Reflux esophagitis

from Wikipedia, the free encyclopedia
Classification according to ICD-10
K20 Esophagitis
K21.0 Gastroesophageal reflux disease with esophagitis
K21.9 Gastroesophageal reflux disease without esophagitis
R12 heartburn
ICD-10 online (WHO version 2019)

Reflux esophagitis is inflammation of the lower part of the esophagus caused by the reflux of gastric juice. Reflux esophagitis is a subtype of gastroesophageal reflux disease , which is associated with endoscopically or histologically visible changes in the lining of the esophagus ( esophagus ) and is known as ERD ( erosive reflux disease ). Opposed to this is NERD ( non-erosive reflux disease ), which is associated with the same symptoms but without any detectable damage to the mucous membrane of the esophagus. It is assumed that up to ten percent of the population in western industrialized nations suffer from reflux oesophagitis.

Etiology and pathogenesis

Reflux esophagitis can have three causes:

  1. emissions of stomach acid is so great that the peristalsis of the esophagus can no longer cope with him
  2. the peristalsis of the esophagus is already impaired and cannot properly reduce normal - and certainly excessive - output of gastric acid
  3. the internal sphincter ( esophageal sphincter ) that separates the esophagus from the stomach is not working properly.

It is usually caused by cardiac insufficiency . The disease is often associated with an axial hiatal hernia : Almost all patients with reflux esophagitis have such a hernia, but only 10% of all patients with such an axial hernia show symptoms of reflux esophagitis.

In addition, other noxae (pollutants) such as coffee, hot spices, peppermint, alcohol, tobacco smoke or medication are usually involved.

Symptoms

Especially at night (caused by lying down), after meals, often after cakes or sweet dishes, when bending over or lifting loads or consuming tobacco smoke or alcohol, acidic belching of gastric juice and / or heartburn occurs . Non-specific chest pain can occur even without heartburn , rarely in the upper abdomen. In these cases, it is difficult to differentiate between heart disease.

Especially patients in speaking professions and singers complain of chronic laryngitis  - see also Laryngitis gastrica  - and a morning feeling as if the "throat is burning" because of the irritation caused by gastric juice and are therefore often severely hampered in their work. Other symptoms include: B. chronic cough, often wrongly diagnosed as bronchial asthma .

Diagnosis

Peptic stricture (stage IV)

Often, the symptoms already indicated suggest that reflux esophagitis is suspected. Trial therapy with proton pump inhibitors can also corroborate this suspicion.

The definitive diagnosis is made endoscopically by gastroscopy ( esophagogastroduodenoscopy , gastroscopy). This is also the only way to take samples and thus detect Barrett's dysplasia. Based on the established extent of the tissue disorders ( lesions ), the defects can be divided into different classifications. At gastroscopy, samples are routinely taken to test for Helicobacter pylori .

A 24h pH measurement (acid measurement) using a nasal esophageal probe is only rarely necessary. It is important here that any proton pump inhibitors taken are discontinued one week in advance.

Catheter-free, capsule-based pH-metry is a rarely required special examination that enables registration over several days.

Classifications

According to Savary and Miller , there are four stages of the disease:

  • I - One or more non-confluent mucosal lesions with redness and exudation
  • II - Confluent erosive and exudative lesions that do not yet occupy the entire circumference ( Latin : "circumference") of the esophagus
  • III - The lesion occupies the entire circumference of the esophagus
  • IV - Esophageal Ulcer , Barrett's Esophagus , strictures, and other chronic mucosal lesions

The Los Angeles classification refers to the endoscopic extent of the defects and divides them into four stages from A to D:

  • A - one or more mucosal lesions less than 0.5 cm
  • B - min. one lesion longer than 0.5 cm, lesions not yet exceeding two mucosal folds
  • C - Multiple mucosal folds are crossed by the lesions, but no circular defects are yet present
  • D - circular defects present

The MUSE classification differentiates between the four endoscopically assessable formations

  • M etaplasie,
  • U lkus,
  • S triktur and
  • E rosion and divided every four in four degrees of severity.

0 = missing; 1 = slightly; 2 = moderate; 3 = severe. This makes the muse classification the most precise, but also the most unwieldy in everyday use.

Non-drug measures

The primary goal of therapy is to prevent the negative effects of gastric acid . The first step is to try to minimize the risk factors for reflux oesophagitis (smoking, alcohol, being very overweight, high-fat foods and eating plenty of food before going to bed). For example, the lying position after a meal favors the reflux of stomach acid into the esophagus. If the production of gastric acid was additionally stimulated by copious and / or high-fat food before bed, this can lead to massive heartburn , especially if there is cardiac insufficiency , which is why it is advisable to eat the last meal no later than about four hours before bed to take in. Highly acidic juices such as pineapple or orange juice as well as carbonated drinks should be avoided as far as possible, especially before going to bed. Furthermore, a sleeping position on the left side of the body (where the stomach entrance has the highest position) and the use of a wedge pillow or a mattress wedge in bed were recommended.

A study in 2010 suggested a positive effect of chewing gum, as this leads to an increase in the flow of saliva and thus ultimately to the fact that the acid can flow out of the esophagus more quickly towards the stomach.

Medical therapy

The acid can be briefly neutralized with an antacid . However, since the stomach reacts to this with an increased output of gastric acid, antacids only combat the acute symptoms and also cause side effects in many of them, long-term therapy with them is not indicated. By contrast, histamine H2 receptor blockers can prevent the stomach from receiving a stimulus for gastric acid production via H 2 receptors, and finally proton pump inhibitors (PPIs), e.g. B. omeprazole , esomeprazole or pantoprazole , the acid production in the parietal cells of the stomach itself is paralyzed. Since these proton pump inhibitors only have a very specific effect on the parietal cells of the stomach and have relatively few side effects, they are currently considered the standard in long-term therapy.

However, in the past they have been associated with increased intestinal inflammation and can also promote the development of osteoporosis and bone fractures, as the stomach can no longer absorb minerals such as calcium or iron as well. The absorption of vitamin B12 can also be impaired, which affects the ability to exercise. If PPI is discontinued after prolonged use, initially more stomach acid is produced than before, because of the persistent effect that gastrin continues to release (so-called rebound effect). Alternatively, you can bind gastric acid with healing earth in the first stage. Flaxseed or gruel protects the stomach walls. Medicinal plants can be used against stomach inflammation in various combinations, such as an extract that also contains the bitter candytuft . The research team led by the Basel surgeon Philipp Kirchhoff discovered zinc as a stomach acid reducing agent. In one study, researchers found that by ingesting 200 mg of zinc sulfate, they could raise the pH of the stomach from 1.5 to 3.5 in minutes. A higher pH means less acid in the stomach. The effects lasted two and a half hours while PPI lasted over 24 hours.

Another treatment option is the administration of a combination of hyaluronic acid , chondroitin sulfate and Poloxamer 407. At body temperature, this changes from a liquid to a semi-solid hydrogel that attaches to the esophageal lining and is supposed to protect it from damage by stomach acid and pepsin . Hyaluronic acid and chondroitin sulphate alleviate reflux symptoms and contribute to the regeneration and wound healing of the damaged mucous membrane.

Due to the increased risk of carcinoma in the presence of reflux esophagitis, regular gastroscopic controls are necessary, during which a biopsy test for Helicobacter pylori should also be performed regularly . For some years now, however, there has also been a Helicobacter breath test , a convenient, non-invasive measurement method with which Helicobacter pylori infestation can also be detected with high accuracy via the breath . If there is a colonization with Helicobacter pylori , so-called eradication therapy is required.

Operative treatment

In serious cases, especially stenoses and persistent swallowing difficulties, surgical intervention is necessary. The operation is usually carried out in a minimally invasive manner, see also laparoscopic surgery . With this method, the indication for surgery can be expanded, as the results are significantly better than those of the conventional open surgical method. In 2005, a total of 160 patients were successfully treated with a new surgical method as part of an international study. The esophagus is narrowed at the connection to the stomach by means of a suture, see Laparoscopic Fundoplication .

Complications

It can be bleeding , ulcers and strictures come in the area of the gastroesophageal junction. The loss of blood can also lead to iron deficiency anemia . In a few patients, this anemia is the first symptom they see to the doctor.

The formation of Barrett's esophagus , a transformation ( metaplasia ) of the epithelium into a gastric or intestinal type, is possible. To calculate the risk, doctors use a simplified rule of ten: Ten percent of all reflux patients develop reflux oesophagitis, from which a Barrett's esophagus develops in ten percent of cases, ten percent of these in turn become malignant; Esophageal carcinoma can occur in about every thousandth patient. Patients with elongated (> 3 cm) Barrett's esophagus are at higher risk of esophageal cancer, but all Barrett's esophagus are considered to be precancerous ( precancerous ). That is why every patient with this disease should have an endoscopic examination every 3–5 years to see whether a cancer has developed.

There is a close connection between reflux disease and bronchial asthma: A comparatively high percentage of asthmatics (at least 30%, probably more) also suffer from reflux. The exact mechanism has not yet been clarified. Some of the gastric juice that flows back may reach the bronchi and cause severe irritation there. It is also possible that the acid irritates the vagus nerve (10th cranial nerve), which then causes constriction of the bronchi (= asthma).

As part of a reflux disease it can also cause erosion of tooth enamel come, especially for children and the disabled, so why dental checks of the oral cavity may be displayed.

literature

  • Holger Stark, Yvonne Syha, Laura Popescu, Manfred Schubert-Zsilavecz: New active ingredients for GERD treatment. In: Pharmacy in our time . 34 (3) (2005), pp. 224-227, ISSN  0048-3664 .
  • Rudolf Nissen , Mario Rossetti: The treatment of hiatal hernias and reflux oesophagitis with gastropexy and fundoplication. Indication, technique and results. G. Thieme, Stuttgart 1959.
  • JP Pearson, S. Parikh, RC Orlando, N. Johnston, J. Allen, SP Tinling, N. Johnston, P. Belafsky, LF Arevalo, N. Sharma, DO Castell, M. Fox, SM Harding, AH Morice, MG Watson, MD Shields, N. Bateman, WA McCallion, MP van Wijk, TG Wenzl, PD Karkos, PC Belafsky: Review article: reflux and its consequences - the laryngeal, pulmonary and oesophageal manifestations. Conference held in conjunction with the 9th International Symposium on Human Pepsin (ISHP) Kingston-upon-Hull, UK, 21-23 April 2010 . In: Aliment Pharmacol Ther . 33 Suppl 1, 2011, p. 1-71 , PMID 21366630 ( wiley.com [PDF]).

Web links

Individual evidence

  1. ↑ Reflux disease (heartburn)
  2. ↑ Esophagitis - premalignant formations. (PDF; 85 kB) (No longer available online.) Www.dgvs.de, archived from the original on August 13, 2011 ; Retrieved January 27, 2011 . Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. @1@ 2Template: Webachiv / IABot / www.dgvs.de
  3. ↑ Chewing gum for heartburn. www.aerzteblatt.de, accessed on June 8, 2010 .
  4. ↑ Chewing gum to complement reflux treatment. www.sodbrennen-welt.de, accessed on June 8, 2010 .
  5. ↑ Too much stomach acid: which remedies help. Retrieved Oct. 24, 2014.
  6. ↑ a b c V. Savarino, F. Pace, C. Scarpignato, the Esoxx Study Group: Randomized clinical trial: mucosal protection combined with acid suppression in the treatment of non-erosive reflux disease - efficacy of Esoxx, a hyaluronic acid-chondroitin sulphate based bioadhesive formulation . In: Alimentary Pharmacology & Therapeutics . tape 45 , no. 5 , March 2017, p. 631–642 , doi : 10.1111 / apt.13914 , PMID 28116754 , PMC 5347926 (free full text) - ( wiley.com [accessed September 23, 2019]).
  7. ↑ Massimo Di Simone, Fabio Baldi, Valentina Vasina, Maria Laura Bacci, Fabrizio Scorrano: Barrier effect of Esoxx® on esophageal mucosal damage: experimental study on ex-vivo swine model . In: Clinical and Experimental Gastroenterology . June 2012, ISSN  1178-7023 , p. 103 , doi : 10.2147 / CEG.S31404 , PMID 22767997 , PMC 3387832 (free full text) - ( dovepress.com [accessed September 23, 2019]).
  8. ↑ B. Palmieri, A. Merighi, D. Corbascio, V. Rottigni, G. Fistetto: Fixed combination of hyaluronic acid and chondroitin-sulphate oral formulation in a randomized double blind, placebo controlled study for the treatment of symptoms in patients with non -erosive gastroesophageal reflux . In: European Review for Medical and Pharmacological Sciences . tape 17 , no. December 24 , 2013, ISSN  1128-3602 , p. 3272-3278 , PMID 24379055 (PMID = 24379055 [accessed September 23, 2019]).
  9. ^ Cancer Therapy and Oncology International Journal (CTOIJ). Retrieved September 23, 2019 .
  10. ↑ Patrick du Souich, Antonio G. García, Josep Vergés, Eulàlia Montell: Immunomodulatory and anti-inflammatory effects of chondroitin sulphate . In: Journal of Cellular and Molecular Medicine . tape 13 , 8A, August 2009, ISSN  1582-4934 , p. 1451–1463 , doi : 10.1111 / j.1582-4934.2009.00826.x , PMID 19522843 , PMC 3828858 (free full text) - (PMID = 19522843 [accessed September 23, 2019]).
  11. ↑ M. Schnabelrauch, D. Scharnweber, J. Schiller: Sulfated Glycosaminoglycans As Promising Artificial Extracellular Matrix Components to Improve the Regeneration of Tissues. 2013, accessed on September 23, 2019 .
  12. ↑ Kessiena L. Aya, Robert Stern: Hyaluronan in wound healing: Rediscovering a major player: Hyaluronan in wound healing . In: Wound Repair and Regeneration . tape 22 , no. 5 , September 2014, p. 579-593 , doi : 10.1111 / wrr.12214 ( wiley.com [accessed September 23, 2019]).
  13. ^ H. Renz-Polster , S. Krautzig: Basic textbook internal medicine 4th edition. 2006, p. 559 f.
  14. ↑ F. Pace, S. Pallotta, M. Tonini, N. Vakil, G. Bianchi Porro: Systematic review: gastro-oesophageal reflux disease and dental lesions . In: Aliment Pharmacol Ther . tape 27 , no. 12 , 2008, p. 1179-1186 , PMID 18373634 .