Reflux esophagitis. Checked by: Balachkevish N. A Done by: Tlemissova G. N
The plan of work: Introduction Etiology The pathophysiology of the disease Clinical manifestations of the disease Classification of the disease Diagnostics Complications Treatment Conclusion List of the literature
Introduction: The disease is characterized by reflux of gastric contents into the esophagus has long been known. Mentions of some symptoms of this pathology, such as heartburn and acid regurgitation are still in the works of Avicenna. Gastroesophageal reflux (GER) was first described in 1879 N. Quinke. From that time was replaced by numerous terms which characterize this nosology. Reflux can also occur in the venous, urinary system, in different parts of the gastrointestinal tract (GIT), mechanism-and manifestations of the disease in each case is different. Sometimes there is the following formulation of diagnosis- gastro esophageal reflux (GER). It is important to note that the very GER may be a physiological phenomenon and occur in completely healthy people. In the last decade and the widespread occurrence of daily esophagogastroscopy p. Hmetry allowed to do the diagnosis of this disease over thoroughly and try to answer many questions. In 1996, the International Classification of the term (GERD) best reflects this pathology. Oesophageal reflux disease - a chronic recurrent disease caused by violation of the motor-evacuation function of the gastroesophageal zone and is characterized by spontaneous or regularly repeated throwing up into the esophagus or gastric duodenal contents, which leads to damage of the distal esophagus.
Specific etiological role: v v v v forced position of the body with the trunk Obesity smoking and alcohol abuse, taking certain medications, lowering the tone of smooth muscles (nitrates, calcium channel blockers, aminophylline, anticholinergics, etc. ) some diseases (such as systemic sclerosis) physiological state (pregnancy).
The pathophysiology of the disease Pathogenesis is due to insufficient assimilation of ascorbic acid and a violation of collagen synthesis. The results of intra-oesophageal p. H monitoring during the day in healthy volunteers have shown that episodes of gastroesophageal refluxis not more than 50 with a total duration more than 1 hour under normal conditions in the lower third of the esophagus p. H is 6, 0. During gastro-esophageal reflux, or the p. H drops to 4. 0 - If it enters the esophagus, stomach acid content, or increase, decreases to 7. 0 - if it enters the esophagus, duodenal content bile and pancreatic juice. Normally, to prevent mucosal lesions (SD) of the esophagus include the following protective mechanisms: A. Gastroesophageal antireflux barrier function connections and the lower esophageal sphincter. 2. Oesophageal clearance (clearance). 3. Resistance of the esophageal mucosa. 4. Timely removal of gastric contents. 5. Control of acid-forming function of the stomach.
The pathophysiology of the disease Abnormalities in the coordination of the first three mechanisms are NAI- greater importance in the development of reflux disease. The most common functions to a decrease in antireflux barrier cite the following reasons: A. Hiatal hernia (more than 94% of patients with reflux esophagitis have a hiatal hernia). 2. Increased spontaneous relaxations (relaxations). 3. Reducing the pressure in the lower esophageal sphincter. The action of the antireflux mechanism is provided by the following schimi factors: • the length of the abdominal part of esophagus; • angle of His (the confluence of the acute angle of the esophagus to the stomach in norm of its size range from 20 to 90 degrees depending on constitutional rights); • Leg diaphragm; • fold Gubareva formed rosette cardia mucosa
The pathophysiology of the disease The important place in fixation of the esophagus in the esophageal opening of the diaphragm is ligament Savvins Morozovs, (diaphragmatic- esophageal ligament). She resists the traction of cardiac up, allowing you to produce movement in the esophagus when swallowing cough, vomiting. Fixation of the esophagus, and also contributes to the peritoneum: the right of the abdominal esophagus is held by two peritoneal leaves, forming aliver-gastric ligament, behind - the gastro-pancreatic fold of the peritoneum, periesophageal fat fiber, gas bubble stomach and left lobe of the liver and contribute to fixation of the esophagus. Arising from age or other causes atrophy of muscle fibers in the esophageal opening, and, above all, Savva Morozov ligaments lead to expanding esophageal opening, the formation of "hernial ring, " an increase in the mobility of the esophagus and predispose to the development of hiatal hernia. The main role in the mechanism of closure of the cardia is given lower esophageal sphincter (LES). NPC - a smooth thickening located at the junction of the esophagus to the cardiac stomach of 3 -4 cm long, has a specific autonomic motor activities, their own innervation, blood supply. On myogenic properties of the smooth muscle LES influenced by various humoral factors, gastrin, motilin, histamine, bombesin, vasopressin, PG F 2 a, α- adrenoceptor agonists, β-blockers - increase the tone of NPC, and secretin, glucagon, cholecystokinin, neurotensin, zhuludochny brake polypeptide, progesterone, PG E 1, E 2, α-blockers, β-agonists, dopamine - lowers the tone of LES. At rest, muscle fibers of the esophagus in a state of tonic constriction, therefore, at rest in healthy human esophagus is closed with that the lower esophageal sphincter pressure is generated between 10 and 30 mm Hg. of Art. (Depending on the phase of respiration). The minimum pressure NPS is determined after the meal, the maximum at night. During swallowing movements, muscle tone of the lower esophageal sphincter reduced after the passage of food into the stomach lumen of the lower part of esophagus closed. GERD occurs when hypotension or atony of the NPC, the pressure in the lower esophageal sphincter is rarely reaches 10 mm Hg.
The pathophysiology of the disease The development of hypotension NPC contribute to the following factors: • consumption of foods containing caffeine (coffee, tea, Cocacola) and drugs, which include the cocaffeine (tsitramon, kofetamin, etc); • receipt of peppermint; • medications that reduce the tone of the LES(antagonists calcium, papaverine, nospa, nitrates, baralgin, anticholinergics, analgesi c, theophylline, doxycycline); • damage the vagus nerve (vagal neuropathy in the self Harn mellitus, vagotomy); • smoking (nicotine significantly reduced the tone of the LES); • use of alcohol (in this case not only decreases the tone of NPC, but is damaging effects of alcohol on the mucous membrane of the esophagus and the sphincter itself); • pregnancy (hypotension NPCs in this case due to the influence of hormonal factors - highestrogenemiey and progeste ronemiey, also has a role in the development of GERD and increased intraabdominal pressure during pregnancy).
The pathophysiology of the disease The esophagus is continually cleaned by swallowing saliva, receiving food and fluid secretion sub-mucosal glands of the esophagus and gravity. With GERD, there are long-term contact (exposure) aggressive factors of gastric mucosa from the shell What the esophagus, esophageal clearance, decreased activity, and elongation of his time (normally it averages 400, with GERD, 600 800, that is almost twice as extended). This is due to dismotorics of oesophageal (esophagus dyskinesia, systemic sclerotized dermis, and other diseases), and salivary gland dysfunction (number and composition of saliva in healthy individuals is regulated esophago-salivary reflections catfish, which is disrupted in the elderly and esophagitis). insufficient accurate saliva is possible with organic and functional diseases of the central nervous system, endocrine diseaseies (diabetes, toxic goiter, hypothyroidism), scleroderma, Sjogrens syndrome , diseases of the salivary glands during radiation therapy tumors in the head and neck in the treatment of cholinolytics. Resistance of the esophageal mucosa due protective system consisting of three main parts: • preepythelial protection (salivary gland, cancer of the esophagus submucosa), including mucin, proteins, bicarbonates, prostaglandin E 2, epidermal growth factor; • epithelial protection - normal regeneration of mucosal membrane of the esophagus, which can be divided into structural (cell membranes, intercellular connective complexes) and functional (transport epithelial Na / H, Na-dependent transport Cl-/HCO 3; intracellular and extracellular buffer systems; cell proliferation and differentiation); • postepithelial Protection (normal blood flow and normal tissue acid-base balance).
Clinical manifestations of the disease Symptoms arising from GERD can be divided into two groups : oesophageal and out of oesophageal symptoms. v For oesophageal symptoms include: • heartburn; • belching; • regurgitation; • dysphagia; • odynophagia (pain sensation during the passage of food through the esophagus, which usually occurs in patients with severe lesions of the mucous esophagus); • epigastric pain, and esophagus; • hiccups; • vomiting; • sensation of a coma in the sternum.
Clinical manifestations of the disease Out of oesophageal symptoms usually develop as a result of either direct extra-esofageal action or initiate ezofago-bronchial , esophago-cardiacreflexes. They include: • pulmonary syndrome; • otolaryngologic symptoms; • Dental syndrome; • anemia; • cardiac syndrome. v Pain often resemble angina, caused by spasm of the esophagus, cropped nitrates. In contrast angina they are not connected to the load, walking and emotions. v Dental symptoms manifested lesions of teeth, due to the destruction of tooth enamel aggressive gastric contents. v Anemia caused by chronic bleeding from erosions or ulcers of the esophagus, sometimes due to diapedetic bleeding in catarrhal esophagitis. v At high casting refluks at can numb the larynx, and develop "otolaryngology Mask" GERD manifests a rough, barking cough, sore throat and hoarseness in the morning (Posterior laryngitis). v Widely known for Mendelson's syndrome - recurrent pneumonia, arising as a result of aspiration of gastric contents, which may be complicated by atelectasis, lung abscess. 80% of patients with idiopathic pneumofibrosis have symptoms of GERD.
Classification of the disease Endoscopic classification of GERD by Savary and Miller (1978) 0 degree GERD without esophagitis (endoscopically negative). I degree Separate not confluent erosions and/or erythema of the distal esophagus. II degree Confluent, but not exciting the entire surface of the mucous erosive lesions. III degree Ulcerative lesions of the lower third of the esophagus, and the merging covering the entire surface of the mucosa. IV degree Chronic ulcers of the esophagus, stenosis, Barrett's esophagus(cylindrical metaplasia of esophageal mucosa).
Classification of the disease By the prevalence of lesions(1997 by the Los Angeles classification) A- the defeat of the mucous membrane within the folds mucosa, with the size of each lesion area does not exceed 5 mm. B - the size of at least one area of damage greater than 5 mm lesion within the same fold, but does not connect two folds. C - mucosal lesion connected vertices of two or more folds, but the process involved at least 75% circumference of the esophagus. D - the lesion covered at least 75% of the circumference of the esophagus.
Diagnostics The main methods of diagnosis of GERD are: ü X-ray examination of the esophagus ü Esophagoscopy ü scintigraphy with radioactive technetium ü gauge study of esophageal sphincter daily monitoring vnutripischevodnogo p. H. Great value intra-ezofagealprolonged p. H monitoring has for atypical forms of GERD (for verification non-cardial chest pain, chronic cough and pulmonary alleged aspiration of gastric contents) for the treatment of refractoriness, in preparing the patient to anti-reflux surgery.
Complications The most common complication of GERD: Ø Esophageal stricture - 7 -23%; Ø Ulceration of the esophagus - 5%; Ø Bleeding from erosions and ulcers of the esophagus - 2%; Ø Formation of Barrett's esophagus - 8 -20%. The most dangerous is the formation of Barrett's syndrome - complete replacement (metaplasia) of multilayer squamous epithelium of the esophagus cylindrical gastric epithelium. Overall, Barrett's esophagus is formed in 0. 4 -2% of the population. According to different authors, Barrett's syndrome occurs in 8 -20% of patients with reflux esophagitis, with 30 -40 times increased risk of developing esophageal cancer.
Treatment The aim of treatment is relieving GERD symptoms, quality of life, treatment ofesophagitis, prevention or elimination of complications. Basic principles of treatment: • decrease the volume of gastric contents; • improving antireflux function NPC; • Increased esophageal clearing; • protection of esophageal mucosa from damage. Conservative treatment Recommendation to the patient a certain lifestyle and diet Admission of antacids and alginic acid derivatives Antisecretory drugs (H 2 blockers, receptor antagonists and proton pump inhibitors) Prokinetics (tserukal, Motilium, Koordinaks) Surgical treatment Abdominal or laparoscopic fund oplication Nissen, Toupet, Door
Conclusion Epidemiological studies show that the frequency of reflux esophagitis in a population is 3 -4%. He detected in 6 -12% of persons who underwent endoscopy. According to foreign researchers while 44% of Americans would be a once a month suffer from heartburn, and 7% of it takes place every day. 13% of U. S. adults turn to antacids two or more once a week, and third - once a month. However, among respondents only 40% of symptoms were so severe that they have were to see a doctor. In France, GERD is one of the most common diseases of the digestive tract. The poll showed 10% of the adult population manifested symptoms of GERD at least one time during the year. All this makes the study of one of the GERD the priorities of modern gastroenterology. The prevalence of GERD is comparable to the prevalence of peptic ulcer, and cholelithiasis. It is believed that each of these diseases affects up to 10% of the population. Daily symptoms of GERD have to 10% of the population, weekly - 30% per month - 50% of adult- population. In the U. S. , the symptoms of GERD have been reported in 44 million.
List of the literature Establishment of the developer: Department of Internal Medicine Propaedeutics Medical Faculty of rate of Gastroenterology MGSMU. Professor I. Maev, H. H Vyuchnova, E. G Lebedev D. T Dicheva, O. Antonenko, I. M Shcherbenko. DTP and editing: Guguchkina Elena Mikheyev, Alexander G. .
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