Gastroesophageal reflux disease (GERD) is a gastroenterological disease characterized by the development of inflammatory changes in the mucous membrane distal esophagus and / or characteristic clinical symptoms due to repeated reflux of gastric and / or duodenal contents into the esophagus.

The failure of the lower esophageal sphincter contributes to the reflux of gastric contents into the esophagus, causing severe pain. Prolonged reflux can lead to esophagitis, stricture, and rarely metaplasia. Diagnosis is clinical, sometimes with endoscopy and gastric acidity testing. Treatment for gastroesophageal reflux disease (GERD) includes lifestyle changes, deacidification with proton pump blockers, and sometimes surgery.

ICD-10 code

K 21.0 Gastroesophageal reflux with esophagitis
K21.9 Gastroesophageal reflux without esophagitis.

ICD-10 code

K21 Gastroesophageal reflux

K21.0 Gastroesophageal reflux with esophagitis

K21.9 Gastroesophageal reflux without esophagitis

Epidemiology of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is common and occurs in 30-40% of adults. It is also common in infants and usually appears after birth.

The increasing urgency of the problem of gastroesophageal reflux disease is associated with an increase in the number of patients with this pathology all over the world. The results of epidemiological studies show that the incidence of reflux esophagitis in the population is 3-4%. It is detected in 6-12% of people undergoing endoscopic examination.

Studies in Europe and the United States have shown that 20-25% of the population suffers from symptoms of gastroesophageal reflux disease, and 7% have symptoms on a daily basis. In general practice, 25-40% of people with GERD have endoscopic esophagitis, but most people have no endoscopic manifestations of GERD.

According to foreign researchers, 44% of Americans suffer from heartburn at least once a month, and 7% have it every day. 13% of the US adult population uses antacids two or more times a week, and 1/3 - once a month. However, among the respondents, only 40% of the symptoms were so pronounced that they had to go to a doctor. In France, gastroesophageal reflux disease (GERD) is one of the most common diseases of the digestive tract. As the survey showed, 10% of the adult population showed symptoms of gastroesophageal reflux disease (GERD) at least once a year. All this makes the study of GERD one of the priority areas of modern gastroenterology. The prevalence of GERD is comparable to the prevalence of peptic ulcer and gallstone disease. It is believed that each of these diseases affects up to 10% of the population. Daily symptoms of GERD are experienced by up to 10% of the population, weekly - 30%, monthly - 50% of the adult population. In the United States, 44 million people have symptoms of gastroesophageal reflux disease (GERD).

What causes gastroesophageal reflux disease (GERD)?

The appearance of reflux suggests a failure of the lower esophageal sphincter (LES), which may be the result of a general decrease in sphincter tone or recurrent transient relaxations (not associated with swallowing). Transient relaxation of the LPS is caused by gastric dilatation or subthreshold pharyngeal stimulation.

Factors that ensure the normal functioning of the gastroesophageal junction include: the angle of the gastroesophageal junction, contraction of the diaphragm, and gravity (i.e., vertical position). Factors contributing to reflux include weight gain, fatty foods, caffeinated sodas, alcohol, tobacco smoking, and medication. Medications that reduce LPS tone include anticholinergics, antihistamines, tricyclic antidepressants, Ca-channel blockers, progesterone, and nitrates.

Gastroesophageal reflux disease (GERD) can cause esophagitis, peptic ulcer of the esophagus, esophageal stricture, and Berrett's esophagus (precancerous disease). Factors contributing to the development of esophagitis include: the caustic nature of refluxate, the inability of the esophagus to neutralize it, the volume of gastric contents and the local protective properties of the mucous membrane. Some patients, especially infants, will aspirate the contents during reflux.

Symptoms of gastroesophageal reflux disease (GERD)

The most prominent symptoms of gastroesophageal reflux disease (GERD) are heartburn, with or without regurgitation of gastric contents into the mouth. Babies develop vomiting, irritability, anorexia, and sometimes signs of chronic aspiration. In adults and infants with chronic aspiration, cough, hoarseness, or stridor may occur.

Esophagitis can cause pain when swallowing and even esophageal bleeding, which is usually hidden but sometimes massive. Peptic stricture causes progressively progressive dysphagia when solid foods are eaten. Peptic ulcers of the esophagus cause pain like a stomach ulcer or duodenum, but the pain is usually localized in the xiphoid process or high retrosternal region. Peptic ulcers of the esophagus heal slowly, tend to recur, and usually scar as they heal.

Diagnostics of the gastroesophageal reflux disease (GERD)

A detailed history usually indicates a diagnosis. Patients with typical signs of GERD can be given trial therapy. In case of ineffectiveness of treatment, prolonged symptoms of the disease or signs of complications, the patient should be examined. Endoscopy with cytological examination of mucosal scrapings and biopsy of the altered areas is the method of choice. Endoscopic biopsy is the only test that consistently detects the appearance of columnar mucosal epithelium in Berrett's esophagus. Patients with questionable endoscopy and persistent symptoms despite treatment with proton pump blockers should have a pH test. Although barium swallowed fluoroscopy indicates esophageal ulcers and peptic stricture, this study is less informative for treatment options to reduce reflux; in addition, most patients with identified pathology require subsequent endoscopy. Esophageal manometry can be used as a guide to probe placement in pH studies and to assess esophageal peristalsis prior to surgery.

Treatment of gastroesophageal reflux disease (GERD)

Treatment of uncomplicated gastroesophageal reflux disease (GERD) consists of raising the head end of the bed by 20 centimeters and excluding the following factors: eating at least 2 hours before bedtime, strong stimulants of gastric secretion (e.g. coffee, alcohol), certain medications (e.g. ., anticholinergics), certain foods (e.g. fats, chocolate) and smoking.

Medication for gastroesophageal reflux disease (GERD) includes proton pump blockers. For adults, omeprazole 20 mg, lansoprazole 30 mg, or esomeprazole 40 mg may be given 30 minutes before breakfast. In some cases, proton pump blockers need to be prescribed 2 times a day. Infants and children can be prescribed these drugs, respectively, at a lower dosage once a day (i.e. omeprazole 20 mg for children over 3 years, 10 mg for children under 3; lansoprazole 15 mg for children under 30 kg, 30 mg for children over 30 kg ). These drugs can be used for a long time, but the minimum dose necessary to prevent symptoms must be selected. H2 blockers (eg, ranitidine 150 mg at bedtime) or motility stimulants (eg, metoclopramide 10 mg orally 30 minutes before meals at bedtime) are less effective.

Antireflux surgery (usually laparoscopic) is performed on patients with severe esophagitis, bleeding, strictures, ulcers, or severe symptoms. For esophageal strictures, repeated balloon dilation sessions are used.

Berrett's esophagus may regress (sometimes treatment is ineffective) with the use of medical or surgical treatment. Since Berrett's esophagus predisposes to adenocarcinoma, endoscopic monitoring of malignancy every 1–2 years is recommended. Observation is of little value in patients with mild dysplasia, but important in severe dysplasia. Alternatively conservative treatment Berrett's esophagus may be considered surgical resection or laser ablation.

How is gastroesophageal reflux disease (GERD) prevented?

Preventive measures have not been developed, therefore gastroesophageal reflux disease (GERD) is not prevented. Screening studies are not performed.

History reference

The disease characterized by the reflux of gastric contents into the esophagus has been known for a long time. Some of the symptoms of this pathology, such as heartburn and sour belching, are mentioned in the writings of Avicenna. Gastroesophageal reflux (GER) was first described by H. Quinke in 1879. Since that time, many terms have changed that characterize this nosology. A number of authors call gastroesophageal reflux disease (GERD) peptic esophagitis or reflux esophagitis, but it is known that more than 50% of patients with similar symptoms do not have damage to the esophageal mucosa at all. Others call gastroesophageal reflux disease simply reflux disease, but reflux can occur in the venous, urinary systems, various parts of the gastrointestinal tract (GIT), and the mechanisms of the onset and manifestation of the disease in each case are different. Sometimes the following formulation of the diagnosis is found - gastroesophageal reflux (GER). It is important to note that GER itself can be a physiological phenomenon and occur in completely healthy people. Despite the widespread prevalence and long "history" until recently, GERD, according to figurative expression E.S. Ryssa, was a kind of "Cinderella" among therapists and gastroenterologists. And only in the last decade, the ubiquitous spread of esophagogastroscopy and the appearance of daily pH-metry made it possible to engage in the diagnosis of this disease more thoroughly and try to answer many accumulated questions. In 1996, the term (GERD) appeared in the international classification, which most fully reflects this pathology.

According to the WHO classification, gastroeophageal reflux disease (GERD) is a chronic recurrent disease caused by a violation of the motor-evacuation function of the gastroesophageal zone and characterized by spontaneous or regularly repeated throwing of gastric or duodenal contents into the esophagus, which leads to damage to the distal esophagus.

RCHD (Republican Center for Healthcare Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols of the Ministry of Health of the Republic of Kazakhstan - 2017

Gastroesophageal reflux (K21), Gastroesophageal reflux without esophagitis (K21.9), Gastroesophageal reflux with esophagitis (K21.0)

Gastroenterology

general information

Short description

Approved
Joint Commission for Quality medical services
Ministry of Health of the Republic of Kazakhstan
dated June 29, 2017
Protocol No. 24

Gastroesophageal reflux disease is a chronic recurrent disease caused by a violation of the motor-evacuation function of the organs of the gastroesophageal zone and characterized by spontaneous or regularly repeated throwing of gastric or duodenal contents into the esophagus, leading to the development of inflammatory changes in the distal esophagus and / or characteristic clinical symptoms.

INTRODUCTORY PART

ICD-10 code (s):

Date of development / revision of the protocol: 2013/ revision 2017

Abbreviations used in the protocol:

ALAT	alanine aminotransferase
ASAT	aspartate aminotransferase
VEM	veloergometry
ER	gastroesophageal reflux
GERD	gastroesophageal reflux disease
GPOD	hiatal hernia
Gastrointestinal tract	gastrointestinal tract
IPP	proton pump inhibitors
NERB	endoscopically negative reflux disease
NPC	lower esophageal sphincter
OBP	organs abdominal cavity
RCT	randomized controlled trials
CO	mucous membrane
XC	cholesterol
EGDS	esophagogastroduodenoscopy
ECG	electrocardiography

Protocol users: general practitioners, therapists, gastroenterologists.

Evidence level scale:

A	High quality meta-analysis, systematic review of RCTs or RCTs with very low probability (++) bias that can be generalized to the relevant population.
V	High-quality (++) systematic review of cohort or case-control studies or high-quality (++) cohort or case-control studies with very low risk of bias or RCTs with low (+) risk of bias that can be generalized to the corresponding population.
WITH	Cohort study or case-control studies or controlled trials without randomization with a low risk of bias (+), the results of which can be generalized to appropriate populations, or RCTs with very low or low bias (++ or +), the results of which may be directly extended to the relevant population.
D	Case series description or uncontrolled research or expert opinion.

Classification

GERD classification:

by clinical forms:
Non-erosive reflux disease (NERD) (60-65% of cases);
Erosive (reflux esophagitis) (30-35% of cases);
Barrett's esophagus (5%).

to assess the severity:
clinical criteria:
Mild - heartburn less than 2 times a week;
· Average - heartburn 2 times a week or more, but not daily;
· Severe - daily heartburn.

endoscopic criteria:
Currently, a modified Savary-Millera classification or Los Angeles classification of esophagitis, 1994 is used. (Table 1).

Table 1... Savary-Miller modified classification of esophagitis

Severity	Endoscopic picture
I	One or several isolated oval or linear erosions are located only on one longitudinal fold of the esophageal mucosa.
II	Multiple erosions that may coalesce and occur on more than one longitudinal fold, but not circularly.
III	Erosions are located circularly (on the inflamed mucosa).
IV	Chronic mucosal damage: one or more ulcers, one or more strictures, and / or short esophagus. Additionally, there may or may not be changes characteristic of the I-III severity of esophagitis.
V	Characterized by the presence of a specialized columnar epithelium (Barrett esophagus) extending from the Z-line, of various shapes and length. Perhaps a combination with any changes in the mucous membrane of the esophagus, characteristic of I-IV degrees of severity of esophagitis.

Table 2. Reflux-esophagitis classification (Los Angeles, 1994)

Degree esophagitis	Endoscopic picture
A	One (or more) lesions of the mucous membrane (erosion or ulceration) less than 5 mm in length, limited to the fold of the mucous membrane
V	One (or more) lesions of the mucous membrane (erosion or ulceration) longer than 5 mm, limited to the fold of the mucous membrane
WITH	The lesion of the mucous membrane extends to 2 or more folds of the mucous membrane, but occupies less than 75% of the circumference of the esophagus
D	The lesion of the mucous membrane extends to 75% or more of the circumference of the esophagus

by phases of the disease:
Exacerbation;
· Remission.

complications of GERD:
Peptic erosive and ulcerative esophagitis;
Peptic ulcer of the esophagus;
Peptic stricture of the esophagus;
• esophageal bleeding;
· Post-hemorrhagic anemia;
Barrett's esophagus
· Adenocarcinoma of the esophagus.

Barrett's esophagus classification:
by type of metaplasia:
Barrett's esophagus with gastric metaplasia;
· Barrett's esophagus with intestinal metaplasia;

by length:
· Short segment (the length of the metaplasia area is less than 3 cm);
· Long segment (the length of the metaplasia area is 3 cm or more).

The formulation of the diagnosis of GERD includes:
· The clinical form of the disease;
· Severity (in the case of esophagitis - an indication of its degree and the date of the last endoscopic detection of erosive and ulcerative lesions);
· The clinical phase of the disease (exacerbation, remission);
· Complications (with Barrett's esophagus - the type of metaplasia, the degree of dysplasia).

Diagnostics

METHODS, APPROACHES AND PROCEDURES OF DIAGNOSTICS AND TREATMENT

Diagnostic criteria: collection of complaints according to Table 3.

Table 3. Clinical manifestations of GERD

Esophageal symptoms

Extraesophageal symptoms

... heartburn - a burning sensation of varying intensity behind the sternum in the lower third of the esophagus and / or in the epigastric region;
... sour belching after eating;
... regurgitation of food (regurgitation);
... dysphagia and single phagia (pain when swallowing) unstable (with swelling of the mucous membrane of the lower third of the esophagus) or persistent (with the development of stricture);
... chest pain (characterized by a relationship with food intake, body position and stopping them by taking antacids).

Bronchopulmonary - attacks of coughing and / or suffocation, mainly at night, after a heavy meal;
· Otolaryngological: constant coughing, food "stuck" in the throat or feeling of a "lump" in the throat, tickling and hoarseness of the voice, pain in the ear;
· Dental: erosion of tooth enamel, the development of caries;
· Cardiovascular: arrhythmias.

Table 4. Basic laboratory and instrumental research

Instrumental research
esophagogastroduodenoscopy	Decreased distance from the anterior incisors to the cardia, gaping or incomplete closure of the cardia, transcardial migration of the mucous membrane, gastroesophageal reflux, reflux-esophagitis, the presence of a contractile ring, the presence of foci of epithelial ectopia - Barrett's esophagus
esophagogastroduodenoscopy with biopsy of the esophageal mucosa in case of suspicion of Barrett's esophagus with biopsy of the mucous membrane of the distal esophagus	The histological specimen shows signs of gastric epithelial metaplasia
X-ray examination method using barium	Edema of the cardia and fornix of the stomach, increased mobility of the abdominal esophagus, smoothness or absence of the His angle, antiperistaltic movements of the esophagus (pharyngeal dance), prolapse of the esophageal mucosa into the stomach, the presence in the esophageal opening and above the diaphragm of mucosal folds characteristic of the gastric mucosa, which directly pass into the folds of the subphrenic part of the stomach, the hernial part of the stomach forms a rounded or irregular protrusion, with even or jagged contours, widely communicating with the stomach.
pH - metry of the esophagus	A change in the intraesophageal pH from neutral to acidic, according to changes in the pH of different parts of the esophagus, it is possible to establish to what level the contents of the stomach rises in the vertical and horizontal position of the patient; esophageal reflux

Additional diagnostic tests:
· X-ray of the esophagus and stomach with contrast - in case of dysphagia, suspected hiatal hernia (hiatal hernia);
· A blood test for tumor markers - if an oncological process is suspected;
Daily pH-metry for endoscopically negative esophagitis (UDA) - according to indications;
· Electrocardiogram - to exclude myocardial infarction.

Indications for specialist consultation:
· Consultation with an oncologist - when Barrett's esophagus or a tumor, esophageal stricture is detected;
· Consultation of other narrow specialists - according to indications.

Diagnostic algorithm for GERD

Differential diagnosis

Differential diagnosis of GERD
Signs	GERD	Ischemic heart disease	Bronchial asthma	Relaxation of the diaphragm (Petit disease)
Anamnesis	Long-term dispensary. observation of GERD; constant intake of anti secretorn. drugs	Retrosternal pain without connection with food intake, change in body position; dispensary registration with a cardiologist, pain is relieved by taking nitroglycerin.	Long-term dispensary observation for bronchial asthma; asthma attacks; constant use of bronchodilator therapy	Congenital pathology of muscle elements; various injuries of the diaphragm, which are accompanied by a violation of the nervous innervation of the diaphragm.
Laboratory data		Lipid metabolism indicators (cholesterol, LDL) may be increased.	In the KLA, there may be a slight eosinophilia, an increase in the number of neutrophils and a shift in the leukocyte formula to the left.	As a rule, without much change
ECG	No special changes	With myocardial infarction, a change in the ST segment. In case of lower localization, an ECG should be recorded on the right half of the chest in leads V3R or V4R.	No special changes	No special Changes
EGDS	Decrease in the distance from the anterior incisors to the cardia, the presence of a hernial cavity, the presence of a "second entrance" to the stomach, gaping or incomplete closure of the cardia, GER, reflux esophagitis, contractile. ring, foci of ectopia of the epithelium, esophagus, Barrett.	Without features	Without features	Without features
X-ray. vanie	Edema of the cardia and fornix of the stomach, increased mobility of the abdominal esophagus, smoothness or absence of the angle of His, antiperistaltic movements of the esophagus, prolapse of the esophagus into the stomach.	Without features	In the interictal period at the onset of the disease, there are no signs of x-ray. In stages 1 and 2, with severe course, pulmonary emphysema and cor pulmonale are detected.	Reducing the resistance of the abdominal obstruction, as a result of which the OBP moves into the chest cavity. Alshevsky-Vinbek's symptom, Velman's symptom. The lower pulmonary field is darkened. The shadow of the heart can be shifted to the right.

Treatment abroad

Get treatment in Korea, Israel, Germany, USA

Get advice on medical tourism

Treatment

Preparations (active ingredients) used in the treatment

Treatment (outpatient clinic)

TACTICS OF TREATMENT AT THE AMBULATORY LEVEL:
Treatment tactics include non-drug methods and pharmacotherapy.

Non-drug treatment:
Non-drug treatment consists in following the recommendations for changing lifestyle and diet (antireflux measures), the implementation of which should be given special importance in the treatment of GERD (Table 5).

Recommendations	Comments (1)
1. Sleep with the head end of the bed raised at least 15 cm. .	Reduces the duration of acidification of the esophagus.
2. Dietary restrictions: - reduce the fat content (cream, butter, fatty fish, pork, goose, duck, lamb, cakes); - increase the protein content: - reduce the amount of food; - do not consume irritating foods (alcohol, citrus juices, tomatoes, coffee, chocolate, strong tea, onions, garlic, etc.).	... fats reduce the pressure of the NPS; ... proteins increase the pressure of the LPS; ... decreases the volume of gastric contents and reflux; ... direct damaging effect. ... coffee, chocolate, alcohol, tomatoes also reduce the pressure of the NPS.
3. Lose weight when obese .	Being overweight contributes to increased reflux.
4. Do not eat before bedtime, do not lie down immediately after eating.	Reduces the volume of gastric contents in a horizontal position
5. Do not wear tight clothing and tight belts.
6. Avoid deep bends, prolonged stay in a bent position ("gardener" pose), lifting weights over 5-10 kg., physical exercise with overstrain of the abdominal muscles.	Increase intra-abdominal pressure, increase reflux
7. Avoid taking drugs: sedatives, hypnotics, tranquilizers, calcium antagonists, anticholinergics.	Reduce the pressure of the LPS and / or slow down peristalsis.
8. Stop smoking.	Smoking significantly reduces LPS pressure and decreases esophageal clearance.

Drug treatment is carried out depending on the severity of GERD and includes the use of antisecretory, prokinetic and antacid medicines... The main pathogenetic drugs are antisecretory drugs (blockers of H2 histamine receptors and proton pump inhibitors). There is evidence of the effectiveness of prokinetics in treatment of mild and moderate GERD. Antacids can be used as symptomatic drugs on demand.

Treatment goals:
Relief of clinical symptoms
Healing of erosions
Prevention or elimination of complications
Improving the quality of life
· Prevention of recurrence.

The purpose antisecretory therapy is a decrease in the aggression of acidic gastric contents on the mucous membrane of the esophagus in GERD. The choice and dosage regimens of antisecretory drugs depend on the characteristics of the course and severity of GERD.

Non-erosive form of GERD and class I-II esophagitis:
1st line drugs:
Blockers of H2 histamine receptors (famotidine, ranitidine)
2nd line drugs:
In case of ineffectiveness / intolerance of therapy, proton pump inhibitors (PPIs) are used

Erosive forms of GERD:
1st line drugs:
PPI (omeprazole, pantoprazole, esomeprazole, rabeprazole, lansoprazole)
2nd line drugs:
Blockers of histamine H2 receptors (famotidine, ranitidine), if necessary, use with drugs that affect the cytochrome P450 system (see Table 5).
PPIs are powerful antisecretory drugs and should only be used when the diagnosis of GERD is objectively documented. Adjunctive H2 blocker therapy along with PPIs has been reported to be beneficial for patients with severe GERD (especially those with Barrett's esophagus) who have nocturnal acid breakthrough. Forms and release, average doses and dosage regimens of antisecretory drugs are presented in Table 6.
The duration of the use of antisecretory drugs for GERD depends on the stage of the disease:
Non-erosive forms of GERD - duration 3-4 weeks
Erosive forms of GERD:
Stage 1 - single erosion, duration 4 weeks
Stages 2-3 - multiple erosions lasting 8 weeks.

Meanwhile, in some cases, longer use is required, incl. supportive therapy. Taking into account the rather long-term use of these groups of drugs, a risk / benefit assessment and a constant reassessment of their prescription, including dosage regimens, are necessary.

When using antisecretory drugs, it must be borne in mind that when using blockers of H2 histamine receptors development is possible:
- pharmacological tolerance
- Caution is required when engaging in potentially hazardous activities that require increased concentration of attention and speed of psychomotor reactions, because dizziness is possible, especially after taking the initial dose.

With an overall good safety profile IPP can:
- disrupt calcium homeostasis
- aggravate irregular heart rhythm
- cause hypomagnesemia.

There is a link between hip fractures in postmenopausal women and long-term PPI use. In this connection, these groups of drugs are not recommended for use in elderly patients for more than 8 weeks. A study by the Agency for Healthcare Research and Quality (AHRQ), based on class A evidence, showed that PPIs were more effective than histamine H2 blockers in resolving GERD symptoms after 4 weeks and healing esophagitis after 8 weeks. In addition, the AHRQ found no difference between individual PPIs for symptom relief after 8 weeks.

The basic PPI is omeprazole, due to its good knowledge and low cost. There is evidence of a more rapid onset of the effect when using esomeprazole, pantoprazole, in accordance with the official instructions for use, has a lesser effect on the cytochrome P450 system, therefore it is safer in combination with drugs metabolized by this system.

When assessing the interaction of antisecretory drugs with other drugs, it should be borne in mind that all PPIs are metabolized by the cytochrome P450 (CYP) system and there is a risk of metabolic interaction between PPIs and other substances whose metabolism is associated with this system (see Table 6). More detailed information is presented in the instructions for use and international drug databases.

Table 6. Threatening antisecretory drug interactions

№	Medicine	Interaction type	Change in the level of drugs in the blood	Tactics
1	Nelfinavir Atazanavir Rilpivirine Dasatinib Erlotinib Pazopanib Ketoconazole Itraconazole	An increase in gastric pH decreases gastrointestinal absorption	Decreased blood levels and decreased pharmacological efficacy	Combined use with antisecretory drugs is not recommended. Occasional use of antacids is possible.
2	Clopidogrel	inhibitory effect of PPI on CYP2C19 and bioactivation of Clopidogrel	Decreased blood levels of Clopidogrel and decreased pharmacological activity	Empiric PPI use should be avoided in patients receiving clopidogrel. PPIs should only be considered in high-risk patients (dual antiplatelet therapy, concomitant anticoagulant therapy, risk of bleeding) after careful assessment of the risks and benefits. If PPIs are required, pantoprazole may be a safer alternative. Otherwise, H2 receptor antagonists or antacids should be prescribed whenever possible.
3	Methotrexate	PPI inhibition of active tubular secretion of MTX and 7-hydroxymethotrexate using renal H + / K + ATPase pumps.	Increased blood levels of methotrexate and increased toxicity	PPI therapy should preferably be discontinued several days prior to methotrexate administration. In addition, the use of high-dose methotrexate PPIs is generally not recommended, especially in the presence of renal impairment. If concomitant use of PPIs is necessary, clinicians should consider the interaction and closely monitor the level and toxicity of methotrexate. The use of H2 receptor blockers may also be a suitable alternative.
4	Citalopram	Interaction with the CYP450 2C19 system	The concentration of citalopram in the blood increases and the risk of prolongation of the QT interval increases	Given the risk of dose-dependent QT prolongation, the dose of citalopram should not exceed 20 mg / day when given in combination with a PPI. Alternative drugs should be prescribed as needed. Hypokalemia or hypomagnesemia should be corrected before starting treatment with citalopram and monitored periodically. Patients should be advised to seek medical attention if they experience dizziness, palpitations, irregular heartbeats, shortness of breath, or fainting.
5	Tacrolimus	Interaction at the level of CYP3A and P-gp substrate).	Increased blood concentration of Tacrolimus	It is recommended to monitor the concentration of acrolimus in blood plasma in the event of starting or ending combined treatment with PPIs.
6	Fluvoxamine other inhibitors of CYP2C19	Inhibit CYP2C19 isoenzyme	Increasing the concentration of PPIs in the blood	PPI dose reduction should be considered
7	Rifampicin St. John's wort preparations (Hypericumperforatum) Other inducers of CYP2C19 and CYP3A4	Induce isoenzymes CYP2C19 and CYP3A4	Decreased blood PPI concentration	A regular assessment of the antisecretory efficacy is required and an increase in the dose of PPIs is possible

Blockers of histamine H2 receptors do not affect the cytochrome P450 system and can be safely used in combination therapy with drugs whose metabolism is associated with this system. In addition, all antisecretory drugs, causing an increase in gastric pH, can reduce the absorption of vitamin B12.

The duration of the use of antisecretory drugs is from 4 to 8 weeks, but in some cases longer use is necessary. In this connection, it is necessary to monitor patients and reassess the effectiveness and safety of treatment. Supportive therapy is carried out in a standard or half dose on demand when heartburn occurs (on average, once every 3 days).

Purpose of therapy prokinetics - increased tone of the lower esophageal sphincter, stimulation of gastric emptying. Prokinetics can be used symptomatically in patients with severe nausea and vomiting. In view of the expressed side effects and numerous drug interactions it is recommended to conduct a risk / benefit assessment when using prokinetics, especially in combination therapy, and their long-term use is not recommended, especially in elderly patients (high risk of extrapyramidal disorders, prolongation of the QT interval, genicomastia, etc.).

Antacids and alginates can be used as a means to relieve infrequent heartburn (prescribe 40-60 minutes after eating, when heartburn and chest pain most often occur, as well as at night), however, preference should be given to taking PPIs on demand.

Criterion for the effectiveness of treatment- persistent elimination of symptoms. In the absence of the effect of the therapy, as well as at 4-5 stages of GERD (detection of Barrett's esophagus with epithelial dysplasia), patients should be sent to institutions where highly specialized care for gastroenterological patients is provided.

If the patient responds to therapy, it is recommended to adhere to a stepdown & stop strategy: reduce the PPI dose by half and gradually continue to reduce the dose until drug therapy is discontinued (the duration of the course is not strictly fixed) If, after discontinuation of drug treatment, clinical manifestations of reflux recur, the doctor may recommend that the patient continue taking the drugs in the smallest effective dose (the duration of maintenance therapy is also not regulated).

Table 7. List of essential medicines used for GERD

№	INN	Release form	Dosage regimen	UD
H2 histamine receptor blockers
1	Famotidine	Film-coated tablets (including film) 20 mg and 40 mg	Orally 20 mg 2 times a day
2	Ranitidine	Film-coated tablets (including film) 150mg and 300mg	Orally 150 mg 2 times a day
Proton pump inhibitors
3	Omeprozole	Capsules (including enteric, extended-release, gastrocapsules) 10 mg, 20 mg and 40 mg		A
4	Lansoprazole	Capsules (including modified release) 15 mg and 30 mg	Orally 15 mg once a day in the morning on an empty stomach.	A
5	Pantoprazole	Film-coated tablets (including enteric); delayed-release 20mg and 40mg	Orally 20 mg once a day in the morning on an empty stomach.	A
6	Rabeprazole	Enteric-coated tablets / capsules 10 mg and 20 mg	Orally 10 mg once a day in the morning on an empty stomach.	A
7	Esomeprazole	Tablets / Capsules (including enteric, solid, etc.) 20 mg and 40 mg	Orally 20 mg once a day in the morning on an empty stomach.	A

Table 8. List of additional medicines used for GERD

№	INN	Release form	Dosage regimen	UD
Prokinetics
1	Metoclopramide	10 mg tablets Solution for injection 0.5% 2 ml Solution for injection 10 mg / 2 ml		V
2	Domperidone	Tablets (including dispersible coated / film-coated) 10 mg Drops, syrup, oral suspension	With severe nausea and vomiting. Prescribe a single dose in 40-60 minutes. After eating, at night	V
	Itoprid	Film-coated tablets 50 mg	Dose for adults - 50 mg (1 tablet) 3 times / day before meals.	WITH
Antacids
4	Magnesium hydroxide and aluminum hydroxide	Chewable tablets Oral suspension 15 ml	Single dose on demand	A
5	Calcium carbonate + sodium bicarbonate + sodium alginate	Chewable tablets Oral suspension	Single dose on demand	A

Treatment (hospital)

STATIONARY TREATMENT TACTICS

Non-drug treatment: see Table 5 ambulatory level.

Goals, treatment tactics, other methods of treatment, criteria for the effectiveness of treatment: watch the outpatient level.

Surgical intervention:
Surgical treatment for GERD is an equally effective alternative to drug therapy and should be offered to patients with an indication (Grade A).

Indications:
With a clarified diagnosis of GERD, the indications for surgical (operative) treatment are:
Ineffective drug treatment (inadequate symptom control, severe regurgitation, uncontrolled acid suppression, and medication side effects);
• patient choice despite successful drug treatment (for reasons of quality of life, which is influenced by the need to take medication throughout life, high cost of medication, etc.) (Grade A);
· The presence of complications of GERD (for example, Barrett's esophagus, peptic strictures, etc.);
The presence of extraesophageal manifestations (bronchial asthma, hoarseness, cough, chest pain, aspiration).

Preoperative examination:
The purpose of the preoperative examination is to select suitable reflux patients for surgical treatment.

Approaches regarding the volume and order of preoperative examinations:
· EGD with biopsy - confirms the diagnosis of GERD, and also identifies other causes of disorders of the esophagogastric mucosa and allows you to take a biopsy;
· PH-metry;
Oesophageal manometry - more often performed before surgery and allows you to determine conditions that may be contraindications to fundoplication (such as achalasia of the esophagus), or to change the type of fundoplication, according to an individual approach based on esophageal motility;
· Study with barium suspension - for patients with a large hiatal hernia, who have a shortened esophagus.

Patients undergoing laparoscopic antireflux surgery should be informed prior to surgery of the potential for recurrence of symptoms and a return to acid-lowering drugs (Grade A).

Identification of Barrett's esophagus with adenocarcinoma involving the submucosal layer or deeper excludes the patient from planned antireflux surgery and requires complete oncotherapy (esophagectomy, chemotherapy, and / or radiation therapy) corresponding to the stage of the process.

Preventive actions:
· Antireflux measures;
· Antisecretory therapy;
· Compulsory supportive therapy;
· Dynamic observation of the patient for monitoring (endoscopic with biopsy according to indications) of complications (identification of Barrett's esophagus).

Further management:
Follow-up to monitor complications, identify Barrett's esophagus, and medically manage symptoms. Intestinal epithelial metaplasia is a morphological substrate of Barrett's esophagus. Its risk factors: heartburn more often 2 times a week, the duration of symptoms is more than 5 years.
With an established diagnosis of Barrett's esophagus, to detect dysplasia and adenocarcinoma of the esophagus, control endoscopic and histological studies should be performed 3, 6 months later and then annually against the background of PPI maintenance therapy. With the progression of dysplasia to a high degree, the issue of surgical treatment(endoscopic or surgical) in a specialized institution of the republican level.

Indicators of the effectiveness of treatment and the safety of diagnostic and treatment methods:
· Relief of clinical symptoms;
· Healing of erosion;
· Prevention or elimination of complications;
· Improving the quality of life.

Hospitalization

INDICATIONS FOR HOSPITALIZATION (UDA)

Indications for emergency hospitalization:
Bleeding from esophageal ulcers;
· Strictures of the esophagus.

Indications for planned hospitalization:
Ineffectiveness of drug treatment (inadequate control of symptoms, severe regurgitation, uncontrolled suppression of acidity and / or side effects of drug treatment);
· Complications of GERD (Barrett's esophagus, peptic strictures);
If there are extraesophageal manifestations (asthma, hoarseness, cough, chest pain, aspiration).

Information

Sources and Literature

Minutes of meetings of the Joint Commission on the Quality of Medical Services of the Ministry of Health of the Republic of Kazakhstan, 2017
1. 1) Gastroenterology. National leadership / edited by V.T. Ivashkina, T.L. Lapina - M. GEOTAR-Media, 2012, - 480 p. 2) Diagnosis and treatment of acid-dependent H. pylori-associated diseases. Ed. R.R.Bektaeva, R.T.Agzamova, Astana, 2005 - 80 p. 3) S. P. L. Travis. Gastroenterology: per. from English / Ed. S.P.L. Travis et al. - M .: Med lit., 2002 - 640 p. 4) Manual of gastroenterology: diagnosis and therapy. Fourth edition. / CananAvunduk – 4th ed., 2008 - 515 p. 5) Practical Manual of Gastroesophgeal Reflux Disease / Ed.by Marcelo F. Vela, Joel E. Richter and Jonh E. Pandolfino, 2013 –RC 815.7.M368 6) Prevention and treatment chronic diseases upper gastrointestinal tract / edited by V.T. Ivashkin.-3rd ed., revised. and additional - MEDpress-inform, 2014.-176 p. 7) Dyspepsia and gastrooesophageal reflux disease: investigation and management of dyspepsia, symptoms suggestive of gastro-oesophageal reflux disease, or both Clinical guideline (update) Methods, evidence and recommendations September 2014 https://www.nice.org.uk/guidance / cg184 / chapter / 1-recommendations 2.Evidence-Based Gastroenterology and Hepatology, Third Edition John WD McDonald, Andrew K Burroughs, Brian G Feagan and M Brian Fennerty © 2010 Blackwell Publishing Ltd. ISBN: 978-1-405-18193-8 8) 8. Diagnosis of extraesophageal manifestations of gastroesophageal reflux disease / N.A. Kovaleva [and others] // Rosmed. zhurn. - 2004. - No. 3. - S. 15-19. 9) Diagnostics and treatment of gastroesophageal reflux disease: a guide for doctors / VT Ivashkin [and others]. - M., 2005 .-- 30 p. 10) The montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus / N. Vakil // Am. J. Gastroenterol. - 2006. - Vol. 101. - P. 1900-2120. 11) Peterson W.L. Improving the Management of GERD. Evidence-based therapeutic strategies / W.L. Peterson; American Gastroenterological Association. - 2002. - Access mode: http://www.gastro.org/user-assets/documents/GERDmonograph.pdf. 12) Gastroesophageal reflux disease: study guide. allowance / I.V. Maev [and others]; ed. I.V. Maeva. - M.: VUNMTs MH RF, 2000 .-- 52 p. 13) LI Aruin VA Isakov. Gastroesophageal reflux disease and Helicobacterpylori. Wedge medicine 2000 № 10 С 62 - 68. 14) VT Ivashkin AS Trukhmanov Diseases of the esophagus Pathological physiology clinic diagnostics treatment. M: "Triada - X" 2000 178 p 15) Kononov AV Gastroesophageal reflux disease: a morphologist's view of the problem. Ros zhurn of gastroenterology, hepatology and coloproctology 2004.- T 14 No. 1 C 71 - 77. 16) Mayev IV, ES Vyuchnova EG Lebedeva Gastroesophageal reflux disease: a teaching aid. M: VUNMTSMZRF 2000 52 s 17) C.A. Fallone, A.N. Barkun, G. Friedman. Is Helicobacter pylori eradication associated with gastroesophageal reflux disease? Am. J. Gastroenterol. 2000. Vol. 95. P. 914 - 920.18) Bordin D.S. A new approach to increasing the efficiency of proton pump inhibitors in a patient with gastroesophageal reflux disease. Therapist. 2015.- No. 2. S. 17-22. 19) 19.Lazebnik L.B., Bordin D.S., Masharova A.A. et al. Factors affecting the effectiveness of treatment of GERD with proton pump inhibitors // Ter.archiv. - 2012.- 2: 16-21. 20) www.drugs.com Medicines database, supported by the FDA (USA) 21) Instructions for the use of medicines database of the National Center for Expertise of Medicines and the Medical Ministry of the Republic of Kazakhstan (www.dari.kz) 22) Gastroesophageal Reflux Disease Treatment & Management (www.http: //emedicine.medscape.com/article/176595-treatment? src = refgatesrc1 # d11) 23) Gastroesophageal reflux disease (GERD) / University of Michigan Health System (UMHS) and the National Guideline Clearinghouse (NGC) / Agency Healthcare Recearch and Qlity (AHRQ) / USA 24) O'Mahony D., O'Sullivan D., Byrne S. et. al. STOPP / START criteria for potentially inappropriate prescribing in older people: version 2 // Age and Ageing. 2014. DOI: 10.1093 / aging / afu145. 25) Körner T1, Schütze K, van Leendert RJ, Fumagalli I, Costa Neves B, Bohuschke M, Gatz G. / Comparable efficacy of pantoprazole and omeprazole in patients with moderate to severe reflux esophagitis. Results of a multinational study / Digestion. 2003; 67 (1-2): 6-13.

Information

ORGANIZATIONAL ASPECTS OF THE PROTOCOL

List of protocol developers with qualification data:
1) Bektaeva Roza Rakhimovna - Doctor of Medical Sciences, Professor, Head of the Department of Gastroenterology and Infectious Diseases, Astana Medical University. Chairman of the National Association of Gastroenterologists of the Republic of Kazakhstan.
2) Iskakov Baurzhan Samikovich - Doctor of Medical Sciences, Professor, Head of the Department of Internal Diseases No. 2 with courses in related disciplines of the Kazakh National medical university named after S.D. Asfendiyarov, chief freelance gastroenterologist of the Health Department of Almaty, Deputy Chairman of the National Association of Gastroenterologists of the Republic of Kazakhstan.
3) Makalkina Larisa Gennadievna - Candidate of Medical Sciences, Associate Professor of the Department of Clinical Pharmacology of Internship, JSC "Astana Medical University", Astana.

No Conflict of Interest Statement: no.

Reviewers:
1) Vadim Petrovich Shipulin - Doctor of Medical Sciences, Professor, Head of the Department of Internal Medicine No. 1 of the National Medical University named after A.A. Bogomolets. Ukraine. Kiev.
2) Bekmurzaeva Elmira Kuanyshevna - Doctor of Medical Sciences, Professor, Head of the Department of Bachelor's Therapy of the South Kazakhstan Pharmaceutical Academy. The Republic of Kazakhstan. Shymkent.

Terms of revision of the protocol: revision of the protocol 5 years after its publication from the date of its entry into force or in the presence of new diagnostic and treatment methods with a level of evidence.

Annex 1

ALGORITHM OF DIAGNOSTICS AND TREATMENT AT THE STAGE OF EMERGENCY CARE:

Diagnostics and treatment at the ambulance stage emergency care:
· Collection of complaints, medical history and life;
· Physical examination.

Diagnostic criteria (UD - D):
Complaints and anamnesis:

Complaints:
Heartburn (persistent, painful) both after eating and on an empty stomach;
· Pain in the chest (burning character), aggravated by physical exertion and bending;
• feeling of discomfort in the chest area;
· weight loss;
· Decreased appetite;
· Cough and attacks of suffocation at night;
Hoarseness of voice in the morning;
Vomiting of blood.

Anamnesis:
· Constant intake of acid-lowering drugs and antacids;
· It is possible that the patient has Barrett's esophagus.

Attached files

Attention!

Self-medication can cause irreparable harm to your health.
The information posted on the MedElement website and in the mobile applications "MedElement", "Lekar Pro", "Dariger Pro", "Diseases: Therapist's Guide" cannot and should not replace an in-person consultation with a doctor. Be sure to contact a healthcare provider if you have any medical conditions or symptoms that bother you.
The choice of medicines and their dosage should be discussed with a specialist. Only a doctor can prescribe the necessary medicine and its dosage, taking into account the disease and the condition of the patient's body.
MedElement website and mobile applications "MedElement", "Lekar Pro", "Dariger Pro", "Diseases: Therapist's Guide" are exclusively information and reference resources. The information posted on this site should not be used to unauthorized changes in the doctor's prescriptions.
The editors of MedElement are not responsible for any damage to health or material damage resulting from the use of this site.

ped / 1177 ped / 1177 radio / 300 radio / 300 med / 857 ped / 1177 ped / 1177 radio / 300 radio / 300 MeSH D005764 D005764

Gastroesophageal reflux disease(GERD) is a chronic relapsing disease caused by spontaneous, regularly repeated reflux of gastric and / or duodenal contents into the esophagus, leading to damage to the lower esophagus.

Etiology

Development The following causes contribute to gastroesophageal reflux disease:

Decreased tone of the lower esophageal sphincter (LES).
Decreased ability of the esophagus to cleanse itself.
The damaging properties of the refluctant, that is, the contents of the stomach and / or duodenum, thrown into the esophagus.
The inability of the mucous membrane to resist the damaging effect of the refluctant.
Impaired gastric emptying.
Increased intra-abdominal pressure.

For development Gastroesophageal reflux disease is also influenced by lifestyle features such as stress, work associated with a tilted torso, obesity, pregnancy, smoking, nutritional factors (fatty foods, chocolate, coffee, fruit juices, alcohol, spicy foods), as well as taking peripheral concentration of dopamine drugs (phenamine, pervitin, other phenylethylamine derivatives).

Clinic

GERD is manifested primarily by heartburn, sour belching, which more often occur after eating, when the body bends forward or at night. The second most frequent manifestation of this disease is chest pain, which radiates to the interscapular region, neck, lower jaw, the left half of the chest.

The extraesophageal manifestations of the disease include pulmonary symptoms (cough, shortness of breath, often occurring when lying down), otolaryngological symptoms (hoarseness, dry throat, tonsillitis, sinusitis, white plaque on the tongue) and stomach symptoms (rapid satiety, bloating, nausea, vomiting ). Night sweats are common symptoms of GERD.

Diagnostics

Diagnostics GERD includes the following research methods:

Research methods	Method capabilities
24-hour monitoring of pH in the lower third of the esophagus	Determines the number and duration of episodes in which pH values are less than 4 and more than 7, their relationship with subjective symptoms, food intake, body position, and medication. Provides an opportunity for individual selection of therapy and control of the effectiveness of drugs.
X-ray examination of the esophagus	Reveals hiatal hernia, erosion, ulcer, esophageal stricture.
Endoscopic examination of the esophagus	Reveals inflammatory changes in the esophagus, erosion, ulcers, esophageal strictures, Barrett's esophagus.
Manometric examination of the esophageal sphincters	Allows you to identify a change in the tone of the esophageal sphincters.
Esophageal scintigraphy	Evaluates esophageal clearance.
Esophageal impedance measurement	Allows to study normal and retrograde peristalsis of the esophagus and refluxes of various origins (acidic, alkaline, gas).

Treatment

Treatment for GERD includes lifestyle changes, drug therapy, and in the most difficult cases, surgery. Drug therapy for GERD and lifestyle changes in patients with GERD are aimed at treating inflammation of the esophageal mucosa, reducing the number of gastroesophageal refluxes, reducing the damaging properties of refluxate, improving the cleansing of the esophagus from aggressive stomach contents and protecting the esophageal mucosa.

Lifestyle change

Normalization of body weight.
Avoiding smoking, reducing the consumption of alcohol, fatty foods, coffee, chocolate, carbonated drinks.
Eating small meals regularly, up to five times a day; dinner no later than 2-3 hours before bedtime.
Elimination of loads associated with increased intra-abdominal pressure, as well as wearing tight belts, belts, etc.
Raised position (15-20 cm) of the head end of the bed at night.

Drug therapy

Drug therapy for GERD is mainly aimed at normalizing acidity and improving motor skills. For the treatment of GERD, antisecretory agents (proton pump inhibitors, blockers of H2-histamine receptors), prokinetics and antacids are used.

Proton pump inhibitors (PPIs) are more effective than histamine H2 receptor blockers and have less side effect... It is recommended to take PPIs rabeprazole 20-40 mg / day, omeprazole 20-60 mg / day, or esomeprazole 20-40 mg / day for 6-8 weeks. In the treatment of erosive forms of GERD, PPIs are taken for a long time, several months or even years. In this situation, the issue of PPI safety becomes important. Currently, there are suggestions about an increase in bone fragility, intestinal infections, community-acquired pneumonia, osteoporosis. Long-term treatment of GERD with proton pump inhibitors, especially in elderly patients, often has to take into account interactions with other medications. If it is necessary to take other drugs simultaneously with PPIs for the treatment or prevention of other diseases, preference is given to pantoprazole, as the safest in relation to interaction with other drugs.

In the treatment of GERD, non-absorbable antacids are used - phosphalugel, maalox, megalak, almagel and others, as well as alginates topalkan, gaviscon and others. The most effective non-absorbable antacids, in particular, maalox. It is taken at 15-20 ml 4 times a day, an hour and a half after meals for 4-8 weeks. For rare heartburn, antacids are used as soon as it occurs.

To normalize motility, prokinetics are taken, for example, motilium 10 mg 3 times a day before meals.

Surgery

Currently, there is no consensus among specialists regarding the indications for surgical treatment. Fundoplication surgery performed laparoscopically is used to treat GERD. However, even surgical intervention does not guarantee a complete rejection of lifelong PPI therapy. Surgery It is performed for such complications of GERD as Barrett's esophagus, grade III or IV reflux esophagitis, strictures or ulcers of the esophagus, as well as for low quality of life due to:

persistent or persistent symptoms of GERD that are not resolved with lifestyle changes or drug therapy,
dependence on taking medications or due to their side effects,
hernia of the esophageal opening of the diaphragm.

The decision on the operation should be made with the participation of doctors from different medical specialties(gastroenterologist, surgeon, possibly cardiologist, pulmonologist and others) and after such instrumental studies as esophagogastroduodenoscopy, X-ray examination of the upper gastrointestinal tract, esophageal manometry and daily pH-metry.

Notes (edit)

Sources of

A. V. Kalinin Gastroesophageal reflux disease, M., 2004. - 40 p.
Ivashkin V.T. and others. Recommendations for the examination and treatment of patients with gastroesophageal reflux disease. Moscow: 2001.
The standard of care for patients with gastroesophageal reflux. Approved by the Order of the Ministry of Health and Social Development of November 22, 2004 N 247
The standard of care for patients with gastroesophageal reflux (with the provision of specialized care). Approved by the Order of the Ministry of Health and Social Development of the Russian Federation of June 1, 2007 N 384
Grinevich V. Monitoring pH, bile and impedance monitoring in the diagnosis of GERD. Clinical and experimental gastroenterology. No. 5, 2004.

Wikimedia Foundation. 2010.

See what "Gastroesophageal reflux disease" is in other dictionaries:

Gastroesophageal reflux disease ICD 10 K21. Gastroesophageal reflux disease (GERD) is a chronic recurrent disease caused by a spontaneous, regularly recurring reflux of the gastric and / or duodenal esophagus ... ... Wikipedia

- (GER; English gastroesophageal reflux; synonym for gastroesophageal reflux) retrograde movement of stomach contents through the lower esophageal sphincter into the esophagus. First described by the German physician Heinrich Quincke in 1879. Contents ... Wikipedia

Active ingredient ›› Pantoprazole * (Pantoprazole *) Latin name Zipantola ATX: ›› A02BC02 Pantoprazole Pharmacological group: Proton pump inhibitors Nosological classification (ICD 10) ›› K21 Gastroesophageal reflux ›› K25 ... ... Dictionary of Medicines

This article focuses on reflux in medicine and physiology. Refluxes in chemistry and chemical industry are discussed in the article Reflux (chemistry). Reflux (Latin refluo to flow back) is the reverse flow of the contents of the hollow organs compared to normal ... ... Wikipedia

Both children and adults can be ill with it. The disease is usually accompanied by heartburn, vomiting and belching. Esophagitis code according to the international classifier ICD-10: K20.

taking acids or alkalis (chemical burn);
physical injury;
infections such as HIV, appendix;
inflammatory processes in the intestines;
food irritants (allergens).

Along the way, the disease is classified into acute and chronic forms.

Classification of esophagitis by morphological forms:

catarrhal-edematous (the mucous membrane becomes red, begins to swell);
erosive (ulcers appear on the esophagus);
hemorrhagic (blood is visible on the walls of the esophagus);
necrotic (black ulcers);
phlegmonous (the esophagus swells, begins to fester);
exfoliative (a film forms on the esophagus, if you tear it off, wounds will appear). It is a sign of diphtheria;
pseudomembranous (typical for scarlet fever).

Esophagitis code according to ICD-10

According to ICD-10 ( international classification diseases) the disease refers to diseases of the esophagus, stomach and duodenum. Reflux esophagitis according to ICD-10 has the following classification: K21.0 - reflux with esophagitis, K21.9 - without esophagitis.

Classification of esophagitis according to Savary Miller:

Grade A: the affected area of the esophagus is relatively small (about 4 mm), there are several ulcers (erosions) that do not merge with each other.
Grade B: the area increases to 5 mm, erosion can merge.
Grade C: the ulcer affects about ѕ part of the esophagus.
Grade D: The esophagus is 75% affected.

Acute reflux esophagitis is accompanied by diseases in the stomach. The causes of chronic - alcohol consumption, smoking, unhealthy diet.

The most important thing is not to overwork your body, to give up active physical activity. Mineral water is also an irreplaceable assistant in this matter. It helps to reduce the acidity of gastric juice, helps the intestines to function normally. If you identify yourself with this disease or if you have the slightest suspicion of it, immediately consult a doctor. Only he can prescribe the correct treatment.

The number of patients with esophagitis began to increase annually. Many are in no hurry to be treated, believing that there is discomfort.

Esophagitis is an inflammatory disease of the walls of the esophagus, the inflammatory process affects the walls of the mucous membrane. At.

One of inflammatory diseases organs of the gastrointestinal tract, namely the esophagus, is esophagitis. It arises from behind.

Comments of readers of the article "Classification"

Leave a review or comment

Add comment Cancel reply

PANCREATITIS

TYPES OF PANCREATITIS

WHOM DOES IT HAVE?

TREATMENT

FOOD BASICS

CONSULT YOUR CARING DOCTOR!

Gastroesophageal reflux (K21)

In Russia, the International Classification of Diseases of the 10th revision (ICD-10) has been adopted as a single normative document to take into account the incidence, the reasons for the population's visits to medical institutions of all departments, and the causes of death.

ICD-10 was introduced into healthcare practice throughout the Russian Federation in 1999 by order of the Ministry of Health of Russia dated 05/27/97. No. 170

A new revision (ICD-11) is planned by WHO in 2017 2018.

As amended and supplemented by WHO

Processing and translation of changes © mkb-10.com

What is reflux esophagitis? Who gets it and why is it dangerous?

Diseases of the digestive tract are increasingly reminiscent of themselves modern man... Due to unhealthy diet and unhealthy lifestyle, the gastrointestinal tract suffers primarily.

One of the most common diseases of the esophagus is reflux esophagitis (gastrointestinal reflux, gastroesophageal reflux disease, GERD, reflux esophagitis, reflux gastroesophagitis).

Let's see what reflux esophagitis is, what kind of disease it is, what are its symptoms, treatment and diet.

What is reflux esophagitis in adults, ICD-10 disease code

Reflux esophagitis is a disease that occurs when the lining of the esophagus comes into contact with the contents of the stomach, when, due to the weakness of the lower sphincter of the esophagus, part of the gastric contents is thrown up into the esophagus.

Due to the increased acidity, the lower part of the esophagus becomes inflamed, and this leads to the appearance pain... Often gastroduodenitis, gastritis, esophagitis and reflux develop and occur simultaneously with each other.

According to the International Classification of Diseases 10 revision, reflux esophagitis belongs to the group of diseases of the esophagus, stomach and duodenum, which have a code (K20-K31). The K20 code refers specifically to esophagitis, but to identify the main cause of the appearance, an additional code is used related to external causes and XX class.

The K20 code contains exceptions for: esophageal erosion, reflux esophagitis and esophagitis with gastroesophageal reflux. Disease of gastroesophageal reflux has a separate code - K21.

Causes of reflux esophagitis in adults

To protect yourself from the appearance of reflux esophagitis, you need to know the main risk factors for the development of this disease and possible reasons its development. Experts note that the main factors that provoke the appearance of such an inflammatory process are:

obesity;
frequent vomiting;
installation of a nasogastric tube (for enteral nutrition);
pregnancy;
hernia of the diaphragm of the alimentary opening.

All this can provoke the appearance of reflux esophagitis. There are a number of reasons why this disease can appear regardless of the above factors:

a stomach or duodenal ulcer;
pylorospasm;
surgical interventions associated with the esophageal opening of the diaphragm;
reception medications that reduce the tone of the esophageal sphincter;
gastritis with pathogenic development of Helicobacter pylori bacteria;
tobacco and alcohol abuse.

Inflammation of the lower part of the esophagus can appear both against the background of existing diseases and as a result of an unhealthy lifestyle.

How does the disease develop

As statistics show, almost half of the adult population has manifestations of gastrointestinal reflux. Of this number, 10% of people showed endoscopic signs of the disease. This suggests that the mechanism of the development of this disease is rather imperceptible.

Sometimes people after a meal feel the appearance of heartburn or nausea, but they do not see the point in going to the doctor's office. Often this esophageal disease is diagnosed as a result of the development of more complex inflammatory processes in the digestive tract.

Nature has gifted our body with several protective functions against the appearance of reflux.

First, the lower esophageal sphincter must establish an anti-reflux barrier in a timely manner.

If the relaxation of this part of the esophagus occurs for a long time, then its mucous membrane is also exposed to the negative effects of acids for a longer time.

Secondly, saliva is able to neutralize the negative effect of hydrochloric acid, which is important when throwing stomach contents into the esophagus. In people who already have developed reflux esophagitis, doctors note unsatisfactory gastric motility and disruptions in the volume of salivation.

What is the role of psychosomatics in development

Even Cicero in the 1st century BC. it has been proven that all diseases of the body arise from pain in the soul. The psychological state plays an important role not only in terms of the treatment of diseases, but also at the stage of their appearance. Diseases of the gastrointestinal tract are often referred to as psychosomatic diseases.

American psychotherapist Milton Erickson claims that each disease initially occurs in our head, and only then does it manifest itself on the body. As for reflux esophagitis, he is sure of its psychosomatic origin. The main problem with this disease is the direction of stomach contents not towards the intestines, but towards the esophagus. That is, the processed food is misdirected.

This condition can appear as a result of changes in gastric motility. Often, the appearance of gastrointestinal reflux at the subconscious level is due to a person's desire to turn back the clock in order to correct some actions in his life.

Psychosomatic disorders are treated by a psychotherapist. His arsenal contains many different methods treatment. The most striking are: NLP, art therapy, hypnosis, psychoanalysis, family therapy, etc.

Varieties of the disease

When it comes to reflux esophagitis, few people know that this disease has several varieties.

Superficial reflux esophagitis

Superficial or catarrhal reflux esophagitis: what is it? Often, the disease is a mechanical damage to the mucous membrane of the esophagus. This type of disease is not characterized by the appearance of erosion. It can often appear due to trauma to the mucous membrane, for example, bones from fish.

Also, this disease can manifest itself due to excessive consumption of fatty foods, coffee, hot spices and alcohol.

Erythematous form

Erythematous reflux esophagitis is characterized by the presence of hemorrhages in the esophagus. It also manifests itself as a result of the long stay of the contents of the stomach in the lower esophagus. When endoscopic examination is performed, the esophagus of such patients has red edema and traces of hemorrhage. The mucous membrane has a purulent effusion.

Peptic reflux esophagitis

Peptic reflux esophagitis is most often chronic in nature, since the reflux of stomach contents occurs constantly. Also, this disease is progressive.

Also, the disease can have varying degrees of severity - 1, 2, 3 or 4 degrees. Details about the degrees of the disease and the symptoms of each of them are described in this article.

Why is reflux esophagitis dangerous?

Often, patients with reflux esophagitis do not consider this disease dangerous, but this is not at all the case. For a long time, such inflammation of the esophagus in general may not declare itself in any way.

The person will think that they just have heartburn or nausea due to overeating. Of course, such cases are possible, but if such symptoms persist for a long time, then you should consult a gastroenterologist.

When the disease is neglected, erosion may appear on the walls of the esophagus, that is, erosive reflux esophagitis is formed. They cause hemorrhages, provoking an even greater proliferation of the ulcer. At the sites of ulcers, in the absence of proper treatment and non-compliance with the diet, oncological neoplasms may appear in the future.

In addition, in advanced cases of the disease, such serious complications of GERD as Barrett's esophagus and achalasia of the cardia can form. Therefore, the appearance of this disease should be taken seriously!

It is impossible to postpone a visit to the doctor, since in the early stages this disease can be cured much faster and easier.

How does the disease manifest: symptoms

The symptoms of this disease are as follows:

heartburn (maybe during the day and at night),
belching
hiccups after eating
aching pain in the sternum (resembles a pain in the heart),
difficulty swallowing
nausea.

It is worth remembering that sometimes the symptoms of gastrointestinal reflux may not be associated with the alimentary tract at all. Rarely, but there are toothaches, rhinitis, pharyngitis, cough.

Useful video

We offer you to watch an interesting and useful video about what reflux esophagitis is and what is important to know about this disease:

How a doctor diagnoses reflux esophagitis

Any diagnosis of a disease should begin with a doctor's consultation. The doctor will clarify the nature of the pain, its frequency and duration. Also, the doctor can find out the patient's dietary habits in order to determine his lifestyle. After the conversation, the doctor may examine the tongue.

With gastrointestinal reflux, the tongue may be coated with a white coating. To exclude other diseases, the doctor should palpate the abdomen.

If no painful sensations are detected, then the patient is then referred for instrumental examination.

With the help of a probe and a camera at its end, you can see a clear picture of the gastrointestinal tract disease. With reflux, the lining of the esophagus will be red. In some cases, the doctor may order tissue sampling in this area for additional research.

Also used for diagnostics:

x-ray,
daily pH-metry (determination of acidity level),
esophagomanometry (determination of the functionality of the lower esophageal sphincter),
ECG (to exclude heart disease),
Chest X-ray (to rule out lung disease).

Together, all diagnostics will allow you to see an accurate picture of the course of the disease. The main thing is to see a doctor on time.

Treatment of the disease

Correct treatment of GERD should be carried out according to the following schemes (see the link for more details). It should be comprehensive and include the appointment of certain medications, including antacids. In addition, with this disease, a special therapeutic diet is prescribed to alleviate the condition.

ICD code: K21.0

Gastroesophageal reflux with esophagitis

Search

Search by ClassInform

Search in all classifiers and reference books on the ClassInform website

Search by tax number

OKPO by TIN

Search for OKPO code by TIN

OKTMO by TIN

Search for OKTMO code by TIN

OKATO by INN

Search for OKATO code by TIN

OKOPF by TIN

Search for OKOPF code by TIN

OKOGU by TIN

Search for OKOGU code by TIN

OKFS by TIN

Search for OKFS code by TIN

PSRN by TIN

Search OGRN by INN

Find out TIN

Search for TIN of the organization by name, TIN IP by name

Counterparty check

Counterparty check

Information about counterparties from the FTS database

Converters

OKOF in OKOF2

Translation of the OKOF classifier code into the OKOF2 code

OKDP in OKPD2

Translation of the OKPD classifier code into the OKPD2 code

OKP in OKPD2

Translation of the OKP classifier code into the OKPD2 code

OKPD in OKPD2

Translation of the OKPD classifier code (OK (KPES 2002)) into the OKPD2 code (OK (KPES 2008))

OKUN in OKPD2

Translation of the OKUN classifier code into the OKPD2 code

OKVED in OKVED2

Translation of the OKVED2007 classifier code into the OKVED2 code

OKVED in OKVED2

Translation of the OKVED2001 classifier code into the OKVED2 code

OKATO to OKTMO

Translation of the OKATO classifier code into the OKTMO code

TN VED in OKPD2

Translation of the TN VED code into the OKPD2 classifier code

OKPD2 in TN VED

Translation of the OKPD2 classifier code into the TN VED code

OKZ-93 in OKZ-2014

Translation of the OKZ-93 classifier code into the OKZ-2014 code

Changes to classifiers

Changes 2018

Feed of effective classifier changes

All-Russian classifiers

ESKD classifier

All-Russian classifier of products and design documents OK

OKATO

All-Russian classifier of objects of administrative-territorial division OK

OKW

All-Russian classifier of currencies OK (MK (ISO 4)

OKVGUM

All-Russian classifier of types of goods, packaging and packaging materials OK

OKVED

All-Russian Classifier of Economic Activities OK (NACE Rev. 1.1)

OKVED 2

All-Russian Classifier of Economic Activities OK (NACE REV. 2)

OGR

All-Russian classifier of hydropower resources OK

Okei

All-Russian classifier of units of measurement OK (MK)

OKZ

All-Russian classifier of occupations OK (ISKZ-08)

OKIN

All-Russian classifier of information on the population OK

OKISZN

All-Russian classifier of information on social protection of the population. OK (valid until 01.12.2017)

OKISZN-2017

All-Russian classifier of information on social protection of the population. OK (valid from 01.12.2017)

OKNPO

All-Russian classifier of primary vocational education OK (valid until 01.07.2017)

OKOGU

All-Russian Classifier of Government Bodies OK 006 - 2011

OK OK

All-Russian classifier of information on all-Russian classifiers. OK

OKOPF

All-Russian classifier of organizational and legal forms OK

OKOF

All-Russian classifier of fixed assets OK (valid until 01.01.2017)

OKOF 2

All-Russian classifier of fixed assets OK (SNA 2008) (valid from 01.01.2017)

OKP

All-Russian classifier of products OK (valid until 01.01.2017)

OKPD2

All-Russian classifier of products by type of economic activity OK (CPA 2008)

OKPDTR

All-Russian classifier of workers' professions, employee positions and OK wage categories

OKPIiPV

All-Russian classifier of minerals and groundwater. OK

OKPO

All-Russian classifier of enterprises and organizations. OK 007–93

OKS

All-Russian classifier of standards OK (MK (ISO / infoko MKS))

OKSVNK

All-Russian classifier of specialties of the highest scientific qualification OK

OCSM

All-Russian classifier of countries of the world OK (MK (ISO 3)

OXO

All-Russian classifier of specialties by education OK (valid until 01.07.2017)

OXO 2016

All-Russian classifier of specialties by education OK (valid from 01.07.2017)

OCTS

All-Russian classifier of transformation events OK

OKTMO

All-Russian Classifier of Territories of Municipal Formations OK

OKUD

All-Russian classifier of management documentation OK

OKFS

All-Russian classifier of forms of ownership OK

OECD

All-Russian classifier of economic regions. OK

OKUN

All-Russian classifier of services to the population. OK

TN VED

Commodity nomenclature of foreign economic activity (TN VED EAEU)

VRI ZU classifier

Classifier of the types of permitted use of land plots

KOSGU

Classifier of General Government Operations

FKKO 2016

Federal classification catalog of waste (valid until 24.06.2017)

FKKO 2017

Federal classification catalog of waste (valid from 24.06.2017)

BBK

International classifiers

Universal Decimal Classifier

ICD-10

International classification of diseases

ATX

Anatomical Therapeutic Chemical Classification of Medicines (ATC)

MKTU-11

International Classification of Goods and Services 11th Edition

ICDO-10

International Classification for Industrial Designs (10th Edition) (LOC)

Directories

Unified tariff and qualification reference book of jobs and professions of workers

EKSD

Unified qualification reference book of positions of managers, specialists and employees

Professional standards

2017 Professional Standards Handbook

Job descriptions

Samples job descriptions taking into account professional standards

FSES

Federal state educational standards

Vacancies

All-Russian database of vacancies Work in Russia

Weapons inventory

State cadastre of civilian and service weapons and ammunition for them

2017 calendar

2017 production calendar

Calendar 2018

2018 production calendar

Gastroesophageal reflux. Other diseases of the esophagus

RCHD (Republican Center for Healthcare Development of the Ministry of Health of the Republic of Kazakhstan)

Version: Archive - Clinical Protocols of the Ministry of Health of the Republic of Kazakhstan (Order No. 239)

general information

Short description

GERD (gastroesophageal reflux disease) is a complex of characteristic symptoms with inflammatory lesions of the distal esophagus due to repeated reflux of gastric and, in rare cases, duodenal contents.

Protocol "Gastroesophageal reflux. Other diseases of the esophagus"

K 21.0 Gastroesophageal reflux with esophagitis

C 21.9 Gastroesophageal reflux without esophagitis

K 22.0 Achalasia of the cardiac part

K 22.1 Ulcer of the esophagus

Classification

GERD classification (according to Tytgat modified by V.F. Privorotsky et al. 1999)

For endoscopic signs:

Grade 1: moderately pronounced focal erythema and (or) looseness of the mucous membrane of the abdominal esophagus. Moderately pronounced motor disorders in the lower esophageal sphincter, short-term provoked subtotal (along one of the walls) prolapse to a height of 1-2 cm, decreased sphincter tone.

Grade 2: signs characteristic of grade 1, in combination with total hyperemia of the abdominal esophagus with focal fibrinous plaque. The appearance of focal surface erosions, more often of a linear form, located at the tops of the folds of the esophageal mucosa, is possible. Motor disorders: clear endoscopic signs of insufficiency of the valves of the stomach, total or subtotal provoked prolapse to a height of 3 cm with possible partial fixation in the esophagus.

Grade 3: signs characteristic of grade 2, combined with the spread of inflammation to the thoracic esophagus. Multiple, sometimes merging erosion, not circularly located. Possible increased contact vulnerability of the mucous membrane. Motor disorders: clear endoscopic signs of insufficiency of the valves of the stomach, total or subtotal provoked prolapse to a height of 3 cm with possible partial fixation in the esophagus, there may be pronounced spontaneous or provoked prolapse above the pedicles of the diaphragm with possible partial fixation.

Grade 4: esophageal ulcer. Barrett's Syndrome. Esophageal stenosis.

1. By origin: primary, secondary.

2. Downstream: acute (subacute), chronic.

3. According to the clinical form: painful, dyspeptic, dysphagic, asymptomatic.

4. According to the period of illness: exacerbation, subsidence of exacerbation, remission.

5. By the presence of complications: uncomplicated, complicated (bleeding, perforation, etc.).

6. By the nature of changes in the mucous membrane of the esophagus: catarrhal, erosive-ulcerative, hemorrhagic, necrotic.

7. By localization of the pathological process: diffuse, localized, reflux esophagitis.

8. By severity: light, medium, heavy.

Diagnostics

Anamnesis - pathology of the upper digestive tract: chronic gastritis, gastroduodenitis, gastric ulcer and duodenal ulcer, etc.

Complaints of pain in the epigastric region, an unpleasant sensation of "rawness, burning" behind the breastbone immediately after swallowing food or while eating. Children with severe pain may refuse to eat. Chest pain can occur when walking fast, running, deep bending, lifting weights. Often, after eating, there is pain behind the sternum and in the epigastric region, aggravated by lying and sitting.

Other dyspeptic phenomena: nausea, sonorous belching, vomiting, hiccups, dysphagia, etc.

The "extraesophageal" manifestations of gastroesophageal reflux disease include reflux laryngitis, pharyngitis, otitis media, night cough. In 40-80% of children with gastroesophageal reflux disease, symptoms of bronchial asthma are recorded, which develops as a result of microaspiration of gastric contents into the bronchial tree.

Physical examination: painful palpation in the epigastrium.

Laboratory examination: OAC, OAM, fecal occult blood test (maybe positive), diagnostics of H. pylori (cytological examination, ELISA, urease test).

Instrumental examination: esophagogastroduodenoscopy in the esophagus - focal erythema and (or) looseness of the mucous membrane of the abdominal esophagus, the presence of erosions, motor disorders - insufficiency of the cardiac pulp, reflux of gastric contents into the esophagus.

Biopsy of the esophageal mucosa - according to indications, X-ray of the esophagus - according to indications.

Indications for consultation:

The required volume of research before planned hospitalization:

1. General analysis blood (6 parameters).

2. General analysis of urine.

4. ALT, AST, bilirubin.

5. Scraping for enterobiasis.

List of main diagnostic measures:

1. UAC (6 parameters).

3. Study of feces for occult blood.

4. Scraping of the worm on the egg.

5. Examination of feces for eggs, worms.

7. Cytological diagnostics to determine the degree of damage and inflammatory changes in the gastric mucosa of the esophagus, refluxes, diagnostics of H. pylori.

8. Endoscopic biopsy.

9. Histological examinations.

10. ELISA for H. pylori.

List of additional diagnostic measures:

1. Determination of cholesterol.

2. Determination of bilirubin.

3. Thymol test.

4. Definition of ALT.

5. Determination of AST.

6. Determination of alpha-amylase.

7. Determination of total protein.

8. Determination of glucose levels.

9. Determination of protein fractions.

10. Determination of alkaline phosphatase.

11. Determination of B-lipoproteins.

12. Determination of iron.

13. Determination of diastase.

14. Swab for candida from the pharynx and pharynx, tongue.

15. Research on HBs Ag.

16. Ultrasound of the liver, gallbladder, pancreas.

17. X-ray of the esophagus.

Differential diagnosis

Treatment

Hospitalization

Prophylaxis

Prevention of erosive and ulcerative esophagitis;

Prevention of Barrett's esophagus.

Gastroesophageal reflux disease

K21.0 Gastroesophageal reflux with esophagitis.

Gastroesophageal reflux disease (GERD) is a chronic recurrent disease characterized by esophageal and extraesophageal clinical symptoms and various morphological changes in the esophageal mucosa due to retrograde reflux of gastric or gastrointestinal contents,

The incidence of GERD in children with lesions of the gastroduodenal zone in Russia ranges from 8.7 to 49%.

Etiology and pathogenesis

GERD is a multifactorial disease directly caused by gastroesophageal reflux (acid reflux - a decrease in the pH in the esophagus to 4.0 or less due to the ingress of acidic gastric contents into the organ cavity; alkaline reflux - an increase in the pH in the esophagus to 7.5 or more when it enters the organ cavity duodenal contents, more often bile and pancreatic juice).

There are the following forms of reflux.

Physiological gastroesophageal reflux,

not causing the development of reflux esophagitis:

occurs in completely healthy people of any age;

observed more often after eating;

characterized by low intensity (no more than 20-30 episodes per day) and short duration (no more than 20 s);

has no clinical equivalents;

does not lead to the formation of reflux esophagitis.

Pathological gastroesophageal reflux (provokes damage to the esophageal mucosa with the development of reflux esophagitis and associated complications):

meets at any time of the day;

often does not depend on food intake;

characterized by a high frequency (more than 50 episodes per day, the duration is at least 4.2% of the recording time according to daily pH monitoring data);

leads to damage to the mucous membrane of the esophagus of varying severity, possibly the formation of esophageal and extraesophageal symptoms.

Leading factor in gastroesophageal reflux

violation of the "locking" mechanism of the cardia due to the influence of the following reasons.

Immaturity of the lower esophageal sphincter in children under 12-18 months.

Disproportion of an increase in body length and esophagus (heterodynamics of organ development and growth).

Relative insufficiency of the cardia.

Absolute cardia insufficiency due to:

malformations of the esophagus;

surgical interventions on the cardia and esophagus;

connective tissue dysplasia;

morphofunctional immaturity of the autonomic nervous system (ANS), CNS damage;

taking certain medications, etc.

Violation of the regime and quality of nutrition, conditions accompanied by an increase in intra-abdominal pressure (constipation, inadequate physical activity, prolonged tilted position of the body, etc.); respiratory pathology (bronchial asthma, cystic fibrosis, recurrent bronchitis, etc.); some drugs (anticholinergics, sedatives and hypnotics, β-blockers, nitrates, etc.); smoking, alcohol; sliding hernia of the esophageal opening of the diaphragm; herpesvirus or cytomegalo- viral infection, fungal infections.

The pathogenesis of GERD is associated with an imbalance of factors of aggression and defense.

Aggressive factors: gastroesophageal reflux (acidic, alkaline); hypersecretion of hydrochloric acid; aggressive effects of lysolecithin and bile acids; medications; some food.

Protection factors: antireflux function of the lower esophageal sphincter; mucosal resistance; effective clearance (chemical and volumetric); timely evacuation of gastric contents.

The severity of gastroesophageal reflux:

with esophagitis (I-IV degree).

The severity of clinical symptoms: mild, moderate, severe.

Extraesophageal GERD symptoms:

An example of a diagnosis formulation

The main diagnosis: gastroesophageal reflux disease (reflux esophagitis II degree), moderate form.

Complication: post-hemorrhagic anemia.

The diagnosis is concomitant; bronchial asthma, non-atopic, moderate form, interictal period. Chronic gastroduodenitis with increased acid-forming function of the stomach, Helicobacter negative, in the stage of clinical subremission.

Esophageal symptoms: heartburn, regurgitation, wet spot symptom, belching with air, sour, bitter, recurrent chest pain, pain or discomfort when food passes through the esophagus (odonophagia), dysphagia, halitosis.

Bronchopulmonary - bronchial asthma, chronic pneumonia, recurrent and chronic bronchitis, prolonged bronchitis, cystic fibrosis.

Otorhinolaryngological - constant coughing, a feeling of "stuck" food or a "lump" in the throat, developing as a result of increased pressure in the upper esophagus, a feeling of soreness and hoarseness of the voice, pain in the ear.

Cardiovascular signs - arrhythmias due to the initiation of the esophagocardial reflex.

Dental - erosion of tooth enamel and the development of caries. Young children often have vomiting, underweight

body, regurgitation, anemia, respiratory disorders up to apnea and sudden death syndrome are possible.

In older children, complaints are predominantly esophageal, respiratory disorders and post-hemorrhagic anemia are possible.

Issedsh? 'Slight abdominal compression. The patency of the esophagus, the diameter, the relief of the mucous membrane, the elasticity of the walls, the presence of pathological narrowings, ampoule-like enlargements, the nature of the peristalsis of the esophagus are assessed. With obvious reflux, the esophagus and stomach radiographically form the figure of an "elephant with a raised trunk," and on delayed radiographs, a contrast agent is again found in the esophagus, which confirms the presence of reflux.

Below is a system of endoscopic signs of gastroesophageal reflux in children (according to J. Titgat in the modification of V.F. Privorotsky and others).

I degree - moderate focal erythema and / or looseness of the mucous membrane of the abdominal esophagus.

II degree - total hyperemia of the abdominal esophagus with focal fibrinous plaque, the occurrence of single superficial erosions, more often of a linear form, located at the tops of the folds of the mucous membrane, is possible.

III degree - the spread of inflammation to the thoracic esophagus. Multiple (sometimes merging) erosion, located noncircularly. Possible increased contact vulnerability of the mucous membrane.

IV degree - esophageal ulcer. Barrett's Syndrome. Esophageal stenosis.

Moderate motor disturbances in the region of the lower esophageal sphincter (2-line rise up to 1 cm), short-term provoked subtotal (along one of the walls) prolapse to a height of 1-2 cm, decreased tone of the lower esophageal sphincter.

Distinct endoscopic signs of cardia insufficiency, total or subtotal provoked prolapse to a height of more than 3 cm with possible partial fixation in the esophagus.

Severe spontaneous or provoked prolapse above the legs of the diaphragm with possible partial fixation.

An example of an endoscopic report: reflux esophagitis P-B degree.

A targeted biopsy of the esophageal mucosa in children with subsequent histological examination of the material is carried out according to the following indications:

discrepancy between radiological and endoscopic data in unclear cases;

atypical course of erosive and ulcerative esophagitis;

suspicion of a metaplastic process in the esophagus (Barrett transformation);

suspicion of malignant tumor of the esophagus.

To reliably determine the state of the esophagus, it is necessary to take at least two biopsies 2 cm proximal to the 2-line.

The "gold standard" for the definition of pathological gastroesophageal reflux.

According to T.R. DeMeester (1993), the normal values for daily pH monitoring are:

maximum gastroesophageal reflux (time) - 00:19:48.

For kids early age a separate regulatory

scale (J. Bois-Oshoa et al., 1980). The indices of daily pH monitoring in children under one year old differ from those in adults (fluctuations ± 10%, Table 1).

The method of intraesophageal impedance measurement is based on the registration of changes in intraesophageal resistance as a result of reflux, restoration of the initial level as the esophagus clears. A decrease in the impedance in the esophagus below 100 ohms indicates the fact of gastroesophageal reflux.

Esophageal manometry is one of the most accurate methods for studying the function of the lower esophageal sphincter, allowing

Table 1. Normal indicators of daily pH monitoring

in children according to J. Bois-Oshoah et al. (1980) Indicators Average value Upper limit of the norm Total time pH

Publication date: 26-11-2019

What is GERD and the ICD-10 disease code?

The ICD-10 code for GERD stands for the international classification of diseases 10 revision and gastroesophageal reflux disease. For therapeutic purposes, the disease is divided into stages, which makes it possible to determine the choice of drugs and the duration of therapy.

If we talk about GERD, then it all depends on the degree of damage to the mucous membrane of the esophagus. Fibrogastroduodenoscopy is used to study the lower part of the intestine, due to which the disease is classified, since the procedure clearly shows how deeply the organ is affected and what changes have occurred as a result of the disease.

Types of pathology

The simplest description of the types of gastroesophageal reflux disease is given in a document called ICD-10. According to clinical signs, the disease in it is divided into the following types:

gastroesophageal reflux disease with esophagitis (the presence of inflammation on the mucous membrane of the esophagus) - ICD-10 code K21;
GERD without the presence of esophagitis - C21.9.

The endoscopic method of classifying GERD began to be used in the early 90s, and is still successfully used in modern medicine. How does GERD develop? At the border of the esophagus and stomach, there is a muscle - the lower esophageal sphincter, which prevents the reflux of digested foods into the esophagus. When it weakens, a violation of the functionality of the muscle occurs, as a result of which the gastric contents, along with hydrochloric acid thrown back.

In the esophagus, due to such a violation, a number of changes occur, in which the mucous membrane is affected.

These changes formed the basis for the classification of the disease.

So, in the first stage, a part of the mucous membrane is affected, which is located closer to the stomach. It becomes inflamed, reddens, small erosive changes may appear on it. At the initial stage of the disease, such changes may be absent, and the diagnosis will be made based on the patient's symptoms or using other diagnostic methods.
The second stage of the disease is characterized by most of the damage to the esophagus (more than 18%). The main symptom accompanying the disease is called heartburn.
At the third stage, the mucous membrane of the esophagus and the lower esophageal sphincter are affected by erosions. Without proper treatment, ulcers appear at the site of erosion. The main symptoms in this case will be burning, pain in the stomach, which most often appear at night.
The fourth stage manifests itself in the form of damage to the entire mucous membrane, erosive changes are observed along the entire circumference of the esophagus. Symptoms at this stage will appear acutely, in full set.
At the last stage, irreversible changes occur in the organ - narrowing and shortening of the esophagus, ulceration, the intestinal epithelium replaces the mucous membrane.

European classification

This classification is also called Los Angeles. It appeared in the late 90s and includes the following degrees of GERD:

A (the organ is slightly affected, and the size of the erosive changes does not exceed 6 mm, while they are located only on one fold of the mucous membrane);
B (erosive changes are not extensive, but the size of the erosions themselves is from 6 mm and more);
C (more than 70% of the esophagus is affected by erosions or ulcers, the size of which is more than 6 mm);
D (the esophagus is almost completely affected).

According to this classification, erosive changes can occur at any of the stages. All of these species have been classified in stages so that practitioners can more easily understand the development of the disease and correctly select the appropriate treatment. It is impossible to independently classify the disease only by symptoms, therefore, if unpleasant symptoms appear, you should consult a doctor. Delaying a visit to the doctor will cost more and take longer.