Treatment of gastroesophageal reflux disease. Gastroesophageal reflux disease in the practice of the doctor of the primary level restriction of medicines

Frequent manifestation of heartburn may indicate the presence of GERD. Gastroesophageal reflux disease is a kind of a malfunction of a chronic recurring digestive system, in which the regular cast of the stomach and / or bile in the region of the esophagus is performed.

Such violations often cause complications in the form of chemical and enzymatic burns, erosions, peptic ulcers, esophagus Barrett, cancer.

Symptoms of the disease are symptoms that share in two categories: esophageal and outstanding. By the first species include such manifestations as heartburn, accompanied by a feeling of burning, belching, bitter or acidic taste in the mouth. Less often meets nausea and gravity in the stomach, pain after swallowing food (identifiagia). The second category includes such painful manifestations as recurring bronchitis and pneumonia (bronchopulmonary), inflammation of the larynx and chronic chickens (otolaryngological), caries (dental), heart pain (cardiac), varieties of vegetative disorders (neurological), changes in blood (anemic).

ADDITIONAL INFORMATION! Gastroesophageal reflux or abbreviated GER is not always pathology. In many cases, heartburn arises from healthy people.

If the symptom is rarely manifested and quickly passes, then you can not worry, as it is considered a physical norm.

Factors affecting the emergence of heartburn and uncomfortable sensations

There are many reasons because of which the digestive system gives malfunctions. These include:

• chronic stress, depression states;
• the presence of bad habits (smoking, consumption of a large amount of alcohol, overeating);
• excess body body, including a period of pregnancy (especially in the last periods);
• incorrect meals, where food preference is given to fat, sharp and smoked products;
• excessive use of certain products: coffee, strong tea, black bread, fresh pastries, tomatoes and dishes with turning on tomato, chocolate, mint, carbonated drinks;
• increase in the level of acidity of the stomach;
• passage of the course of treatment on certain medicines that give a similar side effect;
• rest, consisting in lying immediately after meals;
• postoperative consequences;
• constant work at which slopes are often performed;
• uncomfortable tightening clothing (belt, corsets).

Doctors have been trying to give the exact definition of this disease for many years. This is a challenging task, as healthy people are also manifested, without bringing discomfort and not reflecting by side at the work of the body.

GERB classification

There is no generally accepted classification, so doctors of different countries use more convenient for them.

GRB classification according to severity (ICD-10)

The simplest is considered the ICD-10 (international classification of the tenth revision disease), where GERB is divided into two categories:

• without esophagitis (During the examination, inflammatory processes are found in the mucous membrane of the esophagus, it is found in 70% of cases);
• with esophagitis (The mucous membrane with inflammation, which is clearly visible during endoscopy, is found in 30% of cases).

Endoscopic GERB classification (Savary-Miller classification)

In 1978, Savari and Miller proposed this type of classification, which includes 4 stages depending on the emergence of emerging complications.

• 1st stage. It is actually without complications. Sometimes single erosion and areas with redness are observed. But when examining changes in the mucosa of the esophagus, they are most often not observed, and the doctor puts the diagnosis and prescribes a treatment regimen, focusing on the manifested symptoms.
• 2nd stage. This stage indicates the chronic leakage of heartburn. Erosions or exudative lesions appear, which occupy from 10 to 50% of the esophagus. They do not occupy the entire circumference of this area, but they can merge among themselves.
• 3rd stage. The painful process is characterized by erosive or exudative lesions that occupy the entire circumference of the esophagus. In addition to standard manifestations of heartburn, pains for the sternum may occur. Frequently, night attacks are.
• 4th stage. In this stage, severe complications are developing. Chronic bleeding ulcer affects deep layers of fabrics. Plots of the mucous membrane of the esophagus are replaced by intestinal epithelium (Baretti esophagus).

By availability of complications - Los Angeles classification

This classification originated in 1994. It is based on an accurate description of visible damage and distribute them on the mucous membrane of the esophagus, which helps in the work of practitioners to quickly make a diagnosis and assign treatment. There are four degrees of Harbo degrees in the Los Angeles classification:

1. Degree With a comprehensive examination, one or a number of erosions are detected, an ulcers of a long to 5 mm, affecting the mucous membrane of the esophagus. Each of these defects amazes no more than two folds of the mucous membrane.
2. Degree of B. At this stage, one or a number of lesions of the mucous membrane of the esophagus are observed in the form of erosions or ulcerative manifestations, the length of which is more than 5 mm. Each defect is spread to 2 folds of the mucous membrane.
3. C. It is observed at this stage the lesion of the mucous membrane of the esophagus in the form of one or a number of erosions or ulcers, the length of which exceeds 5 mm. Each defect is located on two and more folds of the mucous membrane. Damage occupy less than 75% of the circumference of the esophagus.
4. Degree of D. At this stage there is a number of serious lesions of the mucous membrane of the esophagus in the form of erosions or ulcerative manifestations. The circumference of the esophagus is damaged at least 75%.

Savary Viku Classification

This classification gives a general idea of \u200b\u200bthe stages of the disease development, but also used in medical practice.

• Stage 0. The inner layers of the esophagus are not damaged. The disease is characterized only by symptomatic manifestations.
• Stage 1. Endoscopic research determines strong redness due to the expansion of capillaries (eritium) and edema of esophageal tissues.
• Stage 2. It is characterized by the formation of small and shallow defects in the form of erosion and ulcers.
• Stage 3. Endoscopic examination determines the deep lesions of the tissues in the form of erosive changes in the round shape. The relief of the mucous membrane may change due to the defect and become similar to brain sinking.
• Stage 4. It is characterized by strong lesions of the surface in the form of ulcers and erosions that carry serious complications.

Complications GERB

IMPORTANT! Ignoring symptoms and lack of timely treatment of GERD makes a chronic disease that can lead to serious consequences.

These include:

• peptic oar of the esophagus;
• esophageal stricture;
• barrett's esophagus;
• esophageal carcinoma.

Serious complications of the disease according to statistics are noted at 30 - 40% of cases.

Esword ulcer (peptic).With regular exposure to the gastric juice on the mucous membrane, burns are formed. Erosions become initial surface defects. If the negative impact on the mucous membrane of the esophagus continues, there are changes in tissues at a deeper level. Most often the bottom third of the body is suffering.

Esword stricture.If the treatment is absent, or GERB proceeds quite aggressively, such a complication may develop as a narrowing of the esophagus. This is due to the substitution of the muscle tissue of the connective and the formation of scars. With this abnormal structure, the enumeration of the organ decreases in diameter to a large extent. The physiological norm of such a lumen is 2-3 cm (3-4 cm may reach tensile).

Barrett's esophagus or Barrett Metaplasia.This is the name of the precancerous state associated with the substitution of the flat layer of the surface of the esophagus mucosa (epithelium), which is the norm for a healthy person, on a cylindrical, more characteristic intestinal.

MetaPlasia is a process at which the surface layer of the body mucosa is completely replaced by another. It is the preceding state of dysplasia for which the structural changes of the cells are characteristic.

This disease has no specific symptoms. The manifestations are all the same as with gastroesophageal reflux disease.

Behind the esophageal of Barrett requires careful observation, as it is a precancerous state. It is characterized by a tendency for the development of a malignant and fast-moving tumor. Such a disease is peculiar for men over the age of 45. It is rare - 1% of the population.

Esophageal carcinoma.For this disease, malignant esophageal neoplasms are characteristic. According to general statistics, among the oncological diseases of the esophagus cancer takes 6th place.

In the early stages of the development of symptoms, the gastroesophageal reflux disease is identical, therefore the disease is usually diagnosed on the 2nd - 3rd stages of the esophagus cancer. During this period, such a manifestation as dysphagia is most often found. It expresses at the initial stage to scratch behind the sternum. And often the feeling is found as if food sticks to the esophageal walls. Patency of the esophagus periodically gives malfunction in the human body, so there is a feeling of awkwardness in the process of swallowing food.

There are four degrees of dysfagia:

• 1st degree. At this stage, a person has solid food (meat, bread) is difficult to go in the esophagus area.
• 2nd degree. The esophagus is poorly coping with the transportation of easier food in the form of porridge and mashed potatoes.
• 3rd degree. The fluid is well passed on the esophagus.
• 4th degree. The esophagus is not able to perform its function, complete obstruction is observed.

Another symptom that manifests itself in the later stages of the disease is pain. They are permanent or periodic. character. Also, they can be divided into independent or resulting from the food intake process.

Gastroesophageal reflux disease (reflux-esophagitis)

Currently, under the term "gastroesophageal reflux disease" (GERD), it is necessary to mean the development of characteristic symptoms and (or) inflammatory damage to the distal part of the esophagus due to a recurring cast in the esophagus of gastric and (or) duodenal content. There are such concepts as "endoscopically positive gastroesophageal reflux disease" and "endoscopically negative gastroesophageal reflux disease". In the first case, there is reflux-esophagitis, and in the second endoscopic manifestations of esophagitis are absent. With endoscopically negative gastroesophageal reflux disease, the diagnosis is established on the basis of a typical clinical picture, taking into account the data obtained under other methods of research (X-ray, pH metric and manometrical).

One of the complications of GERD is the "Barreti esophagus" - the appearance of a subtle-turn metaplazized epithelium in the mucous membrane of the distal esophagus - potentially precancerous state.

The prevalence of GERD among the adult population is up to 40%.

In Western Europe and the United States, wide epidemiological studies suggest that 40% of persons constantly (with different frequencies) have heartburn - the main symptom of GERD. Among those who are conducted endoscopic study of the upper digestive tract departments, in 12-16% of cases, esophagitis of varying degrees of severity are revealed. Barrett's esophagus develops in 15-20% of patients with esophagitis.

Causes of Reflux Ezophagitis

Gastroesophageal reflux disease is considered within the framework of traditional representations as an integral part of the group of acid-dependent diseases, since the hydrochloric acid of the stomach acts as the main pathogenetic factor in the development of symptoms and morphological manifestations of GERD. Each episode of the reflux serves as a manifestation of the lack of lower esophageal sphincter.

The factors predisposing to GERD include the weakening of the stomach motility up to the gastroprota, a decrease in saliva production (Shegon's disease), a violation of the cholinergic innervation of the esophagus. A certain role in the development of GERD is given by Helicobacter Pylori microorganisms, the presence of which in the mucous membrane of the cardiac ventilating department adversely affects the flow of reflux-esophagitis.

A frequent cause of GERB is a diaphragmal hernia, peptic ulcerative disease of the stomach and duodenum, gastric functional dyspepsia (peptic-like and non-union dyspepsia). Drinks containing caffeine, citrus, alcohol, milk, tomatoes, products made of them, horseradish, onions, garlic, pepper and other spices to increase acidoproducts and stomach, irritating its mucous membrane, and reduce the tone of the lower esophageal sphincter.

The main risk factors are the GERD: stress, posture (long trigger of the torso), obesity, pregnancy, smoking, diaphragmal hernia, medication: calcium antagonists, beta-blockers, anticholinergic agents.

Pathogenesis of gastroesophageal reflux disease (reflux-esophagitis)

Gastroesophageal reflux disease develops as a result:

1) Reducing the function of the antirefluxic barrier, which can occur in various ways:

Primary pressure reduction in the lower esophageal sphincter (NPS)

Increasing the number of episodes of spontaneous relaxation of the NPC. The mechanisms of the occurrence of spontaneous (or transient) relaxation of the NPC are not entirely understood. It is clear the role of these relaxation in physiological conditions - the liberation of the stomach from the sword air. It is possible that it depends on the violation of the cholinergic effect or to enhance the inhibitory effect of nitrogen oxide;

Full or partial destructurization, for example, in the hernia of the esophageal hole of the diaphragm;

2) Reducing the clearance of the esophagus:

Chemical - due to a decrease in the neutralizing action of saliva and bicarbonates of esophageal mucus

Volumetric - due to the oppression of secondary peristaltics and reduce the tone of the wall of the inflation of the esophagus.

The listed disorders of the decline in esophageal clearance create conditions for long-term contact of hydrochloric acid and pepsin, and sometimes bile acids with the mucous membrane of the esophagus.

3) damaging properties of reflucutate (hydrochloric acid, pepsin, bile acids);

4) the inability of the mucous membrane of the esophagus is to resist the damaging action.

The acuity of the disease will depend on the damaging properties of the reflucutate and the characteristics of the mucous membrane of the esophagus, which are inability to resist this damaging action. The pre-indental level of protection of the mucous membrane may violate due to a decrease in the content of hydrocarbonate in saliva.

5) disorders of the gastric emptying;

6) increasing intra-abdominal pressure.

Other reasons for the deficiency of the lower esophagus sphincter include sclerodermia, pregnancy, smoking, the use of drugs that reduce the tone of smooth muscles (nitrates, calcium channels, beta adrenergich, eutillin), surgical intervention, etc.

Thus, from a pathophysiological point of view, GERD is an acid-dependent disease, which develops against the background of the primary violation of the motor function of the upper digestive tract.

Symptoms of gastroesophageal reflux disease (reflux-esophagitis)

Characteristic symptoms of gastroesophageal reflux disease - heartburn, belching, tightening, painful and difficult to pass food - are painful for patients, significantly worsen their quality of life, reduce effective performance. The quality of life of Harbo patients with night symptoms is especially significantly reduced.

Heartburn - a peculiar feeling behind the sternum in the course of the esophagus, propagating on the neck, is the most characteristic symptom, occurs in 83% of patients and appears due to the long contact of the acidic (pH of less than 4) gastric content from the esophagus mucosa. Its characteristic of this symptom is its strengthening in the errors in the diet, the reception of alcohol, carbonated beverages, physical voltage, slopes and horizontal position.

Openings as one of the leading HARB symptoms occurs quite often and is detected in 52% of patients. Patients may make complaints about eaten food, acid, possibly with bitterness and unpleasant smell of congestion content. These phenomena are usually enhanced after eating, receiving carbonated drinks.

Flooring observed in some GERB patients is enhanced with physical tension and at a position that promotes regurgitation.

Along with heartburn, belching and tightening, patients complain of pain and difficulty in swallowing, arising from the passage of food on the esophagus (Odynophagia - painful swallowing, DYSPhagia - difficulty swallowing). A characteristic feature of these symptoms is their intermittent character. The basis of dysfagia is the hypermotor dyskinesia of the esophagus, which disturbs its peristaltic function. The appearance of a more resistant dysfagia and a simultaneous decrease in heartburn may indicate the formation of the stricture of the esophagus.

It is often noted such phenomena as an increased salivation - a protective reaction during reflux, an unpleasant taste in the mouth - the feeling of acid (metal taste) or bitterness.

One of the most characteristic symptoms of GERD is pain in the epigastric area, appearing in the projection of the Movid-shaped process shortly after eating and amplifying under inclined movements.

Out of esophageal manifestations of GERD include pains for breasts, similar to angina and bronchopal complications.

Pain in the chest non-cultural origin in most cases are associated with the pathology of the esophagus. The studies have shown that among patients who complained about the underlined pain, in 70% of the surveyed coronary pathology are absent, and the styled pains are associated with esophagospasm or reflux-esophagitis.

Bronchopulmonary manifestations of GERD include chronic cough, bronchopulation, pneumonia, dysphony. Gastroesophageal reflux is detected in 30-90% of bronchial asthma patients, predisposing to the heaviest flow of bronchial asthma. Recognized reasons for the development of bronchorate for GERD are: 1) a reflex mechanism; 2) MicroSpiration. Bronchopulmonary manifestations can act as the only clinical sign of gastroesophageal reflux and determine the insufficient effectiveness of the treatment of bronchial asthma.

The objective inspection data is very scant: dry oral dryness (xerootomy) is detected, often hypertrophied mushroom-like nipples of the language as a result of gastric hypersception, less often left or right-matted symptom, pronounced during laryngitis and combined with voices.

In the case of non-modeine manifestations of GERD in the form of chronic bronchitis, recurrent pneumonia, bronchospasm, dry, dry, wheezing wheezing, wet medium and small-pushed wheezing, alveolar attitudes, elongation of exhalation are listened to the lungs. If there are retrosternal pain, there are no violations of the frequency and rhythm of cardiac activity when there is no cardiovascular pathology.

Complications of GERD are stricture of the esophagus, bleeding from the oral eyelasm. The most significant complication of the GERB is the Barreta Esophageal, which includes the appearance of a subtle-turn metaplazized epithelium in the mucous membrane of the esophagus. "Barrett's esophagus" is a prejudice state.

The rapidly progressive dysphagia and weight loss may indicate the development of adenocarcinoma, but these symptoms occur only in the later stages of the disease, so the clinical diagnosis of esophageal cancer is usually delayed.

Diagnosis of Reflux Ezophagitis

The main methods of instrumental diagnostics include: endoscopic examination, daily monitoring of the internal hydraulic pH, X-ray study, the study of the motor function of the esophagus.

Endoscopic study. In patients who present complaints of heartburn, signs of reflux-esophagitis of various degrees of severity are identified most often with endoscopic examination. Hyperemia and looseness of the mucous membrane (catarrhal esophagitis), erosion and ulcers (erosive esophagitis of varying severity - from 1 to 4 stages are detected - depending on the lesion area), the presence of exudate, fibrin or signs of bleeding. The 4 stages of esophagitis on Savary- Miller distinguish:

1) erythema of the distal esophagus and separate unblocked erosion;

2) merging, but not exciting the entire surface of the erosion mucosa;

3) ulcerative lesion of the lower third of the esophagus and the ring-shaped defeat;

4) Chronic ozaw of esophagus, stenosis, Barrett's esophagus - cylindrical metaplasia of the mucous membrane of the esophagus.

In addition, the prolapse of the gastric mucosa in the esophagus can be noted, especially with the vomit, the true shortening of the esophagus with the location of the esophageal and gastric transition is significantly higher than the diaphragm, the casting of gastric or duodenal content in the esophagus. It is quite difficult to estimate the circusionage function of the cardia in esophagoscopy, as it can be awarded reflexively in response to the introduction of the endoscope and insufflation of air.

In many cases, clinical symptoms and morphological changes at the cellular level are not accompanied by the presence of esophagitis (endoscopically negative GERD).

Manometry. The study of the motor function of the esophagus allows to study the indicators of the movement of the wall of the esophagus and the activities of its sphincter. Under GERD, a pressure gauge examine reveals a decrease in the pressure of the lower esophageal sphincter, the presence of hernias of the esophageal hole of the diaphragm, an increase in the number of transient sphincter relaxation, reducing the amplitude of the peristaltic cutting of the esophagus wall.

RN-metric esophagus study. The main method of diagnosing GERD is a pH metry. The study can be carried out as an outpatient basis, so in stationary conditions. For the diagnosis of GERD, the results of the renteuries are estimated at a total time, during which the pH takes the values \u200b\u200bof less than 4 units, the total number of reflux per day; the number of refluxs lasting more than 5 minutes; The duration of the longest reflux.

The 24-hour pH-metry has the highest sensitivity (88-95%) when the GERD is detected and the individual selection of drugs.

X-ray study. The radiographic study of the esophagus may indicate the presence of hernia of the esophageal hole of the diaphragm, the stricture of the esophagus, diffuse esophagospasm, reveal the reflux as such. This study is used to screen the GERD screening diagnostics.

In the diagnosis of GERD, methods such as bilimetry, scintigraphy, Test Bernstein can be used. Bilimetry allows you to verify alkaline (bile) reflux, scintigraphy reveals disorders of the motor-evacuator function of the esophagus. These techniques are used in highly specialized institutions. The Bernstein test consists of an infusion of 0.1 n ns1 solution in the esophagus, which leads to the appearance of typical symptoms. This test may be useful in the diagnosis of endoscopically negative gastroesophageal reflux disease.

The introduction of chromoendoscopy can allow to identify the metaplastic and dysplastic changes in the epithelial of the esophagus by applying substances to the mucous membrane, in different ways of painting healthy and affected fabrics.

Endoscopic ultrasound examination of the esophagus is the main technique that detects endophynetic growing tumors.

Differential diagnosis

Chest pains can occur with various diseases of the cardiovascular system, mediastinum, respiratory organs, digestion, edges, sterns, etc. The differential diagnosis of esophageal pain is based on the peculiarities and mechanisms of their occurrence, which makes it possible to distinguish them from pain of other origin, first turn with chest tob.

The main role in the origin of the pain playing motility of the esophagus. Dyskinesia of the esophagus, especially its diffuse spasm, hypertension of the lower esophageal sphincter, imperpulsive chaotic reductions of the lower third of the esophagus, the so-called "nutcracker esophagus" may be accompanied by the appearance of pronounced pains of spastic nature. A similar mechanism determines the occurrence of pain syndrome during cardia AChalasia: an obstacle in the form of an unbroken cardiac sphincter along the path of food lumps causes an increased reduction in the esophagus, accompanied by the appearance of pain.

The second factor in the mechanism of pain - GastroeuFagal reflux (GER), in which the peptic aggression of gastric juice is important, and sometimes duodenal content, if, along with GER, there is a duodenogastral reflux. The resulting reflux-esophagitis may be accompanied by a progressary pain.

In addition, with GER, it takes stretching of the esophagus walls, which also causes pain. The main thing - the GER is often the cause of hypersmotor dyskinesia and the associated pain of a spastic nature. Such a mechanism of pain is observed in 60% of patients with gastroesophagagalyuy reflux disease (GERD).

Ezophagitis of any etiology - peptic, candidal, herpety, stagnant (with a violation of the transzezophagealyugo passage of patients with ahalasia cardia, strictures, esophageal tumors) - can also cause the occurrence of prudged pain. Depending on the mechanism of occurrence, the nature of the pain happens different.

Spastic pains with dyskinesia of the esophagus are breditful. They can be burning, gods, tearing, localized behind the sternum, sometimes irradiate in the neck, jaw, back, hands, especially in the left, are accompanied by vegetative manifestations (sensation of heat, sweating, trembling in the body). These pains appear without a clear connection with food intake, they can occur after eating, and at night at rest, and when excitement, they are stopped by a nitroglycerin, a sip of water, prokinetics and analgesics.

With GERB, other pains are observed - impregnable, amplifying in a horizontal position and when tilting the body forward, which are stopped by a variable of the position of the body and receiving antacids.

Esophageal pains can be constant, stupid or burning. Such stricted pains are observed in esophagitis of any etiology (peptic, herpes, candidal), oats of the esophagus, prolonged stomach in the esophagus in the violation of the transzezophageal passage in patients with Haria ahalasia, with a tumor or esophageal stricture, diverticulitis. Sometimes, with esophagitis and ulcers of the esophagus, pain occurs only during swallowing (identifiagia), it depends on the nature of writing, it is enhanced by taking acidic, acute, very hot or very cold food.

A peculiar overtime pain, combined with a feeling of cutting in epigastria and lack of air, is observed in aerophagia. This pain passes after belching.

In the clinical practice of pain caused by the pathology of the esophagus, it is necessary to differentiate with pain of the other origin - with myocardial infarction, separating aortic aneurysm, pulmonary artery thromboembolism, spontaneous pneumothorax.

The absence of signs of the threat of life of the patient during retrosternal pain does not exclude the need to clarify its source. Especially great difficulties occur with the differential diagnosis of esophageal pain with chest toas.

Pseudo-vehicle (angiopodobic) pain for diseases of the esophagus are observed in 20-60% of patients, which often leads to an erroneous diagnosis. Coronary photography conducted with stubborn pains in 30% of cases does not reveal changes in coronary arteries. On the other hand, the elderly patients are often combined by GERD and ischemic heart disease (IBS). In this case, pains can wear a coronary and pseudoconmy.

In the pathology of the esophagus, pain depend not only on the volume of food eaten, but also from its character (acute, very cold or hot). They can continue longer than the attack of angina, to relocate the body position alternation, a sip of water, antacids. Under angina, due to viscero visceral reflexes, belching and nausea can be observed, as in esophageal pains, but during angina, the oppressed mental state (the fear of the impending death), shortness of breath, weakness, which is not typical for diseases of the esophagus is noted.

If clinical features fail to clarify the nature of the pain, the patient must first eliminate IBS. To do this, find out the presence of IBS risk factors (age, gender, heredity, arterial hypertension, hyperlipidemia, etc.), signs of the destruction of the cardiovascular system (left ventricular hypertrophy, change of heart tones, noise). Using instrumental methods of diagnosis of IBS: ECG daily monitoring, cyergometry, echocardiography (at rest and under load), radionuclide studies (myocardial perfusion scintigraphy), and with non-informatives of these methods - coronary artwork.

The elimination of pronounced coronary pathology allows you to more carefully examine the esophagus.

An affordable and reliable method of differential diagnosis that has emerged recently is the RabnAzole test - the disappearance of the corresponding symptoms (pain in the chest or bronchophageless manifestations) during the day after the start of receiving 20 mg of Rabeprazole. This method is based on the unique ability of Rabeprazole, in contrast to other proton pump inhibitors to stop GERD symptoms within 24 hours.

Classification. According to the Los Angeles of the classification approved by the World Gastroenterologists in 1994, Ezophagitis include only such changes in the esophagus, in which there is damage to the integrity of the mucous membrane in the form of erosion or ulcers. Edema, the gain of the vascular pattern does not give grounds for the diagnosis of esophagitis. In accordance with this, according to endoscopic studies, a new classification is proposed, which includes another form of the disease - non-erosive reflux disease:

1. Neurosive reflux disease (endoscopically negative GERD).

2. Erosive reflux disease (endoscopically positive GERD):

Isolated erosion with a diameter of less than 5 mm;

Isolated erosion with a diameter of more than 5 mm;

Drain erosions between two folds of the mucous membrane;

Erosion throughout the circumference of the mucous membrane; 3. Complications - ulcers, stricture, Barrett's esophagus.

Treatment of gastroesophageal reflux disease (reflux-esophagitis)

Treatment should be aimed at reducing reflux, reducing the damaging properties of reflucutate, improvement of esophageal clearance, and protection of the mucous membrane of the esophagus.

Currently, the basic principles of the treatment of GERD are the following. In the treatment of GERD, high doses of drugs or their combinations are required. If the patient is not appointed supporting treatment, then the probability of recurrence of erosive esophagitis during the year is 90%. From this it follows the mandatory need for supporting treatment. The deadlines for the effective treatment of erosive esophagitis are 8-12 weeks. That is, the basic course of treatment should be at least one month, and then for 6-12 months the patient must receive supportive treatment.

The change in lifestyle is the basis of effective antirefluxic treatment in most patients. First of all, it is necessary to exclude smoking and normalize body weight, avoid the use of acidic fruit juices, products that enhance gas formation, as well as fats, chocolate, coffee, garlic, onion, pepper, eliminate alcohol, very sharp, hot or cold food and carbonated Drinks.

Patients should avoid overeating and should not eat before bedtime.

The rise of the head end of the bed with the help of the support significantly reduces the intensity of reflux. Patients should be warned about the undesirability of drugs that reduce the tone of the lower esophageal sphincter (theophylline, progesterone, antidepressants, nitrates, calcium antagonists, enzyme preparations containing bile), and may also be the cause of inflammation (nonsteroidal anti-inflammatory funds, doxycycline, quinidine) .

It is necessary to avoid the load on the muscles of the abdominal press, the work of the clone, wearing the tight belts, belts, etc.

Medical treatment includes well-known groups of drugs.

1. Antacids and alginates are effective in treating medium and infrequent symptoms, especially those that arose in violation of the recommendations on the style of life. Nearby antacids of three generations are used: the 1st generation - phospholyugel, 2nd generation - aluminum-magnesium antacids (Maalox, Melante, Megalak, Almagel), 3rd generation - aluminum-magnesium antacids in combination with algina acid (Topapkan-Topal ). Alginates, creating a thick foam on the surface of the contents of the stomach, with each episode of the reflux return to the esophagus, providing therapeutic effects. First, due to the content of the antacids, they have an acid-neutralizing effect, and secondly, falling into the esophagus, they. Color the protective film, which creates a pH gradient between the mucous membrane and the lumen of the esophagus and protecting the mucous membrane from the aggressive influence of the gastric juice.

Antacids should often be taken in 1-2 tablets or 1-2 dosage packages per day, usually 1.5-2 hours after meals, after 30-40 minutes and for the night, depending on the severity of symptoms. The most effective in the treatment of GERD are aluminum-magnesium unusable antacids of the 2nd generation.

2. Prokinetics lead to the restoration of the normal physiological state of the esophagus, effectively increase the tone of the lower esophageal sphincter, enhance the peristaltics of the esophagus and improve the esophageal clearance. Prokinetic preparations of Motilium and Coordinacians (cisaprid, previlside) are the means of pathogenetic treatment of GERD, normalizing the motor function of the upper digestive tract. The motilium also leads to the restoration of the normal physiological state of the stomach, restoring its active peristalsis and improving the anthroduodenal coordination.

In the treatment of endoscopically negative GERD, in the presence of catarrhal esophagitis, the motilium is prescribed at a dose of 10 mg 4 times a day, the coordinix - 10 mg 2 times a day. They are used in complex therapy of erosive esophagitis in conjunction with proton pump inhibitors.

Thus, prokinetics, being a means of pathogenetic treatment of gastroesophageal reflux, should be used in the treatment of medium-grooved symptoms against the background of endoscopically negative GERD and catarrhal esophagitis as monotherapy and as part of complex therapy with inhibitors of proton pump.

3. In the presence of erosive esophagitis, it is necessary to appoint proton pump inhibitors. Proton pump inhibitors control the level of the pH in the lower third of the esophagus is very effective. Due to the decrease in the contact time of the acid from the mucosa of the esophagus, the symptoms of the disease decrease by intensity and quickly (for the first 2 days) disappear. This powerful depression of acidic products is the main factor and for healing erosive-ulcerative lesions of the mucosa of the esophagus in patients with GERD. The purpose of the proton pump inhibitors should be a means of choice for the treatment of severe esophagitis, and the course of treatment should be at least 8 weeks.

Omeprazole, Pariet (Rabeprazole) applies at a dose of 20 mg once a day for eight consecutive weeks.

Absolute indication for carrying out supporting therapy within 6-12 months is the reflux-esophagitis of the 3rd and 4th degree via Savarymiller, the development of peptic ulcers, the stricture of the esophagus and the "Barrett's esophagus".

4. Surgical treatment. With the ineffectiveness of the conservative treatment of the GERD in recent years, laparoscopic fillpoplasty on the Nissen, which gives lower postoperative mortality, faster rehabilitation compared to traditional open (transstoracal) fondoplasty and in 90% of cases good remote results.

Consultation on the treatment of traditional Eastern Medicine (point massage, manual therapy, acupuncture, phytotherapy, Taoist psychotherapy and other non-medical treatment methods) are held in the Central District of St. Petersburg (7-10 minutes walk from Vladimirskaya / Dostoevskaya metro station), with 9.00 to 21.00, without lunch and weekends.

It has long been known that the best effect in the treatment of diseases is achieved with the combined use of "Western" and "Eastern" approaches. The treatment time is significantly reduced, the likelihood of recurrence of the disease is reduced.. Since the "Eastern" approach besides the technician aimed at the treatment of a major disease, much attention pays "cleaning" of blood, lymphs, vessels, ways of digestion, thoughts, etc. - often it is even a necessary condition.

Consultation is carried out for free and does not oblige you to anything. On it all data from your laboratory and instrumental research methods is extremely desirable. Over the past 3-5 years. Spending only 30-40 minutes of your time you will learn about alternative methods of treatment, find out how can I increase the effectiveness of already designated therapyAnd, most importantly, how you can independently deal with the disease. You may be surprised - how everything will be logically built, and understanding of the essence and reasons - the first step towards a successful problem solving!

RCRZ (Republican Center for Health Development MD RK)
Version: Clinical Protocols MH RK - 2017

Gastroesophageal reflux (K21), gastroesophageal reflux without esophagitis (K21.9), gastroesophageal reflux with esophagitis (K21.0)

Gastroenterology

general information

Short description

Approved
Joint Commission for Medical Services
Ministry of Health of the Republic of Kazakhstan
from "29" June 2017
Protocol No. 24.

Gastroesophageal reflux disease- This is a chronic recurrent disease due to a violation of the motor-evacuator function of the gastroesophageal zone organs and characterized by spontaneous or regularly repeated throwing into the esophagus of gastric or duodenal content, leading to the development of inflammatory changes in the distal esophagus and / or characteristic clinical symptoms.

Input part

Code (s) μb-10:

Date of development / revision of the Protocol:2013/ revision2017.

Abbreviations used in the protocol:

Classification

GERB classification:

clinical forms:
· Neurosive reflux disease (NERB) (60-65% of cases);
· Erosive (reflux-esophagitis) (30-35% of cases);
· Barrett's esophagus (5%).

to evaluate severity:
clinical criteria:
· Easy - heartburn less than 2 times a week;
· Medium - heartburn 2 times a week or more, but not daily;
· Heavy - heartburn daily.

endoscopic criteria:
Currently used modified Savary-Millera classification or Los Angeles Classification of Ezophagitis, 1994. (Table 1).

Table 1. Modified Savary Miller Essophagitis Classification

Diagnostics

Methods, approaches and diagnostic and treatment procedures

Diagnostic criteria:collect complaints according to Table 3.

Table 3.Clinical manifestations of GERB

Differential diagnosis

Treatment abroad

Treat treatment in Korea, Israel, Germany, USA

Get advice on medical examination

Treatment

Preparations (active substances) used in the treatment

Treatment (ambulatory)

Tactics of treatment on an outpatient level:
Tactics of treatment provides for non-drug methods and pharmacotherapy.

Non-drug treatment:
Non-drug treatment is to fulfill the recommendation to change lifestyle and diet (antirefluxual measures), the implementation of which should be emphasized in GERD therapy (Table 5).

Treatment (hospital)

Tactics of treatment at the stationary level

Non-drug treatment:watch table 5 outpatient level.

Objectives, Tactics Treatment, Other Treatment Methods, Criteria for Treatment Efficiency:watch outpatient level.

Surgical intervention:
Surgical treatment of GERD is an equivalent effective alternative to drug treatment and should be offered to patients with indications (degree A).

Indications:
With a refined diagnosis of GERD, the testimony of Khururgical (operational) treatment are:
· Ineffective drug treatment (inadequate monitoring of symptoms, heavily regurgitation, uncontrolled acid suppression and side effects from the reception of medicines);
· The choice of patients, despite the successful drug treatment (for considerations of the quality of life, which is influenced by the need to take medicines throughout life, high cost of medicines, etc.) (degree A);
· Availability of GERD complications (for example, Barrett esophagus, peptic strictures, etc.);
· The presence of extrapish-water manifestations (bronchial asthma, huskiness, cough, chest pain, aspiration).

Preoperative examination:
The purpose of the preoperative examination is the choice of suitable patients with reflux for surgical treatment.

Approaches regarding the volume of preoperative research:
· EGDS with biopsy - confirms the diagnosis of GERD, as well as identifies other causes of violations of esophagogogastral mucosa and allows you to take a biopsy;
· PH-metry;
· Ecoming machine meter - more often is carried out before surgery and allows you to determine states that may be contraindications to the Fundoplication (such as the esophagus ahalasia), or change the type of fondoplikation, according to an individual approach based on the motility of the esophagus;
· Study with barium suspension -for patients with a large hernia of the esophageal hole of the diaphragm, which have a shortening of the esophagus.

Patients undergoing laparoscopic antirefluux surgery should be informed before surgery on the possible frequency of symptoms and return to drugs reduced acidity (degree A).

Detection of the esophagus Barrette with adenocarcinoma involving the submucosal layer or deeper into the process, eliminates the patient from the planned to the antirefluux surgery and requires complete oncotherapy (esopheatectomy, chemical therapy, and / or radiation therapy) corresponding to the process stages.

Preventive actions:
· Antirefluxual measures;
· Antisecretory therapy;
· Mandatory supporting therapy;
· Dynamic observation of patients for monitoring (endoscopic with biopsy according to indications) of complications (detection of the esophagus of Barrett).

Further maintenance:
Dynamic observation of patients for monitoring complications, identifying the esophagus of Barrett and drug control symptoms. Epithelia intestinal metaplasia is a morphological substrate of Barrett's esophagus. His risk factors: heartburn 2 times a week, the duration of symptoms is more than 5 years.
With the prescribed diagnosis of the esophagus of the Barrett to identify dysplasia and adenocarcinoma of the esophagus, control endoscopic and histological studies should be carried out after 3, 6 months and further annually against the background of supporting therapy of the IPA. During the progression of dysplasia, the issue of operational treatment (endoscopic or surgical) in a specialized establishment of the republican level decide to highly solve.

Indicators of the effectiveness of the treatment and safety of diagnostic and treatment methods:
· Saving clinical symptoms;
· Healing erosion;
· Prevention or elimination of complications;
· Improving the quality of life.

Hospitalization

Indications for hospitalization (UBD)

Indications for emergency hospitalization:
· Bleeding with esophagus ulcers;
· Esword stricture.

Indications for planned hospitalization:
· Ineffectiveness of drug treatment (inadequate control of symptoms, severe regurgitation, not controlled acidity suppression and / or side effects of medication treatment);
· Complications of GERD (Barrett's esophagus, peptic strictures);
· If there are extrapish-mode manifestations (asthma, huskiness, cough, chest pain, aspiration).

Information

Sources and literature

1. Meeting Protocols of the Joint Commission on the Quality of Medical Services MD RK, 2017
   1. 1) Gastroenterology. National leadership / edited by V.T. Ivashkin, T.L. Lapina - M.Geotar Media, 2012, - 480 p. 2) diagnosis and treatment of acid-dependent diseases. Ed. R.R.Bektayeva, R. T. Agzamova, Astana, 2005 - 80 s. 3) S. P. L. Trevis. Gastroenterology: per. from English / Ed. S.P.L.Thevisa and others. - M.: Honey Lit., 2002 - 640 p. 4) Manual of Gastroenterology: Diagnosis and Therapy. Fourth Edition. / Cananavunduk-4th Ed., 2008 - 515 p. 5) Practical Manual of Gastroesophgeal Reflux Disease /ed.by Marcelo F. Vela, Joel E. Richter and Jonh E. Pandolfino, 2013 -RC 815.7.M368 6) Prevention and treatment of chronic diseases of the upper sections of the gastrointestinal tract / edited in .T.Ivashkin.-3rd ed., Pererab. and additional-Medpress-Inform, 2014.-176 p. 7) Dyspepsia and gastrooesophageal reflux disease: investigation and management of dyspepsia, symptoms suggestive of gastrooesophageal reflux disease, or both Clinical guideline (update) Methods, evidence and recommendations September 2014 https://www.nice.org.uk/guidance / CG184 / Chapter / 1-Recommendations 2.Evidence-Based Gastroenterology and Hepatology, Third Edition John WD McDonald, Andrew K Burroughs, Brian G Feagan and M BRIAN FENNERTY © 2010 Blackwell Publishing Ltd. ISBN: 978-1-405-18193-8 8) 8. Diagnostics of the extra-mode manifestations of gastroesophagealrefluxus disease / N.A. Kovaleva [et al.] // Ros.Med. journal - 2004. - № 3. - P. 15-19. 9) Diagnostics and treatment of gastroesophagealrefluxus disease: a manual for doctors / V.T.Ivashkin [and others]. - M., 2005. - 30 s. 10) The Montreal Definition and Classification of Gastroesophageal Reflux Disease: A Global Evidence-Based Consensus / N. Vakil // AM. J. Gastroenterol. - 2006. - Vol. 101. - P. 1900-2120. 11) Peterson W.L. Improving the management of gerd. Evidence-Based Therapeutic Strategies / W.L. Peterson; American Gastroenterological Association. - 2002. - Access Mode: http://www.gastro.org/user-assets/documents/gerdmonograph.pdf. 12) Gastroesophagealrefluxus disease: study. - Method. benefit / I.V. Maev [and others]; Ed. I.V. MaEme. - M.: Wuns of the Ministry of Health of the Russian Federation, 2000. - 52 p. 13) L and Aruine B and Isakov. Gastroesophagealrefluxus disease and Helicobacterpylori. Wedge Medicine 2000 № 10 from 62 - 68. 14) In T Ivashkin, and from Torukhamanov of the disease of the esophagus Pathological physiology Clinic Diagnosis treatment. M: "Triad - X" 2000 178 from 15) Kononov A in gastroesophagealrefluxus disease: the look of the morphologist on the problem. Zhurn Gastroenterology of hepatology and coloproktology 2004.- T 14 No. 1 with 71 - 77. 16) Maev and B, e with Vuschnov EG Lebedev Gastroesophagealrefluxus disease: educational and methodical manual. M: WoonSMRF 2000 52 with 17) C.A. Fallone, A.N. Barkun, G. Friedman. Is Helicobacter Pylori Eradication Associated With Gastroesophal Reflux Disease? Am. J. Gastroenterol. 2000. Vol. 95. P. 914 - 920. 18) Bordin D.S. A new approach to an increase in the efficiency of proton pump inhibitors in a patient with gastroesophageal-flowerkind disease. Therapist. 2015.- №2. P. 17-22. 19) 19. Lisebeck L.B., Bordin D.S., Masharova A.A. and others. Factors affecting the effectiveness of the treatment of GERB inhibitors of proton pump // Ter. Archive.- 2012.- 2: 16-21. 20) www.drugs.com Databases for medicines, supported by FDA (USA) 21) Instructions for the use of drugs database of the National Center Examination of Medicines and IMN RK (www.dari.kz) 22) Gastroesophageal Reflux Disease Treatment & Management (www.http: //emedicine.medscape.com/articlement/176595-treatment? SRC \u003d REFGATESRC1 # D11) 23) Gastroesophageal Reflux Disease / University of Michigan Health System (UMHS) And The National Guideline Clearinghouse (NGC) / Agency Healthcare Recearch and QLITY (AHRQ) / USA 24) O'MAHONY D., O'Sullivan D., Byrne S. et. Al. Stopp / Start Criteria for Pottentially InappropriTe Prescription 2 // Age and Ageing. 2014. DOI: 10.1093 / Ageing / AFU145. 25) Körner T1, Schütze K, Van Leendert RJ, Fumagalli I, Costa Neves B, Bohuschke M, Gatz G. / Comparable Efficacy of Pantoprazole and Omeprazole in Patients with Moderate to Severe Reflux esophagitis. Results of a Multinational Study / Digestion. 2003; 67 (1-2): 6-13.

Information

Organizational aspects of the Protocol

List of protocol developers with qualifying data:
1) Bektayev Rosa Rakhimovna-Doctor of Medical Sciences, Professor, Head of the Department of Gastroenterology and Infectious Diseases of Astana Medical University. Chairman of the National Association of Gastroenterologists of the Republic of Kazakhstan.
2) Iskakov Baurzhan Samkovich - Doctor of Medical Sciences, Professor, Head of the Department of Internal Diseases No. 2 with courses of related disciplines of the Kazakh National Medical University named after S.Asfendiyarov, Chief Freelance Gastroenterologist of Health Management G. Almaty, Deputy Chairman of the National Association of Gastroenterologists of the Republic of Kazakhstan.
3) Makolkin Larisa Gennadievna - Candidate of Medical Sciences, Associate Professor of the Department of Clinical Pharmacology of Internship JSC "Medical University of Astana", Astana.

Indication for the absence of conflict of interest:no.

Reviewers:
1) Shipulin Vadim Petrovich - Doctor of Medical Sciences, Professor, Head of the Department of Internal Medicine No. 1 of the National Medical University named after I.A. Bogomolts. Ukraine. Kiev.
2) Bekmurzayev Elmira Kuanyshevna - Doctor of Medical Sciences, Professor, Head of the Department of Bacheloring Therapy of the Southern-Kazakhstan Pharmaceutical Academy. The Republic of Kazakhstan. Shymkent.

Protocol revision conditions:revision of the Protocol 5 years after its publication from the date of its entry into force or in the presence of new methods for diagnosing and treatment with the level of evidence.

Appendix 1

Algorithm for diagnosis and treatment at the stage of ambulance:

Diagnosis and treatment at the stage of ambulance:
· Collection of complaints, anamnesis of disease and life;
· Physical examination.

Diagnostic criteria (UD - D):
Complaints and history:

Complaints:
· Heartburn (stubborn, painful) both after eating and on an empty stomach;
· Pain in the chest (burning nature) amplifying during exercise and slopes;
· Feeling of the discomfort of the zubrotina region;
· weight loss;
· Reducing appetite;
· Cough and attacks of suffocation at night;
· Voice of voice to the morning;
· Vomiting blood.

Anamnesis:
· Permanent intake of acid-incorporating drugs and antacids;
· Perhaps the presence of Barreta's patient esophagus.

Attached files

Attention!

• By self-medication, you can apply irreparable harm to your health.
• The information posted on the MedElement website and in MEDElement mobile applications, "Lekar Pro", "Dariger Pro", "Diseases: Therapist's Directory", cannot and should not replace a full-time doctor consultation. Be sure to contact medical facilities in the presence of any diseases or disturbing symptoms.
• The choice of medicines and their dosages should be stated with a specialist. Only a doctor can prescribe the necessary medicine and its dosage, taking into account the disease and the state of the patient's body.
• Website MedElement and Mobile Applications "MedElement (Medleylement)", "Lekar Pro", "Dariger Pro", "Diseases: Directory of Therapist" are exclusively information and reference resources. The information posted on this site should not be used for unauthorized changes to the doctor's prescriptions.
• The editorial office of MedElement is not responsible for any damage to health or material damage resulting from the use of this site.

Gastroesophageal reflux diseaseb (GERB) - Development of inflammatory changes in the distal esophagus and / or characteristic symptoms due to regularly recurring casts in the esophagus of gastric and / or duodenal content.

MKB-10.
K21.0 Gastroesophageal Reflux with Ezophagitis
K21.9 Gastroesophageal reflux without esophagitis.

An example of the formulation of diagnosis

EPIDEMIOLOGY
The true prevalence of the disease is not known, which is associated with the large variability of clinical symptoms. The symptoms of GERD with a thorough survey are found in 20-50% of the adult population, and endoscopic signs are more than 7-10% of the population. In the US, heartburn - the main symptom of GERDs - 10-20% adults are experiencing weekly. There is no holistic epidemiological picture in Russia.
The true prevalence of GERB is significantly higher than statistical data, including because only less than 1/3 of the GERD patients appeal to the doctor.
Women and men sick equally often.

CLASSIFICATION
Currently, two forms of GERD are distinguished.
■ Endoscopically negative reflux disease, or non-erosive reflux disease, - 60-65% of cases.
■ Reflux-esophagitis - 30-35% of patients.
■ GERB complications: peptic stricture, esophageal bleeding, berette esophagus, esophageal adenocarcinoma.
For reflux-esophagitis, it is recommended to use the classification adopted by the World Congress of Gastroenterologists (Los Angeles, 1994) (Table 4-2).
Table 4-2. Los Angeles Classification of Reflux Ezophagitis

DIAGNOSTICS
The diagnosis of GERD should be assumed if the patient has characteristic symptoms: heartburn, belching, regurgitation; In some cases, single-scale symptoms are observed.
History and physical examination
The GERD is characterized by the absence of the dependence of the severity of clinical symptoms (heartburn, pain, regurgitation) from the severity of changes in the mucous membrane of the esophagus. Symptoms of the disease do not allow differentiate non-erosive reflux disease from reflux-esophagitis.
The intensity of clinical manifestations of GERD depends on the concentration of hydrochloric acid of the system, the frequency and duration of its contact with the mucous membrane of the esophagus, the hypersensitivity of the esophagus.

Esophageal Symptoms GERB
■ Under the heartburn understand the feeling of a difference in various intensity arising behind the sternum (in the lower third of the esophagus) and / or in the epigastric area. Heartburn is found at least in 75% of patients, due to the prolonged contact of the acidic content of the stomach (pH less than 4) with the mucous membrane of the esophagus. The severity of the heartburn does not correlate with the severity of esophagitis. It is characterized by its strengthening after eating, reception of carbonated drinks, alcohol, with physical tension, slopes and horizontal position.
■ Open with sour, as a rule, enhanced after eating, receiving carbonated beverages. Flooring observed in some patients is intensified during exercise and position that promotes regurgitation.
■ Dysphagia and identifiable (swallowing pain) are observed less often. The appearance of the rescue dysfagia indicates the development of the stricture of the esophagus. Rightly progressive dysphagia and body weight loss may indicate the development of adenocarcinoma.
■ Pains for the sternum can be irradiating into the inter-opaque area, neck, lower jaw, left half of the chest; Often imitate angina. For esophageal pain, there is a connection with the use of food, the position of the body and the relief of their use of alkali mineral water and antacids.

Unfinished Harbo Symptoms:
■ Bronchople - cough, seizures of suffocation;
■ Otolaryngological - Voice's probing, dry throat, sinusitis;
■ Dental - caries, erosion enamel teeth.

Instrumental research
Mandatory examination methods
Single Research
■ FEGDS: allows to differentiate non-erosive reflux disease and reflux-esophagitis, identify the presence of complications.
■ biopsy of the mucous membrane of the esophagus with a complicated HARB flow: ulcers, strictures, Bererett esophagus.
■ X-ray examination of the esophagus and stomach: with suspicion of hernia of the esophageal hole of the diaphragm, stricture, adenocarcine esophagus.
Studies held in dynamics
■ FEGDS: Repeated can not be carried out with non-erosive reflux disease.
■ biopsy of the mucous membrane of the esophagus with a complicated GERB flow: ulcers, strictures, Bererette esophagus.
Additional examination methods
Single Research
■ 24-hour Intrapistine PH-Metron: an increase in the total reflux time (pH less than 4.0 more than 5% over the day) and the duration of the reflux episode (more than 5 minutes). The method allows you to evaluate the pH in the esophagus and the stomach, the effectiveness of the LAN; The value of the method is especially high in the presence of off-line and the absence of the effect on therapy.
■ Intrapistine Pressure: Conducted to evaluate the functioning of the lower esophageal sphincter, the motor function of the esophagus.
■ Abdominal ultrasound ultrasound: with GERDs unchanged, are carried out to identify the concomitant pathology of the abdominal organs.
■ ECG, BELOERGOMETRY: Used for differential diagnostics with IBSA, during GERD do not detect changes.
■ Test with proton pump inhibitorB: relief clinical symptoms (heartburn) against the background of the reception of proton pump inhibitors.

Differential diagnosis
With a typical clinical picture of the disease, differential diagnosis usually does not represent difficulties. In the presence of off-line symptoms, it is necessary to differentiate with IBS, bronchopyopatology (bronchial asthma, etc.). For the differential diagnosis of GERD with esophagitis of other etiologists, histological research of biopsy is carried out.

Indications for consultation of other specialists
The patient should be sent to a consultation to specialists in the uncertainty of the diagnosis, positive or non-standard symptoms or suspicion of the emergence of complications. You may need consultation of a cardiologist, a pulmonologist, an otorhinolaryngologist (for example, a cardiologist - in the presence of prochalar, not bubble on the background of the reception of the proton pump inhibitors).

TREATMENT
Objectories of therapy
■ relief clinical symptoms.
■ Healing erosion.
■ Improving the quality of life.
■ Prevention or elimination of complications.
■ Prevention of recurrence.

Indications for hospitalization
■ Conducting antireflury treatment with a complicated course of the disease, as well as in the ineffectiveness of adequate drug therapy.
■ Conducting operational intervention (Fundopling) in the ineffectiveness of drug therapy and endoscopic or surgical interventions in the presence of complications of esophagitis: strictures, esophagus of berette, bleeding.

Non-media treatment
■ Recommendations for lifestyle change and diet, the execution of which has a limited effect in GERD therapy.
✧ Ensure of abundant feeding.
Consumption of products that reduce the pressure of the lower esophageal sphincter and providing an irritating effect on the mucous membrane of the esophagus: products rich in fats (whole milk, cream, cakes, cakes), fatty fish and meat (goose, ducks, and pork, lamb, fatty Beef), alcohol, beverages containing caffeine (coffee, cola, strong tea, chocolate), citrus, tomatoes, onions, garlic, fried dishes, abandon carbonated drinks.
✧Sile feeding to avoid tilts forward and horizontal position; The last meal - no later than 3 hours before sleep.
Kept with a raised head end of the bed.
✧ Enclusive loads that increase intra-abdominal pressure: do not wear close clothes and tight belts, corsets, do not lift gravity more than 8-10 kg on both hands, avoid physical exertion associated with the overvoltage of the abdominal press.
To refer to smoking.
✧ Constate in the normal body weight.
■ Do not take drugs that contribute to the occurrence of refluxB (sedative and tranquilizers, inhibitors of calcium channels, β-adrenoblastors, theophylline, prostaglandins, nitrates).

Drug therapy
TERMS OF TREATMENT OF GERB: 4-6 NA with non-erosive reflux disease and at least 8-12 weeks with reflux-esophagite, followed by supporting therapy for 26-52 weeks.
Medical therapy includes the appointment of prokinetics, antacids and antisecretory agents.
■ Prokineetics: 10 mg domperidone 4 times a day.
■ The goal of antisecretory GERD therapy is to reduce the damaging effect of acidic gastric content on the mucous membrane of the esophagus during gastroesophageal reflux. Preparations of choice - proton pump inhibitors (omeprazole, Lansoprazole, Pantoprazole, Rabeprazole, Ezomeprazole).
✧Harb with esophagitis (8-12 weeks):
-Meprazole 20 mg 2 times a day, or
-Lansoprazole 30 mg 2 times a day, or
-Ezomeprazole 40 mg / day or
-Helaprazole 20 mg / day.
Criterion for the effectiveness of treatment - the relief of symptoms and healing erosions. With the ineffectiveness of the standard dose of proton pump inhibitors should double dose.
✧Neerosive reflux disease (4-6 weeks):
-Meprazole 20 mg / day, or
-Lansoprazole 30 mg / day or
-Ezomeprazole 20 mg / day or
-Helaprazole 10-20 mg / day.
Criterion for the effectiveness of treatment - resistant elimination of symptoms.
■ Taking histamine H2 receptor blockers as antisecretory preparations possible, but their effect is lower than that of proton pump inhibitors.
■ Antacids can be used as a symptomatic tool for relieving non-Speed \u200b\u200bheartburn, however, in this case, preference should be given to the reception of the proton pump inhibitors "on demand". Antacids are usually prescribed 3 times a day after 40-60 minutes after meals, when the heartburn and pain behind the sternum occurs, as well as on the night.
■ With reflux-esophagitis, due to the cast in the duodenal content of the duodenal content (primarily, beating acids), which is usually observed with a gall-eyed disease, a good effect is achieved by the use of ursodeoxycholic acid in a dose of 250-350 mg / day. In this case, ursodeoxychic acid is advisable to combine with prokinetics in a regular dose.
Supporting therapy, as a rule, is carried out using proton pump inhibitors in accordance with one of the following modes.
■ Permanent reception of proton pump inhibitors in a standard or half dose (omeprazole, Ezomeprazole - 10 or 20 mg / day, Rabeprazole - 10 mg / day).
■ Therapy "At the request" - adoption of proton pump inhibitors when symptoms appeared (on average 1 time in 3 days) with endoscopically negative reflux disease.

SURGERY
The purpose of operations aimed at eliminating the reflux (Fundoplikations, including endoscopic), is the restoration of the normal cardi function.
Indications for surgical treatment:
■ the inefficiency of adequate drug therapy;
■ complications of GERD (esophageal stricture, repeated bleeding);
■ Bererette's esophagus with high degree epithelium dysplasia due to the risk of malignancy.

Approximate time of temporary disability
Determined by the relief of clinical symptoms and the healing of erosions during the control FEGDS.

Further suffering of the patient
In the event of non-erosive reflux disease, with full stopping of clinical symptoms, the conduct of the control FEGDS is optional. Remissance of reflux-esophagitis should be confirmed endoscopically. When changing the clinical picture in some cases, FEGDS is carried out.
Conducting supporting therapy is necessary, since without it, the disease recurs in 90% of patients within 6 months (see the section "Dosage therapy").
Dynamic observation of patients are carried out to monitor complications, identifying the esophagus of berette and drug control symptoms of the disease.
Symptoms involving the development of complications should be monitored:
■ Dysphagia and identifiagia;
■ bleeding;
■ body weight loss;
■ early saturation senses;
■ Pain in the chest;
■ Frequent vomiting.
With all these signs, expert advice and further diagnostic examination are shown.
Epithelia intestinal metaplasia serves as a morphological substrate of the asymptomatic esophagus of Berrette. Berrette's esophageal risk factors:
■ heartburn more often 2 times a week;
■ Male floor;
■ Duration of symptoms for more than 5 years.
With a prescribed diagnosis of the esophagus of Berrette, endoscopic studies with biopsy should be carried out annually against the background of constant maintenance therapy with a complete dose of proton pump inhibitors. If the dysplasia is detected, the re-FEGDS with biopsy and histological examination of the bioptat is carried out after 6 months. When maintaining a low-degree dysplasia, it is recommended to perform a re-histological examination after 6 months. When preserving a low-degree dysplasia, repeated histological studies are carried out annually. In case of detection of high-degree dysplasia, the result of histological research is estimated independently two morphologists. If the diagnosis is confirmed, the issue of endoscopic or surgical treatment of Bererette esophagus is deciding.

Patient learning
The patient should be explained that the GERD is a chronic state, typically requiring long-term supporting therapy inhibitors of the proton pump to prevent complications.
The patient must comply with the recommendations on how to change lifestyle (see the section "Non-Media Treatment").
The patient should be informed about the possible GERD complications and recommend it to refer to the doctor in the event of the symptoms of complications (see the "Further Patient" section).
Patients with long-term uncontrolled symptoms of reflux should be explained by the need for endoscopic research to identify complications (such as Berrette's esophagus), and in the presence of complications - the need to periodically hold FEGDS with bioptate.

FORECAST
With non-erosive reflux disease and light degree of reflux-esophagitis, the forecast is mainly favorable. Patients still keep ability to work. The disease does not affect the life expectancy, but significantly reduces its quality during the period of exacerbation. Early diagnosis and timely treatment prevent the development of complications and maintain ability to work. The forecast deteriorates with a high presses of the disease in combination with frequent long-term recurrences, with complicated GERB forms, especially in the development of the esopherling, due to the increased risk of esophageal adenocarcinoma.

Gastroesophageal reflux disease (abbreviated - GERD) is a disease in which the return of the contents of the stomach in the esophagus often occurs, as a result of which inflammation of the esophageal walls occurs.

In some cases, reflux, i.e. Movement of food and gastric juice through the lower esophageal sphincter in the esophagus, episodically occurs in healthy people, for example, with a single overeating. If there are quite a lot of these rates and they are accompanied by unpleasant symptoms, then such a state is a disease.

Two main forms of gastroesophageal reflux disease distinguish:

• non-erosive (endoscopically negative) reflux disease (NERB) - occurs in 70% of cases;
• reflux Ezophagitis (RE) - the frequency of occurrence is about 30% of the total number of diagnoses of GERD.

The condition of the mucosa of the esophagus is estimated at stages according to the Savary-Miller classification or in the degrees of the Los Angeles classification.

Select the following degrees of GERD:

• zero - symptoms of reflux-esophagitis are not diagnosed;
• the first - no merging areas of erosion occur, the hyperemia of the mucous membrane is noted;
• the total area of \u200b\u200berosive sites takes less than 10% of the entire area of \u200b\u200bthe distal part of the esophagus;
• the second - the area of \u200b\u200berosion ranges from 10 to 50% of the total surface of the mucous;
• the third - there are multiple erosive-ulcerative damage, which are located over the entire surface of the esophagus;
• fourth - deep ulcers arise, Barrett's esophagus is diagnosed.

Los Angeles classification applies only for erosive varieties of the disease:

• degree A - in the presence of no more than a few defects of the mucosa with a length of up to 5 mm, each of which extends no more than two folds;
• degree in - the length of defects exceeds 5 mm, none of them applies to more than two folds of the mucous membrane;
• degree C - defects are common in more than two folds, their total area is less than 75% of the circumference of the esophageal hole;
• the degree of D is the defect area exceeds 75% of the circumference of the esophagus.

What is the gastrointestinal reflux?

Gastrointestinal (gastroesophageal) reflux is a throwing of gastric content in the esophagus. Under the term "reflux" means the direction of movement in the opposite, non-physiological side.

With reflux, food cashem with gastric juice can move from the stomach towards the esophagus. This process is quite a permissible phenomenon if only occasionally repeats, for example, after receiving abundant food, with sharp slopes of the body after lunch.

In the absence of pathologies, the periodic gastroesophageal reflux does not lead to the emergence of any adverse effects, since the surface of the mucous membrane of the esophagus is largely protected from damage to the acidic medium of gastric juice.

In a healthy person, the episodes of reflux should not occur more often than once per hour. After that, the cleansing (clearance) of the esophagus walls immediately occurs by re-moving the food casher in the stomach. In a large extent, this contributes to saliva, constantly flowing down the esophage. Bicarbonates contained in it are neutralized by the destructive effect of the gastric juice on the mucous membrane.

Causes of GERB formation

The development of gastroesophageal reflux disease contributes to the following factors:

• reduced tone of the lower esophageal sphincter;
• reducing the ability of the walls of the esophagus to self-cleaning;
• disorder of gastric juice acidity;
• obesity;
• pregnancy at which there is a squeezing of the stomach and other organs of the digestive system by an increasing uterus;
• frequent taking oily, acute food, alcohol, coffee;
• smoking;
• the presence of hernia of the esophageal hole of the diaphragm;
• overeating or too fast absorption of food, as a result of which the air is swallowing in a significant amount;
• abuse of products that are digested in the stomach for a long time;
• increased intra-abdominal pressure due to frequent slopes during operation, performing some exercise, carrying tight clothing, etc.

Methods of diagnosis

The Diagnostics of Gastroesophageal Reflux use the following methods:

• endoscopic examination of the esophagus, which allows you to identify inflammatory changes, erosion, ulcers and other pathologies;
• daily acidity monitoring (pH) at the bottom of the esophagus. Normally, the pH should be in the range from 4 to 7, the change in actual data may indicate the cause of the development of the disease;
• x-ray of the esophagus - allows you to detect the hernia of the esophageal hole of the diaphragm, ulcers, erosion, etc.;
• a manometric study of esophageal sphincters - is performed in order to assess their tone;
• esophageal scintigraphy with radioactive substances - is carried out to evaluate esophageal clearance;
• the biopsy of the esophagus is performed in suspected Barreta esophagus.

During the survey, the GERB should be differentiated from ulcerative, esophagitis and other diseases of the digestive system.

Symptoms

Gastroesophageal reflux disease in adult patients is accompanied by the following symptoms:

• heartburn is the main sign of this disease. As a rule, it occurs within 1 - 1.5 hours after meals, as well as at night. The feeling of discomfort can enhance after receiving carbonated drinks, coffee, after the enhanced physical exertion or overeating;
• pain in the stubborn area, which in some cases may be similar to painful sensations during angina;
• open with gastric content or air. Arises due to the receipt of the contents of the stomach in the esophagus, and then to the oral cavity;
• sour taste in the mouth - appears as a consequence of belching;
• dysphagia (the difficulty of the process of swallowing food) - appears as a result of long inflammation of the walls of the esophagus and irritation of the larynx;
• nausea;
• vomiting - in complicated cases;
• icota - appears due to irritation of the diaphragmal nerve and the subsequent reduction of the diaphragm;
• feeling of the merges in the throat;
• change of voice (dysphony): hoarseness, difficulty trying to talk loudly;
• dental disorders: periodontitis, gingivitis, etc.;
• respiratory manifestations: shortness of breath, cough, especially in the lying position.

In early age children, the physiological gastroesophageal reflux meets much more often than in adults, which is due to the peculiarities of the sphincter apparatus and a small volume of the stomach. In the first three months of life, it is often observed without a vomiting, which do not seek serious danger. With the subsequent establishment of the antirefluxic barrier, these manifestations gradually disappear.

Nevertheless, in some cases, gastroesophageal reflux disease in children is developing at the time when symptoms of jeeping or belching have long supposed to stay behind. At the same time, children can complain about pain when swallowing food, coma feeling in the chest.

One of the characteristic features of the GERD in children is the discovery on the pillow after sleeping the spot of a white shade, which indicates a frequent belching during a night rest.

The remaining symptoms of gastroesophageal reflux in children are usually the same as in adult patients.

Treatment

The treatment of gastroesophageal reflux includes three general groups of methods: lifestyle change, drug treatment, surgical intervention.

Changing lifestyle is to fulfill the following events:

• normalization of body weight;
• exception from the diet of coffee, strong tea, oily, acute and fried food, carbonated drinks, onions, garlic, citrus fruits;
• compliance with the power mode;
• refusal to carry close clothes and accessories (belts, belts), closely compressing the chest and the waist area;
• preventing frequent slopes of the body, refusal of severe physical work;
• night sleep in a slightly elevated position of the head of the bed (15 to 20 cm).

Medical therapy implies the use of the following tools:

• the purpose of the proton pump inhibitors (omeprazole, Rabeprazole) and other antisecretory agents;
• reception of prokinetics to enhance the peristalsis of the stomach and intestines (Cerukal, Motilium);
• the appointment of antacids (Maalox, Phosfaleugel, etc.);
• reception of vitamin preparations, including vitamin B5 and U U in order to restore the mucous membrane of the esophagus and the overall strengthening of the body.

Surgical treatment is performed in the presence of serious complications, such as the defeat of the esophagus of the third or fourth degree, the esophagus Barreta, etc.

Currently, the most common type of operational intervention in the treatment of GERD is the Fundopling, carried out using a laparoscopic method. During the operation, the surgeon forms from a part of the stomach, which is called the bottom, a special fold around the lower part of the esophagus, i.e. creates an artificial valve. The effectiveness of this procedure is rather high: about 80% of patients for the 10 subsequent years do not complain about the appearance of reflux, the rest are forced to take medicines due to the preservation of some symptoms of the disease.

Folk remedies

• the decoction of flax seeds: a teaspoon of raw materials poured with one glass of boiling water, withstand for 5 minutes on a rather slow heat, after which they insist half an hour, filter. Subsequently, they take three times a day on the third part of the glass in warm form;
• sea buckthorn oil or rosehip: take one teaspoon to three times a day;
• harvesting from herbs: Hypericum (4 parts), calendulas, plantain, licorice roots, AIR (2 parts), Pijmas flowers and peppermint flowers (1 part) poured boiling water, after half an hour, filter. Subsequently take three times a day no more than a third part of a glass in heated to a warm state.

Possible complications

One of the most serious complications of GERD is the development of the esophagus of a barret, distinguished by the pathological change of the epithelium. The specified state refers to the number of precancerous diseases, therefore requires effective treatment, in some cases surgical.

Another serious complication is the occurrence of bleeding due to the development of the ulcer of the esophagus.

As a result of long-term erosive-ulcerative damage, scars may later occur, which lead to the appearance of rocks - pathological narrowings of the enlightenment of the esophagus.

Diet

The GERB diet involves compliance with the following recommendations:

• prevention of overeating; meal by small portions after set intervals;
• refusal to eat in late evening and night time;
• exception from the diet or decrease in it the shares of the following products: fatty meat, coffee, tea, milk, cream, carbonated drinks, oranges, lemons, tomatoes, chocolate, garlic, onions;
• reducing the calorie content of the diet in order to normalize body weight.

HARB features in children and newborns

The newborn esophagus has a funnel shape, narrowing in the neck. The diaphragmal narrowing under the age of the year is weakly expressed, so children often observed flashing.

The formation of a developed musculature of the esophagus continues up to 10 years.

The frequency of the occurrence of pathological reflux in breast children is 8 - 10%. The prematched children, as well as babies suffering from allergies or lactose failure, are predisposed to the specified violation.

GERB in children can manifest pronounced symptoms: vomiting a fountain, sometimes with blood or bile, respiratory disorders, including cough.

In young children, crying can be characterized by probing, changing the tonality. More older children often have respiratory diseases such as otitis and bronchitis, which develop due to gastric content through the larynx in the cavity of the ENT organs.

It must be borne in mind that if the child of the first year of life was overcome by otitis, inflammation of the lungs, and at the same time there is a stubborn joining, this is a large degree of probability indicating the presence of reflux disease. If specified signs appear, it is necessary to urgently consult a doctor and go through the appointed examination.

Prevention

To prevent the appearance of reflux violations, it is advisable to comply with the following recommendations:

• normalize body weight;
• abandon alcohol and smoking abuse;
• do not overeat;
• comply with regularity in meals;
• not after 18 - 19 hours;
• reduce in the diet share of oily, acute food;
• do not abuse coffee and strong tea;
• observe the rational meal in order to normalize the digestion process;
• wear comfortable clothes and accessories that are not shy movements. Refuse to carry close jeans, belts, corsets, pulling linen and other close wardrobe items;
• do not rest right away after meals;
• refuse carbonated drinks.

Subject to the compliance with these requirements, the risk of GERD will be minimized.