In recent years… The diagnosis of gastroesophageal reflux disease (GERD) and papers are all over the place. Some scholars in China have pointed out that what is the relationship and difference between GERD and reflux esophagitis, Barrett’s esophagus and esophageal hiatus hernia [HH]? Can some diseases of the past be replaced by GERD? There are abundant clinical resources in China. We are well equipped to discuss, discuss and study the above questions. Our views and opinions are presented. I. Gastroesophageal reflux from the study of esophageal hiatal hernia 1. Relationship between HH and lower esophageal sphincter pressure (LESP): In 1963, the Peking Union Medical College Hospital introduced the first X-ray examination method of HH. Immediately afterwards, a long-term and continuous clinical study of HH began, and a large number of case data were accumulated: from 1980 to 1983, a study of LESP was conducted on healthy people and HH patients. Three types of changes were found in HH patients: first, the lower esophageal sphincter was lower than normal; second, the lower esophageal hypertensive zone moved upward from the lower third of the esophagus. The LESP curve is bimodal. The lower esophageal sphincter is a physiological high pressure area without anatomical structure. The latter gives the esophagus the ability to resist reflux of gastric contents. When the pressure of the LESP decreases or the lower esophageal sphincter (LES) is displaced, the anti-reflux effect of the esophagus is reduced. The anti-reflux effect of the esophagus will be weakened or disappeared. Acid reflux and heartburn will occur easily. In those years, due to the objective conditions, the pH test was not performed. 2. Relationship between GERD and HH: At present, people with acid reflux and heartburn are often diagnosed as GERD, and most of them take gastroscopy as the gold standard. In the outpatient clinic. We can often see that the dentate line on the gastroscopic photograph is shifted 1.5 to 2.5 cm, while in the gastroscopic diagnosis only superficial gastritis, esophagitis. This may be because the physician is not yet familiar with the endoscopic diagnosis of HH. The high or absent LESP is related to the degree of relaxation and widening of the diaphragmatic esophageal fissure. The latter is in turn related to age, chronic disease and trauma. The latter is related to age, chronic disease and trauma, etc. Sometimes patients with acid reflux and heartburn undergo gastroscopy without forgetting the possibility of coexisting HH or other diseases, whether GERD is an independent disease or an early stage of HH. Further research is needed in the future. In clinical cases, we can see that many diseases can have acid reflux and heartburn as the first symptoms. Such as dermatomyositis, systemic sclerosis, diabetes mellitus, acute myocardial infarction, acute pancreatitis, pancreatic cancer, cholelithiasis, renal insufficiency, esophageal hiatal hernia, giant esophageal diverticulum, ulcer disease, gastric stone, gastric torsion, stomach or duodenal tumor, cardia laxity, bronchial asthma, chronic bronchitis in the elderly, habitual constipation, post-gastrectomy, post-pancreatic resection, post-cholecystectomy, etc. Diseases with acid reflux and heartburn as the first symptoms involve many organs (lungs, heart, kidneys, biliary tract, pancreas, etc.) and are not diagnosed immediately by performing gastroscopy. The following cases can be used as reference. Case 1 Female, 33 years old, with acid reflux, heartburn, and a feeling of obstruction in the first bite when eating, was seen at a local hospital with gastroscopy showing reflux esophagus: long acid suppression treatment was ineffective. Three years after the disease, a barium meal angiogram was performed in our hospital showing cardia loss retardation, and the condition improved significantly after treatment with water bladder dilation. The lens can be passed through the cardia without resistance when gastroscopy is performed for cardia loss retardation. If you do not pay attention to esophageal peristalsis and esophageal width. It is easy to be mistaken for esophagitis: ② Esophagogram is the best means of examination for this disease; when the degree of dysphagia is mild, it is easy to be misdiagnosed as esophagitis. Case 2 Male, 48 years old, was hospitalized for pneumonia. After treatment, he was suspected of having esophagitis due to discomfort, acid reflux, and heartburn, and gastroscopy showed gastric cancer (ormann111), while the patient’s appetite and weight did not decrease. The symptoms of gastric cancer are often atypical: ② If the diagnosis is based only on symptoms, it is easy to miss and misdiagnose Case 3 male, 65 years old, due to epigastric pain, acid reflux, heartburn, endoscopy showed reflux esophagitis. He had been taking omeprazole, trade name Loxacol, for more than 11 months, but his appetite decreased and he lost about 3 kg of weight. The above symptoms did not improve, and the diagnosis of pancreatic cancer was confirmed by CT after hospitalization. There was also pressure pain. The abdominal examination was not performed in the outpatient clinic; ③ gastroscopy does not diagnose extra-gastric diseases. Case 4 Male. 56 years old. He was seen for 1 d with nausea, acid reflux and back pain. At the time of hospitalization, treatment as esophagitis was ineffective. The electrocardiogram showed acute myocardial infarction on the same night. Comments: ① this patient only had mild gastrointestinal symptoms, and no abdominal pain and chest pain. The patient was not hypertensive; ② the patient was slightly older. Physicians should be alerted to the diagnosis of myocardial infarction! The diagnosis of GERD should not be made lightly. Third, the clinical understanding of esophageal hiatal hernia 1. symptoms of HH: ① pain of multiple sites and natures: pain of different natures (distension, stabbing pain, hidden pain, knife-like pain, etc.) can occur in the chest and back and abdomen; ② upward rebellious symptoms: acid reflux, heartburn, nausea, belching, food vomiting, vomiting, etc.; ③ bleeding symptoms: tarry stools, vomiting blood, anemia; ④ other: palpitation, shortness of breath, chest tightness, breath-holding, insomnia, pharynx Other: palpitation, shortness of breath, chest tightness, breathlessness, insomnia, foreign body sensation in the throat, etc. Summarize the above HH symptoms. The symptoms are characterized by: (1) diverse nature of symptoms: (2) symptoms often change; (3) symptoms can appear in multiple locations; (4) patients are often seen in multiple hospitals and departments (cardiology, respiratory, gastroenterology, neurology, etc.); (5) a patient can receive several different diagnoses (pharyngeal function, esophagitis, coronary artery disease, hemoptysis pending investigation, etc.). 2, the appearance of HH symptoms can be found in the causative factors: careful questioning of patients can often find causative factors, such as constipation, overeating, overeating, alcoholism, sweets, thin food, lying down, bending, sitting in a low position, etc. 3. X-ray diagnosis of HH: ① Curtain traction: partial hernia of the fundus of the stomach above the esophageal fissure. It is similar to lifting a plastic bag with half a bag of water by hand; ② esophageal shortening; ③ esophageal incision can be seen on the diaphragm, the latter is the connection of gastroesophagus, i.e. dentate line; ④ hernia sac can be seen on the diaphragm, this image is rare; ⑤ gastroesophageal reflux, barium is seen to reflux from the stomach into the esophagus. Most of them are ①②③ and ⑤ clinically. 4. Gastroscopic diagnosis of HH: ① 1.5 to 2.0 cm or more upward shift of the dentate line. Gastroscopy is performed before crossing the cardia. The operator places the gastroscope lens 2 cm from the cardia. Briefly inflate for 2 times. This will trigger the natural turning up of the fundus of the stomach. Patients should be able to proceed without discomfort, and those who move up 2 cm can be diagnosed; ② reversal of the endoscope to observe the relaxation of the cardia; ③ with HH is often accompanied by esophagitis manifestations. Sometimes esophageal ulcer formation is seen: ④ displacement of the gastric body orifice to the esophageal axis: ⑤ supradiaphragmatic hernia sacs are rarely seen (between the two stenoses is the gastric mucosa); ⑥ shortening of the distance of the incisors from the dentate line 5. Differential diagnosis of HH: ① cholelithiasis; ② myocardial infarction; ③ pancreatitis or pancreatic cancer; ④ ulcer disease; ⑤ cardia cancer; ⑥ cardia laxity; ⑦ gastric cancer. 6, HH clinical diagnostic conditions: ① post-gastrectomy: ② trauma history (bruises, falls from height); ③ symptoms are diverse and variable; ④ symptoms involving multiple systems; ⑤ “cardiac symptoms” even after excluding heart disease; ⑥ neurasthenia, insomnia; ⑦ suspected psychosomatic diseases; ⑧ the cause of symptoms (8) The cause of the symptoms is clear; (9) Unexplained bleeding in the upper gastrointestinal tract. 7. Treatment of HH: (1) Life conditioning: The treatment of HH is different from that of hypertension and diabetes mellitus. The emphasis on long-term drug maintenance therapy for GERD or reflux esophagitis does not meet the clinical needs of HH. It is a waste of medical resources. It is a waste of medical resources. The efficacy of medication is not entirely satisfactory. This is the special point of HH treatment, the main content of life conditioning: ① good control of food: to slow meals, three meals can not eat full. If there is a feeling of hunger, add a little after the meal 2 h. Three meals a day should be basically regular, avoid overeating; ② good choice of variety: too sweet, too oily, too spicy food can be used. But there should be a “degree”. To self-control, according to their ability to eat without symptoms, porridge should also drink less, it is easy to cause gastric distension and acid reflux: ③ position adjustment: after meals can walk. Not sitting on a low chair. After lunch, you can read the newspaper or take a nap in a recliner. Avoid bending or squatting after meals. At night, it is advisable to lift the upper body 20. hip with the top of the object, so as not to fall down after sleep, available hand crank or electric bed; ④ stool conditioning: must pay attention to the stool situation, to maintain the daily bowel movements is very important. 2 to 3 d defecation is not desirable. In addition, obesity, lifting heavy objects, waist, smoking, late pregnancy, drinking gas beverages, etc. are factors that trigger GERD. The most important thing to do is to avoid it. Alcohol consumption is detrimental to the treatment of esophagitis. (2) Drug therapy as a supplement: many elderly people have gastroesophageal reflux. If you take proton pump inhibitors for a long time. The effect on digestion will be. The drugs can be taken for a short time when there are symptoms. After the symptoms are relieved, the drug can be discontinued. Generally, most of the drugs used are gastrokinetic drugs (metoclopramide, domperidone, sodium novolac, etc.) and acid suppressants (H2 receptor antagonists, proton pump inhibitors). In the presence of HH, if the patient has had a cholecystectomy or has filled gallbladder stones. With the occurrence of gastroesophageal reflux. The bile in the duodenum is likely to reflux into the stomach or even into the esophagus. These patients can often take gastrodynamic drugs and magnesium aluminum carbonate drugs. To protect the stomach and esophageal mucosa. (3) Surgical treatment (omitted). In conclusion． After the emergence of GERD reports in foreign literature. There is a tendency for domestic clinical diagnosis to be homogenized. The diagnosis of GERD is made when the symptoms of acid reflux and heartburn are encountered, and the history is not comprehensive. The diagnosis of GERD may be misdiagnosed or missed in clinical practice due to incomplete history, incomplete ancillary examinations, and incomplete physical examination. Therefore. The medical history of patients with gastroesophageal reflux (GER) should be taken carefully, such as lung (asthma, chronic cough, etc.), heart (coronary heart disease, hypertension, etc.), digestive system (ulcer disease, pancreatitis, esophageal hiatal hernia, etc.), history of trauma, history of surgery (stomach, bile), dietary habits, stool conditions, and smoking, alcohol consumption, etc. In 2005, the Medical Tribune presented several discussion articles on GERD. This is a very good start. With a large population and a large number of cases in China, if we seriously do some research work on the combination of the basic and clinical aspects of GERD. We can present some of our own views and opinions. Gastroesophageal reflux research work may be more relevant to clinical practice. Lastly, we would like to emphasize again. When making the diagnosis of GERD, please do not forget the possibility of HH disease. In the end, we would like to emphasize again that we should not forget the possibility of HH disease when diagnosing GERD, and we should look at the dentate line and cardia when performing gastroscopy; we should try to improve the clinical and gastroscopic diagnosis. At the same time. When considering GERD, we should also pay attention to the differentiation from other diseases. In order to avoid missed diagnosis or wrong diagnosis.