The term “gastroesophageal reflux” refers to reverse the progress of the contents of the stomach through the lower esophageal sphincter into the esophagus.
The acidity of the stomach contents at a rate of 1.5-2.0 (low acidity due to the secretion of hydrochloric acid). In contrast, the contents of the esophagus has a pH value close to neutral (6,0-7,0).
With the development of gastroesophageal reflux acidity in the esophagus is significantly shifted towards lower values due to the ingress of acidic stomach contents. Prolonged exposure of the esophageal mucosa to acid content of the stomach, in addition, contain digestive enzymes, contributes to the development of inflammation.
Bile acids, enzymes, bicarbonate, included in the content of the duodenum is also able to produce strong damaging action on mucous of esophagus. When casting these substances in the stomach can also occur their promotion into the esophagus.
Gastroesophageal reflux is a normal physiologic manifestation, if it meets the following criteria:
– develops, main by the way, after eating;
– is not accompanied by discomfort;
– duration of refluxes and their frequency during the day small;
– at night the frequency of refluxes small.
Gastroesophageal reflux should be considered as painful, if it has the following features:
– frequent and/or prolonged episodes of reflux;
– episodes of reflux are registered in the daytime and/or nighttime;
– the reflux of gastric contents into the esophagus accompanied by the development of clinical symptoms, inflammation/ damage of the mucosa of the esophagus.
Reasons gastroesophageal reflux
Some of factors contribute to the development of reflux of gastric contents into the esophagus. Among them:
– failure of the lower esophageal sphincter;
– transient episodes of relaxation of the lower esophageal sphincter;
– failure esophageal clearance;
– painful changes in the stomach, which increase the severity of physiological reflux.
Protective, “anti-reflux”, the function of the lower esophageal sphincter is ensured by keeping the tone of his muscles, of sufficient extent sphincter area and the location of the sphincter area in the abdominal cavity. Quite a large part of the patients revealed a decrease in pressure in the lower esophageal sphincter; in other cases, there are episodes of transient relaxation of his muscles.
It was established that in keeping the tone of the lower esophageal sphincter play the role of hormonal factors. Some medications and some foods help to reduce pressure in the lower esophageal sphincter and the development or maintenance of reflux.
The location of the sphincter area in the abdominal cavity, below the diaphragm, is wise adaptive mechanism to prevent reflux of gastric contents into the esophagus at the height of inspiration, in the moment when this contributes to increasing intra-abdominal pressure.
At the height of inspiration in normal conditions there is “clamping” of the lower segment of the esophagus between the legs of the diaphragm. In the case of forming hernia hiatal final segment of the esophagus moves above the diaphragm. “Clamping” of the upper part of the stomach legs diaphragm violates the evacuation of esophageal acid content.
Due to the reduction of the esophagus supports natural cleansing of the esophagus from acid content, and the normal acidity of the esophagus does not exceed 4.
Natural mechanisms enabling the purification of the esophagus, the following:
– motor activity of the esophagus;
– found in the saliva bicarbonate to neutralize the acid content.
Violations of these links helps reduce the ‘purification’ of the esophagus hit him acidic or alkaline content.
Symptoms of gastroesophageal reflux
Manifestations of gastroesophageal reflux disease characterized by a variety of signs that can be observed in isolation and in combinations. According to the results of special studies, the signs of gastroesophageal reflux detected in 20-40% of people in the developed world (according to some – almost half of the adult population). Daily symptoms of gastroesophageal reflux disease have up to 10% of the population, weekly – 30%, monthly – 50% of the adult population.
Some of the most common manifestations of gastroesophageal reflux disease include:
– pain in the chest and in the left half of the chest;
– painful swallowing;
– chronic cough, hoarseness;
– the destruction of tooth enamel.
Unfortunately, the severity of clinical manifestations not fully reflect the severity of reflux. More than 85% of episodes of reducing vnutriryadnoi acidity below 4 is not accompanied by any sensations.
Diagnosis of gastroesophageal reflux
Evaluation of changes in the esophagus in gastroesophageal reflux disease by esophagoscopy with biopsy allows not only to assess the degree of damage of the esophagus, but also to conduct the differential diagnosis of esophagitis.
X-ray examination of the esophagus with barium allows to identify anatomical disorders of the esophagus and stomach, which contribute to the formation of gastroesophageal reflux (a paraesophageal hernia the diaphragm).
24-hour monitoring vnutriryadnoi acidity plays an important role in confirming the presence of gastroesophageal reflux.
Treatment of gastroesophageal reflux
Remedial measures in gastroesophageal reflux disease should be aimed at reducing the severity of reflux, the reduction of the damaging properties of gastric contents, increased esophageal purification, protection of the mucous membrane of the esophagus.
Important to observe the General measures that reduce the severity of reflux of gastric contents into the esophagus. They include:
– normalization of body weight (in patients with excessive body weight, this allows to reduce the severity of the degree of failure of the lower esophageal sphincter);
– the exception of Smoking, reduction of alcohol consumption, limit consumption of fatty foods, coffee, chocolate (these effects help to reduce the tone of the lower esophageal sphincter, fatty food slows the activity of the stomach);
– the exception, of acidic foods, which usually provokes the appearance of heartburn;
– eating small portions regularly;
– eating no later than 2 hours before bedtime;
– avoiding the overhead of the increased intra-abdominal pressure;
– sleep on the bed, head end which is raised 10-15 cm
The ineffectiveness of such events is prescribed antacids. Antacids – group of medicines containing aluminum salts, magnesium, calcium, which neutralize the hydrochloric acid. In addition, antacids can bind and reduce the activity of digestive enzyme of gastric juice, bile acids and lysolecithin is included in the composition of bile and has a damaging effect on the mucosa of the stomach and esophagus.
It is preferable to take antacid preparations in the form of gels. In the lumen of the esophagus and stomach gels form small droplets that enhances their effect. At the present time in the form of gels produced Almagel, Fosfalugel, Maalox, Renagel. These preparations contain aluminum salts or aluminum salts and magnesium in different ratios.
Antacids are 30 minutes before meals and at bedtime (when possible it is advisable to take the drug in the supine position, in small SIPS).
If there is no effect from taking antacids, as well as the presence of endoscopic signs of esophagitis requires the appointment of prokinetics and/or antisecretory drugs.
As prokinetic patients with gastroesophageal reflux disease shows the assignment of domperidone in connection with the presence of metoclopramide systemic side effects. Domperidone is assigned to 10 mg 4 times a day.
In the case of patients with erosive esophagitis need additional assignment of proton pump inhibitors (rabeprazole 20 mg overnight omeprazole 20 mg 2-3 times a day).
The duration of treatment erosive esophagitis should be at least 8 weeks; in the healing of erosion it is necessary to conduct maintenance therapy domperidone (20 mg/day), proton pump inhibitors (rabeprazole 10-20 mg/day, omeprazole 20 mg/day) or their combination.
Complications of gastroesophageal reflux disease observed in 10-15% of patients and determine the prognosis of the disease. In severe reflux esophagitis may develop ulcers and narrowing of the esophagus, esophageal bleeding.