Reflux esophagitis - causes, symptoms, treatment and surgery.

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Gastroesophageal reflux disease
Reflux esophagitis

As a result of regularly repeated spontaneous reflux of gastric and/or intestinal contents into the esophagus, which have an irritating effect, an inflammatory process develops in the wall of the lower esophagus - reflux esophagitis. This chronic relapsing disease can be considered the most common among adults. Reflux esophagitis is diagnosed in 30% of adult patients, although the figures are very approximate, since many simply do not go to the doctor.

Causes of reflux esophagitis

The disease develops due to contact of the contents of the stomach and duodenum with the mucous membrane of the esophagus, which occurs when the lower esophageal sphincter, located at the border of the stomach and esophagus, is incompetent. As a result of impaired motility of the organs of the gastroesophageal zone, acidic gastric contents, being in the esophagus for a certain time, damage the cells of the mucosa.

Factors contributing to the development of reflux esophagitis are hiatal hernia - hiatal hernia, excess weight, pregnancy, leading to increased intra-abdominal pressure, taking certain medications, and smoking.

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Information about the disease

According to epidemiological studies, about 23.6% of the adult population suffers from gastroesophageal reflux disease in Moscow. The peculiarity is the chronic and recurrent nature of the disease. The reflux of gastric contents into the lower parts of the esophagus occurs spontaneously. At the point of contact with the mucous membrane, an inflammatory process develops, which becomes the cause of discomfort and poor health. In medical practice, the full name of the disease is gastroesophageal reflux disease (GERD).

Symptoms

The clinical picture depends on the severity of the inflammatory process and the condition of the esophageal sphincter; reflux esophagitis is accompanied by a complex of dyspeptic, pulmonary and cardiac disorders. The main symptoms of reflux esophagitis are:

Heartburn, manifested as a burning sensation behind the sternum, in the area of the xiphoid process, is the most characteristic symptom, occurring in more than ¾ of patients. Unpleasant and painful sensations can appear after eating, during physical activity, bending the body, and even in a horizontal position; wearing a tight belt can provoke heartburn.
Belching that occurs after eating or carbonated drinks is the second most common symptom of reflux esophagitis. It can appear even in a horizontal position of the body, but more often during physical activity.
Dysphagia is difficulty passing food that occurs when the motility of the upper parts of the digestive tract is impaired or when stricture is a narrowing of the lumen of the esophagus.
Odynophagia is a retrosternal or interscapular pain that occurs when food passes through the esophagus. Painful sensations can radiate to the intercostal space and even resemble an angina attack.
Regurgitation is regurgitation in which the contents of the stomach enter the oral cavity. Appears regardless of body position and physical activity of a person.

There are also extraesophageal manifestations involving other organs, e.g.

bronchopulmonary: cough, attacks of respiratory discomfort or suffocation at night; the cause is the entry of small particles of stomach contents into the bronchi;
otolaryngological: hoarseness, signs of rhinitis, pharyngitis due to refluxant entering the larynx;
dental: thinning of tooth enamel, caries as a result of the aggressive action of acid.

If left untreated, reflux esophagitis can cause severe complications. If the wall of the esophagus is damaged down to the submucosal layer, there is a risk of ulcer formation, which can cause bleeding. Scars formed after healing can lead to stricture, a narrowing of the esophagus.

The most severe complication is Barrett's esophagus syndrome - the squamous epithelium characteristic of the esophagus is replaced by a cylindrical epithelium characteristic of the gastric mucosa. With metaplasia, the likelihood of developing cancer increases by more than 30 times.

Presentation of symptoms and signs

Reflux esophagitis manifests symptoms and signs with varying degrees of severity, which depends on the stage of the disease:

heartburn (the most common manifestation);
pain in the chest near the heart;
lump in throat and difficulty swallowing;
frequent cough and inflammation of the respiratory tract;
weight loss;
hoarse voice;
poor sleep;
nausea and belching;
bloating;
vomit.

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Classification

To assess the patient’s condition and unify data, a classification is used; depending on the degree of damage to the esophagus, several stages of reflux esophagitis are distinguished.

I - rounded and longitudinal delimited, non-merging foci of inflammation, spreading to the mucous membrane of the esophagus from the Z-line - the border of the transition of the multilayered squamous epithelium of the esophageal mucosa into the columnar epithelium of the gastric mucosa;
II - lesions in the Z-line zone merge, but do not cover the entire circumference of the esophagus;
III - merging lesions covering the entire surface of the mucosa;
IV - chronic damage to the esophagus, in which fibrous stenosis, shortening of the esophagus, peptic ulcers, and Barrett's esophagus develop.

To determine the stage of reflux esophagitis, it is necessary to undergo an examination, based on the results of which treatment is prescribed.

Types of GERD, manifestations of the disease and complications

In the medical classification, two types of the disease are distinguished - acute and chronic esophagitis. It differs in the type of inflammatory process. In the acute phase, the walls of the esophagus are exposed, and in the chronic phase, the mucous membrane is affected, with the duration of the disease lasting more than 6 months. Reflux esophagitis begins to develop due to improper nutrition, exposure to chemicals, and extensive infections. In the acute phase, there may be an increase in temperature, general malaise, and discomfort as food moves through the esophagus. Patients experience drooling during attacks, belching, and pain. With alcohol abuse, spicy or rough foods, the inflammatory process progresses. The disease enters the chronic phase. If left untreated, the esophagus changes and scars form.

Diagnostics

There are various diagnostic methods that can accurately determine the degree of damage to the esophagus. This is evidenced by the presence of changes due to the inflammatory process, erosions, ulcers, strictures, and metaplasia. The main diagnostic methods include:

Fibrogastroscopy is an examination of the upper parts of the gastrointestinal tract using endoscopic equipment; during the procedure, it is possible to identify abnormalities in the wall of the esophagus, assess the condition of the mucous membrane, and exclude or confirm diseases of the stomach and duodenum. During the examination, a biopsy can be performed - taking tissue particles from visible pathological areas for the purpose of further histological examination.
X-ray examination allows you to detect a stricture of the esophagus, ulcerative lesions, hiatal hernia, its size, it is also possible to assess the motility of the esophagus and stomach, the presence of reflux during examination using a barium suspension.
Daily pH-metry - determination of the level of gastric secretion and the presence of reflux; it is possible to estimate the duration of reflux episodes, which allows you to select therapy and monitor the effectiveness of the drugs used.
Esophageal manometry is an examination that allows you to determine the tone of the esophageal sphincters and their patency based on measuring pressure in different parts.
pH impedansometry is a study aimed at assessing esophageal peristalsis and differentiation of gastroesophageal reflux, which is important for determining the nature of the disease and its cause.

Depending on the presence of certain symptoms, other examinations may be prescribed: ultrasound, ECG, consultation with an otolaryngologist, etc. In our clinic, patients have access to all the necessary diagnostic procedures, the examination takes a minimum of time.

Treatment of a patient with GERD

a set of recommendations for non-drug therapy (nutrition, lifestyle);
drug therapy:

GERD without esophagitis:

induction therapy: for rare (no more than 2 times a week) symptoms - antacids or H2-blockers (ranitidine 150-300 mg/day, famotidine 20-40 mg/day) on demand; for frequent symptoms - PPI in a standard dose (standard dose is determined according to Table 11 of Appendix 6 to this clinical protocol) 1 time per day in the morning 30-60 minutes before meals for 4 weeks. If the effect is insufficient, the dose is increased by 2 times (double dose). Additionally, if necessary, antacids are prescribed on an “on demand” basis. For non-erosive GERD with extraesophageal manifestations (chronic cough, bronchospasm, hoarseness) - PPI in a double dose for 12 weeks;
maintenance therapy: “on-demand” therapy - when clinical symptoms appear, a single dose of an antacid or an H2-blocker or a PPI in a standard dose (one of the above) or continuous maintenance therapy in the form of a daily half dose of a PPI.

GERD with esophagitis grade A-B:

induction therapy: double dose PPI (standard dose twice daily or double dose in the morning) for 4 weeks, then standard dose for another 4 weeks. If there is no effect, the dose is increased by 2 times. Additionally, if necessary, antacids in the “on demand” mode or prokinetics in standard doses;
maintenance therapy: PPI in a standard dose in an “on demand” mode; in case of ineffectiveness (relapses of esophagitis) - continuous therapy with half or a standard dose of PPI. The minimum duration of continuous therapy is 6 months. If continuous long-term use of PPIs is necessary, the presence of Hp infection should be assessed before starting preventive treatment, and if it is present, eradication therapy should be carried out.

GERD with CD grade esophagitis:

induction therapy: double dose PPI (standard dose twice daily or double dose in the morning) – 8–12 weeks. If the effect is insufficient, the dose is doubled. If necessary, additionally - antacids in the “on demand” mode;
Maintenance therapy: continuous use of PPI at a standard or half the standard dose (a dose is prescribed that ensures the absence of heartburn). The minimum duration of continuous therapy is 6 months. Before starting preventive treatment, the presence of Hp infection should be assessed, and if present, eradication therapy should be carried out.

Monitoring the effectiveness of GERD treatment

the effectiveness of induction therapy for non-erosive GERD is monitored by the disappearance of reflux symptoms within 2–4 weeks, and extraesophageal symptoms within 8–12 weeks;
healing of esophagitis is monitored endoscopically within 4–12 weeks (depending on the severity of esophagitis). It is possible to manage a patient without endoscopic control in case of grade A-B esophagitis and complete disappearance of reflux symptoms during treatment.

Dispensary observation of GERD

Patients with GERD with esophagitis C-D or Barrett's esophagus belong to the follow-up group D (III) and are subject to constant monitoring by a gastroenterologist or local physician (general practitioner).

The scope and timing of examination of a patient with gastroesophageal reflux disease with CD esophagitis during clinical observation are:

Once a year: medical examination to determine BMI, CBC, BIC (bilirubin, AST, ALT, iron), endoscopy;
Once every 2 years: endoscopy with multiple biopsies of the esophagus.

Other cases of GERD, except those listed above, belong to group D(II).

The criteria for the effectiveness of treatment and follow-up for GERD are the absence of clinical and endoscopic symptoms and early detection of complications.

Treatment

Conservative treatment is indicated for patients with mild manifestations. Drug therapy can be aimed at neutralizing the contents thrown from the stomach into the esophagus, reducing gastric acidity, and protecting the esophageal mucosa.

There are various drugs: antisecretory agents, prokinetics and antacids, but they can only eliminate the symptoms. At the end of the course of treatment, signs of the disease return again. It is also worth considering that long-term use of medications that suppress the production of gastric juice can lead to poor digestion of food, which will lead to a number of disorders. When using medications that affect acidity, the risk of malignancy increases.

Classification of acute and chronic esophagitis

Both forms of esophagitis are divided into several morphological types. They differ in the causes of occurrence and types of damage to the mucous membrane. Acute inflammation occurs as a result of bacterial damage, temperature exposure or the influence of toxic substances, as well as injury, for example, a foreign body entering the esophagus. The bacterial nature of inflammation is observed as a complication of fungal infection, scarlet fever, diphtheria, etc.

According to morphological characteristics, acute esophagitis is divided into the following types:

Catarrhal. The cause of this type of disease is exposure to unfavorable factors: hot food and drinks, spicy foods, toxic substances, rough hard foods, etc. Products with a high alkali or iodine content can also cause inflammation of the esophageal mucosa. Also, in some cases, the disease occurs due to physiological abnormalities: hiatal hernia, narrowing/insufficiency of organ parts, high pressure in the peritoneum. In this case, hydrochloric acid is thrown into the esophagus and provokes irritation, and as a result, an inflammatory reaction.

Erosive, ulcerative. Treatment of erosive esophagitis seems more complicated, since with this type of disease erosions or ulcers, sometimes erosions and ulcers, appear on the surface of the mucosa, and there is a risk of bleeding, ruptures of the esophageal wall, and purulent processes. The causes of the disease are infections or aggressive substances that corrode the tissue of the organ lining.
Hydropic. This type of inflammation is a consequence of timely untreated catarrhal esophagitis. Inflammation is accompanied by increased swelling, narrowing of the lumen of the esophagus, and difficulty eating.
Hemorrhagic. The cause of the disease is viruses and bacterial infections. This is one of the types of erosive esophagitis, which may be accompanied by exfoliation of the mucous membrane. It manifests itself as severe bleeding and vomiting of blood.
Pseudomembranous. Provoked by infections, fibrous exudate appears on the inner surface of the esophagus.
Exfoliative. Occurs as a result of exposure to chemicals - alkalis or acids. It is fraught with complications in the form of suppuration or rupture of the esophageal wall.
Necrotic. It is the result of a response to infections. Large areas of the mucous membrane die off. They separate, forming long-term non-healing ulcers.
Phlegmonous. It is formed as a result of injury, for example, the entry of a foreign body, poor-quality endoscopic procedures and the addition of infection. It manifests itself in the form of a diffuse purulent process, which is very dangerous for health and life.

Depending on the areas of mucosal damage, the disease is classified into total, proximal and distal esophagitis.

Esophagitis is also divided depending on the duration/type of adverse effects:

Surgery

If conservative treatment is ineffective, if complications arise, if there is an esophageal hernia, as well as if there is pain behind the sternum or if there are extra-esophageal signs (cough, hoarseness, etc.), surgical treatment is recommended - fundoplication. The purpose of surgery for reflux esophagitis is to restore normal anatomical relationships in the area of the esophagus and stomach, creating a mechanism that will prevent the reflux of gastric contents into the esophagus.

Most surgeons in domestic clinics perform circular Nissen fundoplication; during the operation, a cuff is created - the fundus of the stomach is wrapped around the esophagus 360°, which prevents reflux in the future. But a valve formed in this way leads to the loss of natural protective mechanisms: the ability to regurgitate and vomit. Large portions of food and drinking carbonated drinks lead to the fact that, if necessary, their removal through the cardia is impossible, discomfort and pain appear. The formed cuff often slips off after 1-2 years, which leads to relapse of the disease.

Conservative therapy

For conservative therapy, the following groups of drugs are used:

antacids and alginates
proton pump inhibitors
prokinetics

Antacids and alginates

Antacids and alginates, topical preparations most often containing aluminum and magnesium salts, these drugs act locally, are not absorbed into the blood and do not have a systemic effect. Their advantage is safety of use, but there is also a disadvantage, a short duration of action. Antacids are not used as an independent method of treatment, but are used as first aid for heartburn, and as an intensification of therapy for the speedy healing of erosions and ulcers of the esophagus. Preparations in the form of gels with alginic acid have proven themselves to be the best, which, when interacting with acid in the lumen of the stomach, form foam, thereby increasing the duration of action of the drug and its effectiveness. Antacids are most often prescribed 40 minutes after meals and at night, or on demand in case of heartburn.

Proton pump inhibitors (PPIs)

Today they are the main drugs in the treatment of reflux esophagitis, these include the well-known omeprazole, lansoprazole, rabeprazole, etc. These are systemic drugs, they block the transport of hydrogen molecules into the parietal cells of the stomach, responsible for the secretion of hydrochloric acid, and how do we We remember from the school chemistry course, this acid consists of a molecule of hydrogen and chlorine, no hydrogen, no acid. These drugs have revolutionized the treatment of reflux esophagitis, significantly improving the outcome and reducing the number of complications. Previously, H2 histamine receptor blockers were used, which were much less effective and had more side effects. It must be said that these drugs are sometimes used now in combination with PPIs to enhance the effect. The main disadvantage of proton pump inhibitors (PPIs) is their fairly rapid removal from the blood, which requires repeated use throughout the day, and even with double use, so-called acid breakthroughs are described, when, more often at night, the acidity of gastric juice sharply increases. Most often, PPIs are prescribed 20 mg twice a day 20 minutes before meals, morning and evening for 6 to 8 weeks. Then maintenance therapy is prescribed at 10 mg per day or 10 mg twice a day.

Prokinetics

Prokinetics are drugs that improve and normalize peristalsis of the gastrointestinal organs, including the esophagus. The most commonly prescribed drug is itopride, which is considered the most effective and safe drug. Motilium is also prescribed. The previously popular cerucal has recently been deprecated due to its central effect on the brain. Prokinetics are prescribed 1 tablet three times a day 20 minutes before meals. A course of 2 weeks is recommended.

Problems of conservative therapy

The vast majority of patients with reflux esophagitis are treated conservatively, achieving good functional results, but unfortunately, therapy is not always effective. As we wrote above. The cause of reflux esophagitis is the reflux of gastric contents into the esophagus. So the first problem with conservative therapy is that it does not eliminate the cause, but only relieves the symptoms. With conservative therapy, reflux remains, but is no longer acidic, and therefore patients do not feel any complaints. Although some researchers believe that due to the neutralization of acid, bile begins to flow into the esophagus, since it ceases to be inactivated in the stomach, and bile is an even more aggressive environment for the development of complications of esophagitis. Although it should be noted that this is still a theory that has not received sufficient confirmation. But at the same time, a number of scientists associate the growth of esophageal cancer with this hypothesis. Since, despite the widespread use of PPI drugs, the incidence of esophageal cancer is steadily increasing.

Taking medications in itself can cause complications. Evidence has been obtained that proton pump inhibitors increase the risk of stroke, osteoporosis and heart attack, and although the risk is not quite high, about 0.4 - 0.6% per year, it is still there.

Well, perhaps the main thing is that the effect of conservative therapy is temporary and is not always sufficiently effective. So, 6 months after stopping therapy, complaints return in 40-50% of patients, and after 12 months in 80-90%, that is, most patients are forced to take medications daily for many years. Considering the sufficient safety of the drugs, this may not be scary, although it certainly reduces the quality of life. But the problem lies in the fact that with long-term therapy, after three or five years, the effectiveness of the drugs decreases and in 20 - 30% of patients complaints reappear and complications of esophagitis develop, despite the constant use of the prescribed drugs.

My approach to treatment

When surgically treating patients with reflux esophagitis, I, like most specialists in European clinics, use a more effective technique that does not have the above-mentioned disadvantages - partial Toupet fundoplication with a cuff rotation of 270°. The technique I improved has a number of advantages:

the physiological functioning of the esophageal sphincter is restored;
maintaining a functional esophagogastric valve allows the patient to do without medications throughout his life;
the ability to belch and vomit—the body’s natural defense reactions—is preserved;
no pain after overeating or carbonated drinks;
the number of relapses does not exceed 2% within a year after surgery, after 5 years this figure is about 4%.

A Russian Federation patent has been issued for an improved technique - Toupet 270° fundoplication.

Reflux esophagitis

Indications for hospitalization of patients with GERD

esophagitis grades C, D without complications or Barrett's esophagus (hospitalization of the patient to the therapeutic, gastroenterological departments of the district health care organization (hereinafter - RHO), city health care organization (hereinafter - GOZ), regional health care organization (hereinafter - OHO));
esophagitis with complications (bleeding, penetration, stenosis) (hospitalization of the patient to the surgical department of the ROZ, GOZ, OZ);
GERD with a course resistant to treatment and the need to clarify the diagnosis (hospitalization of the patient to the gastroenterology department of the state health department or public health unit).

How is the operation performed using a modified technique?

During the operation, a symmetrical cuff is formed from the upper part of the stomach, covering the esophagus at 270°. The anterior right side of the esophagus remains free; The cuff created in this way strengthens the lower esophageal sphincter and prevents the backflow of stomach contents. In the presence of a hiatal hernia, the lower part of the esophagus and the upper third of the stomach are first separated from the adhesions and returned to their natural position. The diaphragmatic hole is sutured to normal size. To prevent relapse and perform diaphragmocruroplasty, I use mesh implants, which reduces the risk of recurrence of the disease from 65% to 1%.

Surgery for reflux esophagitis is performed through laparoscopic access: all manipulations are performed through several small punctures on the anterior abdominal wall. In the future, the puncture marks become almost invisible. The operation is performed using endoscopic equipment equipped with a miniature video camera, which allows all manipulations to be carried out under visual control as accurately as possible. Since important structures (vagus nerve, blood vessels) are located in the surgical area, there is virtually no risk of damage to them.

During the operation, when isolating the esophagus and stomach, I use a dosed tissue ligation device LigaSure (USA), which is capable of “sealing” vessels without the risk of damage to surrounding tissues, as well as the development of bleeding. At the same time, the duration of the operation is reduced. The use of modern suture material promotes rapid recovery.

Publications in the media

Gastroesophageal reflux disease (GERD) is the development of inflammatory lesions of the distal part of the esophagus and/or characteristic symptoms due to repeated reflux of gastric and/or duodenal contents into the esophagus. Endoscopically positive gastroesophageal reflux disease—endoscopic examinations reveal reflux esophagitis. Endoscopically negative gastroesophageal reflux disease - there are no endoscopic manifestations of esophagitis.

Frequency. Symptoms of GERD are detected in almost half of the adult population, endoscopic signs - in more than 10% of people who have undergone endoscopic examination. Berrett's esophagus develops in 20% of patients with reflux esophagitis (0.4% of the population).

Etiology • Surgical interventions on or near the esophageal opening of the diaphragm: •• Vagotomy •• Resection of the cardia of the stomach •• Esophagogastrostomy •• Gastric resection •• Gastrectomy • Hiatal hernia • Peptic ulcer of the stomach and duodenum • Pylorospasm or pyloroduodenal stenosis • Scleroderma • Exogenous intoxications: •• Smoking •• Alcohol • Pregnancy • Drugs that can reduce the tone of the LES: •• Anticholinergic drugs •• B2-adrenergic receptor agonists and theophylline •• Calcium channel blockers and nitrates • Insufficiency of the cardiac sphincter in obesity.

Pathogenesis. Gastroesophageal reflux due to LES dysfunction. Variants and causes of dysfunction of the LES: • reduced tone of the LES at rest • prolonged or repeated transient relaxation of the LES • transient increase in intragastric and intra-abdominal pressure (with flatulence, constipation, obesity, pyloric spasm) • delayed gastric emptying • changes in esophageal motility • dilatation of the stomach • weakening mechanical factors supporting the antireflux barrier (diaphragmatic crura and cardioesophageal angle of His) • short esophagus.

Pathological anatomy • Changes are localized mainly in the distal part of the esophagus: •• limited (single erosions and ulcers without a tendency to merge) •• diffuse •• confluent, circularly covering the mucous membrane of the esophagus • In mild cases - moderate hyperemia and edema of the mucous membrane • In severe cases course - erosions, ulcers, scars, shortening of the esophagus, columnar cell metaplasia of the epithelium (Berrett's ulcer), longitudinal wrinkling of the esophagus (Berrett's syndrome) • In 8–10% of cases, ulcers become malignant.

Classification of reflux esophagitis • Grade A - one (or more) mucosal lesion less than 5 mm, limited to the mucosal fold • Grade B - one (or more) mucosal lesion more than 5 mm, limited to the mucosal fold • Grade C - one (or more) mucosal lesions extending to 2 or more mucosal folds but occupying less than 75% of the esophageal circumference • Grade D—one (or more) mucosal lesions extending to 75% or more of the esophageal circumference.

Clinical picture • Heartburn is the most characteristic symptom (83% of patients), appears as a result of prolonged contact of acidic (pH <4) gastric contents with the mucous membrane of the esophagus. Heartburn increases with errors in diet, drinking alcohol, carbonated drinks, physical stress, bending over and in a horizontal position • Belching increases after eating, drinking carbonated drinks • Regurgitation of food increases with physical stress and in a position conducive to regurgitation • Dysphagia of an intermittent nature, which is associated with hypermotor dyskinesia of the esophagus • Pain in the epigastrium (in the projection of the xiphoid process) or behind the sternum - appears soon after eating, intensifies when bending the body, in a horizontal position • Less commonly, odynophagia occurs, a feeling of a lump in the throat when swallowing, pain in the ear and lower jaw, chest pain that can be provoked by physical activity • Extraesophageal manifestations of GERD - chronic cough, pneumonia, dysphonia, broncho-obstruction, dental erosion, etc. - are caused by the ingress of gastric contents onto neighboring organs and the vagal reflex between the esophagus and the lungs.

Diagnostics • X-ray examination lying on the back or in an upright position with a strong anterior tilt of the patient: reflux of barium sulfate into the distal parts of the esophagus, X-ray picture of esophagitis • Endoscopic examination with biopsy: reflux esophagitis of varying severity, prolapse of the gastric mucosa into the esophagus, true shortening esophagus, reflux of gastric and/or duodenal contents into the esophagus. In the case of endoscopically negative GERD, there are no signs of esophagitis • Esophagotonokymography (manometry) - decrease in expiratory sphincter pressure, destructuring of the sphincter, increase in the number of transient relaxations of the LES, decrease in the amplitude of peristaltic contractions of the thoracic esophagus • Daily pH-metry - the main method for diagnosing GERD and monitoring the effectiveness of treatment . It is recommended to evaluate: the total time of reduced acidity with pH<4 (the most significant criterion) in a standing and lying position; total number of refluxes per day; number of reflux lasting more than 5 minutes; duration of the longest reflux • Bilimetry is performed to identify alkaline (bile) reflux • Scintigraphy is indicated to identify motor-evacuation disorders of the esophagus • Omeprazole test - clinical symptoms of GERD are significantly reduced within 3-5 days of daily intake of 40 mg omeprazole • Bernstein test - if present GERD injection of 0.1 N HCl solution into the esophagus leads to the appearance of clinical symptoms, incl. and in the case of endoscopically negative GERD.

TREATMENT

Non-drug measures • Lifestyle changes •• Smoking cessation •• Normalization of body weight •• Raising the head end of the bed •• Avoid stress on the abdominal muscles, bending the body, wearing tight belts • It is undesirable to take drugs that reduce the tone of the LES (nitrates) , calcium antagonists, theophylline, progesterone, antidepressants) • Diet: limiting foods that increase gas formation, spicy, very hot or cold foods; avoid drinking alcohol, foods that reduce the tone of the LES (onions, garlic, pepper, coffee, chocolate, etc.); Avoid overeating, last meal no later than 3-4 hours before bedtime.

Drug therapy is carried out for at least 8–12 weeks, followed by maintenance therapy for 6–12 months • Antacids and alginates •• Usually prescribed 1.5–2 hours after meals and at night •• Effective in the treatment of moderate and infrequent symptoms • Prokinetics - domperidone, metoclopromide, cisapride 10 mg 4 times a day • Proton pump inhibitors (omeprazole, lansoprazole, rabeprazole) in regular or double dosage. In cases of severe esophagitis, they are usually required to be prescribed in combination with prokinetics.

Surgical treatment • Indications for surgical treatment •• Complications of GERD (esophageal strictures, recurrent bleeding, Berrett's esophagus) •• Ineffectiveness of drug therapy in young patients •• Combination of GERD with bronchial asthma, refractory to adequate antireflux therapy • Antireflux operations, such as Nissen fundoplication .

Complications • Benign stricture of the esophagus • Ulceration of the esophagus • Bleeding from latent to profuse from the ulcerated mucous membrane of the esophagus • Cicatricial changes in the esophagus, up to its shortening and stenosis • Laryngospasm • Pulmonary aspiration • Berrett's esophagus.

Abbreviations. GERD - gastroesophageal reflux disease; LES - lower esophageal sphincter

ICD-10 • K21 Gastroesophageal reflux

Appendix • Berrett's syndrome is a chronic peptic ulcer of the lower esophagus with an epithelium resembling that of the cardial mucosa; esophageal stricture, most often develops as a result of gastroesophageal reflux “Berretta's esophagus • Berretta's esophagus is a complication of GERD in the form of metaplasia of the mucous membrane of the distal esophagus into the small intestinal epithelium. Berrett's esophagus is considered a precancerous condition • Schatzki rings - membranes of the mucous membrane in the lower third of the esophagus, narrowing or closing its lumen, of unknown etiology; the disease is more common in patients with gastroesophageal reflux. Diagnosis - X-ray contrast study using barium sulfate confirms the diagnosis when constriction is detected in the lower part of the esophagus. Treatment is esophageal dilatation and antireflux surgery. The course is chronic, progressive. Synonym. Ring syndrome in the lower part of the esophagus. ICD-10. Q39.4 Esophageal membrane.

Advantages of laparoscopic surgery

Less traumatic and no pain in the postoperative period;
Short period of hospitalization - no more than three days;
Rapid recovery - after two weeks, patients return to their normal lifestyle.

Since patients often have other diseases that require surgical treatment, so-called simultaneous operations can be performed using laparoscopic access. I have been performing similar interventions for more than two decades. When performing a simultaneous operation during one anesthesia, you can immediately get rid of 2-5 surgical pathologies (for example, calculous cholecystitis, cholelithiasis, tumors, cysts, etc.).

Many, even experiencing painful attacks of heartburn, are in no hurry to see a doctor, trying to alleviate the condition in various ways, including with the help of medications. Is it necessary to treat reflux esophagitis if the symptoms are eliminated with the help of drugs that can be bought at any pharmacy? Of course, since there is a risk of developing severe complications. In addition, in the absence of adequate treatment, you will have to take medications throughout your life and adhere to strict dietary restrictions. At the same time, the effect of the drugs is very short-lived, and any physical activity immediately causes unpleasant and even painful sensations. To determine the extent of the disease and choose the most appropriate treatment tactics, just contact me by email or by scheduling a consultation.

Carrying out surgical interventions for diseases of the esophagus and stomach requires excellent command of surgical techniques, including endoscopic suture, which is impossible without appropriate experience. Over more than 25 years of experience, I have performed more than 2000 surgical interventions for reflux esophagitis, GERD and hiatal hernia. I am the author of monographs and more than 50 scientific papers devoted to these problems. I also regularly conduct seminars and master classes on these diseases, which are attended by specialists from various clinics and centers.

Reflux without pathology

The problem of reflux is familiar to every pregnant woman in the later stages of pregnancy. It is not associated with either infection or overeating. The fetus provokes the release of acid from the esophagus. The growing uterus with the unborn child inside puts pressure on organs, including the stomach, not allowing it to expand and accommodate food.

Forced to be in a constrained state, the stomach is unable to hold incoming food. As a result, acid and fragments of liquid food and drinks easily escape into the esophagus, especially when a pregnant woman is in a horizontal position.

Taking medications even from the antacid group is undesirable during pregnancy, as it can affect the course of pregnancy. Therefore, doctors recommend that pregnant women in their final stages eat frequently, but in small portions. After eating, sit or walk for 40-60 minutes. Do not drink a lot of liquid at one time, as it is easier for the drink to enter the esophagus when the size of the stomach is limited.

If split meals do not help get rid of the problem, you need to consult with your local doctor about choosing a safe option for neutralizing the acid.

Treatment of esophagitis

Treatment of non-erosive esophagitis consists of identifying the causes and influencing them (for example, fighting infection, removing a foreign body, replacing a constantly taken drug, etc.). For acid reflux, your doctor will prescribe a drug that suppresses or neutralizes acid production. Conservative therapy may include the following:

taking prokinetics, antisecretory, enveloping agents;
physiotherapeutic methods (electrophoresis, electrical stimulation, etc.);
laser treatment (endoscopic laser therapy).

Treatment of ulcerative esophagitis may include taking medications that accelerate healing, restoratives and other means.

Surgical treatment is required less frequently, only for strict indications, such as Barrett's esophagus, frequent bleeding, high risk of rupture, and mass formations of the esophagus.

Effective therapy is unthinkable without diet. The doctor selects it individually, taking into account risk factors, causes, and general health. Prohibited are alcoholic drinks, strong tea and coffee, citrus fruits, sour juices, and tomatoes. It is preferable to adhere to the principles of fractional nutrition, to refuse fatty foods, spicy, smoked foods, marinades, and sauces with the addition of vinegar. During periods of exacerbation, it is better to eat soft foods that will not disturb the mucous membrane of the esophagus.

There are a number of products that can speed up the healing of the mucous membrane. These include mashed potatoes, rice porridge, oatmeal, and egg whites. It is recommended to consume boiled chicken, low-fat broths, and herbal tea.

Prevention of esophagitis

The best prevention of esophagitis and other gastrointestinal diseases is:

Mode.
Proper nutrition.
Normalized intake of biostimulants.
Consuming warm (but not hot) food.
Quitting smoking and excessive alcohol consumption.
Do not take antibiotics or other drugs without a doctor's prescription.

In case of chronic esophagitis, the patient must undergo regular medical examinations from the attending physician and go to sanatorium-resort treatment once or twice a year.

This article is posted for educational purposes only and does not constitute scientific material or professional medical advice.

Consequences of esophagitis

Common complications of esophagitis:

phlegmon, abscess;
stenosis – narrowing of the esophagus;
perforation – rupture of the walls of the esophagus;
peptic ulcer (with Barrett's diagnosis);
metaplasia - degeneration of the surface epithelium of the esophagus (precancerous condition).

Timely diagnosis of the disease will help to avoid complications and irreversible pathologies in the gastrointestinal tract. After completing a course of therapy, the patient must follow a diet for a long time, the recommended diet and undergo a follow-up examination.