Gastroesophageal reflux disease. How to treat gerb: recommendations and prescriptions from doctors Treatment regimens for gerb

In the treatment of gastroesophageal reflux disease, antacids, histamine receptor blockers, proton pump inhibitors and prokinetic drugs are used.

The use of a specific group of drugs depends on the age of the patient, the stage of the pathological process, and the severity of symptoms. Next we will describe how to treat reflux esophagitis and what pills the doctor prescribes.

Antacids

– a group of drugs whose purpose is to neutralize excess acidity of gastric juice through chemical reactions. Most modern drugs contain magnesium, calcium, and aluminum in the form of chemical compounds. The mechanism of action is based on these substances.

In addition to the main components, the composition may contain excipients that have the following effects:

• laxative;
• antispasmodic;
• anesthetic (anaesthetic) and others.

Antacids are classified on the:

• absorbable (systemic);
• non-absorbable (non-systemic).

The difference between them is that systemic ones have the ability to be absorbed into the blood, while non-systemic ones do not.

Systemic antacids

These drugs are also used for reflux esophagitis. Their positive side is the speed of onset of the therapeutic effect; patients note the elimination of heartburn within a few minutes.

On the other hand, the effect of using these drugs is quite short-lived. In addition, gastroenterologists describe the phenomenon of rebound after discontinuation of absorbable drugs. It consists in the fact that when the intake of the active substance into the body is stopped, the synthesis of hydrochloric acid (HCl) by the parietal cells of the stomach increases.

Another disadvantage is the formation of carbon dioxide during the chemical neutralization of hydrochloric acid. This leads to distension of the stomach, which provokes new gastroesophageal reflux.

Excessive absorption of the active substance into the blood can cause a shift in the acid-base balance towards alkalization (alkalosis).

Among the drugs in the group of non-systemic antacids are:

• Rennie;
• Bourget mixture;
• sodium bicarbonate;
• calcium carbonate;
• magnesium oxide and others.

With long-term use of calcium-containing products, constipation and the formation of kidney stones may occur, and when combined with dairy products, nausea, vomiting, and bloating may occur.

Non-systemic antacids

They differ from systemic ones in the slower onset of the therapeutic effect. However, the non-absorbable group lasts much longer than the absorbed drugs.

Non-systemic drugs do not have the rebound phenomenon, do not form carbon dioxide when neutralizing hydrochloric acid, and generally have fewer side effects.

According to their composition, they are divided into:

• containing aluminum phosphate (Phosphalugel);
• magnesium-aluminum products (Alumag, Almagel, Maalox);
• calcium-sodium (Gaviscon);
• containing aluminum, magnesium, calcium (Talcid, Rutacid).

In addition, there are combination medications, the most popular of which are magnesium-aluminum combinations. Almagel A includes anesthesin, which adds an analgesic effect to the drug.

Simethicone is also added to the main substance, which is used in the treatment of bloating (flatulence). Such remedies include Gestid, Almagel Neo. Other drugs are also used to treat reflux esophagitis in adults.

Histamine receptor blockers

Histamine (H2) receptor inhibitors have the ability to suppress the secretion of hydrochloric acid by the parietal cells of the stomach. This is a fairly old group of drugs, which is now used only in certain categories of patients.

This is due to the fact that they cannot provide 100% control over the production of hydrochloric acid, since its production, in addition to histamine, is also regulated by gastrin and acetylcholine. Also, H2 blockers have the rebound phenomenon, which was described above.

In addition, the effect of their use decreases with each repeated dose (tachyphylaxis). Tachyphylaxis appears on the third day of daily use of the medicine. As a result, histamine receptor blockers cannot be used for very long-term treatment of reflux esophagitis.

It is worth noting that the above phenomena manifest themselves in each person individually.

There are several generations of this group:

The most effective drug Based on the degree of inhibition of hydrochloric acid secretion, Famotidine (trade name Kvamatel) is considered. The relatively low incidence of side effects and economic factors also support it.

3rd generation drugs may be indicated for the treatment of gastroesophageal reflux disease in patients who do not experience tachyphylaxis.

Proton pump inhibitors

What other medications help with reflux esophagitis? Proton pump blockers (PPIs, Na/KATPase inhibitors) are a group of drugs aimed at inhibiting the secretion of HCl (hydrochloric acid) by acting on the parietal cells of the stomach. Unlike H2 blockers, PPIs allow complete control of secretion through dosage adjustment.

PPIs are considered effective and are used in gastroduodenitis with high acidity, peptic ulcer of the duodenum and stomach.

When taken orally, the active substance of the drug dissolves into the bloodstream, then into the liver, after which it enters the membranes of the main cells of the gastric mucosa. Further, as a result of complex physicochemical interactions, cells stop secreting hydrochloric acid, thereby reducing the acidity level (PH) of gastric juice.

There are up to 7 generations of PPIs, but they are all identical in their mechanism of action, differing only in the speed of onset of the effect (slightly) and the speed of elimination of the active substance from the body.

The most famous and the most commonly used PPI drug is Omeprazole(Omez). It belongs to the first generation of proton pump inhibitors and is considered the best in terms of price-quality ratio.

There are also widespread drugs for reflux esophagitis, such as:

In case of long-term use of large dosages, the risk of fractures of the limbs and spine increases, and there is a risk of developing hypomagnesemia (decreased magnesium levels in the blood).

Prokinetics

Prokinetics are a group of drugs that normalize gastrointestinal motility. They are divided into several subgroups according to their mechanism of action, but the most popular are representatives of dopamine receptor blockers (D2).

In the treatment of gastroesophageal reflux disease, they are used due to their ability to eliminate pathological reflux of gastric contents into the esophagus, and prokinetics generally have a positive effect on the peristalsis of the stomach and intestines.

A representative of the first generation is Metoclopramide (Cerucal), it is also classified as an antiemetic. This is a fairly old medicine, which is gradually fading into the background after the advent of the 2nd generation of prokinetic agents ( Domperidone, Domrid, Motilium).

The difference between the first and second generations is that the latter have fewer side effects. This is achieved due to the fact that 2nd generation dopamine receptor blockers have the ability not to penetrate the blood-brain barrier. Therefore, they do not cause spasms of the muscles of the face and eyes, protrusion of the tongue and others. Also, the 2nd generation practically does not provoke fatigue, headaches, weakness, or noise in the head.

How to treat reflux esophagitis? Drugs Itopride (Itomed, Primer) also included in the subgroup of D2 receptor blockers, but in addition it is capable of inhibiting acetylcholinesterase. This increases the amount of the mediator acetylcholine, which is necessary to improve gastrointestinal motility.

Antibiotics and vitamins in the treatment of GERD

Antibacterial drugs, that is, antibiotics, are not prescribed for reflux esophagitis. Their target is bacteria that cause an inflammatory response. In the case of GERD, inflammation is caused only by the reflux of acidic stomach contents into the alkaline environment of the esophagus.

Macrolide antibiotics(Azithromycin, Clarithromycin), which are used for the eradication of Helicobacter pylori (type B gastritis, peptic ulcer) have a positive effect on gastric motility, reducing the number of gastroesophageal refluxes. But their use is not indicated in the treatment of reflux esophagitis.

Vitamins for reflux esophagitis

Multivitamin complexes may be prescribed ( Duovit, Aevit, Vitrum, Multi-Tabs). Their use helps prevent hypovitaminosis and increase the protective and regenerative functions of the body.

Useful video: tablets for reflux esophagitis

Treatment regimen

When treatment is carried out for reflux esophagitis, what medications to take - we figured it out, now it is important to know how to do it. The frequency of administration, dosage and choice of medications is carried out by the attending physician after a face-to-face consultation. Self-medication can lead to a worsening of the disease, a decrease in quality of life, and irreversible consequences.

To eliminate the neutralization of hydrochloric acid in the first few days, systemic ( Rennie) or non-systemic antacid drugs ( Phosphalugel, Almagel). In case of intense pain, it is more rational to use Almagel A.

From the first day, the use of proton pump inhibitors is indicated ( Omeprazole, Omez) course for 4-6 weeks. During this period, the doctor adjusts the dose, selecting the optimal minimum dosage for a particular person. It is worth noting that PPIs are considered the main component of treatment for GERD in adults.

The last link is prokinetic drugs ( Domperidone) course for several weeks to reduce the number of gastroesophageal refluxes.

In some cases, the use of H2 blockers is allowed ( Famotidine) instead of proton pump inhibitors. This is basic information on the topic of treatment of reflux esophagitis, the most effective medications.

Gastroesophageal reflux disease (GERD) questions and answers

The International Foundation for Functional Gastrointestinal Diseases (IFFGD), USA, has prepared a range of materials on functional gastrointestinal disorders for patients and their families. This material is devoted to gastroesophageal reflux disease.

Originally written by Joel Richter, Philip O. Katz, and J. Patrick Waring, edited by William F. Norton. In 2010, an updated version was prepared by Ronnie Fass.

Even a little knowledge can make a big difference

Introduction

Gastroesophageal reflux disease, abbreviated as GERD, is a very common disease, affecting at least 20% of adult US men and women. It is also common in children. GERD often goes unrecognized because its symptoms can be misinterpreted and this is unfortunate, since GERD is usually treatable, and if left untreated, serious complications can occur.

The purpose of this publication is to gain a deeper understanding of issues such as the nature of GERD, its definition and its treatment. Heartburn is the most common, but not the only symptom of GERD. (The disease can even be asymptomatic). Heartburn is not a specific symptom for GERD and may result from other diseases of the esophagus or other organs. GERD is often treated independently, without consultation with specialists, or treated incorrectly.

GERD is a chronic disease. Her treatment must be on a long-term basis, even after her symptoms are under control. Proper attention must be paid to changes in daily life habits and long-term medication use. This can be done through follow-up and patient education.

GERD is often characterized by painful symptoms that can significantly impair a person's quality of life. Various methods are used to effectively treat GERD, ranging from lifestyle changes to medications and surgery. For patients suffering from chronic and recurrent symptoms of GERD, it is important to obtain an accurate diagnosis and receive the most effective treatment available.

What is GERD?

Gastroesophageal reflux disease or GERD is a very common condition. Gastroesophageal means that it relates to both the stomach and the esophagus. Reflux- that there is a reverse flow of acidic or non-acidic stomach contents into the esophagus. GERD is characterized by its symptoms and can develop with or without damage to the tissues of the esophagus, resulting from repeated or prolonged exposure of the esophageal mucosa to acidic or non-acidic stomach contents. If tissue damage is present, the patient is said to have esophagitis or erosive GERD. The presence of symptoms without visible tissue damage is called non-erosive GERD.

GERD is often accompanied by symptoms such as heartburn and sour belching. But sometimes GERD occurs without visible symptoms and is detected only after complications become obvious.

What causes reflux?

After swallowing, food passes down the esophagus. Once in the stomach, it stimulates cells that produce acid and pepsin (an enzyme), which are necessary for the digestion process. A bundle of muscles at the bottom of the esophagus, called the lower esophageal sphincter (LES), acts as a barrier to prevent stomach contents from flowing back (reflux) into the esophagus. To allow the swallowed portion of food to pass into the stomach, the LES relaxes. When this barrier relaxes at the wrong time, when it is weak, or when it is otherwise not effective enough, reflux can occur. Factors such as bloating, delayed stomach emptying, a significant hiatal hernia, or too much stomach acid can also trigger acid reflux.

What Causes GERD?

It is not known whether there is a single cause of GERD. Failure of the esophageal defenses to resist aggressive gastric contents entering the esophagus during reflux can lead to tissue damage to the esophagus. GERD can also occur without damage to the esophagus (approximately 50-70% of patients have this form of the disease).

Surgery . Surgical treatment may be indicated in the following cases:

• the patient is not interested in long-term drug therapy;
• symptoms cannot be controlled by methods other than surgery;
• symptoms return despite treatment;
• serious complications develop.

When choosing surgical treatment, a thorough analysis of all circumstances with the participation of a gastroenterologist and surgeon is recommended.

How long do you need to take medication to keep GERD from getting out of control?

GERD is a chronic disease, and most patients require long-term therapy to keep its symptoms effectively controlled. Similar to how patients with high blood pressure or chronic headaches also require regular treatment. Even after symptoms are controlled, the underlying disease remains. It is possible that you will need to take medications for the rest of your life to control GERD. Unless new drugs and treatments are developed during this time.

Is taking long-term medications to treat GERD harmful?

Long-term use of any medication should only be done under the guidance of a physician. This applies to both prescription and over-the-counter medications. Side effects are rare, however, any drug can potentially have unwanted side effects.

H2 blockers have been used to treat reflux disease since the mid-1970s. Since 1995, they have been available over the counter in reduced doses to treat rare heartburn. They have proven to be safe, although they sometimes cause side effects such as headache and diarrhea.

The proton pump inhibitors omeprazole and lansoprazole have been regularly used by patients with GERD for many years (omeprazole was approved in the US in 1989 and worldwide a few years after that). Side effects from these drugs are rare and mainly include occasional diarrhea, headache, or stomach upset. These side effects are generally no more common than with placebo and usually occur when starting to use the drug. If none of these side effects have appeared after months or years of taking proton pump inhibitors, they are unlikely to appear later.

Patients with heart disease who are taking clopidogrel (Plavix) should avoid taking proton pump inhibitors such as omeprazole and esomeprazole. In addition, recent studies have shown that long-term use of PPIs, especially more than once daily, can cause osteoporosis, bone fractures, pneumonia, gastroenteritis, and hospital-acquired colitis. Patients should discuss this with their healthcare provider.

When is surgery an alternative to therapeutic treatment for GERD?

Drug therapy helps control symptoms as long as the medication is taken correctly. Surgery is an alternative usually when long-term treatment is either ineffective or undesirable, or when there are serious complications of GERD.


The most common surgical procedure to treat GERD is a Nissen fundoplication. It can be performed laparoscopically by an experienced surgeon. The purpose of the operation is to increase pressure in the lower esophageal sphincter to prevent reflux. When performed by an experienced surgeon (who has performed at least 30-50 laparoscopic operations), its success approaches that of well-planned and carefully executed therapeutic treatment with proton pump inhibitors.

Side effects or complications associated with surgery occur in 5-20% of cases. The most common is dysphagia, or difficulty swallowing. It is usually temporary and goes away after 3-6 months. Another problem that occurs in some patients is their inability to burp or vomit. This is because the operation creates a physical barrier to any type of backflow of any stomach contents. A consequence of the inability to belch effectively is “gas-bloat” syndrome - bloating and discomfort in the abdomen.

The surgically created anti-reflux barrier can “break” in much the same way as a hernia penetrates other parts of the body. The recurrence rate has not been determined, but may be in the range of 10-30% within 20 years after surgery. Factors that may contribute to this “breakdown” include: weightlifting, strenuous exercise, sudden changes in weight, severe vomiting. Any of these factors can increase blood pressure, which can lead to weakening or disruption of the anti-reflux barrier created as a result of surgery.

In some patients, even after surgery, symptoms of GERD may persist and medication will need to be continued.

Living with GERD

It is important to recognize that GERD is a disease that should not be ignored or self-medicated. Heartburn, the most common symptom, is so common that its importance is often underestimated. It may be overlooked and not associated with GERD.

It is important to understand that GERD can have serious consequences. The complications that can arise, as well as the discomfort or pain from acid reflux, can affect all aspects of a person's daily life - emotional, social and professional.

Studies that measure the emotional state of those with untreated GERD often report worse scores than those with other chronic diseases, such as diabetes, high blood pressure, peptic ulcers, or angina. However, almost half of those suffering from acid reflux do not recognize it as a disease.

GERD is a disease. It is not a consequence of an incorrect lifestyle. It is usually accompanied by obvious symptoms, but can occur in the absence of them. Ignoring them or improperly treating them can lead to more serious complications.

Most people with GERD have a mild form of the disease, which can be controlled with lifestyle changes and medications. If you suspect you have GERD, the first step is to see your doctor for an accurate diagnosis. Once recognized, GERD is usually treatable. By partnering with your doctor, you can develop the best treatment strategy available to you.

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The views of the authors do not necessarily reflect the position of the International Foundation for Functional Gastrointestinal Diseases (IFFGD). IFFGD does not warrant or endorse any product in this publication or any claims made by the author and does not accept any liability regarding such matters.

This brochure is in no way intended to replace medical advice. We recommend visiting a doctor if your health problem requires an expert opinion.

GASTROESOPHAGEAL REFLUX DISEASE

Gastroesophageal reflux disease(GERD) is a chronic relapsing disease caused by spontaneous, regularly repeated reflux of gastric and/or duodenal contents into the esophagus, leading to damage to the lower esophagus.

Reflux esophagitis- an inflammatory process in the distal part of the esophagus, caused by the effect on the mucous membrane of the organ of gastric juice, bile, as well as enzymes of pancreatic and intestinal secretions during gastroesophageal reflux. Depending on the severity and prevalence of inflammation, five degrees of EC are distinguished, but they are differentiated only on the basis of the results of an endoscopic examination.

Epidemiology. The prevalence of GERD reaches 50% among adults. In Western Europe and the USA, extensive epidemiological studies indicate that 40-50% of people constantly (with varying frequencies) experience heartburn - the main symptom of GERD.
Among those who underwent endoscopic examination of the upper digestive tract, esophagitis of varying severity is detected in 12-16% of cases. The development of esophageal strictures was noted in 7-23%, bleeding - in 2% of cases of erosive-ulcerative esophagitis.
Among people over 80 years of age with gastrointestinal bleeding, erosions and ulcers of the esophagus were their cause in 21% of cases, among patients in intensive care units who underwent surgery, in ~25% of cases.
Barrett's esophagus develops in 15-20% of patients with esophagitis. Adenocarcinoma - in 0.5% of patients with Barrett's esophagus per year with a low degree of epithelial dysplasia, in 6% per year - with high degree dysplasia.

Etiology, pathogenesis. Essentially, GERD is a kind of polyetiological syndrome; it can be associated with peptic ulcer disease, diabetes mellitus, chronic constipation, occur against the background of ascites and obesity, complicate the course of pregnancy, etc.

GERD develops due to a decrease in the function of the anti-reflux barrier, which can occur in three ways:
a) primary decrease in pressure in the lower esophageal sphincter;
b) an increase in the number of episodes of his transient relaxation;
c) its complete or partial destruction, for example, with a hiatal hernia.

In healthy people, the lower esophageal sphincter, consisting of smooth muscle, has a tonic pressure of 10-30 mmHg. Art.
Approximately 20-30 times a day, transient spontaneous relaxation of the esophagus occurs, which is not always accompanied by reflux, while in patients with GERD, with each relaxation, refluxate refluxes into the lumen of the esophagus.
The occurrence of GERD is determined by the ratio of protective and aggressive factors.
Protective measures include the antireflux function of the lower esophageal sphincter, esophageal cleansing (clearance), resistance of the esophageal mucosa and timely removal of gastric contents.

Factors of aggression include gastroesophageal reflux with reflux of acid, pepsin, bile, and pancreatic enzymes into the esophagus; increased intragastric and intraabdominal pressure; smoking, alcohol; drugs containing caffeine, anticholinergics, antispasmodics; mint; fatty, fried, spicy foods; binge eating; peptic ulcer, diaphragmatic hernia.

The most important role in the development of RE is played by the irritating nature of the liquid - refluxate.
There are three main mechanisms of reflux:
1) transient complete relaxation of the sphincter;
2) transient increase in intra-abdominal pressure (constipation, pregnancy, obesity, flatulence, etc.);
3) spontaneously occurring “free reflux” associated with low residual sphincter pressure.

The severity of RE is determined by:
1) the duration of contact of the refluxate with the wall of the esophagus;
2) the damaging ability of acidic or alkaline material that gets into it;
3) the degree of resistance of esophageal tissues. Recently, when discussing the pathogenesis of the disease, the importance of the full functional activity of the legs of the diaphragm has become more often discussed.

The incidence of hiatal hernia increases with age and after 50 years it occurs in every second person.

Morphological changes.
Endoscopically, RE is divided into 5 stages (Savary and Miller classification):
I - erythema of the distal esophagus, erosions are either absent or single, non-confluent;
II - erosions occupy 20% of the circumference of the esophagus;
III - erosions or ulcers of 50% of the circumference of the esophagus;
IV - multiple drain erosions, filling up to 100% of the circumference of the esophagus;
V - development of complications (ulcer of the esophagus, strictures and fibrosis of its walls, short esophagus, Barrett's esophagus).

The latter option is considered by many to be precancrosis.
More often you have to deal with the initial manifestations of esophagitis.
Clinical picture. The main symptoms are heartburn, chest pain, dysphagia, odynophagia (painful swallowing or pain when food passes through the esophagus) and regurgitation (the appearance of the contents of the esophagus or stomach in the oral cavity).
Heartburn can serve as a proof sign of RE when it is more or less constant and depends on the position of the body, sharply intensifying or even appearing when bending over and in a horizontal position, especially at night.
Such heartburn can be combined with sour belching, a feeling of a “cola” behind the sternum, and the appearance of brackish liquid in the mouth associated with reflex hypersalivation in response to reflux.

The contents of the stomach may flow into the larynx at night, which is accompanied by the appearance of a rough, barking, unproductive cough, a feeling of soreness in the throat and hoarseness of the voice.
Along with heartburn, RE may cause pain in the lower third of the sternum. They are caused by esophagospasm, dyskinesia of the esophagus, or mechanical compression of the organ and the area of ​​the hernial opening when combined with diaphragmatic hernias.
The pain in nature and radiation may resemble angina pectoris and can be relieved with nitrates.
However, they are not associated with physical and emotional stress, intensify during swallowing, appear after eating and with sudden bending of the body, and are also relieved by antacids.
Dysphagia is a relatively less common symptom in GERD.
Its appearance requires differential diagnosis with other diseases of the esophagus.
Pulmonary manifestations of GERD are possible.
In these cases, some patients wake up at night from a sudden attack of coughing, which begins simultaneously with regurgitation of gastric contents and is accompanied by heartburn.

A number of patients may develop chronic bronchitis, often obstructive, recurrent, difficult to treat pneumonia caused by aspiration of gastric contents (Mendelssohn syndrome), and bronchial asthma.

Complications: esophageal strictures, bleeding from esophageal ulcers. The most significant complication of EC is Barrett's esophagus, which involves the appearance of small intestinal metaplastic epithelium in the esophageal mucosa. Barrett's esophagus is a precancerous condition.

Rapidly progressive dysphagia and weight loss may indicate the development of adenocarcinoma, but these symptoms occur only in late stages of the disease, so the clinical diagnosis of esophageal cancer is usually delayed.

Therefore, the main way to prevent and early diagnose esophageal cancer is to diagnose and treat Barrett's esophagus.

Diagnostics. It is carried out primarily using instrumental research methods.
Of particular importance is daily intraesophageal pH monitoring with computer processing of the results.
A distinction is made between endoscopically positive and negative forms of GERD.
In the first case, the diagnosis must be detailed and include a description of the morphological changes in the mucous membrane of the esophagus during endoscopy (esophagitis, erosion, etc.) and possible complications.
Mandatory laboratory tests: general blood test (if there is a deviation from the norm, repeat the test once every 10 days), once: blood group, Rh factor, stool occult blood test, urine test, serum iron. Mandatory instrumental studies: once: electrocardiography, twice: esophagogastroduodenoscopy (before and after treatment).

Additional instrumental and laboratory tests are carried out depending on concomitant diseases and the severity of the underlying disease. It is necessary to remember about fluoroscopy of the stomach with the mandatory inclusion of examination in the Trendelenburg position.

In patients with erosive reflux esophagitis, Bernstein's test is positive in almost 100% of cases. To detect it, the mucous membrane of the esophagus is irrigated with a 0.1 M solution of hydrochloric acid through a nasogastric catheter at a rate of 5 ml/min.
Within 10-15 minutes, with a positive test, patients develop a distinct burning sensation in the chest.

Consultations with specialists according to indications.

Histological examination. More often, epithelial atrophy and thinning of the epithelial layer are detected, but occasionally, along with atrophy, areas of hypertrophy of the epithelial layer can be detected.
Along with pronounced dystrophic-necrotic changes in the epithelium, vascular hyperemia is noted.
In all cases, the number of papillae is significantly increased.
In patients with a long history, the number of papillae is increased in direct proportion to the duration of the disease.
In the thickness of the epithelium and in the subepithelial layer, focal (usually perivascular) and in some places diffuse lymphoplasmacytic infiltrates with an admixture of single eosinophils and polynuclear neutrophils are detected.

With actively ongoing esophagitis, the number of neutrophils turns out to be significant, and some of the neutrophils are found in the thickness of the epithelial layer inside the cells (leukopedesis of the epithelium).
This picture can be observed mainly in the lower third of the epithelial layer.
In isolated cases, along with neutrophils, interepithelial lymphocytes and erythrocytes are found. Some new methods for diagnosing R.E.
Detection of the pathology of the p53 gene and signs of disruption of the DNA structure of Barrett's esophageal epithelial cells will in the future become a method of genetic screening for the development of esophageal adenocarcinoma.

Using fluorescence cytometry, it will be possible to detect aneuploidy of cell populations of metaplastic epithelium of the esophagus, as well as the ratio of diploid and tetraploid cells.

The widespread introduction of chromoendoscopy (a relatively inexpensive method) will make it possible to identify metaplastic and dysplastic changes in the epithelium of the esophagus by applying substances to the mucous membrane that stain healthy and diseased tissue differently.

Flow. GERD is a chronic, often recurring disease that lasts for years.

In the absence of maintenance treatment, 80% of patients experience relapses of the disease within six months.
Spontaneous recovery from GERD is extremely rare.

Treatment. Timely diagnosis of GERD during its initial clinical manifestations, still without signs of esophagitis and erosions, allows for timely initiation of treatment.

Among many functional diseases, it is with GERD that the “palette” of medical care actually turns out to be quite wide - from simple useful advice on regulating nutrition and lifestyle to the use of the most modern pharmacological agents, for many months and even years.

Dietary recommendations. Food should not be too high in calories; overeating and nighttime snacking should be avoided.
It is advisable to eat in small portions; 15-20 minute intervals should be taken between dishes.
You should not lie down after eating.
It is best to walk for 20-30 minutes.
The last meal should be at least 3-4 hours before bedtime.

You should exclude from your diet foods rich in fat (whole milk, cream, fatty fish, goose, duck, pork, fatty lamb and beef, cakes and pastries), coffee, strong tea, Coca-Cola, chocolate, foods that reduce the tone of the lower esophageal sphincter (peppermint, pepper), citrus fruits, tomatoes, onions, garlic.
Fried foods have a direct irritant effect on the esophageal mucosa.
Do not drink beer, any carbonated drinks, champagne (they increase intragastric pressure and stimulate acid formation in the stomach).

You should limit your consumption of butter and margarines.
Main measures: exclusion of a strictly horizontal position during sleep, with a low headboard (and it is important not to add extra pillows, but to actually raise the head end of the bed by 15-20 cm).
This reduces the number and duration of reflux episodes as effective esophageal clearance due to gravity is increased.
It is necessary to monitor body weight, stop smoking, which reduces the tone of the lower esophageal sphincter, and alcohol abuse. Avoid wearing corsets, bandages, and tight belts that increase intra-abdominal pressure.

It is undesirable to take medications that reduce the tone of the lower esophageal sphincter: antispasmodics (papaverine, no-shpa), prolonged nitrates (nitrosorbide, etc.), calcium channel inhibitors (nifedipine, verapamil, etc.), theophylline and its analogues, anticholinergics, sedatives , tranquilizers, b-blockers, sleeping pills and a number of others, as well as agents that damage the mucous membrane of the esophagus, especially when taken on an empty stomach (aspirin and other non-steroidal anti-inflammatory drugs; paracetamol and ibuprofen are less dangerous from this group).

It is recommended to start treatment with a “two options” scheme.
The first is gradually increasing therapy (step-up - “step up” the stairs).
The second is to prescribe gradually decreasing therapy (step-down - “step down” the stairs).

Complex, step-up therapy is the main method of treating GERD at the stage of the initial symptoms of this disease, when there are no signs of esophagitis, i.e., with an endoscopically negative form of the disease.

In this case, treatment should begin with non-drug measures, “therapy on demand” (see above).
Moreover, the entire complex of drug-free therapy is preserved for any form of GERD as a mandatory constant “background”.
In cases of episodic heartburn (with an endoscopically negative form), treatment is limited to episodic (“on demand”) doses of non-absorbable antacids (Maalox, Almagel, phosphalugel, etc.) in the amount of 1-2 doses when heartburn appears, which instantly stops it.
If the effect of taking antacids does not occur, you should once again resort to topalcan or motilium tablets (you can take a sublingual form of motilium), or an H2 blocker (ranitidine - 1 tablet 150 mg or famotidine 1 tablet 20 or 40 mg).

For frequent heartburn, a course of step-up therapy is used. The drugs of choice are antacids or topalcan in usual doses 45 minutes to 1 hour after meals, usually 3-6 times a day and before bedtime, and/or motilium.
The course of treatment is 7-10 days, and it is necessary to combine an antacid and a prokinetic agent.

In most cases, with GERD without esophagitis, monotherapy with Topalcan or Motilium for 3-4 weeks is sufficient (stage I of treatment).

In cases of ineffectiveness, a combination of two drugs is used for another 3-4 weeks (stage II).

If, after discontinuation of the drugs, any clinical manifestations of GERD reappear, but are significantly less pronounced than before the start of treatment, it should be continued for 7-10 days in the form of a combination of 2 drugs: an antacid (preferably Topalcan) - a prokinetic agent (Motilium) .

If, after discontinuation of therapy, subjective symptoms resume to the same extent as before the start of therapy, or the full clinical effect does not occur during treatment, you should proceed to the next stage of GERD therapy, which requires the use of H2-blockers.

In real life, the main treatment method for this category of patients with GERD is “on demand” therapy, which most often uses antacids, alginates (Topalcan) and prokinetics (Motilium).

Abroad, in accordance with the Ghent Agreements (1998), there is a slightly different tactical scheme for treating patients with an endoscopically negative form of GERD.
There are two options for treating this form of GERD; the first (traditional) includes H2-blockers and/or prokinetics, the second involves the early administration of proton pump blockers (omeprazole - 40 mg 2 times a day).

Currently, the appearance on the pharmaceutical market of a more powerful analogue of omeprazole - Pariet - will probably make it possible to limit it to a single dose of 20 mg.
An important detail in the management of patients with GERD according to an alternative regimen is the fact that after a course of treatment, in cases of necessity (“on demand”) or lack of effect, patients should be prescribed only representatives of proton pump blockers in lower or higher doses.
In other words, in this case, the principle of treatment according to the “step down” scheme is obviously violated (with a gradual transition to “lighter” drugs - antacid, prokinetic, H2-blockers).

For an endoscopically positive form of GERD, the selection of pharmacological drugs, their possible combinations and tactical treatment regimens are strictly regulated in the “Diagnostic Standards...”.

For reflux esophagitis of I and II severity, prescribe orally for 6 weeks:
- ranitidine (Zantac and other analogues) - 150-300 mg 2 times a day or famotidine (gastrosidine, quamatel, ulfamide, famocid and other analogues) - 20-40 mg 2 times a day, for each drug taken in the morning and evening with a mandatory interval of 12 hours;
- Maalox (Remagel and other analogues) - 15 ml 1 hour after meals and before bedtime, i.e. 4 times a day for the period of symptoms.
After 6 weeks, drug treatment is stopped if remission occurs.

For reflux esophagitis of III and IV severity, prescribe:
- omeprazole (zerocide, omez and other analogues) - 20 mg 2 times a day, morning and evening, with a mandatory interval of 12 hours for 3 weeks (total for 8 weeks);
- at the same time, sucralfate (Venter, Sucrat gel and other analogues) is prescribed orally 1 g 30 minutes before meals 3 times a day for 4 weeks and cisapride (Coordinax, Peristil) or domperidone (Motilium) 10 mg 4 times a day for 15 minutes before meals for 4 weeks.
After 8 weeks, switch to a single dose of ranitidine 150 mg or famotidine 20 mg in the evening and periodic intake (for heartburn, a feeling of heaviness in the epigastric region) of Maalox in the form of a gel (15 ml) or 2 tablets.
The highest percentage of cure and maintenance of remission is achieved with combined treatment with proton pump inhibitors (Pariet 20 mg per day) and prokinetics (Motilium 40 mg per day).

For reflux esophagitis of grade V severity - surgery.

For pain syndrome associated not with esophagitis, but with spasm of the esophagus or compression of the hernial sac, the use of antispasmodics and analgesics is indicated.

Papaverine, platiphylline, baralgin, atropine, etc. are used in normal doses.
Surgical treatment is performed for complicated types of diaphragmatic hernias: severe peptic esophagitis, bleeding, strangulated hernias with the development of gangrene of the stomach or intestinal loops, intrathoracic dilatation of the stomach, esophageal strictures, etc.

The main types of operations are suturing the hernial orifice and strengthening the esophageal-diaphragmatic ligament, various types of gastropexy, restoration of the acute angle of His, fundoplasty, etc.

Recently, methods of endoscopic esophageal plastic surgery (Nissen method) have been very effective.

The duration of inpatient treatment for grades I-II is 8-10 days, for grades III-IV - 2-4 weeks.

Patients with GERD are subject to dispensary observation with a complex of instrumental and laboratory examinations for each exacerbation.

Prevention. Primary prevention of GERD is to follow recommendations for a healthy lifestyle (excluding smoking, especially “hard” smoking, on an empty stomach, drinking strong alcoholic beverages).
You should refrain from taking medications that disrupt the function of the esophagus and reduce the protective properties of its mucosa.
Secondary prevention is aimed at reducing the frequency of relapses and preventing progression of the disease.
An obligatory component of secondary prevention of GERD is compliance with the above recommendations for primary prevention and non-drug treatment of this disease.
To prevent exacerbations in the absence of esophagitis or with mild esophagitis, timely therapy “on demand” remains important.

Gastroesophageal reflux disease is a pathological process that results from deterioration of the motor function of the upper gastrointestinal tract. It occurs as a result of reflux - a regularly repeated reflux of stomach or duodenal contents into the esophagus, resulting in damage to the mucous membrane of the esophagus, and damage to overlying organs (larynx, pharynx, trachea, bronchi) can also occur. What kind of disease is this, what are the causes and symptoms, as well as the treatment of GERD - we will look at this in this article.

GERD - what is it?

GERD (gastroesophageal reflux disease) is the reflux of gastric (gastrointestinal) contents into the lumen of the esophagus. Reflux is called physiological if it appears immediately after eating and does not cause obvious discomfort to a person. This is a normal physiological phenomenon if it occurs occasionally after eating and is not accompanied by unpleasant subjective sensations.

But if there are many such reflux and they are accompanied by inflammation or damage to the mucous membrane of the esophagus, and extra-esophageal symptoms, then this is already a disease.

GERD occurs in all age groups, in both sexes, including children; the incidence increases with age.

Classification

There are two main forms of gastroesophageal reflux disease:

• non-erosive (endoscopically negative) reflux disease (NERD) - occurs in 70% of cases;
• (RE) - the incidence rate is about 30% of the total number of GERD diagnoses.

Experts distinguish four degrees of reflux damage to the esophagus:

1. Linear defeat– individual areas of inflammation of the mucous membrane and foci of erosion on its surface are observed.
2. Drain lesion– the negative process spreads over a large surface due to the merging of several foci into continuous inflamed areas, but not the entire area of ​​the mucous membrane is yet covered by the lesion.
3. Circular lesion– zones of inflammation and foci of erosion cover the entire inner surface of the esophagus.
4. Stenosing lesion– against the background of complete damage to the inner surface of the esophagus, complications are already occurring.

Causes

The main pathogenetic substrate for the development of gastroesophageal reflux disease is gastroesophageal reflux itself, that is, retrograde reflux of stomach contents into the esophagus. Reflux most often develops due to incompetence of the sphincter located at the border of the esophagus and stomach.

The following factors contribute to the development of the disease:

• Decreased functional ability of the lower esophageal sphincter (for example, due to destructuring of the esophagus due to hiatal hernia);
• Damaging properties of gastrointestinal contents (due to the content of hydrochloric acid, as well as pepsin, bile acids);
• Gastric emptying disorders;
• Increased intra-abdominal pressure;
• Pregnancy;
• Smoking;
• Overweight;
• Decreased clearance of the esophagus (for example, due to a decrease in the neutralizing effect of saliva, as well as bicarbonates of esophageal mucus);
• Taking medications that reduce smooth muscle tone (calcium channel blockers, beta-agonists, antispasmodics, nitrates, M-anticholinergics, bile-containing enzyme preparations).

Factors contributing to the development of GERD are:

• disorders of motor functions of the upper digestive tract,
• hyperacidotic conditions,
• reduced protective function of the esophageal mucosa.

Symptoms of gastroesophageal reflux disease

Once in the esophagus, the contents of the stomach (food, hydrochloric acid, digestive enzymes) irritate the mucous membrane, leading to the development of inflammation.

The main symptoms of gastroesophageal reflux are as follows:

• heartburn;
• belching acid and gas;
• acute sore throat;
• discomfort in the pit of the stomach;
• pressure that occurs after eating, which increases after eating food that promotes the production of bile and acid.

In addition, acid from the stomach, entering the esophagus, has a negative effect on local tissue immunity, affecting not only the esophagus, but also the nasopharynx. A person suffering from GERD often complains of chronic pharyngitis.

GERD often occurs with atypical clinical manifestations:

• chest pain (usually after eating, worse when bending over),
• heaviness in the stomach after eating,
• hypersalivation (increased salivation) during sleep,
• bad breath,
• hoarseness.

Symptoms appear and intensify after eating, physical activity, in a horizontal position, and decrease in a vertical position, after drinking alkaline mineral waters.

Signs of GERD with esophagitis

Reflux disease in the esophagus can cause the following reactions:

• inflammatory process,
• damage to the walls in the form of ulcers,
• modification of the lining layer in contact with the refluxate into a form unusual for a healthy organ;
• narrowing of the lower esophagus.

If the above symptoms occur more than 2 times a week for 2 months, you should consult a doctor for examination.

GERD in children

The main reason for the development of reflux disease in children is the immaturity of the lower sphincter, which prevents the evacuation of food from the stomach back into the esophagus.

Other causes that contribute to the development of GERD in childhood include:

• functional insufficiency of the esophagus;
• narrowing of the gastric outflow tract;
• recovery period after surgery on the esophagus;
• operations for gastric resection;
• consequences of serious injuries;
• oncological processes;
• difficult childbirth;
• high intracranial pressure.

Common symptoms of GERD in a child are as follows:

• frequent burping or burping;
• poor appetite;
• pain in the stomach;
• the child is excessively capricious during feeding;
• frequent vomiting or retching;
• hiccups;
• labored breathing;
• frequent cough, especially at night.

Treatment for gastroesophageal reflux disease in children will depend on symptoms, age, and overall health. In order to prevent the development of this disease in a child, parents should closely monitor his diet.

Complications

Gastroesophageal reflux disease can cause the following complications in the body:

• esophageal stricture;
• ulcerative lesions of the esophageal mucosa;
• bleeding;
• the formation of Barrett's syndrome - complete replacement (metaplasia) of the stratified squamous epithelium of the esophagus with columnar gastric epithelium (the risk of esophageal cancer with epithelial metaplasia increases 30-40 times);
• malignant degeneration of esophagitis.

Diagnostics

In addition to the diagnostic methods described, it is important to visit the following specialists:

• cardiologist;
• pulmonologist;
• otorhinolaryngologist;
• surgeon, his consultation is necessary in case of ineffectiveness of the ongoing drug treatment, the presence of large diaphragmatic hernias, or in the event of complications.

To diagnose gastroesophageal reflux, the following methods are used:

• endoscopic examination of the esophagus, which allows to identify inflammatory changes, erosions, ulcers and other pathologies;
• daily monitoring of acidity (pH) in the lower part of the esophagus. Normal level pH should be between 4 and 7, changes in evidence may indicate the cause of the disease;
• radiography - allows you to detect ulcers, erosions, etc.;
• manometric examination of the esophageal sphincters - performed to assess their tone;
• scintigraphy using radioactive substances - performed to assess esophageal clearance;
• biopsy - performed if Barrett's esophagus is suspected;
• ECG and daily ECG monitoring; Ultrasound examination of the abdominal organs.

Of course, not all methods are used for accurate diagnosis. Most often, the doctor only needs the data obtained during the examination and interview of the patient, as well as the conclusion of the FEGDS.

Treatment of reflux disease

Treatment of gastroesophageal reflux disease can be medication or surgery. Regardless of the stage and severity of GERD, during therapy it is necessary to constantly adhere to certain rules:

1. Do not lie down or lean forward after eating.
2. Do not wear tight clothes, corsets, tight belts, bandages - this leads to an increase in intra-abdominal pressure.
3. Sleep on a bed in which the part where the head is located is raised.
4. Do not eat at night, avoid large meals, do not eat too hot food.
5. Quit alcohol and smoking.
6. Limit consumption of fats, chocolate, coffee and citrus fruits, as they are irritating and reduce LES pressure.
7. Lose weight if you are obese.
8. Stop taking medications that cause reflux. These include antispasmodics, β-blockers, prostaglandins, anticholinergic drugs, tranquilizers, nitrates, sedatives, calcium channel inhibitors.

Medications for GERD

Drug treatment of gastroesophageal reflux disease is carried out by a gastroenterologist. Therapy takes from 5 to 8 weeks (sometimes the course of treatment lasts up to 26 weeks) and is carried out using the following groups of drugs:

1. Antisecretory agents (antacids) have the function of reducing the negative effect of hydrochloric acid on the surface of the esophagus. The most common are: Maalox, Gaviscon, Almagel.
2. As a prokinetic Motilium is used. The course of treatment for catarrhal or endoscopically negative esophagitis lasts about 4 weeks, for erosive esophagitis 6-8 weeks, if there is no effect, treatment can be continued up to 12 weeks or more.
3. Taking vitamin supplements, including vitamin B5 and U in order to restore the mucous membrane of the esophagus and generally strengthen the body.

GERD can also be caused by an unbalanced diet. Therefore, drug treatment must be supported by proper nutrition.

With timely identification and compliance with lifestyle recommendations (non-drug treatment measures for GERD), the prognosis is favorable. In the case of a prolonged, often relapsing course with regular refluxes, the development of complications, and the formation of Barrett's esophagus, the prognosis noticeably worsens.

The criterion for recovery is the disappearance of clinical symptoms and endoscopic findings. To prevent complications and relapses of the disease, monitor the effectiveness of treatment, it is necessary to regularly visit a doctor, therapist or gastroenterologist, at least once every 6 months, especially in the fall and spring, and undergo examinations.

Surgical treatment (operation)

There are various methods of surgical treatment of the disease, but in general their essence comes down to restoring the natural barrier between the esophagus and the stomach.

Indications for surgical treatment are as follows:

• complications of GERD (repeated bleeding, strictures);
• ineffectiveness of conservative therapy; frequent aspiration pneumonia;
• diagnosing Barrett's syndrome with high-grade dysplasia;
• the need of young patients with GERD for long-term antireflux therapy.

Diet for GERD

Diet for gastroesophageal reflux disease is one of the main areas of effective treatment. Patients suffering from esophagitis should adhere to the following dietary recommendations:

1. Eliminate fatty foods from your diet.
2. To stay healthy, avoid fried and spicy foods.
3. If you are ill, it is not recommended to drink coffee or strong tea on an empty stomach.
4. People prone to esophageal diseases are not recommended to consume chocolate, tomatoes, onions, garlic, mint: these products reduce the tone of the lower sphincter.

Thus, the approximate daily diet of a patient with GERD is as follows (see daily menu):

Some doctors believe that for patients diagnosed with gastroesophageal reflux disease, these dietary rules and a healthy lifestyle are more important than the foods from which the menu is composed. You should also remember that you need to approach your diet taking into account your own feelings.

Folk remedies

Alternative medicine involves a large number of recipes; the choice of a specific one depends on the individual characteristics of the human body. But folk remedies cannot act as a separate therapy; they are included in the general complex of therapeutic measures.

1. Sea buckthorn or rosehip oil: take one teaspoon up to three times a day;
2. The home medicine cabinet of a patient with reflux disease should contain the following dried herbs: birch bark, lemon balm, flax seeds, oregano, St. John's wort. You can prepare a decoction by pouring a couple of tablespoons of the herb with boiling water in a thermos and letting it sit for at least an hour, or by adding a handful of the medicinal plant to boiling water, remove the pan from the stove, cover with a lid and let it brew.
3. Crushed plantain leaves(2 tbsp.), St. John's wort (1 tbsp.) Place in an enamel container, pour boiling water (500 ml). After half an hour, the tea is ready to drink. You can take the drink for a long time, half a glass in the morning.
4. Treatment of GERD with folk remedies involves not only herbal medicine, but also the use of mineral waters. They should be used at the final stage of the fight against the disease or during remissions in order to consolidate the results.

Prevention

In order to never encounter an unpleasant disease, it is important to always pay attention to your diet: do not overeat, limit the consumption of unhealthy foods, and monitor your body weight.

If these requirements are met, the risk of GERD will be minimized. Timely diagnosis and systematic treatment can prevent the progression of the disease and the development of life-threatening complications.

We would like to preface the discussion of therapeutic options for gastroesophageal reflux disease (GERD) with brief information on the mechanisms of development and diagnosis of this pathology. The possibilities of surgical treatment of GERD will not be discussed in this article.

Definition

So, A.S. Trukhmanov defines GERD as the occurrence of characteristic symptoms and (or) inflammatory damage to the distal parts of the esophagus due to repeated reflux of gastric contents into the esophagus .

As defined by the International Working Group, the term "gastroesophageal reflux disease" should be applied to all individuals at risk of physical complications of gastroesophageal reflux, or experiencing a significant deterioration in health-related well-being (quality of life), as a result of reflux symptoms, after adequate assurance of benign nature of symptoms .

The term "endoscopically negative reflux disease" should be used in individuals who meet the definition of gastroesophageal reflux disease, but who do not have either Barrett's esophagus or visible mucosal defects (erosions or ulcers) on endoscopic examination. .

Development mechanisms

Without dwelling in detail on the pathogenetic mechanisms of development of this disease, we will only say that it is based on the effect of acid and pepsin on the esophageal mucosa due to the combination (in varying proportions) of pathological reflux of gastric contents into the esophagus with a violation of its clearance. Pathological reflux of contents, in turn, is caused by dysfunction of the lower esophageal sphincter (either as a result of a decrease in its tone or an increase in the frequency of spontaneous relaxation, or due to its anatomical defect, for example, with a hernia of the esophagus). Impaired esophageal clearance may be caused by decreased saliva production or impaired esophageal motility. As a result of all of the above, there is an imbalance between aggressive factors and protective factors, which leads, but not necessarily, to the occurrence of reflux esophagitis.

Epidemiology

According to S.I. Pimanova, symptoms of GERD are occasionally observed in half of the adult population, and the endoscopic picture of esophagitis is observed in 2-10% of examined people . It must be remembered that GERD is not always accompanied by esophagitis. Up to 50 - 70% of patients with heartburn at the time of seeking medical help have endoscopically negative GERD . The attitude of a number of practitioners towards endoscopically negative GERD as the mildest degree of this disease that does not require intensive drug therapy is fundamentally incorrect. A number of studies have demonstrated that the quality of life in patients with endoscopically positive and negative GERD is impaired to almost the same extent . Studies have shown that endoscopically negative GERD very rarely turns into reflux esophagitis, which in turn rarely progresses to more severe forms over time .

Diagnostics

Since the diagnosis of GERD is widely described in many manuals, we will dwell only on some of its points. The main symptom of GERD, observed in at least 75% of patients, is heartburn. . There may also be pain or a burning sensation in the sternum, belching, etc. Most often, GERD symptoms occur after eating.

Diagnosis of erosive esophagitis is based on endoscopic examination. X-ray with barium has a fairly high sensitivity for severe (98.7%) and moderate (81.6%) esophagitis, but is insensitive (24.6%) for mild esophagitis . Endoscopy with biopsy is the only reliable method for diagnosing Barrett's esophagus. The severity of erosive reflux esophagitis on the endoscopic picture is divided into 4 degrees A, B, C and D (according to the Los Angeles classification).

pH monitoring is a sensitive and specific diagnostic test and is especially important for identifying endoscopically negative GERD. More than 50 episodes of pH below 4 are considered diagnostic criteria for GERD . In a number of patients, a less significant decrease in the pH of the esophagus occurs, but when most episodes of such a decrease coincide with the onset of symptoms, it allows us to speak of a “hypersensitive esophagus.”

Among provocative tests, the Bernstein test plays a certain role (the appearance of typical symptoms after the introduction of a weak solution of hydrochloric acid into the esophagus and their disappearance after the introduction of saline). Determining the pressure of the lower esophageal sphincter is useful when deciding on surgical treatment.

Treatment

Before moving on to consideration of individual aspects of the treatment of GERD, it is necessary to emphasize the fact that its main goal is to quickly relieve patients from the symptoms that bother them. The disappearance of symptoms usually correlates well with the healing of mucosal defects in erosive esophagitis .

Changing your lifestyle.

Although, according to the GERD working group, lifestyle factors do not play a determining role in the development of GERD , recommendations aimed at eliminating factors contributing to reflux or worsening esophageal clearance should be given.

Diet. It is necessary to stop taking reflux-inducing foods (fatty foods, chocolate and excessive amounts of alcohol, onions and garlic, coffee, carbonated drinks, especially various types of colas) and drugs with low pH (orange and pineapple juices, red wine). However, an attempt to sharply limit a patient’s diet (especially a young one) is rarely possible in practice; your recommendations simply will not be followed. It makes more sense to identify which products cause the appearance or exacerbation of symptoms in a given patient and try to at least give them up. The patient should be informed that overeating must be avoided. After eating, it is advisable not to take a horizontal position or work in an inclined position. The last meal should be 3 hours before bedtime.

Weight control. Losing weight does not always resolve symptoms, but losing weight may reduce the risk of developing a hiatal hernia. However, giving advice to lose weight is much easier than implementing it. Overweight people sometimes try to hide their lack of waist by over-tightening the waist belt, which leads to increased intra-abdominal pressure and the development of reflux (as does wearing clothes that are too tight).

Smoking is a contributing factor to GERD as a result of both sphincter relaxation and decreased salivation and should accordingly be stopped . Although, according to some researchers, smoking cessation has a minimal positive effect on GERD .

Raising the head of the bed is important for patients with nocturnal or LA symptoms (which constitute a small proportion of patients with GERD), but its necessity in other cases is questionable.

A number of medications such as antispasmodics, beta blockers, hypnotics and sedatives, nitrates and calcium antagonists can contribute to the development of reflux.

Antacids.

When discussing the use of antacids, of which there are a great many in our time (almagel, phosphalugel, maalox, rutacid, etc.), I would like to emphasize that, in our opinion, antacids do not play an independent role in the treatment of GERD and can only be used as a short-term remedy symptom control. The low effectiveness of antacids is based on the short duration of pH control achieved by their use. Data from many authors confirm the minimal effect of antacids (even in combination with lifestyle changes) for reflux esophagitis, although it is superior to the placebo effect . We suggest that patients (being treated for GERD) use antacids as a method of quickly controlling symptoms that occur, usually after a violation of diet or exercise, and in those with rare (no more than 4 per month) episodes of heartburn without endoscopic signs of esophagitis.

Antisecretory drugs.

The most effective way to treat GERD is to reduce acid production in the stomach using H2 blockers or proton pump inhibitors. The goal of this therapy is to increase the pH of gastric juice to 4 and during the period of greatest likelihood of reflux occurring, i.e. not the prevention of reflux as such, but the elimination of the pathological effects of gastric juice components on the esophagus. H2 blockers. Before the advent of proton pump inhibitors, H2 blockers were the drug of choice in the treatment of GERD. There are currently 4 H2 histamine receptor blockers used in practice (cimetidine, ranitidine, famotidine and nizatidine). The mechanism of action of the drugs is to block gastric secretion stimulated by histamine. However, two other stimulation pathways, acetylcholine and gastrin, remain open. It is this fact that is associated with a lower degree of suppression of secretion than with proton pump inhibitors (PPI) and a gradual decrease in the degree of inhibition of gastric secretion with long-term use of H2 blockers, when stimulation of acid production begins to increasingly occur through other mediators (mainly gastrin).

Cimetidine (first generation H2 blocker). Use 200 mg 3-4 times a day and 400 mg at night. The maximum daily dose is 12 grams.

Ranitidine (second generation) is used at a dosage of 150 mg 2 times a day, which can, if necessary, reach 300 mg 2 times a day (maximum dose 9 grams per day). For nighttime symptoms - 150-300 mg at night. Maintenance therapy - 150 mg at night.

Famotidine (third generation) is used at a dose of 20 mg twice daily, with a maximum daily dose of 480 mg. For nocturnal symptoms, 20-40 mg at night, maintenance therapy 20 mg at night.

Nizatidit (fourth generation) is taken 150 mg twice a day or 300 mg at bedtime.

Due to a very wide range of side effects (from androgenic effects to blockade of respiratory enzymes) and inconvenient dosage, cimetidine is not currently used in practice. Of all the other H2 blockers, we prefer famotidine (as the drug with the least common side effects). It must be remembered that all H2 blockers are discontinued gradually in order to prevent the “recoil” syndrome - a sharp increase in acidity after stopping treatment.

Based on 33 randomized trials (involving 3000 people), the following data were obtained: the use of placebo led to relief of GERD symptoms in 27% of patients, H2 blockers in 60% and PPI in 83% . Esophagitis was relieved in 24%, 50% and 78% of cases, respectively. These figures allow us to conclude that H2 blockers are effective in the treatment of GERD, which, however, is significantly inferior to that of PPI. H2 blockers retain a certain role in the treatment of GERD. They are effective as a treatment for reflux that occurs at night. , even if you continue to take PPI and as on-demand therapy.

Proton pump blockers.

Their action is based on blocking the ATPase of the influx pump (due to the formation of an irreversible bond with the cystine residue of the enzyme). It must be remembered that PPI only blocks the currently active proton pump. Drugs of this group are absorbed in the form of inactive compounds, turning into the active substance directly in the tubular systems of secretory cells. All PPIs, except esomeprazole, have a short half-life (30 - 120 minutes). PPI destruction occurs in the liver, and there are two ways of their destruction - fast and slow. The destruction process is stereodependent. The dextrorotatory isomer decays along the fast path, and the left-handed isomer decays along the slow path. All PPIs, again except esomeprazole (only the levorotatory isomer), are represented by right and left-handed isomers. This fact explains the longer retention of the minimum therapeutic concentration by esomeprazole compared to other PPIs.

PPIs are prescribed before meals (usually 30 minutes before breakfast, with a single dose), so that the effect occurs when the maximum number of active proton pumps is present - 70 - 80% of their total number. The next dose of PPI again blocks 70-80% of the receptors (remaining and regenerated), so the peak of the antisecretory effect occurs on days 2-3 (slightly faster when using esomeprazole). PPIs are virtually ineffective as an on-demand therapy (the onset of heartburn symptoms indicates that an acid surge has already occurred, followed, as a rule, by a decrease in the number of active pumps and, therefore, the absence of a target for PPI action).

When analyzing the comparative effectiveness of various PPIs, it can be concluded that there are no significant advantages between omeprazole, rabeprazole, lansoprazole and pantoprazole. The effectiveness of esomeprazole (Nexium) is slightly higher. When comparing the duration of maintaining intragastric pH > 4 using different PPIs, data were obtained about better control of gastric secretion when using Nexium (Fig. 1).

Although it should be noted that when using 40 mg of omeprazole, the difference is not so noticeable. The benefits of Nexium are more pronounced in severe forms of esophagitis (grade D) . Omeprazole is used in a dose of 20 - 40 mg per day (either a single dose in the morning or twice a day). In severe cases, the dose can reach 60 mg per day. Lansoprazole is used at 30 mg/day, pantoprazole at 40 mg/day, rabeprazole at 20 mg/day and Nexium at 40 mg/day. Discontinuation of the drug should also be gradual.

Prokinetic drugs.

Prokinetic drugs (domperidone, metoclopramide, and cisapride) may increase lower esophageal sphincter pressure, improve esophageal clearance, and accelerate gastric emptying. Cisapride is only available for limited use in the US due to concerns regarding cardiac arrhythmias (see below). Metoclopamide causes weakness, anxiety, tremor, parkinsonism or tardive dyskinesia in 20-50% of cases. Use 10 mg 3-4 times a day. The maximum single dose is 20 mg, daily dose is 60 mg.

Cisapride. Although cisapride was generally considered virtually safe, its recent widespread use in the United States has been associated with the occurrence of cardiac arrhythmias. Most often they developed when taking cisapride in combination with drugs that inhibit cytochrome P-450 and increase the level of cisapride. As a result, the manufacturer has partially restricted the use of this drug in the United States. Studies comparing the effectiveness of cisapride 910 mg four times a day) with H2 receptor antagonists (ranitidine 150 mg twice a day) and cimetidine (400 mg four times a day) demonstrated their superiority over placebo and similar effectiveness in relieving the symptoms of GERD and curing esophagitis . The combination of H2 blockers with cisapride gives a better effect than each drug individually, but is inferior to omeprazole .

Domperidone (Motilium) has a mechanism of action similar to metoclopramide, but does not penetrate the blood-brain barrier and therefore does not cause central side effects, but increases the level of prolactin in the blood. Use 10 mg 3-4 times a day. None of the drugs gave a good therapeutic effect in severe degrees of esophagitis.

The role of HP infection.

Currently, the role of HP infection in GERD remains controversial. Although, according to the Maastrik Agreements, GERD is an indication for eradication therapy, not all authors agree with this. A number of studies have shown that Hp eradication does not cure reflux esophagitis, nor does it have a preventive role in terms of its relapse . The fact that Hp infection can cause either an increase or decrease in gastric secretory function makes its role in the development of GERD even more controversial. Data from some authors even indicate a protective role of HP infection in GERD , due to the alkalizing effect, and in the further development of mucosal atrophy.

Almost the only factor justifying eradication therapy for GERD is that chronic use of PPI, against the background of existing HP infection, contributes to the development of atrophic gastritis and metaplasia . According to Kuipers EJ comparing the likelihood of developing atrophic gastritis in groups of patients with GERD and HP infection who received omeprazole or underwent fundoplication, it developed in 31% and 5% of patients, respectively. Although another study did not find such a pattern . In turn, eradication therapy does not cause exacerbation or worsening of GERD .

In our practice, we test for the presence of HP and perform eradication in patients with GERD only if they have a concomitant disease of the upper gastrointestinal tract whose connection with HP infection has been established (for example, peptic ulcer) or when planning chronic (more than a year) constant use of proton pump inhibitors.

New directions of pharmacotherapy.

According to Ciccaglione et al, the drug, which reduces the number of spontaneous relaxations of the lower esophageal sphincter, baclofen at a dosage of 10 mg 3 times a day for a month showed significant superiority over placebo, improvement in esophageal pH monitoring data and a decrease in the severity of GERD symptoms . It was also noted to be well tolerated. The drug inhibits 34-60% of spontaneous relaxation of the lower esophageal sphincter and increases its basal pressure . However, there is still insufficient data to justify the widespread use of baclofen in the treatment of GERD.

Treatment regimens.

Currently, there are two main tactical approaches to the treatment of GERD, the so-called step-up and step-down. The first is the use of the weakest measures (lifestyle modification, antacids) as the first stage of treatment with the gradual use of increasingly powerful drugs if ineffective (H2 blockers, then their combination with prokinetics and only then PPI). The second treatment option involves prescribing the most effective treatment (PPI), which allows you to quickly relieve symptoms, and then reduce the dose of medications and possibly switch to weaker drugs.

In our practice, we adhere only to step-down therapy because... We believe that the patient comes to us for the fastest relief of the symptoms that bother him, which should be achieved by prescribing a group of drugs from which the best effect can be expected. You should not forget about the advice on lifestyle changes, but in combination with the administration of a standard dose of PPI. As for starting treatment with H2 blockers, followed by switching, if necessary, to PPI - you won’t be judged for this, but does it make sense? H2 blockers have no fewer potential side effects, and their price is not significantly lower. We'll leave them for on-demand therapy and nocturnal reflux episodes. It is true that there is a very small group of patients with reflux esophagitis refractory to proton pump inhibitor therapy in whom sufficient pH control can be achieved using high doses of H2 blockers .

What to do with endoscopically negative GERD? Yes, exactly the same. As mentioned above, the degree of morphological changes in the esophagus does not correlate well with the severity of symptoms . Moreover, in this group of patients there is often a less pronounced effect of antisecretory therapy with a longer persistence of symptoms . It must also be remembered that the effectiveness of H2 blockers for endoscopically negative GERD does not exceed that for erosive reflux esophagitis .

In severe reflux esophagitis (C, D), therapy with the most powerful PPI (Nexium) or the maximum dose of other proton pump inhibitors is rational.

For nocturnal episodes of heartburn, despite the use of PPI, it is rational to add a single evening dose of an H2 blocker. Antacids can be used as patient-controlled, on-demand therapy.

So, we follow a knowledgeable management strategy when a new patient with GERD appears.

• Proton pump inhibitors in a standard dose (for 2-4 weeks for endoscopically negative reflux esophagitis and erosive esophagitis grades A, B and for 8 weeks for its more severe forms).
• In case of ineffectiveness (determined by the persistence of symptoms after 7-10 days of treatment or the preservation of the endoscopic picture of esophagitis), increase the dose of PPI to the maximum or switch to a potentially more effective PPI - Nexium.
• If ineffective, pH monitoring is required during treatment. Trying to switch to high doses of H2 blockers in combination with prokinetics? Antireflux surgery?
• If effective, gradually reduce the dosage until the drug is discontinued. If symptoms recur, take the minimum effective dose of the drug (every other day therapy or weekend therapy is possible), discuss the possibility of antireflux surgery.

Maintenance therapy.

Based on the chronic nature of GERD, there is a need for maintenance therapy. Reducing the dose of medication or attempting maintenance therapy with a drug less potent than the one used for treatment often leads to a high relapse rate. Only in approximately 20% of patients after a course of treatment, lifestyle changes and periodic use of antacids are sufficient to maintain remission. H2 blockers and prokinetics are ineffective in maintaining remission in patients who achieved it using PPI . Low dose PPI therapy is most effective. The effectiveness of weekend therapy and every other day is controversial.

Conclusion.

Drug therapy remains the mainstay of treatment for GERD. PPIs are the drugs of choice for treatment and long-term maintenance therapy. The role of HP infection in the development and natural history of GERD, as well as its effect on the outcome of treatment, are not completely clear. The development of new drugs and comparison of the effectiveness of various schemes for their use is a promising direction for further improving the quality of treatment of this pathology.

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