Reflux esophagitis definition
Reflux esophagitis defined as the effortless retrograde movement of gastric contents including gastric acid upwards into the esophagus. Stratified flattened epithelium of the esophagus is resistant to injury from foods. But it is sensitive to acid. The sub mucosal glands contribute to mucosal protection by secretion of mucous and bicarbonate. Constant lower esophageal sphincter tone prevents regurgitation of acidic gastric contents. Regurgitation of gastric contents into the lower part of esophagus is the most frequent cause of reflux esophagitis. Reflux esophagitis is the most common cause of gastro intestinal disease in the United States. The associated clinical condition of reflux esophagitis is termed as gastro esophageal reflux disease (GERD). Reflux esophagitis resulting in heartburn affects approximately 30% of the general population.
Reflux esophagitis in children
In children less than 1 year , reflux esophagitis is not always a disease. Physiological reflux esophagitis (spitting up) is normal in infants younger than 8 to 12 months old. Nearly half of all infants are reported to spit up at 2 months of age. Most infants who regurgitate stomach contents meet the criteria for physiologic reflux esophagitis. Most of them who maintain adequate nutrition and have no signs of respiratory or peptic complications. As infants grow up, they spend more time in upright posture, eat solid foods. Then they develop a longer and larger diameter esophagus. They now have a larger and more compliant stomach and now they experience lower calorie needs per unit of body weight. So most infants stop spitting up by 9 to 12 months of age.
Reflux esophagitis is diagnosed clinically in older children when reflux causes persistent symptoms with or without inflammation of the esophagus. Older children with Reflux esophagitis have less frequent vomiting than infants. And they complain of adult-type symptoms of regurgitation of food into the mouth, pain in chest, and difficulty in swallowing. Children who have asthma, cystic fibrosis, developmental handicaps, hiatus hernia, and repaired trachea esophageal fistula are in a greater risk of reflux esophagitis.
Causes of reflux esophagitis
Occasional episodes of gastro esophageal reflux are common in healthy person. Reflux is normally followed by esophageal peristalsis waves which efficiently clear the gullet. Alkaline saliva neutralizes residual acid, and symptoms do not occur. Reflux esophagitis develops when the esophageal mucosa is exposed to gastro duodenal contents for prolonged periods of time, resulting in symptoms and, in a proportion of cases, esophagitis. Several factors are known to be involved.
Factors involved in reflux esophagitis in children include liquid diet; horizontal body position; short, narrow esophagus; small, noncompliant stomach; frequent, relatively large volume feedings; and an immature lower esophageal sphincter.
In adults causes are nearly same. The followings are major concern:
Abnormality of the lower esophageal sphincter
In health, the lower esophageal sphincter is contracted, relaxing only during swallowing. Some patients with gastro esophageal reflux disease have low tone of lower esophageal sphincter. This permits regurgitation when abdominal pressure increases. In some person basal sphincter tone is normal but reflux occurs in response to frequent episodes of inappropriate sphincter relaxation.
Hiatus hernia causes reflux because the pressure gradient between the abdominal and thoracic cavities, which normally closes the hiatus, is lost. In addition, the oblique angle between the cardiac end of stomach and esophagus disappears. Many patients who have large hiatus hernias develop reflux symptoms, but the relationship between the presence of a hernia and symptoms is poor. Hiatus hernia can be present in individuals who have no symptoms of hiatus hernia. And some of symptomatic patients have only a very small or no symptoms of hernia. Nevertheless, almost all patients who develop esophagitis, Barrett’s esophagus or peptic strictures have a hiatus hernia.
Delayed esophageal clearance
Defective esophageal peristalsis is commonly found in those who have esophagitis. It is a separate abnormality, since it persists after esophagitis has been healed by acid-suppressing drug therapy. Poor esophageal clearance leads to increased acid exposure time.
Gastric acid is the most important esophageal irritant and there is a close relationship between acid exposure time and symptoms.
Defective gastric emptying
Gastric emptying is delayed in patients with gastro esophageal reflux disease. The reason for this is unknown.
Increased intra-abdominal pressure
Pregnancy and obesity are established predisposing causes. Weight loss may improve symptoms.
Dietary and environmental factors
Dietary fat, chocolate, alcohol and coffee relax the lower esophageal sphincter and may provoke symptoms.
Visceral sensitivity and patient vigilance play a role in determining symptom severity and consulting behavior in individual patients.
Symptoms reflux esophagitis
The classical triad of symptoms is burning pain behind sternum (heartburn), upper abdominal pain (sometimes radiating through to the back) and regurgitation. Most patients do not experience all three.
Symptoms are often provoked by food, particularly those that delay gastric emptying (e.g. fats, spicy foods). As the condition becomes more severe, gastric juice may reflux to the mouth and produce an unpleasant taste often described as ‘acid’ or ‘bitter’. Heartburn and regurgitation can be brought on by stooping or exercise. A proportion of patients have pain in esophagus with hot beverages, citrus drinks or alcohol. Patients with nocturnal reflux and those who reflux food to the mouth nearly always have severe reflux esophagitis.
Some patients present with less typical symptoms such as angina like chest pain, pulmonary or laryngeal symptoms. Difficulty in swallowing is usually a sign that a stricture has occurred, but may be caused by an associated motility disorder. Because reflux esophagitis is such a common disorder, it should always be the first thought when a patient presents with esophageal symptoms that are unusual or that defy diagnosis after a series of investigations.
- 24-hour pH recording is the ‘gold standard’ for diagnosis of reflux esophagitis.
- Transient lower esophageal sphincter relaxation is the most important manometric findings in reflux esophagitis.
- The length and pressure of the lower esophageal sphincter are also important.
Barium swallow X ray
This study plays a limited role. In patients with severe difficulty in swallowing, it is sometimes obtained prior to endoscopy to identify a stricture.
Upper endoscopy with biopsy is excellent for documenting the type and extent of tissue damage in gastro esophageal reflux. And for detecting other gastro esophageal lesions that may mimic reflux esophagitis and for detecting reflux esophagitis complications, including esophageal stricture, Barrett’s esophagus, and esophageal carcinoma. In reflux esophagitis there is visible mucosal damage, characterized by single or multiple erosions or ulcers in the distal esophagus at the junction of esophagus and stomach. In patients treated with a proton pump inhibitor prior to endoscopy, preexisting reflux esophagitis may be partially or completely healed. The Los Angeles classification grades reflux esophagitis on a scale of A (one or more isolated mucosal breaks 5 mm that do not extend between the tops of two mucosal folds) to D (one or more mucosal breaks that involve at least 75% of the esophageal circumference).
Treatment of reflux esophagitis in children
In otherwise healthy young infants (well-nourished), no treatment is necessary, other than a towel on the shoulder of the caretaker. For infants with complications of reflux esophagitis, drug therapy with a proton-pump inhibitor should be offered. Lesser benefits are obtained with H2 receptor antagonists. Pro kinetic drugs, such as metoclopramide, occasionally may be helpful by enhancing gastric emptying and increasing lower esophageal sphincter tone, but are seldom very effective. When severe symptoms persist despite medication, or if life-threatening aspiration is present, surgical intervention may be required. Fundoplication procedures, such as the Nissen operation, are designed to enhance the anti reflux anatomy of the lower esophageal sphincter. In children with a severe neurologic defect who cannot tolerate oral or gastric tube feedings, placement of a feeding jejunostomy should be considered.
Treatment of reflux esophagitis in adult
Reflux esophagitis medications
Most sufferers from reflux esophagitis do not consult a doctor and do not need to do so. They self-medicate with over the counter medicines such as simple antacids, antacid alginate preparations and H2-receptor antagonists. Consultation is more likely when symptoms are severe, prolonged and unresponsive to the above treatments.
Simple measures that are often neglected include advice about weight loss, smoking, excessive consumption of alcohol, tea or coffee, the avoidance of large meals late at night and a modest degree of head-up tilt of the bed.
Tilting the bed has been shown to have an effect that is similar to taking an H2-receptor antagonist. The common practice of using additional pillows has no significant effect.
Proton pump inhibitors are the most effective drug treatment for reflux esophagitis. Indeed, they are so effective that, once started, patients are very reluctant to stop taking them. Given an adequate dose for 8 weeks, most patients have a rapid improvement in symptoms (within a few days), and more than 90 per cent can expect full mucosal healing at the end of this time. For this reason, a policy of ‘step-down’ medical treatment is advocated based on the general advice outlined above and a standard dose of a proton pump inhibitor given for 8 weeks. At the end of that time, the dose of proton pump inhibitor is reduced to that which keeps the patient free of symptoms, and this might even mean the cessation of proton pump inhibitor treatment. Because most patients do not make major lifestyle changes and because PPIs are so effective, many remain on long-term treatment. For the minority who do not respond adequately to a standard dose, a trial at an increased dose or the addition of an H2-receptor antagonist is recommended. If unsuccessful, these patients should be formally investigated. Proton pump inhibitor therapy is also important in patients with reflux-induced strictures, resulting in significant prolongation of the intervals between endoscopic dilatation. As yet, fears that chronic acid suppression might have serious long-term side effects including the risk of gastric cancer seem unwarranted.
Strictly speaking, the need for surgery should have been reduced as medication has improved so much. Paradoxically, the number of anti reflux operations has remained relatively constant and may even be increasing. This is probably due partly to increased patient expectations and partly to the advent of minimal access surgery, which has improved the acceptability of procedures.
A number of endoscopic treatments have been tried in the last ten years that attempt to augment a failing lower esophageal sphincter. These involve endoscopic suturing devices that plicate gastric mucosa just below the cardiac end of stomach to accentuate the angle of His, radiofrequency ablation applied to the level of the sphincter and the injection of sub mucosal polymers into the lower esophagus. The procedures have generally been applied to patients with only small hiatus hernias or none at all, so only a small proportion of patients who present to hospitals are suitable. While all methods produce some temporary improvement in symptoms and objective assessments of reflux, failure rates at one year are over 50 per cent, and there are no large case series that have reported long term outcomes. Among the various operations for the surgical correction of reflux esophagitis these are common:
- Nissen fundoplication
- Hill procedure
- Belsey mark IV operation
- Laparoscopic fundoplication
Complications of reflux esophagitis
- Shortening of esophagus
- Stricture of esophagus
- Barrett’s esophagus