Lectures on the treatment of gastroesophageal reflux disease

2021-08-07 01:44 PM

Diagnosis based on clinical examination can be supplemented by a 2-week trial with a double dose of proton pump inhibitor. This method is sensitive.

Diagnose

Symptom

Diagnosis of gastroesophageal reflux disease is mainly based on functional symptoms. Most patients have the typical symptom of heartburn. However, many patients do not understand this symptom well. Therefore, this symptom should be described as a burning sensation from the stomach or lower chest spreading to the neck. Asking like this helps us find more reflux patients than just asking about heartburn.

Note the overlap in symptoms of gastroesophageal reflux disease and peptic ulcer disease, non-ulcer gastrointestinal disorders, and irritable bowel syndrome. About two-thirds of patients also have dyspepsia (epigastric pain or discomfort) and about 40% of patients with irritable bowel syndrome also have symptoms of GERD.

The severity of symptoms is not a reliable indicator of the severity of esophagitis. However, symptoms of dysphagia, dysphagia, difficulty breathing at night, vomiting blood, or weight loss are warning signs of serious illness, complications, or other diseases.

Trial treatment

Diagnosis based on clinical examination can be supplemented by trial treatment with a double dose of proton pump inhibitor for 2 weeks. This method has a sensitivity and specificity comparable to esophageal pH monitoring and better than esophagogastroduodenoscopy.

Exploratory methods

Not all patients with suspected reflux symptoms should be offered exploratory procedures. Patients with mild symptoms typical of reflux and no warning symptoms should try treatment first without any other investigation.

Exploratory methods should be performed when:

The diagnosis is unclear because the symptoms are nonspecific and atypical for reflux or are mixed with other gastroduodenal symptoms such as associated epigastric pain.

Symptoms persist or do not decrease after treatment.

Symptoms are suggestive of severe or complicated esophagitis (hematuria, persistent dysphagia).

Other diseases have not been excluded:

Infectious or drug-induced esophagitis.

Esophageal malignancy.

Gastroduodenal disease.

Heart attack or ischemia.

Probe selection method

Esophageal-gastro-duodenal endoscopy is the first choice because:

It is the most sensitive test for the diagnosis of reflux esophagitis.

Provides the most accurate diagnosis for other mucosal lesions such as infectious esophagitis, peptic ulcer, malignancies, or other diseases of the gastrointestinal tract that are difficult to distinguish from reflux if based solely on history.

As the most effective way to grade esophagitis, this is important in choosing treatment for this condition.

It is the most sensitive method for the diagnosis of Barrett's esophagus.

Useful for detecting and treating ulcerative esophageal stricture.

However, endoscopy also has limitations because more than half of patients with gastroesophageal reflux disease have negative endoscopy results. In these patients, a routine biopsy is not required because only < 25% of biopsies will detect esophagitis and while the cost of this will increase without compromising treatment aimed at symptom control.

In patients with alarming symptoms, endoscopy should be performed immediately prior to trial therapy. Endoscopy is also indicated for patients with atypical symptoms or when unresponsive to initial treatment. Endoscopy should be repeated within 6 months prior to surgical planning to rule out new or unexpected pathologies.

The role of endoscopy in cases of reflux that have received long-term endoscopic therapy is less convincing. Healing of lesions is equivalent to symptom control; therefore, endoscopic evaluation is only necessary if the disease recurs despite good treatment, especially to consider long-term treatment or to rule out potential complications. risk of severe esophagitis.

Indications and applications of endoscopy:

There are alarming symptoms (dysphagia, dysphagia, weight loss, bleeding, abdominal mass, anemia).

Difficult to diagnose (symptoms are confused, nonspecific, atypical).

Symptoms do not respond to initial treatment.

Preoperative assessment.

Increase trust when words are not convincing enough.

Symptoms are persistent, frequent, and bothersome.

To monitor drug treatment.

The LOS ANGELES classification system for esophagitis endoscopically:

Degree

Define

A

There is one (or more) mucosal scrapes but less than 5 mm, and does not exceed two crests of the chronic folds

B

There is one (or more) mucosal abrasions exceeding 5 mm, and not exceeding the two apex of the mucosal folds

C

There is one (or more) mucosal abrasions across two or more apical mucosal folds, but not exceeding 75% of the esophageal circumference.

D

There is one (or more) mucosal break that exceeds 75% of the circumference of the esophagus.

Contrast esophagogram - stomach:

It is an inappropriate diagnosis because it is insensitive and nonspecific for reflux disease. However, it is useful to evaluate and plan treatment for patients with persistent dysphagia with suspected stenosis or investigation for a hernia.

Monitor esophageal pH for 24 hours:

To investigate whether the symptoms are related to the occurrence of reflux, it is useful for cases where the diagnosis is unknown after trial therapy and endoscopy.

Treatment

Gastroesophageal reflux disease is a chronic disorder. It is important to educate patients to modify their lifestyles and habits that may promote GERD and to encourage them to choose new habits for long-term beneficial results.

Target

Reduce symptoms and restore quality of life.

Heal esophagitis if present prevents a recurrence.

Reduce the risk of complications.

Non-drug treatment (lifestyle changes)

Lifestyle changes are also valuable in patients with mild and infrequent symptoms, where lifestyle changes and the use of antacids or H2-receptor antagonists may suffice.

In patients with moderate disease, lifestyle changes only add to drug therapy because there is sufficient evidence that they are relatively ineffective at improving symptoms as well as ineffective for healing. esophagitis.

Some measures to help increase the removal of acid from the esophagus or reduce the frequency of reflux episodes include:

Dietary changes:

Patients often determine for themselves which foods cause reflux symptoms and which they avoid. However, unnecessarily strict dietary advice often leads to patient incoordination.

Foods that are often because of reflux include foods that are high in fat and spices. Some drinks that can aggravate symptoms include cola, strong coffee, tomato juice, and orange juice.

Other changes that are also useful include:

Avoid late meals and overeating.

Avoid lying on your back immediately after a meal.

Avoid wearing clothes that are too tight right after a meal.

Raise the head of the bed:

May be good for patients with nocturnal or laryngeal symptoms but is not always effective and can also be unnecessarily uncomfortable. Sleeping with a high pillow is preferred because it does not affect the people sharing the bed.

Alcohol:

Excessive drinking can increase symptoms, so don't drink too much. Drinks with a low pH like red wine can increase symptoms. Moderate drinking is acceptable in most cases.

Medicine:

Many medications can increase reflux symptoms including:

Progesterone or birth control pills containing progesterone.

Anticholinergic.

Sleeping pills, opiates.

Sedative.

Theophylline.

Beta-adrenergic agonists.

Calcium inhibitors.

Nitrate.

Aspirin and nonsteroidal anti-inflammatory drugs can make esophagitis worse.

Fat:

As a risk factor for reflux, whether weight loss improves symptoms varies from person to person. However, because of the benefits of weight loss, we should advise obese patients to lose weight.

Smoking:

Increases reflux and increases the risk of esophageal and other cancers. Smoking cessation is part of holistic health care.

Drug treatment

Patient self-medication:

Patients often self-administer antacids, antacid/anginate combinations and H2-receptor antagonists. This helps in mild cases and infrequent symptoms. Patients who take the drug regularly should consult a doctor to make the treatment more effective. Use of antacids is not effective in patients with moderate symptoms and non-healing esophagitis.

Drug treatment for the patient for the first time:

Purpose: there are 4 purposes in order of importance:

Confirm the diagnosis of gastroesophageal reflux disease by the response to treatment because most patients, with or without endoscopy, will be diagnosed by examination.

Relieves reflux symptoms because symptoms cause injury.

Reassure patients because some people fear cancer.

Treat esophagitis, if present, because esophagitis can cause strictures, bleeding, and Barrett's esophagus. Healing can take a long time.

Select the first drug treatment:

In most patients with reflux, treatment tends to be high-level at the outset because of better disease improvement, rapid response, and lower cost.

Proton pump inhibitors are the first-line treatment

Treatment with proton pump inhibitors for 4 weeks.

The above treatment should not be given to patients whose symptoms are not severe enough as defined by the disease.

Maintenance treatment:

Purpose: There are 3 goals in order of importance usually applied to the chronic stage of the disease.

Symptom control is effective because symptoms are most important to the patient and to the long-term goal of treatment.

Control risk because in a small number of patients this condition can cause complications and treatments have their own risks.

Minimize costs for long-term treatment because overtreatment can increase costs unnecessarily.

Approach to long-term treatment:

Each patient will respond to long-term treatment differently. Treatment regimens should be defined based on symptom control and not repeat endoscopy.

Try discontinuing the drug:

A small number of patients do not experience recurrence after discontinuation of treatment. That means it's right to try discontinuing the drug.

Patients with severe esophagitis (Los Angeles grades C and D) should not attempt discontinuation because of recurrent symptoms and should take a daily maintenance proton pump inhibitor.

Re-treat the cases of relapse and treat gradually according to symptoms:

Most patients will have a relapse, at which point treatment should be repeated as previously used successfully.

When patients respond to medication, symptomatic interval therapy should be attempted with H2-receptor antagonists or proton pump inhibitors.

Patients should take the standard dose once a day for symptomatic days.

Taking antacids has similar benefits.

Taking acid-suppressing drugs every day continuously:

Symptomatic treatment will be administered daily if interval therapy proves ineffective.

Because proton pump inhibitors are better than H2 blockers, they are used when H2 blockers fail.

Increasing the dose of H2 blockers is not clearly effective.

Drugs that regulate peristalsis, drugs that increase lower esophageal sphincter pressure and clear the esophagus:

Usually less effective than proton pump inhibitors.

The role of endoscopy in long-term treatment:

Patients requiring daily proton pump inhibitor therapy also require endoscopy to control disease risk during ongoing therapy.

Special cases:

When a patient fails to respond to a standard daily dose of a proton pump inhibitor, it may be due to:

Insufficient effect of proton pump inhibitors on gastric pH.

Misdiagnosis or severe complications of esophagitis.

A doubling of the therapeutic dose may be effective, but the patient should consult a specialist.

Surgery

Reflux surgery includes several types of pleated sutures with or without repair of the hiatal hernia. Surgery can be performed by open surgery or laparoscopically.

Point:

Unresponsive to medical treatment despite taking the full dose.

The drug has side effects or the patient is uncooperative.

Desire to not have to take long-term medication.

Risks and benefits:

The technique of suturing gastric aneurysms through laparoscopic surgery has been applied, with the advantages of reducing postoperative pain, shortening hospital stay, and returning to work faster than open surgery. The mortality rate is 0.2% and the morbidity rate is lower than open surgery. The results of surgery depend on the skill of the surgeon, including the control of symptoms and the rate of postoperative sequelae.

Possible sequelae after surgery such as increased indigestion, difficulty swallowing solid foods such as meat and bread, and eating quickly.

Generally, 88-93% of patients respond to surgery for a long time (10 years) and they see a complete reduction in symptoms, and the best mental health is those who have had long-term medical treatment without a cure. However, some patients still need to take antacids from time to time.

Perform:

Patients with indications for surgery should have the diagnosis of esophagitis confirmed by endoscopy at some point during the disease or by 24-hour pH monitoring. Contrast esophagography is not sensitive in the diagnosis of reflux. Esophageal manometry or esophageal motility is indicated to rule out primary sphincter disorders when suspected and also to rule out the absence of esophageal motility. Endoscopy should be performed within 6 months prior to a scheduled surgery to rule out other conditions.

Treatment of complications

Esophageal stricture:

If swallowing is not difficult: continue with a maintenance proton pump inhibitor.

If difficulty swallowing: add esophageal dilation, if failed, surgery.

Barrett's esophagus:

The consequence of gastroesophageal reflux is the transition from the squamous epithelium of the terminal esophagus to the columnar epithelium with associated intestinal metaplasia, which occurs in 10% of patients with gastroesophageal reflux disease. endoscopically detectable endoscopically. If only cells of the gastric epithelium or, rarely, of the pancreas are present, there is no high risk of cancer. However, if there is intestinal metaplasia, the risk of esophageal cancer is high. Most patients with Barrett's esophagus are often undiagnosed and unaware of the condition. Once Barrett's esophagus has developed, there is no convincing evidence that controlling acid with medication or surgery will prevent dysplasia. This could be a precancerous lesion.

Initial diagnosis: There is no convincing evidence that endoscopic screening of Barrett's mucosa is of any practical benefit. If the patient is undergoing endoscopy because of clinical symptoms of reflux and an incidental finding of Barrett's esophagus, multiple biopsies should be performed at four angles approximately 2 cm from Barrett's lesion to rule out dysplasia or accompanying cancer. The ability to detect malignancy of Barrett's esophagus at initial diagnosis is highest. If Barrett's mucosa is associated with esophagitis, dysplasia or atypical epithelial cells may be misdiagnosed. In this case, endoscopy should be repeated 3 months after treatment. There are no serological or endoscopic markers for dysplasia, and the definitive diagnosis should be based on histology.

Follow-up after diagnosis: In patients with severe dysplasia or early cancer, appropriate interventions can increase survival time. Endoscopy was performed every 2 years with biopsies of 4 corners of the esophagus 2 cm apart along the length of Barrett's mucosa. However, because the annual frequency of cancer transformation is only #0.5%, it is only necessary to follow up endoscopically every 4 years. It is not known that screening for the disease can reduce mortality, so screening should only be recommended. Consider for patients well enough for esophagectomy if needed. Screening of patients with Barrett's lesions shorter than 3 cm is under discussion because of the low cancer risk.

Dysplasia treatment:

If low-grade dysplasia, repeat endoscopy and biopsy within 6 months after the patient has received adequate proton pump inhibitor therapy to assess whether high-grade dysplasia has been missed. If low-grade dysplasia persists, reassess after 6 months and then annually. If high-grade dysplasia is suspected, a repeat biopsy should be performed. About one-third of cases of high-grade dysplasia have underlying cancer. About 15-60% of people with high dysplasia will turn to cancer within 1 - 4 years. Single-site dysplasia has a lower risk of cancer progression than multi-focal dysplasia.

If high-grade dysplasia is identified and no cancer is present, esophagectomy may be an option. In addition, it is possible to actively monitor every 3 months until cancer in the mucosa is detected, then esophagectomy will be performed. However, patients with high dysplasia are often elderly with many other comorbidities, if the patient refuses or is unsuitable for surgery, treatment with photodynamic or argon plasma coagulation may be chosen. or without endoscopic resection of the lesion. However, these measures are not effective for high-grade dysplastic lesions.

Helicobacter pylori, gastroesophageal reflux disease, and proton pump inhibitors

Helicobacter pylori and esophagitis:

H. pylori infection does not increase the risk of reflux esophagitis. Similarly, infection with H. pylori in most patients does not reduce the risk of reflux and esophagitis. The prevalence of H. pylori infection in patients with reflux is similar to that of the general population. Controlled studies have shown no difference in the prevalence of H. pylori infection in patients with and without esophagitis. The higher prevalence of esophagitis in populations with low H. pylori infection rates indicates epidemiological differences but not a cause-and-effect relationship.

Physiological studies with pH monitoring have shown that abnormal acid exposure of the esophagus (a marker of gastroesophageal reflux) is not affected by the presence or absence of H. pylori infection.

A small subset of patients infected with H. pylori with a more inflammatory strain (such as a cagA-positive strain) had less severe esophagitis and Barrett's esophagus. The cause is H. pylori infection in these patients often causes severe gastritis with atrophy and intestinal metaplasia that reduces the amount of acid secreted. However, they have a higher risk of stomach cancer or ulcers, so eradication of H. pylori needs to be set.

Consequences of reflux treatment for H.pylori infection:

Proton pump inhibitors aggravate gastritis histologically in patients with H. pylori infection. This phenomenon is accompanied by the development of atrophy of the gastric mucosa.

The risk of gastric mucosal atrophy is absent with long-term proton pump inhibitors in patients without H. pylori infection and in patients with previous successful eradication of H. pylori. This is very important, especially in young patients.

Consequences of H. pylori eradication for gastroesophageal reflux disease:

After H. pylori eradication therapy, reflux disease, and esophagitis did not improve or get significantly worse.

In a small group of patients eradication of H. pylori improves heartburn symptoms.

Eradicating H. pylori does not make controlling reflux symptoms more difficult