Gastroesophageal Reflux - Barrett's Esophagus

Definition

According to the Montreal Agreement, gastroesophageal reflux is characterized by

symptoms and / or structural changes in the esophagus caused by reflux

stomach contents into the esophagus and are associated with deterioration in the quality of life of patients.

Pathogenesis

The cause of reflux is multifactorial, i.e. there are usually several factors involved in weakening the reflux barrier.

 

The most important is the spontaneous relaxation of the lower esophageal sphincter muscle. Other contributing factors include septal hernia, impaired esophageal motility, obesity, increased intra-abdominal pressure, disturbed gastric emptying, etc.

The whole process is complex and there is no correlation between the extent of the reflux on the one hand and the intensity of the symptoms on the other.

It is worth noting that 10% of patients with reflux form a metaplastic, acid-resistant, mucosa in the lower esophagus (Barrett esophagus), and are at potentially increased risk of developing malignancy (adenocarcinoma).

Diagnosis

The most important diagnostic measure is to obtain a detailed medical history.

In addition, gastroscopy plays an important role, which can reveal lesions such as reflux esophagitis including its complications (stenosis, ulcer, bleeding). It is worth noting that in about 60% of cases, however, there are no mucosal lesions (the so-called non-corrosive reflux, NERD).

 Gastroscopy is also very important in the diagnosis of Barrett's esophagus, as this can only be done endoscopically (with biopsies). To detect its neoplastic changes in patients with Barrett's esophagus, special chromoendoscopy and magnification endoscopy techniques are used that give us valuable information.

Functional diagnostic tests also include impedance Ph-measurement which allows the differentiation between acidic and non-acidic reflux, especially in treatment-resistant patients.

Treatment

According to international guidelines, treatment with proton pump inhibitors (PPIs) is the treatment of choice in patients with reflux disease. Thus, depending on the severity of esophagitis, a cure is seen in 80-95% of cases within about six to eight weeks.

For long-term prophylaxis against relapse, PPIs represent the predominant form of treatment, but at a reduced dosage. In patients with extra-esophageal manifestations such as cough, throat clearing, laryngitis the effectiveness of PPIs is the subject of modern studies.

Surgical treatment of gastroesophageal reflux disease is effective for a small portion of the population. In the context of surgeries that are currently performed exclusively laparoscopically, the functionality of the lower esophageal sphincter is restored (partially or completely) by vaulting.

Newer surgeries such as electrical stimulation or placement of a magnetic ring around the lower esophageal sphincter are expected to be evaluated in long-term studies.