Reflux esophagitis is an inflammatory lesion of the esophageal mucosa caused by the reflux of gastric and/or duodenal fluids into the esophagus. The pathogenesis is mainly due to the weakening of the lower esophageal sphincter, and secondary esophageal motility disorders are the factors that make esophagitis persist and worsen.
Symptoms
1. Burning sensation: burning sensation or pain in the posterior sternum, subxiphoid or epigastric region one hour after meal, spreading to the neck, shoulders and back, aggravated when lying down or when the trunk is bent forward or bent over, and relieved when standing or sitting or after taking antacid medication.
2, gastric reflux: regurgitation is often accompanied by a burning sensation, acidic or bile-containing gastric contents spill into the mouth, which is easy to occur when the trunk is bent forward or lying in bed, and can cause choking and coughing or aspiration pneumonia when sleeping because the refluxed fluid is inhaled into the trachea.
3, dysphagia: secondary esophageal spasm due to esophagitis, mostly intermittent, persistent often suggests esophageal stricture. Complications of reflux esophagitis In addition to complications such as esophageal strictures, bleeding, and ulcers, refluxed gastric juice can also erode 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.
Auxiliary tests
I. Esophageal acid drip test
The patient is placed in a sitting position and a gastric tube is placed through the nasal cavity. When the end of the tube reaches 30-35 cm, first drip saline, about 10 ml per minute, for 15 minutes. If the patient has no special discomfort, switch to 0.1N hydrochloric acid and drip at the same rate for 30 minutes. During the acid drip, a positive reaction is defined as a painful or burning sensation behind the sternum, which occurs mostly within the first 15 minutes of the acid drip. If the positive reaction occurs twice and can be relieved by saline drip, it can be judged that there is acid GER, and the sensitivity and specificity of the test is about 80%.
II. Intraluminal pH measurement of esophagus
A pH electrode placed in the lumen is gradually pulled into the esophagus and placed at about 5cm above the LES. Under normal conditions, the pH in the stomach is very low. At this time, the patient is asked to take a supine position and make movements to increase the pressure in the abdominal pain, such as closing the mouth, covering the nose, exhaling deeply or flexing the legs, and blowing the nose 3 to 4 times. If the pH in the esophagus drops to below 4 times, it indicates the presence of GER. Also, inject 300ml of 0.1N hydrochloric acid into the gastric cavity. Before injecting hydrochloric acid and 15 minutes after injecting, ask the patient to lie on his back and make abdominal pressure increasing movements respectively. In the presence of GER, the pH in the lumen of the esophagus decreased significantly after the injection of hydrochloric acid. In recent years, 24-hour esophageal pH monitoring has become a standard for determining the presence or absence of acidic GER. The measurement includes the percentage of pH <4 in the esophagus, the percentage of pH <4 in the prone and standing positions, the number of times pH <4, the number of times pH <4 lasts for more than 5 minutes and the longest duration. Our normal 24-hour esophageal pH monitoring for pH <4 is less than 6% of the time, the number of times it lasts more than 5 minutes ≤ 3 times, and the longest duration of reflux is 18 minutes. These parameters can help determine the presence or absence of acid reflux and help elucidate the relationship between chest pain and pulmonary disease and acid reflux.
III. Measurement of intraesophageal luminal pressure
Intraluminal esophageal pressure is usually measured using a water-filled continuous perfusion catheter system to estimate the function of the LES and esophagus. For pressure measurement, the pressure catheter is first inserted into the stomach, and later, the catheter is withdrawn at a rate of 0.5 to 1.0 cm/min and the intraesophageal pressure is measured. In normal people, the LES pressure at rest is about 2-4 kPa (15-30 mmHg), or the ratio of LES pressure to pressure in the gastric lumen is >1. When the LES pressure at rest is <0.8 kPa (6 mmHg), or the ratio between the two is <1, it indicates that the LES is not functioning adequately, or that GER exists.
Gastro-esophageal scintigraphy
This method can estimate the gastric-esophageal reflux. The patient’s abdomen is tied with an inflatable lap band, and 300 ml of acidified orange juice solution containing 300 μCi99mTc-Sc (containing 150 ml of orange juice and 150 ml of 0.1 NHCL) is taken orally on an empty stomach, and 15-30 ml of cold boiled water is drunk to remove the residual test solution from the esophagus, and the image is visualized upright. In normal people, no radioactivity exists above the stomach after 10 to 15 minutes. Otherwise, it indicates the presence of GER. The sensitivity and specificity of this method is about 90%.
V. Barium swallow X-ray examination of the esophagus is less sensitive and has more false negatives.
VI. Endoscopy and biopsy
Endoscopy and biopsy can determine whether there are pathological changes of reflux esophagitis and whether there is bile reflux whether the severity of the pathology of reflux esophagitis has important value.
Inflammatory lesions in reflux esophagitis can be classified into 4 grades according to the Savary and Miller subgroup criteria.
Grade I for single or several non-confluent lesions presenting as erythema or superficial erosions.
Grade II as fused lesions, but not diffuse or circumferential.
Grade III lesions diffuse circumferentially, with vesicles but without stenosis.
Grade IV shows chronic lesions with ulceration, stricture, fibrosis, wide shortening of the esophagus and Barrett’s esophagus. Treatment measures for reflux esophagitis
1, general treatment: diet should be small and many meals, should not be too full; avoid smoking, alcohol, coffee, chocolate, acid food and excessive fat; avoid lying down immediately after meals; bed head elevated 20-30cm when lying down, trouser belt should not be tied too tightly, avoid all kinds of cause abdominal pressure too high state.
2.Promote the emptying of the esophagus and stomach: apply metoclopramide (gastrofluan), domperidone (morpholine), cisapride (c), etc.
3.Reducing gastric acid
Acid suppressants: can neutralize gastric acid, thus reducing the activity of pepsin and reducing the damage to the esophageal mucosa from acidic gastric contents. Application of aluminum hydroxide gel and magnesium oxide, metacycline, furosemide and famotidine, omeprazole and lansoprazole, etc.