Gastroesophageal reflux disease (GERD): symptoms

When considering the clinical picture of GERD, one should keep in mind its extreme variability. DO Castell figuratively considers this disease as a kind of "iceberg". The majority (70-80%) of patients have mild and only sporadic symptoms, because of which they do not resort to medical care, engaged in self-medication over-the-counter (usually antacids), and widely use the advice of friends ("telephone refluxes"). This is the underwater part of the iceberg. The average, above-water part of it is composed of patients with reflux esophagitis with more pronounced or persistent symptoms, but without complications, which require regular treatment - "ambulatory refluxes" (20-25%). The tip of the "iceberg" is a small group of patients (2-5%) who developed complications (peptic ulcers, bleeding, strictures) - "hospital reflux".

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

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

Esophageal symptoms include:

• heartburn;
• eructation;
• regurgitation;
• dysphagia;
• lonely phagia (sensation of pain when passing food through the esophagus, which is usually found with a pronounced lesion of the esophageal mucosa);
• pain in the epigastrium and esophagus;
• hiccough;
• vomiting;
• feeling the coma behind the sternum.

Out-oesophageal symptoms develop usually as a result of either direct extra-esophageal action, or initiation of esophagobarchial, 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 taken for angina pectoris, pneumonia, anemia. The clinical picture of this chronic disease is polymorphic, with many "masks". Harrington called the hernia of the esophageal opening of the diaphragm a "masquerade of the upper abdomen". This figurative definition can be applied to clinical manifestations of GERD.

Among the main symptoms, heartburn is central - a feeling of retro-intestinal burning that spreads upwards from the xiphoid process.

Heartburn with GERD has some peculiarities: it can be almost permanent throughout the day, but the pathognomonic symptom for GERD is its clear dependence on the position of the body, and it arises either at inclines or at night in a lying position. To provoke the occurrence of heartburn may be the use of certain foods (hot freshly baked bakery products, sweet, sour, spicy dishes), overeating, or may occur after smoking, drinking alcohol. It is fundamentally important to distinguish between heartburn and the feeling of heat behind the sternum in case of coronary insufficiency. Prognostically unfavorable gradual disappearance of heartburn and the emergence of dysphagia, indicating the development of peptic stricture as a result of reflux esophagitis or cancer of the esophagus. The sensation of an increased amount of fluid in the mouth occurs simultaneously with heartburn and is caused by an esophagolytic reflex.

Belching and regurgitation are involuntary sharp ejections into the mouth from the cavity of the esophagus or stomach of air or a mixture of air and gastric contents. The eructation can be acidic during acid casting and bitter, caused by regurgitation of duodenal contents. Regurgitation is belching food and air. These symptoms are characterized by a general mechanism of development - insufficiency of the lower esophageal sphincter.

Dysphagia is a violation of the passage of food through the esophagus. Causes of dysphagia in patients with GERD - esophageal thrombosis, mechanical obstruction (with esophageal stricture). With esophagitis, most often dysphagia occurs when you take any food. Pain in the epigastrium and esophagus is often observed in patients with GERD, can be associated and not associated with food intake, more likely to occur during meals, characterized by a relationship of pain with swallowing, occasionally pain can irradiate to the apex of the heart. Hiccups are often a marked sign of the disease, due to the excitation of the diaphragmatic nerve, irritation and contraction of the diaphragm, which sometimes is quite painful, there are cases of indomitable 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 in the night, causing bronchospasm. Osier in 1892 for the first time associated the attack of asphyxiation with the aspiration of gastric contents into the airways. Currently, the term "reflux-induced asthma" has been introduced. According to the literature, 80% of patients with bronchial asthma have GERD. In this case, a vicious circle is formed: GERD due to direct action and initiation of the esophagobromchial reflex induces the development of bronchospasm and inflammatory process, in turn, drugs used in bronchial asthma induce the development of GERD.

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

Mendelssohn syndrome is widely known - repeated pneumonia due to aspiration of gastric contents, which can be complicated by atelectasis, lung abscess. 80% of patients with idiopathic pneumofibrosis have GERD symptoms.

With high casting, refluxatum can flow into the larynx, and the "otorhinolaryngic mask" of GERD develops, manifested by a coarse, barking cough, a sore throat, and hoarseness in the morning (back laryngitis). According to foreign authors, the risk of developing cancerous degeneration of the larynx and vocal cords is extremely high in patients with GERD. The formation of ulcers, a granuloma of the vocal cords, stenosis of the distal regions of the vocal cicle is described. Often occurs laryngitis, manifested chronic hoarseness (78% of patients with chronic hoarseness have symptoms of GERD), often complicated by laryngeal croup. The cause of chronic rhinitis, recurrent otitis, otalgia can also be a pathological GER.

There is an opinion among forensic experts that gastroesophageal reflux can be one of the mechanisms leading to the death of a person when, due to ingestion of acidic gastric contents into the pharynx and larynx, spasm of the larynx develops and reflex stops the breathing.

With GERD, there may be pain behind the sternum, along the esophagus, creating a "coronary mask" of GERD, the so-called "non-cardiac chest pain" symptom. The pains often resemble angina, are caused by a spasm of the esophagus, are stopped by nitrates. In contrast to angina pectoris, they are not associated with exercise, walking and emotions. In half of the cases in elderly patients, combinations of IHD are possible, and in some patients, in order to differentiate the pain, even coronary angiography is necessary. As a result of the initiation of the esophagocardial reflex, arrhythmias occur.

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

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

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

Complications of gastroesophageal reflux disease

The most common complications of gastroesophageal reflux disease:

• stricture of the esophagus - 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 multilayer 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 different authors, Barrett syndrome occurs in 8-20% of patients with reflux esophagitis, with a 30-40-fold increase in the risk of esophageal cancer.

The complexity of diagnosing this complication lies in the absence of pathognomonic clinical manifestations. The main role in identifying Barrett's esophagus is given to endoscopic research ("tongues of flame" - velvet-like mucous membrane of red color). To confirm the diagnosis of Barrett's esophagus, a histological examination of biopsies of the esophagus mucosa is performed. Barrett's esophagus can be confirmed if at least one of the biopsy specimens reveals a cylindrical epithelium, with the presence of goblet cells in the metaplastic epithelium. When immunohistochemical research can identify a specific marker of the epithelium Barret - sucrasizomaltase. Endosonography helps in identifying early esophageal cancer.

Esophagus cancer often has a squamous cell structure with or without keratinization. By the nature of growth, exophytic, endophytic and mixed forms of the tumor are isolated. Metastasis of cancer occurs mainly along the lymphatic pathways. Significantly, there is hematogenous metastasis in the liver, pleura and lungs. In cancer of the esophagus, telethematherapy, surgical and combined (radiation and surgical) treatment are used. The choice of method depends on the localization of the method, its sensitivity to irradiation and the prevalence of the process.

[1], [2], [3], [4]