Gastroesophageal reflux disease (GERD). Gastroesophageal reflux disease in the practice of a primary care physician Gerb erosive form 2 degree of activity

Gastro-esophageal reflux disease (GERD) is a chronic relapsing disease that manifests itself with characteristic symptoms and / or inflammatory lesions of the distal esophagus (esophagitis), caused by reflux (retrograde reflux) of gastric and / or duodenal contents into the esophagus.

The famous German physician Heinrich Quincke (Heinrich Quincke, 1842-1922) was the first to describe gastroesophageal reflux in 1879. For the first time, Winkelstein wrote about esophagitis caused by the reflux of gastric contents into the esophagus in 1935, and the term " reflux esophagitis”introduced in 1946 by Allison when describing a benign esophageal ulcer against the background of esophagitis.

Prevalence

The main symptom of GERD is heartburn. According to foreign researchers, 44% of Americans suffer from heartburn at least once a month, and 7-10% experience it daily. During pregnancy, heartburn is even more common (60-80%).

According to the results of epidemiological studies, reflux esophagitis is detected in 6-12% of persons who underwent endoscopic examination.

Thus, the prevalence of GERD reaches 25-40% (according to different authors) of the adult population and exceeds the prevalence of peptic ulcer and gallstone disease, which is believed to affect up to 10% of the population.

Classification

1. According to the endoscopic picture

Distinguish between endoscopically positive and endoscopically negative GERD. This division is of great importance in the choice of treatment tactics.

Non-erosive GERD or endoscopically negative (with symptoms, proven reflux, but no esophagitis) occurs in about 60% of patients.

With non-erosive GERD, atypical manifestations (cardiac, larygophageal, pulmonary) are more often observed, and irritable bowel syndrome is significantly more common as a concomitant disease.

Erosive GERD or endoscopically positive (there are symptoms and proven reflux esophagitis) occurs in approximately 40% of patients.

In 1994, at the World Congress of Gastroenterology in Los Angeles, the following classification of reflux esophagitis was adopted:

DegreeEndoscopic picture
AMucosal defects (one or more) 5 mm or less in size, not extending beyond 2 folds of the esophageal mucosa
INMucosal defects (one or more) larger than 5 mm, not extending beyond 2 folds of the esophageal mucosa
WITHMucosal defects that do not extend beyond 2 mucosal folds of the esophagus but involve less than 75% of the circumference of the esophagus
DMucosal defects involving more than 75% of the circumference of the esophagus
Note:The term "damage to the esophageal mucosa" refers to all changes in the mucosa of the esophagus that occur during erosion, including erythema (limited inflammatory hyperemia) and white fibrin deposits on the surface, ulceration.

2. By the presence or absence of complications

Distinguish between uncomplicated and complicated GERD. Complications (as well as symptoms), in turn, are divided into esophageal and extraesophageal.

Examples of the formulation of the diagnosis

GERD, a non-erosive form with a predominance of bile reflux, a persistent course during PPI treatment.

GERD: esophagitis, grade B, exacerbation (or remission). Chronic laryngitis, bronchospastic syndrome.

GERD: esophagitis, grade C, exacerbation (or remission). Barrett's esophagus, high grade dysplasia.

Pathogenesis

1. Decreased function of the antireflux barrier of the lower esophageal sphincter

  • Anatomical errors - hernia of the esophageal opening of the diaphragm, surgical interventions on the esophageal opening of the diaphragm or near it (vagotomy, resection of the cardia of the stomach).
  • Reducing the tone of the lower esophageal sphincter at rest and the development of its insufficiency.
  • An increase in the number of episodes of spontaneous relaxation of the lower esophageal sphincter (normally, there are no more than 50 episodes of relaxation per day and these relaxations are tied to food intake).

2. Decreased clearance (cleansing) of the esophagus due to insufficient salivation to neutralize hydrochloric acid abandoned from the stomach, reducing esophageal peristalsis.

3. Damaging effect of the refluxant on the mucous membrane of the esophagus.

4. Reduced resistance of the esophageal mucosa to the damaging effects of aggressive factors of gastric and duodenal contents.

5. Disorders of gastric emptying(pylorospasm in peptic ulcer disease, pyloric stenosis, diabetic gastroparesis, iron deficiency anemia, long-term use of antispasmodics, nitrates, calcium antagonists, etc.) Slowing down the emptying of the stomach leads to its stretching, increased pressure in it and ultimately contributes to the discharge of gastric contents into the esophagus.

6. Increased intra-abdominal pressure(obesity, intake of large amounts of food, flatulence, pregnancy, ascites).

7. Helicobacter infection? This issue cannot be considered definitively studied. It is believed that Helicobacter pylori (HP) occurs in the esophagus itself only when small intestinal metaplasia develops in it, i.e. " Barrett's esophagus(but not in all patients). At the same time, in patients infected with HP, Barrett's esophagus is less common, and the incidence of erosive esophagitis in patients with peptic ulcer increases after eradication therapy.

File Creation Date: September 05, 2011
Document modified: 05 September 2011
Copyright Vanyukov D.A.

S.S. Vyalov, S.A. Chorbinskaya

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

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

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

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

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

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

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

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

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

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

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

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

Predisposing factors:

  • hiatal hernia;
  • obesity;
  • alcohol consumption;
  • medicines (drugs with anticholinergic properties, tricyclic antidepressants, H2-blockers, phenothiazines, nitrates, universal antispasmodics, opiates, etc.)

Resolving factors:

  • dysfunction of the lower esophageal sphincter;
  • decreased esophageal clearance; slow gastric emptying
  • involutional changes in the esophagus in old age (replacement of muscle fibers with connective tissue, a decrease in the number of secretory cells, a decrease in the protective properties of the mucosa and a delay in reflux in the esophagus).

GERD classifications

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

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

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

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

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

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

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

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

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

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

Clinical and endoscopic classification

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

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

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

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

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

Classification of endoscopically positive GERD

(Los Angeles, 1995):

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

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

Classification of endoscopically negative GERD:

  • symptomatic, without mucosal injury.

Complaints

I. Esophageal complaints

  • painful swallowing (odynophagia);
  • sensation of "coma" in the throat;
  • sensation of a large amount of liquid in the mouth;
  • pain in the epigastric region, in the projection of the xiphoid process, occurs after eating, with torso bending and at night;
  • dysphagia;
  • heartburn, aggravated by errors in diet, alcohol intake, carbonated drinks, slopes; in a horizontal position;
  • belching food, aggravated after eating, taking carbonated drinks;
  • regurgitation of food is aggravated by physical exertion.

II. Extraesophageal complaints

  • retrosternal pain that mimics angina pectoris (cardialgia) is associated with food intake and the physical properties of food, body position, and is stopped by taking alkaline mineral waters or antacids;
  • chronic cough, shortness of breath, often occurring in the supine position;
  • hoarseness of voice, salivation;
  • erosion on the gums;
  • bloating, nausea, vomiting.

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

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

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

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

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

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

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

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

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

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

Anamnesis

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

Objectively

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

Formulation of the diagnosis

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

Differential Diagnosis

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

Diagnostics (examination)

I. Basic diagnostic methods

II. Additional diagnostic methods

  • EGDS: reflux esophagitis; hyperemia and edema of the esophageal mucosa; erosion of the distal esophagus, HH.
  • VEGDS: reflux esophagitis; hyperemia and edema of the esophageal mucosa; erosion of the distal esophagus, HH.
  • X-ray of the esophagus and stomach: HH, esophageal strictures, esophagospasm, erosive and ulcerative changes, reflux.
  • Daily pH monitoring: frequency and duration of refluxes, individual selection of drugs.
  • Manometry: indicators of the movement of the esophageal wall and the function of its sphincters.
  • Esophageal scintigraphy with technetium.
  • Chromoendoscopy: detection of metaplastic and dysplastic changes in the esophagus.
  • Bilimetry: verification of alkaline and bile reflux; spectrophotometry of refluxate containing bilirubin.
  • Endoscopic ultrasound: detection of endophytic growing tumor.
  • omeprazole test.

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

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

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

General principles of treatment

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

1. Lifestyle change

  • after eating, avoid tilting, do not lie down (within 1.5 hours); sleep on a bed with a head end raised by at least 15 cm;
  • do not wear tight clothes and tight belts, corsets, bandages,
  • avoid work in an incline (leading to an increase in intra-abdominal pressure);
  • stop smoking and drinking alcohol.

2. Changing the diet

  • avoid heavy meals, do not eat too hot food, do not eat at night (3-4 hours before bedtime);
  • limit the consumption of fats, alcohol, coffee, chocolate, citrus fruits, green onions, garlic, avoid the use of acidic fruit juices, products that increase gas formation (irritate the mucous membrane);
  • avoid weight gain, reduce body weight in obesity.

3. Restriction of taking medicines

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

Medical therapy

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

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

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

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

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

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

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

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

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

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

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

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

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

3. Prokinetics- have anti-reflux action:

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

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

Treatment regimens depending on the degree of reflux esophagitis:

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

Active Surveillance

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

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

Indications for surgical treatment

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

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

Complications

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

Barrett's esophagus

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

Management of patients with Barrett's esophagus

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

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

The following endoscopic techniques are used:

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

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

Gastroesophageal reflux disease (abbreviated as GERD) is a disease in which there is often a backflow of stomach contents into the esophagus, resulting in inflammation of the esophageal walls.

In some cases, reflux, ie. the movement of food and gastric juice through the lower esophageal sphincter into the esophagus, occasionally occurs in healthy people, for example, with a single overeating. If there are quite a lot of such casts and they are accompanied by unpleasant symptoms, then this condition is a disease.

There are two main forms of gastroesophageal reflux disease:

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

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

There are the following degrees of GERD:

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

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

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

What is gastroesophageal reflux?

Gastroesophageal (gastroesophageal) reflux is the backflow of stomach contents into the esophagus. The term "reflux" refers to the direction of movement in the opposite, non-physiological direction.

With reflux, food gruel with gastric juice can move from the stomach towards the esophagus. This process is quite acceptable if it is repeated only occasionally, for example, after eating a large meal, with sharp torso bending after dinner.

In the absence of pathologies, periodic gastroesophageal reflux does not lead to any adverse effects, since the surface of the esophageal mucosa is largely protected from damage by the acidic environment of gastric juice.

In a healthy person, reflux episodes should not occur more than once an hour. After that, cleansing (clearance) of the walls of the esophagus immediately occurs by re-moving the food gruel into the stomach. To a large extent, this is facilitated by saliva, constantly flowing down the esophagus. The bicarbonates contained in it neutralize the destructive effect of gastric juice on the esophageal mucosa.

Causes of GERD

The following factors contribute to the development of gastroesophageal reflux disease:

  • decreased tone of the lower esophageal sphincter;
  • decrease in the ability of the walls of the esophagus to self-cleaning;
  • violation of the acidity of gastric juice;
  • obesity;
  • pregnancy, in which the stomach and other organs of the digestive system are squeezed by the growing uterus;
  • frequent intake of fatty, spicy foods, alcohol, coffee;
  • smoking;
  • the presence of a hernia of the esophageal opening of the diaphragm;
  • overeating or too fast absorption of food, as a result of which air is swallowed in a significant amount;
  • abuse of foods that take a long time to digest in the stomach;
  • increased intra-abdominal pressure due to frequent bending during work, performing some physical exercises, wearing tight clothes, etc.

Diagnostic methods

For the diagnosis of gastroesophageal reflux, the following methods are used:

  • endoscopic examination of the esophagus, which allows you to identify inflammatory changes, erosion, ulcers and other pathologies;
  • daily monitoring of acidity (pH) in the lower part of the esophagus. Normally, the pH level should be in the range from 4 to 7, a change in the actual data may indicate the cause of the development of the disease;
  • x-ray of the esophagus - allows you to detect a hernia of the esophageal opening of the diaphragm, ulcers, erosion, etc.;
  • manometric study of esophageal sphincters - performed to assess their tone;
  • scintigraphy of the esophagus using radioactive substances - is performed to assess esophageal clearance;
  • esophageal biopsy - performed if Barrett's esophagus is suspected.

When conducting an examination, GERD should be differentiated from peptic ulcer, esophagitis and other diseases of the digestive system.

Symptoms

Gastroesophageal reflux disease in adult patients is accompanied by the following symptoms:

  • heartburn is the main symptom of this disease. As a rule, it occurs within 1 - 1.5 hours after a meal, as well as at night. The feeling of discomfort may increase after taking carbonated drinks, coffee, after increased physical activity or overeating;
  • pain in the retrosternal region, which in some cases can be similar to pain in angina pectoris;
  • eructation of gastric contents or air. Occurs as a result of the entry of stomach contents into the esophagus, and then into the oral cavity;
  • sour taste in the mouth - appears as a result of belching;
  • dysphagia (difficulty in swallowing food) - appears as a result of prolonged inflammation of the walls of the esophagus and irritation of the larynx;
  • nausea;
  • vomiting - in complicated cases;
  • hiccups - appears due to irritation of the phrenic nerve and subsequent contraction of the diaphragm;
  • sensation of sore throat;
  • voice change (dysphonia): hoarseness, difficulty speaking loudly;
  • dental disorders: periodontitis, gingivitis, etc.;
  • respiratory manifestations: shortness of breath, cough, especially when lying down.

In young children, physiological gastroesophageal reflux is much more common than in adults, due to the peculiarities of the sphincter apparatus and the small volume of the stomach. In babies in the first three months of life, regurgitation or vomiting is often observed, which do not pose a serious danger. With the subsequent establishment of an antireflux barrier, these manifestations gradually disappear.

However, in some cases, gastroesophageal reflux disease develops in children at a time when the symptoms of spitting up or belching should have long been behind. At the same time, children may complain of pain when swallowing food, a feeling of a coma in the chest.

One of the characteristic signs of GERD in children is the detection of white spots on the pillow after sleep, which indicates frequent belching during a night's rest.

Other symptoms of gastroesophageal reflux in children are usually the same as in adults.

Treatment

Treatment of gastroesophageal reflux includes three general groups of methods: lifestyle changes, drug treatment, and surgery.

Lifestyle change consists of the following activities:

  • normalization of body weight;
  • exclusion from the diet of coffee, strong tea, fatty, spicy and fried foods, carbonated drinks, onions, garlic, citrus fruits;
  • compliance with the diet;
  • refusal to wear tight clothing and accessories (belts, belts) that tightly compress the chest and waist;
  • avoidance of frequent torso bending, refusal of heavy physical work;
  • night sleep in a slightly elevated position of the head of the bed (15 - 20 cm).

Drug therapy involves the use of the following means:

  • the appointment of proton pump inhibitors (omeprazole, rabeprazole) and other antisecretory agents;
  • taking prokinetics to enhance the peristalsis of the stomach and intestines (cerucal, motilium);
  • the appointment of antacids (maalox, phosphalugel, etc.);
  • taking vitamin preparations, including vitamin B5 and U, in order to restore the mucous membrane of the esophagus and overall strengthen the body.

Surgical treatment is performed in the presence of serious complications, such as damage to the esophagus of the third or fourth degree, Barrett's esophagus, etc.

Currently, the most common type of surgical intervention in the treatment of GERD is fundoplication, performed using the laparoscopic method. During the operation, the surgeon forms a special fold around the lower part of the esophagus from a part of the stomach, which is called the fundus, that is, creates an artificial valve. The effectiveness of this procedure is quite high: about 80% of patients do not complain about the appearance of reflux over the next 10 years, the rest are forced to take medication due to the persistence of some symptoms of the disease.

Folk remedies

  • a decoction of flax seeds: a teaspoon of raw material is poured with one glass of boiling water, kept for 5 minutes on a rather slow fire, after which it is insisted for half an hour, filtered. Subsequently, they are taken three times a day, on average, a third of a glass in a warm form;
  • sea ​​buckthorn or rosehip oil: take one teaspoon up to three times a day;
  • collection of herbs: St. John's wort (4 parts), calendula, plantain, licorice roots, calamus (2 parts each), tansy flowers and peppermint (1 part each) pour a glass of boiling water, filter after half an hour. Subsequently, three times a day, no more than a third of a glass is taken in the form heated to a warm state.

Possible Complications

One of the most serious complications of GERD is the development of Barrett's esophagus, which is characterized by pathological changes in the epithelium. This condition is one of the precancerous diseases, therefore, it requires effective treatment, in some cases - surgical.

Another serious complication is the occurrence of bleeding due to the development of esophageal ulcers.

As a result of long-term erosive and ulcerative lesions, scars may subsequently occur, which lead to the appearance of streaks - pathological narrowing of the lumen of the esophagus.

Diet

The diet for GERD involves the following recommendations:

  • avoidance of overeating; eating small meals at regular intervals;
  • refusal to eat in the late evening and at night;
  • exclusion from the diet or a decrease in the share of the following products in it: fatty meat, coffee, tea, milk, cream, carbonated drinks, oranges, lemons, tomatoes, chocolate, garlic, onions;
  • reducing calorie intake in order to normalize body weight.

Features of GERD in children and newborns

In newborns, the esophagus is funnel-shaped, tapering at the neck. Diaphragmatic narrowing at the age of up to a year is weakly expressed, therefore, regurgitation of food is often observed in children.

The formation of the developed muscles of the esophagus continues until the age of 10 years.

The incidence of pathological reflux in infants is 8-10%. Premature babies, as well as babies suffering from allergies or lactose deficiency, are predisposed to this violation.

GERD in children can be manifested by pronounced symptoms: vomiting with a fountain, sometimes with an admixture of blood or bile, respiratory disorders, including cough.

In young children, crying can be characterized by hoarseness, a change in tone. In older children, respiratory diseases such as otitis and bronchitis often occur, which develop as a result of the ingestion of gastric contents through the larynx into the cavity of the ENT organs.

It must be borne in mind that if a child of the first year of life has been ill with otitis media, pneumonia, and persistent regurgitation is observed, then this most likely indicates the presence of reflux disease. If these signs appear, you should immediately consult a doctor and undergo an examination.

Prevention

To prevent the occurrence of reflux disorders, it is advisable to follow the following recommendations:

  • normalize body weight;
  • give up alcohol abuse and smoking;
  • do not overeat;
  • observe regularity in eating;
  • do not eat after 18 - 19 hours;
  • reduce the proportion of fatty, spicy foods in the diet;
  • do not abuse coffee and strong tea;
  • observe a rational diet in order to normalize the digestive process;
  • wear comfortable clothing and accessories that do not restrict movement. Refuse to wear tight jeans, belts, corsets, slimming underwear and other tight wardrobe items;
  • do not lie down to rest immediately after eating;
  • give up carbonated drinks.

If these requirements are met, the risk of GERD will be minimized.

Gastroesophageal reflux disease b (GERD) - the development of inflammatory changes in the distal esophagus and / or characteristic symptoms due to regularly repeated reflux of gastric and / or duodenal contents into the esophagus.

ICD-10
K21.0 Gastroesophageal reflux with esophagitis
K21.9 Gastroesophageal reflux without esophagitis.


EXAMPLE FORMULATION OF THE DIAGNOSIS


EPIDEMIOLOGY
The true prevalence of the disease is not known, which is associated with a large variability in clinical symptoms. Symptoms of GERD upon careful questioning are found in 20–50% of the adult population, and endoscopic signs in more than 7–10% of the population. In the US, heartburn, the main symptom of GERD, is experienced by 10–20% of adults weekly. There is no complete epidemiological picture in Russia.
The true prevalence of GERD is much higher than the statistics, including because only less than 1/3 of GERD patients go to the doctor.
Women and men get sick equally often.


CLASSIFICATION
Currently, there are two forms of GERD.
■ Endoscopically negative reflux disease, or non-erosive reflux disease, in 60-65% of cases.
■ Reflux esophagitis - 30-35% of patients.
■ Complications of GERD: peptic stricture, esophageal bleeding, Berrett's esophagus, adenocarcinoma of the esophagus.
For reflux esophagitis, it is recommended to use the classification adopted at the X World Congress of Gastroenterologists (Los Angeles, 1994) (Table 4-2).
Table 4-2. Los Angeles classification of reflux esophagitis

DIAGNOSTICS
The diagnosis of GERD should be assumed if the patient has characteristic symptoms B: heartburn, belching, regurgitation; in some cases, extraesophageal symptoms are observed B.
HISTORY AND PHYSICAL EXAMINATION
GERD is characterized by the absence of dependence of the severity of clinical symptoms (heartburn, pain, regurgitation) on the severity of changes in the mucosa of the esophagus. Symptoms of the disease do not allow differentiating non-erosive reflux disease from reflux esophagitis.
The intensity of clinical manifestations of GERD depends on the concentration of hydrochloric acid in the refluxate, the frequency and duration of its contact with the mucosa of the esophagus, hypersensitivity of the esophagus.


ESOPHAGEAL GERD SYMPTOMS
■ Heartburn is understood as a burning sensation of varying intensity that occurs behind the sternum (in the lower third of the esophagus) and / or in the epigastric region. Heartburn occurs in at least 75% of patients, occurs due to prolonged contact of the acidic contents of the stomach (pH less than 4) with the mucosa of the esophagus. The severity of heartburn does not correlate with the severity of esophagitis. It is characterized by its increase after eating, taking carbonated drinks, alcohol, with physical exertion, bending over and in a horizontal position.
■ Sour eructation, as a rule, increases after eating, taking carbonated drinks. Regurgitation of food, observed in some patients, is aggravated by exercise and a position that promotes regurgitation.
■ Dysphagia and odynophagia (pain when swallowing) are less common. The appearance of persistent dysphagia indicates the development of esophageal stricture. Rapidly progressive dysphagia and weight loss may indicate the development of adenocarcinoma.
■ Pain behind the sternum can radiate to the interscapular region, neck, lower jaw, left half of the chest; often mimic angina pectoris. Esophageal pain is characterized by a connection with food intake, body position and their relief by taking alkaline mineral waters and antacids.


EXTRA-ESophageal GERD SYMPTOMS:
■ bronchopulmonary - cough, asthma attacks;
■ otolaryngological - hoarseness, dry throat, sinusitis;
■ dental - caries, erosion of tooth enamel.



INSTRUMENTAL STUDIES
MANDATORY EXAMINATION METHODS
SINGLE STUDIES
■ FEGDS: allows to differentiate between non-erosive reflux disease and reflux esophagitis, to identify the presence of complicationsA.
■ Biopsy of the mucous membrane of the esophagus in complicated GERD: ulcers, strictures, Berrett's esophagusC.
■ X-ray examination of the esophagus and stomach: if a hernia of the esophageal opening of the diaphragm, stricture, adenocarcinoma of the esophagus is suspected.
RESEARCH IN DYNAMICS
■ FEGDS: it is possible not to carry out again with non-erosive reflux disease.
■ Biopsy of the mucous membrane of the esophagus in complicated GERD: ulcers, strictures, Berrett's esophagus.
ADDITIONAL EXAMINATION METHODS
SINGLE STUDIES
■ 24-hour intraesophageal pH-metry: increase in total reflux time (pH less than 4.0 more than 5% during the day) and the duration of the reflux episode (more than 5 minutes). The method allows you to evaluate the pH in the esophagus and stomach, the effectiveness of drugs; the value of the method is especially high in the presence of extraesophageal manifestations and the absence of the effect of therapy.
■ Intraesophageal manometry: carried out to assess the functioning of the lower esophageal sphincter, the motor function of the esophagus.
■ Ultrasound of the abdominal organs: with GERD without changes, it is carried out to identify concomitant pathology of the abdominal organs.
■ ECG, bicycle ergometry: used for differential diagnosis with IBSA, GERD does not show changes.
■ Proton pump inhibitor test B: relief of clinical symptoms (heartburn) while taking proton pump inhibitors.


DIFFERENTIAL DIAGNOSIS
With a typical clinical picture of the disease, differential diagnosis is usually not difficult. In the presence of extraesophageal symptoms, it should be differentiated from ischemic heart disease, bronchopulmonary pathology (bronchial asthma, etc.). For differential diagnosis of GERD with esophagitis of a different etiology, a histological examination of biopsy specimens is performed.


INDICATIONS FOR CONSULTATION OF OTHER SPECIALISTS
The patient should be referred for specialist advice if the diagnosis is uncertain, if there are atypical or extraesophageal symptoms, or complications are suspected. You may need to consult a cardiologist, pulmonologist, otorhinolaryngologist (for example, a cardiologist - in the presence of retrosternal pain that does not stop while taking proton pump inhibitors).


TREATMENT
GOALS OF THERAPY
■ Relief of clinical symptoms.
■ Healing of erosions.
■ Better quality of life.
■ Prevention or elimination of complications.
■ Prevention of recurrence.


INDICATIONS FOR HOSPITALIZATION
■ Carrying out antireflux treatment in case of complicated course of the disease, as well as in case of ineffectiveness of adequate drug therapy.
■ Conducting surgery (fundoplication A) in case of failure of drug therapy and endoscopic or surgical interventions in the presence of complications of esophagitis: stricture, Berrett's esophagus, bleeding.


NON-DRUG TREATMENT
■ Lifestyle and dietary recommendations that have limited effect in the treatment of GERD.
✧ Avoid large meals.
✧Limit consumption of foods that reduce the pressure of the lower esophageal sphincter and have an irritating effect on the mucous membrane of the esophagus: foods rich in fats (whole milk, cream, cakes, pastries), fatty fish and meat (goose, duck, as well as pork, lamb, fatty beef), alcohol, drinks containing caffeine (coffee, cola, strong tea, chocolate), citrus fruits, tomatoes, onions, garlic, fried foods, avoid carbonated drinks.
✧After eating, avoid bending forward and horizontal position; the last meal - no later than 3 hours before bedtime.
✧Sleep with the head end of the bed elevated.
✧Exclude loads that increase intra-abdominal pressure: do not wear tight clothes and tight belts, corsets, do not lift weights of more than 8–10 kg on both hands, avoid physical exertion associated with overexertion of the abdominal press.
✧ Quit smoking.
✧Maintain normal body weight.
■ Do not take drugs that cause reflux B (sedatives and tranquilizers, calcium channel inhibitors, β-blockers, theophylline, prostaglandins, nitrates).


DRUG THERAPY
Terms of treatment for GERD: 4–6 weeks for non-erosive reflux disease and at least 8–12 weeks for reflux esophagitis, followed by maintenance therapy for 26–52 weeks.
Drug therapy includes the appointment of prokinetics, antacids and antisecretory agents.
■ Prokinetics: domperidone 10 mg 4 times a day.
■ The goal of antisecretory therapy for GERD is to reduce the damaging effect of acidic gastric contents on the esophageal mucosa in gastroesophageal reflux. The drugs of choice are proton pump A inhibitors (omeprazole, lansoprazole, pantoprazole, rabeprazole, esomeprazole).
✧GERD with esophagitis (8-12 weeks):
–omeprazole 20 mg twice a day, or
lansoprazole 30 mg twice daily, or
– esomeprazole 40 mg/day, or
– rabeprazole 20 mg/day.
The criterion for the effectiveness of treatment is the relief of symptoms and the healing of erosions. If the standard dose of proton pump inhibitors is ineffective, the dose should be doubled.
✧ Non-erosive reflux disease (4-6 weeks):
–omeprazole 20 mg/day, or
– lansoprazole 30 mg/day, or
– esomeprazole 20 mg/day, or
– rabeprazole 10–20 mg/day.
The criterion for the effectiveness of treatment is the persistent elimination of symptoms.
■ The use of histamine H2 receptor blockers as antisecretory drugs is possible, but their effect is lower than that of proton pump inhibitors.
■ Antacids can be used as a symptomatic treatment for infrequent heartburn B, but in this case, preference should be given to taking proton pump inhibitors on demand. Antacids are usually prescribed 3 times a day 40-60 minutes after a meal, when heartburn and chest pain most often occur, as well as at night.
■ With reflux esophagitis caused by the reflux of duodenal contents (primarily bile acids) into the esophagus, which is usually observed in cholelithiasis, a good effect is achieved by taking ursodeoxycholic acid at a dose of 250-350 mg / day. In this case, it is advisable to combine ursodeoxycholic acid with prokinetics at the usual dose.
Maintenance therapy A is usually carried out with proton pump inhibitors in accordance with one of the following regimens.
■ Continuous use of proton pump inhibitors in a standard or half dose (omeprazole, esomeprazole - 10 or 20 mg / day, rabeprazole - 10 mg / day).
■ On-demand therapy - taking proton pump inhibitors when symptoms appear (on average once every 3 days) for endoscopically negative reflux disease.


SURGERY
The purpose of operations aimed at eliminating reflux (fundoplications, including endoscopic ones) is to restore the normal function of the cardia.
Indications for surgical treatment:
■ failure of adequate drug therapy;
■ complications of GERD (stricture of the esophagus, repeated bleeding);
■ Berrett's esophagus with high-grade epithelial dysplasia due to the risk of malignancy.


APPROXIMATE TERMS OF TEMPORARY INABILITY TO WORK
They are determined by the relief of clinical symptoms and the healing of erosions during the control FEGDS.


FURTHER MANAGEMENT
In the case of non-erosive reflux disease with complete relief of clinical symptoms, a control FEGDS is not necessary. Remission of reflux esophagitis should be confirmed endoscopically. When the clinical picture changes, in some cases FEGDS is performed.
Maintenance therapy is mandatory, since without it the disease recurs in 90% of patients within 6 months (see the section "Drug therapy").
Dynamic monitoring of the patient is carried out to monitor complications, identify Berrett's esophagus and drug control of the symptoms of the disease.
Monitor for symptoms suggestive of complications:
■ dysphagia and odynophagia;
■ bleeding;
■ weight loss;
■ early satiety;
■ chest pain;
■ frequent vomiting.
In the presence of all these signs, consultations of specialists and further diagnostic examination are indicated.
Intestinal epithelial metaplasia serves as the morphological substrate of asymptomatic Berrett's esophagus. Risk factors for Berrett's esophagus:
■ heartburn more than 2 times a week;
■ male gender;
■ duration of symptoms for more than 5 years.
Once the diagnosis of Berrett's esophagus is established, endoscopic examinations with biopsy should be performed annually on the background of continuous maintenance therapy with a full dose of proton pump inhibitors. If low-grade dysplasia is detected, repeated FEGDS with biopsy and histological examination of the biopsy is performed after 6 months. If low-grade dysplasia persists, a repeat histological examination is recommended after 6 months. If low-grade dysplasia persists, repeated histological examinations are carried out annually. In the case of high-grade dysplasia, the result of the histological examination is evaluated independently by two morphologists. When the diagnosis is confirmed, the issue of endoscopic or surgical treatment of Berrett's esophagus is decided.


EDUCATION OF THE PATIENT
The patient should be explained that GERD is a chronic condition, usually requiring long-term maintenance therapy with proton pump inhibitors to prevent complications.
The patient must follow the recommendations for lifestyle changes (see the section "Non-drug treatment").
The patient should be informed about the possible complications of GERD and advised to consult a doctor if symptoms of complications occur (see the section "Further management of the patient").
Patients with prolonged uncontrolled reflux symptoms should be explained the need for endoscopic examination to detect complications (such as Berrett's esophagus), and in the presence of complications, the need for periodic FEGDS with biopsy.


FORECAST
In non-erosive reflux disease and mild reflux esophagitis, the prognosis is generally favorable. Patients retain their ability to work for a long time. The disease does not affect life expectancy, but significantly reduces its quality during the period of exacerbation. Early diagnosis and timely treatment prevent the development of complications and preserve the ability to work. The prognosis worsens with a long duration of the disease, combined with frequent long-term relapses, with complicated forms of GERD, especially with the development of Berrett's esophagus, due to an increased risk of developing adenocarcinoma of the esophagus.

GASTROESOPHAGEAL REFLUX DISEASE

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Consultations of experts according to indications.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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