Gastroesophageal reflux disease (GERD) - Symptoms

When considering the clinical picture of GERD, one should remember its extreme variability. DO Castell figuratively considers this disease as a kind of "iceberg". The majority (70-80%) of patients have mild and only sporadically occurring symptoms, for which they do not seek medical help, self-medicating with over-the-counter drugs (usually antacids), and widely use the advice of friends ("telephone reflux"). This is the underwater part of the "iceberg". The middle, above-water part, is made up of patients with reflux esophagitis with more pronounced or constant symptoms, but without complications, who require regular treatment - "outpatient reflux" (20-25%). The top of the "iceberg" is a small group of patients (2-5%) who have developed complications (peptic ulcers, bleeding, strictures) - "hospital reflux".

The intensity of clinical manifestations of GERD depends on the concentration of hydrochloric acid in the refluxate, the frequency and duration of its contact with the esophageal mucosa, and the presence of esophageal hypersensitivity.

Symptoms that occur with GERD can be divided into two groups: esophageal and extraesophageal symptoms.

Esophageal symptoms include:

• heartburn;
• belching;
• regurgitation;
• dysphagia;
• odynophagia (a sensation of pain when food passes through the esophagus, which usually occurs with severe damage to the esophageal mucosa);
• pain in the epigastrium and esophagus;
• hiccups;
• vomit;
• a feeling of a lump behind the breastbone.

Extraesophageal symptoms usually develop as a result of either direct extraesophageal action or initiation of esophagobronchial, esophagocardial reflexes.

They include:

• pulmonary syndrome;
• otolaryngological syndrome;
• dental syndrome;
• anemic syndrome;
• cardiac syndrome.

The variety of symptoms and syndromes leads in practice to numerous diagnostic errors, when GERD is mistaken for angina, pneumonia, anemia. The clinical picture of this chronic disease is polymorphic, with many "masks". Harrington called the clinical picture of a hernia of the esophageal opening of the diaphragm "a masquerade of the upper abdomen". This figurative definition can also be applied to the clinical manifestations of GERD.

Among the main symptoms, the central place is occupied by heartburn - a feeling of retrosternal burning, spreading upward from the xiphoid process.

Heartburn in GERD has some features: it can be almost constant during the day, but the pathognomonic symptom for GERD is its clear dependence on the position of the body, and it occurs either when bending over or at night in a lying position. Heartburn can be provoked by the use of certain foods (hot freshly baked bakery products, sweet, sour, spicy dishes), overeating, or can occur after smoking, drinking alcohol. It is fundamentally important to distinguish heartburn from a feeling of heat behind the breastbone in coronary insufficiency. The gradual disappearance of heartburn and the occurrence of dysphagia, indicating the development of peptic stricture as a result of reflux esophagitis or esophageal cancer, are prognostically unfavorable. The feeling of an increased amount of liquid in the mouth occurs simultaneously with heartburn and is due to the esophagosalivary reflex.

Belching and regurgitation are involuntary sharp ejections of air or a mixture of air and gastric contents from the esophagus or stomach into the mouth. Belching can be sour when acid is thrown up and bitter, caused by regurgitation of duodenal contents. Belching is belching of food and air. These symptoms have a common development mechanism - insufficiency of the lower esophageal sphincter.

Dysphagia is a disorder of food passage through the esophagus. Causes of dysphagia in patients with GERD are esophageal dysmotility and mechanical obstruction (with esophageal stricture). With esophagitis, dysphagia most often occurs when eating any food. Pain in the epigastrium and esophagus is often observed in patients with GERD, may or may not be associated with food intake, most often occurs during meals, pain is typically associated with swallowing, and occasionally pain can radiate to the apex of the heart. Hiccups are often a pronounced symptom of the disease, caused by excitation of the phrenic nerve, irritation and contraction of the diaphragm, and can sometimes be quite painful; there are cases of uncontrollable vomiting.

Pulmonary manifestations are the main mask of gastroesophageal reflux disease. A number of patients at any age develop aspiration pneumonia and bronchial asthma, while pathological gastroesophageal reflux is a trigger for asthma attacks, mainly at night, causing bronchospasm. Osier in 1892 was the first to associate an attack of suffocation with aspiration of gastric contents into the airways. Currently, the term "reflux-induced asthma" has been introduced. According to literary data, 80% of patients with bronchial asthma have manifestations of GERD. In this case, a vicious circle is formed: GERD, due to the direct action and initiation of the esophagobronchial reflex, induces the development of bronchospasm and inflammation, in turn, drugs used in bronchial asthma induce the development of GERD.

According to B.D. Starostin (1998), approximately 75% of patients with chronic bronchitis have a long-term, bothersome dry cough associated with GERD.

Mendelson's syndrome is widely known - repeated pneumonias arising from aspiration of gastric contents, which can be complicated by atelectasis, lung abscess. 80% of patients with idiopathic pneumofibrosis have symptoms of GERD.

With high reflux, the refluxate can flow into the larynx, and the "otolaryngological mask" of GERD develops, manifested by a rough, barking cough, sore throat and hoarseness in the morning (posterior laryngitis). According to foreign authors, patients with GERD have an extremely high risk of developing cancerous degeneration of the larynx and vocal cords. The formation of ulcers, granulomas of the vocal cords, stenosis of the sections located distal to the glottis have been described. Laryngitis is often encountered, manifested by chronic hoarseness (78% of patients with chronic hoarseness have symptoms of GERD), often complicated by laryngeal croup. Pathological GER can also be the cause of chronic rhinitis, recurrent otitis, otalgia.

There is an opinion among forensic experts that gastroesophageal reflux may be one of the mechanisms leading to human death, when, as a result of acidic gastric contents entering the pharynx and larynx, laryngeal spasm and reflex respiratory arrest develop.

GERD can cause pain behind the breastbone, along the esophagus, creating a "coronary mask" of GERD, the so-called "non-cardiac chest pain" symptom. The pain often resembles angina, is caused by spasm of the esophagus, and is relieved by nitrates. Unlike angina, it is not associated with stress, walking, or emotions. In half of the cases, elderly patients may have a combination of coronary heart disease, and in some patients, coronary angiography is even necessary to differentiate the pain. As a result of the initiation of the esophagocardial reflex, arrhythmias occur.

Dental syndrome is manifested by damage to teeth due to destruction of tooth enamel by aggressive gastric contents. According to RJ Loffeld, 32.5% of 293 patients with confirmed GERD had damage to the upper and/or lower incisors. Patients with GERD are often diagnosed with caries, followed by the development of halitosis, dental erosions. In rare cases, aphthous stomatitis develops.

Anemic syndrome occurs due to chronic bleeding from erosions or ulcers of the esophagus, sometimes due to diapedetic bleeding in catarrhal esophagitis. Most often, this is hypochromic iron deficiency anemia.

Along with symptomatic forms, there are low-symptomatic, asymptomatic (latent) and atypical forms of GERD.

Complications of gastroesophageal reflux disease

The most common complications of gastroesophageal reflux disease are:

• esophageal strictures - 7-23%;
• ulcerative lesions of the esophagus - 5%;
• bleeding from erosions and ulcers of the esophagus - 2%;
• formation of Barrett's esophagus - 8-20%.

The most dangerous is the formation of Barrett's syndrome - complete replacement (metaplasia) of the multilayered squamous epithelium of the esophagus with cylindrical gastric epithelium. In general, Barrett's esophagus is formed in 0.4-2% of the population. According to various authors, Barrett's syndrome occurs in 8-20% of patients with reflux esophagitis, while the risk of developing esophageal cancer increases 30-40 times.

The difficulty in diagnosing this complication is the lack of pathognomonic clinical manifestations. The main role in identifying Barrett's esophagus is given to endoscopic examination ("flame tongues" - velvet-like red mucous membrane). To confirm the diagnosis of Barrett's esophagus, a histological examination of biopsies of the esophageal mucosa is performed. Barrett's esophagus can be confirmed if at least one of the biopsies reveals cylindrical epithelium, with the presence of goblet cells in the metaplastic epithelium. Immunohistochemical examination can reveal a specific marker of Barrett's epithelium - sucrasuisomaltase. Endosonography helps in identifying early esophageal cancer.

Esophageal cancer most often has a squamous cell structure with or without keratinization. According to the nature of growth, exophytic, endophytic and mixed forms of tumor are distinguished. Cancer metastasis occurs mainly through the lymphatic pathways. Hematogenous metastasis to the liver, pleura and lungs is much less common. In case of esophageal cancer, telegammatherapy, surgical and combined (radiation and surgical) treatment are used. The choice of method depends on the localization of the method, its sensitivity to radiation and the prevalence of the process.

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