Gastroesophageal reflux disease (GERD) is defined as a movement, in other words, penetration of hydrochloric acid and bile into the esophagus. Approximately 15-20% of the population of Germany suffer from this pathological condition, which can be accompanied by heartburn, severe chest pain, especially behind the sternum. It is possible to diagnose and treat reflux disease in a timely manner by using various methods such as gastroscopy or pH-metry.
The main treatment for reflux disease includes the administration of medications that suppress the secretion of hydrochloric acid in the stomach and the maintenance of diet, as well as the refusal of alcohol and nicotine. When conservative therapy is used, it is possible to reduce or eliminate complaints in most cases. In the late stages of reflux disease, or in the cases when it does not respond well to the treatment, surgery may be necessary. The information on the types of reflux disease, symptoms, causes, diagnosis and therapy will help readers who are interested in it to understand if they have reflux disease or not.
Symptoms of Reflux Disease
Typical symptoms of reflux disease are heartburn, dysphagia and nausea. The discomfort often increases when the patient is lying or stooping, because the change in the position of the body contributes to the gastric acid reflux from the stomach into the esophagus under the effect of gravity. Burning pain or a feeling of pressure behind the sternum are also typical complaints. Other symptoms may include sore throat and hoarseness.
Types of Esophageal Reflux Disease
In healthy people, the reflux of hydrochloric acid and bile secretion into the esophagus is prevented by the muscles in the lower part of the esophagus. If this function is impaired, hydrochloric acid penetrates into the esophagus. If this condition lasts for a long period of time or is frequently repeated, the delicate mucous membrane of the esophagus may be damaged. The disease is often accompanied by painful inflammation and ulceration of the esophagus. Inflammation without any changes in the mucous membrane is called non-erosive gastroesophageal reflux disease. About 60 per cent of patients suffer from this type of reflux disease. Inflammation involving mucous membrane lesions is called erosive gastroesophageal reflux disease.
Modern medicine also distinguishes between primary and secondary reflux disease. A common characteristic of the disease is that the lower esophageal sphincter loses its ability to function properly. Primary reflux disease is the most common type of the disease. Its peculiarity is that there are no obvious causes of the disease. It is only visible that the lower esophageal sphincter is weakened outside the normal act of swallowing, and thus the esophagus is not tightly closed on the side of the stomach. The causes of primary reflux disease are obesity, unhealthy diet or weakness of the diaphragm. Secondary reflux disease is always caused by the presence of predisposing factors, such as pregnancy or diaphragmatic hernia.
Reflux Disease with Esophagitis
When untreated, reflux disease can lead to esophagitis. It is a disease that causes inflammation and ulcers (ulceration) in the esophagus. Doctors describe this pathology as a reflux disease with esophagitis. The degree of severity of esophagitis, according to the Savary-Miller classification system, is divided into four grades.
Barrett's Reflux Esophageal Disease
Barrett's reflux esophageal disease is a pathological change in the esophageal mucosa that causes the transformation of the cells (metaplasia) in the esophagus and increases the long-term risk of malignant tumor formation. Long-term studies have shown that the risk of esophageal cancer is around 40 times higher at a later stage of the disease.
Reflux Disease and Other Complications
Other complications of the late stages of reflux disease are inflammation and laryngeal and tracheal edema. Patients often suffer from hoarseness and irritating coughing. Sometimes pneumonia develops because of the acid load on the trachea.
Defintion of GERD
With a prevalence of 10-20% in Western Europe and North America, gastroesophageal reflux disease (GERD) is one of the most common benign diseases of the upper gastrointestinal tract in industrialized countries. Far larger shares of Western population complain of less frequent reflux symptoms with no disease value. The prevalence of GERD has increased continuously in recent years; on the one hand, presumably due to the changed lifestyle, on the other hand, also by improving the Diagnosis. Because of this, your therapy has an important place in everyday clinical practice. GERD is defined as a condition with annoying symptoms and / or complications due to reflux of gastric contents goes into the esophagus. Another definition of the 1999 Genval Workshop defines GERD as the presence of esophageal mucosal defects or the occurrence of reflux-induced symptoms that are severe are enough to affect the quality of life. Occasionally occurring reflux without consequential damage and without impairing the quality of life is therefore not considered to be pathological; conversely, reflux disease according to the definition also exists if there are no subjective symptoms, but only morphological reflux-typical changes (reflux esophagitis, Barrett's esophagus, stricture). Reflux symptoms occurring on 2 or more days per week make the presence of reflux disease likely. Studies showed that even minor complaints that occur with this frequency are accompanied by a significant decrease in quality of life, which was measured by a disease-specific questionnaire (QUOLRAD - Quality of Life in Reflux and Dyspepsia).
Diagnosis of GERD
If there is anamnestic evidence of GERD, various diagnostic measures can be considered, which will be discussed in detail below.
Endoscopy in case of GERD
Basically, according to the recommendation of the Genaval Workshop and various other authors, endoscopy is not absolutely required for the diagnosis of GERD, but only if there is no symptom control after probatory PPI therapy or if there are alarm symptoms such as dysphagia or bleeding. This recommendation can be justified by the results of a prospective study in which there was no correlation between typical reflux symptoms and the presence of carcinoma. In 4% of the patients with alarm symptoms, however, carcinoma could be detected gastroscopically and in 13% other clinically relevant findings such as ulcerations, strictures and severe esophagitis. On the other hand, the AWMF guideline recommends early endoscopy even if the reflux symptoms are clear and there are no alarm symptoms.
Frantz also describes endoscopy as the gold standard in the diagnosis of GERD and thus as the first measure in cases of suspected GERD. Endoscopic evidence of Typical erosive mucosal lesions in the distal esophagus or following the Z line allow the diagnosis of reflux esophagitis and are therefore considered sufficient evidence for the presence of a GERD. In the event of erosion, a biopsy of the affected mucosa should be carried out in order to be able to histologically classify reflux esophagitis. Furthermore, the biopsy serves to exclude Barrett's mucosa / malignancy before further therapy. The macroscopic endoscopic classification of GERD is based on one of the following 3 Savary-Miller classifications, the Los Angeles or the MUSE classification. The Savary-Miller classification is most commonly used in German-speaking countries; In recent years, however, the Los Angeles classification has become increasingly popular. In> 95% of GERD patients, the endoscopic stage does not change over the course of several years, so that regular control endoscopies are not necessary. Progression of esophagitis severity is unlikely, particularly with therapy that adequately controls symptoms. A longitudinal study showed, however, that a transition from an endoscopic negative reflux disease to an erosive esophagitis and vice versa is rare, but not excluded, since the determining factors such as the acid exposure of the esophagus, the reaction of the mucosa and visceral sensitivity with age , with stress and other factors can change. If there are no erosions, this does not rule out GERD. Endoscopy is also used to (approximately) determine the size of a hiatal hernia.
24-hour esophageal pH monitoring
The pH measurement is used for the quantitative measurement of the acid exposure of the distal esophagus and the manometry is primarily carried out when surgical treatment is being considered. It is the diagnostic method with the highest sensitivity (77-100%) and specificity (85-100%) in patients with endoscopically confirmed reflux esophagitis. A significantly lower sensitivity (0-71%) is found in patients with endoscopically negative GERD . The diagnostic sensitivity of 24-hour pH measurement is often overestimated. For example, up to 25% of patients with reflux oesophagitis as well as a third of patients with non-erosive reflux disease can expect quantitatively normal values. A score developed by T. DeMeester to quantify the reflux is calculated from the following measured values: percentage acid exposure time pH < 4, number of refluxes > 5 minutes, duration of the longest reflux and the total number of refluxes. Securing the diagnosis using pH-measurement is of great importance, not least for forensic reasons, before surgery.
Another diagnostic option that is frequently used in primary care is to carry out a so-called PPI test, in which PPI is usually taken in double standard doses (e.g. omeprazole 20 1-0-1) over about 7-14 days. If the symptoms go away, GERD is considered very likely. The sensitivity and specificity of this test are assessed at 78% and 86% respectively and elsewhere with a sensitivity of 80%, specificity 74% in patients with noncardiac chest pain vs. Sensitivity 78%, specificity 54% in patients with reflux symptoms without chest pain . The diagnostic value of this test is therefore comparable to that of a 24-hour pH measurement. However, it should be borne in mind that PPI therapy is sometimes associated with a clear placebo effect. In addition, the Diamond study observed a positive response of GERD patients to PPI in 54% of cases (71% in patients with classic re ux symptoms), but 35% of patients with upper abdominal symptoms without GERD also felt one Symptom improvement through PPI, which speaks for a very low specificity of the PPI test.