diagnose
For patients with burning sensation or pain behind the sternum, the presence or absence of GER can be determined by measuring pH value in esophageal cavity, pressure in esophageal cavity and gastroesophageal scintigraphy. Esophageal acid drop test can be used to determine whether symptoms are caused by gastroesophageal reflux. If necessary, the diagnosis can be made by esophageal endoscopy and biopsy.
Reflux esophagitis should be differentiated from peptic ulcer, angina pectoris, esophageal cancer and esophageal fungal infection.
Treatment measures
(a) the general treatment diet should be a small amount of meals, not too full; Avoid smoking, drinking, coffee, chocolate, sour food and excessive fat; Avoid lying flat after meals; When lying flat, the head of the bed is raised by 20 ~ 30cm, and the belt should not be tied too tightly, so as to avoid all kinds of situations that cause excessive abdominal pressure.
(2) promoting the emptying of esophagus and stomach
1. Dopamine antagonists These drugs can promote the emptying of esophagus and office and increase the tension of LES. These drugs include metoclopramide (metoclopramide, metoclopramide) and domperidone (domperidone, domperidone), both of which are 10 ~ 20 mg, and are taken 3 ~ 4 times a day before going to bed and meals. The former, if the dose is too large or taken for a long time, can lead to extrapyramidal nerve symptoms, so the elderly patients should use it with caution; Long-term use of the latter will also cause hyperprolactinemia, resulting in adverse reactions such as mammary gland hyperplasia, lactation and amenorrhea.
2. Cisapride promotes the peristalsis and emptying of esophagus and stomach by releasing acetylcholine from the postganglionic nerve of intestinal muscle plexus, thus reducing gastroesophageal reflux. 10 ~ 20 mg, 3 ~ 4 days a day, with few adverse reactions.
3. The cholinergic drug carbamoyl choline can increase the tension of LES, promote esophageal contraction, and accelerate the emptying of acidic food in esophagus to improve symptoms, 25mg each time, 3 ~ 4 times a day. This mouth can stimulate gastric acid secretion, so take it carefully for a long time.
(3) Reducing gastric acid ① Acidifier can neutralize gastric acid, thus reducing the activity of pepsin and reducing the damage of acidic gastric contents to esophageal mucosa. Alkaline drugs themselves can also increase the tension of LES. Aluminum hydroxide gel 10 ~ 30ml and magnesium oxide 0.3g, 3 ~ 4 times a day. Gariscon (alginate) contains alginic acid, sodium alginate and acidulant, which can float on the surface of stomach contents to prevent reflux of stomach contents. ② Histamine H2 receptor antagonists can be cimetidine, ranitidine and famotidine, with the dosage of 200mg, 3 ~ 4 times /d respectively. 150mg twice a day, 30mg a day. The course of treatment is 6-8 weeks. These drugs can strongly inhibit gastric acid secretion and improve gastroesophageal reflux. If the above symptoms cannot be improved, the dosage can be increased to 2 ~ 3 times. (3) proton pump inhibitors. These drugs can block H+-K+-ATPase in parietal cells. Omeprazole and lansoprazole have been widely used in clinic. The former 20mg/d and the latter 30mg/d can improve its symptoms.
(4) The combination of drugs for promoting esophageal and gastric emptying and antacids has a synergistic effect, which can promote the healing of esophagitis. Dopamine antagonists or cisapride can also be used in combination with histamine H2 receptor antagonists or proton pump inhibitors.
After stopping taking the drug, about 80% of the cases relapsed within 6 months because LES tension could not be fundamentally improved. If histamine H2 receptor antagonists, proton pump inhibitors or dopamine are used to antagonize the anti-Japanese occupation, or drugs are taken in time when symptoms occur, better curative effects can be achieved.
(5) Surgical treatment is mainly suitable for esophageal scar stenosis (feasible expansion or surgical correction) and medical treatment is ineffective, recurrent bleeding, recurrent pneumonia, etc.
pathogenesis
24-hour esophageal pH monitoring found that normal people had gastroesophageal reflux (GER) but no clinical symptoms, so it was called physiological GER. Its characteristics are as follows: it occurs mostly during the day and is rare at night; Reflux usually occurs during or after meals; Total reflux time 1. When the resting pressure of LES is less than 0.8 kPa (6 mmHg), or the ratio of the two is less than 1, it indicates that LES is not functional or GER exists.
(4) Gastroesophageal scintigraphy This method can estimate gastroesophageal reflux. Put the inflatable abdominal band on the patient's abdomen, take 300ml of acidified orange juice solution containing 300μCi99mTc-Sc orally on an empty stomach (containing orange juice 150ml and HCl150ml 0/n), and then drink 15 ~ 30ml of cold boiled water to remove the residual test in esophagus. Normal people 10 ~ 15 minutes later, there was no radioactivity above the stomach. Otherwise, it means that GER exists. The sensitivity and specificity of this method are about 90%.
(5) The sensitivity of X-ray examination of esophageal barium swallowing is low, and there are many false negatives.
(VI) Endoscopy and biopsy Through endoscopy and biopsy, it is of great value to determine whether there are pathological changes of reflux esophagitis, bile reflux and pathological severity of reflux esophagitis. According to Savary and Miller's classification criteria, the inflammatory lesions of reflux esophagitis can be divided into four grades: Grade ⅰ is single or several non-fusion lesions, showing erythema or superficial erosion; Grade ⅱ is a fusion disease, but it is not diffuse or peripheral; Grade ⅲ lesions were diffuse around, with erosion but no stenosis; Grade ⅳ showed chronic diseases, such as ulcer, stenosis, fibrosis, relaxation and shortening of feeding, Barrett's esophagus.