Fighting the esophageal flood: Identification and treatment of gastroesophageal reflux disease

Author: Mi Lin, attending physician at the East China Hospital affiliated to Fudan University

Reviewer: Huang Yiqin, Chief Physician, Huadong Hospital Affiliated to Fudan University

1. What is gastroesophageal reflux disease?

Gastroesophageal reflux disease is a very common chronic disease in gastroenterology. It is caused by the reflux of gastric contents into the esophagus, which causes symptoms such as acid reflux and heartburn. Reflux can also cause damage to the surrounding tissues of the esophagus, such as the mouth, throat, and airway, resulting in symptoms such as foreign body sensation in the throat and cough. In 2022, a study published in the New England Journal of Medicine[1] reported that the prevalence of gastroesophageal reflux disease accounts for about 13.3% of the global population. The incidence rate is higher in Western countries, but the incidence rate in the Asia-Pacific region has been on the rise in recent years. Gastroesophageal reflux disease is not only a gastroenterology disease, but also has a close relationship with other disciplines, such as otolaryngology, respiratory medicine, cardiology, thoracic surgery, dentistry, psychology, etc., and has attracted more and more attention and attention from disciplines.

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2. What are the symptoms of gastroesophageal reflux disease?

The most typical symptoms of gastroesophageal reflux disease are heartburn (i.e., a burning sensation behind the sternum) and acid reflux, which often occur after a full meal, improper eating, or drinking a lot of alcohol. Lying, squatting, bending over, etc. can induce it. In addition, this disease also has some atypical manifestations, including chest pain, upper abdominal pain, belching, sour mouth, bitter mouth, asthma, pharyngeal discomfort, cough, etc. Some patients repeatedly visit cardiovascular and respiratory departments for fear of heart disease and lung disease, and even develop psychological problems due to long-term symptoms and lack of diagnosis and treatment. Of course, for atypical reflux symptoms, other causes should be ruled out first. Most patients have mild clinical manifestations, but some patients' quality of life and work are affected by this disease. Even worse, they may experience severe airway obstruction, asthma attacks, laryngeal spasms, aspiration pneumonia, suffocation and other life-threatening situations, which require more active medical intervention.

3. Why does gastroesophageal reflux disease occur?

The pathogenesis of gastroesophageal reflux disease is relatively complex, and multiple factors and locations are involved in the occurrence and development of the disease. Among them, hiatal hernia is one of the main causes of gastroesophageal reflux disease. The gastroesophageal junction discontinuously shifts upward into the abnormally enlarged esophageal cavity, forming a hiatal hernia, which in turn makes it easy for gastric contents to reflux upward.

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In addition, dysfunction of the junction between the stomach and esophagus (such as relaxation of the lower esophageal sphincter), decreased clearance function of the esophagus itself, weakened defense function of the esophageal epithelium, age ≥ 50 years, obesity, smoking, high-sugar and high-fat diets, and drugs such as non-steroidal anti-inflammatory drugs can also weaken the anti-reflux ability of the esophagus and increase the high sensitivity of the esophagus. The resistance and clearance ability of extraesophageal organs such as the pharynx and airway to reflux is weaker than that of the esophagus.

4. How is gastroesophageal reflux disease diagnosed?

The proton pump inhibitor (PPI) test is simple and effective and can be used as a primary diagnostic method for gastroesophageal reflux disease. Generally, symptom relief is evaluated after double doses of PPI drugs for at least 8 weeks.

In addition, 24-hour dynamic esophageal pH monitoring can be used as a means of reflux monitoring, which is also the current "gold standard" for diagnosing gastroesophageal reflux disease, but due to tolerance and other issues, its clinical application is relatively limited.

With the continuous development of endoscopic examination technology, upper gastrointestinal endoscopy is becoming more and more convenient to diagnose gastroesophageal reflux disease. According to the esophageal mucosal manifestations under gastroscopy, it can be divided into non-erosive reflux disease and erosive reflux disease. When the squamous epithelium of the distal esophagus is replaced by columnar epithelium ≥1cm, and tissue biopsy confirms intestinal metaplasia, it can be diagnosed as Barrett's esophagus. Endoscopic findings of erosive esophagitis, Barrett's esophagus and peptic stricture can confirm gastroesophageal reflux disease.

5. What should I do if I have gastroesophageal reflux disease?

Gastroesophageal reflux disease should be treated individually, and the patient's lifestyle and psychology can be adjusted, combined with Western medicine, Chinese medicine or acupuncture treatment. If the drug treatment is not effective, the patient can also undergo endoscopic plication, laparoscopic anti-reflux surgery, etc. The treatment methods can complement each other in order to achieve the goal of relieving the patient's symptoms, improving the patient's quality of life, reducing complications and reducing long-term drug treatment.

For patients with mild symptoms, clinical observation can be performed first, and their lifestyle can be adjusted or a low-intensity on-demand treatment plan can be adopted. If the patient's symptoms recur frequently or complications occur, medical intervention is required.

Lifestyle adjustment and disease education are the basis for the prevention and treatment of gastroesophageal reflux disease. Regardless of the treatment method used, lifestyle changes should be carried out throughout, including weight loss, raising the head of the bed, quitting smoking/drinking, avoiding late night meals and full meals, avoiding exercise after eating, and eating less foods that may promote reflux (such as chocolate, coffee, spicy foods, oranges, tomatoes, high-fat foods), etc.

Drug therapy is the first-line treatment. Patients who take long-term medications need to be alert to and monitor adverse drug reactions. Commonly used drugs include acid suppressants, antacids, gastrointestinal prokinetics, mucosal protectants, bile acid sequestrants, neuromodulators, and traditional Chinese medicine. The efficacy of combined medication is usually better than that of single medication.

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PPI, as an acid suppressant, is the first choice for the treatment of gastroesophageal reflux disease. It can quickly relieve symptoms in most patients and reverse some complications. PPI is relatively safe in most patients, and adverse reactions are rare. However, patients with erosive esophagitis, peptic stenosis, Barrett's esophagus, central obesity, hiatal hernia, and some extraesophageal reflux may need to take PPI for a long time, and should pay attention to the possible risks of long-term medication (such as osteoporosis, cardiovascular and cerebrovascular diseases, chronic kidney disease, etc.), conduct regular assessments, and consider endoscopic or laparoscopic anti-reflux treatment when necessary.

For refractory patients with severe symptoms and significantly reduced quality of life and work ability, if it is confirmed that they have visceral hypersensitivity or mental and psychological diseases, neuromodulators can be used for treatment, and joint diagnosis and treatment with psychiatric specialists can be carried out if necessary.

References:

[1] FASS R. Gastroesophageal Reflux Disease[J]. N Engl J Med, 2022,387(13):1207-1216.

[2] Gastrointestinal Motility Group, Gastrointestinal Functional Diseases Collaborative Group, Esophageal Diseases Collaborative Group, Chinese Society of Gastroenterology. Chinese Guidelines for Diagnosis and Treatment of Gastroesophageal Reflux Disease[J]. Chinese Journal of Digestion, 2023, 43(9): 588-598.