Gastroesophageal Reflux Disease
Gastroesophageal reflux disease includes all symptoms caused by the reflux of stomach contents into the esophagus. Gastroesophageal reflux is a phenomenon of passage of stomach contents into the esophagus, a physiological phenomenon, which becomes pathological when antireflux mechanisms are overcome. Reflux esophagitis represents all esophageal lesions caused by gastroesophageal reflux disease, not seen in all cases of gastroesophageal reflux disease. Gastroesophageal reflux disease is a clinical entity relatively common in medical practice and is often has a polymorphic symptomatic picture.
Gastroesophageal reflux disease has a prevalence of 4% in the general population, increasing with age. The current trend is the increase in the incidence of the disease.
In the case of gastroesophageal reflux disease, are describe two mechanisms that determine the inefficient antireflux mechanism:
- decreased lower esophageal sphincter pressure. Under normal conditions, lower esophageal sphincter pressure is 20 to 25 mm Hg and disappears only when swallowing. Gastroesophageal reflux occurs when the lower esophageal sphincter relaxes outside swallowing, or when lower esophageal sphincter pressure falls below 6 mm Hg, thus allowing the passage of stomach contents into the esophagus. Lower esophageal sphincter pressure may be reduced by factors like drugs (anticholinergics, benzodiazepines, calcium channel blockers), food (chocolate, onions, fats, citrus), coffee, smoking and alcohol;
- decreased gastric motility with delayed gastric emptying;
- damage to esophageal clearance by acid stomach contents which flows backward into the esophagus. This esophageal clearance with the swallowed saliva serve as a tampon mechanism for the acid content of the stomach which flows backward into the esophagus;
- hiatal hernia causes a decrease of the tonus of the lower esophageal sphincter, which favors the reflux;
- increased intra-abdominal pressure leads to widening of the diaphragmatic hiatus, explaining the occurrence of gastroesophageal reflux disease in pregnant women, obese, etc.;
- His angle widening, the angle between the esophagus and stomach is usually very sharp, with the role of a valve at the entrance of the stomach. In obese it widens and loses physiological role.
Development and severity of gastroesophageal reflux disease is caused by the presence of three conditions:
- increased frequency of reflux;
- increased duration reflux;
- aggressive effect of stomach contents on the esophageal mucosa.
Symptoms are relatively typical, translating by acid regurgitation and heartburn, with continuous or discontinuous character. Symptoms may be occasional or permanent.
Retrosternal pain or dysphagia are relatively rare. The presence of these two symptoms should lead thinking at more severe pathology. Rarely, in atypical forms of gastroesophageal reflux disease, symptoms can mimic a heart disease with angina type of pain or the onset of bronchial asthma.
- pyrosis is the sensation of heartburn that goes to the neck. It is accentuated by maneuvers that increase intra-abdominal pressure (bending forward, going to bed immediately after eating, weight lifting) is sometimes accompanied and acid regurgitation. If lower esophageal sphincter incompetence is increased, then will appear food regurgitation;
- chest pain often provide diagnostic problems with heart disease. Can occur isolated unaccompanied by heartburn, predominantly in irritating food intake;
- odynophagia (pain swallowing) and disafagia (difficult to swallowing) occur in the case of spastic contraction of the lower esophageal sphincter;
- respiratory symptoms (choking, shortness of breath at night, asthma) or otolaryngology symptoms (laryngitis, faringene paresthesia, hoarseness) are due to regurgitation of acid stomach contents and aspiration of this contents.
Paraclinical examination necessary for evidence of gastroesophageal reflux disease are:
Upper gastrointestinal endoscopy: in the presence of esophageal symptoms distressing, persistent, especially in the presence of dysphagia and pain will be performed esophageal-gastroscopy. This can reveal any mucosal lesions, or may exclude them. May reveal a peptic associated lesion which causing symptoms. May be evidence the presence of a hiatal hernia. Also by endoscopy detected lesions can be biopsied. Consequence of gastroesophageal reflux disease, reflux esophagitis is an esophageal mucosa injury under the effect of acid or alkaline reflux.
The severity of endoscopic lesions is estimated by Los Angeles classification of esophagitis which have several degrees:
- A: one or more areas of substance loss, less than 5 mm;
- B: at least one area by substance loss greater than 5 mm, none of which extends between the tops of two mucosal folds;
- C: at least one area by extensive substance loss between 3 or 4 mucosa folds, but which involve less than 75% of the esophageal circumference;
- D: circumferential loss of substance.
Esophageal pH-metric: over 24 hours is very useful to find out the duration of the reflux. It is useful to correlate symptoms with acid pH, but also atypical symptoms may be correlated with the reflux.
Esophageal manometer: coupled with pH-meter allows detection of fine lesions and their correlation with esophageal symptoms.
Barium X-ray: may detect motor disorders of the esophagus.
Complications which occur in gastroesophageal reflux disease are:
- Reflux esophagitis, in varying degrees, up to esophageal ulcers and esophageal stenosis;
- Barrett’s esophagus, represents a epithelial cylindrical metaplasia of the normal esophageal mucosa, as a consequence of the healing of gastroesophageal reflux disease and is a preneoplastic lesions and cancer of the esophagus;
- Upper gastrointestinal bleeding, a rare complication.
Dietary treatment: a lot of cases of gastroesophageal reflux disease can be solved by diet, these measures are:
- avoiding large meals, avoiding foods that decrease lower esophageal sphincter pressure: coffee, chocolate, carbonated beverages, mint products, fats, alcohol, or avoiding foods that increase acid secretion: orange juice, white wine, acidic foods;
- Avoid smoking because it is believed to increase acid secretion and decreased lower esophageal sphincter pressure;
- avoiding bedtime after eating;
- obese people are advised to lose weight.
Drug treatment: includes the following types of drugs:
Anti-secreting drugs, these drugs reduce acid secretion, the two main groups of anti secretory are:
- histamine H2 blockers: ranitidine, famotidine, which can be used over a period of 4-8 weeks in case of esophagitis, and if the symptoms are occasionally recommended to be administrated on demand;
- proton pump inhibitors, are represented by omeprazole, lansoprazole, esmoprazol and rabeprazol. Treatment duration is 4 to 8 weeks.
In the treatment of gastroesophageal reflux disease, there are two therapeutic strategies, “step down” and “step up”.
The “step down” strategy means starting therapy with a higher dose of proton pump inhibitors, which then, in case of positive response, the dosage can be halved or administration can proceed to histamine H2 blockers.
The “step up” strategy means staring therapy with histamine H2-blockers and in case of failure to pass the administration of proton pump inhibitors.
Prokinetic medication. In this category are metoclopramide and domperidomul, drugs that increase lower esophageal sphincter tonus and gastric emptying. Treatment strategy in gastroesophageal reflux disease is as follows: start with taking a proton pump inhibitor, and in case of failure add a prokinetic