Gastroesophageal reflux disease is an inflammation of the walls of the lower esophagus that occurs as a result of regular reflux (reverse movement) of gastric or duodenal contents into the esophagus. It is manifested by heartburn, belching with a sour or bitter taste, pain and difficulty swallowing food, dyspepsia, pain behind the sternum and other symptoms that worsen after eating and physical exertion. Diagnostics includes FGDS, intraesophageal pH-metry, manometry, radiography of the esophagus and stomach. Treatment involves non-drug measures, the appointment of symptomatic therapy. In some cases, surgical interventions are recommended.
Meaning
Gastroesophageal reflux disease (GERD) is a morphological change and symptom complex that develops due to the throwing of the contents of the stomach and the duodenum into the esophagus. It is one of the most common pathologies of the digestive system, having a tendency to develop numerous complications. The high prevalence, the severe clinic, which significantly worsens the quality of life of patients, the tendency to develop life-threatening complications and the frequent atypical clinical course make GREB one of the most pressing problems of modern gastroenterology. The constant increase in morbidity requires a thorough study of the mechanisms of GERD development, improvement of early diagnosis methods and the development of effective pathogenetic treatment measures.
Subjectively, reflux is felt as the occurrence of heartburn – burning behind the sternum – and belching. If heartburn occurs regularly (more than 2 times a week), it suggests GERD and requires a medical examination. Chronic reflux, which takes place for a long time, leads to chronic esophagitis, and later a change in the morphological structure of the mucosa of the lower esophagus and the formation of the Barrett’s esophagus.
Causes of gastroesophageal reflux disease
Factors contributing to the development of pathology are disorders of the motor functions of the upper digestive tract, hyperacidotic conditions, reduced protective function of the esophageal mucosa. Most often, with GERD, there is a violation of two mechanisms provided by nature to protect the esophagus from the aggressive environment of the stomach: esophageal clearance (the ability of the esophagus to evacuate contents into the stomach) and resistance of the mucous wall of the esophagus. Stress, smoking, obesity, frequent pregnancies, diaphragmatic hernia, medications (beta-blockers, calcium channel blockers, anticholinergetics, nitrates) increase the likelihood of developing the disease.
Pathogenesis
The main factor in the development of gastroesophageal reflux disease is the insufficiency of the lower esophageal sphincter. In healthy people, this muscular circular formation normally keeps the opening between the esophagus and stomach closed and prevents the reverse movement of the food lump (reflux). In case of insufficiency of the sphincter, the opening is open and when the stomach contracts, its contents are thrown back into the esophagus. Aggressive gastric environment causes irritation of the walls of the esophagus and pathological disorders in the mucosa up to its deep ulceration. In healthy people, reflux can occur when bending the trunk, exercising, at night.
Gastroesophageal reflux disease symptoms
The typical clinical picture of the disease is characterized by heartburn, which increases with bending, physical exertion, after a plentiful meal and in a lying position, belching with a sour or bitter taste. May be accompanied by nausea and vomiting. Depending on the severity of the course, dysphagia is noted – a swallowing disorder, which may be primary (as a result of impaired motor skills) or be a consequence of the development of strictures (narrowing) of the esophagus.
GERD is often found with atypical clinical manifestations: chest pain (usually after eating, which increases with bending), heaviness in the abdomen after eating, hypersalivation (increased salivation) in a dream, bad breath, hoarseness. Indirect signs indicating a possible pathology are frequent pneumonia and bronchospasms, idiopathic pulmonary fibrosis, a tendency to laryngitis and otitis media, damage to the enamel of teeth. GERD, which proceeds without pronounced symptoms, is particularly dangerous in terms of the development of severe complications.
Complications
The most frequent (in 30-45% of cases) complication of GERD is the development of reflux esophagitis – inflammation of the mucous membrane of the lower esophagus, resulting from regular irritation of the walls with gastric contents. In case of ulcerative erosive lesions of the mucosa and their subsequent healing, the remaining scars can lead to strictures – narrowing of the esophageal lumen. A decrease in the patency of the esophagus is manifested by developing dysphagia, combined with heartburn and belching.
Prolonged inflammation of the esophageal wall can lead to the formation of ulcers – a defect that damages the wall up to the submucosal layers. An esophageal ulcer often contributes to the occurrence of bleeding. Long-term gastresophageal reflux and chronic esophagitis provoke epithelium normal for the lower parts of the esophagus to gastric or intestinal. Such a rebirth is called Barrett’s disease. This is a precancerous condition, which in 2-5% of patients transforms into adenocarcinoma (esophageal cancer) – a malignant epithelial tumor.
Diagnostics
The main diagnostic method for detecting GERD and determining the severity and morphological changes in the esophageal wall is esophagogastroduodenoscopy. It is performed after consultation with an endoscopist. During this study, a biopsy sample is also taken to study the histological picture of the mucosa and diagnose Barrett’s esophagus.
During radiography of the esophagus, it is possible to detect an esophageal ulcer, the presence of strictures, diaphragmatic hernia. In half of the cases, reflux can be noted. The pressure of the lower sphincter of the esophagus is determined by manometry. Characteristic of gastroesophageal reflux disease is a positive Bernstein test (when 0.1% hydrochloric acid solution is injected into the esophagus, a burning sensation appears), as well as the rapid disappearance of clinical symptoms when taking antacids (alkaline test). The motor function of the esophagus is examined using electromyography.
For early detection of mucosal changes according to the type of Barrett’s disease, endoscopic examination (gastroscopy) with biopsy of the esophageal mucosa is recommended for all patients suffering from chronic heartburn. Often patients note cough, hoarseness of voice. In such cases, an otolaryngologist’s consultation is necessary to detect inflammation of the larynx and pharynx. If the cause of laryngitis and pharyngitis is reflux, antacids are prescribed. After that, the signs of inflammation subside.
Gastroesophageal reflux disease treatment
Non-medicinal therapeutic measures for gastroesophageal disease include normalization of body weight, adherence to a diet (in small portions every 3-4 hours, eating no later than 3 hours before bedtime), refusal of products that promote relaxation of the esophageal sphincter (fatty fish, chocolate, spices, coffee, oranges, tomato juice, onion, mint, alcoholic beverages), an increase in the amount of animal protein in the diet, refusal of hot food and alcohol. It is necessary to avoid tight clothes that squeeze the torso.
It is recommended to sleep on a bed with the headboard raised by 15 centimeters, smoking cessation. It is necessary to avoid prolonged work in an inclined state, heavy physical exertion. Contraindicated drugs that negatively affect the motility of the esophagus (nitrates, anticholinergetics, beta-blockers, progesterone, antidepressants, calcium channel blockers), as well as nonsteroidal anti-inflammatory drugs that have a toxic effect on the mucous membrane of the organ.
Medical treatment of gastroesophageal reflux disease is carried out by a gastroenterologist. Therapy takes from 5 to 8 weeks (sometimes the course of treatment reaches a duration of up to 26 weeks), is carried out using the following groups of drugs: antacids (aluminum phosphate, aluminum hydroxide, magnesium carbonate, magnesium oxide), H2-histamine blockers (ranitidine, famotidine), proton pump inhibitors (omeprazole, rebeprazole, esomeprazole).
In cases where conservative GERD therapy does not have an effect (about 5-10% of cases), surgical treatment is carried out with the development of complications or diaphragmatic hernia. The following surgical interventions are used: endoscopic implication of the gastroesophageal junction (sutures are applied to the cardia), radiofrequency ablation of the esophagus (damage to the muscular layer of the cardia and gastroesophageal junction, in order to scar and reduce reflux), gastrocardiopexy and laparoscopic Nissen fundoplication.
Prognosis and prevention
Prevention of the development of GERD is maintaining a healthy lifestyle with the exception of risk factors contributing to the occurrence of the disease (quitting smoking, alcohol abuse, fatty and spicy foods, overeating, lifting weights, prolonged stay in an inclined state, etc.). Timely measures are recommended to identify motor disorders of the upper digestive tract and treatment of hernia of the diaphragm.
With timely detection and compliance with lifestyle recommendations (non-drug treatment measures for GERD), the outcome is favorable. In the case of a prolonged, often recurrent course with regular reflux, the development of complications, the formation of Barrett’s esophagus, the prognosis worsens markedly.
Literature
- Gastroesophageal Reflux Disease: A Review. Maret-Ouda J, Markar SR, Lagergren J. JAMA. 2020 Dec 22;324(24):2536-2547. link
- Reflux and acid peptic diseases in the elderly. Soumekh A, Schnoll-Sussman FH, Katz PO. Clin Geriatr Med. 2014 Feb;30(1):29-41. link
- Multimodality evaluation of patients with gastroesophageal reflux disease symptoms who have failed empiric proton pump inhibitor therapy. Galindo G, Vassalle J, Marcus SN, Triadafilopoulos G. Dis Esophagus. 2013 Jul;26(5):443-50. link
- Upper endoscopy for gastroesophageal reflux disease: best practice advice from the clinical guidelines committee of the American College of Physicians. Shaheen NJ, Weinberg DS, Denberg TD, Chou R, Qaseem A, Shekelle P; Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med. 2012 Dec 4;157(11):808-16. link
- AGA Clinical Practice Update on the Personalized Approach to the Evaluation and Management of GERD: Expert Review. Yadlapati R, Gyawali CP, Pandolfino JE; CGIT GERD Consensus Conference Participants. Clin Gastroenterol Hepatol. 2022 May;20(5):984-994.e1. link