Reflux esophagitis (RE) is an inflammatory esophageal lesion caused by the reflux of gastric and duodenal contents into the esophagus, which endoscopically manifests as a breakdown of the esophageal mucosa, i.e. esophageal erosions and/or esophageal ulcers. Reflux esophagitis can occur in people of any age, with the incidence increasing with age in adults. The prevalence is high in Western countries and low in Asia. This geographical variation may be related to genetic and environmental factors. However, there is a global trend of increasing incidence in the last two decades. Middle-aged and elderly people, obesity, smoking, alcohol consumption and mental stress are the high prevalence of reflux esophagitis.
I. Etiology
1. Destruction of the anti-reflux barrier
The lower esophageal sphincter (LES) is a high-pressure area within 3 to 5 cm above the junction line between the esophagus and the stomach. The resting pressure there is 15-30 mmHg, constituting a pressure barrier that plays a physiological role in preventing the reflux of gastric contents into the esophagus. In normal subjects, an increase in intra-abdominal pressure can cause the LES contraction reflex through the vagus nerve, causing an exponential increase in LES pressure to prevent GER.
In addition, the incidence of GER increases with increased plasma progesterone levels during pregnancy, oral progesterone-containing contraceptives and late menstrual cycle.
2.Disorders of esophageal acid scavenging function
Normal esophageal acid contouring function includes two parts: esophageal emptying and saliva neutralization. When acidic gastric contents reflux, only one to two times (10-15 seconds) of secondary peristalsis of the esophagus is needed to empty almost all the refluxed material. The small amount of acid that remains in the esophageal mucosal trap can then be neutralized by saliva (1000-1500 ml per hour of saliva with pH 6-8 enters the stomach through the esophagus in normal people).
The function of esophageal acid contouring is to reduce the time limit of esophageal mucosa immersed in gastric acid, so it has the effect of preventing reflux esophagitis. Salivary secretion almost stops during nighttime sleep, and secondary peristalsis of the esophagus rarely occurs, so the acid contouring of the esophagus at night is significantly delayed, so the danger of GER is more serious at night.
3. Damage to the anti-reflux barrier function of esophageal mucosa
When the defense barrier is damaged, esophagitis can occur even under normal reflux conditions. It has been found that the weakened ability of esophageal epithelial cells to proliferate and repair is one of the major causes of reflux esophagitis.
4. Gastroduodenal malfunction
(1) Abnormal gastric emptying.
(2) Gastroduodenal reflux When the pyloric sphincter tone and LES pressure are low at the same time, hydrochloric acid and pepsin in gastric juice, bile acid, pancreatic juice and hemolytic lecithin in duodenal juice can flow back into the esophagus at the same time, eroding the keratinized layer of esophageal epithelial cells and making them thin or fall off. The H+ and pepsin in the regurgitated material can penetrate deeply into the esophagus through the new squamous epithelial cell layer, causing esophagitis.
5. hiatal hernia
It is common to have a sliding hernia. The esophagogastric junction is displaced upward with the stomach body into the thoracic cavity. The rise of the gastric body separates the foot of the diaphragm and enlarges the hiatal hernia. When the hernia sac is small, it slides up and down with body position, force and cough. When the hernia sac enlarges, it no longer slides, changing the normal anatomical relationship near the cleft hole and causing incomplete closure of the esophagogastric junction. Herniation of the stomach causes loss of the His angle of esophageal entry into the stomach, elongation and thinning of the diaphragmatic esophageal membrane, and upward displacement of the ventral segment of the esophagus, which further deteriorates the closure function of the junction. Reflux esophagitis occurs in more than half of the patients with hiatal hernia.
6.Pregnancy vomiting
A hiatal hernia due to increased intra-abdominal pressure from pregnancy can cause reflux esophagitis, but it can recover after delivery without any treatment. Vomiting and long-term erratic reflux can also cause reflux esophagitis by opening the cardia frequently, which can return to normal after removing the cause.
7.Other diseases
Reflux occurs in newborns and infants during development due to malfunction of the lower esophageal sphincter, and most of it can be reduced with the development of young children. Primary lower esophageal sphincter dysfunction makes the closure incomplete, and organic diseases such as tumors of the lower esophagus and cardia, scleroderma and various causes of pyloric obstruction, can cause reflux esophagitis.
Therefore, reflux esophagitis is usually the result of the combined action of refluxed bile and gastric acid on the esophageal mucosa, and pylorus and LES dysfunction must exist before bile can cause esophageal injury; reflux esophagitis is often accompanied by gastritis. Sliding esophageal hiatal hernia is often complicated by LES and pylorus dysfunction; duodenal ulcer is associated with high gastric acid secretion, which leads to sinus spasm and pylorus dysfunction, and is therefore more frequent. Obesity, large amount of fluid in the abdomen, late pregnancy, increased gastric pressure, as well as tobacco, alcohol and drugs can induce the disease.
Clinical manifestations
The severity of esophagitis is not correlated with reflux symptoms. The actual fact is that you can find a lot of people who are not able to get a lot of money for their own personal use. The clinical manifestations of patients with severe esophagitis are not necessarily very serious.
2, the typical symptoms are burning sensation behind the sternum (heartburn), reflux and chest pain. Heartburn is a burning sensation behind the sternum radiating to the neck, and reflux refers to the reflux of stomach contents into the pharynx or mouth. Reflux symptoms mostly occur after a full meal and affect the patient’s sleep at night when reflux is severe.
3, late in the disease esophageal scar formation narrowing, burning sensation and burning pain gradually reduced, but the emergence of permanent swallowing difficulties, eating solid food can cause blockage feeling or pain.
4. In severe esophagitis, bleeding can occur due to esophageal mucosal erosion, mostly chronic bleeding in small amounts. Long-term or massive bleeding can lead to iron deficiency anemia.
Examination
1.Barium X-ray examination of upper gastrointestinal tract
Pay attention to the presence of gastro-esophageal reflux, esophageal hiatal hernia or esophageal stricture, and understand the situation of stomach and duodenum.
2.Endoscopy and biopsy
Endoscopy is the gold standard for the diagnosis of reflux esophagitis. Endoscopy can confirm the diagnosis of reflux esophagitis and allow assessment and grading of its severity. It can also exclude organic diseases of the upper gastrointestinal tract such as esophageal cancer and gastric cancer.
3.Nucleotide gastroesophageal reflux test
Observe whether there is excessive gastroesophageal reflux when lying down and abdominal pressure with isotope labeled liquid.
4.Esophageal acid drip test
Patients in sitting position, insert nasogastric tube and fixed at 30-35cm from the incisor, first drip saline 5-10ml for 15 minutes, if there is no discomfort, then drip 0.1mol hydrochloric acid for 15 minutes by the same method, if there is pain or burning sensation behind the sternum is positive.
5.Electrocardiogram
An electrocardiogram should be performed during the onset of pain in order to differentiate it from angina pectoris.
IV. Diagnosis
The diagnosis can be made based on the above symptoms, signs and laboratory tests.
Differential diagnosis
Reflux esophagitis is often confused with the following diseases.
1. Esophageal cancer
Esophagoscopy and barium swallow X-ray examination can be used to differentiate.
2.Peptic ulcer
They are often chronic, rhythmic, seasonal and cyclic, and ulcerative lesions can be seen in the stomach or duodenal bulb on barium x-ray and gastroscopy.
3.Angina pectoris
The retrosternal pain of esophagitis and angina can exist separately or sometimes simultaneously, both can be relieved by nitroglycerin, etc. It is difficult to differentiate.
4, hysterical ball
It is a patient complaining of foreign body sensation in the throat, unable to start swallowing, with blockage, and no organic lesion is seen in clinical examination. It is thought to be caused by irritation of the upper esophagus due to high gastric reflux. Sometimes it is the only symptom of a few patients and leads to misdiagnosis.
VI. Complications
In addition to complications such as esophageal stricture, bleeding, and ulceration, refluxed gastric juice can also attack the pharynx, vocal cords, and trachea and cause chronic pharyngitis, chronic vocal cord inflammation, and tracheitis, clinically known as Delahunty syndrome. Gastric reflux and aspiration into the respiratory tract can also lead to aspiration pneumonia. Recent studies have shown that GER is associated with some recurrent episodes of asthma, cough, nocturnal apnea, and angina-like chest pain.
VII. Treatment
1.Medical treatment
The purpose of medical treatment is to reduce reflux and reduce the irritation and corrosion of gastric secretions. Generally, sliding hernia without complaint symptoms does not require treatment. Those with mild symptoms of reflux esophagitis or due to age, combination of other diseases and reluctance to surgery can be treated medically. In obese patients, weight reduction may reduce intra-abdominal pressure and reflux. Avoid weight holding, bending and other movements, and do not wear tight clothing. Elevate the head of the bed 15 cm during sleep, do not eat 6 hours before bedtime, and avoid smoking and alcohol can reduce the onset of esophageal reflux.
In terms of medication, use acid reducers to neutralize gastric acid and reduce the activity of pepsin. For prolonged gastric emptying, gastrodynamic drugs such as domperidone (morpholine), etopride, etc., H2 receptor antagonists or proton pump inhibitors can reduce gastric acid and protease secretion. The combination of acid-suppressing drugs and prokinetic drugs can improve the efficacy in some patients.
2.Promote the emptying of esophagus and stomach
(1) dopamine antagonists These drugs can promote the emptying of the esophagus and stomach and increase the tension of the LES. Such drugs include metoclopramide (gastric reassurance) and domperidone (morpholine), taken before bed and before meals. The former can lead to extrapyramidal neurological symptoms if taken in excessive doses or for long periods of time, so use with caution in elderly patients; the latter can also lead to hyperprolactinemia and produce adverse effects such as mastopathy, lactation and amenorrhea when taken for long periods of time.
(2) Cisapride promotes peristalsis and emptying of the esophagus and stomach through the release of acetylcholine from the postganglionic nerves of the intestinal muscular plexus, thereby reducing gastroesophageal reflux.
(3) Cholinergic drug Uracholine can increase the tension of LES, promote esophageal contraction, and accelerate the emptying of acidic food in the esophagus to improve the symptoms. This mouth can stimulate gastric acid secretion, long-term use should be cautious.
3.Reducing gastric acid
(1) Acid suppressants can neutralize gastric acid, thereby reducing the activity of pepsin and reducing the damage to the esophageal mucosa from acidic gastric contents. Alkaline drugs themselves also have the effect of increasing LES tension. Aluminum hydroxide gel and magnesium oxide. Alginic acid foam contains alginic acid, sodium alginate and acid making agent, which can float on the surface of gastric contents and can stop the reflux of gastric contents.
(2) Histamine H2 receptor antagonist Metacycline, furosemide and famotidine can be used. These drugs can strongly inhibit gastric acid secretion and improve acid reflux in the gastroesophagus. If the above symptoms do not improve, the dose can be increased to 2-3 times.
(3) Proton pump inhibitors These drugs can block the H+-K+-ATPase of mural cells, such as omeprazole and lansoprazole have been widely used in clinical practice.
3., Combination of drugs
The combination of esophageal and gastric emptying agents and acidulants has a synergistic effect and can promote the healing of esophagitis. Dopamine antagonists or cisapride can also be used in combination with histamine H2 receptor antagonists or proton pump inhibitors.
4.Surgical treatment
The purpose of surgical treatment is to repair the hernia fissure and correct the esophageal stricture with anti-reflux.
5.Chinese medicine treatment
(1) Body acupuncture The main points are Neiguan and Feosanli, and the preparation points are Liver Yu, Stomach Yu, Epigastric and Gongsun.
(2) Ear acupuncture Take Shen Men, stomach and esophagus, moderate stimulation and keep the needle.
VIII. Prevention
1, avoid alcohol and quit smoking: because tobacco contains nicotine, it can reduce the pressure of the lower esophageal sphincter, leaving it in a relaxed state and aggravating reflux; the main component of wine is ethanol, which not only stimulates gastric acid secretion, but also relaxes the lower esophageal sphincter, which is one of the causes of GERD.
2, pay attention to a small number of meals, eat a low-fat diet, can reduce the frequency of reflux symptoms after eating. On the contrary, a high-fat diet can promote the release of cholecystokinin from the small intestinal mucosa, which can easily lead to reflux of gastrointestinal contents.
3, dinner should not be eaten too much, avoid lying down immediately after the meal.
4, obese people should reduce weight. Because excessive obesity increased abdominal pressure, can promote gastric reflux, especially lying position more serious, should actively reduce weight to improve reflux symptoms.
5, keep a relaxed mood, increase the appropriate physical exercise.
6, the head of the bed at bedtime should be raised 10 to 15 cm, to reduce the night reflux is a proven method.
7.Minimize activities that increase intra-abdominal pressure, such as excessive bending, wearing tight-fitting clothes and pants, tightening the belt, etc.
8.Medication should be used under the guidance of a doctor to avoid side effects from indiscriminate use of drugs.