1. What is gastroesophageal reflux disease? Is it an esophageal disease or a gastric disease?
Gastroesophageal reflux disease (GERD) is a disease in which stomach contents reflux into the esophagus, causing corresponding esophageal symptoms and/or complications, whose typical symptoms are heartburn and reflux, chest pain, and reflux can cause esophageal damage, manifesting as erosive esophagitis (i.e. reflux esophagitis); GERD can also cause damage to tissues other than the esophagus, such as the pharynx and airway. It is a disease of the esophagus.
Gastroesophageal reflux disease includes three types of reflux esophagitis and non-erosive reflux disease, Barrett’s esophagus.
2. Is GERD a rare disease?
GERD is a common disease with varying prevalence in different parts of the world. It has been reported that GERD patients account for about 7% to 15% of the population and reflux esophagitis accounts for 3% to 4% of the population in Western countries. The prevalence in Asia is relatively low. A survey in Beijing and Shanghai, China shows that the prevalence of GERD is 5.77%.
3.Why do you get GERD?
GERD is a disorder of the digestive tract dynamics caused by a variety of factors. In normal people, there is an anti-reflux mechanism that prevents the reflux of gastric contents into the esophagus and can remove these refluxes in time. The lower esophageal sphincter, located at the junction of the esophagus and stomach, plays a valve-like role in anti-reflux, and effective contraction of the body of the esophagus is essential for the removal of reflux. When the lower esophageal sphincter pressure decreases and excessive transient lower esophageal sphincter relaxation occurs, effective peristalsis and clearance of the esophageal wall decreases, gastric emptying is delayed, and duodenal retroperistalsis increases, gastroesophageal reflux is likely to occur, and weakened upper gastrointestinal mucosal barrier function is one of the reasons for the development of esophageal erosive inflammation. Excessive reflux of gastric contents (mainly gastric acid) into the esophagus can cause damage to the esophageal mucosa, as can refluxed bile and digestive enzymes.
Risk factors for the development of GERD include: age, gender, smoking, increased body mass index, excessive alcohol consumption, use of NSAIDs and anticholinergic drugs, physical work, social factors, psychosomatic diseases and family history.
Such as smoking, drinking alcohol, drinking a lot of coffee, strong tea and chocolate, obesity, eating too much, excessive consumption of spicy, sour and sweet and other irritating foods, long-term constipation, stimulation of certain drugs, mental factors, body position such as body flexion, bending, head down, supine and other positions, lap band pressure, seasonal and climatic factors can aggravate esophageal reflux.
4.What are the manifestations of GERD?
GERD typical symptoms are heartburn and reflux, but also chest pain, regurgitation, dysphagia, painful swallowing, atypical symptoms include epigastric pain, belching, bloating, epigastric discomfort, foreign body sensation in the throat, etc. There can also be extra-esophageal symptoms such as chronic cough, asthma and aspiration pneumonia, pharyngitis, etc. Heartburn is a burning sensation behind the sternum. Reflux is a sensation of stomach contents flowing in the direction of the pharynx or mouth, which can be acid reflux.
5, GERD patients which symptoms are “alarm” symptoms?
Some symptoms of GERD are difficult to distinguish from organic diseases of the esophagus and adjacent organs of the esophagus, so when patients have the following “alarm” symptoms, they should be actively examined accordingly to exclude organic diseases. These “alarm” symptoms include: progressive dysphagia, painful swallowing, weight loss, anemia, vomiting blood and/or black stool. Patients with a family history of esophageal and/or gastric cancer, patients in areas with a high incidence of esophageal and gastric cancer, and patients aged 40 years should also be actively examined to definitively rule out tumors.
6.Gastroesophageal reflux can cause those consequences?
GERD can cause esophageal symptoms and erosive esophagitis (EE), which can be combined with upper gastrointestinal bleeding, esophageal ulcer, esophageal stricture, and Barrett’s esophagus, which may develop into esophageal adenocarcinoma. GERD is also associated with chronic cough, pharyngitis, asthma syndrome, dental caries, etc. It is still controversial whether GERD is associated with sinusitis, idiopathic pulmonary fibrosis and recurrent otitis media.
7.How to diagnose GERD?
GERD can be diagnosed based on a cluster of GERD symptoms. If a patient.
① have typical symptoms of heartburn and reflux without evidence of pyloric obstruction or GI obstruction, the diagnosis of GERD can be clinically considered.
(ii) have extra-esophageal symptoms with reflux symptoms, the diagnosis of GERD can also be considered, and the extra-esophageal symptoms may be due to reflux.
(③) Reflux symptoms are atypical, or only extraesophageal symptoms without typical heartburn and reflux symptoms, the diagnosis of GERD cannot be diagnosed clinically, and further examination is needed to clarify the diagnosis of GERD and the presence of reflux esophagitis.
8.Does GERD have to be examined by gastroscopy?
It is difficult to determine clinically from the symptoms of GERD whether there is esophagitis and the degree of severity of esophagitis. Some symptoms of GERD (such as dysphagia and painful swallowing) are difficult to distinguish from other organic diseases of the esophagus or adjacent organs, and because China is a region with a high incidence of esophageal cancer and gastric cancer, it is advisable for patients with proposed GERD to undergo gastroscopy, especially for those with frequent and severe symptoms. Gastroscopy should be actively performed for those who are >40 years old, have atypical symptoms, accompanied by alarm symptoms, and have a family history of esophageal cancer/gastric cancer tumor; gastroscopy should be arranged in a timely manner for patients who are more apprehensive or require gastroscopy. Gastroscopy can clarify the presence or absence of esophagitis and the severity of esophagitis, the presence or absence of esophageal hiatal hernia, and clearly exclude diseases such as upper gastrointestinal tumors.
For patients who are unwilling to undergo gastroscopy or cannot tolerate/cooperate with gastroscopy, barium meal angiography of the upper gastrointestinal tract can be performed. Barium meal angiography is more accurate than gastroscopy for the observation of esophageal hiatal hernia and reflux.
9.What are the common tests for GERD?
There are many methods that can help clinicians determine if a patient has GERD.
(1) 24-hour esophageal pH monitoring, which mainly monitors acid reflux.
(2) Esophageal bilirubin monitoring, primarily to monitor for alkaline reflux.
(3) Esophageal manometry: does not directly reflect gastroesophageal reflux, but can detect abnormal esophageal dynamics associated with reflux and help localize esophageal pH electrodes and bilirubin electrodes.
(4) X-ray and nuclear examinations: they are not highly sensitive for the diagnosis of GERD and are not specific for the occurrence of reflux during the examination, so they are rarely used for the diagnosis of GERD.
(5) Wireless esophageal pH measurement, the monitoring electrode capsule is placed in the lower part of the esophagus with a titanium clip through the gastroscope, which can prolong the time of acid reflux monitoring.
(6) Intraluminal impedance technique, which allows monitoring all reflux events and specifying the nature of the refluxed material (gas, liquid or gas-liquid mixture). The latter two tests are new and not yet commonly used in clinical practice. Readers can refer to the chapter “Ancillary tests for gastrointestinal motility disorders and functional gastrointestinal diseases” for details of the tests.
10.What is erosive esophagitis? How is it graded?
Eosinophilic esophagitis refers to inflammation, erosion, ulceration and fibrosis of the esophageal mucosa caused by the reflux of gastric contents into the esophagus, which can be seen on gastroscopy as mucosal breakdown of the esophageal mucosa at or above the gastroesophageal junction, i.e., erosion, or ulceration. It is important to note that in patients with erosive esophagitis, the presence of mucosal breakdown can be intermittent.
Currently, erosive esophagitis is often graded using the Los Angeles classification, based on the degree of damage to the esophageal mucosa seen on gastroscopy: normal with no esophageal mucosa breakage; Grade A – one or more esophageal mucosal breaks of no more than 5 mm in length; Grade B – one or more esophageal mucosal breaks of at least 1 5 mm that are not fused to each other Grade C – mucosal rupture with fusion, but 75% of the circumference of the esophagus; Grade D – mucosal rupture with fusion, reaching at least 75% of the circumference of the esophagus.
11.What is NERD?
NERD refers to non-erosive reflux disease, in which the patient has typical reflux symptoms but no esophageal mucosal rupture and Barrett’s esophagus are seen on gastroscopy, and clear evidence of reflux can be found if further reflux-related tests are performed. Clinically, when the patient has heartburn symptoms as the main complaint, the diagnosis of NERD can be made if other diseases that may cause heartburn symptoms can be ruled out and no esophageal mucosal rupture is seen on endoscopy.
12.How to evaluate the value of PPI test in the diagnosis of GERD?
For patients with typical reflux symptoms, if there are no alarm symptoms, GERD can be clinically considered, and proton pump inhibitor (PPI) treatment can be given with standard dose twice a day for 1-2 weeks, and GERD patients can have rapid relief of symptoms 3-7 days after taking the drug. This is the PPI trial. the PPI trial treatment is effective and does not exclude endoscopy. For those who are >40 years old and have alarm symptoms, gastroscopy should be performed first to clarify the diagnosis before treatment.
13.How should GERD be treated?
The goals of GERD treatment are: to relieve symptoms, cure esophagitis, improve quality of life, and prevent recurrence and complications. Treatment includes two stages: initial and maintenance treatment. The purpose of initial treatment is to relieve symptoms and cure esophagitis as soon as possible.
Inhibition of gastric acid secretion is currently the main treatment for GERD. Proton pump inhibitors are the most effective drugs. Proton pump inhibitors work by inhibiting the proton pump of the gastric mucosal lining cells and thus blocking the secretion of gastric acid Current proton pump inhibitors include: omeprazole, lansoprazole, pantoprazole, rabeprazole, and esomeprazole. Standard doses of proton pump inhibitors (usually one tablet/capsule) provide relief of heartburn symptoms in most patients within 5 days. Some patients with severe symptoms/esophagitis and unsatisfactory symptom control may be treated with a higher dose or a different proton pump inhibitor. The treatment course is 8-12 weeks, and the healing rate of proton pump inhibitors for celiac esophagitis is 80-90%.
H2 receptor antagonists (H2RA) are only indicated for the treatment of mild to moderate GERD, including cimetidine, ranitidine, and famotidine, and have a healing rate of 50% to 60% for celiac esophagitis.
In the treatment of GERD, if the acid suppression therapy is not effective, consider the combination of prokinetic drugs, such as dovalin, mosapride, etc., especially for patients with delayed gastric emptying.
14.How to prevent GERD recurrence?
GERD is a chronic disease that requires maintenance therapy to prevent recurrence. At present, there are three methods of maintenance treatment: maintaining the original dose or reducing the dose, intermittent medication, and on-demand treatment.
1. Maintenance at the original dose or reduced dose: maintain the original dose or reduced dose of proton pump inhibitor once a day for a long time to maintain lasting relief of symptoms and prevent recurrence of esophagitis.
2.Intermittent treatment: The dose of proton pump inhibitor remains the same, but the interval between doses is extended, the most common method is alternate day therapy or once every 3 days.
3. On-demand therapy: The drug is administered only when symptoms appear and is discontinued once the symptoms are relieved. On-demand treatment is recommended under the guidance of physicians and controlled by the patients themselves according to the symptoms, without a fixed treatment time and with lower treatment cost.
15.How does changing poor lifestyle help in treatment?
Lifestyle changes are the basic treatment for GERD, including weight reduction, smoking and alcohol cessation, not eating 3 hours before bedtime, elevating the head of the bed, avoiding tight clothing, avoiding overeating and foods and drinks that can aggravate GERD symptoms (such as spicy foods, fatty diets, mint, chocolate, onions, citrus juices and carbonated drinks), avoiding drugs that lower LES pressure and drugs that cause delayed gastric emptying. Avoid medications that lower LES pressure and those that cause delayed gastric emptying. Although these changes are not sufficient to relieve symptoms in most patients, they can reduce the amount of medication used.
Is endoscopic therapy or surgical treatment of GERD really a one-time solution?
Preliminary short-term studies suggest that endoscopic treatment can improve GERD symptom scores, improve patient satisfaction and quality of life, and reduce the use of proton pump inhibitors. However, there is a lack of data on long-term efficacy, patient acceptability and safety, and effectiveness in relieving atypical symptoms of GERD. Endoscopic treatment has some rare but serious complications (including perforation, death, etc.).
Anti-reflux surgery is comparable to pharmacological treatment in terms of symptom relief and healing of esophagitis. However, surgical complications and mortality are closely related to the surgeon’s experience and skill level. A significant proportion of patients (11%-60%) still require regular medication after surgery. Therefore, endoscopic treatment and surgery for GERD patients should be considered together before making a prudent decision.
17.What is Barrett’s esophagus? Can it become cancerous?
Barrett’s esophagus is a condition in which the squamous epithelium of the proximal part of the gastroesophageal junction is partially replaced by the metaplastic columnar epithelium; Barrett’s esophagus itself usually does not cause symptoms, and the clinical manifestations are mainly GERD symptoms, such as heartburn, reflux, retrosternal pain and dysphagia.
Barrett’s esophagus is the main precancerous lesion of esophageal adenocarcinoma, and long segment BE with intestinal epithelial metaplasia is an important risk factor for esophageal adenocarcinoma.
18.How should Barrett’s esophagus be treated and monitored?
For patients with Barrett’s esophagus with erosive esophagitis and reflux symptoms, they can be treated with high-dose proton pump inhibitors. Endoscopy can be performed regularly in patients with Barrett’s esophagus for the purpose of early detection of heterogeneous hyperplasia and cancer. The interval of endoscopy should depend on the degree of heterogeneous growths. For patients without heterogeneous hyperplasia, endoscopy should be repeated once every 2 years. If heterogeneous hyperplasia and cancer are not detected in 2 reviews, the follow-up interval can be relaxed as appropriate; for patients with mild heterogeneous hyperplasia, endoscopy should be repeated once every 6 months in the first year, and if heterogeneous hyperplasia does not progress, it should be repeated once a year thereafter; for patients with severe heterogeneous hyperplasia, endoscopic mucosal resection or surgery is recommended, and close monitoring and follow-up should be performed.
19.What is esophageal hiatal hernia? Is there any relationship between esophageal hiatal hernia and erosive esophagitis?
There is a muscle between the thoracic cavity and the abdominal cavity, which is called “diaphragm” in anatomy, and there is a “fissure” in the center of it. This is called the “esophageal foramen”. This fissure is relaxed and widened, and part of the stomach can enter the thoracic cavity through the esophageal fissure of the diaphragm persistently or repeatedly, forming a hernia called “esophageal fissure hernia”.
A large hiatal hernia is often associated with moderate to severe erosive esophagitis.
20. Why are elderly people prone to esophageal hiatus hernia?
The prevalence of esophageal hiatus hernia increases with age, from less than 9% in those under 40 years of age to 38% in those over 50 years of age and up to 70% in those over 70 years of age. This may be due to the atrophy and loss of elasticity of the muscle tissue and diaphragmatic esophageal membrane constituting the esophageal hiatus with age, resulting in relaxation and widening of the hiatus, as well as relaxation of the relevant ligaments that hold the esophagus in place, which reduces its ability to hold the esophagus in place and makes it easier for the esophagus to slip into the thoracic cavity when the abdominal pressure increases. Therefore, elderly people are prone to suffer from esophageal hiatal hernia.