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Gastroesophageal reflux symptoms

Introduction
Cause
Examine
Diagnosis

Introduction

Introduction Gastroesophageal reflux disease (GERD) is an esophageal and gastric motility disorder. During the relaxation of the lower esophageal sphincter (LES), the gastric contents of the reflux esophagus called gastroesophageal reflux (GER) gastroesophage have two kinds of physiological reflux and pathological reflux. Physiological reflux is caused by the spontaneous relaxation of LES, which is conducive to the discharge of gas in the stomach. The esophagus will promote the peristalsis to push the gastric juice into the stomach. Under normal circumstances, it will not cause damage to the esophageal membrane. Pathological reflux is a pathological phenomenon caused by a variety of factors caused by gastroesophageal anti-reflux insufficiency. Gastroesophageal reflux disease is a disease caused by reflux of the human esophagus in the stomach or duodenal contents. Often combined with esophagitis, about 10%-20% of the population have symptoms of gastric collateral reflux, but X-ray endoscopy can be found without abnormalities and may not be known for a long time. Sustained development can lead to serious complications such as esophageal strictures, ulcers, hemorrhage and Barrett's esophagus, the latter being precancerous lesions. Complications outside the esophagus may also occur. Such as acid laryngitis, respiratory tract spasm, lung injury complications.

Cause

Cause

Etiology classification

There are many factors that cause gastroesophageal reflux disease, which can be roughly divided into two categories:

First, primary gastroesophageal reflux

Primary esophageal sphincter insufficiency is the cause of primary gastroesophageal reflux disease. Gastroesophageal reflux is demonstrated by a multifaceted examination of patients with reflux symptoms. However, some patients can't trace any cause of reflux; so the primary esophageal sphincter is insufficiency. This condition is more common in the elderly, and may be related to the relaxation of connective tissue in the elderly, the weakening of the "spring clip" effect in the hiatus of the esophagus, and the intrinsic function decline of the lower esophageal sphincter (LES).

Second, secondary gastroesophageal reflux

Any cause of decreased esophageal sphincter pressure can cause gastroesophageal reflux disease. The description is as follows:

(1) Esophageal hiatus hernia

Gastroesophageal reflux occurs because the hiatal hernia destroys the normal anatomical relationship of the esophageal hiatus and causes the LES to be incompletely closed. Sliding esophageal hiatus hernia, the junction of the esophagus and the stomach is in a vertical direction, that is, a concentric structure, so the His angle disappears, the connection between the esophagus and the stomach is vertical, and the valve against the reflux is lost; the esophagus moves up. The thoracic cavity loses the antagonistic effect of intra-abdominal pressure; the diaphragm is elongated and becomes weak and weak, eliminating the support of the lower esophageal sphincter; when the hole is enlarged, the "spring clip" effect of the spacer is lost. The auxiliary effects of these lower esophageal sphincters are eliminated in the presence of hiatal hernia, so that the lower esophageal sphincter is insufficient to counteract intra-abdominal pressure, and gastroesophageal reflux will inevitably occur. According to statistics, 85% of patients with reflux esophagitis have hiatal hernia, and more than half of cases of schizophrenia have reflux esophagitis. Therefore, hiatal epilepsy is a common cause of gastroesophageal reflux disease.

(2) Congenital malformations

l, congenital esophageal lower esophageal columnar epithelialized esophageal epithelium is composed of squamous epithelium, in which a non-squamous epithelial area called columnar epithelialization, the columnar superiorization of this congenital esophageal stimuli only Occurred in the lower esophageal membrane without associated or concurrent anatomical abnormalities. Table shows the symptoms of gastroesophageal reflux, often with reflux esophagitis.

2, esophageal abdominal segment too short abdominal esophageal segment plays an important role in anti-gastroesophageal reflux, the normal length of about 3-4cm if this segment is too short (average <1cm) is likely to cause reflux.

(three) stomach cramps

Gastroparesis can be caused by many different causes, the most common causes being diabetes, stomach surgery, vagus nerve surgery, and drugs. However, the cause is usually unclear and it is an idiopathic gastroparesis. Gastroparesis is delayed in gastric emptying or has gastric contents retained. At the same time, patients with gastroparesis also have lower esophageal sphincter and lower esophageal muscle spasm, which reduces the anti-reflux function of lower esophageal sphincter and decreases esophageal clearance rate, resulting in stomach. Esophageal reflux.

(four) esophagitis

Reflux can cause reflux esophagitis. Esophagitis caused by other causes can reduce the primary peristaltic pressure of the esophagus, lower esophageal sphincter pressure, and reduce the esophageal clearance rate by 31. Esophageal reflux and exacerbation of esophagitis.

(5) Yang dyspepsia "NIjD"

The patient has a gastric motility disorder similar to gastroparesis and may cause gastroesophageal reflux.

(6) Increased intra-abdominal pressure

Excessive obesity, ascites, late pregnancy and other causes of increased intra-abdominal pressure, can cause gastroesophageal reflux. Some patients are caused by increased intra-abdominal pressure.

(7) Food and drugs

Certain foods or drugs can reduce the pressure of the lower esophageal sphincter causing gastroesophageal reflux. Common foods, food ingredients and irritants are: high-fat meals, chocolate, alcohol, mints, caffeine, nicotine, etc. Common drugs are: anticholinergic drugs or drugs with anti-biliary side effects, liver adrenergic receptor agonists (isopropyl epinephrine octaphylline benzodiazepines. Calcium antagonists (Vila Pami X Nifedipine, thiazolone, opioids.

(8) Other systemic diseases

Esophageal and other systemic diseases other than gastrointestinal, mainly caused by gastroesophageal reflux caused by affecting the function of the lower esophageal sphincter. Because the lower esophageal sphincter is composed of visceral smooth muscle, any systemic disease affecting smooth muscle can cause gastroesophageal reflux. Such as: scleroderma, hypothyroidism, diabetes, amyloidosis.

(9) Others

Vomiting, gastric tube, anesthesia, long-term snoring and coma. Due to long-term sputum J vomiting, the cardia is often open, the lower esophageal sphincter is weak in anesthesia and coma, the gastric tube can not be completely closed, and most of these patients stay in bed for a long time, losing the gravity of the stomach contents. Therefore, gastroesophageal reflux occurs.

(10) Surgery

The vagus nerve is cut or damaged by surgery, or the normal anatomical relationship between the original esophagus and the gastrointestinal tract is changed by surgery, or the normal structure of the hole is broken, or the fixed structure of the stomach in the abdominal cavity. Can cause duodenal juice or high jejunal fluid into the esophagus caused by reflux of alkaline fluid, causing reflux esophagitis, or postoperative gastroesophageal reflux caused by the temple.

mechanism

The anatomical structure of the gastroesophageal junction is beneficial for anti-reflux, including the lower esophageal sphincter and the esophageal ligament, the acute angle between the esophagus and the stomach. The most important of these is the lower esophageal sphincter. It has the function of a sphincter, about 1.5-2.5 cm long, and at a resting high pressure zone (LESP) reaches 1.33-4.4 kPa (10-30mmHg). When the fire swallows, the lower esophageal sphincter relaxes, allowing the bolus to pass. Normal people in the stomach also have physiological gastroesophageal reflux after meals. The reflux is small. It can be removed by the gravity of food, the volume of esophageal body and the chemical clearance of saliva. It does not cause damage to the esophageal membrane, and often has no clinical symptoms. If the lower esophageal sphincter tension is low or there is frequent relaxation, pathological reflux will occur. If the esophageal clearance is low, the esophagus is easily damaged and causes esophagitis. Excessive gastroesophageal reflux, especially when exposed at night, causes pharyngitis in the pharynx, or reflux or mainly acid or acid mist. Inhalation of the airway causes airway spasm, secondary pulmonary complications. At present, the study considers that gastroesophageal reflux disease is caused by many factors. In general, its mechanism is classified into two aspects: one is the decline of anti-reflux defense function; the other is the enhancement of reflux attack factor.

First, the anti-reflux defense function declines

(1) Lower esophageal sphincter dysfunction

(B) the removal of the esophageal body

The peristalsis of the esophageal body is weakened, which reduces the volume clearance of the reflux and reduces the secretion of saliva. It also affects the chemical scavenging effect of the reflux.

(3) Delayed gastric emptying

About 11/2 of patients with gastroesophageal reflux disease have delayed gastric emptying, which in the supine position sleeps with a meal or drink) is easy to promote gastroesophageal reflux.

(D) the barrier function of the esophageal membrane

The esophageal surface layer is covered with multiple layers of closely packed squamous epithelial cells. My membrane surface is attached to the skin to prevent the release of pepsin. The surface of the tympanic membrane also has HCO- ions, which can neutralize part of the reflux H+. A defense barrier before the esophageal epithelium. The new membrane blood flow and its acid-base state are the esophageal epithelial barrier. The degree of gastroesophageal reflux and the degree of esophageal membrane damage are not parallel, and the individual differences are large, which is obviously related to the barrier function of the esophageal membrane.

Second, the reflux attack factor enhancement

Gastroesophageal reflux occurs when the defense function declines, and the esophageal membrane damage is caused by the reflux. The degree of damage is related to the quality and quantity of the reflux and also to the time of contact with the membrane. Among them, the strongest lesion in the esophageal membrane is gastric acid. When the pH is <3, the membrane epithelin is denatured, and the pepsin activity enhances the digestion of the epithelin. Studies have shown that patients with gastroesophageal reflux disease do not have increased gastric acid secretion, which is caused by frequent refluxing of the esophageal membrane acidification. After H+ passes through the protective layer before the esophageal epithelium, it continues to destroy the cells of the epithelial layer. The boundary between the cells reaches the deeper epithelial cells, causing cell death, and thus the esophageal epithelial erosion, ulceration, and thus the proliferation of basal cells. There is a stomach cut. In addition to history or excessive duodenal regurgitation, cholic acid The trypsic acid can increase the permeability of the esophageal membrane and aggravate the damage of gastric acid and pepsin on the esophageal membrane. At night, the volume elimination and chemical clearance are significantly decreased, and the reflux of the esophagus or membrane is prolonged, which is easy to occur with esophagitis.

In patients with severe reflux esophagitis, the lower esophageal sphincter pressure was significantly decreased. When the lesion progressed to Barretts, the lower esophageal sphincter pressure became lower. After esophagitis was cured, the lower esophageal sphincter pressure could not completely return to normal. Esophagitis is the result of dysmotility, which in turn affects the function of LESP, thus forming a vicious circle, the starting factors of which are gastric acid and pepsin. Studies have also shown that about 40% of patients with gastroesophageal reflux disease have autonomic dysfunction; resection or injury of the vagus nerve can cause gastroesophageal reflux disease, indicating that vagal abnormalities may be related to the pathogenesis of gastroesophageal reflux disease.

Examine

an examination

Related inspection

Ultrasound examination of gastro-intestinal tract disease with gastrointestinal diseases

The first step in diagnosis must be to understand the medical history. If only mild reflux symptoms such as heartburn, pantothenic acid, and anti-feeding are used, the gastric motility drug cisapride, an acid suppressant such as HZ receptor orange antagonist or antacid is tested and treated. Can make a diagnosis of gastroesophageal reflux, without having to check his many tests, so as not to bring more inconvenience to patients. If the symptoms are severe or the patients with complications or vague symptoms are considered, or those who have failed treatment, the cause of reflux should be further sought. All relevant examinations must be performed.

First, medical history

The clinical manifestations of gastroesophageal reflux can be divided into four groups.

(a) gastroesophageal reflux symptoms

Mainly manifested as pantothenic acid, snoring, anti-feeding light, acid reflux bitter gastric juice, or upward regurgitation when bending over, anti-acid heavy can be asleep at night, acidic irritants spray back to the throat causing cough, asthma or The suffocation can also cause excessive salivation due to reflux of esophageal acid. Returning food is generally seen in heavier people, and the anti-food has a strong sour taste.

(2) Symptoms caused by reflux to stimulate the esophagus

Mainly manifested heartburn, chest pain, chest pain when swallowing. Heartburn is a common symptom of gastroesophageal reflux disease, showing a burning sensation or discomfort after the sternum, often occurring 30 minutes after a meal, especially after a full meal. The body is flexed when it is flexed to the upper position or forced to hold the breath. Stimulation of reflux can cause esophageal spasm. Reflux acid stimulation causes a feeling of winning when the upper esophageal sphincter pressure rises. In the presence of esophagitis, especially in the esophagus, the membrane erosion often has swallowing chest pain. Some chest pains are like angina, and the pain is radiated to the shoulders, upper limbs, neck or behind the ears.

(three) irritating symptoms outside the esophagus

Lung damage to the stomach contents caused by acid and enzyme damage caused by pharyngitis, secondary infection; reflex bronchoconstriction that stimulates esophageal secondary neuromodulation after gastric reflux can cause cough, bronchial asthma, asphyxia and other symptoms. Some patients are mainly respiratory symptoms, sore throat, hoarseness, difficulty in speech and oropharyngeal symptoms: excessive salivation, tooth damage, periodontal disease, otitis media, etc. The symptoms of reflux are not obvious.

(4) Symptoms of complications

1, esophageal stenosis: long-term gastroesophageal reflux can cause esophagitis, leading to fibrosis, loss of compliance or formation of a significant narrow esophageal wall, often occurs at the distal end of the esophagus or the gastroesophageal junction. Patients often have difficulty swallowing, and they feel guilty after eating dry food. It is also difficult to further develop food intake. Or food incarceration. The symptoms of heartburn sometimes decrease when there is a narrow esophageal stenosis.

2, bleeding and perforation: reflux esophagitis can cause a small amount of oozing, some manifestations of occult blood positive or iron deficiency anemia, diffuse esophagitis or esophageal ulcer can occur a large amount of bleeding.

Occasionally, severe esophagitis or Barretts esophageal ulcers can be complicated by esophageal perforation.

3, Barretts esophagus: for long-term chronic gastroesophageal reflux complications, due to long-term reflux, the lower esophageal squamous epithelium can be replaced by metaplastic columnar epithelium, patients often have typical reflux symptoms. Some of these patients can develop into esophageal cancer. 4, extra-esophageal complications with lung complications such as: bronchitis, bronchiectasis, inhalation pneumonia, lung abscess.

Second, the device inspection

There are many methods of examination for gastroesophageal reflux disease, such as barium meal. Endoscopy, radionuclide gastroesophageal reflux examination, esophageal pH monitoring, esophageal manometry, acid induction test, etc., in which esophageal pH measurement is a gold indicator for diagnosis.

(1) Meal

Head-down barium meal examination can show barium gastroesophageal reflux; swallowing 20% barium sulfate in the supine position can show the esophageal and esophageal sphincter drainage in patients with gastroesophageal reflux disease. Can also show the performance of certain complications of the esophagus, such as: lower esophageal membrane wrinkle thickening, smooth (esophageitis) sputum (esophageal ulcer) and esophageal stricture. Can show the performance of the esophageal hiatus temple.

(two) fiber endoscope

It is an ideal method for determining esophagitis. For suspicious lesions such as esophageal erosion, ulcer or stenosis, endoscopic brushing or biopsy pathology can be used to prove the benign and malignant nature of the lesion. Esophageal hiatus can also be found. Endoscopically, the reflux esophagitis is divided into four levels according to the degree of the lesion: the grade: for the light gastroesophageal junction and the lower esophageal mucosa longitudinal congestion, mild mild erosion, surface exudate. Level 11: There is a fusion of erosion, but the lesions are not diffuse. Dish level: The above lesions are diffuse, and the surface of the lesion is covered with a large piece of floating liquid film. Grade IV: manifested as a chronic lesion with ulceration, esophageal stricture, or Barrett metaplasia. In reflux esophagitis, the dentate line is often blurred, and the capillaries in the lower esophagus proliferate, often with small white particles or spots; pathologically confirmed squamous epithelial hyperplasia.

(three) 24hpH determination

It is a reliable method for determining gastroesophageal reflux, which can determine physiological gastroesophageal reflux and pathological gastroesophageal reflux, and help to clarify the relationship between chest pain and acid reflux. Physiological reflux refers to reflux during sleep, with short duration and few times. The number of such reflux is less than 50 within 24 h, and the total time of pH in the esophagus below 40 does not exceed lh. Pathological reflux refers to more than 50 times of 24 h reflux, and (or) PH less than 4 knives for more than 1 h within 24 h. It should be mentioned that pathological reflux does not necessarily produce symptoms; physiological reflux may also present symptoms.

(four) esophageal nucleus gastroesophageal reflux examination

The liquid is labeled with a radionuclide, showing excessive gastroesophageal reflux when resting and when the abdomen is pressurized. When the lungs showed an increase in nuclide, it was indicated that there was excessive gastroesophageal reflux and intrapulmonary inspiratory.

(5) Esophageal manometry

It is a method to explore the cause of reflux, and it is best to measure the esophagus, the lower esophageal sphincter and the intragastric pressure at the same time. Can show lower esophageal sphincter pressure, frequent relaxation of the lower sphincter and esophageal peristaltic contraction amplitude is low or disappear. Continuous esophageal pressure monitoring can detect abnormal esophageal motility in more patients. Esophageal manometry combined with chest pain induction experiments can help determine chest pain caused by reflux.

(6) Acid perfusion experiment

It is valuable for the identification of cardiogenic or esophageal chest pain, and can check the sensitivity of the esophagus to acid and the presence or absence of esophagitis. Heartburn, pantothenic acid, anti-feeding and post-sternal pain are common symptoms of gastroesophageal reflux disease.

Diagnosis

Differential diagnosis

First, angina

Gastroesophageal reflux disease sometimes has other obvious reflux symptoms and is mainly characterized by post-sternal pain, which is similar to angina pectoris; and coronary heart disease angina pectoris and gastroesophageal reflux disease are both senile diseases. The two are easily confused and need to be identified, identified by means of electrocardiogram, 24h dynamic electrocardiogram, esophageal 24hpH monitoring. Acid perfusion induced test. It is extremely difficult to identify coronary angiography.

Second, gastroesophageal reflux disease often has complications of esophagitis, and the cause of esophagitis caused by his cause is accompanied by reflux symptoms. Although endoscopic 0 examination is a reliable method for diagnosing esophagitis, it cannot be judged. One of the identification is mainly based on the history of X-ray barium meal, food I tube pressure measurement, etc. to find the original cause of reflux caused by the element.

Third, digestive stenosis of the esophagus

As with esophagitis, gastroesophageal reflux can be a cause and effect. Identification is based on a history, gastric acid secretion, barium meal, endoscopy and other comprehensive analysis. In the medical history, special attention was paid to the history of surgery and the history of surgery. Barium meal and endoscopy are helpful to show the possible causes of stenotic lesions and stenosis; increased gastric acid secretion is seen in digestive stenosis, and gastric acid reflux is not high in gastric esophageal reflux disease.

Fourth, esophageal tumor

Esophageal tumors may have symptoms of gastroesophageal reflux disease, which can be identified by barium meal and endoscopy. Special endoscopy can clearly see the location, size and shape of the tumor at a glance, and combine the biopsy pathology to determine its benign and malignant properties.

5. Functional dyspepsia (NUD)

There are often symptoms of gastroesophageal reflux disease, the identification of the two should be based on medical history, gastroesophageal pressure, esophageal 24 h pH measurement, gastroscopy. Barium meal. In the medical history, attention should be paid to the mental factors. Gastroesophageal manometry may show that the gastroesophageal pressure is reduced or increased. Barium meal examination may show an increase or decrease in esophageal motility, no pathological findings under endoscopy or mild superficial gastritis.

In short, there are many diseases with symptoms of gastroesophageal reflux disease, and the identification method is based on medical history, experimental treatment, and selection of necessary device examinations according to different situations to confirm the diagnosis. Pay attention to the possible causes of gastroesophageal reflux disease in the medical history; burn. Those with mild motion and reflux may be treated with gastric motility drugs, antacids, and Hi receptor orange antagonists. The success rate of these drugs may be exempted from device examination, and those who are seriously ill or unsuccessful in trial treatment may Endoscopic examination excludes tumor and digestive stenosis; to determine gastroesophageal reflux, esophageal 24 h pH monitoring is required; if gastroesophageal reflux is sought, it is often necessary to measure esophageal and gastric pressure.