1, what is gastroesophageal reflux disease gastroesophageal reflux disease (GERD) refers to the gastric? GERD is a clinical syndrome characterized by heartburn and acid reflux caused by the reflux of duodenal contents into the esophagus. Acid reflux is a clinical syndrome mainly characterized by heartburn and acid reflux [1]. According to the endoscopic findings can be divided into two types: non-erosive gastroesophageal reflux disease (NERD), which is called “symptomatic reflux”, if there are no obvious lesions in the mucosa; and inflammatory lesions such as obvious erosions and ulcers. Inflammatory lesions such as erosions and ulcers are referred to as reflux esophagitis (RE), or so-called “pathologic reflux”. The common clinical term “gastroesophageal reflux disease (GERD)” refers to NERD, which in the past was considered to be a milder form of RE, and the progression of GERD was from NERD to RE, and then to Barrett’s esophagus (BE) and esophageal adenocarcinoma. Recent studies have tended to view NERD, RE, and BE as three separate diseases, each with its own individual pathogenesis and complications, virtually unrelated to each other, and RE, although more severe than NERD, responds better to treatment than NERD, and there is no evidence to support the progression of NERD to RE, or to prove that BE is a consequence of either RE or NERD. The incidence of GERD is very high in western countries, with a population prevalence of 10-30%. GERD was rare in China in the past, but the incidence has gradually increased in the last 10 years or so? Epidemiologic survey in Beijing, Shanghai and Xi’an. Epidemiologic surveys in Shanghai and Xi’an have shown that the incidence of reflux symptoms such as heartburn and acid reflux is high. Acid reflux and other reflux symptoms of the incidence of 8,9% and 16,9%, the prevalence of diagnosed GERD for 3,87% and 5,77%, reflux esophagitis for 1,92% and 2,40% 2,GERD pathogenesis is what NERD occurs is the esophageal cardia anti-reflux defense mechanism decline and reflux material on the esophageal mucosa to enhance the attack of the results? Under normal circumstances, the lower esophageal sphincter (LES) pressure exceeds the high pressure band of intragastric pressure, which prevents gastric contents from refluxing into the esophagus? When the LES pressure decreases and the intra-abdominal pressure increases, the septal pressure difference increases, which can trigger the development of this disease? where transient LES relaxation (TLESR) plays an important role in the pathogenesis. In addition, hiatal hernia? delayed gastric emptying, impaired esophageal peristalsis or decreased clearance are also associated with the development of NERD [2]? Some cases are also associated with elevated esophageal sensitivity and mental? Psychological disorders are also associated with NERD [2]. Although this disease is an acid-related disease, it is often not accompanied by increased gastric acid secretion? The effect of Helicobacter pylori (H, pylori) infection on this disease remains controversial. It has been suggested that gastric body gastritis caused by H, pylori infection can make the gastric gland atrophy leading to a reduction in acid, pepsin, and through the production of ammonia to neutralize the gastric acid, while the patients prone to GERD play a protective role? 3, the clinical type of gastroesophageal reflux disease non-erosive gastroesophageal reflux disease (NERD): reflux symptoms, but endoscopic examination of the esophageal mucosa without obvious lesions reflux esophagitis (RE): reflux symptoms, endoscopic examination of the esophageal mucosa with obvious erosion? Inflammatory lesions such as ulcers, etc. 4, non-erosive gastroesophageal reflux disease diagnostic points: (1) heartburn? The main points of diagnosis of non-celiac gastroesophageal reflux disease: (1) heartburn? The main points of non-erosive gastroesophageal reflux disease are Poststernal pain; or accompanied by chronic cough? Pharyngeal discomfort, a chronic course; (2) endoscopic examination of the gastroesophageal mucosa did not see obvious lesions or the emergence of esophageal erosions, ulcers; (3) 24h lower esophageal pH measurement, ph < 4 time ≥ 4, 0%; (4) taking proton pump inhibitor (PPI) symptom relief. 5, the clinical manifestations of gastroesophageal reflux disease GERD from the symptoms can be divided into three categories, namely: typical symptoms, atypical symptoms and symptoms outside the digestive tract? Typical symptoms are heartburn, acid reflux and regurgitation. Acid reflux, regurgitation; atypical symptoms for chest pain, epigastric pain and nausea; digestive tract symptoms, including the mouth, throat, lungs and other parts of the body (such as the brain?) symptoms, such as coughing, coughing and nausea. heart), such as cough, throat discomfort, asthma, etc.? Clinical recurrence of heartburn and acid reflux, especially with retrosternal pain and discomfort, should first consider the possibility of GERD? Heartburn is the most prominent symptom of GERD, which is characterized by a burning sensation behind the sternum or under the raphe, often extending upward from the lower part of the sternum, mostly appearing 1h after a meal, and aggravated by recumbency, bending over, or increased abdominal pressure? Reflux refers to the gastric contents rushing into the mouth without nausea and exertion, in which the reflux is acidic is called acid reflux? It is worth noting that more and more patients are clinically diagnosed with laryngitis, cough, asthma as the first symptom. The first diagnosis of GERD need to pay attention to exclude angina? The former is a chronic course, recurrent, the course of the disease is often related to the position, the use of PPI-type acid suppressants can be relieved? Angina pectoris often radiates to the left shoulder and left arm, the pain is often triggered, the duration is short, sublingual nitroglycerin can relieve it quickly, and there are often abnormalities in the ST segments of the electrocardiogram during the attack? Since the symptoms of this disease may include heartburn, chest pain, pharyngeal foreign body sensation, cough, asthma, etc., involving different parts and different systems, endoscopy and experimental acid-suppressing treatment are important methods to identify this disease? When the effect of treatment with extraesophageal symptoms is still poor, experimental treatment can often achieve significant results. 6, Gastroesophageal reflux disease endoscopy gastroscopy is used for clinical staging and to rule out possible complications or other diseases, such as esophageal stenosis, hiatal hernia, Schatzki's ring, Barrett's esophagus, and carcinoma, etc. Gastroesophageal reflux disease can be identified by endoscopy. The initial diagnosis of NERD is made in the absence of erosions or ulcers on examination, and the diagnosis of RE is made in the presence of erosions and ulcers. Early stages of reflux esophagitis or milder lesions are characterized by mucosal flushing, congestion, brittleness, and dentition. The early stage of reflux esophagitis or mild lesions have mucosal redness, congestion, brittleness and blurring of the dentate line, etc., but these are not enough to be the basis for the diagnosis of RE. The most typical endoscopic manifestation is mucosal erosion, which extends proximally from the dentate line in a longitudinal pattern, and the mucosal erosions may fuse with each other or form an ulcer. Diagnosis of reflux esophagitis requires classification of the extent of the lesion.There are various endoscopic classifications of RE, and the most commonly used internationally is the 1994 Los Angeles classification criteria [5]? The Gastrointestinal Endoscopy Branch of the Chinese Medical Association held a national symposium on the diagnosis and treatment of esophageal diseases in Jinan in 2003 to develop a domestic RE grading standard? The examination must indicate: each lesion site (upper, middle and lower esophagus) and length; if there is a stricture, indicate the diameter and length; Barrett's esophagus should be indicated by its length, with or without esophageal hiatal hernia. 7, endoscopic classification of the degree of reflux esophagitis lesions grade 0: normal (may have histological manifestations); grade Ⅰa: punctate or striated redness, erosion <2; grade Ⅰb: punctate or striated redness, erosion ≥2; grade Ⅱ: striated erosion and fusion, but not peripheral; grade Ⅲ: ulceration or erosion is peripheral, fusion ≥75%. 8, , On lower esophageal pH measurement as the gold standard for the diagnosis of NERD. Dynamic monitoring of pH changes in the lower esophagus is essential for the determination of NERD and for the etiologic diagnosis of suspected symptoms, such as noncardiogenic chest pain? Chronic pharyngitis, hoarseness or cough are important in determining whether they are caused by reflux. In addition, it can also be used to evaluate the efficacy of acid suppression therapy and anti-reflux surgical treatment? Portable pH recorders are generally used to continuously monitor the esophageal pH of patients under physiological conditions for 24h, which is currently being replaced by wireless pocket pH testers. Normal intraesophageal pH is 5,5-7,0, and when the total time of pH<4 is ≥4,0%, it is considered as the "gold standard" for the diagnosis of acid reflux? However, not all patients are clinically positive on pH ambulatory monitoring, and even in typical RE, 1/4 show normal acid exposure? This may be due to the fact that some patients do not have acid reflux but rather duodenal alkaline reflux. For those with alkaline reflux, the BILITEC2000 detector can be applied for monitoring? The electrode is usually placed 5 cm above the upper edge of the lower esophageal sphincter during testing? Routine pH monitoring does not require strict dietary restrictions, and removing those time periods when the overall results are analyzed eliminates the interference caused by eating acidic foods (e.g., coffee, tea, citrus, carbonated beverages, yogurt, etc.)? Esophageal manometry can also be used in clinical studies to measure luminal pressure with a water-filled continuous perfusion catheter system. Normal LES shows a high pressure band of 10-30 mmHg, which prevents reflux of gastric contents into the esophagus, and LES pressure of <6 mmHg is likely to lead to reflux? Multi-polar esophageal luminal impedance detection (MII) is a new technique to evaluate esophageal function and gastroesophageal reflux, which can simultaneously detect the esophageal luminal pressure and pH (MII-pH). 9, diagnostic therapeutic test proton pump inhibitor (PPI) has a powerful and rapid acid suppression effect, the main drugs in this category are Nexium, Pollit, Omeprazole, etc., the patient can take the symptoms can be rapidly relieved, and thus can be used as a diagnostic tool for GERD patients? For patients suspected of GERD can be given esomeprazole 40mg, qd or 20mg, 2 times / d, oral 7d, significant relief of symptoms can be diagnosed? Suspected reflux-associated extra-gastrointestinal symptoms, such as pharyngeal foreign body sensation, hoarseness, chronic cough, asthma, or non-cardiogenic chest pain, the duration of experimental treatment should be at least 12 weeks, and the diagnosis can be confirmed by symptomatic relief [5]? If the patient has dysphagia, emaciation, malaise, bleeding and other alarming symptoms, this test should not be used to avoid delay? 9.Other examination value of gastroesophageal reflux esophageal barium swallow X-ray is not highly sensitive in mild cases, but it is helpful in the differential diagnosis of esophageal cancer, pancreatic achalasia, esophageal hiatal hernia, esophageal diverticulosis and other esophageal diseases? Radionuclide scanning also has some significance in the diagnosis of esophageal reflux, patients fasting oral nuclide labeling solution (containing 99mTC sulfide colloid), and then drink cold boiled water to remove the residual reagent in the esophagus?15min later, first take the standing position to observe the esophagus with or without radioactivity, if not, then take the supine position and with a compression belt bound to the stomach to give different pressures, and at the same time for the gastro-esophageal part of the γ-photographs? If there is radioactivity in the esophagus, it suggests gastroesophageal reflux. This method is simple and non-invasive, but not very sensitive? The Carlsson questionnaire can be used to screen GERD patients in the population, but the specificity of this method is poor and it is not suitable for the diagnosis of people with diabetes mellitus. At present, some new questionnaires have been designed internationally, which can exclude other related diseases such as peptic ulcer and functional dyspepsia while diagnosing GERD. 10. Treatment points of GERD: (1) pay attention to dietary habits and sleeping patterns; (2) apply PPI acid-suppressing drugs; (3) apply pro-dynamic drugs; (4) apply mucosal protective drugs; (5) anti-reflux surgery 11. The treatment strategy of GERD mainly focuses on alleviating symptoms? Promote recovery of mucosal inflammation, treat complications, and prevent recurrence? Since acid reflux is the main cause of the disease, acid-suppressing agents are currently the most important therapeutic agents. If the patient is ineffective on conventional treatment with acid suppressants, the diagnosis should be analyzed to see if the diagnosis is correct, whether the patient has alkaline reflux or has complications such as stenosis, and at the same time pay attention to the factors affecting the drug, such as patient compliance, differences in the bioactivity produced by orally ingested PPIs in different individuals, and the effect of hepatic drug enzyme P450 on the metabolism of PPIs, etc.? Since the disease involves long-term treatment, comprehensive and individualized treatment plans should be considered in the treatment, such as increasing the dose of PPI, switching to enzyme preparations that do not affect cytochrome P450, adding H2RA or kinetic drugs? Surgery, etc.GERD is a chronic recurrent disease that may develop in infancy in some patients and requires lifelong treatment [7]? Most patients experience symptomatic relief after 4-8 weeks of initial treatment, but most relapse within six months, with a disease recurrence rate of about 57% to 90%, so maintenance therapy to prevent relapse is particularly important. There are two types of maintenance programs: continuous treatment and discontinuous treatment. The former involves the use of a regular dose of an acid suppressant taken orally as one tablet per day for more than six months after reflux symptoms have been controlled. Discontinuous treatment can be intermittent dosing or on-demand dosing? Intermittent dosing refers to short-term dosing at certain intervals, usually 1 to 2 weeks? On-demand treatment is where the patient decides to take the medication, there is no set course of treatment, the medication is given at the onset of symptoms and is stopped when the symptoms are controlled? Discontinuous treatment can save the cost of treatment and reduce the rebound of acid secretion after long-term continuous treatment? If the on-demand treatment fails, switching to maintenance medication can still achieve better results? 12, about eating habits and sleep mode change lifestyle is an important treatment of GERD, including a small number of meals, avoid oversatiety? Stand and walk appropriately after meals and do not eat before bedtime. Avoid drinking aerated or acidic beverages and stimulating foods such as orange juice? Lemon juice? Tobacco and alcohol? Strong tea? Coffee, chili peppers, etc. Chili peppers, etc., eat less desserts and low-fat diet can reduce bloating? Obese patients can lose weight to reduce abdominal pressure? Elevate the head of the bed 15~20cm or shoulder pads when sleeping? To make patients have a correct understanding of the disease, so as not to increase the psychological burden and the pursuit of inappropriate treatment measures? 13,, about the application of acid suppressants GERD the most effective drugs are acid suppression drugs, but drug treatment can only relieve heartburn symptoms but can not stop reflux, so many patients need lifelong treatment?GERD patients with basal gastric acid secretion and maximum gastric acid secretion after stimulation does not increase, but there is a reflux of acid and other substances, reduce the acidity in the stomach can help to alleviate the symptoms of reflux [8]? Currently, there are two classes of acid-suppressing drugs: histamine H2 receptor antagonists (H2RA) and proton pump inhibitors (PPIs).H2RA has a strong ability to inhibit histamine? H2RA has a strong inhibitory effect on gastric acid secretion induced by histamine and pentagastrin, and H2RA can reduce 24h gastric acid secretion by 50%~70%, so it can improve the clinical symptoms caused by reflux to a certain extent. However, because H2RA cannot effectively inhibit gastric acid secretion caused by feeding, and long-term use will produce drug resistance, it is only suitable for patients with mild to moderate symptoms or for maintenance therapy. However, since H2RA is not effective in suppressing acid secretion caused by eating and long-term use can lead to drug resistance, it is only suitable for mild to moderate patients or for maintenance therapy. The earliest H2RA used in the clinic was cimetidine (400mg, 2x/d orally), followed by the second generation ranitidine (150mg, 2x/d orally) and the third generation famotidine (20mg, 2x/d orally), which have stronger acid-suppressing effects, and the dosage and side effects are significantly reduced? However, there is no statistical difference in the efficacy of various H2RA in clinical practice? In the case of suboptimal treatment, increasing the dose does not increase the efficacy? In addition, H2RA, although superior to PPIs in controlling nocturnal acid breakthrough, did little to control extraesophageal symptoms? PPI acts on the final step of gastric acid secretion through the inhibition of proton pump (there exists a kind of H+-K+-ATPase on the secretory tubules of the stomach's mural cells, and gastric acid secretion has to pass through this enzyme in order to play a role, so it is called acid proton pump), therefore, it plays a powerful inhibitory effect on the secretion of basal gastric acid, histamine, acetylcholine, gastrin, and gastric acid secretion induced by various stimuli such as food, etc.? Currently in the clinical use of more widely used PPI preparations include: omeprazole (OME, 20mg), lansoprazole (LAN, 30mg)? Pantoprazole (PAN, 40mg)? Rabeprazole (RAB, 10mg) and esomeprazole (ESO, 20mg)?ESO is the levorotatory isomer of OME, which is significantly more potent than omeprazole in terms of both pharmacokinetics and pharmacodynamics? More sustained inhibition of gastric acid? 14, Treatment regimens for acid-suppressing drugs There are currently three regimens for acid-suppressing drugs, namely, step up? The step up method (step down) and on demand treatment (on demand)? The step up method is to first use H2RA or the regular dose of the power drug orally, H2RA plus the regular dose of the power drug orally, the regular dose of the PPI orally, the regular dose of the PPI twice the dose of the PPI in the morning and the regular dose of the PPI in the evening. The tapering method is to first use the regular dose of H2RA or the power drug orally, the regular dose of PPI orally, twice the regular dose of PPI orally in the morning and in the evening? The tapering method is to start with two times the regular dose in one dose in the morning and one dose in the evening. The tapering approach starts with two times the regular dose orally once in the morning and once in the evening, and then gradually switches to maintenance doses of H2RA and kinetics after complete control of symptoms. The on-demand approach is to start treatment and stop when symptoms disappear until the patient is symptomatic again, at which point the medication is started. Regardless of the treatment regimen, the effective dose of treatment is at least 4-8 weeks? Since the acid-suppressing effect of PPIs is maximized when food stimulates the cells of the stomach lining to an active state, taking them 15-30 min before meals is ideal for controlling stomach acidity? If taken twice daily, it should be taken before breakfast and dinner? Although it has been reported that eradication of Hp will affect the acid-suppressing effect of PPI, for patients with childhood onset of disease, eradication of HP is not harmful, and can prevent the occurrence of atrophic gastritis and cancer. 15.What is meant by nocturnal acid breakthrough? Patients taking proton pump acid suppressant have obvious epigastric heartburn and other symptoms at night, which is known as NAB, probably due to the increased excitability of the vagus nerve at night, and increased gastric acid secretion at night stimulated by the action of histamine on the cholinergic nerves. In addition, there is also a relationship with nocturnal proton pump regeneration. Dynamic monitoring of pH changes in the lower esophagus, the duration of nocturnal intragastric pH <4 is more than 60 min or more. There are more factors in the pathogenesis of nocturnal acid breakthrough, which are closely related to the inhibition and regeneration of the proton pump, in addition to the bioavailability of PPIs and differences in drug metabolism. Proton pump regeneration is mainly accomplished at night? Therefore, acid breakthrough is more often seen at night? In addition, the mechanisms of daytime and nighttime gastric acid secretion are different: the increase in gastric acid during the daytime is related to the increase in serum gastrin due to feeding, while the increase in gastric acid secretion at night is due to the increased excitability of the vagus nerve during the night, and the increase in gastric acid secretion during the night stimulated by histamine-activated cholinergic nerves. For NAB with GERD, PPI can be added twice daily with one nocturnal H2RA, such as the addition of ranitidine 150~300mg or famotidine 20~40mg before bedtime effect is better than the addition of omeprazole 20mg before bedtime? Because PPI only has an inhibitory effect on the activated proton pump in the acidic environment of the secretory tubule, and has no inhibitory effect on the resting proton pump? Food stimulates gastric acid secretion, which can increase the activated proton pump by 10 times? Because there is no food or other factors to stimulate the secretion of gastric acid before bedtime, most of the effects of taking PPI at this time are the quiescent proton pumps that can not be inhibited by PPI, so the effects of taking PPI before bedtime are not obvious? PPI is metabolized by CYP4502C19 and 3A4 in the liver to become ineffective or weakly active metabolite, and finally cleared by the kidneys, and the degree of activity of the CYP2C19 enzyme is caused by the difference in the degree of individual PPI metabolism. Different levels of CYP2C19 enzyme activity result in differences in PPI metabolism between individuals, thus causing differences in PPI efficacy between individuals. Esomeprazole or rabeprazole are less dependent on CYP2C19 metabolism? therefore metabolized more slowly than omeprazole and have more bioavailability when the same dose of drug is taken orally? Therefore better efficacy can be achieved when other acid-suppressing drugs are ineffective or NAB is present. 16, on the application of prokinetic drugs prokinetic drugs in theory, although there is an increase in the lower esophageal sphincter and improve the role of acid clearance, but in practice they are in the treatment of severe esophagitis, in addition to improving the symptoms of gastric emptying outside the role is not obvious, on the main mechanism of GERD formation of the lower esophageal sphincter a transient relaxation of the sphincter has almost no obvious effect? Therefore, these drugs are suitable for patients with obvious gastric dysfunction, and most of them are applied simultaneously with acid-suppressing drugs in order to obtain a better therapeutic effect. Currently the main commonly used dynamics are domperidone? Cisapride and Mosapride? Domperidone is a peripheral dopamine receptor blocker, directly blocking the dopamine receptors in the gastrointestinal tract, which can increase the pressure of the lower esophageal sphincter, enhance gastric peristalsis, increase pyloric diastolic tension, but does not affect the frequency of pyloric opening, so that the gastric sinus and duodenal motility coordination? Cisapride is a partial 5 HT receptor agonist, a total gastrointestinal stimulant? Its pharmacological action is to act through the agonism of 5HT4 receptors, increase the physiological release of acetylcholine from the interosseous plexus, increase the pressure of the lower esophageal sphincter, promote peristalsis of the lower esophagus, reduce the number of gastroesophageal reflux, increase gastric contraction, increase duodenal coordination, thus increasing the rate of gastric emptying, also reducing gastroduodenal reflux, and at the same time significantly accelerate the small bowel? colon passage time, increasing peristaltic contractions and reducing retrograde peristalsis? The above pharmacologic effects of cisapride are effective not only in improving the symptoms of acid reflux, but also in inhibiting the occurrence of base reflux? However, excessive prolongation of the QT interval has been reported to occur occasionally with cisapride? tip-twisting ventricular tachycardia and/or ventricular fibrillation, so its use in clinical practice is somewhat limited? Mosapride has similar pharmacologic effects to cisapride, but according to available clinical observations, no significant prolongation of the QT interval has been found, with little effect on the heart, and the side effects need to be further verified? The usage of the above three kinds of gastrointestinal stimulants are 10mg, 3 times a day, half an hour before meal orally? 17.About the application of mucosal protective agents can increase the resistance of mucosa to acid and alkali, promote the repair of epithelial damage, suitable for the treatment of RE? At present, the clinical application of mucosal protective agents have oral absorption (such as Schwesol) and direct action (aluminum thiosulphate? Magnesium aluminum carbonate) two categories, the direct action of the mucosa of the drug should avoid the application of capsules or tablets, because the latter oral directly into the stomach is not easy to play a protective effect on the esophageal mucosa. Magnesium aluminum carbonate (Talcid, Daxi) is a chewable tablet with a layered structural arrangement, which can neutralize gastric acid and prevent the damage of pepsin and bile acid on the esophagus? Since GERD is often associated with bile reflux, it is a commonly used mucosal protective agent? 18,, GERD can be surgically treated for the clinical symptoms of heavy, large dose of drugs for RE, can be used in a combination of drugs and surgical treatment? Surgery can be performed endoscopically or laparoscopically, or directly open surgery. There are various methods of endoscopic treatment, the commonly used one is endoscopic suture treatment also known as fundoplication, which involves the use of an endoscopic suture device known as the Bard Gastroscopic Intraluminal Fold, which is used to suture the gastric wall tissues under the dentate line under direct visualization to form folds and increase the tension near the cardia opening to block the reflux of gastrointestinal contents? Sutures include longitudinal sutures along the side of the lesser curvature, circumferential sutures along the periphery of the cardia, and spiral sutures. Since the approval of endoscopic treatment of GERD by the US FDA in 2000, this technique has been able to be widely practiced worldwide, but data from several prospective studies and follow-ups [9] have shown that this method can only provide short-term relief of clinical symptoms and increase intraesophageal pH, but these effects cannot be maintained in the long term due to the disappearance of the original endoscopic suture folds after 1 year? Therefore, it is not recommended as a routine treatment? For better efficacy, some reports have suggested the possibility of combining endoscopic radiofrequency therapy or injection therapy. Radiofrequency therapy involves delivering a radiofrequency needle through the endoscopic biopsy orifice to the vicinity of the dentate line, where it pierces the muscularis propria of the lower esophagus and thermally cauterizes the muscle layer, causing it to "fibrillate" and increasing the tension in the lower esophagus, which in turn acts as an anti-reflux agent? Injectable therapy involves injecting a non-biodegradable and antigenic biosoluble substance or sclerosing agent into the cardia or lower esophageal sphincter under direct endoscopic visualization, so that the injected part can form a fibrous cystic package to increase the pressure on the lower esophageal sphincter and reduce postprandial lower esophageal sphincter relaxation? Internationally, a dedicated endoscopic radiofrequency therapeutic instrument, i.e., the Stretta instrument, has been introduced, with better results in some patients. Surgical laparoscopic treatment of esophageal reflux disease is mainly to restore the function of the lower esophageal "sphincter-like", with Nissen fundoplication as the main procedure? It is important to note that the pathogenesis of GERD involves delayed gastric emptying? Reduced esophageal peristalsis? The pathogenesis of GERD involves delayed gastric emptying, decreased esophageal peristalsis, esophageal mucosal damage, etc., and anti-reflux surgery alone does not solve all the problems? Many patients still need to continue to use drugs after surgery, and some patients may experience complications such as gastrointestinal flatulence, diarrhea, nausea and dysphagia, so anti-reflux surgery is not used as a common treatment option in clinical practice, and is only suitable for strictly screened patients, such as those for whom regular medical treatment is effective, but who are unwilling to take medication for the rest of their lives? ineffective; or those with complications such as esophageal ulcers, bleeding, stenosis, or cancer, as well as those with moderate to severe respiratory syndromes. Patients should be clearly informed that they cannot expect that they will no longer need medical drug therapy or that all symptoms of GERD will disappear after surgery? Even anti-reflux surgery is ineffective in patients with poor pharmacologic outcomes, and medications are still needed after surgery? 19. Gastroesophageal reflux disease commonly used drugs Esomeprazole Esomeprazole Nexium,10mg/tablet omeprazole S-isomer, can be in the mural cell acid secretion microtubules in the highly acidic environment of the concentration and converted to the active form, specific inhibition of the H+-K+ ATPase (proton pump), thus inhibiting the basis of the gastric acid secretion and various stimuli caused by the gastric acid. Compared to omeprazole first-pass metabolism is reduced, body clearance is reduced, the drug reaching the site of action is increased, more proton pumps can be inhibited, and thus there is a stronger and more rapid acid suppression effect. The drug should be swallowed whole 1 hour before meals and should not be chewed or crushed. Side effects are minimal and safe for long-term use. Headache and gastrointestinal symptoms such as abdominal pain, diarrhea, bloating, nausea, constipation may occur in some patients after taking the drug. Occasionally, skin itching and urticaria may occur. It can be recovered after stopping the drug. Theoretically, long-term use of reduced gastric acid secretion can cause hypergastrinemia, which may lead to gastric pheochromocyte hyperplasia and carcinoid tumors, but there are no clinical reports of increased cancer potential. Although experimental studies have not found any damage to embryonic (or fetal) development, it is prohibited for lactating women. Serious hepatic insufficiency and pregnant women should use with caution. Magnesium Aluminum Carbonate Chewable Tablets Hydrotalcite Chewable Table Daxi Talcid 0,5g/tablet Chewing disintegration, the active ingredient magnesium aluminum carbonate release, the formation of laminar network lattice structure, deposited in the upper gastrointestinal tract mucosal surface to form a protective layer, when the gastric lumen pH <3, OH- immediate dissolution and neutralization of gastric acid, pH>5 is the termination of the reaction, the pH of gastric juice can be maintained between 3~5. It can maintain the pH value of gastric juice between 3~5. The adsorption rate of toxic non-polar bile acids reaches 100%. The drug can stimulate the synthesis of mucosal prostaglandin E2 and the release of epidermal growth factor, thus improving the mucosal barrier function. Adverse effects are few and mild, with only a few gastrointestinal disturbances, dyspepsia, vomiting, and increased stool frequency. Long-term use does not cause serum aluminum, magnesium and other mineral disorders. For gastric acid deficiency, ulcerative colitis, chronic diarrhea, intestinal obstruction and other prohibited. For severe cardiac and renal insufficiency, the first three months of pregnancy and patients with high magnesium or hypercalcemia, use with caution. Generally 0.5~1.0g each time, 3 times a day, 2h after meal or between meals and bedtime after chewing. Commonly used prokinetic drugs: domperidone/morpholino tablets, 10mg orally, 3 times/d; metoclopramide/gastrofibromide tablets, 10mg orally, 3~4 times/d; clobopride: Vicentin tablets, 0,68mg orally, 3 times/d; mosapride/sodium xinluo or gasicin tablets, 5mg orally, 3 times/d; etoricorubicin: for lisinopril 5mg orally, 3 times/d.