The term ” gastroesophageal reflux” refers to the reverse movement of the contents of the stomach, through the lower esophageal sphincter, into the esophagus.
The acidity index of the contents of the stomach is normally 1.5-2.0 (low acidity is due to the secretion of hydrochloric acid). In contrast, the contents of the esophagus have acidity levels close to neutral (6.0-7.0).
With the development of gastroesophageal reflux, the acidity in the esophagus significantly shifts towards lower values due to the ingress of the acidic contents of the stomach. Long contact of the mucous membrane of the esophagus with the acidic contents of the stomach, in addition, containing digestive enzymes, contributes to the development of its inflammation.
Bile acids, enzymes, bicarbonates, which are part of the contents of the duodenum, can also have a strong damaging effect on the mucous membrane of the esophagus. When these substances are thrown into the stomach, their movement into the esophagus can also be observed.
Gastroesophageal reflux is a normal physiological manifestation if it meets the following criteria:
- develops mainly after meals;
- not accompanied by discomfort;
- the duration of refluxes and their frequency during the day is small;
- at night the frequency of reflux is small.
Gastroesophageal reflux should be considered painful if it has the following characteristics:
- frequent and / or prolonged reflux episodes;
- reflux episodes are recorded during the day and / or at night;
- throwing gastric contents into the esophagus is accompanied by the development of clinical symptoms, inflammation / damage to the esophageal mucosa.
A number of factors contribute to the development of reflux of gastric contents into the esophagus. Among them:
- failure of the lower esophageal sphincter;
- transient episodes of relaxation of the lower esophageal sphincter;
- insufficiency of esophageal clearance;
- painful changes in the stomach, which increase the severity of physiological reflux.
The protective, “ antireflux ”, function of the lower esophageal sphincter is ensured by maintaining the tone of its muscles, a sufficient length of the sphincter zone and the location of a part of the sphincter zone in the abdominal cavity. A sufficiently large proportion of patients show a decrease in pressure in the lower esophageal sphincter; 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 lower esophageal sphincter. A number of medicines and some foods contribute to pressure reduction in the lower esophageal sphincter and the development or maintenance of reflux.
The location of a part of the sphincter zone in the abdominal cavity, below the diaphragm, serves as a wise adaptive mechanism preventing the gastric contents from being thrown into the esophagus at the height of the inhalation, at a time when increased intra-abdominal pressure contributes to this.
At the height of inhalation in normal conditions, there is a “clamping” of the lower segment of the esophagus between the legs of the diaphragm. In cases of formation of a hernia of the esophageal opening of the diaphragm, the final segment of the esophagus is shifted above the diaphragm. “Clamping” the upper part of the stomach with the diaphragm legs violates the evacuation of acidic contents from the esophagus.
Due to the reduction of the esophagus, the natural cleansing of the esophagus from acidic contents is maintained, and normally the intra-esophageal acidity does not exceed 4.
- esophageal motor activity;
- salivation; bicarbonates contained in saliva neutralize acidic contents.
Violations on the part of these links helps to reduce the “cleansing” of the esophagus from acidic or alkaline contents that have entered it.
Manifestations of gastroesophageal reflux are characterized by a variety of symptoms that can be observed in isolation and in combinations. According to the results of special studies, signs of gastroesophageal reflux are detected in 20-40% of people in developed countries (according to some data, in almost half of the adult population). Daily signs of gastroesophageal Reflux disease is experienced by up to 10% of the population, weekly – 30%, monthly – 50% of the adult population.
The most characteristic manifestations include:
- pain in the chest and in the left half of the chest;
- painful swallowing;
- prolonged cough, hoarseness;
- tooth enamel destruction
Unfortunately, the severity of clinical manifestations is far from fully reflecting the severity of reflux. In more than 85% of cases, episodes of decrease in intra esophageal acidity below 4 are not accompanied by any sensations.
Evaluation of changes in the esophagus with gastroesophageal reflux disease through esophagoscopy with biopsy allows not only to assess the degree of damage to the esophagus, but also to make a differential diagnosis with esophagitis.
X-ray examination of the esophagus with barium reveals anatomical disorders of the esophagus and stomach that contribute to the formation of gastroesophageal reflux (hernia of the esophageal opening of the diaphragm).
24-hour monitoring of intra-esophageal acidity plays an important role in confirming the presence of gastroesophageal reflux.
Therapeutic measures for gastroesophageal reflux disease should be aimed at reducing the severity of reflux, reducing the damaging properties of gastric contents, increasing esophageal cleansing, protecting the esophageal mucosa.
It is important to comply with general measures that contribute to the reduction of the severity of reflux of gastric contents into the esophagus. These include:
- normalization of body weight (in patients with overweight, this measure reduces the severity of the degree of insufficiency of the lower esophageal sphincter);
- exclusion of smoking, reduction of alcohol consumption, restriction of consumption of fatty foods, coffee, chocolate (these effects help reduce the tone of the lower esophageal sphincter, fatty foods slow down the activity of the stomach);
- the exclusion of acidic foods, which, as a rule, provoke the appearance of heartburn;
- food in small portions, regularly;
- food intake no later than 2 hours before bedtime;
- avoidance of loads associated with increased intra-abdominal pressure;
- sleep on a bed, the head end of which is raised by 10-15 cm.
With the ineffectiveness of such activities prescribed antacids. Antacids are a group of drugs containing aluminum, magnesium, calcium salts that neutralize hydrochloric acid. In addition, antacids are able to bind and reduce the activity of the digestive enzyme of gastric juice, bile acids and lysolecithin – which are part of the bile and have a damaging effect on the mucous membrane of the stomach and esophagus.
It is preferable to take antacids in the form of gels. In the lumen of the esophagus and stomach gels form small drops, which enhances their effect. Currently, Almagel , Phosphalugel , Maalox, Remagel are produced in the form of gels . These preparations contain aluminum salts or aluminum and magnesium salts in various ratios.
Antacids are taken 30 minutes before meals and at night (if possible, it is desirable to take the drug in the supine position, in small sips).
In the absence of the effect of taking antacids, as well as in the presence of endoscopic signs of esophagitis, prokinetic and / or antisecretory preparations should be prescribed.
As prokinetics in patients with gastroesophageal reflux disease shows the purpose of domepridone due to the presence of systemic side effects in metoclopramide. Domperidone is administered 10 mg 4 times a day.
If a patient has an erosive esophagitis, additional administration of proton pump inhibitors is necessary ( rabeprazole 20 mg at night, omeprazole 20 mg 2-3 times a day).
The duration of treatment of erosive esophagitis should be at least 8 weeks; during the healing of erosion, it is necessary to carry out maintenance therapy with domperidone (20 mg / day ), proton pump inhibitors ( rabeprazole 10-20 mg / day , omeprazole 20 mg / day ), or their combination.
Complications of gastroesophageal Reflux disease observed in 10-15% of patients and determine the prognosis of the disease. With severe reflux esophagitis development of ulcers and narrowing of the esophagus, esophageal bleeding.