Chapter 4. Diseases of digestive system and hepatobiliary tract

Formulating a diagnosis

Components of the diagnosis: form; severity of esophageal affection; complications

Gastroesophageal reflux disease (GERD) is a chronic recurrent disease caused by motor evacuation function disorder of gastroesophageal organs characterized by regularly repeated reflux of gastric and sometimes duodenal contents into esophagus, which leads to occurrence of clinical symptoms that worsen quality of patients’ life.

Morphological changes in GERD are represented by damage to the distal esophagus mucosa with the development of dystrophic changes in non-keratinized stratified squamous epithelium, catarrhal or erosive-ulcerative esophagitis (reflux esophagitis), and in some patients — Barrett’s syndrome.

According to prevalence, GERD ranks first among gastroenterological diseases.

A key factor in GERD pathogenesis is pathologically high frequency and/or duration of gastric contents reflux into the esophagus.

Imbalance of protection and aggression factors in the majority of patients is accompanied by slow pH level recovery in distal part of esophagus after each reflux episode (table 4.1).

Table 4.1. Esophageal mucosa protection factors

Quick tips

Normally, pH in distal part of the esophagus is 5.5–7.0.

Reflux with pH of less than 4 or more than 7 lasting more than 5 minutes, with a frequency of more than 50 times a day and lasting more than 1 hour is considered pathological (according to Ph-impedancemetry).

Reflux of gastric contents into esophagus occurs due to:

• decreased tonicity of lower esophageal sphincter (LES);
• dysmotility of esophagus and stomach;
• reduced esophageal peristalsis (esophageal clearance);
• intraabdominal pressure increase.

Provoking factors:

• stomach repletion (hearty meals, pyloric stenosis);
• forward pitches, lying position after a meal;
• increased intragastric pressure (obesity, pregnancy, ascites, wearing tight belts, corsets, bandages);
• smoking;
• medications [nitrates, calcium antagonists, β-blockers, cholinolytics, theo­phylline, beta-adrenergic agonists, non-steroidal anti-inflammatory drugs (NSAIDs), dopamine agonists, tricyclic antidepressants, bisphosphonates, benzodiazepines, barbiturates, doxycycline, quinidine, oral contraceptives, hormone replacement therapy (estrogens)];
• certain foods (tomatoes, sour fruit juices, products that increase flatus, fatty foods, chocolate, coffee, alcohol, very hot and cold food, car­bonated drinks);
• scleroderma (CREST syndrome);
• surgical treatment.

Gastroesophageal reflux disease form

Currently, there are two types of GERD:

• endoscopically negative or non-erosive reflux disease (NERD) (it accounts for 65–70% of cases);
• erosive esophagitis (reflux esophagitis, endoscopically positive reflux disease) — 30–35% of cases.

Severity of esophageal affection

It is recommended to use classification of reflux esophagitis by the grade of esophageal mucosa affection adopted at the Tenth World Congress of Gastroenterologists (Los Angeles, 1994) (table 4.2).

Table 4.2. Los Angeles Classification of Reflux Esophagitis

Complications

• Esophageal ulcers.
• Bleeding from esophageal ulcers.
• Esophageal stricture.
• Barrett’s esophagus (replacement of esophageal stratified squamous epithelium with metaplastic intestinal epithelium, which increases the risk of esophageal adenocarcinoma).
• Esophageal adenocarcinoma.

Examples of diagnoses

DS: Gastroesophageal reflux disease, non-erosive.

DS: Gastroesophageal reflux disease, erosive, grade A esophagitis.

DS: Gastroesophageal reflux disease, erosive, grade C esophagitis. Barrett’s esophagus, high-grade dysplasia.

Diagnosis verification

Diagnosis of gastroesophageal reflux disease is established on the basis of: patient complaints, patient history data, and physical examination. Laboratory and instrumental examinations are carried out to clarify the form and/or presence of complications.

Patient̕s complaints

The Mayo criteria are used for clinical diagnosis: presence of pyrosis and/or acid regurgitation once a week and more frequently during the last 12 months.