Gastroesophageal reflux

disease

L. V. Borisova
Docent., Ph. D.
GASTROESOPHAGEAL REFLUX DISEASE
Chronic recurrent disease caused by a violation of the
motor-evacuation function of the gastroesophageal zone
and characterized by spontaneous or regularly recurring
reflux of gastric or duodenal contents into the esophagus,
which leads to damage to the distal part of the esophagus
with the development of erosive-ulcerative, catarrhal
and/or functional disorders in it
 GASTROESOPHAGEAL REFLUX DISEASE

The most characteristic symptoms of GERD are

heartburn and regurgitation, and the most a common

complication is reflux esophagitis.

X съезд НОГР 2010

 GERD

Extraesophageal
SYNDROMES

Esophageal
syndromes
 Classification of GERD
Esophageal syndromes Extraesophageal syndromes
Syndromes, Syndromes Symptoms Syndromes that
manifested solely by are thought to be
the symptoms (in the with damage to related to associated with
absence of structural the esophageal GERD is GERD
damage to the complications installed
esophagus)
of GERD
1. Classic reflux 1. Reflux 1. Cough of a 1. Pharyngitis
syndrome esophagitis reflux nature 2. Sinusites
2. Stricture of the 2. Laryngitis of 3. Idiopathic
2. Chest pain
esophagus reflux nature pulmonary
syndrome fibrosis
3. Barrett's 3. Bronchial
4. Recurrent otitis
Esophagus asthma of reflux
media
4. Adenocarcioma nature
4. Erosion of
dental enamel of
reflux nature
 NERD(non- Erosive Barrett's
erosive) esophagitis37 Esophagus3
% %
60%

Not progressing is not● Esophageal stricture Adenocarcinoma of

complicated for ● Ulcers of the the esophagus
esophagus
● Bleeding
 THE PATHOPHYSIOLOGY OF GERD
The excess body weight.
Exercise
Violation of MOTILITY OF THE
the ESOPHAGUS
protection of
the
esophageal
mucosa

TRANSIENT RELAXATION
OF THE NPS Esophageal
H+ HERNIA
Pepsin
Increased intra-abdominal
pressure (obesity, horizontalput
after eating, tight clothing)

Cholic refluxes
Slowing the evacuation of (fat)

de Caestecker, 2001.
Johanson, 2003.
Degree of re Endoscopic picture
Degree A One (or more) mucosal lesion (erosion or ulceration) less than 5 mm long,
limited to the limits of the mucosal fold.
Degree B One (or more) mucosal lesion longer than 5 mm, limited to the limits of the
mucosal fold.
Degree C The lesion of the mucous membrane extends to 2 or more folds of the
mucous membrane, but occupies less than 75% of the circumference of the
esophagus.
Degree D The lesion of the mucous membrane extends to 75% or more of the
circumference of the esophagus.
 Endoscopic classification

Degree A Degree В

Degree С Degree D
 Clinical picture
1. heartburn occurs during prolonged contact of
acidic gastric contents with the esophageal
mucosa (pH<4)
increases:
- errors in the diet,
- - drinking alcohol and carbonated beverages,
- - physical tension and bending of the torso,
- - in the horizontal position of the patient
 Heartburn – –
1. burning sensation behind the sternum and / or " in
the stomach»
2. spreading from the bottom up,
3. individually occurring in a sitting, standing, lying
position or when the torso is tilted forward,
4. sometimes accompanied by a feeling of acid and / or
bitterness in the throat and mouth,
5. often associated with a feeling of overflow in the
epigastrium,
6. occurs on an empty stomach or after the
consumption of any type of solid or liquid food,
7. alcoholic or non-alcoholic beverages, or the act of
Smoking
1. belching and regurgitation-in 20% of patients is
intermittent, due to hypermotor dyskinesia of
the esophagus, which violates its peristaltic
function.
2. Regurgitation should be understood as the ingress of
stomach contents due to reflux into the mouth or
lower part of the pharynx (Montreal definition, 2005).
Diagnosis of GERD
I. Main diagnostic methods-analysis of the
clinical picture of the disease-frequency of
heartburn 1 or more times a week
II. II. Additional research methods
■ Endoscopy
■ Histological examination
■ Manometry24-48 hour pH-metry of the esophagus
■ Test with proton pump inhibitors (Bernstein test)
■ Chromoendoscopy
■ Endoscopic ultrasound
■ Intra-light impedance monitoring
 When identifying extraesophageal syndromes and
determining indications for surgical treatment of
GERD

specialist advice
- cardiologist,
- - pulmonologist,
- - throat,
- - dentist,
- - psychiatrist, etc.
SYNDROMES OF DAMAGE OF THE
ESOPHAGUS AND COMPLICATIONS

Stricture of the esophagus

Anemia
Bleedings
Perforation

Nathoo, Int J Clin Pract 2001; 55: 465–9.

 BARRETT'S ESOPHAGUS
acquired, genetically deterministic state, when where the
flat epithelium is replaced cylindrical (metaplasia of
the epithelium)

GASTRIC LIKE INTESTINAL LIKE

The diagnosis is morphological!!!!!!!

Barrett's esophagus with intestinal metaplasia - pre-tumor
condition of the esophagus
Pathological acid reflux is a proven risk factor for Barrett's
esophagus
Prolonged suppression of PPI acidity reduces the risk of
esophageal neoplasia
 treatment

■ Lifestyle change
■ Pharmacotherapy
■ Endoscopic treatment methods
■ Antireflux surgery
 Gerd treatment options
1. Lifestyle change
Recommendations
1.Sleep with the head end of the
bed raised at least 15 cm
2.Dietary restriction
To reduce the fat content
To increase the protein content
To reduce the amount of food
Avoid irritating foods (juices, citrus
fruits, tomatoes, coffee, tea, chocolate,
etc.)
Notes
Reduces the duration of esophageal
acidification
Fats reduce the pressure of the lower
esophageal sphincter (NPS)
Proteins increase the pressure of the NPS
Decreases the volume of gastric contents
and refluxes
Direct damaging effect (Coffee, tea,
chocolate, alcohol, ..)also reduce the
pressure of the NPS
 Gerd treatment options 2.Changing
your lifestyle
Recommendations
3.To reduce the weight for obesity
4. Do not eat before going to bed, do not lie
down after eating
5. Stop Smoking
6. Avoid tight clothing, tight belts
7. To avoid taking a number of drugs:
anticholinergics, sedatives, tranquilizers,
theophylline, CA antagonists, prostaglandins
Notes
Overweight is the suspected cause
of reflux
Reduces the volume of gastric
contents in a horizontal position
Smoking significantly reduces the
pressure of the NPS
Increase intra-abdominal pressure,
NSL reflux
Reduce the pressure of the NPS or
slow down the peristalsis of the
esophagus
 control symptoms and treat complications of
GERD (reflux esophagitis, Barrett's
esophagus)
the most effective proton pump inhibitors (omeprazole 20 mg,
lansoprazole 30 mg, pantoprazole 40 mg, rabeprazole 20 mg or
esomeprazole 20 mg) are prescribed 1-2 times a day for 20-30
minutes before meals.
The duration of the main course of therapy is at least 6-8 weeks.
In elderly patients with erosive reflux esophagitis, as well as in the presence of
extraesophageal syndromes, its duration increases to 12 weeks.
Features of metabolism in the cytochrome P450 system provide the lowest profile of
drug interactions of pantoprazole, which makes it the safest when taking drugs for
the treatment of synchronous diseases (clopidogrel, digoxin, nifedipine, phenytoin,
theophylline, R-warfarin, etc.).
 Chronic gastritis

Chronic inflammation of the gastric mucosa

that manifests:
- its cellular infiltration,
- violation of physiological regeneration and
consequently atrophy of the glandular
epithelium,
- intestinal metaplasia,
- disorder of the secretory,
- -motor and often endocrine function of the
stomach
 Chronic gastritis
Definition
Chronic gastritis is a group of chronic diseases that are
morphologically characterized by the presence of
inflammatory and dystrophic processes in the gastric
mucosa, progressive atrophy, functional and structural
restructuring.
The most common cause of chronic gastritis is HP, which is
due to the high prevalence of this infection.
Modern ideas or what a doctor needs to know when he is
diagnosed with chronic gastritis (Maastrich V)

The diagnosis of "Chronic gastritis" is a morphological diagnosis

this disease has no clinical equivalent

clinical manifestations may be associated with both HP-associated
gastritis and concomitant functional dyspepsia

The presence of gastritis does not explain the onset of symptoms of

dyspepsia

screening for precancerous changes in the gastric mucosa

 The Sydney classification

Visual-analog scale for semi-quantitative

definition:
- activity and severity of gastritis,
- atrophies
- intestinal metaplasia,
- degrees of colonization of H. pylori
 Houston classification, according to which
distinguish:
■ Chronic non-atrophic gastritis (primarily caused by H.
pylori) *
■ Chronic atrophic gastritis
■ • Multifocal gastritis (as the outcome of long-term
gastritis associated with H. pylori)
■ • Autoimmune gastritis
■ • Special forms of gastritis.
 Principles of treatment of chronic
gastritis
Treatment of chronic gastritis is differentiated, depending
on clinics, etiopathogenetic and morphological form of
the disease.
Chronic antral gastritis, HP-associated (type B)
The main principle of treatment of this type of
chronic gastritis is the eradication of HP
 Chronic chemical (reactive) gastritis (reflux
gastritis, type C)
The cause of gastritis C is the casting (reflux) of the duodenal contents into the
stomach.
The cause of gastritis C is the casting (reflux) of the contents of the duodenum into
the stomach.
The damaging properties of bile acids depend on the pH of the stomach: at pH < 4,
taurine conjugates have the greatest effect on the gastric mucosa, and at pH > 4,
non – conjugated bile acids have a significantly greater damaging effect.
In the treatment of reflux gastritis, use:
-bismuth tripotassium dicitrate (120 mg 4 times or 240 mg 2 times a day);
-sucralfat (500-1000 mg 4 times a day) most effectively binds conjugated bile
acids at pH 2, with an increase in pH, this effect is reduced, so it is not
advisable to use it simultaneously with antisecretory drugs;
ursodeoxycholic acid preparations (250 mg 1 time a day from 2-3 weeks to 6
months);
for the normalization of motor function, prokinetics (metoclopramide,
domperidone, itopride does hydrochloride) and regulators of motility
(trimedat, mebeverine)