reflux disease

Reflux disease: description

The occasional reflux of gastric juice into the esophagus is quite normal during the day. In gastroesophageal reflux disease, the amount of acidic gastric juice, which rises back into the esophagus (esophagus), but increased morbid. Gastric acid is good if left in the stomach. There the low pH between 1 and 4 helps in the digestion process and the killing of harmful substances. The stomach is also specially protected from the acid. Not so the esophagus – her mucous membrane is not resistant enough and is attacked by the acid.

On the way from the mouth to the stomach, the esophagus passes through a small opening in the diaphragm. Here is usually the cause of the reflux disease: Because the lower sphincter muscles, which actually ensure that after swallowing the food porridge, the esophagus closes again, are dysfunctional. Reflux disease causes the lower esophageal sphincter (lower esophageal sphincter) to no longer seal completely when lying down or bending over, and the hydrochloric acid from the gastric juice comes into contact with the esophageal mucosa. If this happens for a longer period of time, the mucous membrane of the esophagus is damaged. This can lead to a painful inflammation with mucosal changes (Gastroesophageal reflux disease) to lead.

Reflux disease: who is affected?

In the western population, ten to twenty percent of people suffer from the reflux disease. It is therefore a very common disease that affects women more often than men. The incidence of reflux disease increases with age, but in rare cases, babies and toddlers are affected.

Reflux disease: forms

Distinction NERD and ERD

If there is a reflux without changes in the mucosa one speaks of one non-erosive gastroesophageal reflux disease (NERD). NERD accounts for about 60 percent of those with gastroesophageal reflux disease. On the other hand, if mucosal changes can be detected in a tissue sample from the esophageal reflection, this is referred to as erosive reflux disease (ERD).

Distinction between primary and secondary reflux disease

In addition, two different forms of reflux disease are differentiated: primary and secondary reflux disease. Both have either a loss of function of the lower oesophageal sphincter (esophageal sphincter) and / or a restriction of the mobility of the esophagus. This means that the body’s own cleaning mechanism of the esophagus is impaired. Normally, it eliminates gastric acid through its proper movements (peristalsis). If mobility is limited, however, the contact duration of the acid to the oesophageal mucosa is prolonged and damage occurs easily.

Primary reflux disease

The primary gastroesophageal reflux disease By far the most common form of reflux disease. Primary means that no clear cause has been found for it. But it is clear that the lower sphincter of the esophagus relaxes outside of the regular swallowing act and the esophagus no longer seals sufficiently against the stomach. There are several factors that favor the development of primary reflux disease. These include obesity, certain dietary habits (see Causes and risk factors), a weakening of the diaphragm or inadequate protective mechanisms of the esophagus (reduced mobility or reduced production of saliva).

Secondary reflux disease

One secondary gastroesophageal reflux arises as a result of a known physical change – it occurs less often than the primary reflux disease. For example, in 50 percent of women in the last trimester of pregnancy pregnancy causes a reflux disease due to the pressure increase in the abdomen. Furthermore, digestive tract disease leading to an anatomical change in the esophagus or stomach may trigger a secondary reflux disease.

Reflux disease: symptoms

For everything important to the typical signs of reflux disease, see Reflux Symptoms.

Reflux Disease: Causes and Risk Factors

Reflux disease is usually due to relaxation of the lower oesophageal sphincter (lower oesophageal sphincter). The sphincter does not adequately seal the esophagus outside the swallowing cycle with respect to the stomach. Especially when lying down and bending over, acidic gastric contents enter the esophagus and irritate the mucous membrane. In other cases there is a reduced motility of the esophagus, whereby the esophagus can not cleanse sufficiently and the gastric acid has longer contact with the mucous membrane. The corrosive gastric acid damages the mucous membrane, which in many cases causes burning pain (heartburn).

Primary reflux disease – causes

The exact mechanism leading to repeated leakage of gastric contents in primary reflux disease has not been fully elucidated. However, there are several factors that cause increased gastric acid production and sagging of the esophageal sphincter, thus favoring reflux disease.

Primary reflux disease – nutrition

Nutrition has a major impact on gastroesophageal reflux disease. Certain foods irritate the mucous membrane and stimulate the stomach to produce more acid. On the one hand, coffee, fatty or sweet foods and alcohol irritate the mucous membrane of the esophagus and promote inflammation. In addition, caffeine, nicotine as well as stress and tension stimulate gastric acid production. Alcohol also inhibits the mobility of the lower esophageal sphincter, which can also progress the reflux disease.

Primary reflux disease – diaphragmatic weakness, diaphragmatic hernia, increased His angle

90 percent of those affected by the reflux disease also suffer from a diaphragmatic hernia (axial hiatal hernia). The diaphragm is a large respiratory muscle that separates the ribcage from the abdomen. The three openings for the esophagus, the main artery (aorta) and the vena cava (vena cava) are natural weak points of the muscle. In a diaphragmatic fracture, the stomach pushes upwards through the diaphragmatic opening of the esophagus, whereupon the lower sphincter of the esophagus is distended and promotes gastroesophageal reflux. Although most patients with reflux disease have axial hiatal hernia, not every patient suffers from reflux disease. According to experts, therefore, a hiatal hernia is not directly the cause of the reflux disease.

Another factor that promotes reflux disease is an increased “His angle”. The His angle is the angle between the esophageal junction in the stomach and the uppermost portion of the stomach. Normally it is about 50 to 60 degrees. If it is increased over 60 degrees, it can easily return acidic gastric juice to the esophagus.

Secondary reflux disease – causes

In secondary reflux disease, the weakness of the esophageal musculature is caused by another disease or a change in the body. The causes are usually an increase in pressure in the abdomen or anatomical changes in the surrounding structures.

pregnancy

Pregnancy causes in 50 percent of women, that the increase in pressure in the abdominal cavity, the stomach contents can easily flow back into the esophagus. The further the pregnancy progresses and the abdominal circumference increases, the sooner the reflux disease occurs. The sphincter of the esophagus no longer seals adequately, and the acidic contents of the stomach increasingly enter the esophagus. In most women, the reflux disease develops after childbirth on its own.

Organic diseases

There are several organic diseases that can cause a narrowing of the gastric outlet (pyloric stenosis). The gastric contents are not transmitted to the small intestine, but accumulate. A gastric tumor can also hinder the outflow of gastric contents. If the stomach contents back up, the pressure increases and the stomach contents can more easily enter the esophagus and lead to reflux symptoms.

In addition, a rare hardening of the connective tissue in the esophagus, the systemic scleroderma, can lead to a lack of mobility of the esophageal musculature and thus to impaired self-cleaning of the esophagus. This is also the case with the so-called achalasia, in which a permanent mobility of the esophagus is not possible due to a permanent tension of the lower esophageal sphincter.

Reflux disease: examinations and diagnosis

The right contact person for the suspected reflux disease is your family doctor or a specialist in internal medicine and gastroenterology. By providing a detailed account of your symptoms and any pre-existing conditions, you can provide the doctor with important information about your current state of health (anamnesis). To get an accurate picture of your condition, the doctor could ask you the following questions:

• Do you suffer from heartburn?
• Do the complaints increase while lying or bending over?
• Do you have to knock open more?
• Do you suffer from a feeling of pressure in the throat?
• Do you suffer from dysphagia?
• Have you noticed a dry cough that occurs more at night?
• Have you noticed bad breath more often?
• Do you have pre-existing conditions in the esophagus or stomach?
• Do you take medicine?
• Do you drink alcohol and coffee, do you smoke and how do you feed yourself?

The doctor will usually add you physically examineto rule out other causes of your condition. He will ask you to free the upper body. By listening to the heart with the stethoscope, he can gain clues as to whether, for example, a feeling of pressure in the chest is also triggered by a disease of the heart and not by a reflux disease. In addition, the doctor may look at your mouth and throat. Because a fungal infection, for example, cause similar symptoms. However, gastroscopy or long-term pH measurement over 24 hours is always necessary for the reliable diagnosis of reflux disease.

Further investigations

Gastroscopy (esophago-gastro-duodenography)

If you have a gastroscopy, the doctor can look at the upper digestive tract with the aid of a camera inserted in a tube (endoscope). The patient should not eat or drink for six hours prior to the examination so that the examiner has a clear view of the tissue. The patient lies on the left side and is briefly put under anesthetic if desired. A mouthpiece between the teeth prevents the patient from accidentally biting the endoscope. The doctor then pushes the tube through the esophagus into the stomach down to the small intestine. With the aid of the gastroscopy, he can judge whether and how much the reflux disease has already damaged the mucous membrane. Furthermore, it can be searched in the stomach for a possible cause of the reflux disease. In addition, the physician takes tissue samples from conspicuous mucous membrane areas. These are then assessed by a pathologist under the microscope.

Long-term pH-metry (over 24 hours)

The pH measurement in the esophagus over 24 hours is the standard method for the reliable diagnosis of reflux disease. A long-term pH-metry is particularly important if the gastroscopy has revealed no evidence of mucosal damage.

In long-term pH-metry, a thin tube (probe) is advanced through the nose to the esophagus (and possibly to the stomach). The probe measures the pH of the stomach and esophagus for one day and one night. With severe gagging, throat numbing can be helpful. It is important that any anti-acid medication you take is discontinued at least 72 hours before the examination to avoid false negative results. In some cases, an X-ray image is taken to ensure the correct position of the probe. The probe is connected to a small recorder which the patient carries with him for 24 hours. In addition, the patient keeps a diary in which he notes the meals and activities of the day. The records are evaluated together with the patient’s notes. Reflux disease is considered confirmed if a pH of four or less is measured in the esophagus for more than eight percent of the time measured.

Reflux disease: treatment

The reflux disease can be treated. General measures, as well as a change in dietary habits and lifestyles already lead to a significant relief of symptoms for many people affected. A drug-based reflux treatment helps 90 percent of those affected. In addition, a particularly difficult course of the reflux disease surgery can help.

General measures

Wearing too tight pants should be avoided in reflux disease. As a result, the pressure in the abdomen can be increased, it is easier stomach contents enter the esophagus. It also helps most patients to sleep at night with a slightly elevated upper body and left lateral position. Gravity is used to counteract the reflux naturally. Physical activity and, above all, weight loss in case of obesity are particularly conducive to reducing abdominal pressure and stimulating digestion.

Reflux – nutrition

Sufferers often suffer from indigestion as part of their reflux disease. In contrast, diets rich in protein are often well tolerated. Because the proteins stimulate the stomach to produce the peptide hormone gastrin. The gastrin increases the muscle tension of the sphincter muscle to the esophagus, whereupon it closes better again. On the other hand, gastrin increases gastric acid production. Choosing the right foods and amounts of food can also have a beneficial effect on reflux disease: small, low-carbohydrate and low-fat portions should be preferred. Meals should also be taken some time before bedtime so that the contents of the stomach have already been transferred to the small intestine when you go to bed.

Avoid harmful substances

The consumption of alcohol should be avoided. Alcohol directly damages the mucous membrane. On the other hand, alcohol leads to relaxation of the lower esophageal sphincter. He is thus a very significant factor influencing the reflux disease. The effect of coffee on the reflux disease, however, is controversial. On the one hand, caffeine stimulates the stomach to produce gastric acid, which can further irritate the mucous membrane. On the other hand, caffeine also increases the production of gastrin, closing the oesophageal sphincter better. Just try how well and how much coffee you can tolerate. You should abstain from smoking. Smoking, and especially nicotine, causes excessive gastric acidity and has numerous other negative effects on the whole body.

Medicinally inhibit acid production

So-called proton pump inhibitors (PPIs) are considered the drug of choice in reflux therapy. These substances include, for example, omeprazole or pantoprazole. Proton pump inhibitors are generally considered to be well tolerated and 90 percent of those affected no longer have any complaints. Intake of the proton pump inhibitors should be started in high doses and subsequently reduced. However, at full weaning, 50 percent of patients experience a recurrence of the symptoms. There is also the possibility to promote gastric movements in the direction of the small intestine with the active ingredient domperidone. Thus, the drainage of the stomach acid is improved and the reflux symptoms may be improved. In addition to excessive gastric acid production, the use of other gastric acid-reducing drugs (so-called antacids) may be useful.

Reflux – surgery

If the reflux disease is in a very advanced stage and can not be treated by medication, surgery may be necessary. In the so-called surgical technique “Nissen Fundoplication”, a cuff is formed from the upper area of ​​the stomach, placed around the lower end of the esophagus and sewn shut. The cuff serves as a stabilizer of the esophageal sphincter. The surgery can be fraught with complications and should therefore only be performed if, for example, no improvement can be achieved despite proton pump inhibitors or antacids. Even if gastric juice has already returned to the trachea (aspiration), surgery should be discussed otherwise it may lead to pneumonia. In addition to Nissen fundoplication, other surgical procedures such as hiatoplasty and fundopexy are also available.

Reflux Disease home remedies

Many people swear in heartburn on the use of substances that neutralize the acid (antacids). This includes, for example, the so-called Bullrich salt. This consists of 100 percent sodium bicarbonate, which compensates for gastric acidity. While Bullrich salt often works well against acute heartburn, it’s proven to boost acid production in the stomach. So it is by no means a means that you should constantly use against heartburn. Better tolerated are the commonly used proton pump inhibitors.

Another home remedy for reflux is chamomile tea. This has anti-inflammatory properties and can help to reduce gastric acid production. Naturopathic orientated doctors recommend a chamomile tea roll cure in particular. First, some chamomile tea is drunk, then you lie down for five minutes on the back. Then you drink some sips of chamomile tea again and lie down for five minutes on the left side. According to this principle, one continues with the abdominal and right lateral position. Overall, the chamomile tea roll cure takes about 20 minutes. The purpose of Rollkur is to moisten the stomach wall as completely as possible with chamomile tea.

Reflux disease: disease course and prognosis

The listed therapies reduce the discomfort in most patients. However, if left untreated, acid exposure can lead to various complications.

Gastroesophageal reflux disease with esophagitis

Esophagitis is an inflammation of the esophagus caused by increased acid contact in the gastroscopy with changes in the mucosa. Typically, the inflamed mucosa is red and swollen. If there are no mucosal changes in a gastroscopy and the tissue samples taken, it is a non-erosive gastroesophageal reflux (NERD).

Barrett’s esophagus

The mucous membrane of the esophagus is not made for contact with stomach acid. As a result of high levels of acidity and recurring inflammation, the mucosa in some patients changes and adapts to constant contact with the stomach acid. The tissue is rebuilt and then contains more resilient cells (columnar epithelium) with mucus-producing cells (goblet cells) which are more resistant to gastric acidity. This cell transformation (metaplasia) of the esophagus is referred to as Barrett’s esophagus or Barrett’s syndrome. The cell changes, however, increase the risk of a malignant tumor (adenocarcinoma) of the esophagus. About every tenth patient with Barrett’s esophagus develops esophageal cancer. Therefore, with known Barrett’s esophagus, a consistent reflux treatment should be performed with regular controls.

Reflux disease – further complications

There is a risk that the stomach acid gets into the trachea. The corrosive properties can irritate the larynx, causing inflammation (laryngitis). Patients often suffer from hoarseness. In addition, the “inhalation” of stomach acid can cause a chronic irritable cough. Acid-induced damage to the lungs also causes pneumonia (aspiration pneumonia). In addition, mucosal damage to the esophagus can lead to chronic bleeding, which can lead to anemia (anemia). The reflux disease should therefore always be treated in order to avoid the consequential damage.