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

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

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

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

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

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

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

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

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

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

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

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

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

Provoking development factors this disease are:

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

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

GERD with reflux esophagitis

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

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

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

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

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

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

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

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

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

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

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

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

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

Symptoms of GERD with Esophagitis

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

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

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

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

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

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

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

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

Non-esophageal symptoms are the appearance of:

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

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

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

Treatment of GERD with Esophagitis

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

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

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

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

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

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

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

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

Surgical treatment

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

Surgical treatment is carried out in the presence of:

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

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

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

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

The causes of GERD without esophagitis are:

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

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

Useful video: how to treat GERD reflux esophagitis

Basics of dietary nutrition

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

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

findings

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

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

Causes of Reflux

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

Reflux disease symptoms

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

Complications

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

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

Diagnostic examinations

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

Treatment and prevention of GERD

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

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

Gastroesophageal reflux disease (GERD) is a chronic, relapsing disease caused bymotor-evacuation functions gastroesophageal zone and characterized by spontaneous or regularly repeated throwing of gastric and duodenal contents into the esophagus, which leads to damage to the distal esophagus and the appearance of characteristic symptoms (heartburn, retrosternal pain, dysphagia).

ICD-10:

K21 - Gastroesophageal reflux with esophagitis

K22 - Gastroesophageal reflux without esophagitis

Epidemiology

The true prevalence of the disease is little studied, which is associated with a large variability of clinical manifestations - from episodically occurring heartburn to clear signs of complicated reflux esophagitis. Symptoms of gastroesophageal reflux disease are detected by careful questioning in almost 50% of the adult population, and endoscopic signs - in more than 10% of individuals who have undergone endoscopic examination. Barrett's esophagus develops in 20% of patients with reflux esophagitis and occurs at a frequency of 376 per 100,000 (0.4%) of the population. The trend towards an increase in the incidence of GERD was the reason to proclaim the slogan at the 6th European Gastroenterological Week (Birmingham, 1997): "XX century - the century of peptic ulcer, XXI century - the century of GERD".

Etiology

GERD is a multifactorial disease. There are the following predisposing factors:

Obesity;

Pregnancy;

Smoking;

Hiatal hernia;

Medications (calcium antagonists, anticholinergics, P-blockers, etc.).

The development of the disease is associated with a number of reasons:

1) with insufficiency of the lower esophageal sphincter;

2) with reflux of gastric and duodenal contents into the esophagus;

3) with a decrease in esophageal clearance;

4) with a decrease in the resistance of the esophageal mucosa.

The immediate cause of reflux esophagitis is prolonged contact of gastric (hydrochloric acid, pepsin) or duodenal contents (bile acids, trypsin) with the esophageal mucosa.

Pathogenesis

Since the pressure in the stomach is higher than in the chest cavity, the reflux of gastric contents into the esophagus should be a constant phenomenon. However, due to the locking mechanisms of the cardia, it rarely occurs, for a short time (less than 5 minutes) and, as a result, is not considered a pathology.

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

Incompetence of the lower esophageal sphincter;

Transient episodes of relaxation of the lower esophageal sphincter;

Insufficiency of esophageal clearance;

Pathological changes in the stomach, which increase the severity of physiological reflux.

1. A group of factors that form the failure of the lower esophageal sphincter. The protective "anti-reflux" function of the lower esophageal sphincter (LES) is ensured by maintaining the tone of its muscles, the sufficient length of the sphincter zone and the location of a part of the sphincter zone in the abdominal cavity.

The pressure in the LES at rest is normally 10-35 mm Hg. Art., which exceeds the basal pressure in the esophagus and stomach cavity. The tone of the sphincter is influenced by the phases of breathing, body position, food intake, etc. So, at night, the tone of the lower esophageal sphincter is the highest; it decreases with food intake.

In a fairly large proportion of patients suffering from GERD, a decrease in basal pressure in the LES is detected; in other cases, episodes of transient relaxation of his muscles are observed.

It has been established that hormonal factors play a role in maintaining the tone of the LES. The relaxing effect of progesterone is believed to be a significant contributor to the development of GERD symptoms in pregnant women.

A number of medications and some foods help to reduce basal pressure in the LES and the development or maintenance of pathological reflux.

Drugs, food components, and "other harmful effects that reduce pressure in the lower esophageal sphincter

A sufficient length of the sphincter zone and the intra-abdominal segment of the LES also serves as an important antireflux factor. The total length of the sphincter zone is from 2 to 5 cm. With a decrease in this value and / or a decrease in the length of the intra-abdominal segment of the sphincter, which is influenced by positive intra-abdominal pressure, the likelihood of developing pathological reflux increases.

The location of part of the sphincter zone in the abdominal cavity, below the diaphragm, serves as a wise adaptive mechanism to prevent the reflux of gastric contents into the esophagus at the height of inhalation, at a time when increasing intra-abdominal pressure contributes to this. At the height of inhalation under normal conditions, the lower segment of the esophagus is “clamped” between the crura of the diaphragm. In cases of formation of a hernia of the esophageal opening of the diaphragm, the final segment of the esophagus is displaced above the diaphragm. "Clamping" of the upper part of the stomach by the legs of the diaphragm disrupts the evacuation of acidic contents from the esophagus.

2. Transient relaxation of the LES- these are episodes of spontaneous, not associated with food intake, a decrease in pressure in the sphincter to the level of intragastric pressure lasting more than 10 s. The reasons for the development of transient relaxation of the LES and the possibility of drug correction of this disorder are not well understood. A likely triggering factor may be stretching of the body of the stomach after a meal. It seems that it is the transient relaxation of the LES that causes gastroesophageal reflux in normal conditions and the main pathogenetic mechanism for the development of reflux in patients with GERD with normal pressure in the LES.

3. A group of factors contributing to a decrease in esophageal clearance. Due to the peristalsis of the esophagus and the secretion of bicarbonates by the esophageal glands, the natural clearance ("cleansing") of the esophagus from acidic contents is maintained, and normally the intraesophageal pH is not changed.

The natural mechanisms by which clearance is carried out are as follows:

Gravity;

Motor activity of the esophagus:

a) primary peristalsis (the act of swallowing and a large peristaltic wave initiated by swallowing);

b) secondary peristalsis, observed in the absence of swallowing, which develops in response to stretching of the esophagus and / or a shift in intraluminal pH towards low values;

c) salivation; bicarbonates contained in saliva neutralize the acid content.

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

4. Pathological changes in the stomach, which increase the severity of physiological reflux. Distension of the stomach is accompanied by a decrease in the length of the lower esophageal sphincter, an increase in the frequency of episodes of transient relaxation of the LES. The most common conditions in which there is stretching of the stomach against the background (or without) a violation of the evacuation of its contents:

Mechanical obstruction (most often observed against the background of cicatricial-ulcerative stenosis of the pylorus, duodenal bulb, tumor lesion) contributes to an increase in intragastric pressure, distension of the stomach and the development of pathological reflux into the esophagus;

Violations of the nervous regulation and relaxation of the body of the stomach during meals (most often as a consequence of vagotomy, a manifestation of diabetic neuropathy; with idiopathic gastroparesis observed after viral infections);

Excessive expansion of the stomach with overeating, aerophagia.

Clinic G astroesophageal reflux disease

The clinical manifestations of GERD are quite diverse. The main symptoms of the disease are associated with impaired motility of the upper gastrointestinal tract, including the esophagus, and hypersensitivity of the stomach to distension. There are also extraesophageal (atypical) manifestations of GERD.

The main symptoms of GERD:

Heartburn (burning) is the most characteristic symptom, occurring in 83% of patients. Characteristic of this symptom is an increase in heartburn with errors in diet, alcohol intake, carbonated drinks, physical activity.

tension, slopes and in a horizontal position.

Criteria for assessing the severity of GERD according to the frequency of heartburn:

Mild - heartburn less than 2 times a week;

Medium - heartburn 2 times a week or more, but not daily;

Severe - heartburn daily.

Belching, as one of the leading symptoms of GERD, is common, found in half of patients; aggravated after eating, taking carbonated drinks.

The spitting up of food seen in some GERD patients is aggravated by physical exertion and positioning that promotes regurgitation.

Dysphagia (difficulty, discomfort in the act of swallowing or inability to take a sip) appears as the disease progresses. The intermittent nature of dysphagia is characteristic. The basis of such dysphagia is hypermotor dyskinesia of the esophagus. The appearance of more persistent dysphagia and a simultaneous decrease in heartburn may indicate the formation of a stricture of the esophagus.

Odynophagia - pain during the passage of food through the esophagus - is observed with a pronounced inflammatory lesion of the mucous membrane of the esophagus. It, like dysphagia, requires differential diagnosis with esophageal cancer.

Pain in the epigastric region is one of the most characteristic symptoms of GERD. The pains are localized in the projection of the xiphoid process, appear soon after eating, intensify with oblique movements.

Some patients may experience chest pain, including angina-like pain. In 10% of patients with GERD, this disease is manifested only by chest pain, reminiscent of angina pectoris. In addition, chest pain in GERD, as well as in angina pectoris, can be provoked by exercise. Perhaps the development of the type of atrial fibrillation (violation of the rhythm of heart contractions). In this case, the patient feels discomfort, chest pain, shortness of breath, but taking antiarrhythmic drugs does not affect the intensity of the pain syndrome.

Symptoms associated with esophageal and gastric dysmotility and/or gastric hypersensitivity to distension include:

Feeling of early satiety, heaviness, bloating;

A feeling of fullness in the stomach that occurs during or immediately after eating.

Extraesophageal symptoms of GERD include:

Dysphonia;

Rough chronic cough;

Feeling of a lump in the throat;

dyspnea;

Nasal congestion and discharge;

Pressure in the sinuses;

- "facial" headache.

In addition, the disease can cause recurrent sinusitis, otitis media, pharyngitis, laryngitis, not amenable to standard therapy.

There are 2 main mechanisms that help explain the involvement in the pathological process of organs located near the esophagus:

1)direct contact associated with the ingestion of the contents of the stomach into neighboring organs, causing their irritation;

2)vagal reflex between the esophagus and the lungs.

For the occurrence of bronchopulmonary complications are of great importance:

Protective reflexes of the respiratory tract (cough, swallowing, vomiting, palatine);

Cleansing ability of the bronchial tree (mucociliary clearance).

Therefore, all aspiration complications in gastroesophageal reflux most often develop at night when the patient is sleeping. Aspiration is facilitated by taking sleeping pills, alcohol, and drugs.

Numerous foreign and domestic studies have shown an increase in the risk of bronchial asthma, as well as the severity of its course in patients with GERD.

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

Classification of clinical forms of GERD:

1. Non-erosive GERD.

2. Erosive GERD.

3. Barrett's esophagus.

Diagnosis of gastroesophageal reflux disease

Various tests and diagnostic methods are used to make a diagnosis.

1. A therapeutic test with one of the proton pump inhibitors (PPI) is performed within 7-14 days with the appointment of the drug in a standard dosage (omeprazole 20 mg 2 times a day). If heartburn, pain behind the sternum and / or in the epigastric region have disappeared during this period, then the diagnosis of GERD is considered confirmed. The therapeutic test with PPI can be used to clarify the condition of patients with bronchopulmonary and cardiovascular diseases, accompanied by chest pain. The disappearance or reduction of this symptom while taking a PPI may rule out heart disease and/or identify concomitant GERD. In some cases, a therapeutic test with PPI reveals endoscopically "negative" GERD, which often occurs in patients with extraesophageal symptoms of this disease.

2. A more reliable method for detecting gastroesophageal reflux is a 24-hour pH-metry of the esophagus, which allows to assess the frequency, duration and severity of reflux. Thus, 24-hour pH-metry is the "gold standard" for the diagnosis of gastroesophageal reflux.

3.Manometric study. Among patients with GERD, in 43% of cases, LES pressure is within normal limits, in 35% of cases it is reduced, and in 22% of cases it is increased. When studying the motor function of the thoracic (body) of the esophagus, in 45% of cases it turns out to be normal, in 27% of cases hypomotor is detected, and in 28% of cases - hypermotor dyskinesia. When conducting a correlation analysis between the data of endoscopic examination (stages of esophagitis) and manometry indicators, a positive correlation is revealed between the reduced pressure of the LES and endoscopic data (stages of esophagitis).

4. The main method for diagnosing GERD is endoscopic. Endoscopy can confirm the presence of reflux esophagitis and assess its severity.

According to the endoscopic classification of GERD, adopted in 2004, there are 4 stages of esophagitis:

I stage - without pathological changes in the mucous membrane of the esophagus (in the presence of symptoms of GERD), i.e. endoscopically "negative" GERD;

stage II - esophagitis (in the presence of diffuse changes in the mucous membrane of the esophagus);

III stage - erosive esophagitis;

IV stage - peptic ulcer of the esophagus (erosive-ulcerative esophagitis).

According to this classification, bleeding, peptic stricture of the esophagus, Barrett's esophagus, and adenocarcinoma are considered complications of GERD.

In addition, it may be noted:

Prolapse of the gastric mucosa into the esophagus, especially with vomiting;

True shortening of the esophagus with the location of the esophageal-gastric junction significantly above the diaphragm;

Reflux of gastric or duodenal contents into the esophagus.

5. Holding x-ray examination of the esophagus most appropriate in terms of diagnosing complications of GERD (peptic stricture, shortening of the esophagus, peptic ulcer), concomitant lesions (hiatal hernia, gastric and duodenal ulcers), as well as to confirm or exclude a malignant process.

6. Esophageal scintigraphy with a radioactive isotope of technetium. A delay in the ingested isotope in the esophagus of more than 10 minutes indicates a slowdown in esophageal clearance. The study of daily pH and oesophageal clearance allows you to identify cases of reflux before the development of esophagitis.

Complications of GERD

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

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

3. A serious complication of GERD is Barrett's esophagus, since this dramatically increases (30-40 times) the risk of developing the most serious complication of gastroesophageal reflux disease - adenocarcinoma. Against the background of cylindrical metaplasia of the epithelium, peptic ulcers often form and esophageal strictures develop. Barrett's esophagus is found at endoscopy in 8-20% of patients with GERD. Clinically, Barrett's esophagus is manifested by general symptoms of reflux esophagitis and its complications. The diagnosis of Barrett's esophagus should be confirmed histologically (detection in biopsy specimens of columnar rather than stratified squamous epithelium).

4. 2% of patients with GERD may develop moderate bleeding with intermittent relapses, which may last for several days and lead to severe anemia. Significant bleeding with the appearance of hematemesis or melena is uncommon. Venous bleeding may occur if erosions have developed against the background of esophageal varices in hepatological patients.

5. Perforation of the esophagus in GERD is rare.

Differential Diagnosis

GERD is included in the range of differential diagnostic search in the presence of unclear chest pain, dysphagia, gastrointestinal bleeding, broncho-obstructive syndrome.

When conducting a differential diagnosis between GERD and coronary heart disease, it must be borne in mind that, unlike angina pectoris, pain in GERD depends on the position of the body (occurs with a horizontal position and torso tilts), is associated with food intake, is stopped not by nitroglycerin, but by taking antacids and antisecretory drugs.

GERD can also provoke the occurrence of various cardiac arrhythmias (extrasystole, transient blockade of the legs of the bundle of His, etc.). Timely detection of GERD in such patients and its adequate treatment often contribute to the disappearance of these disorders.

Treatment of gastroesophageal reflux disease

The goal of treatment is to relieve symptoms, improve quality of life, treat esophagitis, and prevent or eliminate complications. Treatment for GERD can be conservative or surgical.

I. Conservative treatment

Taking antacids and alginic acid derivatives;

Antisecretory drugs (proton pump inhibitors and histamine H2 receptor blockers);

Prokinetics that normalize motility (activation of peristalsis, increased activity of the LES, acceleration of evacuation from the stomach).

Basic rules to be observed by the patient:

After eating, avoid bending forward and do not lie down;

Sleep with your head elevated;

Do not wear tight clothing and tight belts;

Avoid large meals;

Do not eat at night;

Limit the consumption of foods that cause a decrease in LES pressure and have an irritating effect (fats, alcohol, coffee, chocolate, citrus fruits);

Stop smoking;

Avoid accumulation of excess body weight;

Avoid medications that cause reflux (anticholinergics, sedatives and tranquilizers, calcium channel inhibitors, beta-blockers, theophylline, prostaglandins, nitrates).

2. Antacids and alginates

Antacid therapy aims to reduce the acid-proteolytic aggression of gastric juice. By increasing the intragastric pH, these drugs eliminate the pathogenic effect of hydrochloric acid and pepsin on the mucosa of the esophagus. Currently, alkalizing agents are produced, as a rule, in the form of complex preparations, they are based on aluminum hydroxide, magnesium hydroxide or hydrogen carbonate, i.e. non-absorbable antacids (phosphalugel, maalox, magalfil, etc.). The most convenient pharmaceutical form for GERD are gels. Usually drugs are taken 3 times a day after 40-60 minutes. after meals, when heartburn and retrosternal pain are most common, and at night. It is also recommended to adhere to the following rule: each attack of pain and heartburn should be stopped, since these symptoms indicate progressive damage to the esophageal mucosa.

In the treatment of reflux esophagitis, preparations containing alginic acid have proven themselves well. Alginic acid forms a foamy antacid suspension that floats on the surface of the gastric contents and enters the esophagus in case of gastroesophageal reflux, providing a therapeutic effect.

3. Antisecretory drugs

The goal of antisecretory therapy for GERD is to reduce the damaging effect of acidic gastric contents on the esophageal mucosa in gastroesophageal reflux. PPIs (omeprazole, lansoprazole, pantoprazole) have found the widest use in reflux esophagitis. By inhibiting the proton pump, they provide a pronounced and prolonged suppression of gastric secretion. Proton pump inhibitors are especially effective in peptic erosive-ulcerative esophagitis, providing scarring of the affected areas in 90-96% of cases after 4-5 weeks of treatment. Today, PPIs are called the main drugs in the treatment of GERD at any stage.

In some patients, when prescribing PPIs, it is not possible to achieve complete control over the acid-producing function of the stomach - with a 2-time intake of PPIs at night, gastric secretion continues with a decrease in pH<4. Данный феномен получил название «ночного кислотного прорыва». Для его преодоления дополнительно к 2-кратному приему ИПН назначаются блокаторы Н2-рецепторов гистамина (фамотидин) вечером.

It should be emphasized that antisecretory drugs, contributing to the healing of erosive and ulcerative lesions of the esophagus, do not eliminate reflux as such.

4.Prokinetics

Prokinetics have an antireflux effect. One of the first drugs in this group was the central dopamine receptor blocker metocloiramide. Metoclopramide increases LES tone, accelerates evacuation from the stomach, has a positive effect on esophageal clearance and reduces gastroesophageal reflux. The disadvantages of metoclopramide include its undesirable central action.

Recently, instead of metoclopramide in reflux esophagitis, domperidone, which is an antagonist of peripheral dopamine receptors, has been successfully used. The effectiveness of domperidone as a prokinetic agent does not exceed that of metoclopramide, but the drug does not pass through the blood-brain barrier and has practically no effect. side effects; appoint 1 table. (10 mg) 3 times a day for 15-20 minutes. before meals.

With reflux esophagitis caused by reflux of duodenal contents (primarily bile acids) into the esophagus, which is usually observed in cholelithiasis, a good effect is achieved when taking non-toxic ursodeoxycholic bile acid.

Currently, the main problems in the treatment of GERD are the following:

GERD is a "lifelong" disease in which there is a very low rate of self-healing.

In the treatment of GERD, high doses of drugs or their combinations are required.

High recurrence rate.

II. Surgical treatment of GERD

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

Indications for surgical treatment (antireflux operations):

1. Inefficiency of conservative treatment.

2. Complications of GERD (strictures, repeated bleeding).

3. Frequent aspiration pneumonia.

4. Barrett's esophagus (due to the risk of malignancy).

Especially often, indications for surgery occur with a combination

GERD with hiatal hernia.

The main type of surgery for reflux esophagitis is the Nissen fundoplication. Currently, methods of laparoscopic fundoplication are being developed and implemented.

Choice of treatment method associated with the course and cause of GERD. In 2008, the Asia-Pacific Consensus for the Treatment of Patients with GERD was published, the main provisions of which are currently used.

Outline of the Asia-Pacific Consensus for the Treatment of Patients with GERD (2008)

Reducing body weight and elevating the head of the bed can improve clinical symptoms in a patient with GERD. There is no convincing evidence to support other lifestyle recommendations (28:II-2, B)

The most effective treatment for patients with erosive and non-erosive forms of GERD is the use of proton pump inhibitors (29:1, A)

H2 blockers and antacids are indicated primarily for the treatment of episodic heartburn (30:1, A)

The use of prokinetics as monotherapy or in combination therapy with proton pump inhibitors may be useful for the treatment of GERD in Asian countries (31: D-C, C)

Patients with non-erosive GERD require continuous initial treatment with proton pump inhibitors for at least 4 weeks (32:III, C)

Patients with erosive GERD require continuous initial treatment with proton pump inhibitors for at least 4–8 weeks (33:III, C)

In the future, in patients with a non-erosive form of GERD, “on demand” therapy is adequate (34:1, A)

For patients with GERD who would like to stop permanent drug treatment, a fundoplication is indicated, provided that the operating surgeon has sufficient experience (35:1, A)

Antireflux surgery does not reduce the risk of developing malignancy in Barrett's esophagitis (36:1, A)

Endoscopic treatment of GERD should not be recommended outside of properly designed clinical trials (37:1, A)

Patients with chronic cough and laryngitis associated with typical GERD symptoms should receive proton pump inhibitors twice daily after ruling out non-GERD etiologies (38:1, B)

Prevention of GERD

Primary prevention is to follow the recommendations:

Healthy lifestyle (no smoking, drinking strong alcoholic beverages);

Proper nutrition (exclusion of a hasty meal, a large amount of write, especially at night, very hot and spicy food);

To refrain from taking a number of drugs that disrupt the function of the esophagus and reduce the protective properties of its mucous membrane, primarily NPS.

Target secondary prevention of GERD: reducing the frequency of relapses and preventing the progression of the disease.

The first and mandatory component of secondary prevention of GERD is to comply with the above recommendations for primary prevention and non-pharmacological treatment of this disease.

In addition, secondary prevention of GERD involves the following measures, taking into account the severity of the disease:

Dispensary observation of all patients with GERD with esophagitis;

Timely adequate pharmacotherapy for exacerbation of GERD;

Prevention of the development of cylindrical metaplasia (Barrett's esophagus);

Prevention of the development of esophageal cancer in Barrett's esophagus;

Prevention of the development of esophageal cancer in esophagitis;

Timely implementation of surgical treatment.

If you are sure of the presence of severe dysplasia, it is necessary to carry out surgical treatment.

Dysfunction of the esophagus, causing acid imbalance, has a negative impact not only on the upper gastrointestinal tract. Information about atypical clinical manifestations of gastroesophageal reflux disease (GERD) will help to choose an adequate therapeutic approach and prevent the development of complications.

Reflux is the physiological act of getting the contents of the stomach or the flow of gastric juice into the lower esophagus. A portion of a liquid or food slurry that has not been used for its intended purpose is called reflux. This phenomenon provokes excess pressure created in the stomach by food masses and (or) gases.

Under normal physiological conditions, gastric contents securely hold a special muscular valve at the border with the esophagus, the so-called lower esophageal sphincter (LES). The tone of the LES is regulated by fluctuations in the acidity of gastric juice: alkalization contributes to its disclosure and vice versa.
The main causes of reflux and the development of gastroesophageal reflux disease are:

• weakening of the motor functions of the esophagus;
• low muscle tone of the LES;
• excessive intra-abdominal pressure;
• disorders of gastric peristalsis;
• increased acidity of gastric juice.

These circumstances cause prolonged "acidification" of the esophagus, especially its lower section, and mucosal lesions. A feeling of constant heartburn or recurring attacks of heartburn suggest the development of GERD.

Symptoms of pathology

LPS deficiency is the root cause of the painful symptoms of GERD: both typical (heartburn, belching, and damage to the esophageal walls), clearly associated with the digestive tract, and atypical, associated with impaired respiratory functions - the so-called pulmonary symptoms of GERD.

Heartburn

The mucous membranes of the esophagus and stomach, although they are called the same, have a completely different structure and purpose. The ingress of acidic gastric juice on the esophageal walls is not a physiological norm. On the contrary, it becomes a sharp traumatic factor, leading to a burn.

A burning sensation in the sternum - heartburn - is a classic symptom of GERD, evidence of a persistent lesion of the esophageal walls, and the more extensive it is, the stronger and longer the attacks of heartburn. In some cases, the course of GERD does not cause inflammatory changes in the esophageal mucosa. The acidity of the reflux is crucial.

Prolonged irritation of the walls of the esophagus, causing constant heartburn, is an alarming symptom of GERD. In the future, it can lead to the formation of ulcerative lesions, the gradual thinning of the esophageal walls and their perforation (rupture). In such cases, urgent surgery is the only chance to save a person's life.

Belching

Often, dysfunction of the LES is accompanied by the release of gastric gases from the esophagus. This phenomenon occurs when the larynx is closed and is called belching. The volume of gas reflux is much greater than liquid reflux, as is the pressure it creates in the stomach. Gas reflux can cause the upper esophageal sphincter to open, reaching the larynx and even the oral cavity. This causes symptoms of GERD that at first glance have nothing to do with the digestive system.

In the case of reflux of gastric contents, the eructation has a pronounced sour taste. When reflux is cast from the duodenum, the bitter taste of eructation is due to the presence of bile acids and trypsin (pancreatic secretion).

Bile reflux is evidence of insufficiency of the lower valve of the stomach (pylorus), which separates the duodenum from the stomach, as well as diseases of the biliary tract.

Heartburn and chronic belching are typical but not the only symptoms of GERD. The adaptive reaction of the body to prolonged irritation of the mucosa becomes the degeneration of the tissues of the esophageal walls: their thickening, scarring, leading to a narrowing of the lumen of the esophagus, cell metaplasia.

Esophageal obstruction

The consequence of inflammatory processes is tissue scarring and narrowing (stricture) of the esophagus, which makes it difficult to move food masses, causing swallowing disorders (dysphagia). Over time, the movement of the food bolus begins to cause discomfort and pain when swallowing (odynophagia).

The causes of odynophagia, in addition to GERD, can also be:

• esophagitis of an infectious nature (fungal or viral lesions);
• tumors of the esophagus;
• chemical injuries of the esophageal walls.

In some cases, obstruction of the esophagus develops, leading to death from starvation.

Formation of a diverticulum

In some cases, a local expansion is formed over the site of narrowing of the esophagus, where food begins to accumulate. The greater the volume of accumulated food mass, the more the esophagus expands and its walls stretch. Part of the wall, consisting of submucosal and mucous tissue, protrudes in the form of a hernia - a diverticulum.

Which has a thin muscle layer, sometimes completely absent. Most often, diverticula form on the posterior wall of the esophagus. In the protruding part of the wall, food accumulates and an inflammatory process develops, which is accompanied by pain, bad breath and periodic regurgitation. In the event of a rupture of the diverticulum, the contents enter the surrounding tissues, the chest cavity, leading to tragic consequences.

Barrett's esophagus

Degeneration (metaplasia) of cells is a protective reaction of the body to regular damage to the upper layer of the esophageal mucosa. The lower third of the esophageal tube is most often affected.

The mucosal cells formed as a result of regeneration (recovery) are not identical to the former cells typical of this type of tissue. They are called atypical cells. The presence of such cells is a symptom of Barrett's esophagus, the first step towards the occurrence of malignant tumors, such as adenocarcinoma of the esophagus or stomach.

Congestion in the stomach: cause and effect of GERD

Digestive disorders in the stomach are caused by disorders of its motor activity. Depending on the nature of these disorders, the release of the stomach from the food mass can slow down or accelerate.

Reasons for slowing down the evacuation of food and stagnation in the stomach:

1. spasm of the pylorus caused by disorders of the nervous regulation of its muscles;
2. pyloric spasm caused by reflex irritations from other organs;
3. organic changes in the pylorus (presence of ulcers, scars, tumors, compression);
4. increased acidity of gastric juice;
5. relaxation of the stomach (atony).

Stagnation of food masses causes their bacterial decomposition. The accumulation of gases and decay products irritates the gastric mucosa, causing heartburn, a feeling of heaviness and fullness, and reflux phenomena. Abnormally rapid satiety, bloating, foul-smelling belching, and nausea are gastric symptoms of GERD.

The peristalsis of the stomach depends on the nature of the food, its temperature, consistency, and the presence of components that irritate the mucous membranes. For example, fatty acids and fat reduce the intensity of peristaltic waves, leading to a decrease in stomach tone.

Achalasia

Insufficient relaxation (persistent spasm of the LES) is a chronic disease - achalasia. It also leads to violations of the patency of the esophagus and the expansion of certain parts of it. Progressive achalasia leads to the development of inflammation of the esophageal mucosa (esophagitis) and heartburn. Heartburn in this case is not associated with GER, but with the formation of lactic acid as a result of the decomposition of food blocked in the esophagus.

Paradoxically, both insufficient and excessive relaxation of the LES causes similar symptoms:

• heartburn;
• rotten belching;
• chest pain;
• nausea;
• discomfort in the epigastric region;
• increased salivation.

Increased salivation

Increased salivation (hypersalivation) can cause inflammation in the oral cavity. But more often it is observed with reflex irritations of special secretory nerves by reflux products, it is a companion of inflammatory processes of the digestive tract, especially the abdominal organs.

Excessive salivation affects the formation of a bolus (a lump of food) and its impregnation with salivary mucus. A pathological increase in the amount of saliva neutralizes the acid reaction of gastric juice, reduces the intensity of gastric digestion, stimulates the development of fermentation, putrefaction, and further complicates the course of GERD.

Similar clinical symptoms: diagnostic difficulties

Chest pain in violation of the esophagus occurs in about half of the cases. It is associated with spasms of the muscular layer of the esophagus or pressure of voluminous food boluses in its expanded part. Sometimes pain is localized between the shoulder blades, simulating angina pectoris. Sometimes pain also radiates to the lower jaw and neck. The difference between chest pain associated with GERD and heart pain is that they depend on the position of the body, food intake and are copied by soda or alkaline mineral water.

Ischemic heart disease (CHD) occurs due to a lack of blood supply to the main heart muscle - the myocardium. One of the main symptoms is shortness of breath and chest pains of varying intensity and localization. The general innervation of the chest organs explains the similar nature of pain in GERD and coronary artery disease, complicates differential diagnosis, the choice of a therapeutic scheme and preventive measures.

The course of GERD may be accompanied by symptoms that at first glance are not associated with the gastrointestinal tract. Chronic (the so-called gastric) cough, discomfort when inhaling, dry wheezing in the lungs, shortness of breath and other respiratory disorders are a manifestation of the esophagotracheobronchial (for simplicity, let's call it a cough) reflex caused by the ingress of gastric contents into the respiratory tract.

Additional Information! Vagus receptors "react" to an irritant only in the presence of inflammatory changes in the mucosa, so the cough reflex and asthma attacks are not stimulated by physiological reflux.

To establish the cause of the cough and determine the method of treatment, the completeness of the anamnesis is of key importance. To date, two main causes of the cough reflex are known:

1. Irritation by gastric contents of special (vagal) receptors located in the lower esophagus. A cough of this etiology precedes the appearance of "classic" symptoms of GERD, it is dry, prolonged (up to several years) and greatly complicates the course of SARS.
2. Irritation of the receptors of the larynx, trachea and bronchi when reflux microparticles enter them (microaspiration). In this case, the typical symptoms of GERD occur more frequently and precede respiratory distress. As a result of irritation of the mucous membranes, signs of inflammation of the larynx, damage to the vocal cords appear: hoarseness, weakness of the voice, falsetto.

See a doctor immediately

The reason for a visit to the doctor is regular bouts of heartburn, pain, fetid belching, prolonged cough of an unknown nature, frequent pneumonia.

As well as coughing, vomiting blood, progressive weakness, weight loss, black stools.

The benign nature of the symptoms can only be assessed by a qualified specialist.

Note! Dysfunctions of the immune system sometimes provoke the development of eosinophilic esophagitis, similar in symptoms to GERD. Under these conditions, therapy with secretion-regulating drugs becomes ineffective.

The positive dynamics of the disease is caused by hormonal antiallergic drugs and a strict diet.

Treatment

Diagnosis of GERD involves antireflux therapy. The most informative and sensitive diagnostic method is daily pH-metry.

The main directions of drug therapy for GERD:

• restoration of esophageal motility (self-cleaning ability);
• decreased acidity reflux;
• protection of the esophageal mucosa (anti-inflammatory therapy);
• reduction in the number and duration of refluxes.

Drugs called histamine H 2 receptor blockers are not intended to prevent the phenomenon of reflux, but to reduce the acidity of the food mass at the time of its reflux into the esophagus. Before the advent of proton pump inhibitors (PPIs), they were the mainstay of treatment for GERD.

The most used blockers are cimetidine, ranitidine, nizatidine, famotidine. The effectiveness of drugs reduces their selective effect on one type of receptor, while acid production is stimulated by three of their varieties.

Attention! The abrupt cancellation of blockers can provoke a “recoil” - a jump in acidity.

Prokinetics are drugs that stimulate the motility of the esophagus and stomach. Domperidone, cisapride, metoclopramide are more effective in the initial stage of the disease, especially in combination with blockers.

Prolonged and effective suppression of gastric acidity is provided by PPIs, therefore they are the basis of the therapeutic regimen: these are rabeprazole, lansoprazole, omeprazole, esomeprazole (Nexium). The regimen and dosage depends on the set and severity of symptoms, but the first daily intake is indicated half an hour before meals. The drugs of this group retain a long-term therapeutic concentration in the blood, and the maximum therapeutic effect is achieved on the 2nd-3rd day of administration.

The mucosal protection function is performed by antacids (Maalox, Almagel, Phosphalugel), designed to quickly relieve the unpleasant symptoms of GERD in case of a diet or excessive physical exertion, to stop occasional attacks of heartburn.

To reduce the frequency and duration of GERD symptoms, alginic acid preparations - alginates are widely used. Reacting with stomach acid, alginates form a gel-like viscous mass that makes reflux impossible. It envelops the walls of the stomach and has a neutral reaction. One of the most popular drugs in this group is Gaviscon Forte.

When medical methods treatments do not bring results, and in the event of complications that are life-threatening for the patient, surgical methods of treatment are used - gastric fundoplication (laparoscopic or open), as well as the elimination of anatomical defects in the form of hiatal hernia as the cause of GERD.

Prevention

Prevention of GERD, like its treatment, is long-term and requires an integrated approach. Long-term remission of the disease is possible only with strict adherence to the diet and a radical change in lifestyle: a complete cessation of smoking and reasonable physical activity are necessary. Losing weight reduces the risk of hiatal hernia.

A high-protein diet and minimal (about 45 g per day) fat intake is shown. Products that irritate the gastric mucosa and stimulate acidity should be excluded from the diet. These are alcohol, spices, chocolate, coffee, carbonated drinks, sour fruits.

Food should be taken in small portions and no later than 2 hours before bedtime.

Tight uncomfortable clothing, excessive physical activity after eating impede the motility of the gastrointestinal tract, reduce the function of the LES as one of the regulators of the balance of the digestive system.

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.

What is GERD

Gastroesophageal reflux disease, reflux esophagitis, or GERD is chronic relapsing disease of the digestive system. Recently, scientists and clinicians have noted an increase in the number of patients with GERD, and, as a rule, the sick are successful, fairly young people living in large industrial centers, large cities and leading a sedentary lifestyle. In GERD, the acidic contents of the stomach and, more rarely, the duodenum enter the esophagus, causing irritation, gradually the esophageal mucosa becomes inflamed, it forms foci of erosion, and then ulcers. 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. According to scientists, GERD may well take the place of gastritis among diseases triggered by lifestyle, as the increase in the number of cases is due to a decrease in physical activity of people, bad habits and malnutrition.

Causes of gastroesophageal reflux disease

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 the reduction 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. malnutrition and wrong position body- 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

Most patients with GERD at the beginning of the disease are not even aware of their problem, the symptoms of the disease appear rarely, do not cause much inconvenience, and are rarely correctly diagnosed by patients. So, most patients believe that they have indigestion, gastritis or stomach ulcers.

The main symptoms of gastroesophageal disease

• Heartburn or the release of acidic stomach contents is the main symptom of GERD. Heartburn appears immediately after or some time after eating, the patient feels a burning sensation that spreads from the stomach to the esophagus, and with severe attacks feels bitterness and an unpleasant taste in the mouth. Heartburn attacks in GERD are not always associated with food intake, they can occur when the patient is lying down, at night, during sleep, when lifting, bending over and, especially, after eating heavy meat meals.
• dyspepsia syndrome- occurs in about half of patients with GERD, more often occurs in the presence of other diseases of the gastrointestinal tract. With dyspepsia, the patient feels pain and heaviness in the stomach, a feeling of fullness, nausea after eating, less often there is vomiting of sour or food.
• Pain behind the sternum- a characteristic symptom of GERD, helping to distinguish it from gastritis and ulcers. In gastroesophageal reflux disease, due to irritation of the esophagus with acid, patients experience severe pain and burning behind the sternum, sometimes pain in GERD is so intense that they are confused with attacks of myocardial infarction.
• Upper respiratory tract symptoms- less often in patients, due to constant irritation of the vocal cords and throat with acid, symptoms such as hoarseness and sore throat occur; dysphagia is a swallowing disorder in which patients feel a lump in the throat when they swallow or food gets stuck in the esophagus, causing severe chest pain. GERD can also cause persistent hiccups, coughing, and sputum production.

Diagnosis of GERD

Diagnosis of GERD is quite complicated, usually patients seek medical help quite late, when the disease goes into stage 3-4. The diagnosis of the disease is made on the basis of clinical signs: persistent heartburn, sour belching and after special studies that allow visualization of damage in the esophagus and disruption of the upper gastric sphincter:

• x-ray examination of the stomach with the use of functional tests - allows you to identify damage to the mucous membrane of the stomach and esophagus, as well as impaired motility;
• fibroesophagogastroduodenoscopy (FGDES) - allows the doctor to visually assess the degree of damage to the esophageal mucosa;
• esophageal manometry - pressure is measured in the distal esophagus, with insufficiency of the esophageal sphincter - the pressure in the stomach and esophagus is almost the same;
• a proton pump inhibitor test - the use of omeprazole or rabeprozole, which reduces the production of hydrochloric acid, reveals the presence or absence of GERD;

If it is difficult to diagnose the disease, other, more specific diagnostic methods are used: impedancemetry, electromyography, scintigraphy, intraesophageal pH monitoring, and others.

Treatment

The basis of the treatment of uncomplicated GERD, without severe damage to the esophageal mucosa, is lifestyle changes:

• complete cessation of smoking and drinking alcohol;
• change in diet - rejection of heavy, meat dishes, carbonated drinks, coffee, strong tea and any other products that provoke increased production of hydrochloric acid;
• change in diet - fractional meals - 5-6 times a day, in small portions;
• increased physical activity;
• normalization of weight;
• refusal to take such drugs, such as nitrates, calcium antagonists, beta-blockers and others.

If the patient suffers from severe heartburn, chest pain and other symptoms, he is prescribed: drugs that reduce the production of hydrochloric acid: proton pump inhibitors(omeprazole, rabeprozole), H2-histamine receptor blockers(famotidine), prokinetics(domperidone, motilium), antacids(phosphalugel, gaviscon forte).

Also, for the treatment of GERD, such folk remedies are used, such as a decoction of flaxseed and others.

In severe cases, with the ineffectiveness of therapeutic methods and in the presence of complications: cicatricial narrowing of the esophagus, ulcers, bleeding from the veins of the esophagus, surgical treatment is performed. Depending on the severity of the disease and the presence of complications, partial or complete removal of the esophagus, fundoplication or expansion of the esophagus is performed.