reflux esophagitis
Introduction
Introduction to reflux esophagitis Refluxesophagitis refers to the fact that the gastroesophageal reflux is divided into physiological and pathological conditions due to the reverse flow of gastric and/or duodenal contents into the esophagus. Physiological gastroesophageal reflux is seen in normal people. It has no clinical significance. If reflux occurs more frequently than normal people, it can not remove acidic digestive gastric juice and pepsin, bile, pancreatic juice in time, it will cause inflammation, erosion, ulcer and esophageal mucosa. Lesions such as fibrosis belong to gastroesophaeal reflux disease (GERD). Symptoms of reflux esophagitis are easily confused with peptic ulcer and are easily misdiagnosed. basic knowledge Sickness ratio: 0.5% Susceptible people: no special people Mode of infection: non-infectious Complications: esophageal perforation
Cause
Causes of reflux esophagitis
24-hour esophageal pH monitoring found that the normal population has gastro-esophageal reflux (GER) phenomenon, but without any clinical symptoms, it is called physiological GER, which is characterized by: often occurring during the day and rare at night; There is more reflux during meals or after meals; total reflux time <hours/24 hours, physiological GER can be converted into pathological GER and even developed into reflux esophagitis under the following conditions.
Anatomy of the esophagogastric junction and destruction of the physiological anti-reflux barrier (20%):
The anti-reflux barrier of the esophagogastric junction is also known as the first anti-reflux screen. The most important structure is the lower esophageal sphincter (LES). The LES is within the range of 3 to 5 cm above the junction between the esophagus and the stomach. In the high-pressure area, the resting pressure is about 2.0-4.0 kPa (15-30 mmHg), which constitutes a pressure barrier and plays a physiological role in preventing the stomach contents from flowing back into the esophagus. The increase of normal intra-abdominal pressure can cause LES through the vagus nerve. Contraction reflex, which makes the LES increase in multiples to prevent GER, LES low pressure and increased intra-abdominal pressure can not cause a strong LES contraction reaction, can lead to GER, studies have shown that LESD <0.8kPa, it is easy to reverse Flow, about 17% to 39% of GER in patients with reflux esophagitis, cholinergic and -adrenergic analog drugs, -adrenergic antagonists, dopaan, diazepam, calcium Receptor antagonists, morphine and fat, alcohol, caffeine and smoking, and other food factors can affect LES function, induce GER, in addition, during pregnancy, oral progesterone-containing contraceptive period and late menstrual cycle, plasma progesterone levels Increase, the incidence of GER Also increase accordingly.
Obstacles to esophageal acid clearance function (15%):
Normal esophageal acid clearance function includes esophageal emptying and saliva neutralization. When the acidic stomach contents are refluxed, it only takes 1 or 2 times (about 10 to 15 seconds) to egress the esophagus and emptied almost everywhere. All the reflux, a small amount of acid remaining in the esophageal mucosa, can be neutralized by saliva (normal humans about 1000-1500 ml per hour, pH 6-8 saliva through the esophagus into the stomach), esophageal acid clearance The function is to reduce the time limit of esophageal mucosa immersion in gastric acid, so it has the effect of preventing reflux esophagitis. It is found that most of the esophageal emptying abnormalities occur early in esophagitis, but it is rare to have esophagitis caused by decreased salivation. Salivation is almost stopped during nighttime sleep, and secondary peristalsis of the esophagus is rare. The nighttime esophageal acid clearance is obviously delayed, so the nighttime GER is more serious.
Damage to the anti-reflux barrier function of the esophageal mucosa (20%):
The anti-reflux barrier function of the esophageal mucosa consists of the following factors: 1 pre-epithelial factors including mucus layer, HCO-3 concentration on mucosal surface; 2 epithelial factors including epithelial cell membrane and intercellular junction structure, and epithelial transport, intracellular buffer , cell metabolism and other functions; 3 post-epithelial factors refer to the internal basal acid status and blood supply of the tissue, when the above-mentioned defensive barrier is damaged, even in the case of normal reflux, can also cause esophagitis, the study found that esophageal epithelium The weakening of cell proliferation and repair ability is one of the important reasons for the development of reflux esophagitis.
Gastric duodenal dysfunction (10%):
1. Abnormal gastric emptying: The incidence of delayed gastric emptying in patients with reflux esophagitis is above 40%, but the causal relationship between the two is still controversial.
2, gastroduodenal reflux: under normal circumstances, esophageal squamous epithelial cells have a keratinized surface layer, can prevent H + infiltration into the mucosa, to protect the esophageal mucosal surface from acid reflux, when the pyloric sphincter tension and When the LES pressure is low, the hydrochloric acid and pepsin in the gastric juice, the bile acid in the duodenal juice, the pancreatic juice and the hemolytic lecithin can simultaneously flow back into the esophagus, erode the keratinized layer of the esophageal epithelial cells, and change it. Thin or shedding, H+ and pepsin in the reflux penetrate deep into the esophageal tissue through the layer of newborn squamous epithelial cells, causing esophagitis.
Split hole 10 (10%):
Commonly, the sliding sputum, the esophagus and stomach joints are displaced upwards into the chest cavity with the stomach body. The rise of the corpuscles separates the squats, the sacs are enlarged, the sacs are small, and the sacs are moved up and down with the body position, force and cough. No longer sliding, changing the normal anatomical relationship near the hole, causing the esophagogastric junction to be incompletely closed. The invasion of the stomach causes the His-angle of the esophagus to enter the stomach to disappear, the esophageal membrane is elongated, thinned, and the esophagus of the abdominal segment moves up. The closing function of the joint is further deteriorated, and more than half of the patients with hiatal hernia develop reflux esophagitis.
After surgery (5%):
Disruptive esophagitis can occur after surgery, such as vagus nerve ablation, lower esophageal myotomy, major gastrectomy, etc. Inserting the stomach tube can cause the esophagitis to be completely closed, but the cause can be recovered after the cause is removed.
Pregnancy vomiting : The hiatal hernia caused by increased intra-abdominal pressure during pregnancy can cause reflux esophagitis, but it can be recovered after delivery without any treatment. Vomiting and long-term hiccup can also cause the sputum to open frequently and cause reflux esophagus. Inflammation, it can return to normal after removing the cause.
Other diseases : neonatal and infants develop regurgitation due to dysfunction of the lower esophageal sphincter. Most of them can be alleviated with the development of the youngest esophageal sphincter, and there is still a dysfunction of the primary esophageal sphincter. Organic diseases such as tumors in the lower esophagus and cardia, scleroderma and various pyloric obstructions can cause reflux esophagitis.
Therefore, reflux esophagitis is usually the result of reflux bile and gastric acid in the esophageal mucosa, and pyloric and LES dysfunction must exist before bile-induced esophageal injury; reflux esophagitis is often accompanied by gastritis Sliding esophageal hiatal hernia is often complicated by LES and pyloric dysfunction. Duodenal ulcer is associated with high gastric acid secretion and is easy to cause antrum and pyloric dysfunction. Obesity, a large amount of ascites, late pregnancy, increased intragastric pressure and other factors can induce this disease.
Pathogenesis
Under normal physiological conditions, the tubular esophagus enters the gastric sac to the right side at an angle called His angle, pushing the fundus to the esophagus to act as a flap, mechanically preventing the reflux of the gastroesophageal tube, and collecting the mucosa at the entrance of the esophagus at the cardia. And the high pressure area under the esophagus is also an important factor to prevent reflux. These normal anatomical relationships play a role in preventing gastroesophageal reflux, destroying the mechanism of preventing gastroesophageal reflux, and incomplete closure of the esophagus and stomach joints will result in frequent Reflux.
There are different opinions on gastroesophageal reflux. It is generally considered that the esophageal membrane attachment point of patients with gastroesophageal reflux is lower than that of normal people. The esophageal segment of the abdomen is short or disappears, so that the whole esophageal segment is subjected to a subatmospheric negative pressure. The esophageal lumen is enlarged and reflux occurs. Another mechanism that may cause reflux is that the tension of the esophageal membrane is increased, so that the distal end of the esophagus is often pulled and opened. The reflux occurs often in patients with abnormal body weight or excessive exertion or posture. At that time, for example, obesity patients had more fat in the esophageal membrane, which reduced the length of adhesion to the esophageal ventral segment. People with heavy smoking and drinking had non-specific esophagitis, which caused adhesion between the esophageal membrane and the distal esophagus. The length of the esophagus in the abdomen is reduced, and the above assumptions all involve an abnormality of the esophageal membrane.
The reflux is physiological to a certain extent. If it is accompanied by esophagitis, it becomes pathological. The long-term exposure of the esophageal epithelium to the reflux of gastric acid is the cause of esophagitis. The duration of contact between the esophageal mucosa and gastric acid is determined by reflux. Frequency and duration of each reflux, and the speed of acid removal by the esophagus, continuous monitoring of the pH value of the esophagus after 24h, the normal value is 5.0 ~ 6.8, the pH value below 4.0 is considered to be the presence of reflux, Because pH 1.8 ~ 3.8 is the upper limit of the most appropriate activity of protease, in the upright position and awake state, due to gravity removal and swallowing action and neutral saliva neutralization, normal people's reflux does not cause damage, frequent reflux Especially in the supine and deep sleep, the esophagus has no activity, although the reflux is small, but the removal is slow, there is no gravity to help clear, and there is no neutralization of saliva, so the incidence of reflux esophagitis is high, the reflux In addition to food, gastric juice contains acid, protease and mucus, plus bile salts, pancreatic enzyme is extremely sensitive to esophageal mucosa, can occur esophagitis or esophageal function changes, or both, The above factors, reflux, promote the occurrence of esophagitis.
In patients with chronic reflux, the mucosa of the ulcer is healed, the neoplastic epithelium is replaced by the columnar epithelium of the esophagogastric junction, and the columnar epithelium at the upper end of the cardia is called Barrett's esophagus or columnar epithelium. If there is persistent reflux, the squamous epithelium Ulcers can occur at the junction and there is a high risk of developing adenocarcinoma.
Prevention
Reflux esophagitis prevention
1, obese people should lose weight, because obese people with increased abdominal pressure, can promote gastric reflux, especially in the supine position, should actively reduce weight to improve reflux symptoms.
2, to maintain a comfortable mood, increase the appropriate physical exercise.
3, bed at the end should be raised by 10 cm ~ 15 cm overall, is a effective way to reduce nighttime reflux.
Complication
Reflux esophagitis complications Complications perforation of the esophagus
In addition to complications such as esophageal stricture, hemorrhage, ulcer, etc., the reflux of gastric juice can also erode the pharynx, vocal cords and trachea and cause chronic pharyngitis, chronic vocal corditis and bronchitis, clinically known as Delahunty syndrome, gastric juice Reflux and inhalation of the respiratory tract can cause aspiration pneumonia. Recent studies have shown that GER is associated with partial recurrent asthma, cough, nocturnal apnea, and angina-like chest pain.
Symptom
Reflux esophageal inflammatory symptoms Common symptoms Hiccups heartburn heartburn, flatulence, gastroesophageal sputum, nausea, pain
Pathological change
Macroscopically visible esophageal mucosal bleeding, edema, brittle and easy bleeding, acute esophagitis, mucosal epithelial necrosis, formation of erosion and superficial ulcer, severely the entire epithelial layer can fall off, but generally does not exceed the mucosal muscle layer, chronic esophagitis Mucosal erosion can cause fibrosis, and can cross the mucosal muscle layer and affect the entire esophageal wall, esophageal mucosal erosion, repeated formation of ulcers and fibers, esophage scarring can occur, squamous epithelium can be seen under the microscope Basal cell hyperplasia, milk penetration extends to the surface layer of the epithelium, accompanied by vascular proliferation, neutrophil infiltration in the lamina propria, scar formation in the esophageal stricture, submucosal or muscular layer, severe esophagitis, visible The base layer of the mucosal epithelium is destroyed, and because the ulcer is too large, the squamous epithelial cells at the edge of the ulcer cannot repair the ulcer by re-epithelialization, and the epithelial metaplasia is called Barrett's esophagus. The ulcer that occurs in the Barrett epithelium is called Barrett's soup. .
Clinical manifestation
1. Burning or pain in the back of the sternum
According to the distribution of the vagus nerve, it can sometimes radiate to the neck, ankle or ear. It is common to radiate to the shoulders on both sides of the back. The burning sensation can be stimulated by drinking water or taking acid or sugar blocks. Salivation and esophageal primary peristalsis are alleviated, especially after eating some spicy foods, which can be caused by bending, exerting force or lying down, and the upright position is relieved. This is because the walking in an upright position promotes esophageal clearance. The role of orthostatic burning pain is aggravated, highly suggestive for reflux, gastric acid deficiency, burning sensation is mainly caused by bile reflux, the effect of sulphuric acid is not enough, the severity of burning sensation is not necessarily related to the lesion The severity of the disease, severe esophagitis, especially in the formation of scars, may have no or only a slight burning sensation.
2, stomach, esophageal reflux
Every time after a meal, lying in bed or sleeping in bed at night, there is acidic liquid or food from the stomach, esophagus reflux to the pharynx or mouth, this symptom occurs before the burning of the sternum or burning pain occurs.
3, swallowing pain
Due to the stimulation of the esophagus or esophageal fistula caused by the food mass, the distribution of spasm and heartburn is the same as that of the radioactive part. The esophagus is acutely dilated in the esophagitis area and in some areas of stenosis or motor incompatibility, resulting in a third contraction or paralysis. The patient can feel that the food or liquid is stopped above the esophagus. Wait for the group to rush down or drink. The dilated esophagus above the group pause can cause very serious pain. The spastic pain can also be caused by reflux.
4, difficulty in swallowing
In the early stage, intermittent esophageal fistula may cause intermittent pharyngeal difficulty. In the later stage, esophageal scar formation may be narrowed, burning sensation and burning pain are gradually reduced, and it is replaced by permanent pharyngeal difficulty. When eating solid foods Can cause blockage or pain at the xiphoid.
5, nausea
Gastric acid or bile reflux into the posterior wall of the mouth indicates that the gastroesophageal reflux, the contents of the stomach can be spit or swallowed, leaving a sour or bitter taste in the pharynx and mouth, causing bad breath or taste damage, chronically irritated lips There may be a burning sensation, nausea after eating, exertion or body position change, often accompanied by flatulence, hiccups, nighttime reflux can also cause cough, aspiration pneumonia or suffocation.
6, bleeding and anemia
Severe esophagitis can cause esophageal mucosal erosion and cause bleeding, mostly chronic small amount of bleeding, long-term or massive bleeding can lead to iron deficiency anemia.
7, other symptoms
The reflux enters the throat through the pharyngeal sphincter, which can cause laryngeal and tracheal aspiration, inflammatory vocal cord polyps, susceptible patients can easily induce asthma, diffuse esophagitis or invasive ulcer can cause vomiting, chronic blood loss, a few penetrating Ulcers can occur in the esophagus.
Examine
Reflux esophagitis examination
(1) Esophageal acid perfusion test (acid perfusion test)
The patient takes the sitting position and places the stomach tube through the nasal cavity. When the tube end reaches 30-35cm, the physiological saline is first dripped, about 10ml per minute, for 15 minutes. If the patient has no special discomfort, use 0.1N hydrochloric acid for the same drip rate. Instillation for 30 minutes, during the acid drop process, the sternal pain or burning sensation is positive, and more than the first 15 minutes of the acid, such as repeated positive reaction, and can be dripped into saline Relief, can be judged to have acid GER, the sensitivity and specificity of the test is about 80%.
(two) esophageal lumen pH determination
A pH electrode placed in the cavity is gradually pulled into the esophagus and placed about 5 cm above the LES. Under normal circumstances, the pH in the stomach is very low. At this time, the patient is placed in the supine position and the abdominal pain is increased. The action, such as closing, blowing nose, deep exhalation or flexing the leg, and rubbing the nose 3 to 4 times, if the pH in the esophagus drops to 4 times, indicating the presence of GER, can also inject 0.1N hydrochloric acid into the stomach cavity. Explain that 300ml, before injecting hydrochloric acid and after injecting for 15 minutes, respectively, the patient is supine and increased abdominal pressure. In patients with GER, the pH in the esophageal lumen is significantly decreased after injection of hydrochloric acid. In recent years, 24-hour esophageal pH monitoring has been measured. The standard for the presence or absence of acid GER, including the percentage of pH < 4 in the esophagus, the percentage of pH < 4 in the supine and standing positions, the number of times pH < 4, the number of times pH < 4 lasts more than 5 minutes, and the longest duration, etc. Index, China's normal 24-hour esophageal pH monitoring pH < 4 time is below 6%, the number of times lasting more than 5 minutes 3 times, the maximum duration of reflux is 18 minutes, these parameters can help determine the presence or absence of acid reflux, It also helps to clarify the relationship between chest pain and lung disease and acid reflux.
(C) esophageal pressure measurement
The pressure in the esophageal lumen is usually measured by a continuous perfusion catheter system filled with water to estimate the function of the LES and the esophagus. When measuring pressure, the pressure catheter is first inserted into the stomach, and then the catheter is withdrawn at a speed of 0.5 to 1.0 cm/min. And measure the pressure inside the esophagus, the LES pressure is about 2 ~ 4kPa (15 ~ 30mmHg) when the normal person is at rest, or the ratio of LES pressure to gastric pressure is > 1, when the LES pressure is <0.8kPa (6mmHg) when stationary, or the ratio of the two <1, it indicates that the LES function is incomplete, or there is a GER.
(four) gastric-esophageal scintigraphy
This method can estimate the reflux of the stomach-esophagus, attach the inflatable abdomen on the patient's abdomen, and take 300ml of acidified orange juice solution containing 300Ci99mTc-Sc (containing 150ml of orange juice and 150ml of 0.1N HCL) on an empty stomach, and then drink cold water. ~ 30ml, in order to remove the residual test solution in the esophagus, erect imaging, normal people 10 to 15 minutes after the absence of radioactivity in the stomach, otherwise it indicates the presence of GER, the sensitivity and specificity of this method is about 90%.
(5) X-ray examination of esophageal swallowing
Less sensitive, more false negatives.
(6) Endoscopy
And biopsy examination by endoscopy and biopsy can determine whether there is pathological changes in reflux esophagitis, and whether there is bile reflux or not, the severity of pathology of reflux esophagitis is of great value.
The inflammatory lesions of the standard reflux reflux esophagitis grouped by Savary and Miller can be divided into 4 levels:
I degree: mild inflammation, endoscopic findings of the lower esophageal mucosa slightly redder than normal, biopsy microscopic examination of the esophageal epithelial basement membrane hyperplasia, surface cells have shedding, near the surface of the vascular nipple, has not yet formed true esophagitis, not reflux The resulting features do not require anti-reflux treatment.
II degree: The inflammation is heavier, but there is no ulcer. The endoscopic mucosa is obviously red, and the histology is the vascularized epithelium and the small lesion of hemorrhage.
III degree: the surface epithelium continues to fall off, surface ulcer (IIIa) occurs, ulcers are extensive and fused (IIIb), endoscopy is easy to confirm, ulcers can progress to ulcerative esophagitis.
IV degree: esophageal stenosis, the deep development of ulcer involves the tissues and lymph nodes around the esophagus, resulting in thickening and edema of the esophageal wall. Esophageal scar and fibrotic contraction occur in the intermittent period, causing esophageal stricture, and the stenosis is often located above the esophagogastric junction. 3 to 5 cm, the esophagus can be shortened, so that the esophagus and stomach joints are lifted into the mediastinum, and the esophagogastric junction cannot be returned to the abdominal cavity during the surgical treatment.
Diagnosis
Diagnosis and diagnosis of reflux esophagitis
diagnosis
Diagnosis can be performed based on clinical performance and laboratory tests.
Differential diagnosis
1, spleen (heartache): chest tightness or paroxysmal chest pain mainly, often after exertion, no sternum: post-burning sensation and difficulty swallowing, ECG shows ST-T ischemic changes, esophageal drops The acid test was negative.
2, esophageal cancer, esophageal fistula: with sputum as the main disease, esophagoscopy and X-ray swallowing examination can be identified.
3, stomach ulcers: pain is mostly located in the stomach, often chronic, rhythmic, seasonal and periodic attacks, X-ray barium meal and fiber endoscopy in the stomach or duodenal bulb can be seen ulcer lesions.
4, angina pectoris: esophageal muscle pain and angina can exist alone, sometimes at the same time, can be alleviated with nitroglycerin, identification is very difficult, cardiogenic pain often horizontal chest radiation, and esophageal pain vertical radiation, two types The pain can be caused by sudden movement, but when the posture is forced, reflux can occur, and continuous exercise without force can cause angina.
5, snoring ball: refers to the patient complained of a foreign body sensation in the throat, can not start swallowing, there is a sense of blockage, clinical examination of no organic lesions, is considered to be caused by high reflux of the stomach caused by upper esophageal stimulation, sometimes a minority The patient's only symptoms lead to misdiagnosis.
