Gastroesophageal Reflux Disease
Reflux disease is a chronic condition resulting from the return of contents from the stomach and duodenum to the esophagus, causing various esophageal signs or symptoms that may or may not be associated with tissue damage.
Reflux disease occurs when the muscle at the end of the esophagus, called the lower esophageal sphincter, does not function properly. This muscle should be closed most of the time, opening only for food to enter the stomach. But it may be somewhat incapable and may not close completely, which allows the stomach contents to return to the esophagus.
Other situations can contribute to reflux, such as increased gastric acid production, obesity, pregnancy, hiatus hernia, Zollinger-Ellison syndrome, hypercalcemia and systemic sclerosis.os.
The main clinical manifestations are:
Heartburn (heartburn): a burning sensation in the chest, behind the breastbone, which can reach the throat. This is the most common symptom of reflux and can get worse when a person eats, squats or lies down. It is sometimes confused with myocardial infarction or angina;
Feeling of gastric fullness: reported by patients as stomach bloating or poor digestion;
Burning pain in the “mouth of the stomach” (upper abdomen), which usually wakes the person up in the middle of the night;
Belching (belching);
Nausea;
Excessive salivation;
Acid regurgitation: reflux of liquid or food from the stomach to the mouth;
Dysphagia (difficulty swallowing): manifested by choking;
Sensation of nocturnal suffocation;
Hoarseness, especially in the morning;
Sore throat;
Clearing throat or needing to clear throat repeatedly;
Chronic cough, recurrent pneumonia, asthma, chronic sinusitis;
Tooth enamel wear, halitosis (bad breath).
The intensity and frequency of symptoms are not signs of esophagitis severity. But there is a correlation between the duration of symptoms and the increased risk for the development of Barrett's Esophagus and adenocarcinoma (cancer) of the esophagus. Some symptoms are considered “alarm manifestations” and should be investigated more quickly. They are: difficulty in swallowing, sore throat, anemia, digestive hemorrhage, weight loss, family history of cancer, nausea and vomiting, in addition to symptoms of great intensity and/or nocturnal occurrence.
Diagnosis
Diagnosis is based on a detailed clinical history. Patients who present with symptoms at least twice a week for 4 to 8 weeks should be considered possible GERD carriers.
As the clinical manifestations are varied, complementary tests such as upper digestive endoscopy, contrast-enhanced radiological examination of the esophagus, scintigraphy, manometry, 24-hour pH monitoring or therapeutic tests may be necessary to aid in the diagnosis.
Upper gastrointestinal endoscopy is particularly important in patients over 40 years of age, as well as in those with “alarm manifestations”. It allows you to directly see the mucosa. But it is important to know that a normal endoscopy does not exclude the diagnosis of GERD, as it may be present in 25-40% of patients with GERD. Look for a specialist in gastroenterology to assess your symptoms and the need for additional tests for diagnosis.
In Brazil, due to the low cost of the endoscopic exam, it is part of the initial workup for patients with a clinical history and symptoms of GERD, even under the age of 40 years.
Treatment
There are two types of treatment: behavioral measures (changes in habits) and pharmacological measures (use of medications). They must be implemented simultaneously at all stages of the disease. Patients aware of the importance of changing their lifestyle help a lot in the treatment.
The following are part of the behavioral measures:
Elevation of the head of the bed by 15 centimeters;
Moderate intake of fatty foods, citrus, coffee, alcoholic beverages, fizzy drinks, mint, mint, tomato products, condiments and whole milk;
Special care for the use of medications that can worsen reflux, such as anticholinergics, theophylline, tricyclic antidepressants, calcium channel blockers, ß-adrenergic agonists, and alendronate;
Avoid eating up to two hours before bedtime (bedtime);
Avoid copious meals. It is best to have fractionated meals, more times a day;
Quit smoking;
slimming;
Avoid wearing tight clothing, as they increase pressure on the abdomen, worsening reflux;
The presence of esophagitis at endoscopy indicates the use of proton pump inhibitor (PPI) drugs for a minimum period of 6 weeks, although 4 weeks can also be used. Those who do not respond satisfactorily to treatment with a PPI for 12 weeks should have the dose doubled for another 12 weeks before being considered as therapeutic failure.
Sometimes surgical treatment may be recommended, depending on the indications.
The most common complications are:
Esophagitis: inflammation of the esophagus;
Stenosis: reduction in the size of the esophagus, making it difficult to swallow solid foods;
Ulcer: appearance of an open sore in the esophagus;
Barrett's esophagus: replacement of the stratified and squamous epithelium of the esophagus by columnar epithelium with intestinalized or mixed cells, in any extension of the organ. It is an alteration in which the normal pink tissue of the esophagus is replaced by a “salmon” colored tissue that more closely resembles the lining of the stomach and primarily affects white males over 40 years of age;
Esophageal bleeding: it is usually slow and insidious and is often responsible for chronic anemia. Clinical treatment is the best treatment option;
Esophageal Cancer: Barrett's Esophagus can progress to esophageal cancer in 2 to 5 percent of people with this condition.
