- Causes of disease
- Disease classification
- Symptoms of reflux esophagitis
- Diagnosis of the disease
- Treatment of reflux esophagitis
- Prevention of reflux esophagitis
- Prognosis of the disease
Reflux esophagitis is called inflammation of the mucous membrane of the lower esophagus, resulting from the frequent and long-term return casts of aggressive contents of the stomach. It is one of the stages of the disease, called gastroesophageal reflux disease. According to unbiased statistics, 2% of adults have reflux esophagitis, which is more often (2 times) detected in men.
The contents of the stomach consists of food, mucus, gastric digestive enzymes, hydrochloric acid, and sometimes even bile acids and / or pancreatic juice. The process of throwing it (gastroesophageal reflux) into the esophagus can also occur in a perfectly healthy person. But there are no more than two reflux episodes per day (lasting up to five minutes) and it happens more often in the daytime (usually after eating). Most of them do not even feel.
To prevent more frequent returns in the normal body, there are certain protection mechanisms. These include:
- sufficient tone of the sphincters (upper and lower) of the esophagus - muscle formations, slightly resembling valves, separating the esophagus from the throat and stomach;
- adequate esophageal self-purification (neutralization of the reflux fluid that has fallen into it);
- the integrity and strength of the esophageal mucosa (its normal blood flow, sufficient production of mucus, bicarbonates and prostaglandins by the esophageal glands, adequate renewal of mucosal cells, etc.);
- rapid evacuation of invaded gastric contents;
- control gastric acid production.
Causes of illness
The occurrence of reflux esophagitis can lead to any factors that reduce or completely eliminate the effectiveness of these protective mechanisms. They may be:
- excess weight;
- excessive physical exertion (especially on the abdominals), including the lifting of a heavy burden;
- dietary errors (fatty, spicy, sour dishes);
- overeating at night;
- alcohol abuse;
- emotional overstrain;
- tight clothing (bandages, corsets, etc.);
- damage to the esophageal sphincter during surgery or bougienage;
- hernia of the esophageal opening of the diaphragm (part of the stomach moves through the too wide diaphragmatic opening into the chest cavity);
- prolonged use of certain drugs (calcium antagonists, anti-inflammatory drugs, nitrates, certain antibiotics, theophylline, antidepressants, quinidine, sedatives, adrenergic blockers, hormones, drugs, etc.);
- persistent constipation;
- abnormalities of the formation of the neuromuscular apparatus (in children).
First, hydrochloric acid, active gastric enzymes (pepsin), bile acids, lysolecithin simply irritate the esophageal mucosa, causing clinical manifestations of the disease. Then the inflammatory process begins. In the case of massive and prolonged contact of the mucous with refluxate, erosions develop, which gradually transform into ulcers. These defects, in turn, can be the cause of cicatricial deformities (strictures) and bleeding. In addition, long-term uncontrolled inflammation can provoke first precancerous changes (Barrett's esophagus), and then malignant degeneration (adenocarcinoma).
Reflux esophagitis is:
- non-erosive (with endoscopic examination only redness and swelling are observed);
- erosive (erosive lesions of varying length are detected).
When erosive esophagitis is detected, endoscopists often indicate its degree (it varies from A to D or from I to V). It is determined by the number and area of mucosal defects, the presence of complications (strictures, ulcers, shortened esophagus, Barrett's esophagus).
Symptoms of reflux esophagitis
Reflux esophagitis can occur completely hidden, and can annoy the patient with many clinical manifestations. At the same time, its symptoms are divided into:
Esophageal symptoms are often triggered by overeating, late dinner, dietary errors, alcoholic or carbonated drinks, psycho-emotional unrest or physical overload. They occur when the body assumes a horizontal position, in the middle of the night, or when bending and lifting heavy things. These esophageal symptoms include:
- heartburn (in 75% of patients);
- excessive salivation (sometimes patients in the morning find a wet spot on the pillowcase);
- belching food, sour or bitter;
- disgusting taste in the mouth in the morning (bitter or sour);
- swallowing disorders (due to spasmodic contractions of the esophagus);
- pain in the process of swallowing;
- burning pains behind the sternum and in the epigastric (epigastric) zone, which can be transmitted to the neck, interscapular region, left side of the chest (sometimes they are confused with heart pain, angina attacks, and even myocardial infarction).
The listed esophageal symptoms are classic. Sometimes they are enough to suspect inflammation of the esophagus and / or its movement disorders and recommend a proper examination. Extraesophageal symptoms are much more difficult to associate with reflux esophagitis. Such patients often bypass many specialists and undergo various studies before finding out the true cause of their illness. These symptoms are:
- feeling of coma or prolonged discomfort in the throat;
- lesion of the vocal cords (ulcers, granulomas);
- prolonged cough without sputum;
- damage to tooth enamel;
- laryngeal papillomatosis;
- pain localized in the lower jaw;
- periodic heart rhythm disorders;
- neck pain;
- fetid odor from the mouth.
Diagnosis of the disease
In the presence of the mentioned symptoms, the patient must certainly be examined, since the severity of clinical manifestations does not always correspond to the severity of mucosal damage. Therefore, even banal heartburn can be a formidable symptom. And only the data of the performed diagnostic procedures provide the doctor with the information necessary for effective treatment.
- fibroesophagogastroduodenoscopy (a highly informative examination using an endoscopic device allows you to see the condition of the esophageal mucosa, assess the presence of swelling, redness, erosions, ulcers, constrictions, scars, motility disorders, determine the extent of the inflammatory process, you can take biopsies of all modified areas by using special biopsy forceps) research;
- chromoesophagoscopy (dyes injected into fibroesophagogastroduodenoscopy into the esophagus: indigo carmine, Lugol solution, toluidine blue, methylene blue; detect areas of precancerous changes, from which the mucosa pieces are carefully sampled for a thorough microscopic analysis of their structure);
- morphological assessment (analysis of the mucous membrane under a microscope eliminates malignant degeneration and establishes signs of reflux esophagitis: inflammatory cells in the mucous membrane, its edema, microchromosomes, etc.);
- X-ray examination with contrast - barium suspension (reveals inflammatory changes, ulcers, contractions, the patient is examined both vertically and horizontally, it helps to verify gastroesophageal and duodenogastric reflux, diaphragmatic hernia, well tolerated by patients);
- daily intra-esophageal pH-metry (a daily study determines the acidity of the esophagus and assesses the number, duration of reflux, informatively with atypical symptoms);
- intra esophageal manometry (the method confirms a decrease in the tone of the esophageal sphincters, the formation of diaphragmatic hernia, a decrease in the severity of movements of the esophageal wall, but it is not easily accessible);
- gastroesophageal scintigraphy (radioisotope research verifies disorders of the motor and evacuation capacity of the esophagus).
Treatment of reflux esophagitis
When detecting a varying degree of reflux esophagitis, the following therapeutic measures can be recommended to patients:
- lifestyle correction;
- diet therapy;
- surgical treatment.
The vast majority of patients are treated on an outpatient basis. Only those patients with reflux esophagitis who have a complicated course, in whom all the outpatient-prescribed methods have not had the desired effect or need endoscopic or surgical treatment, require hospitalization.
Any competent specialist acquaints his patient with these simple but absolutely necessary recommendations. Most of them should be performed not only during the period of active treatment, but also after its completion. They should become a new lifestyle for the patient. Otherwise, all manifestations of the disease after some time will return again.
Doctors usually recommend:
- stop smoking and overuse of strong drinks;
- normalize your weight (if it is raised);
- raise the head end of your bed by 10 or 15 centimeters (extra pillows will not correct the situation, but only increase the intra-abdominal pressure and, accordingly, aggravate reflux);
- do not lie down for three hours immediately after eating;
- stop wearing pressure corsets, bandages, stiff belts, rubber bands and belts for the next two hours after eating;
- exclude at the same time all the loads on the abdominals (including household chores, sports activities, bends, yoga, etc.);
- not to lift weights weighing more than 8 kg (at least within two hours after eating);
- bring your chair back to normal;
- consider replacing or adjusting the dosages of all drugs that negatively affect the tone of the lower esophageal sphincter or irritate the esophageal mucosa (prostaglandins, adrenergic blockers, prolonged nitrates, doxycycline, progestins, nitrites, calcium antagonists, levodopa, benzodiazepines, etc.).
In order to fulfill the latter request, it may be necessary to consult the specialized medical specialists who prescribed these medicines.
To enhance the effect of pharmacotherapy, patients are prescribed a gentle therapeutic diet. For its implementation in daily nutrition, patients need to:
- do not overeat (it is recommended to eat regularly 4 times a day, in small portions);
- stop eating just before bedtime (the interval from dinner to bedtime should reach two hours);
- eliminate from your diet all sharp, hot and excessively cold dishes that can damage the sensitive esophageal mucosa;
- limit or completely remove from the diet all drinks and dishes that lower the tone of the esophageal sphincter (carbonated drinks, coffee, citrus fruits, mint, chocolate, garlic, cocoa, green onions, tomatoes, fat meat, red fish, duck, goose, fat milk, pepper , cream, fried dishes, margarine, egg yolks, butter, etc.).
It is highly desirable that, even after the onset of strong remission, patients do not forget about the nutrition that is right for them. After all, a violation of these principles can trigger the resumption of clinical and endoscopic manifestations of reflux esophagitis.
Drug therapy (pharmacotherapy)
Proper treatment of confirmed reflux esophagitis involves two therapeutic strategies. The first begins with the most powerful drugs, then the intensity of the medicinal effect is reduced (its doctors call step-down). The second strategy first recommends medications with minimal efficacy with a further increase in pharmacological effects. Most doctors use the first one in their practice.
The basis of modern treatment is considered antisecretory (secretolytic) drugs that lower gastric secretion. Reducing the acidity of gastric refluxate reduces its detrimental effect on the delicate esophageal mucosa. Secretoliticians include:
- proton pump inhibitors - the most effective and powerful drugs (lansoprazole, rabeprazole, pantoprazole, omeprazole, esomeprazole, dexlansoprazole);
- H2 (histamine) - blockers (nizatidine, roxatidine, famotidine, cimetidine, ranitidine) are less active, resistance to them sometimes develops;
- M-anticholinergics (metacin, platifillin, etc.), but these drugs can simultaneously reduce the pressure of the esophageal sphincters.
The duration of the course of antisecretory drugs is based on the degree of developed reflux esophagitis, the presence of erosions and precancerous transformations. She is determined by the doctor. The minimum rate lasts about a month, the maximum can take more than one year. Sometimes the treatment is forced to spend for life.
In case of detection of erosive forms of esophagitis, prokinetics are included in the prescribed treatment regimen. These drugs mediate motility. These include:
- metoclopramide (raglan, cerrucal, etc.);
- itopride (ganaton and others);
- Domperidone (motilium, motonix, motilak, passenger, etc.).
If bile is present in the contents of refluctate, sometimes treatment is supplemented with ursodeoxycholic acid preparations (Urdox, Ursosan, Ursodex, Ursofalk, etc.), which are advised to be consumed overnight.
Soft drugs are all kinds of antacids and alginates. They neutralize harmful hydrochloric acid, inactivate pepsins, adsorb lysolecithin, bile acids. But their impact is short term and often insufficient. Therefore, they are now advised to use as an auxiliary symptomatic means. Antacids are renny, riopan, phosphalugel, milant, almagel, gastal, relzer, maalox, rutacid, etc. Alginates (topalkan, Gaviscon, topaal, etc.) form a foam that protects the esophageal mucosa during a gastroesophageal reflux.
In order to increase the stability of the esophageal mucosa, in some cases, doctors may recommend misoprostol, sucralfate or flaxseed broth.
In the case of erosive esophagitis at the end of the course of treatment, endoscopic examination must be performed. Indeed, clinical improvement and the complete disappearance of symptoms do not in all cases indicate a true positive dynamic of the process. And continued erosion or ulceration at any inopportune moment can be a source of bleeding.
In the absence of the effect of the described non-invasive techniques and frequent relapses of reflux esophagitis, the endoscopic treatment may first be advised to the patient. It consists of flashing the lower of the esophageal sphincters or introducing various polymeric substances into it, contributing to the normalization of its barrier function. Upon detection of precancerous mucosal transformations, photodynamic or laser destruction, thermal destruction, electrocoagulation, local endoscopic resection of these modified mucosal areas are possible. But not all methods are still widely used.
Indications for radical surgery include:
- preservation of symptoms and endoscopic manifestations of esophagitis subject to adequate medical treatment for six months;
- the development of complications (repeated bleeding, narrowing, etc.);
- Barrett's esophagus with established severe dysplasia;
- frequent pneumonia, developing due to aspiration of gastric acidic contents;
- a combination of reflux esophagitis with intractable bronchial asthma;
- personal desire of the patient.
In all these situations, surgeons perform fundoplication (the lower part of the esophagus is reduced by 2-3 centimeters into the abdominal cavity, a kind of cuff is formed from the gastric wall at the place of its connection with the esophagus and hemmed to the diaphragm, the excessively wide opening in the diaphragm is sutured, and the cuff is moved to mediastinum). Access can be traditional (when the abdomen or chest is cut) or laparoscopic (all necessary manipulations are carried out through small holes - punctures through which the necessary endoscopic instruments are inserted into the abdominal cavity). Laparoscopic surgery is considered preferable, as it is faster, less traumatic, has less unpleasant complications and cosmetic defects, patients tolerate it more easily and are more likely to recover in the postoperative period.
Prevention of reflux esophagitis
In order to reduce the number of recurrences of reflux esophagitis and its further progression, it is necessary to combat all the factors contributing to its appearance. Patients must strictly follow a diet, struggle with excess weight, addiction to tobacco and alcohol-containing beverages, change the rest and work regime, choose the right garments, avoid excessive loads on your abdominals, and limit the intake of certain medications.
With confirmed precancerous changes, banal heartburn can serve as a signal for the need for an immediate visit to your doctor and timely examination. In the case of Barrett's esophagus, endoscopic examination with biopsy specimens should be carried out annually and even more often (if severe dysplasia is present, established under a microscope by at least two morphologists).
Prognosis of the disease
Reflux esophagitis has, as a rule, a favorable prognosis for disability and life. If there are no complications, then it does not shorten its duration. But with inadequate treatment and non-compliance with the recommendations given by the doctors, new recurrences of esophagitis and its progression are possible.