is no need to perform an exhaustive list of studies for every patient with heartburn and regurgitation.

When GERD is suspected in a symptomatic patient with no warning signs, a PPI is recommended as the first step in treatment. A positive PPI response confirms the diagnosis to some extent, although it cannot be considered a diagnostic criterion. Along with this, some patients deserve a deeper examination. Indications that force you to continue the diagnostic search include:

the need to confirm the diagnosis of GERD in patients refractory to drug therapy;
the presence of a reason to start identifying complications of GERD;
the likelihood of changing the diagnosis to an alternative one;
4 preoperative examination.

Upper GI endoscopy complements the diagnosis, especially if findings suggestive of erosive esophagitis, peptic strictures, or Barrett's esophagus are found. However, the majority of patients with typical symptoms of GERD (approximately 70%) do not have such symptoms. Endoscopic examination should not be performed in patients with warning symptoms. These include dysphagia, anemia, melena, and weight loss. It is extremely important to exclude such complications of GERD as peptic strictures and malignant tumor of the esophagus.

Ambulatory reflux monitoring is the only method that allows you to evaluate the intensity of acid exposure to the esophagus, the frequency of reflux reflux and the relationship of reflux to clinical manifestations. In the outpatient setting, reflux is monitored in two ways: using a telemetry capsule, which is either fixed in the distal esophagus (wireless pH capsule), or lowered on a transnasal probe (like a catheter), or by testing with a combined impedance-pH-metric probe. The telemetric capsule is fixed to the mucous membrane of the lower part of the esophagus during endoscopic examination of the upper gastrointestinal tract. The advantage of the capsule is that it allows you to record data for 48 hours (up to 96 hours if necessary). Catheter monitoring allows information to be collected over a 24-hour period and, if supplemented by the use of impedance with an appropriate transducer, it is possible to detect weak acid and non-acid refluxes. Both methods can be used with or without therapy. Experts continue to argue which of the methods should be called optimal.

Other complementary measures are often used as well, but routinely, and based on them alone, are not recommended for assessing GERD. For example, an x-ray of the esophagus with a barium swallow may be taken when the patient complains of dysphagia or strictures and ring-shaped narrowings are needed, but in other cases of GERD there is no indication for it. Esophageal manometry in GERD is also not suitable as a single diagnostic study, since neither low LES pressure nor movement disorders are specific to GERD. The main purpose of esophageal manometry in GERD is to exclude achalasia or changes in the esophagus similar to those seen in scleroderma before prescribing antireflux surgery, since both nosologies are on the list of contraindications.

The diagnosis is based on typical complaints (heartburn, sour eructation), endoscopy data (hyperemia, erosion, etc.) and daily intraesophageal pH-metry.

Informative alginate test - a single dose of Gaviscon, which relieves heartburn in patients with GERD with a sensitivity of 97% and a specificity of 88%.

A frequent severe complication of GERD is Barrett's esophagus - substitution in the lower third of the esophagus of the cylindrical epithelium of the esophagus. Diagnosis of Barrett's esophagus is carried out using a biopsy, narrow-spectrum endoscopy (Narrow Band Imaging), which gives an optical improvement in the image of the structure of the surface of the mucous membrane, magnifying endoscopy by 150 times, fluorescent endoscopy.

Differential diagnosis of gastroesophageal reflux disease

Peptic ulcer of the stomach and duodenum (peptic ulcer)
Non-ulcer dyspepsia
Esophageal motility disorders
Esophagitis of an infectious nature
Drug esophagitis
Eosinophilic esophagitis
Cardiovascular pathology
Diseases of the biliary tract
Esophageal carcinoma

It is most important to distinguish GERD, accompanied by burning pain, from angina pectoris. With GERD, the symptoms are associated with eating, bending over, the pain can be long-lasting, relieved after drinking water. With angina pectoris, pain is caused by physical activity or stress, may have a typical irradiation, disappears after the cessation of the load, taking nitroglycerin. Verify with the help of instrumental studies (ECG, stress tests and methods for examining the esophagus).

GERD is differentiated from chronic gastritis and peptic ulcer.

The characteristic clinical manifestations of esophageal cancer are dysphagia in the form of discomfort. The analyzes reveal the acceleration of ESR, anemia. A tumor is detected using barium radiography of the esophagus, esophagoscopy with biopsy, CT.

The number of patients with infectious esophagitis is increasing, which is due to the spread of immunodeficiencies. Esophageal candidiasis develops in patients with hemoblastoses, AIDS, with long-term treatment with steroids, antibiotics. Often combined with oropharyngeal candidiasis, which is manifested by pain during chewing and swallowing, when trying to put on dentures, loss of taste. Candida esophagitis is diagnosed by detecting white plaques and plaques on the esophageal mucosa during esophagoscopy and detecting yeast fungi with pseudohyphae during histological examination. If it is difficult to conduct these studies, for example, in patients with AIDS, a diagnosis is made by trial therapy with systemic antifungal drugs.

Complications of GERD

Benign esophageal stricture

Fibrous strictures develop as a consequence of long-term esophagitis. In most cases, they occur in elderly patients with poor peristaltic activity of the esophagus. There are symptoms of dysphagia, more pronounced for solid foods. Obstruction by a piece of unchewed food, for example, when eating meat, causes absolute dysphagia. A history of heartburn is common, but not necessarily: many older patients with strictures do not have prior heartburn.

The diagnosis is established by endoscopy, during which a biopsy can be taken to rule out a malignant neoplasm. Effectively endoscopic ballooning or bougienage of the esophagus. After this, long-term treatment with inhibitors of H + , K + -ATPase in a full therapeutic dose is necessary to reduce the risk of recurrence of esophagitis and re-formation of stricture. Patients are advised to chew food thoroughly, and for this it is important to have a sufficient number of teeth.

Volvulus of the stomach

Occasionally, a large hiatus hernia may twist through either the organoaxial or lateral axis, resulting in gastric volvulus. This leads to complete esophageal or gastric obstruction and is manifested by severe chest pain, vomiting, and dysphagia. Diagnosis is by chest x-ray (gas bubbles in the chest) and by contrast study after ingestion of barium sulfate. Many cases resolve spontaneously, but there is a tendency to relapse, so surgery after nasogastric decompression is indicated.

Management of a patient with gastroesophageal reflux disease

The management of a patient with GERD first of all requires clarifying the diagnosis with the help of FEGDS, identifying esophagitis (to make the last diagnosis, as a rule, one has to resort to a trial prescription of drugs that suppress acid formation). A biopsy of the esophagus (its mucous membrane) usually does not allow to prove reflux disease, but it can be used to characterize the inflammatory process, to identify changes in the esophagus.

In relation to patients who respond poorly to treatment, as well as complaining of chest pain, intraesophageal pH-metry lasting 24 hours is indicated.

Treatment of gastroesophageal reflux disease (GERD)

Treatment goals:

elimination of symptoms of the disease;
prevention and treatment of complications;
relapse prevention.

To prevent the occurrence of gastroesophageal reflux, dietary recommendations must be followed. Significantly limit fatty foods, including whole milk and cream, irritants that stimulate gastric secretion: alcohol, coffee, strong tea, chocolate, citrus fruits, onions, garlic, spicy, canned, smoked foods, carbonated drinks, acidic fruit juices.

Pathogenetic therapy involves reducing the damaging effect of acidic gastric juice. With rare attacks of heartburn, antacids (almagel, maalox, phosphalugel) can be used.

Alginates (Gaviscon) are effective, forming a gel barrier that floats in the stomach and creates a pH of about 7, and significantly reduces the frequency of reflux episodes.

To improve motor skills and prevent regurgitation, prokinetics are prescribed.

In refractory forms of GERD, alkaline reflux should be excluded, in the treatment of which prokinetics are effective.

Severe esophagitis, bleeding make one consider the possibility of fundoplication surgery, the effectiveness of which is not high enough due to relapses during the first year and the possible development of persistent dysphagia.

Barrett's esophagus may regress with effective therapy. However, the presence of intestinal metaplasia is considered a potentially precancerous condition. In this case, an annual endoscopic examination should be performed.

Most patients respond well to treatment with drugs that reduce or eliminate gastric acid secretion:

Drug therapy eliminates esophagitis and reflux symptoms, but drugs do not restore or normalize the antireflux barrier at the level of the transition between the stomach and esophagus. In this regard, discontinuation of medication usually leads to a surge in acid secretion (the “rebound” phenomenon) and, accordingly, to the development of a relapse.
Surgical interventions are offered as an alternative to conservative therapy and as a way that allegedly provides a clearer effect. However, modern methods of surgical treatment are not ideal, since the operation is always associated with certain health consequences, and, as a rule, it does not relieve the patient from the need to continue taking medication.
Currently, a number of endoscopic manipulations have been developed to improve the barrier function of the lower esophagus.

The treatment program for GERD includes changes in lifestyle and diet, drug therapy, and for a very specific group of patients, surgery. Depending on the severity of the disease, an approach is justified both towards the intensification of treatment and the gradual reduction in the severity of measures and their cancellation.

So, in the first case, they begin with a change in lifestyle and the appointment of BHRH. This tactic is suitable for patients with mild symptoms in the absence of signs of erosive esophagitis during endoscopic examination. On the contrary, the approach in the form of a gradual decrease in the intensity of therapy, which begins with the use of PPI, is more acceptable for patients with moderate or severe clinical picture, erosive esophagitis.

Antacids and alginates also give symptomatic improvement. H2 receptor blockers also relieve symptoms but do not cure esophagitis.

The drugs of choice for severe symptoms are H + , K + -ATPase inhibitors. Symptoms resolve almost completely, and esophagitis is curable in most patients.

When treatment is stopped, relapses often occur, and some patients need to take the drug for life at the lowest effective dose.

Antireflux surgery should be considered when drug therapy is ineffective in patients who refuse to take H + , K + -ATPase inhibitors for a long time, and in patients whose main symptom is severe regurgitation. The operation can be performed by open access or laparoscopically.

Recently, new endoscopic techniques for fundoplication have been developed.

Drug treatment of gastroesophageal reflux disease: "H + , K + -ATPase inhibitors are more effective than H 2 receptor blockers in the treatment of esophagitis and reducing the severity of symptoms"

Opportunities in the treatment of gastroesophageal reflux disease

Changes in lifestyle and dietary principles traditionally include the following measures: weight loss, elevating the head end of the bed, avoiding late evening meals, and eliminating dietary components that become reflux triggers (chocolate, caffeine, and alcohol). A 2006 systematic review of 16 randomized lifestyle trials for GERD found that weight loss and head-of-bed elevation alone improved esophageal pH and improved symptoms of GERD.

A decisive element in the conservative treatment of GERD is the elimination of the acid factor. This usually provides excellent results both in terms of healing of the esophagus and the elimination of clinical manifestations. BHR, suppress histamine-induced stimuli acting on the parietal cells of the stomach. These drugs are moderately effective and are sometimes used to enhance PPI therapy, in which case BGH2 is prescribed at bedtime to block nocturnal acid reflux. Unfortunately, against this background, tachyphylaxis very often develops, which limits the long-term effectiveness of such tactics. PPIs are more powerful suppressors of acid-forming function and, compared with BGR 2, heal the esophagus faster and reduce the frequency of relapses. The action of PPIs is to irreversibly suppress the pump in the form of H + -K + -adenosine triphosphatase at the final stage of acid production. Currently, seven members of the PPI group are known without any proven difference in their clinical efficacy. I would like the specialists, after a comprehensive discussion of the problem, to be able to offer the most optimal regimen for prescribing PPIs, which can provide the best results. To date, PPI therapy begins with a daily single dose 30-60 minutes before breakfast. If it was possible to achieve only a partial effect, then for a deeper suppression of the symptoms of GERD, the drug is prescribed in two doses or replace one PPI with another. Patients with recurrence of symptoms after discontinuation of PPIs and in cases where the disease proceeds with complications should be recommended long-term maintenance therapy. On the other hand, a number of studies have shown that patients without reflux with erosions and other complications of GERD can be successfully managed on PPIs with medication on an event basis, although there is still no pharmacokinetic justification for this approach.

Finally, there is a subgroup of patients with symptoms consistent with GERD but not responding to optimal conservative therapy. In this category of patients, it is important to undertake a more in-depth examination in order to differentiate patients with persistent acid reflux that persists despite the use of PPIs from those with other pathological processes other than GERD. The first step in treatment is to ensure the optimal dosage of the PPI and ensure that the patient adheres to the prescribed drug regimen. After that, it makes sense to increase the dose, switch to a double dose of medication, or change PPIs. If the clinical picture does not change, in order to exclude other possible variants of the pathology, EGDS is performed. In the case of negative endoscopic results, pH monitoring (using a wireless capsule or transnasal probe) is indicated. It will make sure that the diagnosis of GERD is correct. On the other hand, pH-metry is a method that will document the insufficient effectiveness of PPIs, will indicate the need for an increase in therapeutic measures (for example, in a trial additional prescription of BGH2, the addition of |3-GABA agonists, baclofen, which reduces the number of TRNPS and thereby reduces the amount reflux episodes) and will help decide on the appropriateness of surgical intervention. If there are no signs of GERD in a patient with characteristic symptoms, including heartburn, the identification of "functional heartburn" can be stated.

According to the Rome III recommendations, in order to settle on the diagnosis of functional heartburn, all the symptoms from the following list must be present: discomfort in the form of burning behind the sternum or pain; the absence of obvious signs of gastroesophageal acid reflux as a cause of heartburn; exclusion of histopathological changes that can disrupt esophageal motility. In such patients, it is reasonable to consider prescribing visceral analgesics such as TCAs, selective serotonin reuptake inhibitors, or trazodone, since esophageal hypersensitivity is theoretically the cause of functional heartburn.

Surgery is another treatment option for GERD. Before deciding on surgery, it is necessary to obtain objective confirmation of GERD by esophageal pH-metry or endoscopy, since the most pronounced positive effect of surgical treatment is observed in patients with typical symptoms, in whom PPIs are effective, and in the case when, with altered pH results -metry shows a clear correlation of this indicator with the manifestations of the disease. Good surgical outcomes are less likely in patients with atypical clinical presentation and extraesophageal manifestations.

According to the recommendations of the Society of American Gastroenterological Surgeons and Endoscopists, for some patients, surgical treatment has to be insisted upon receiving an objective confirmation of the diagnosis of GERD. Patients who do not respond to conservative therapy (poor symptom control or side effects of drugs) fall into this category; patients in need of surgical treatment, despite the success of conservative methods - due to the need for lifelong medication, the high cost of medications, the presence of complications of GERD; as well as patients with extraesophageal manifestations (cough, cases of aspiration, chest pain, etc.). Preoperative evaluation for patient selection for optimal outcomes includes upper GI endoscopy, esophageal pH and manometry, radiography with contrast, and, in selected patients, scanning with 4-hour gastric emptying of solids.

The most popular surgical intervention for GERD is laparoscopic Nissen fundoplication, however, in case of GERD against the background of pronounced obesity (body mass index - more than 35 kg / m 2), it is recommended to apply a gastric bypass, since "Nissen fundoplication is often ineffective. And, finally, for some patients, LES augmentation with the LINX Reflux system is the optimal solution.The operation consists of placing a titanium bead bracelet with a magnetic core around the LES through laparoscopic access. And finally, a method for endoscopic treatment of GERD has been developed, which consists in performing a fundoplication without incisions with access through the mouth, but there are still practically no data on the prospective effectiveness of this intervention.

Key aspects of patient management

Patients with typical manifestations of GERD in the absence of warning symptoms (eg, dysphagia) and symptoms indicating possible complications of GERD, it is reasonable to prescribe empirical therapy.
Ambulatory pH-metry (using a catheter or capsule) is the only way to objectively assess the degree of pH decrease in the esophagus and the ability to compare the patient's symptoms with episodes of acid reflux over time.
Before talking about surgical treatment, it is necessary to document the fact of gastroesophageal reflux, since the greatest effect of surgical treatment can be achieved in patients with typical symptoms, responding to PPI therapy, and in patients with abnormal pH values that clearly correlate with symptoms.