Gastroesophageal reflux disease is the reflux of gastroduodenal contents into the esophagus, causing damage to the esophagus and extraesophageal tissues. It includes endoscopy-negative gastroesophageal reflux disease or non-erosive reflux disease in 50%, reflux esophagitis in 40%, and Barrett’s esophagus (squamous epithelium of the lower esophagus replaced by chemosis of columnar epithelium, a precancerous lesion of esophageal adenocarcinoma) in 10%.
Through ten years of observation in outpatient clinics and wards, the prevalence of GERD has increased significantly, accounting for about 20-30% of all gastroenterology outpatient visits. Many patients repeatedly visit the clinic and take medication for a long time, which is relatively painful. The following is my clinical experience and my understanding of the disease.
I. Clinical manifestations
1. Typical symptoms: heartburn, acid reflux, regurgitation, etc.
2. Atypical symptoms: chest pain, epigastric pain, nausea.
Extra-digestive symptoms: difficulty in swallowing, gastric distension, excessive salivation; excessive reflux of regurgitated material, irritation of the pharynx leading to laryngitis, as well as pharyngeal discomfort, foreign body sensation or blockage; some other patients have coughing and asthma due to aspiration of regurgitated material into the airway, which can lead to pneumonia and interstitial fibrosis in severe cases.
In severe cases, bleeding and esophageal stricture may occur.
II. Diagnosis
1. Endoscopy Endoscopy is the most valuable diagnostic tool for this disease. It can accurately determine the presence or absence of reflux esophagitis and its degree of inflammation.
2. 24h esophageal pH measurement 24h esophageal pH monitoring can accurately determine whether there is gastroesophageal reflux and the degree of reflux, which provides an important basis for the diagnosis of reflux esophagitis.
3. Esophageal pressure measurement The ratio of the pressure of the lower esophageal sphincter to the intragastric pressure is greater than 1 in normal people, which can prevent excessive reflux. When the ratio is less than or equal to 1, gastroesophageal reflux is likely to occur.
4. Proton pump inhibitor (PPI) test If the diagnosis of this disease is suspected, use a standard dose of PPI twice a day for 1-2 weeks, the effect is obvious and the diagnosis is generally established.
III. Treatment
1. GERD/reflux esophagitis is a common disease, and it is currently considered a lifelong disease, which means that it cannot be completely cured. Therefore, the psychological expectation of treatment should be properly adjusted, and be prepared to co-exist with it for a long time.
2. Western medicine treatment
1) Gastrointestinal stimulants
(1) Domperidone (morpholine) is routinely administered at 10mg three times a day orally before meals or half an hour before bedtime.
②Moxaburi Enhance the peristalsis of the digestive tract, reduce the number of reflux and esophageal acid exposure time, the conventional use is 5-10mg per time, three times a day, oral before meals.
(3) Trimebutine, which regulates the motility of the GI tract in both directions, is routinely administered as 100mg three times a day by mouth before meals.
There are also etoposide, erythromycin, etc.
2) Acid-suppressing drugs
(1) H2 receptor antagonist (H2RA) can reduce 24h acid secretion by 50% to 70%, but cannot effectively inhibit gastric acid secretion stimulated by eating, so the acid suppression effect is not very strong, and is suitable for elderly patients with mild to moderate esophagitis.
(2) Proton pump inhibitors can produce stronger and longer-lasting acid suppressing effect than H2RA, and are mainly used clinically in patients with heavy esophagitis symptoms. They include omeprazole, lansoprazole, pantoprazole, rabeprazole and esomeprazole, etc. Choose one as appropriate.
(3) mucosal protective drugs This class of drugs are more commonly used in aluminum phosphate, Daxi, Fagitide, etc., can be taken to form a protective film on the surface of the gastric mucosa, reducing the stimulation of gastric acid on the mucosa.
①Aluminium magnesium carbonate (Daxi) conventional use for each time 2 tablets, twice a day, chewed between meals, or take when there are symptoms.
②Faginide (Huizhong) Regular use is 2 tablets per time, three times a day, taken orally before meals.
③Ribapent is routinely administered as 2 tablets three times a day by mouth before meals.
3. Medication experience
(1) For certain patients with reflux esophagitis who are not sensitive to drugs or have severe symptoms, we can consider a combination of drugs. Triple therapy refers to the combination therapy of PPIs + mucosal protective agents + prokinetic drugs. For example, we use acid suppressants such as Dacrypromine, mucosal protectors such as Daxil, and motivational agents such as Martindrin.
(2) It can be treated on demand, i.e., taking drugs for a period of time when the symptoms are obvious and stopping them when the symptoms are relieved, which can save the cost of drugs and reduce the side effects of drugs. The medication should be discontinued gradually, such as changing from taking the medication daily to every other day, and then to twice a week, gradually stopping the medication.
(3) Chinese medicine is effective and can be considered. Chinese medicine requires evidence-based treatment and can be broadly classified as liver-stomach (spleen) disharmony, phlegm-dampness in obstruction, (spleen)-stomach weakness and phlegm-qi cross obstruction. Commonly used Chinese medicines include: Chai Hu Dredging Liver San, Xiang Sha Ping Stomach, Wenzhi Tang and Shen Xiang Dredging. Soup medicine is more effective.
(4) If there are psycho-emotional factors, anti-anxiety/depressant drugs such as Dextran, Celete, etc. can be used, sometimes with miraculous results.