Gastroezofagealny reflux disease
Gastroezofagealny reflux disease (GERB) - a disease at which the inflammation of walls of the lower department of a gullet arises as result of a regular reflux (the return movement) of gastric or duodenal contents in a gullet. GERB is shown by heartburn, an eructation with sour or bitterish smack, pain and difficulty of a proglatyvaniye of food, dyspepsia, pains behind the breast and other symptoms amplifying after meal and physical activities. Diagnostics of GERB includes FGDS, an intra esophageal rn-metriya, a manometriya, a X-ray analysis of a gullet and stomach. Treatment of a gastroezofagealny reflux disease can be medicamentous or quick.
Gastroezofagealny reflux disease
Gastroezofagealny reflux disease (GERB, reflux-ezofagit) – the morphological changes and simptomokompleks developing owing to throwing of contents of a stomach and a 12-perstny gut in a gullet. GERB one of the most widespread pathologies of a gastrointestinal tract having tendency to development of numerous complications. The high extent of distribution, heavy clinic considerably worsening quality of life of patients tendency to development of life-threatening complications and a frequent atypical clinical current do a gastroezofagealny reflux disease of one of the most urgent problems of modern gastroenterology. Constant growth of incidence demands careful studying of mechanisms of development of GERB, improvement of methods of early diagnostics and development of effective measures of pathogenetic treatment.
One of significant complications of GERB is formation of a gullet of Barrett – regeneration mucous a gullet, being a precancer state (repeatedly increases probability of development of cancer of gullet). For early identification of changes mucous as Barrett's disease the endoscopic research (gastroscopy) with carrying out a biopsy mucous a gullet is recommended to all patients having chronic heartburn.
Major factor of development of a gastroezofagealny reflux disease is insufficiency of the lower sphincter of a gullet. At healthy people this muscular circular education in a usual state keeps in a close state an opening between a gullet and a stomach and obstructs the return traffic of a food lump (reflux). In case of insufficiency of a sphincter the opening is opened and at reduction of a stomach there is the return throwing of its contents in a gullet. Hostile gastric environment causes irritation of walls of a gullet and pathological violations in mucous up to its deep ulceration. At healthy people the reflux can arise at a trunk inclination, physical exercises, at night.
Subjectively the reflux is felt as developing of heartburn – burning behind a breast – and an eructation. If heartburn is shown regularly (more than 2 times a week), it suggests an idea of GERB and demands medical examination. The chronic reflux taking place throughout a long time conducts to a chronic ezofagit, and later to change of a morphological structure mucous the lower department of a gullet and to formation of a gullet of Barrett.
Reasons of development of GERB
The factors promoting development of GERB are: violations of motor functions of the top departments of a digestive tract, giperatsidotichesky states, the lowered protective function of a mucous membrane of a gullet.
Most often at GERB violation of two mechanisms of protection of a gullet against hostile environment of a stomach provided by the nature is noted: ezofagealny clearance (ability of a gullet to evacuate contents in a stomach) and resistance of a mucous wall of a gullet.
Stresses, smoking, obesity, frequent pregnancies, diafragmalny hernia, medicines increase probability of development of a gastroezofagealny reflux disease (beta , blockers of calcic channels, antikholinergetik, nitrates).
The typical clinical picture of a gastroezofagealny reflux disease is characterized by heartburn which amplifies at an inclination, to physical activity, after plentiful food and lying, an eructation with sour or bitter smack. Can be followed by nausea and vomiting. Depending on weight of a current note a dysphagy – disorder of swallowing which can be as primary (as a result of motility violation), and a consequence of development (narrowings) of a gullet.
Quite often GERB meets atypical clinical manifestations: breast pain (as a rule, after food, amplifying at an inclination), weight in a stomach after meal, a gipersalivation (the raised salivation) in a dream, an unpleasant smell from a mouth, hoarseness.
The indirect signs indicating a possible gastroezofagealny reflux disease are frequent pneumonia and bronchospasms, idiopathic pulmonary fibrosis, tendency to laryngitis, average otitises, damages of enamel of teeth, throat cancer. Special danger in the development plan for heavy complications is constituted by GERB proceeding without the expressed symptomatology.
The most frequent (in 30-45% of cases) a complication of GERB is development a reflux-ezofagita – inflammations of a mucous membrane of the lower departments of the gullet resulting from regular irritation of walls gastric contents. In case of ulcer and erosive damages mucous and their subsequent healing the remained hems can lead to striktura – narrowings of a gleam of a gullet. Decrease in passability of a gullet is shown by the developing dysphagy, combined with heartburn and an eructation.
The long inflammation of a wall of a gullet can lead to formation of an ulcer – the defect damaging a wall up to submucous layers. The gullet ulcer often promotes developing of bleeding. It is long the existing gastrezofagealny reflux and chronic ezofagit lead to replacement of an epithelium gullet, normal for the lower departments, on gastric or intestinal. Such regeneration is called Barret's disease. This precancer state which at 2-5% of patients develops in a gullet adenocarcinoma – a malignant epitelialny tumor.
Diagnostics of GERB
The main diagnostic method for identification of GERB and definition of severity and morphological changes in a wall of a gullet is the ezofagogastroduodenoskopiya. It is carried out after consultation of the endoscopist. During this research also take bioptatichesky sample for studying of a histologic picture of a state mucous and diagnosings of a gullet of Barrett.
At a X-ray analysis of a gullet it is possible to reveal a gullet ulcer, existence , diafragmalny hernia. In half of cases it is possible to note a reflux. Pressure of the lower sphincter of a gullet is determined by a manometriya.
Positive test of Bernstein (at introduction to a gullet of 0,1% of solution of hydrochloric acid there is a burning sensation), and also bystry stukhaniye of clinical symptoms at reception antatsidny means (the alkaline test) is characteristic of a gastroezofagealny reflux disease. Motor function of a gullet is investigated by means of an electromyography.
Often patients note cough, hoarseness of a voice. Consultation of the otolaryngologist is necessary for identification of an inflammation of a throat and a throat. For specification that the reason of laryngitis and pharyngitis is the reflux, appoint reception of antatsid. After that signs of an inflammation abate.
Treatment of GERB
Nemedikamedikamentozny therapeutic measures at a gastroezofagealny disease:
- normalization of body weight, observance of a diet (small portions each 3-4 hours, meal not later than 3 hours to a dream), refusal of the products promoting relaxation of an esophageal sphincter (fat looking for, chocolate, spices, coffee, oranges, tomato juice, onions, mint, alkogolsoderzhashchy drinks), increase in amount of animal protein in a diet, refusal of hot food and alcohol;
- it is necessary to avoid the hard clothes pressing a trunk;
- the dream is recommended for beds with the headboard raised on 15 centimeters;
- refusal of smoking;
- it is necessary to avoid long work in an inclined state, heavy physical activities;
- the medicines which are negatively influencing motility of a gullet (nitrates, antikholinergetik, beta , progesterone, antidepressants, blockers of calcic channels), and also the nonsteroid resolvents toxic operating on a mucous membrane of a gullet are contraindicated.
Drug treatment of a gastroezofagealny reflux disease is carried out by the gastroenterologist. Therapy takes from 5 to 8 weeks (sometimes the course of treatment reaches duration up to 26 weeks), is carried out with use of the following groups of medicines: antatsida (aluminum phosphate, aluminum hydroxide, magnesium carbonate, magnesium oxide), H2-histamine blockers (ranitidine, ), inhibitors of a proton pomp (, , ).
In cases if conservative therapy of GERB does not give effect (about 5-10% of cases), or at development of complications or diafragmalny hernia carry out expeditious treatment. Surgical interventions at a gastroezofagealny reflux disease: an endoscopic plikation of gastroezofagialny connection (seams on a sebesten), a radio-frequency ablyation of a gullet (damage of a muscular layer of a sebesten and gastroezofagealny connection, for the purpose of scarring and reduction of a reflux are imposed), a gastrokardiopeksiya and a laparoscopic fundoplikation across Nissen.
Prevention and forecast of GERB
Prevention of development of GERB is maintaining the healthy lifestyle excluding the risk factors promoting developing of a disease (refusal of smoking, abuse of alcohol, greasy and spicy food, an overeating, heavy lifting, long stay in an inclined state, etc.). Also prevention is promoted by timely measures for identification of violations of motility of the top departments of a digestive tract and treatment of hernia of a diaphragm.
At timely identification and observance of recommendations about a way of life (non-drug measures of treatment of GERB) forecast favorable. In case of long often recidivous current with regular refluxes, development of complications, formations of a gullet of Barrett the forecast considerably worsens.