Gastroesophageal reflux

Content

Introduction

Introduction

Gastroesophageal reflux is a very common condition in which the contents of the stomach go up into the "esophagus. It occurs equally in both men and women and usually occurs in adulthood, between the ages of thirty and fifty". In Italy it affects one in three people and the likelihood of the onset of reflux increases with advancing age. Gastroesophageal reflux in the newborn and during pregnancy is also very common.

The esophagus is the tube that carries food from the mouth to the stomach. At the lower end there is a valve (lower esophageal sphincter) which prevents the passage of stomach contents into the esophagus and is released after swallowing to allow food to pass into the stomach. If the valve does not function properly, reflux of hydrochloric acid, bile and food from the stomach into the esophagus can occur. Sometimes, it can be favored by a hiatal hernia, that is, a rise of the stomach into the chest through the diaphragm, but hiatal hernia is not always associated with reflux and vice versa.

Gastroesophageal reflux within certain limits is physiological: the amount of acid that goes up in the esophagus, usually after meals, is limited, and therefore does not cause particular problems (read the Bufala).

The main disorder (symptom) associated with gastroesophageal reflux is the burning sensation (also called heartburn) felt in the upper abdomen (epigastrium) and behind the breastbone. Acid regurgitation and the return of food to the mouth can be associated with this. Most people can occasionally have these disorders after particularly large meals, but when they become particularly frequent (more than twice a week) and, above all, negatively affect the feeling of well-being, it is called "gastroesophageal reflux disease" (GERD). which may or may not be associated with changes in the esophageal mucosa due to the presence of acid.

GERD can be treated with medication and lifestyle changes. Surgery may only be necessary in a few cases.

If the disturbances (symptoms) are particularly frequent and / or annoying, such as to affect the feeling of well-being, it is advisable to consult a doctor. In particular if:

  • the ailments are very frequent and intense
  • over-the-counter medication (self-medication) for two weeks has no effect
  • there is difficulty in swallowing (swallowing)
  • there are disorders that could suggest a more serious problem, such as repeated vomiting, vomiting blood, unexplained weight loss, feeling of choking while eating or difficulty swallowing food and liquids, chest pain
Symptoms

Symptoms

The most common symptoms (symptoms) caused by GERD are heartburn and acid regurgitation.

  • stomach ache, it is an unpleasant burning sensation in the upper abdomen (epigastrium) or in the chest, behind the breastbone. The burning sometimes extends to the throat. Usually worse after meals, lying down, or when leaning forward, such as tying your shoes
  • acid regurgitation, occurs as a result of the rise of stomach acids and stomach contents in the esophagus, throat and mouth. An unpleasant sour taste is usually felt in the back of the mouth

Other symptoms

  • bad breath (halitosis)
  • frequent belching
  • bloating and flatulence
  • feeling of lump in the throat
  • difficulty and / or pain in swallowing (dysphagia)
  • repeated (recurring) sore throat, hoarseness or change in tone of voice
  • persistent cough and wheezing, especially during the night
  • inflammation of the gums and erosion of the tooth enamel
  • chest pain

Disorders (symptoms) may or may not be accompanied by inflammation of the esophagus (esophagitis).

In the presence of difficulty in swallowing (dysphagia), hoarseness, persistent cough and chest pain the attending physician should be consulted.

Gastroesophageal reflux disease can worsen asthma symptoms in predisposed subjects, as gastric acids irritate the respiratory tract.

Causes

Causes

Gastroesophageal reflux disease (GERD) is usually caused by the weakening of the valve located at the lower end of the esophagus.

Under normal conditions this valve opens to allow the passage of food from the esophagus to the stomach and closes to prevent the acid content of the stomach from rising into the esophagus. (symptoms) such as burning and acid regurgitation.

Some factors can increase the risk of GERD:

  • overweight or obesity: pressure on the stomach can weaken the muscles in the lower end of the esophagus
  • consumption of high-fat foods: the stomach takes longer to digest these foods and the surplus acid produced can go back up into the esophagus
  • smoking, alcohol, coffee or chocolate: they can help relax the muscles at the lower end of the esophagus
  • pregnancy: hormonal changes and pressure on the stomach due to fetal growth can cause MERG (see Gastroesophageal Reflux in Pregnancy)
  • hiatal hernia: occurs when a part of the stomach slides into the chest through the diaphragm (thin muscle layer between the chest and abdomen)
  • gastroparesis: occurs when the stomach takes longer than normal to get rid of gastric acids and excess acid goes up the esophagus
  • medications: some drugs such as, for example, calcium channel blockers (used to treat hypertension), nitrates (used to treat angina) and non-steroidal anti-inflammatory drugs (NSAIDs) can cause or worsen gastroesophageal reflux disorders
  • stress
  • use of clothes or belts that are too tight

Gastroesophageal reflux disease sometimes affects members of the same family: it is therefore hypothesized that it may have a familiar character or that a genetic predisposition to develop it is inherited.

Diagnosis

Diagnosis

The family doctor can ascertain (diagnose) gastroesophageal reflux disease (GERD) based on the visit (clinical examination) and the complaints reported by the patient. It will generally prescribe adequate treatment without the need for further investigation which, however, will become necessary if:

  • the symptoms (symptoms) are particularly severe or persistent
  • prescribed medications are ineffective
  • the doctor thinks surgery is needed
  • there are signs such as difficulty swallowing (dysphagia) or unexplained weight loss
  • chest pain is present

In these cases, the attending physician may request a visit to the gastroenterologist specialist and the cardiologist to rule out a heart disease. The gastroenterologist may use one or more of the following specific tests to ascertain GERD: endoscopy, barium radiography, manometry, esophageal pH-metry / 24 hours and some blood tests.

Esophagus-gastro-duodenoscopy
The examination consists of exploring the inside of the body through an endoscope, a thin flexible tube with a light and a video camera at the end. The endoscope is inserted through the mouth and throat: the patient is usually awake and / or subjected to light sedation. The "observation with the" endoscope allows you to assess the state of the mucous membranes of the esophagus and stomach (erosions, ulcers) and any complications due to reflux.

Barium X-ray
It allows to evaluate the ability to swallow (swallow) and the presence of any obstructions or abnormalities in the esophagus. The patient drinks a solution containing barium, a harmless substance but clearly visible on X-rays in its path in the digestive system, and is subsequently underwent x-ray.

Manometry
It allows you to measure the pressure inside the esophagus to evaluate the relaxation of the valve located at the lower end of the same. During this procedure, a thin tube containing pressure sensors is inserted through the nose to the esophagus.

esophageal pH-metry / 24 hours
This test is used to measure the acidity level (pH) during the 24 hours, through a thin tube, equipped with sensors, inserted through the nose to the esophagus. The tube is usually connected to a device for recording data, positioned around the waist. The patient will need to push a button every time they experience reflux disturbances. The feeding should be normal during the examination period to ensure an accurate result.

Blood analysis
It may be useful to carry out blood tests to rule out the presence of anemia, due to internal bleeding.

Therapy

Therapy

Gastroesophageal reflux disease (GERD) can be treated with simple steps and self-medication.

If these measures are not sufficient, the doctor may prescribe other medicines or recommend a specialist visit.

Changes in lifestyle and nutrition

  • eating small and frequent meals, do not drink alcohol in the three or four hours before bed, avoid large meals in the evening
  • avoid foods that can worsen reflux disorders (symptoms), such as coffee, chocolate, tomatoes, alcohol, spices, high fat foods
  • do not wear clothes or belts that are too tight
  • raise the head of the bed of 10-15 cm by inserting a shim under the legs of the bed
  • avoid sources of stress and use relaxation techniques
  • maintain a healthy weight and lose weight if you are overweight
  • stop smoking

If you are taking medications for other health problems, ask your doctor if they can make your reflux symptoms (symptoms) worse and, if so, check with him to replace them.

Medicines
Various medications are available to treat GERD disorders (symptoms).

Over-the-counter (or self-medication) drugs sold without a prescription:

  • antacids, neutralize the effects of gastric acids. Antacids can interfere with the absorption of other drugs. It is therefore advisable to consult with your doctor if you are taking other medicines
  • aginati, form a film that protects the stomach and esophagus from acidity
  • aginati + antacids
  • proton pump inhibitors (for example, pantoprazole), drugs capable of reducing acid secretion from the stomach, relieving the disorders caused by reflux. Sometimes they have to be taken for a long time and can cause mild unwanted effects (side effects), such as headache, constipation, diarrhea, nausea, dizziness and skin rashes. Your doctor may lower the dosage of the drug to reduce side effects
  • H2 receptor atagonists (H2 antagonists), drugs that block the action of histamine on the cells of the stomach wall, thus decreasing the release of hydrochloric acid: the undesirable effects (side effects) of H2 antagonists are infrequent and sometimes consist in diarrhea, headache, dizziness, rash and fatigue

The drugs described, previously prescribed only by the doctor, have recently also been approved for self-medication. It is important that they are taken according to the recommended dose and that they are not taken beyond two weeks if the symptoms (symptoms) do not go away.

The long-term (chronic) administration of drugs used in the treatment of gastroesophageal reflux disease must be followed by the treating physician and / or specialist doctor who will decide the dosage, method of administration and duration.

Surgical care
Surgical treatment (therapy) could be an alternative if the drugs do not give good results or cause too many undesirable effects (side effects) or if you do not want to take medicines for a long period of time.

The most used surgical procedure is thefundoplication according to Nissen, performed laparoscopically, i.e. through the insertion of special surgical instruments through small incisions in the abdomen. The surgery aims to narrow the valve located at the lower end of the esophagus, thus preventing the acid from rising from the stomach, and is performed under general anesthesia. After surgery, it is generally necessary to stay in hospital for two or three days before returning home for recovery which usually lasts about six weeks During recovery, you should eat soft or semi-liquid foods such as mashed potatoes or soups and avoid heavy work.

New endoscopic procedures
In recent years, new endoscopic techniques have been developed (endosuture and endoplication, radiofrequency thermocoagulation, injection of various substances) for the treatment of GERD. These are techniques that must be applied in centers with recognized specific experience, not yet studied with regard to long-term effects. The surgeon will be able to provide more information.

Complications

Complications

Gastroesophageal reflux disease (GERD) can cause a number of complications, especially if it has been around for a long time.

Esophageal ulcers
The continuous rise of acid in the esophagus can damage the mucosa and cause erosions and ulcers. The ulcers can bleed, cause pain and difficulty in swallowing. Treatment with drugs such as proton pump inhibitors helps to heal ulcers.

Stricture of the esophagus
Gastric acids can cause scarring of fibrous tissue and narrowing (stricture) of the esophagus. Swallowing, in this case, becomes difficult and painful. The therapy consists in restoring the original size of the esophagus by inserting a balloon or other medical device.

Barrett's esophagus
Esophageal reflux disease, especially if present for a long time, can cause changes in the cells of the epithelium of the lower part of the esophagus, which are replaced by cells similar to those of the intestine, more resistant to acidity. This condition, calledBarrett's esophagus, occurs in one in ten patients with GERD. There is a risk that the mutated cells are transformed into cancer cells: it is therefore necessary to keep them under control by endoscopy to be repeated over the years with the frequency indicated by the doctor.

Cancer of the esophagus
It is estimated that for every 10-20 patients diagnosed with Barrett's esophagus, one will develop esophageal cancer within 10-20 years. Disorders (symptoms) that can lead to suspicion of their presence include:

  • progressive weight loss preceded by difficulty in swallowing which usually appears gradually first for solid foods and then for liquid ones
  • hoarseness or altered tone of voice
  • stubborn cough and blood loss in phlegm
  • frequent vomiting
  • chest pain

It is important to report these symptoms to your doctor: esophageal cancer, if diagnosed early, can be surgically removed.

Bibliography

Bibliography

Casini V, Pallotta S, Pace F. Endoscopic therapy in gastroesophageal reflux disease.Italian Journal of Digestive Endoscopy. 2008; 31: 311-317

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