Gastroesophageal reflux,

see also: the strange chest pain. and abdominal pain

notes Dr. Claudio Italiano, gastroenterologist hospital

Always on my site, in terms of the esophagus, not wanting to create panic in my gentle surfers, but to explore the theme of chest pain and dysphagia, I invite you to compare:

. Gastroesophageal reflux (GERD) is a pathological condition characterized by symptoms or histopathological lesions of the esophagus caused by acid reflux material from the stomach into the esophagus, where normally there must be an environment with pH tending towards alkalinity. GERD has a prevalence of 5-6% of the general population, with peaks in the elderly, pregnant women, where the pressure of gravid uterus facilitates the rise of acid into the esophagus even in 48-79% of times / day. Can cause major complications such as Barrett's esophagus and esophagus, especially in males.



Pathogenesis. Normally there is an activity of the esophagus clearance (cleaning) for which peristaltic waves and the same saliva allow the progression of ingest and material esophagus to the stomach. In normal subjects there are defense systems that prevent the reflux of acid into the esophagus and material that are made by the lower esophageal sphincter or LES, from the snare of Allison and the angle that the esophagus has the axis of the stomach following the caliper snare Allison. But even in healthy individuals may experience regurgitation in approximately 2% of the subjects in standing and even less at night. The same swallowed saliva can help to expel material into the esophagus because it gives rise to a peristaltic wave: normally the subject swallow 192 times per hour during the meal and 72 times per day. During sleep, however, swallowing drops to 7 times per hour. Thus in the pathogenesis of GERD disease depends on:

.... A) impaired clearance activities

b) compromised defense systems (eg SLE, snare Allison, etc...)

The activity of dell'esaofago clearance, for example, is reduced in patients with scleroderma, where the lack of LES barrier and there is no peristalsis: the esophagus is just a pipe. Another condition is gastroparesis, the stomach contents where the pond and you slow digestion (gastroparesis of diabetic and of the elderly). If, however, the sphincter apparatus, it was seen that SLE measure 3-4 cm and has a pressure of 10-30 mmHg, when the pressure is <6 mmHg, then appears reflux disease (endoscopically the gastric cardia may appear beante , sometimes there can be from hiatus hernia slides (the cardia, where the dates in the chest for laxity continence systems and determine the acid reflux but in 33-70% of individuals) malposition cardial etc...) LES pressure can be reduced in patients using drugs such as alpha-adrenergic antagonists, beta agnoni adrenenrgici, abusive chocolate, alcohol, fats, meat broth, mint, calcium channel blockers, morphine, benzodiazepines, etc..

Symptoms. Symptoms appear 3-5 minutes after ingestion of milk and acid; consist belching juice or gastric contents, with dysgeusia (bad taste), acid regurgitation of stomach contents, especially if you bend forward (sign of shoelaces!), dysphagia, ie difficulties to swallow, swallowing, or feel pain when swallowing (for esophagitis, for esophageal candidiasis in AIDS patient, to herpetic infection or CMV).

Diagnosis. To understand the symptoms depend on what the patient complains (Warning to other situations that occur with chest pain: think also to ischemic heart!) Examination will be indicated esophagogastroduodenoscopy that allows us to make an endoscopic classification of esophagitis that follows the GERD.

.. Classification of reflux oesophagitis

Grade 0 normal esophagus but only relief of GERD

A grade 1 or more confluent lesions accompanied by erythema or exudate at the top level of the gastroesophageal transition zone.

Grade 2 lesions exudative, erosive, non-circumferential confluent.

Grade 3 erosive and exudative lesions circumferential

Grade 4, chronic mucosal lesions (ulcers, Barrett's esophagus or narrowing)

Diagnostics.

The patient performs the tests with acid or Bernstein, confirming the symptoms when instilled into the esophagus in 0.1 N HCl diluted with distal esophageal probe. Furthermore, esophageal manometry and ambulatory 24 hours PH metry by pHmeter electrode.

Therapy. The therapy uses tablets antacids after meals and at bedtime, sucralfate, H2-antagonists, proton pump inhibitors, prokinetic drugs to increase the tone of the LES and to facilitate gastric emptying, it is, however, long treatments, continue with the advice of your doctor.

Complications. If medical therapy has failed and you are certain serious injuries, such as Barrett's esophagus, ie islands of gastric mucosa in the esophagus, which reflect a degeneration of the metaplastic esophageal rivestimentyo laminated flooring that goes to precancerous columnar epithelium (5 -7% of subjects) can think of a probe laser ablation BICAP metaplastic segment followed by alkaline gastroesophageal reflux.

In the case of stenosis, may be used to esophageal dilatation with Maloney in polyvinyl catheters filled with mercury or Savary dilators American Gulliard wire guided balloon tires endoscopy. In severe cases should be the placement of implants raffiungere sufficient dilatation of 14 mm or 44 F.

The diet for acid reflux oesophagitis



Other causes of chest pain. (See Esophageal manometry)

The nutcracker esophagus is the most common manometric abnormality. The name derives from the extremely high pressures generated by esophageal peristalsis. Diagnosis is based on a capacity peristaltic average> 180 mmHg during swallowing.

The nonspecific esophageal dysmotility is a diagnostic category that includes individuals with weak or so minor, is the second manifold exhibit in order of motility.

Diffuse esophageal spasm occurs when swallowing produces simultaneous waves instead of the normal peristalsis, ie the succession of waves that determine the sequence of swallowing movements.

High basal LES pressure associated with chest pain.

achalasia means the loss of peristalsis with low complete lower esophageal sphincter relaxation after degutizione. It 'an inherited disorder, familial rare (1:1,000,000), sometimes caused by a parasite Trypanosoma Cruzy that can destroy the ganglia of myenteric plexus of the distal esophagus, vagus nerve injury also may determine the presence of achalasia or adenocarcinoma involving the stomach and / or cancer of the 'distal esophagus (WHY' Warning as there are swallowing problems!). The symptom is the inability to swallow, dysphagia that accompanies regurgitation of undigested food, such as white foamy mass, also appears a sense of chest pain as crushing, substernal, which radiates to the neck and jaw. Patients lose weight.

Investigations to be conducted. Profit esophagus barium X-ray image that will give the "bird's beak" in endoscopy will be difficult to cross the gastroesophageal junction (Z line); manometry readings confirming the diagnosis of non-relaxing lower esophageal sphincter (LES ), hypertonic LES, peristalsis almost absent.

Therapy. Consists of the pneumatic dilation of the sphincter with the aim of determining a controlled tear of the muscles of LES (risk of perforation!), Or surgery to Heller (myotomy of the sphincter), which is to create an indentation in the musculature of the LES .
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