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Gastroesophageal reflux disease (GERD)
Last reviewed: 18.10.2021
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Gastroesophageal reflux disease (GERD) is a gastroenterological disease characterized by the development of inflammatory changes in the mucous membrane of the distal esophagus and / or the characteristic clinical symptoms due to repeated transmission to the esophagus of gastric and / or duodenal contents.
The failure of the lower esophageal sphincter promotes reflux of the gastric contents into the esophagus, causing acute pain. Prolonged reflux can lead to esophagitis, stricture and rarely to metaplasia. The diagnosis is established clinically, sometimes with the implementation of endoscopy and the study of the acidity of gastric juice. Treatment of gastroesophageal reflux disease (GERD) includes lifestyle changes, a decrease in the acidity of gastric juice by proton pump inhibitors and sometimes surgical treatment.
ICD-10 code
- K 21.0 Gastroesophageal reflux with esophagitis
- K21.9 Gastroesophageal reflux without esophagitis.
Epidemiology of gastroesophageal reflux disease
Gastroesophageal reflux disease (GERD) is common and occurs in 30-40% of adults. It is also quite common in infants and usually occurs after birth.
The growing relevance of the problem of gastroesophageal reflux disease is associated with an increase in the number of patients with this pathology all over the world. The results of epidemiological studies show that the frequency of reflux-esophagitis in the population is 3-4%. It is detected in 6-12% of persons who undergo endoscopy.
Studies conducted in Europe and the United States have shown that 20-25% of the population suffer from symptoms of gastroesophageal reflux disease, and 7% have symptoms daily. In conditions of general medical practice, 25-40% of people with GERD have esophagitis based on the results of endoscopy, but in most people GERD does not have endoscopic manifestations.
According to foreign researchers, 44% of Americans suffer from heartburn at least once a month, and 7% have it every day. 13% of the US adult population resort to antacids two or more times a week, and 1/3 - once a month. However, only 40% of the respondents were so symptomatic that they had to go to the doctor. In France, gastroesophageal reflux disease (GERD) is one of the most common diseases of the digestive tract. As shown by the survey in 10% of the adult population, the symptoms of gastroesophageal reflux disease (GERD) were manifested at least 1 time during the year. All this makes the study of GERD one of the priority areas of modern gastroenterology. The prevalence of GERD is comparable to the prevalence of ulcerative and cholelithiasis. It is believed that up to 10% of the population suffers from each of these diseases. Every day GERD symptoms are experienced by up to 10% of the population, weekly - 30%, monthly - 50% of the adult population. In the US, symptoms of gastroesophageal reflux disease (GERD) are noted in 44 million people.
The true prevalence of gastroesophageal reflux disease is much higher than statistical data, including because only less than 1/3 of GERD patients seek medical attention.
[1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12]
What causes gastroesophageal reflux disease (GERD)?
The appearance of reflux suggests the inferiority of the lower esophageal sphincter (NPS), which may be the result of a general decrease in sphincter tone or recurrent transient relaxation (not associated with swallowing). Transient relaxation of NPCs is caused by gastric dilatation or subthreshold pharyngeal stimulation.
Factors that ensure the normal functioning of the gastroesophageal transition include: the angle of the gastroesophageal transition, the contraction of the diaphragm, and gravity (i.e., the vertical position). Factors contributing to reflux include increasing the weight. Fatty foods, carbonated drinks with caffeine, alcohol, tobacco smoking and medicines. Medications that reduce the tone of NPC include anticholinergic drugs, antihistamines, tricyclic antidepressants, blockers of Ca-channels, progesterone and nitrates.
Gastroesophageal reflux disease (GERD) can cause esophagitis, peptic ulcer of the esophagus, esophageal stricture and Berretta's esophagus (precancerous disease). Factors contributing to the development of esophagitis include: the corrosive nature of refluxate, the inability of the esophagus to neutralize it, the volume of gastric contents and the local protective properties of the mucous membrane. Some patients, especially infants, aspirate the contents with reflux.
Symptoms of gastroesophageal reflux disease (GERD)
The most vivid symptoms of gastroesophageal reflux disease (GERD) are heartburn, with or without regurgitation of gastric contents into the oral cavity. Infants have vomiting, irritability, anorexia and sometimes signs of chronic aspiration. In adults and infants with chronic aspiration, coughing, hoarseness, or stridor may occur.
Esophagitis can cause pain while swallowing and even esophageal bleeding, which is usually hidden, but can sometimes be massive. Peptic stricture causes gradually progressive dysphagia when taking solid food. Peptic ulcers of the esophagus cause pain, as in the ulcer of the stomach or duodenum, but the pain is usually localized in the region of the xiphoid process or the high retrosternal region. Peptic ulcers of the esophagus heal slowly, tend to recur and usually cicatrize during healing.
Where does it hurt?
What's bothering you?
Diagnosis of gastroesophageal reflux disease (GERD)
A detailed anamnesis usually indicates a diagnosis. Patients with typical signs of GERD can be prescribed a trial therapy. If the treatment is ineffective, prolonged symptoms of the disease or signs of complications, a patient should be examined. Endoscopy with cytological examination of scraping with mucosa and biopsy of altered areas is a method of choice. Endoscopic biopsy is the only test that consistently reveals the appearance of the cylindrical epithelium of the mucous membrane in the esophagus of Berretta. Patients with questionable results of endoscopy and maintenance of symptoms, despite treatment with proton pump inhibitors, need to perform a pH study. Although fluoroscopy with a sip of barium indicates esophageal ulcers and peptic stricture, this study is less informative for choosing a method of treatment that reduces reflux; In addition, most patients with identified pathology require subsequent endoscopy. Manometry of the esophagus can be used as a guide when placing the sensor in the study of pH and assessing the peristalsis of the esophagus before surgery.
What do need to examine?
What tests are needed?
Who to contact?
Treatment of gastroesophageal reflux disease (GERD)
Treatment of uncomplicated gastroesophageal reflux disease (GERD) consists in raising the head of the bed by 20 centimeters and excluding the following factors: eating at least 2 hours before bedtime, strong stimulants of gastric secretion (eg, coffee, alcohol), certain medications (eg ., anticholinergics), certain foods (eg, fats, chocolate) and smoking.
Medication for gastroesophageal reflux disease (GERD) includes proton pump blockers. Adults can be prescribed omeprazole 20 mg, lansoprazole 30 mg or esomeprazole 40 mg for 30 minutes before breakfast. In some cases, proton pump blockers should be administered 2 times a day. Infants and children may be given these drugs at a lower dosage, respectively, once a day (ie omeprazole 20 mg for children over 3 years, 10 mg for children less than 3 years old, lansoprazole 15 mg for children less than 30 kg, 30 mg for children greater than 30 kg ). These drugs can be used for a long time, but the minimum dose necessary to prevent symptoms should be selected. H2-blockers (eg ranitidine 150 mg at bedtime) or motility stimulants (eg, metoclopramide 10 mg orally 30 minutes before eating before bedtime) are less effective.
Antireflux surgery (usually laparoscopic) is performed in patients with severe esophagitis, bleeding, strictures, ulcers, or severe symptoms. With strictures of the esophagus, repeated balloon dilatation sessions are used.
Esophagus of Berretta can regress (sometimes treatment is ineffective) with the use of medication or surgical treatment. Because Berretta's esophagus predisposes to adenocarcinoma, endoscopic control of malignant degeneration is recommended every 1-2 years. Observation is of little importance in patients with unexpressed dysplasia, but it is important for severe dysplasia. As an alternative to conservative treatment of the esophagus of Berretta, surgical resection or laser ablation can be considered.
How is gastroesophageal reflux disease (GERD) prevented?
Preventative measures are not developed, therefore gastroesophageal reflux disease (GERD) is not prevented. Screening studies are not conducted.
Historical reference
A disease characterized by the transfer of gastric contents into the esophagus has been known for a long time. Mention of some symptoms of this pathology, such as heartburn and belching sour are still in the writings of Avicenna. Gastroesophageal reflux (GER) was first described by H.Quinke in 1879. Since that time, many terms have been changed that characterize this nosology. A number of authors call gastroesophageal reflux disease (GERD) peptic esophagitis or reflux esophagitis, but it is known that in more than 50% of patients with similar symptoms there is no lesion of the esophageal mucosa. Others call gastroesophageal reflux disease simply a reflux disease, but reflux can occur in the venous, urinary and various parts of the gastrointestinal tract (GIT), and the mechanisms of the onset and manifestation of the disease in each specific case are different. Sometimes there is the following formulation of the diagnosis - gastroesophageal reflux (GER). It is important to note that the GER alone can be a physiological phenomenon and can be found in absolutely healthy people. Despite the wide prevalence and lengthy "anamnesis" until recently GERD, according to the figurative expression of E.S. Ryssa, was a kind of "cinderella" among therapists and gastroenterologists. And only in the last decade, the ubiquitous spread of esophagogastroscopy and the appearance of a daily pH-metry allowed us to deal with the diagnosis of this disease more thoroughly and try to answer many of the accumulated questions. In 1996, the international classification was termed (GERD), most fully reflecting this pathology.
According to the WHO classification, gastroesophageal reflux disease (GERD) is a chronic relapsing disease caused by a violation of the motor-evacuation function of the gastroesophageal zone and characterized by a spontaneous or regularly repeated throbbing of the gastric or duodenal contents into the esophagus, which leads to damage to the distal esophagus.