Gastroesophageal reflux disease in the elderly

Introduction to elderly patients with gastroesophageal reflux disease Gastroesophageal reflux disease (GERD) refers to diseases caused by excessive stomach and duodenal contents flowing back into the esophagus. It often has heartburn, acid reflux and other symptoms, and can cause esophagitis and pharynx, larynx and airway. Damage to tissues other than the esophagus. basic knowledge The proportion of illness: 0.025% Susceptible people: the elderly Mode of infection: non-infectious Complications: upper gastrointestinal bleeding Barrett's esophagus peptic ulcer

Etiology of gastroesophageal reflux disease in the elderly

Lower esophageal sphincter (LES) function (30%):

The anti-reflux effect of the anatomical structure of the gastroesophageal junction weakens the anti-reflux structure of the gastroesophageal junction to form an anti-reflux barrier of the esophagus; it is a complex anatomical region, including the lower esophageal sphincter (LES), the diaphragmatic foot, and the iliac crest. The esophageal ligament, the acute angle between the esophagus and the fundus (His angle), etc., the most important depends on the functional state of the LES, the LES has the function of the sphincter, and the defects or functional reduction of the above anatomical structures can lead to gastroesophageal reflux.

(1) LES insufficiency: LES is a ring-shaped muscle bundle located 3 to 4 cm long at the end of the esophagus. It is a high-pressure zone at rest, which constitutes a pressure barrier and has a physiological effect of preventing the contents of the gastroduodenum from flowing back into the esophagus. Known as the LES barrier, the LES pressure (LESP) is 1.33 to 4.00 kPa (10 to 30 mmHg) in normal humans. The physiological function of LES is regulated by neuro-humoral fluid, and some factors may lead to a decrease in LESP; such as vagal dysfunction, non-biliary Inhibition of alkalirgic nerves, certain hormones (such as secretin, glucagon, cholecystokinin, etc.), drugs (such as calcium channel blockers, diazepam), certain foods (such as coffee, high fat) , chocolate), etc., studies have shown that LESP 0.8kPa (6mmHg) is prone to gastroesophageal reflux, under normal circumstances, LES relaxes with swallowing action, food can enter the stomach, and transient LES relaxation (transit lower Esophageal sphincter relaxation (TLESR) is different from LES relaxation caused by swallowing. It can be produced without swallowing action and esophageal peristalsis stimulation, and the relaxation time is longer, the LESP decline rate is faster, and the LESP low pressure value is lower, frequently occurring. LES Spontaneous relaxation severely weakens the anti-reflux barrier of the esophagus, leading to GERD, which is currently considered to be the main cause of gastroesophageal reflux. In addition, elevated intragastric pressure (such as gastric dilatation, delayed gastric emptying, etc.) and abdomen Passive relaxation of LES due to increased internal pressure (such as ascites, vomiting, and late pregnancy) can lead to a corresponding decrease in LESP and gastroesophageal reflux. About 1/2 of patients with GERD have delayed gastric emptying.

(2) Esophageal hiatus hernia: Many patients with moderate to severe reflux esophagitis have sliding hiatal hernia, but there are many esophageal hiatus hernias without reflux esophagitis. There is no clear cause relationship between the two. At present, the mechanism of esophageal hiatal hernia combined with reflux esophagitis is mainly due to the low LES tension and/or the frequent occurrence of LES spontaneous relaxation. Sliding hernia is the most common type of hiatal hernia, which makes the His angle dull. Aggravation of gastroesophageal reflux, patients with hiatal hernia are often accompanied by varying degrees of gastroesophageal reflux.

Gastric and duodenal dysfunction (30%):

Esophageal clearance is normal. Under normal conditions, the contents of the esophagus pass through gravity, and part of it is discharged into the stomach. Most of the esophagus is caused by the spontaneous peristalsis and reflux caused by swallowing action. The esophageal wall is stimulated by the esophageal wall. The top-down secondary peristalsis is discharged into the stomach to achieve volume clearance. It is the main way to clear the esophagus. The volume clearance reduces the capacity of the acid in the esophagus. The remaining acid is in the swallowed saliva. And, saliva is rich in carbonate, pH is 6-8, 1000-1500ml per hour is swallowed into the stomach, which can neutralize part of the acidic stomach contents that flow back into the esophagus, while in reflux esophagus, the esophageal body The peristalsis is weakened, which reduces the volume clearance of the reflux, reduces the salivation, and also affects the chemical scavenging effect on the reflux, causing the acidic reflux to stay in the esophagus and cause tissue damage.

Barrier function of esophageal mucosa (30%):

Esophageal mucosal barrier in gastroesophageal reflux disease, only 48% to 79% of patients with esophageal inflammation, and other patients with reflux symptoms, but no obvious esophageal mucosal damage, revealing that the mucosa has a reflux Defensive effect, this defensive effect is called esophageal mucosal tissue resistance, including mucus on the esophageal epithelial surface, non-moving water layer and surface HCO3-, stratified squamous epithelial structure and functional defense ability, and protective effect of mucosal blood supply. The esophageal mucosa stratified squamous epithelium is closely arranged, without permeation and absorption. The mucus attached to the mucosal surface acts as a barrier to pepsin. The surface of the mucosa also has HCO3- ions, which can neutralize H+ in a part of the reflux. The defense mechanism before the esophageal epithelium, part of H+ passes through the protective layer before the esophageal epithelium, and continues to destroy the protective mechanism of the epithelial layer, impairing the boundary between the H-penetrating cells of the epithelial cells, reaching the deeper epithelial cells, causing cell death. Therefore, the epithelium is eroded and ulcerated, thereby promoting the proliferation of the basal cells. The factors after the epithelium refer to the blood flow of the mucosa and the acid-base condition. Good mucosal blood circulation provides support for esophageal mucosa and renewal of esophageal mucosal cells. The degree of gastroesophageal reflux and esophageal mucosal damage are not parallel, and individual differences are large, which is obviously related to the above factors.

The reflux agitation factor enhances patients with gastroesophageal reflux disease. Only when the esophageal defense function is weakened and the attack factor is dominant, tissue lesions can occur. The degree of esophageal mucosal damage is related to the length of contact between the reflux and mucous membranes, especially The quality of the fluid is related to the amount; the attack factor of the reflux refers to gastric acid, pepsin, bile salts and pancreatic enzymes in the reflux, among which the most strong lesion of the esophageal mucosa is gastric acid, and the pH is <3, the mucosal epithelium Protein denaturation, while pepsin is active, digestive epithelial protein, pyloric sphincter function status can also affect gastroesophageal reflux, when the pyloric sphincter and LES tension is low or there is a history of major gastrectomy caused by too many duodenogaspin In the presence of fluid, bile acid, pancreatic juice and lysolecithin in the intestinal juice can simultaneously flow back into the esophagus, increase the permeability of the esophageal mucosa, aggravate gastric acid, damage the pepsin to the esophageal mucosa, and erode the epithelial cells of the esophageal keratinized surface. , thinning or shedding, and deep into the esophageal tissue through the layer of newborn squamous epithelial cells, nighttime volume clearance and chemical clearance significantly decreased Esophageal reflux film contacting prolonged, complicated esophagitis.

Pathology: In patients with GERD with reflux esophagitis, diffuse or regional edema of the esophageal mucosa was observed under endoscopy, flushing, sometimes granulated, brittle and prone to bleeding; the above performance was more pronounced when the lesion was aggravated, and erosion occurred. Or longitudinal superficial ulcers, or even the entire epithelial layer can fall off, but generally do not exceed the mucosal muscle layer, the lesions are mostly located at the lower end of the esophagus and the stomach junction, some patients can invade the middle esophagus, the late stage of reflux esophagitis due to mucosal erosion, Repeated ulceration and fibrosis can lead to scarring of the esophagus. The histopathological changes of esophagitis can include:

1 stratified squamous epithelial cells proliferate, squamous epithelial cells balloon-like changes.

2 The papillary protrusion is deepened, and the surface of the epithelial cavity is prolonged, generally reaching 1/2 or 2/3 of the entire mucosa.

3 The lamina propria is neutrophil infiltration.

4 erosion and ulcers, in addition, due to chronic stimulation of the reflux, the esophageal and gastric junction of the dentate line more than 2cm of esophageal mucosa squamous epithelium can be metamorphosed into columnar epithelial cells, called Barrett's esophagus, which can cause cancer At the endoscope, the typical esophageal mucosa area with pinkish grayish appearance shows the orange-red color of the gastric mucosa. The boundary is clear, the shape is ring-shaped, tongue-shaped or island-shaped, histologically special columnar epithelium, cardia type or The fundus type epithelium.

Elderly patients with gastroesophageal reflux disease prevention

GERD has the following characteristics:

1 The course of disease is long, the symptoms are insidious, and the atypical stage is long and easy to be ignored.

2 The incidence rate increases with age, and the prevalence rate of the elderly increases.

3 chronic recurrence tendency, long-term unhealed, its recurrent episodes can easily lead to esophageal ulcers, esophageal stricture, Barrett's esophagus and other serious complications, threatening human health, especially affecting the quality of life of the elderly, it is necessary to carry out and actively prevent and Take appropriate interventions.

1. Three-level prevention of gastroesophageal reflux disease

Primary prevention (cause prevention): Any cause of esophageal anti-reflux mechanism and affecting esophageal mucosal defense should be avoided as much as possible, including:

1 control diet, eat less meals, do not immediately supine after meals to reduce reflux; reduce the intake of coffee, chocolate, alcohol and fatty foods to avoid reducing LES pressure, quit smoking.

2 When the bed is raised, the bed is raised 15-20 cm, and the gastric emptying is accelerated.

3 reduce intra-abdominal pressure: such as weight loss, women do not wear tight underwear, treatment of constipation in the elderly.

4 elderly patients with related diseases taking nitroglycerin preparations or calcium channel blockers can increase reflux, should be avoided.

Secondary prevention

(early diagnosis, early treatment): The disease can be found in the esophageal tissue before the damage to the esophageal tissue or endoscopy, or only non-specific changes are difficult to confirm, the pH monitoring in the esophagus is limited, can not be popularized, but based on Detailed consultation, the resulting heartburn, typical symptoms of gastric reflux, and foreign body sensation of the throat, sputum ball, sputum sour water, chest pain, paroxysmal cough, asthma, etc., for differential diagnosis and analysis, can be roughly diagnosed, such as When antacids can relieve symptoms, most of them can be diagnosed. Physicians should strengthen their understanding of gastroesophageal reflux symptoms, and correctly analyze and analyze various auxiliary examinations in order to find early detection in the clinic, to achieve early diagnosis and early treatment. .

Tertiary prevention

(correct diagnosis, appropriate treatment and rehabilitation): After the diagnosis of gastroesophageal reflux disease is established, comprehensive treatment measures should be taken, correct guidance, systemic treatment, the disease is easy to relapse, so it should continue to maintain treatment after the end of the treatment, rational use of drugs.

2. Risk factors and interventions The incidence of the disease is high in the elderly, while the elderly have their physiological characteristics, the elderly have loose cardia, low LES tension, easy to reflux; esophageal mucosa repair function, less saliva secretion; secondary There are many patients with esophageal hiatus, and the drug used in geriatric diseases is complicated, and the medication is long. Some drugs have effects on LES function and esophageal mucosa, etc., and should be given proper guidance in living habits and medications, as well as esophageal hiatus hernia. , constipation, etc. give early treatment.

3. Community intervention This disease is more common. According to the current social characteristics of China, the proportion of middle-aged and elderly people is increasing. The majority of the elderly are scattered at home. Most elderly people do not have a good understanding of medical and health knowledge. Therefore, community medical services are very important. The purpose is to provide correct guidance to the elderly through health consultation, health education, including the understanding of the disease, daily life, eating habits and medications with related diseases, as well as rational use of drugs and treatment supervision for patients with this disease. Wait.

Complications of gastroesophageal reflux disease in the elderly Complications Upper gastrointestinal bleeding Barrett esophageal peptic ulcer

1. Upper gastrointestinal bleeding with reflux esophagitis, due to esophageal mucosal inflammation, erosion or ulceration, may have hematemesis and (or) black feces, a small amount of bleeding in the esophageal mucosa can cause mild iron deficiency anemia; ulcer Even can cause a lot of bleeding.

2. Esophageal stenosis Long-term repeated gastroesophageal reflux causes esophagitis, fibrous tissue hyperplasia, loss of compliance of the esophageal wall to form esophageal stenosis, stenosis usually occurs in the distal segment of the esophagus, length 2 ~ 4cm or longer, long-term The placement of the nasogastric tube is prone to stenosis, and the endoscopic dilatation treatment is required when the symptoms are obvious. After the stenosis appears, there is generally no obvious heartburn.

3. Barrett's esophagus in the process of esophageal mucosal repair, the squamous epithelium is replaced by columnar epithelium called Barrett's esophagus, which can cause peptic ulcer, also known as Barrett ulcer, Barrett's esophagus is the main precancerous lesion of esophageal adenocarcinoma, its gland The incidence of cancer is 30 to 50 times higher than that of normal people.

Symptoms of gastroesophageal reflux disease in the elderly Common symptoms Dysphagia Gastroesophageal reflux symptoms Weight loss Upper gastrointestinal bleeding Esophageal reflux symptoms Esophageal sputum Heartburn Stomach Swallowing Chest pain Throat pharyngitis

The original clinical manifestations of GER are diverse and vary in severity. Some symptoms are typical, such as heartburn and nausea. Some symptoms are confusing and non-characteristic, thus neglecting the diagnosis and treatment of this disease. Most patients have a chronic recurrence process, and their clinical manifestations can be Divided into four groups, namely:

1GER symptoms, such as nausea, acid reflux.

2 due to reflux caused by esophageal symptoms, such as heartburn, chest pain, chest pain when swallowing.

3 Symptoms other than esophagus, such as cough, asthma and pharyngitis.

4 complications symptoms.

1. Heartburn and acid reflux are the most common symptoms of GER. The contents of the stomach are called nausea when there is no nausea and no force. The reflux contains occasionally a small amount of food, which is mostly acidic or bitter. It is called acid reflux. The acid reflux is often accompanied by heartburn. The heartburn refers to the burning sensation or discomfort after the sternum. It is often extended from the lower part of the sternum and often appears 1 hour after the meal, especially after a full meal, lying down, bending over the posture or exerting force. Increased when holding your breath, you can wake up when you are asleep.

2. Ingestion pain and difficulty in swallowing Inflammation or complicated esophageal ulcer, swallowing pain may occur, mostly occurs when eating acidic or overheated food, some patients have difficulty swallowing, intermittent, eating solid or liquid Food can occur, every time at the beginning of the meal, the sternal infarction, may be due to esophageal spasm or dysfunction, a small number of patients with esophageal stenosis, persistent pharyngeal difficulty, progressive aggravation, dry Food is especially obvious.

3. Post-sternal pain often has burnt-like discomfort or pain behind the sternum. In severe cases, it can be severely tingling. It can be released to the xiphoid, shoulder area, neck, ear and arm. It resembles angina. Most patients are Heartburn develops, but some patients with gastroesophageal reflux disease do not have typical symptoms such as heartburn and acid reflux, especially in the identification.

4. Other patients showed dysfunction of pharyngeal discomfort, but no real dysphagia, known as sputum, is due to acid reflux caused by elevated esophageal sphincter pressure, severe reflux esophagitis Inhalation of reflux can lead to chronic pharyngitis, hoarseness and hoarseness, asthma attacks or aspiration pneumonia.

The diagnosis of GERD should be based on the following conditions: first, there are excessive symptoms of gastroesophageal reflux; second, endoscopic signs of reflux esophagitis; third, objective evidence of excessive gastroesophageal reflux Clinically, if the patient has typical symptoms of gastroesophageal reflux such as heartburn and acid reflux, a preliminary clinical diagnosis of GERD can be made. In the four basis of GERD diagnosis:

1 typical symptoms.

2 Proton pump inhibitor test (PPI test).

3 endoscopy has evidence of reflux esophagitis, and can rule out esophageal lesions caused by other causes.

4 esophageal 24h pH monitoring is positive, if 1+2 is positive, clinical diagnosis can be made, 1+3 or 1+4 positive can be diagnosed, the literature considers PPE test (omeprazole 20mg, 2 times / d, for 7 days) Sensitivity is no less than simple 24h pH monitoring, is a safe and simple clinical basis for the diagnosis of GERD, but if people have dysphagia, weight loss, cachexia, bleeding and other alarm symptoms, this test should not be used, so as not to delay the disease, due to internal Mirror examination is becoming more and more popular, and mucosal morphology can be observed and biopsy can be performed. At present, it is still the preferred method of examination in clinical practice. In addition, patients with atypical clinical manifestations often need to combine endoscopy, 24h esophageal pH monitoring and PPI test. A comprehensive analysis is made to determine if there is excessive gastroesophageal reflux.

Examination of elderly patients with gastroesophageal reflux disease

1.24h esophageal pH measurement: esophageal pH measurement can understand the pH of the esophagus, using a portable pH recorder to continuously monitor the patient's 24-hour esophageal pH under physiological conditions, can record the percentage of pH<4 during daytime and nighttime and within 24h. , the number of times of pH < 4, the number of times more than 5 minutes, the longest duration and other observation indicators, these parameters can help determine whether there is excessive gastroesophageal reflux under physiological activity, it is generally believed that 24h monitoring of gastroesophageal flow Most reliable, this combination of detection and endoscopy is the "gold standard" for the diagnosis of gastroesophageal reflux disease.

Significance: It is generally believed that the pH value in normal esophagus is 5.5-7.0. When pH<4, it is considered as acid reflux index. The parameters of pH monitoring in 24h esophagus are based on this. The following six parameters are commonly used as judgment. There are indicators of pathological reflux:

Total percentage time of pH < 4 within 124 h.

2 Percentage time in the standing position pH<4.

3 percent time in the supine position pH < 4 .

4 number of reflux.

5 times the number of refluxes longer than 5 minutes.

6 The longest reflux time is maintained. Among the 6 parameters, the positive rate is the highest with the total percentage of pH<4. The total score can also be calculated according to the Demeester score method. The above parameters can be compared with the normal values. Whether there is excessive acid reflux in the esophagus.

Advantages and Disadvantages: This monitoring method is the best method to judge pathological gastroesophageal reflux, especially in patients with atypical symptoms or typical symptoms but ineffective treatment, as well as endoscopic negative GERD patients have more important diagnostic value, but for gastric acid secretion Too low to have gastroesophageal alkaline reflux, the diagnosis is lost; this monitoring method can not understand the morphological changes of esophageal mucosa, not intuitive; although the pain to the patient is not great, but after all, it should be placed for 24h, and one instrument can only check one per day. One patient has limited clinical application, and more clinically applied endoscopy, barium meal and other more intuitive examination methods.

2. Endoscopy and biopsy Endoscopy is the most accurate method for diagnosing reflux esophagitis. It can directly detect mucosal lesions, determine the severity of reflux esophagitis and have complications, combined with biopsy It can be differentiated from esophagitis caused by other causes, which is helpful to determine the benign and malignant nature of the lesion. Since the histological findings of the mucosa at the end of the normal esophageal area of 2.5 cm may be mildly inflammation, it must be taken 5 to 10 cm above the gastroesophageal junction. Mucosal specimens, endoscopic refractory esophagitis can confirm the diagnosis of GERD, but the esophagus shows normal, can not exclude GERD, at this time must be applied esophageal pH monitoring, esophageal swallow X-ray examination and other methods comprehensive judgment, according to The degree of esophageal mucosal damage, endoscopic grading diagnosis of reflux esophagitis is conducive to disease judgment and guidance treatment, the proposed grading standards are many, the long-established Savary-Miller classification method to divide reflux esophagitis into 4 Grade: Grade I is a single or several non-fusion lesions, characterized by erythema or superficial erosion; Grade II is a fusion lesion, but not diffuse or circumferential; Grade III lesions are pervasive, with erosion No stenosis; grade IV is chronic lesions, manifested as ulcers, stenosis, esophageal shortening and Barrett's esophagus, when reflux esophagitis, the dentate line is often blurred, the capillaries in the lower esophagus proliferate, often with small white particles or spots, For squamous epithelial hyperplasia, some patients have esophageal hiatus hernia, which is characterized by dentate line movement, and the sac is seen between the level of the hole. The cardia is often open.

3. Esophageal swallow X-ray examination to understand the presence or absence of gastroesophageal reflux is a simple method for patients with supine or elevated bed foot X-ray examination, this test is not sensitive to the diagnosis of reflux esophagitis, in the light patient Often no positive findings, patients with esophagitis can be seen in the lower esophageal mucosa rough, not smooth, severe or late visible sputum, stenosis, etc., can also be found weakened esophageal peristalsis, inconsistent or irregular contraction, etc., small doses of swallowing in the supine position Barium sulphate (such as 200% barium sulphate 6ml), showing that most patients with GERD have delayed esophageal and LES sputum, the advantages are:

1 This test can be performed for those who do not want to accept or can not tolerate endoscopy.

2 esophageal swallowing can understand the entire esophagus, the motor function state of the stomach, and determine the lesion site more accurately.

3 can understand the presence or absence of esophageal hiatal hernia, exclude esophageal cancer, esophageal diverticulum and other diseases caused by esophagitis.

4. Esophageal acid test patients in a single blind place to introduce a nasal catheter, fixed at 30cm from the nostril, instilled saline 10 to 12ml per minute, for 15min, then instill 0.1N hydrochloric acid at the same rate, in the acid During the process, patients with post-sternal pain or heartburn were positive, and more than the first 1.5 minutes of acid drop, indicating the presence of active esophagitis; after switching to saline, the symptoms gradually relieved, but severe esophagitis Patients may also be negative for acid-insensitive reactions; lack of gastric acid, symptoms mainly caused by reflux of alkaline substances such as bile, may also be negative; cardiogenic chest pain or other non-oeangiitis or LWS insufficiency The chest pain caused by the negative reaction, this test is conducive to the differential diagnosis of post-sternal pain.

5. Esophageal manometry can measure the length and location of LES, LES pressure, LES relaxation pressure, esophageal sphincter pressure and esophageal body pressure, etc., can show that LES pressure is low, LES frequent relaxation and esophageal peristaltic contraction amplitude is low or Disappeared, these are the pathological basis of gastroesophageal reflux. For example, LES pressure <6mmHg is easy to cause reflux. Because the range of LES pressure data measured by normal people and gastroesophageal reflux group overlap, use this test to judge the stomach. Esophageal reflux is not very reliable, and the equipment is expensive. It is difficult for general hospitals to carry out. When GERD medical treatment is not effective, it can be used as an auxiliary diagnosis method.

Diagnosis and differential diagnosis of gastroesophageal reflux disease in the elderly

Diagnostic criteria

GERD has a high incidence in the elderly and has the following characteristics compared with young people. Pay special attention to the diagnosis process:

1. Reasons for the increased prevalence of GERD in the elderly

1 With the increase of age, the secretion of salivary glands is reduced, the clearance of acid to the esophagus is weakened, and the acid exposure time of the esophagus is prolonged.

2 The elderly esophageal epithelial hyperplasia and repair function is weakened, and it is not easy to repair after mucosal damage.

3 elderly LES tension is poor, the cardia is slack, prone to gastroesophageal reflux.

2. Elderly GERD secondary to esophageal hiatal hernia more esophageal hiatus sputum affects the function of LES, it is prone to gastroesophageal reflux, the incidence of esophageal hiatal hernia in the elderly is significantly higher than young people, it is also the elderly GERD One of the reasons for the increased incidence.

3. The severity of GERD in the elderly is heavier than that of young people. This is related to the long course of the elderly and is not related to timely diagnosis and treatment. In severe cases, it can cause upper gastrointestinal bleeding, esophageal fibrosis, esophageal stricture, short esophagus, and even cancer.

4. There are more elderly patients with GERD coexisting gastric ulcer, and non-elderly patients with duodenal ulcer.

5. Chest pain in elderly GERD, it is easy to be misdiagnosed as coronary heart disease, angina.

6. In the elderly, some common medications associated with the disease can aggravate GERD.

Differential diagnosis

The clinical symptoms of GERD in the elderly are most painful in the posterior sternum. The painful part is also under the xiphoid or upper abdomen. It can be radiated to the shoulder, the lower jaw, and more to the left arm, also known as esophageal chest pain. It is easy to be confused with angina. The esophageal and cardiac sensory nerve fibers overlap on the body wall and the skin. For example, the esophagus is the neck 6 to the neck 10, and the heart is the chest 1 to the chest 4. Therefore, it is difficult for the two to locate from the pain. Identification, these two diseases are common diseases in the elderly, so if GERD is mainly manifested as chest pain, it should be differentiated from various causes of cardiogenic and non-cardiac chest pain. The post-sternal pain of this disease often occurs in meals. After, related to body position, taking acid can make symptoms relieve or disappear, and cardiogenic chest pain such as angina is not, the latter often occurs during exercise, rest can be relieved for a while, while angina can be positive for ECG and exercise test Found, and esophageal acid test negative, should pay attention to reflux reflux esophagitis with alkali reflux, esophageal acid test is also negative, should be combined with endoscopy, barium meal and other tests, in general, should exclude cardiogenic chest pain After, then To conduct an examination of esophageal chest pain, the disease has difficulty in swallowing, mainly to distinguish from esophageal cancer, esophageal achalasia, for patients with swallowing pain, while endoscopic findings of esophagitis should be infective Esophagitis (such as fungal esophagitis), drug-induced esophagitis, etc., with asthma as the main manifestation, should consider the reflux into the respiratory tract, causing bronchial smooth muscle spasm, should be differentiated from bronchial asthma, especially due to asthma It is often treated with drugs such as aminophylline, because it can reduce LES pressure and aggravate gastroesophageal reflux, so it should be paid more attention. In addition, clinically, it should be compared with other causes of esophagitis, peptic ulcer, digestion of various reasons. Bad, biliary tract disease and esophageal motility diseases are identified.

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