- Causes of the disease
- Classification of the disease
- Symptoms of reflux esophagitis
- Diagnosis of the disease
- Treatment of reflux-esophagitis
- Prevention of reflux esophagitis
- Prognosis of the disease
Reflux esophagitis is the inflammation of the mucosa of the lower part of the esophagus, which arises from frequent and prolonged backfilling of aggressive stomach contents into it. 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 (in 2 times) detected in men.
The contents of the stomach consists of food, mucus, gastric digestive enzymes, hydrochloric acid, and sometimes even from bile acids and / or pancreatic juice. The process of its casting (gastroesophageal reflux) into the esophagus can occur in a completely healthy person. But for a day there are no more than two episodes of reflux (lasting up to five minutes) and it happens more often in the daytime (usually after eating). Most of them are not even felt at all.
To prevent more frequent back-casting in the normal body, there are certain protection mechanisms. These include:
- sufficient tone of the sphincters (upper and lower) of the esophagus - muscular formations, slightly reminiscent of the valves that delimit the esophagus from the pharynx and stomach;
- adequate esophageal self-purification (neutralization of the reflux liquid that has entered it);
- integrity and strength of the esophageal mucosa (its normal blood flow, sufficient production of mucus glands by the glands, bicarbonates and prostaglandins, adequate renewal of mucosal cells, etc.);
- rapid evacuation of penetrated gastric contents;
- control of acid formation of the stomach.
Causes of the disease
The occurrence of reflux esophagitis can result in any factors that reduce or completely eliminate the effectiveness of the listed protective mechanisms. They may be:
- excess weight;
- excessive physical exertion (especially on the abdominal press), including the lifting of a heavy burden;
- dietary errors (fatty, spicy, acidic dishes);
- overeating at night;
- alcohol abuse;
- emotional overstrain;
- close clothing (bandages, corsets, etc.);
- damage to the esophageal sphincter during surgery or bougie;
- Hernia of the esophageal opening of the diaphragm (a part of the stomach moves through the too wide diaphragmatic opening into the thoracic cavity);
- long-term use of some medications (calcium antagonists, anti-inflammatory drugs, nitrates, individual antibiotics, theophylline, antidepressants, quinidine, sedatives, adrenoblockers, hormones, drugs, etc.);
- obstinate constipation;
- anomalies in 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 a massive and prolonged contact of the mucosa with reflux, erosions develop, which gradually transform into ulcers. These defects, in turn, can cause scar deformations (strictures) and bleeding. In addition, prolonged uncontrolled inflammation can trigger first precancerous changes (Barrett's esophagus), and then malignant degeneration (adenocarcinoma).
Classification of the disease
- non-erosive (with endoscopic examination only redness and swelling are observed);
- erosive (erosive lesions of different lengths are revealed).
When an erosive esophagitis is found, endoscopists often indicate its degree (it varies from A to D or 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 be completely hidden, and can annoy a patient with a multitude of clinical manifestations. In this case, his symptoms are divided into:
Esophageal symptoms are often provoked by overeating, late supper, dietary errors, alcoholic or carbonated beverages, psychoemotional worries or physical overload. They arise when the body takes a horizontal position, in the middle of the night or when it tilts and lifts heavy things. Such esophageal symptoms include:
- Heartburn (in 75% of patients);
- excessive salivation (sometimes patients in the morning find a wet spot on the pillowcase);
- burping food, sour or bitter;
- a disgusting taste in the mouth in the morning (bitter or sour);
- swallowing disorders (due to spastic contractions of the esophagus);
- pain during swallowing;
- burning pain behind the breastbone and in the epigastric zone, which can be transmitted to the neck, the interlopar area, the left part of the chest (sometimes they are confused with heart pains, with attacks of angina and even myocardial infarction).
The listed esophageal symptoms are classical. Sometimes they are enough to suspect an inflammation of the esophagus and / or its motor disorders and recommend a proper examination. Oesophageal symptoms are more difficult to relate to reflux esophagitis. Such patients often bypass many specialists and are subjected to all sorts of research before they discover the true cause of their ailment. These symptoms are:
- hoarseness of voice;
- a feeling of coma or prolonged discomfort in the throat;
- defeat of the vocal cords (ulcers, granulomas);
- prolonged cough without phlegm;
- damage to the enamel of the teeth;
- inflammation of the gums;
- papillomatosis of the larynx;
- pain localized in the lower jaw;
- periodic heart rhythm disorders;
- pain in the neck;
- fetid smell from the mouth.
Diagnosis of the disease
In the presence of this symptomatology, 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.
- fibro-esophagogastroduodenoscopy (highly informative examination with the help of the endoscopic device allows to see the state of the esophageal mucosa, assess the presence of swelling, redness, erosions, ulcers, constrictions, scars, motor disorders, determine the degree of inflammation, special biopsy forceps can take biopsies from all altered sites) research;
- Chromoesophagoscopy (injected in the course of fibroesophagogastroduodenoscopy into the esophagus dyes: indigocarmine, Lugol's solution, toluidine blue, methylene blue detect zones of precancerous changes, of which the mucosal pieces are sampled for careful microscopic analysis of their structure);
- morphological evaluation (mucosal analysis under a microscope excludes malignant degeneration and establishes the signs of reflux-esophagitis: inflammatory cells in the mucosa, its edema, microcirculation, etc.);
- X-ray examination with contrast - barium suspension (reveals inflammatory changes, ulcers, narrowing, patient is examined both in vertical and horizontal position, it helps to verify gastroesophageal and duodenogastric reflux, diaphragmatic hernia, perfectly tolerated by patients);
- daily intra-esophageal pH-metry (daily study determines the acidity of the esophagus and estimates the number, duration of reflux, informatively for atypical symptoms);
- intraepithelial manometry (the method confirms a decrease in the tone of esophageal sphincters, the formation of diaphragmatic hernia, a decrease in the severity of movements of the esophageal wall, but it is inaccessible);
- gastroesophageal scintigraphy (radioisotope study verifies motor and evacuation disorders in the esophagus).
Treatment of reflux esophagitis
If any degree of reflux esophagitis is detected, the following treatment measures can be recommended to patients:
- correction of lifestyle;
- diet therapy;
- surgical treatment.
The vast majority of patients are treated as outpatients. Hospitalization requires only those patients with reflux esophagitis who have a complicated course, in whom all the prescribed outpatient methods do not have the desired effect or who need endoscopic or surgical treatment.
Any competent specialist acquaints his patient with these simple, but absolutely necessary recommendations. Most of them should be performed not only during active treatment, but also after its completion. They should become a new style of the patient's life. Otherwise, all manifestations of the disease will return again after a while.
Usually doctors recommend:
- refrain from smoking and excessive entrainment with hot drinks;
- normalize your weight (if it is increased);
- Raise the head end of your bed by 10 or 15 centimeters (excess cushions will not fix the situation, but will only increase intra-abdominal pressure and, accordingly, exacerbate reflux);
- do not lie for three hours immediately after eating;
- to stop wearing of pressing corsets, bandages, tight belts, elastics and belts during the next two hours after eating;
- To exclude for the same time all the stresses on the abdominal press (including household chores, sport classes, slopes, yoga, etc.);
- Do not lift weights of more than 8 kg (at least two hours after eating);
- normalize your chair;
- to think over the replacement or adjust the dosage of all drugs that negatively affect the tone of the lower esophageal sphincter or irritating the esophageal mucosa (prostaglandins, adrenoblockers, prolonged nitrates, doxycycline, progestins, nitrites, calcium antagonists, levodopa, benzodiazepines, etc.).
For the implementation of the latter request, it may be necessary to consult the specialized doctors who have appointed these medicines.
To increase the effect of pharmacotherapy, patients are prescribed a sparing medical diet. For its implementation in daily nutrition, patients need:
- Do not overeat (it is recommended to eat regularly 4 times a day, in small portions);
- stop eating immediately before bedtime (the interval from dinner to bedtime should reach two hours);
- Exclude from their diet all hot, hot and excessively cold dishes that can damage sensitive esophageal mucosa;
- limit or completely remove from food all drinks and dishes that lower the tone of the esophageal sphincter (carbonated drinks, coffee, citrus, mint, chocolate, garlic, cocoa, green onions, tomatoes, fatty meat, red fish, duck, goose, fatty milk, pepper , cream, fried dishes, margarine, egg yolks, butter, etc.).
It is highly desirable that even after the onset of a lasting remission, patients do not forget about the proper nutrition for them. After a violation of the above principles can serve as an impetus to the resumption of clinical and endoscopic manifestations of reflux esophagitis.
Drug therapy (pharmacotherapy)
The competent treatment of confirmed reflux esophagitis involves two therapeutic strategies. The first starts with the most powerful medications, then the intensity of the drug effect is reduced (her doctors call step-down). The second strategy first recommends drugs 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 (secretolitics) drugs that reduce gastric secretion. Reducing the acidity of gastric reflux reduces its deleterious effect on the delicate esophageal mucosa. The secretolithics include:
- proton pump inhibitors are the most effective and potent medications (lansoprazole, rabeprazole, pantoprazole, omeprazole, esomeprazole, dexlansoprazole);
- H2 (histamine) - blockers (nizatidine, roxatidine, famotidine, cimetidine, ranitidine) - less active, they sometimes develop resistance;
- M-holinolitiki (metacin, platifillin, etc.), but these drugs can simultaneously reduce the pressure of esophageal sphincters.
The duration of the course of antisecretory drugs is based on the degree of developed reflux-esophagitis, the presence of erosion and precancerous transformations. It is determined by the doctor. The minimum course lasts about a month, the maximum can take more than one year. Sometimes treatment is forced to spend for life.
In the case of detection of erosive forms of esophagitis, prokinetics are included in the prescribed treatment regimen. These drugs are used to build motor skills. These include:
- metoclopramide (raglan, cerucal, etc.);
- itopride (ganaton, etc.);
- domperidone (motilium, motoniks, motilak, passenger, etc.).
If bile is present in the content of reflux, sometimes the treatment is supplemented with preparations of ursodeoxycholic acid (Urdox, Ursosan, Ursodex, Ursofalk, etc.), which are advised to be taken at night.
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 not enough. So now they are advised to use as an auxiliary symptomatic. Antatsida are renni, riapan, phosphalugel, milantha, almagel, gastal, raltser, maaloks, rutatsid, etc. Alginates (topalcan, geviscon, topaal, etc.) form a foam that protects the esophageal mucosa during gastroesophageal reflux.
In order to increase the resistance of the esophageal mucosa, in a number of cases, doctors can recommend misoprostol, sucralfate or decoction of flaxseed.
In the case of erosive esophagitis, a control endoscopic examination is mandatory at the end of the course. After all, the clinical improvement and the complete disappearance of the symptoms do not in all cases indicate a true positive dynamics of the process. And persistent erosion or ulcers at any inappropriate time can become a source of bleeding.
In the absence of effect from the described non-surgical techniques and frequent relapses of reflux-esophagitis, the patient can first be advised of endoscopic treatment. It consists in sewing the lower of the esophageal sphincters or in the introduction into it of various polymeric substances that promote the normalization of its barrier function. When detecting precancerous mucosal transformations, photodynamic or laser destruction, thermal destruction, electrocoagulation, local endoscopic resection of these altered mucosal areas are possible. But not all methods are still widely used.
Indications for radical surgery are:
- preservation of symptoms and endoscopic manifestations of esophagitis under condition of adequate drug treatment within six months;
- 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 an inadequate bronchial asthma;
- personal desire of the patient.
In all these situations, surgeons spend fundoplication (the lower part of the esophagus is reduced by 2-3 centimeters into the abdominal cavity, from the gastric wall they form a kind of cuff in the place of its connection with the esophagus and sew it to the diaphragm, suture an excessively wide opening in the diaphragm, and move the cuff in mediastinum). Access can be traditional (when the stomach or thorax is cut) or laparoscopic (all the 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 performed more quickly, less traumatic, has less unpleasant complications and cosmetic defects, it is easier for patients to tolerate and more likely to recover during the postoperative period.
Prevention of reflux esophagitis
In order to reduce the number of relapses of reflux esophagitis and its further progression, it is necessary to combat all the factors contributing to its appearance. Patients should strictly follow the diet, fight excess weight, addiction to tobacco and alcohol-containing beverages, change the mode of rest and work, choose the right garments, avoid unnecessary strain on your abdominal press, and limit the intake of certain medications.
With confirmed precancerous changes, banal heartburn can serve as a signal for the need for an urgent visit to your doctor and timely examination. In the case of Barrett's esophagus, endoscopic examination with taking biopsies should be performed annually and even more often (if there is severe dysplasia, established under a microscope by at least two morphologists).
Prognosis of the disease
Reflux esophagitis has, as a rule, a favorable prognosis for work capacity and life. If there are no complications, then it does not shorten its duration. But with inadequate treatment and non-observance of data by the doctors of the recommendations, new relapses of esophagitis and its progression are possible.