reflux esophagitis



Overview

Definition

Reflux esophagitis is an inflammatory disease in which the contents of the stomach and duodenum reflux into the esophagus, causing erosion and ulceration of the esophageal mucosa.

Reflux esophagitis is a type of gastroesophageal reflux disease (GERD). In addition to reflux esophagitis, GERD also includes non-erosive reflux disease (NERD) in which the esophageal mucosa is not erosive and ulcerated.

GERD that does not respond to 8 weeks of treatment with standard-dose proton pump inhibitors (PPIs) is called refractory GERD.

Pathogenesis

The incidence of reflux esophagitis is about 2%.

Etiology

Causes

The exact etiology is unclear. The following factors may lead to reflux of gastroduodenal contents into the esophagus, damaging the mucosa, which in turn causes inflammation.

Increased intra-abdominal pressure: such as pregnancy, obesity, ascites, vomiting, etc., resulting in damage to the structure of the lower esophageal sphincter, causing reflux of gastroduodenal contents.

After cardia resection: causing the lower esophageal sphincter to be removed, causing gastroduodenal contents to reflux.

Hiatal hernia: Abnormal length or pressure of the lower esophageal sphincter and part of the stomach enters the thoracic cavity through the esophageal hiatus in the diaphragm, causing gastroduodenal reflux.

Delayed gastric emptying: can lead to prolonged increased intragastric pressure, causing reflux of gastroduodenal contents.

Drug effects: Diazepam, calcium channel blockers (e.g., nitroprusside), and hormones (e.g., cholecystokinin, glucagon) can cause a decrease in pressure in the lower esophageal sphincter, leading to gastroduodenal reflux.

Food effects: Chocolate, high-fat foods, etc. can cause a decrease in lower esophageal sphincter pressure, leading to gastroduodenal reflux.

Risk factors

Risk factors include age >40 years, obesity, smoking, and alcohol consumption.

Pathogenesis

Abnormal anti-reflux barrier

The lower esophageal sphincter is a group of muscles located at the junction of the esophagus and stomach.

Under normal conditions, there is a high-pressure zone under the lower esophageal sphincter that prevents reflux of gastric contents into the esophagus.

When the lower esophageal sphincter is abnormal, it can cause reflux of stomach contents. These include structural and functional abnormalities of the lower esophageal sphincter.

Reduced esophageal reflux clearance

Esophageal clearance function includes propulsive peristalsis, neutralization of saliva, and gravity of the esophageal mass, of which propulsive peristalsis function is the most important.

Half of GERD patients have loss of peristalsis in the middle esophagus and dysfunction of distal esophageal motility.

Weakened esophageal mucosal barrier

The esophageal mucosal barrier consists of 3 main aspects:

Pre-epithelial factors: HCO3- concentration in the mucus layer, mucosal surface.

Epithelial factors: structure of inter-epithelial cellular junctions, epithelial transport, intracellular buffer system, and cellular metabolic function.

Post-epithelial factors: basal acid status of tissues and blood supply, etc.

Symptoms

The severity of clinical symptoms is sometimes not consistent with the degree of histologic changes in esophagitis.

Main symptoms

The main symptoms are heartburn and reflux, which often appear after 1 hour after a meal, and are aggravated by lying down, bending over, or increased abdominal pressure (e.g., pregnancy, ascites), or at night when sleeping. Some patients may have no symptoms of heartburn or reflux, but only secondary symptoms.

Heartburn: refers to a burning sensation behind the sternum.

Reflux: refers to the sensation of stomach contents flowing toward the pharynx or mouth. Acid reflux (when it contains a sour taste or when the reflux is only acidic water), regurgitation of food, belching, and sometimes reflux of bile may occur.

Other symptoms

Chest pain: caused by irritation of the esophagus by the reflux material, which can be a severe stabbing pain similar to angina in severe cases.

Epigastric discomfort: such as burning sensation in the epigastric region, epigastric pain, epigastric distension, belching, etc. Symptoms may be intermittent, and can occur when eating liquid or solid food, which may be caused by digestive tract dysfunction.

Swallowing abnormalities: in severe cases, there may be swallowing pain, and a few patients have a choking sensation in swallowing.

Complications

Upper gastrointestinal bleeding: excessive reflux causing mucosal breakdown can lead to esophageal bleeding with black stool or vomiting of blood, which may also be associated with varying degrees of anemia.

Barrett’s esophagus: endoscopically the junction line of esophageal squamous and columnar epithelium is displaced upward relative to the gastroesophageal junction, and histology confirms that the normal complex squamous epithelium has been replaced by a metaplastic columnar epithelium. There is a tendency for malignant transformation into adenocarcinoma.

Esophageal stenosis: recurrent episodes of esophagitis cause fibrous tissue proliferation, leading to esophageal stenosis.

Consultation

Department of Medicine

Gastroenterology

Symptoms such as acid reflux, heartburn and chest pain suggest prompt medical attention.

Preparation

Preparing for your visit: registering, preparing your documents, and frequently asked questions.

Tips for medical treatment

Record the specific circumstances and pattern of symptoms for your doctor’s reference.

Preparation List

Symptom list

Pay particular attention to the time of onset of symptoms, special manifestations, etc.

Is there a burning sensation behind the sternum?

Is there any reflux of fluid or food from the stomach into the throat or mouth?

Is there nausea?

Do you feel pain in the upper abdomen?

Does the heartburn and reflux interfere with sleep at night?

Are you taking any medications on your own and what medications are you taking?

Medical History Checklist

Is there any history of Helicobacter pylori infection?

Is there any irregular diet, heavy alcohol consumption, long-term smoking, stress, etc.?

Is there any gastritis or peptic ulcer?

Does immediate family member have peptic ulcer or chronic gastritis?

Have you had gastroscopy, Helicobacter pylori test and other related examinations?

Checklist

Test results in the last six months, which can be brought to the doctor’s office

Gastroscopy, pathology report card

Esophageal 24-hour pH monitoring, esophageal 24-hour impedance measurement

Barium meal imaging, abdominal CT examination

List of medications

Medication used in the last 3 months, if available in boxes or packages, bring with you to the doctor’s office

Acid suppressants: omeprazole, epprazole, lansoprazole, pantoprazole, rabeprazole, famotidine

NSAIDs: aspirin, clopidogrel, ibuprofen, indomethacin

Diagnosis

Diagnosis is based on

Medical history

Most of the patients have no specific medical history; a few patients have a history of pancreatic resection, hiatal hernia of the esophagus, and long-term use of calcium channel blocking drugs.

Clinical manifestations

There are symptoms of reflux and/or heartburn.

Gastroscopy

Gastroscopy allows direct observation of the esophagus and stomach, and biopsies can be taken from areas where lesions are suspected.

Gastroscopy is recommended for first-time patients with reflux symptoms to rule out malignant tumors of the upper gastrointestinal tract and to diagnose reflux esophagitis, reflux stricture and Barrett’s esophagus.

Early gastroscopy is beneficial for tumor screening and assessment of disease status.

Other Related Auxiliary Tests

Esophageal Reflux Monitoring

Esophageal reflux monitoring can detect the presence or absence of reflux of gastric contents in the esophageal lumen and provide objective diagnostic evidence of gastroesophageal reflux.

Patients with typical reflux symptoms but normal gastroscopy, atypical symptoms, ineffective medication, or proposed anti-reflux surgery need to undergo esophageal reflux monitoring.

Reflux monitoring includes pH monitoring, pH-impedance monitoring, pH-impedance-pressure monitoring and so on.

Esophageal reflux monitoring can be catheterized or capsule-based.

Catheter-based monitoring: monitoring time is usually 24 hours.

Capsule type monitoring: wireless capsule monitoring time up to 96 hours.

Key indicators of esophageal reflux monitoring

Acid Exposure Time (AET) Percentage: The percentage of time in a 24-hour period that the esophageal pH is <4. AET percentage can be used to predict whether PPI therapy is effective. An AET >4.2% is usually used as a criterion for abnormal acid reflux.

Reflux Symptom Index and Symptom Correlation Probability: can be used to assess the correlation between reflux and symptoms and to predict the efficacy of acid suppression therapy.

Barium esophagography

For patients with atypical reflux symptoms such as chest pain and dysphagia, barium esophagography is feasible in order to determine the presence of gastroesophageal conjunction outflow tract obstruction or esophageal dynamics abnormality.

Esophageal Mucosal Impedance Technology

This technique reflects the barrier function of the esophageal mucosa by detecting the instantaneous impedance value of the esophageal mucosa, and then determines whether there is long-term chronic reflux, with a minimally invasive detection method.

Esophageal High Resolution Manometry

It can understand instantaneous lower esophageal sphincter relaxation, low pressure at the gastroesophageal junction and decreased esophageal clearance function, and clarify whether there is a combination of esophageal hiatal hernia.

Endoscopic Functional Endoluminal Imaging Probe Technique

This technique can be used to evaluate the degree of dilatation of the luminal structures. A balloon is placed at the gastroesophageal junction of the patient, and the ratio of pressure to cross-sectional area during isovolumetric dilatation of the plane where the balloon is located is measured through the impedance channel in the balloon to determine the dilatability of the gastroesophageal junction of the patient, which is helpful for assessing the function of the anti-reflux barrier of the patient and guiding anti-reflux surgery.

Grading

Based on the length and extent of gastroscopic esophageal mucosal breach, the 1996 Los Angeles grading of reflux esophagitis classifies it into 4 grades.

Grade A: There is 1 or more esophageal mucosal breach with a length <5 mm.

Grade B: 1 or more esophageal mucosal breaks with a long diameter >5 mm, but no fusion lesions.

Grade C: mucosal breaks with fusion but less than 75% of esophageal circumference.

Grade D: Mucosal tears are fused to at least 75% of the circumference of the esophagus.

Differential Diagnosis

Angina pectoris

Similarities: Both can be characterized by retrosternal pain.

Differences: patients with angina pectoris have a history of coronary artery disease, which can be relieved by rest or nitroglycerin; ST-segment depression and T-wave inversion can be seen on the electrocardiogram (ECG) during the attack, and the ECG can return to normal after the symptoms are relieved.

Peptic ulcer

Similarity: Both may have acid reflux.

Differences: peptic ulcer can have acid reflux, and the symptoms can be relieved by taking acid-suppressing drugs; gastric or duodenal ulcer can be seen under endoscopy, and the mucous membrane can have limited or diffuse congestion, edema, erosion, mucus and inflammatory exudate on the surface, and most of them are infected with Helicobacter pylori.

Esophageal cancer

Similarity: both may have acid reflux, heartburn, retrosternal pain and difficulty in swallowing.

Difference: esophageal cancer typically manifests as progressive dysphagia, which can be distinguished by endoscopy and pathological examination.

Treatment

The principle of treatment is to strengthen the anti-reflux barrier, reduce the irritation of reflux material and enhance the resistance of esophageal mucosa.

Lifestyle modification

Lifestyle modification is the most basic treatment, mainly including the following.

Weight loss: it improves the success of drug therapy and significantly reduces patient symptoms. A decrease in body mass index (BMI) of more than 3.5 significantly reduces symptoms in both patients who are not on medication and those who are on medication. Try to keep your BMI under 25.

Smoking cessation: Symptoms and the number of refluxes per day improved significantly with smoking cessation.

Elevate the head of the bed: Elevating the head of the bed during sleep significantly shortens esophageal acid exposure and effectively controls reflux symptoms.

Dietary modifications: Avoid foods that decrease the pressure on the lower esophageal sphincter, such as chocolate, coffee, strong tea, peppermint and cola.

Others: Avoid drugs that affect gastric emptying and lower the pressure of the lower esophageal sphincter, such as calcium channel blockers, nitroglycerin, theophylline, etc.; try to avoid actions that can increase the abdominal pressure, such as prolonged bending over and wearing tight pants.

Medication

Acid-suppressing drugs

Proton pump inhibitor (PPI)

Indications: PPI is suitable for patients with symptomatic reflux esophagitis.

Commonly used drugs: including omeprazole, esomeprazole, rabeprazole, lansoprazole, pantoprazole, epprazole and so on.

Efficacy: Better than H2 receptor antagonists in relieving symptoms and healing reflux esophagitis, it is the drug of choice for the treatment of this disease.

Course of treatment: The generally recommended course of treatment is 8 weeks.

ADVERSE REACTIONS: There are relatively few adverse reactions to PPIs for both short-term and long-term use.

Adverse reactions for short-term use: may include leukopenia, headache, diarrhea, and lack of appetite.

Adverse effects of long-term use: may include vitamin and mineral deficiencies, secondary infections, osteoporosis, and intestinal flora shift.

Indications: For patients with mild to moderate symptoms (Los Angeles grading A and B).

Commonly used drugs: cimetidine, ranitidine, famotidine and rosatidine, etc.

Efficacy: Whether short-term or long-term application, the efficacy is weaker than PPI.

Duration of treatment: generally 8 to 12 weeks.

Adverse reactions: safety is good, but for the older age, or with other diseases such as renal insufficiency, easy to produce headache, diarrhea, fatigue and other adverse reactions. Use with caution in the elderly.

Gastrointestinal stimulants

Indications: For the poor effect of acid-suppressing treatment, can be combined with gastrointestinal stimulants, not recommended to use alone. It can promote esophageal and gastric emptying, so as to improve the ability of esophageal acid removal and reduce the occurrence of reflux.

Commonly used drugs: domperidone, mosapride, itopride and so on.

Adverse reactions: can cause abdominal pain, diarrhea, palpitations and other adverse reactions of the digestive system and cardiovascular system, there can also be electrocardiogram QT interval prolongation. In addition, domperidone can cause elevated blood prolactin levels, leading to lactation during non-lactation.

Antacids

Antacids refer to medications that rapidly neutralize gastric acid and provide rapid relief of reflux symptoms, but long-term use is not advocated.

Indications: Only for patients with mild symptoms and intermittent episodes for temporary relief of symptoms.

Commonly used drugs: aluminum hydroxide, calcium carbonate, etc.

Adverse reactions: mild, may appear abdominal distension, belching, nausea, vomiting, etc..

Gastric mucous membrane protective agent

Commonly used drugs: colloidal bismuth, aluminum sulfate, magnesium aluminum carbonate, etc.

Adverse reactions: less. A few patients may have constipation, dyspepsia, skin rash, etc.

Surgical treatment

Endoscopic radiofrequency ablation

Radiofrequency treatment can heal reflux esophagitis, increase the base pressure of the lower esophageal sphincter, and improve various clinical observations in a short period of time, including a significant decrease in the time of esophageal acid exposure and a significant improvement in heartburn symptoms.

Fundoplication

The goal is to stop the reflux of gastric and duodenal contents into the esophagus.

It can lead to a reduction in acid reflux, an increase in lower esophageal sphincter pressure, and symptomatic relief.

Anti-reflux surgery may be considered for those who are unwilling to use PPI therapy for a long period of time, or who have poor efficacy of PPI therapy, or who have longstanding chronic cough and pharyngolaryngitis associated with reflux.

Currently, fundoplication is considered to be the best anti-reflux surgical procedure, and laparoscopic fundoplication is superior to open fundoplication.

Magnetic Sphincter Augmentation Surgery (MAS)

Through laparoscopy, a ring of magnetic beads is placed at the gastroesophageal junction to enhance the anti-reflux barrier. Studies have shown that MAS reduces reflux symptoms with fewer complications and is comparable in efficacy to fundoplication, but stronger evidence-based medical evidence is needed.

Prognosis

Cure

Reflux esophagitis is largely curable with aggressive treatment, but is prone to recurrence.

Hazards

Symptoms associated with reflux can cause chest/abdominal discomfort, dietary restrictions, and sleep disturbances, which can affect the patient’s quality of life.

Excessive reflux causes mucosal breakdown, which can lead to esophageal bleeding and may be accompanied by varying degrees of anemia.

It can be complicated with Barrett’s esophagus, which has a tendency to malignant transformation into adenocarcinoma.

Repeated episodes of reflux esophagitis cause fibrous tissue proliferation, leading to esophageal stenosis.

Daily

Daily management

Dietary management

Eat small and frequent meals to reduce food residue.

Encourage obese patients to adjust dietary structure and balance nutrition.

Reduce the intake of high-fat meals.

Avoid foods that decrease the tone of the lower esophageal sphincter such as strong tea, coffee and chocolate.

Avoid stimulating foods such as too cold, too hot or spicy foods.

Drink moderate amount of warm boiled water after meals and reflux to reduce the irritation of food to the esophagus.

Life management

Avoid eating 3 hours before bedtime to minimize food stimulation of gastric acid secretion at night.

When sleeping at night, raise the head of the bed appropriately at an angle of 15°～20° to reduce the occurrence of reflux.

Stand or walk after meals to promote food emptying with the help of gravity, avoid strenuous exercise.

Avoid strenuous exercise.

Follow-up and review

Patients with reflux esophagitis, especially those with severe reflux esophagitis (Los Angeles Class C and D), should be seen regularly after treatment.

Prevention

Weight control

Try to keep BMI under 25.

Avoid medications that affect the lower esophageal sphincter

Avoid medications that affect gastric emptying and lower the pressure on the lower esophageal sphincter, such as calcium channel blockers, nitroglycerin, and theophylline.

Avoid food effects on the lower esophageal sphincter

Avoid foods that lower the pressure on the lower esophageal sphincter such as strong tea, coffee, and chocolate.

Avoid irritating foods such as foods that are too cold, too hot or spicy.

Eat small, frequent meals and reduce the intake of high-fat meals.