Gastroesophageal reflux (GER); is a physiological condition. Food that passes into the stomach through the esophagus after swallowing does not normally return from the stomach. Several times during the day, a very small portion of the food returns to the esophagus during the digestion process and positionally and is conveyed back to the stomach. Stomach fluid is generally in an alkaline reaction during the resting period, that is, when digestion is not taking place. Whenever food is delivered to the stomach, the stomach secretes acid for the digestion of these foods and tries to break down the food. In healthy individuals, reflux is the reflux of gastric fluid from the initial part of the stomach, the cardia, to the esophagus, during rest or digestion, without causing any complaints or wear on the esophagus, without retching and vomiting. VIEW is a physiological event that occurs 8-10 times a day, usually for short periods of time, usually after meals (with a total duration of up to 60 minutes a day). VIEW It causes some complaints due to acid-peptic gastric fluid, bile and pancreatic fluids, and if these complaints persist and disrupt the individual's quality of life, it is considered a disease. These complaints may occur due to mucosal damage in the esophagus, or they may occur as complaints related to the pharynx, larynx, middle ear and lungs due to damage to the upper respiratory tract, eustachian tube and pulmonary system due to the reflux of stomach-bile-pancreatic fluids described above. When these complaints disrupt the person's quality of life and cause complications, it is called gastroesophageal reflux disease (GERD). Pyrosis (burning) and regurgitation (bitter water or food coming into the mouth ) These are typical symptoms of GERD. Reflux esophagitis is a clinical condition accompanied by endoscopic or histopathological inflammation of the esophageal mucosa, which occurs in some cases of GERD. A wide spectrum of clinical manifestations are encountered in GERD, ranging from simple reflux to serious complications such as erosive esophagitis, Barrett's metaplasia, esophageal cancer and proximal stomach adeno-cancers.
IN GERD. EPIDEMIOLOGY
Prevalence and Incidence
GERD is one of the most common diseases of the upper gastrointestinal system in our daily practice. Studies have found that the frequency of erosive esophagitis among upper gastrointestinal system endoscopic procedures performed in gastroenterology services is 7% in the USA and 2-10% in Europe. In studies conducted in Western society, the frequency of GERD varies between 15-20% and has been increasing over the last 30 years. In Asian society, the frequency of GERD is lower (3-7%). In countries that are socio-economically developing and have different nutritional habits compared to western societies, the incidence of GERD is low, low body mass index, low-fat diet intake, low gastric acid secretion and Helicobacter pylori infection ( Hp)incidence is related to its height. In the prevalence study conducted in our country, the frequency of GERD was found to be 20-23%. This rate was determined in a study conducted on 630 volunteers randomly selected from a population of 8857 low-income people. Again, in this study, the incidence of heartburn was found to be low, while the incidence of regurgitation was found to be higher. has been determined. It can be predicted that GERD may occur more frequently in regions with high income levels.
Etiopathogenesis
GERD It is a multifactorial disease. We can say that these factors include disruptions in mechanical barriers, luminal clearance mechanism and the integrity of the esophageal epithelial resistance.GERD occurs as a result of the stomach content refluxing into the esophageal lumen disrupting the integrity of the esophageal epithelium, which is not acid-resistant, and affecting the protective mechanisms in a time that makes them insufficient. . There are studies showing that there is a normal amount of acid in the esophagus despite insufficiency in mechanical barriers or impairment in luminal clearance mechanisms. In these studies, 24-hour intraesophageal pH-metry was found to be within normal limits in 30% of the cases with endoscopically detected ulcerous esophagitis, as well as in 50% of the cases with normal endoscopy and typical complaints. This shows that epithelial resistance deficiency plays an important role in the pathogenesis of GERD. We can talk about two main factors in preventing GER under physiological conditions. The first of these is the anatomical presence of the esophageal sphincter, the angle of His, and mechanical barriers such as the phrenoesophageal ligament. The second is luminal clearance mechanisms such as esophageal peristalsis (primary and secondary) and salivary bicarbonate secretion. These barrier systems and clearance systems shorten the interaction time of gastric content with the esophageal epithelium. The duration of interaction is an important feature for the development of esophagitis, and long-term contact may cause wear and damage to a normal esophageal epithelium. In an epithelium with inadequate defense mechanisms, damage may occur in a relatively short contact time. It can be removed. In this case, there is either an increase in aggressive factors, that is, a disorder in mechanical barriers or luminal clearance mechanisms that will increase the contact of acid with the epithelium, or an insufficiency in defense, that is, an insufficiency of epithelial defense factors, or the presence of external factors that are severe enough to destroy these defense factors.
Table 1: Factors Responsible for GERD
1) Disorders in the gastroesophageal junction
Hiatal hernia
Lower Inadequate contraction and temporary relaxation of the esophageal sphincter
2) Stomach factors
Gastric emptying defects, hyperacidity, bile reflux
3) Delay in esophageal clearance
Motility disorders, Saliva
4) Environmental factors
Smoking, alcohol, fatty foods, medications, heat
GERD CLINIC
The most common and typical findings of GERD are prosis and regurgitation. Prosis is defined as a burning sensation behind the sternum. It occurs especially in the postparandial period. Regurgitation is the perception of gastric reflux contents in the mouth and hypopharynx. Prosis is the most common reflux symptom in western society. Unlike Western countries, GERD in our country has different clinical features. Pyrosis is less common (9.3%), and regurgitation is significantly more common (16.6%). Dysphagia can be seen in patients with long-term complaints of prosis and erosive esophagitis. A good response is observed in these patients with PPI (Proton pump inhibitor) treatment. Gradually increasing dysphagia, especially to liquids, indicates peptic esophagitis. Adenocarcinoma or squamous cell carcinoma secondary to Barrett's metaplasia Difficulty in swallowing due to a mass arising from esophageal carcinoma should be taken into consideration in the differential diagnosis. Painful swallowing (odynophagia) may occur in esophageal ulcers due to GERD. GERD-related chest pain can mimic angina pectoris. However, it differs from typical cardiac chest pain in that it responds to anti-acids and PPI, is unrelated to effort, and does not spread to the arms, neck or jaw, which are typical areas of spread in angina pectoris. It should not be forgotten that reflux and angina pectoris can coexist in the same person in some cases. It is appropriate to exclude the diagnosis after all the necessary tests (including angiography if necessary) have been performed to clearly determine whether angina pectoris is due to coronary insufficiency.
GERD >other symptoms
- Chest pain,
- Globus sensation,
- Nausea,
- Tooth decay, >
- Gingivitis,
- Bad breath,
- Hypersalivation,
- Sore throat,
- Earache,
- Otitis media,
- Laryngitis,
- Hoarseness,
- Postnasal discharge,
- Sinusitis, pharyngitis,
- Cough,
- Wheezing,
- Shortness of breath,
- Pneumonia,
- Asthma,
- Apnea,
- Bronchitis,
- Atelectasis,
- Pulmonary fibrosis
DIAGNOSIS
A good anamnesis is often sufficient to make a diagnosis of GERD. Although it is suggested in clinical practice that most of the tests are unnecessary to make the diagnosis and start treatment, it is important to evaluate each patient very carefully and within his/her own conditions. “Stubborn post pr I believe that the presence of andial pyrosis and regurgitation should always be approached with caution and caution. For this reason, the evaluation of the gastroenterologist is extremely important in making the definitive diagnosis of cases in which reflux is suspected by the physician at every stage, after proceeding to the treatment phase (trial and error). In cases where the diagnosis is in doubt, when esophageal tissue damage needs to be determined, in the presence of alarm symptoms, when there is no adequate response to treatment, in cases of Barrett's esophagus and suspicion of malignancy, it may be necessary to resort to one or more of these tests. Acid suppression treatment trials with proton pump inhibitors (PPI) (20 mg omeprazole twice a day for 4 weeks) are helpful in determining whether the symptoms belong to reflux. It has a limited place in making a definitive diagnosis, and it should not be forgotten that it may delay the making of a definitive diagnosis in certain cases.
It has been suggested in the literature that a response to a 4-week trial treatment may be sufficient to determine whether atypical chest pain is due to GERD. is being driven. As I mentioned above, I find it useful to repeat. After proving whether atypical chest pain is due to coronary artery insufficiency with coronary angiography, if necessary, it should be investigated with methods such as upper gastrointestinal endoscopy and pH-metry to evaluate extra-cardiac causes. As a physician who has been involved in the practice of gastroenterology for many years, we must be extremely careful, contrary to the views that suggest that a patient with chest pain is diagnosed through trial and error PPI treatments. I think. I think it will be enough to say that the lives of patients with atypical chest pain who cannot be diagnosed correctly have a negative impact on their lives when they have to receive psychological treatment.
Table 2 Alarm Symptoms
