Gastroesophagic reflux

Template:Infobox - disease Esophageal reflux disease is a disease caused by pathological gastroesophageal reflux. Its most common complication is damage to the lining of the esophagus (reflux esophagitis).

Gastroesophageal reflux (GER) is the backflow of stomach contents into the esophagus. Episodes of short-term GER occur commonly. It becomes pathological if it causes difficulties and/or inflammatory changes in the mucosa of the esophagus.

Pathological-anatomical picture

Due to the presence of HCl, the squamous epithelium is desquamated. This induces increased proliferation of cells in the basement membrane. Immature cells are less resistant' to further action of the refluxate and also to infections. Over time, the cells begin to disappear and erosion and ulceration form. In the case of deeper changes, there is an overlap with cylindrical epithelium - metaplasia, the so-called Barrett's esophagus (Barrett's ulcer - it arises in an area with cylindrical epithelium, can bleed, sometimes even perforation).

Classification

1. Endoscopically positive reflux disease esophagus,
2. endoscopically negative reflux disease – clinical symptoms with negative endoscopy but positive biopsy,
3. extraesophageal (larynx, pharyngx, bronchi, middle ear).

The cause of reflux disease is a disorder of esophageal motility, especially insufficiency of the lower esophageal sphincter (the mechanism of temporary relaxation of the lower sphincter, its hypotension or disruption of the gastroesophageal junction associated with hiatal hernia).

Clinical picture

Esophageal symptomatology

•  Pyrosis ("heartburn"; burning behind the sternum moving from the epigastrium to the manubrium sterna, most often after eating, in a horizontal position or when bending forward),
•  regurgitation (flow of stomach contents into the esophagus and mouth),
•  dysphagia (difficult swallowing),  odynophagia (pain when swallowing behind the sternum) – signs of severe involvement of the esophagus,
• paroxysmal salivation,
•  globus (feeling of a foreign body in the throat),
•  chest pain.

Extraesophageal symptomatology

•  Dry throat,  earache,  bad breath,
•  snoring, laryngitis, repeated lung infections,
• irritation of the vagus (bradycardia, bronchoconstriction).

Diagnosis

Endoscopic examination (esophagoscopy) with biopsy

The gold standard in diagnostics. The endoscopic finding of reflux esophagitis has 4 grades according to Savary-Miller (grade 4 is metaplasia by cylindrical epithelium (Barrett's esophagus), microscopically, esophagitis is mild, moderate or severe).

24-hour pHmetry of the esophagus

In other words, esophageal pHmetry is valid and reliable for determining acid or alkaline reflux, its temporal relationship with symptoms.

Examination description: introduction of a thin probe through the nose into the esophagus; connecting the probe to a device that can record the pH in the esophagus; within 24 hours, the patient performs normal activities, eats normal food, then the probe is removed and the recording is evaluated.

Esophageal manometry

Provides information on pressure conditions in the lower esophageal sphincter, does not diagnose GER. Suitable to rule out achalasia.

Examination description: a measuring probe is inserted through the nose into the esophagus and then into the area of ​​the lower esophageal sphincter; the course of the act of swallowing is measured when swallowing "empty" and when swallowing 10 ml of water; it is performed on an empty stomach.

X-ray passage through the esophagus (esophagogram)

It is neither sensitive nor specific for the diagnosis of GER. Useful to rule out anatomical abnormalities of the upper digestive tract (malrotation, annular pancreas, esophageal stenosis/stricture, hiatal hernia, achalasia).

Other examinations carried out: scintigraphy with food labeled ^99mTc, perfusion test, diagnostic therapeutic test (14 days of omeprazole administration, disappearance of symptoms confirms the diagnosis).

Differential diagnosis

AP, peptic ulcer, Ca esophagus.

Complications

Barrett's esophagus - endoscopic image

Barrett's esophagus - microscopic image

• Erosive esophagitis - mucosal inflammation → erosions → ulcers
• Ulceration - can lead to:
  • bleeding
  • iron deficiency anemia
• Strictures - due to chronic inflammation + fibrosis → progressive dysphagia (solids → liquids)
• Barrett esophagus - squamous → intestinal-type columnar epithelium (with goblet cells) adaptive but premalignant, it progress to
• Esophageal adenocarcinoma - via: metaplasia → dysplasia → carcinoma
• Extraesophageal complications - chronic cough, laryngitis, hoarseness, asthma-like symptoms (microaspiration)

Course of the disease

The course is chronic relapsing (recurrences after the end of treatment).

Treatment

1. Regimen measures – reduction of body weight, limitation of intra-abdominal pressure increase, smoking ban, dietary restrictions (non-irritating diet excluding alcohol, fatty foods, sweet yeast bread, chocolate, coffee, peppermint; smaller portions; do not eat before going to bed),
2. pharmacotherapy – H₂-blockers (ranitidineTemplate:HVLP), proton pump inhibitors (omeprazoleTemplate:HVLP) , prokinetics (domperidoneTemplate:HVLP, itoprideTemplate:HVLP), antacids,
3. surgical treatment – ​​fundoplication according to Nissen.

HIATAL HERNIA

Hiatal hernia is the movement of the cardia or part of the stomach from the peritoneal cavity to the mediastinum through the esophageal hiatus. The hiatus oesophageus is formed by the diaphragm and the gastroesophageal junction enters the mediastinum (sliding hernia - par glissement), the gastric fundus (paraesophageal hernia), or the fundus enters the mediastinum even with the gastroesophageal junction with a preserved His angle ( mixed hernia). An extreme case is the dislocation of the entire stomach into the mediastinum, the so-called upside-down stomach, when the cardia and pylorus remain in the abdominal cavity, the stomach (and other intra-abdominal organs) can be displaced into the mediastinum or pleural cavity even in severe injuries. These are false hernias' (protrusions), the gate of which is a traumatic rupture of the diaphragm.

Types of hiatal hernia: A - anatomical position, B - pre-staged hernia, C - slippery hernia, D - paraesophageal hernia

Division

• Sliding - the most common, false hernia - is not a hernia sac, the angle of His is missing, the main complication is gastroesophageal reflux.
• Paraesophageal - rare, hernia sac is formed, gastroesophageal junction remains in peritoneal cavity, angle of His is preserved, complications are venostasis with bleeding, ulceration, necrosis with wall perforation during strangulation, obstruction with disruption passages, oppression of intrathoracic structures (heart, lungs).
• Mixed - a combination of the previous types.

Clinical symptoms

• Heartburn (pyrosis)
  • retrosternal burning, worse after meals or lying down
• Regurgitation
  • acidic or bitter fluid into mouth
• Dysphagia
  • difficulty swallowing (especially with large hernias or strictures)
• Chest pain
  • can mimic angina
  • often postprandial or positional
• Epigastric discomfort / fullness**feeling of pressure after eating

• Belching (eructation)
  • due to air trapping

Diagnostics

The diagnosis is made using X-ray (swallowing of a contrast agent - will determine the type of hernia), X-ray of the chest (gastric bubble in the mediastinum), endoscopy (evidence of esophagitis - gastroesophageal reflux, otherwise indicated pH-metry) .

Hiatus hernia on X-ray image

Therapy

Conservative treatment consists of administration of proton pump inhibitors (omeprazole, e.g. Helicid®) or H₂-blockers (ranitidine , e.g. Ranital®, Ranisan®; famotidine, e.g. Quamatel®) for gastroesophageal reflux (slip hernia).

Surgical treatment is indicated for every paraesophageal hernia and for conservatively unmanageable reflux, includes repositioning of the stomach, resection or retention of the hernia sac, closure of the hernia gate (hiatorrhaphy), possibly. fixation of the fundus to the diaphragm (fundopexy - can also be used to close the defect) and fixation of the anterior stomach wall to the abdominal wall (gastropexy), in case of gastroesophageal reflux, fundoplication according to Nissen-Rossetti is indicated.

Links

You can watch the osmosis video

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