Reflux esophagitis (RE) is a chronic inflammation caused by the reflux of gastric contents (including duodenal fluid) into the esophagus and the breakdown of the esophageal mucosa caused by the acid in it, which can lead to esophageal ulceration, stricture and even cancer. Reflux esophagitis belongs to the category of gastroesophageal reflux disease, and about 1/3 of GERD patients have RE. RE is a common and frequent disease, and according to epidemiological surveys, the incidence of RE in Beijing and Shanghai in China is 1.92%. Since 2007, when the Gastrointestinal Dynamics Group of the Chinese Society of Gastroenterology proposed the “consensus opinion on the treatment of GERD” in Xi’an, RE has also received wide attention, and in recent years, RE has become a hot spot for research by experts and scholars at home and abroad, and has made great progress in the fields of etiology, pathogenesis, diagnosis and treatment of RE. The following is a review.
Etiology and pathogenesis
As a type of GERD, the etiology and pathogenesis of RE are due to the decrease of the defense mechanism of the esophagus against the reflux of gastric and duodenal contents, which causes the attacking factors of gastric acid, pepsin, bile salts and pancreatic enzymes on the esophageal mucosa. The pathophysiological mechanism is mainly the result of decreased anti-reflux defense mechanism and increased attack of reflux on esophageal mucosa.
Decreased anti-reflux defense mechanism
Low lower esophageal sphincter pressure (LESP) and diaphragm function, transient esophageal sphincter relaxation (TLESR), esophageal hiatus hernia and other factors cause the destruction of the anti-reflux barrier in the esophagus: weakened peristaltic contraction, reduced salivary secretion (e.g., dry syndrome) reduces the ability of esophageal clearance; decreased resistance of the esophageal wall to reflux (e.g., smoking, alcohol consumption, etc.), dilatation of the refluxed stomach and delayed gastric emptying All lead to a weakened anti-reflux mechanism.
Attack of reflux
On the basis of the weakened defense mechanism described above. The mucosa is irritated and damaged by the reflux. The degree of mucosal damage is related to the quality and quantity of the reflux, as well as to the duration of mucosal contact, with gastric acid and pepsin being the most powerful in damaging the esophageal mucosa.
Others
In recent years, it has been suggested that the development of RE may also be related to autonomic dysfunction and psychological factors. For example, the incidence of RE is significantly higher in people with anxiety, depression, and obsessive-compulsive disorder, which may be due to increased gastrointestinal sensitivity caused by endogenous physical and psychological factors, as well as activation of the immune and endocrine systems. The successful preparation of a more ideal animal model of reflux esophagitis in China is expected to open new avenues for the study of the pathogenesis of RE.
Clinical manifestations
The clinical manifestations of RE are diverse and vary in severity, with the following four main manifestations
Reflux symptoms
Acid reflux, regurgitation, regurgitation, belching, etc., mostly obvious or aggravated after meals, easily appearing when lying down or tilting the body forward.
Symptoms of esophageal irritation
Heartburn, chest pain, difficulty in swallowing, etc. Heartburn often appears 1h after a meal and can be aggravated when bending over, lying down or when abdominal pressure is increased.
Symptoms of extra-esophageal irritation
Cough, asthma, pharyngitis, etc. Galli et al. performed esophageal pH testing in 34 patients with pharyngitis and showed that 67.7% of patients had pathological reflux. It has been noted that up to one-third of patients with chronic persistent pharyngitis suffer from GERD, but less than 10% also have typical symptoms such as acid reflux and burning sensation in the epigastrium. In addition, GERD may be a triggering factor for asthma, suggesting that extraesophageal irritation is not uncommon in RE patients.
Complications
Common complications include esophageal stricture, upper gastrointestinal bleeding, and Berrett’s esophagus. In addition to the typical symptoms of RE, the study of atypical symptoms of RE has also become a focus of attention in recent years. According to statistics, 40%-10% of patients attending ENT departments have symptoms related to GERD.
Ancillary tests
The esophageal acid drip test does not directly prove the presence of RE. Because acid is associated with the typical symptoms of RE, but the two are not necessarily present at the same time, its diagnostic value is limited.
Endoscopy
Endoscopy is the main method for diagnosing RE. Some studies have shown that endoscopy can clarify the pathogenesis of RE and provide an objective basis for the assessment of drug efficacy. At present, there are more than 30 endoscopic classifications of RE, but there is no uniform and satisfactory classification method. However, the extent was less than 75% of the circumference of the esophagus; D: the lesions were fused and the extent was greater than 75% of the circumference of the esophagus.
Radiological examination
(1)Barium swallow X-ray of esophagus: the sensitivity of this test is only 30.3%, so it is considered to be less sensitive and should not be used as a routine diagnostic tool.
(2) Nucleotide gastroesophageal reflux test: This method is not yet popular, and the implementation method varies, and its specificity and sensitivity are still controversial, but it can be used as a direction for future research on RE diagnostic methods.
24h esophageal pH measurement
This measurement has the characteristics of sensitivity and high specificity. Wireless pH monitoring, in which Bravo capsules are fixed to the distal esophagus through endoscopy to monitor changes in esophageal pH, is a recent development. This method is more in line with the physiology of the GI tract and may become a trend in esophageal pH monitoring.
Esophageal bile reflux monitoring
Duodenal contents are mainly bile acid and pancreatic protease, this method cannot make monitoring for acid reflux, so it can improve the diagnosis by synchronizing with pH monitoring.
Ultrasound
It is a real-time and visual image examination method, which can understand the pathophysiological changes of esophagus and is valuable for the study of its pathogenesis.
Intraluminal multi-point impedance monitoring
It is expected to be a widely used diagnostic measure in clinical practice because it can not only understand the esophageal transmission time but also monitor the characteristics of the esophageal mass as it passes through the esophagus. It is particularly useful for the assessment of the condition of those who remain symptomatic after treatment.
Diagnosis
Some foreign scholars believe that the diagnosis of RE can be considered as long as the symptoms of typical reflux esophagitis are present, and that experimental treatment with a proton pump inhibitor (PPI) can be used to establish the diagnosis if the effect is significant. Domestic scholars also generally believe that the role of symptoms, especially typical symptoms, should be emphasized in the diagnosis of RE, but RF must be differentiated from other etiologies of esophagitis and peptic ulcer, so the diagnosis of RE also depends on the comprehensive judgment of clinical manifestations and auxiliary examinations. Endoscopy and 24h esophageal pH monitoring have been considered as the “gold standard” for the diagnosis of RE, which has been challenged in recent years by the increasing research and the emergence of new methods, but is still considered the best combination of tests for the diagnosis of RE, and experimental PPI therapy is an important tool for the diagnosis of RE.
Treatment
The updated guidelines for the diagnosis and treatment of GRED published by the American College of Gastroenterology in 2005 and the consensus opinion on the treatment of GERD presented by the Chinese Medical Association in 2007 both suggest the goals of treatment for GERD: relief of symptoms, cure of esophagitis, improvement of quality of life, and prevention of recurrence and complications. Based on the above diagnosis and treatment guidelines and related research, the treatment of RE is mainly in the following aspects.
Basic treatment
Such as elevating the head of the bed, no more food 3h before bedtime, avoiding high-fat diet, stopping smoking and alcohol, and reducing the consumption of foods that lower LES pressure (chocolate, coffee, strong tea, etc.). Smoking significantly increases the incidence of acid reflux and decreases salivary secretion function, leading to increased esophageal exposure to acid and prolonged acid clearance, so smoking cessation is also a treatment for RE. However, further studies are needed to determine the efficacy of treating RE through lifestyle changes.
Pharmacological treatment
Pharmacological treatment of RE is still the main tool, and the main drugs are.
(l) acid control agents: such as aluminum hydroxide, magnesium oxide, Lecithromycin, Gastric, etc.;
(2) mucosal protective agents: such as aluminum thioglycollate, colloidal bismuth citrate, etc;
(3) drugs that inhibit gastric acid secretion: H2 receptor flickers and PPI class;
(4) Gastrointestinal motility drugs: such as morpholine, cisapride, gastroflucan, etc;
(5) Chinese medicinal preparations: such as hemihsia and houpo soup. Among them, drugs that inhibit gastric acid secretion have the most significant effect in the treatment of RE. Liu Deyuan et al. reported that drugs can be selected according to the following scheme: for patients with mild reflux symptoms and mild RE a single choice of H2 receptor antagonist can effectively relieve symptoms; for moderate and severe RE, PPI-type drugs can satisfactorily control symptoms; for RE with motility disorders pro-gastrointestinal motility drugs can achieve better results. The combination of H2 receptor antagonists or PPI drugs and gastrointestinal stimulants can often achieve synergistic effects and increase the efficacy. With the increase of research on the treatment of RE with TCM, many scholars pointed out that TCM has good efficacy in improving symptoms, regulating the function of the lower esophageal sphincter (LES), inhibiting reflux, and promoting the repair of damaged esophageal mucosa.
Endoscopic treatment
Endoscopic treatment is a newly emerged treatment technique, which mainly includes GERD anti-reflux treatment, cardia suture ligation, submucosal injection of drugs, radiofrequency energy, thermal injury and other modalities. As a new treatment technique, endoscopic treatment has the characteristics of less trauma, less side effects and faster recovery, but its long-term efficacy and complications need to be confirmed by further research.
Surgical treatment
For patients with ineffective dilatation treatment of esophageal stricture, severe reflux symptoms and ineffective medical treatment for 3 months, bleeding esophageal ulcer that cannot be cured, and moderate or above heterogeneous hyperplasia, surgical treatment is appropriate.