Heartburn treatment for herb. Gastroesophageal reflux disease: symptoms and treatment. Myth: Gerb only occurs in people with hyperacidity.

Many are familiar discomfort heartburn, belching after eating, pain in the abdomen or a little higher after a hearty festive meal. Can they be ignored or are they a sign of a serious illness?

GERD - what is it?

Gastroesophageal reflux disease is a disease caused by frequent reflux (reflux) of semi-digested food from the stomach or small intestine into the esophagus. At the same time, the mucous membrane of the latter is irritated by aggressive digestive components (hydrochloric acid, enzymes, bile, pancreatic juice), inflammation and unpleasant subjective symptoms occur.

The exact prevalence of the disease has not yet been established. After all, its main manifestation - heartburn - occurs with varying frequency both among adults and children. And the severity and severity of the process do not correlate with the intensity of the symptoms. This means that the patient is serious damage the esophagus may not experience any discomfort at all, have no complaints and not seek medical help.

Causes of gastroesophageal reflux disease

Mucosal damage occurs due to several factors:

• weakening of the anatomical antireflux barrier;
• a decrease in the ability of the esophagus to quickly evacuate food to the underlying sections of the gastrointestinal tract;
• decrease in the protective properties of the lining of the esophagus (production of mucus, alkaline components);
• this or that disease of the stomach with excessive production of hydrochloric acid, the reflux of bile from the intestines up the digestive system.

Nature has provided many devices that protect against this disease. The esophagus "flows" into the stomach at an angle, it is covered by ligaments and muscle fibers of the diaphragm so that it is tightly fixed. From the inside, the mucous membrane has a special fold that acts as a valve that does not allow gastric contents to pass upward. In addition, the gas bubble is located in the stomach in such a way that there is no reflux of food.

In a healthy person, the muscular ring surrounding the transition of the esophagus to the stomach opens only occasionally for a few seconds to release excess swallowed air. Gastroesophageal reflux is not an outflow of air, but a reflux of liquid contents, it should not be normal. Defense mechanisms fail for a variety of reasons.

• Excess in the diet of foods containing caffeine (coffee, tea, chocolate, Coca-Cola), citrus fruits, tomatoes, alcoholic and carbonated drinks, fatty foods.
• A hasty and plentiful meal, in which large volumes of air are swallowed.
• Smoking.
• Some drugs: antispasmodics (No-shpa, Papaverine), painkillers, nitrates, calcium antagonists.
• Vagus nerve injury (eg. diabetes or after surgical incision).
• Chemical dysregulation of function digestive system(excess production of glucagon, somatostatin, cholecystokinin or other substances).
• Other diseases - hiatal hernia, short esophagus, scleroderma.
• Conditions accompanied by an increase in intra-abdominal pressure: pregnancy, overweight, chronic constipation, flatulence, ascites, prolonged cough, regular weight lifting.

Symptoms of GERD

The patient's feelings may vary from total absence signs of disease to excruciating pains resembling those of the heart. Any combination of symptoms is possible.

• Heartburn is a burning sensation behind the sternum that occurs when the mucous membrane of the esophagus comes into contact with the acidic contents of the stomach. It usually appears in healthy people if you lie down immediately after eating.
• Belching of air and regurgitation of food, aggravated by error in diet.
• Pain behind the sternum, extending to the neck, jaw, shoulder, interscapular region, left half chest. The sensations can be very similar to the pain of angina pectoris.
• Difficult or painful swallowing of food, sensation of a "lump" in the esophagus.
• Possible obsessive hiccups, occasionally vomiting, which is usually a symptom of diseases of the stomach or intestines.

The so-called extraesophageal symptoms are distinguished - signs of the disease associated with the involvement of other organs in the disease. So, the contents of the stomach can be thrown quite high, up to the oral cavity, and end up in the respiratory tract. In this case, there is dryness and sore throat, hoarseness of voice, choking cough. If during a night's sleep there is a leakage of digestive juices far into Airways develop bronchitis or pneumonia.

GERD classification

According to the results additional examination distinguish:

• non-erosive reflux disease (no visible changes in the esophagus),
• GERD with esophagitis (inflammation of the lining of the esophagus caused by regular reflux from the stomach).

Depending on the volume of affected tissues, 4 degrees of the disease are distinguished, from A to D.

Confirmation of the diagnosis

To distinguish GERD from other diseases, the attending physician will prescribe an examination.

1. FEGDS (fibroesophagogastroduodenoscopy) - examination of the esophagus, stomach and part duodenum using a special camera. In this case, a biopsy of the altered areas is necessarily taken (a small piece of tissue is excised and examined under a microscope).
2. An X-ray examination allows a good examination of the contours of the esophagus and reveals the existing anatomical anomalies.
3. Daily pH-metry - 24-hour monitoring of the acidity of the esophagus. It makes it possible to judge the frequency of refluxes and their intensity.
4. Esophageal scintigraphy helps to assess the rate of evacuation of the contrast agent (and, accordingly, food) down the gastrointestinal tract.
5. Manometry measures the strength of the muscular ring that surrounds the junction of the esophagus with the stomach.
6. Esophageal impedancemetry allows you to assess the intensity and direction of peristalsis (pushing muscle contractions).

It is not necessary that the person who applied for help will go through all of the listed procedures. Depending on the manifestations of the disease, only a part of them and some others can be prescribed.

Should gastroesophageal reflux be treated?

Even if there are no unpleasant symptoms, the disease must be treated, as it threatens with serious complications. Peptic ulcers are large and deep defects in the wall of the esophagus that occur due to constant exposure to aggressive substances. Ulcers can penetrate the wall through and cause inflammation in the surrounding tissues. The treatment of such extensive inflammation is complex and lengthy and necessarily requires hospitalization in a hospital.

Bleeding occurs if on the way of the forming ulcer met blood vessel, and the esophagus is surrounded by several large wide veins. Bleeding can be very intense and quickly lead to death. Strictures are strong connective tissue scars at the site of chronic inflammation. They change the shape of the esophagus, narrow its lumen, significantly complicate swallowing even liquids.

Barrett's esophagus is a disease in which the esophageal mucosa changes its epithelium to gastric or intestinal. It is a precancerous condition.

Treatment for GERD

As with any chronic disease, it is important to make lifestyle adjustments when GERD is diagnosed. Otherwise, it will not be possible to cure reflux with drugs, and the time intervals between exacerbations will be short.

• Eliminate a possible increase in intra-abdominal pressure - lifting weights, tight belts, belts and corsets.
• Sleep on a high headboard.
• Avoid overeating, especially in the evening. The latest meal should be 3 hours before bedtime.
• After a meal, do not lie down or bend over. Try to stay upright and don't slouch. Small walks of 30 minutes are ideal.
• Stick to a diet for GERD. Avoid fatty foods (whole milk, cream, pork, duck, lamb). Avoid caffeinated and carbonated drinks. Don't drink alcohol. Reduce the amount of citrus fruits, tomatoes, onions, garlic and fried foods on the menu. Do not abuse legumes, white cabbage and brown bread - they increase gas formation.
• Talk to your doctor about any medications you take regularly.
• Quit smoking.
• Control body weight.

In addition to these measures, the doctor will tell you how to treat the disease with drugs. They will help to establish the passage of food in gastrointestinal tract from top to bottom, reduce the content of hydrochloric acid in gastric juice, accelerate the healing of existing defects. In uncomplicated cases surgery usually not required.

Treatment with folk remedies

As part of complex therapy use herbal treatment that accelerates the healing of epithelial defects and reduces the acidity of gastric juice.

Mix 6 tbsp. dry plantain leaves, 1 tbsp. chamomile flowers and 4 tbsp. hypericum herbs. The resulting dry collection pour 1 liter of boiling water and soak on low heat for a quarter of an hour. Let the broth brew, cool and strain. Use 1 tbsp. ready-made medicine half an hour before meals three times a day.

1 tbsp 500 ml of boiling water is poured over dried centaury herb, hermetically sealed, wrapped in a towel and insisted for at least half an hour. Healing infusion take 1/4 cup in the morning and evening.

Do not engage in self-diagnosis and self-treatment! Without expert supervision folk methods can be not only useless, but also dangerous to health!

Gastroesophageal reflux disease (GERD)- one of the most common chronic diseases digestive tract, which occurs due to insufficiency of the lower esophageal sphincter and the reflux of gastric contents into the esophagus. characteristic symptoms GERD are heartburn and sour belching.

- a burning sensation behind the sternum, which can radiate to the neck, shoulders, interscapular region. It occurs as a result of reflux (reflux) of the contents of the stomach into the esophagus due to weakness of the lower esophageal sphincter located between the esophagus and the stomach. Heartburn is often noted in patients with increased production of hydrochloric acid, which is facilitated by certain types of food, alcohol, smoking, strong emotions and chronic stress. Once in the esophagus, gastric contents (hydrochloric acid and digestive enzymes) irritate the delicate mucous membrane of the esophagus, leading to the development of its inflammation, manifested by heartburn, sour belching, and sometimes pain. Heartburn in patients with GERD usually appears 1-1.5 hours after eating or occurs at night (late heartburn), increases after eating, drinking carbonated drinks, when exercising physical activity, in a horizontal position of the body and inclinations of the torso.

Belching sour(reverse flow of gastric contents with the appearance of a sour taste in the mouth). A feeling of bitterness in the mouth occurs when there is an admixture of bile in the contents of the stomach (due to insufficiency of the sphincter between the stomach and the duodenum).

When thrown into the upper esophagus, the acidic contents of the stomach can irritate the respiratory tract, causing hoarseness, paroxysmal or chronic cough which is difficult to treat.

Prolonged course of GERD in the absence of adequate treatment can lead to complications in the form of erosions, ulcers of the esophagus with the formation of cicatricial changes - strictures that narrow the lumen of the esophagus and disrupt the passage of food, as well as the development of precancerous diseases (Barrett's esophagus).

If you have the above symptoms that appear with a frequency of 2 or more times a week for 4-8 weeks or more, you should urgently consult a doctor for the diagnosis of GERD.

If you have been diagnosed with GERD, you must strictly follow the doctor's recommendations for taking prescribed medications, maintain an appropriate lifestyle and diet.

Timely diagnosis and systematic treatment will prevent the progression of the disease and the development of life-threatening complications.

1. If you smoke, be sure to give up this bad habit.
2. If you are overweight (body mass index, which is calculated as the ratio of body weight (in kg) to height (in m) squared, more than 25 kg / m 2), consult a doctor who will help you in choosing measures aimed at on its normalization, including the selection of a diet, the calculation of the calorie content of food according to the characteristics of your body, lifestyle and physical activity.
3. Sleep with the head of the bed elevated, but do not use multiple pillows for this (due to the bending of the body, intra-abdominal pressure may increase and increase the risk of reflux of gastric contents into the esophagus).
4. Avoid large meals, eat 4-5 times a day in small portions.
5. Eat food warm (temperature 38-40°C). Do not eat cold or hot food.
6. After eating, avoid bending forward and horizontal position for 2-3 hours.
7. Do not eat 2-3 hours before bedtime.
8. Do not wear tight belts, corsets, or tight clothing.
9. Avoid eating foods and drinks that increase the production of hydrochloric acid in the stomach and reduce the tone of the lower esophageal sphincter:

Coffee, tea, cola, chocolate, carbonated drinks, pickles, citrus fruits, tomatoes, as well as fatty, sour, spicy foods and spices;

Alcohol, acidic fruit juices, beer (in addition to stimulating the production of acid in the stomach, they can irritate the mucous membrane of the esophagus and stomach);
- skimmed milk (may increase the acidity of gastric juice);
- cabbage, peas, beans, beans (contribute to increased gas production and subsequently increase intra-abdominal pressure).

10. Include in your diet fish fat, mackerel, salmon, linseed oil(contain linoleic acid, which helps to reduce inflammatory processes in the mucous membrane of the esophagus), and olive oil, eggs, butter, sea buckthorn oil (contain vitamins A and E, help improve the renewal of the esophageal mucosa). Dietary advice regarding right choice food products are presented in the table.
11. If you accept medications prescribed by other specialists for concomitant diseases, be sure to inform your doctor, as taking some of them can lead to a decrease in the tone of the esophageal sphincter (nitrates, calcium antagonists, beta-blockers, theophylline, oral contraceptives, antidepressants, belladonna drugs) or cause damage to the mucous membrane of the esophagus and stomach (non-steroidal anti-inflammatory drugs, doxacycline, quinidine). In this case, your doctor will carry out a medical correction to optimize the therapeutic effect.
12. Avoid exercise and work related to forward bending of the torso and lifting weights of more than 8-10 kg. If you visit a gym, consult with an instructor (trainer) to exclude exercises that increase abdominal muscle tension and intra-abdominal pressure.
13. Observe the regime of work and rest, do not overwork, do not allow negative emotions. If you have for a long time Bad mood, irritability and sleep disturbance, consult a doctor.
14. If you develop symptoms such as skin rashes, nausea, vomiting and headache be sure to tell your doctor about it to identify possible side effects drugs.
15. Visit your doctor regularly (at least once every 6 months), go necessary examination. This will contribute to the correct selection of drugs, monitoring the effectiveness of treatment and preventing complications.

Treatment of GERD is a lengthy process that must be carried out under constant medical supervision.

Don't try to heal yourself. Take care of your health!

Original taken from gastroscan Q Why are heartburn and GERD sometimes not treated with the best medicines?

In modern medical recommendations adopted in the United States, and in Europe, and in Russia, proton pump inhibitors (PPIs) are considered the main antisecretory drugs for the treatment of GERD. However, persistence of the classic symptoms of GERD (heartburn and regurgitation) after the end of PPI therapy is common. A survey conducted by the American Gastroenterological Association in patients with symptoms of GERD who received PPI therapy showed that 38% of participants had residual manifestations of the disease.

Reasons for the ineffectiveness of PPI (scientifically refractoriness) in relation to the therapy can be divided into:

• related to the patient's behavior (non-compliance with the PPI regimen, etc.) and
• associated with therapy (the presence of HH in the patient, the composition of the refluxate, etc.).

V.D. Pasechnikov, D.V. Pasechnikov, R.K. Goguev
In the pathogenesis of gastroesophageal reflux disease (GERD), the acid component of the refluxate is the main factor responsible for the onset of symptoms and the development of damage to the esophageal mucosa. Despite the fact that proton pump inhibitors (PPIs) in comparison with placebo and other drugs have a pronounced efficacy (rapid resolution of symptoms, high rate of healing of mucosal defects), some patients remain refractory to adequate acid-suppressive therapy.

Definition

The definition of "refractory GERD" has been the subject of a debate that has been going on for several years. Currently licensed in Europe for the treatment of GERD are 5 standard dose PPIs (esomeprazole 40 mg, lansoprazole 30 mg, omeprazole 20 mg, rabeprazole 20 mg, pantoprazole 40 mg) and one double dose (omeprazole 40 mg). PPI standard doses are licensed for the treatment of erosive esophagitis for 4-8 weeks, and a double dose is licensed for the treatment of refractory patients who have already been previously treated with standard doses for up to 8 weeks. Standard doses are prescribed once a day, a double dose - twice a day.

Is the patient refractory to PPI therapy on a once daily regimen? Some experts believe that the lack of a satisfactory response (reduction of symptoms) with this regimen is enough to declare the failure of GERD. Should twice-daily PPIs be recommended to overcome single-dose refractoriness? Obviously, to judge this, one should take into account not only the frequency of taking PPIs, but also the duration of treatment.

What are the time criteria for determining the phenomenon of PPI inefficiency? Some authors believe that a 4-week prescription of the drug with a single dose regimen is necessary to conclude that PPIs are ineffective. Others suggest using the term "PPI-resistant GERD" when twice-daily dosing for at least 12 weeks fails or provides partial or incomplete relief.

It should be emphasized that the discussed concept of refractoriness to PPI therapy, as a rule, is not associated with a specific loss of sensitivity of proton pumps to inhibitors of their activity, with the exception of a rather rare specific H + / K + -ATPase mutation leading to the development of true refractoriness.

Prevalence

Persistence of the classic symptoms of GERD (heartburn and regurgitation) after the end of PPI therapy is common. With a once-daily regimen, approximately 20% of patients, mostly those with non-erosive disease (NERD), persist with symptoms. A recent survey by the American Gastroenterological Association (AGA) of 1,000 patients with GERD symptoms treated with PPIs showed that 38% of participants had residual disease. More than half of this number took additional drugs to control the manifestations of the disease. medications, most commonly antacids (47%).

Reasons for non-response in GERD treatment can be divided into two categories: patient-related and therapy-related.

Patient-Related Causes of Treatment Resistance

As already mentioned, despite the regimen of taking PPIs twice a day, in some patients, in the lumen of the esophagus, high level acid exposure. Several mechanisms are known to explain this situation. This may be due, first of all, to the skipping of the drug due to the patient's insufficient adherence to therapy.

Lack of adherence to therapy

In the case of a correctly established diagnosis, the patient's adherence to the prescribed treatment should be clarified. The conducted surveys showed the absence of such in a significant number of patients with GERD taking PPIs. Many stop taking them as soon as possible after the start of therapy, others do not follow the recommendations that determine the time of taking the drug and the connection with food intake.

Non-compliance with the time and frequency of taking the drug

These two factors, combined with lack of adherence to therapy, are critical in terms of maximizing efficacy. drug treatment. Most common causes leading to a violation of the correct regimen of taking the drug and, accordingly, to the development of resistance to ongoing therapy, is the patient's personal choice of the time of admission and the lack of clear instructions on how to take the drug. Gunaratnam et al. found that out of 100 patients with persistent symptoms while taking PPIs, only 46% took the drug in accordance with the prescribed instructions (optimal intake). Of those patients in whom the PPI regimen was considered suboptimal, 39% took the drug more than 1 hour before a meal, 30% after a meal, 28% before bed in bed, and 3% when needed. established by the patient.

Meanwhile, it is known that PPIs must be activated in parietal cell canals for subsequent binding to H+/K+-ATPase. Since most of the pumps are in an inactive state in the preprandial period, the recommendation to take the drug before breakfast or dinner is justified precisely by this circumstance, since food intake stimulates the transition of the pumps into an active state and their incorporation into the membrane of the canalicle of the parietal cell. The accepted regimen is to take the PPI 30 minutes before breakfast, as this approach is guaranteed to provide the maximum pharmacodynamic effect. It has previously been found that if PPIs are taken before a meal, this provides a more effective suppression of gastric acid formation than after taking them on an empty stomach without a subsequent meal.

Among the reasons leading to the development of resistance to PPI therapy, one should name not only a violation of the correct regimen for taking the drug by patients, but also the lack of proper competence among doctors, who sometimes do not give appropriate recommendations. Thus, in a survey of 1046 primary care physicians medical practice in the US, only 36% of them advised their patients on when and how to take a PPI in the treatment of GERD.

In fairness, it should be said that so far there is no clear evidence that the restoration of an adequate drug regimen in patients with refractory to PPI therapy leads to a reduction in GERD symptoms.

Impaired barrier function of the esophagus due to hiatal hernia

Resistance to PPI therapy may be due to the presence of hiatal hernia (HH). J. Fletcher et al. showed that in healthy people in the postprandial period in the area of ​​the gastric esophageal junction, a reservoir is localized - an acid pocket ("acid pocket"). In GERD patients with HH, during spontaneous relaxation of the lower esophageal sphincter (LES), the acid pocket migrates into the hernial sac and thus becomes a source of re-reflux from a reservoir located above the diaphragm. This significantly increases the amount of acid exposure in the lumen of the esophagus.

A significant mechanism for the development of resistance to PPI therapy is an increase in the number of transient relaxations of the LES (TRNS), accompanied by an increase in the number of refluxes and acid exposure in the esophagus. It has been found that when the acid pocket is located above the diaphragm in large HH, 70-80% of RNPs are accompanied by acid reflux. If it is localized below the diaphragm, then only 7-20% of such episodes are recorded. PPIs do not affect the frequency of PRNPS, do not inhibit the reflux of gastric contents. From a therapeutic point of view, PPIs, by reducing the size of the acid pocket and, accordingly, the amount of acid in it by suppressing acid formation in the stomach, have positive action for GERD. It should be remembered that the dose of PPI in the presence of HH detected by endoscopy or fluoroscopy should be higher than in the absence of this anatomical anomaly, in order to adequately control acid exposure in the lumen of the esophagus.

The composition of the refluxate

The pathophysiology of GERD is multifactorial and not fully understood. However, it is known that symptoms and damage to the esophageal mucosa can be caused by exposure to reflux with different properties. The reflux may consist of stomach contents (pepsin, hydrochloric acid, food components) and, in some cases, duodenal contents (bile, bicarbonate, and pancreatic enzymes). In adults, reflux of duodenal contents into the lumen of the stomach is a physiological process, especially in the postprandial period and at night. In the case of reflux of duodenal contents into the esophagus, the condition is called duodenogastroesophageal reflux (DGPR).

In animal experiments and studies in humans, a synergistic effect has been established in the induction of esophageal injury between acid and duodenogastric reflux. Symptoms of GERD, compared with the data of prolonged pH-metry, indicate a more frequent association of their occurrence with episodes of acid reflux than non-acid ones. However, symptoms that persist during acid-suppressive therapy are more often associated with episodes of non-acid reflux. G. Karamanolis et al. Using a combination of intraesophageal pH-metry and bilimetry in patients with an unsatisfactory response to PPI therapy, in 62% of cases, these patients were found to have either bile or mixed (bile + acid) reflux. Bile reflux ( bile acids) exacerbates acid reflux-induced damage to the esophagus and also causes the development of resistance to PPIs, which is manifested by the persistence of GERD symptoms in the absence of acid exposure in the esophagus.

Until recently, 24-hour pH monitoring in the lumen of the esophagus was considered the "gold standard" for diagnosing reflux. The reflux episode was considered pathological and was recorded by a special program in case of a sudden decrease (failure) in pH<4. Все рефлюксные эпизоды в диапазоне от 7 до 4 не рассматривались как патологические (некислотные) и не использовались для характеристики кислотной экспозиции в пищеводе у больных ГЭРБ.

With the introduction of a new technology - impedance-pH-monitoring - it became possible to register all episodes of reflux, regardless of the nature of the refluxate (gas, liquid, mixed refluxate) and its pH, which made it possible to distinguish acidic (pH<4), слабокислотные (рН между 4 и 7) и слабощелочные (рН >7) refluxes.

Based on the studies, it was suggested that the development of refractoriness of GERD patients to PPI therapy (preservation of typical and atypical symptoms) may be associated with exposure to non-acidic (weak acid or weakly alkaline) refluxes. Using impedance-pH-metry, it was discovered that non-acid reflux episodes cause exactly the same symptoms as acid ones.

Interestingly, in patients not taking PPIs, about half of the reflux episodes are acidic, the other half are weakly acidic. Mild alkaline reflux is extremely rare, accounting for less than 5% of total reflux episodes. It should be noted that mild alkaline refluxes are not identical to BPH and are not indicators of bile reflux. Because bile mixes with the contents of the stomach, the pH of bile reflux may not differ or differ little from an acid reflux episode.

Is there a relationship between the development of resistance to ongoing PPI therapy and weak acid reflux? Recent studies have shown that in a proportion of patients with NERD (about 37%) who do not respond to PPI therapy, persistent symptoms are associated with ongoing weak acid reflux into the lumen of the esophagus.

It is reasonable to assume that in some cases, inadequate suppression of acid formation with the appointment of various PPIs increases the proportion of weak acid refluxes in the total pool of reflux episodes. Indeed, M.F. Vela et al. , using pH-impedance technology in patients who developed refractoriness to a double daily dose of PPI, showed a change in the nature of reflux before and during therapy. Thus, before taking PPIs, patients were predominantly characterized by acid refluxes (pH<4), а во время терапии - в основном слабокислотные (рН >4). There were no differences in the number of reflux episodes. Thus, PPIs, by exerting a suppressive effect on proton pumps, convert acid refluxes into non-acid ones. More than 90% of reflux episodes that develop during PPI therapy are subacid.

Can non-acid reflux into the lumen of the esophagus cause GERD symptoms, what is their mechanism, and are they different from the symptoms that are caused by acid reflux? It has been established that the persistence of typical (regurgitation), as well as atypical symptoms (cough), despite ongoing PPI therapy, may be associated with non-acidic (weak acid or weakly alkaline) refluxes. It was noted that in comparison with the period before the start of therapy in patients with no effect from the appointment of a double dose of PPI, regurgitation or bitter-sour taste in the mouth became the dominant symptom, and not heartburn, which prevailed before the start of PPI intake. Studies (24-hour ambulatory impedance-pH-metry) have shown that the persistence of acid reflux in GERD patients refractory to PPI therapy (incomplete inhibition of acid formation) is associated with 7-28% of persistent symptoms. On the contrary, weak acid refluxes in 30-40% of cases preceded the onset of GERD-associated symptoms.

In another study using impedance pH-metry, it was found that in patients with GERD who were refractory to ongoing PPI therapy, up to 68% of heartburn episodes were associated with exposure to weak acid refluxes. Recent studies have shown that mild acid reflux can cause heartburn and regurgitation that is no different from similar symptoms caused by acid reflux. Although weak acid refluxes can induce the development of GERD symptoms, it is still not known whether they can cause damage to the esophageal mucosa.

GERD symptoms due to impaired reflux clearance and delayed gastric emptying

The persistence of symptoms, despite PPI therapy, may be due to a violation of the clearance of the esophagus from damaging factors (acids, alkalis) and an increase in the time of exposure of the refluxate to the mucosa of the esophagus, even with a small amount of content. Esophageal peristalsis and gravity are the main mechanisms of esophageal clearance from reflux, and impaired clearance is associated with the development of inefficient motility or lack of peristalsis. Dysmotility of the stomach is one of the factors in the development of reflux into the lumen of the esophagus. Delayed emptying of the stomach leads to its distension and an increase in the volume of contents. Increased gastric distension is a trigger for PRNPS, which, combined with an increase in the volume of contents, contributes to the development of refluxes into the lumen of the esophagus.

Thus, the delay in gastric emptying, causing an increase in the volume of contents, contributes to the development of refluxes, and together with impaired clearance of the esophagus, leads to an increase in the contact time of the esophageal mucosa with aggressive contents, resulting in damage to the gastric mucosa. Compared with GERD patients responding to PPI therapy, delayed gastric emptying is a more common factor found in treatment refractory patients. S. Scarpignato et al. it is believed that an increase in the volume of gastric contents and the development of reflux are the causes of the development of resistance to therapy.

Influence of Helicobacter pylori on the development of resistance to therapy

Despite the fact that H. pylori infection can impair the antisecretory effect and response to PPIs, in a study by V.E. Schenk et al. it has been shown that in order to achieve the success of therapy in this case, it is not necessary to adjust the dose of PPI for patients with GERD, regardless of whether they are infected or not.

Resistance to PPI Therapy Due to Proton Pump Mutations

The fact of rare, specific resistance to omeprazole (pH<4 в желудке как минимум в течение 50% времени суток) вследствие развившихся мутаций в 813 и 822 положении цистеина в молекуле Н+/К+-АТФазы . До сих пор не известно, существует ли резистентность к действию других ИПП из-за мутаций кислотной помпы.

Reasons for the development of resistance associated with therapy

PPI metabolism

Another explanation for the existence of high acid exposure in the lumen of the esophagus during ongoing PPI therapy may be related to PPI metabolism. Basically, PPIs are metabolized by hepatocyte enzymes - cytochromes P450. There is a significant variability in the metabolizing activity of hepatocytes, determined by the genetic polymorphism of P450 cytochromes. A small proportion of patients in whom therapy is considered unsuccessful may be represented by the so-called "rapid metabolizers". Significant destruction of PPI by cytochrome P450 isoenzymes during passage through the liver causes a low level of PPI in the blood serum, which is not adequate to ensure suppression of acid formation in the stomach. Slow metabolizers, on the contrary, demonstrate a higher antisecretory response and, accordingly, better clinical efficacy when prescribing PPIs than fast metabolizers and metabolizers with an intermediate level of metabolism. The slow metabolizing PPI phenotype is more common in the Asian population than in the European population. It is worth paying attention to the fact that the concentration in blood plasma and the acid-inhibiting effect of omeprazole, lansoprazole and pantoprazole depend on the activity of the P450 enzyme subtype - CYP2C19, while the catabolism of rabeprazole occurs mainly through various non-enzymatic pathways and is less dependent on the functional state of the liver. On the other hand, the metabolism of esomeprazole in the liver with repeated administration occurs mainly with the participation of the P450 subtype - CYP3A4. Oral bioavailability may be significantly reduced when PPIs are taken with food or antacids.

Nocturnal acid breakthrough phenomenon

Nocturnal acid breakthrough (NLE) is also associated with PPI metabolism and may be responsible for the persistence of symptoms in some patients. LCP is defined as a pathological condition that develops in patients receiving PPI therapy and is characterized by a "failure" of pH<4 на период как минимум 1 ч в течение ночи. Была предложена гипотеза, что НКП является патофизиологическим механизмом, ответственным за развитие рефрактерной ГЭРБ. Однако НКП не всегда ассоциируется с развитием симптомов ГЭРБ, совпадающих по времени их появления с указанным феноменом. Так, у 71% пациентов, не ответивших на прием ИПП дважды в день, развился НКП, но только у 36% из них имелась корреляция между этим феноменом и симптомами ГЭРБ . Клиническая оценка НКП остается достаточно противоречивой, поскольку он является более частым явлением у пациентов с тяжелой формой рефлюкс-эзофагита или пищевода Баррета и менее часто встречается у большинства пациентов с неосложнененной ГЭРБ.

State of gastric secretion

The presence of multiple ulcers of the duodenum or small intestine in combination with diarrhea and refluxes refractory to PPI therapy may be associated with a hypersecretory state - Zollinger-Ellison syndrome. Gastric secretion and motility are two interrelated functions that should not be considered in isolation from each other. It is known from physiology that many of the factors responsible for stimulating gastric secretion also modify gastric emptying through a mechanism independent of their secretory effect. Antisecretory agents also alter gastric motility, while motility stimulants rarely modify the secretory process. The appearance of symptoms of dyspepsia or their exacerbation when taking PPIs is not typical for patients with GERD or functional dyspepsia. However, this may be the case in some cases, as delayed gastric emptying with PPIs is a reported phenomenon. In this case, the appointment of prokinetics is justified, helping to overcome the side effects of antisecretory drugs that reduce the occurrence of new symptoms, which is incorrectly considered as a manifestation of refractoriness.

GERD symptoms in the absence of esophageal reflux

The lack of desired treatment results in a number of patients is associated with an erroneous diagnosis of functional heartburn, which is indistinguishable by clinical sensations from the manifestation of GERD. The symptoms of GERD due to stretching of the muscles of the esophagus may not depend on the presence of acid in the lumen of the esophagus or may be aggravated by its presence. Some patients develop mechanoreceptor sensitization in response to stretch; in such cases, symptoms may appear in response to the advancement of a bolus of food or gas reflux, i.e., a functional disorder of the esophagus is formed - "functional heartburn". In addition, stimulation of mechanoreceptors triggers a vagal-mediated reflex arc with induction of bronchospasm, cough, or other extraesophageal receptors. The introduction of impedance-pH-metry into clinical practice showed that in half of the cases, the presence of symptoms in these patients is not associated with refluxes of any nature; is not a phenomenon of refractoriness to PPIs. Although the basis for the formation of these symptoms is not known, there is a reasonable assumption that the pathophysiology of the process is associated with visceral hypersensitivity and disturbances in the modulation of pain impulses in the central nervous system, often accompanied by the development of psychological comorbidity.

Hypersensitivity of the esophagus to the normal content of acid in its lumen

In a subset of patients with normal upper GI endoscopy and normal esophageal acid exposure, there is a strong correlation between physiological reflux and the presence of GERD symptoms. This phenomenon has not been disclosed, it is assumed that receptors of the esophageal mucosa sensitized to a small amount of acid are involved, i.e., the development of visceral hypersensitivity in patients. As candidates for the role of such receptors, the acid-sensitive receptor, belonging to the class of cationic channels with changing potential, and the vanilloid receptor, localized in sensory neurons and responding to acid stimulation with the appearance of burning or pain, the expression of which increases with the development of esophagitis in patients with GERD, are considered.

Patients with resistance to PPI therapy may have increased sensitivity of the esophagus to small changes in pH in its lumen, due to weak acid refluxes. At the same time, these studies found a significant overlap between weak acid reflux episodes, causing and not causing the development of symptoms. In particular, it was found that in patients resistant to twice-daily PPIs, in addition to the proximal advance of reflux, the reflux that caused the development of symptoms was represented by a combination of gas and liquid. There are several potential explanations for the association between proximal reflux migration and the development of symptoms. They include an increase in the sensitivity of the proximal esophagus compared to the distal esophagus and/or a summation effect due to the involvement of more sensitized pain receptors in this process when the reflux moves along the esophagus. Patients whose GERD symptoms are due to exposure to weak acid reflux do not have an increased number of reflux episodes, suggesting the development of esophageal hypersensitivity to less acid reflux. Persistent cough in GERD patients taking PPIs may be due to weak acid reflux, as determined by impedance pH-metry.

Acceptance of generic PPIs with unsatisfactory quality

In many countries, in order to reduce the cost of therapy, health authorities promote the promotion of generic drugs on the market - drugs containing the same active ingredients as in the original drugs. Such active promotion requires appropriate control of the stability, quality and efficacy of generics. T. Shimatani et al. conducted a comparative study of the original omeprazole and three "brands" of its generics. Mean levels of intragastric pH and percentage of time with pH<4 за 24 ч при назначении всех форм омепразола были выше, чем при плацебо. Однако в ночной период два из трех генериков не оказывали достоверного влияния на уровень кислотной продукции. Эти данные указывают на то, что при выборе в целях терапии конкретного ИПП следует оценивать его эффективность, снижение которой может быть связано со снижением биодоступности, разрушением препарата и другими факторами. В то же время некоторые генерики омепразола практически не отличаются от оригинального препарата и обеспечивают сходный уровень воздействия на париетальные клетки . Так, назначение омеза по 20 мг 2 раза в сутки за 30 мин до приема пищи в течение 7 дней обусловило достоверно значимое снижение кислотообразующей функции желудка, что, в свою очередь, привело к уменьшению показателей кислотной экспозиции в пищеводе больных ГЭРБ. Использование других генериков омепразола не привело к достоверно значимому изменению кислотообразования в желудке и соответственно к снижению кислотной экспозиции в пищеводе .

So, PPIs, acting on the acid pumps of parietal cells, lead to an increase in the number of non-acid refluxes. The combined technology of impedance-pH-metry makes it possible to detect these refluxes (gas, liquid, mixed composition of refluxate with a slightly acidic or slightly alkaline character), helps to identify patients in whom, despite the use of PPIs and the absence of acid refluxes during traditional pH-metry, persist or new symptoms of GERD appear. The reason for the persistence (appearance) of symptoms in some patients is the reflux of non-acidic material (liquid, gaseous or mixed composition) into the lumen of the esophagus, subject to increased visceral sensitivity of the organ. This kind of reflux is caused by PRNPS, hypotensive NPS, HH with the formation of an "acid pocket" in the hernial sac or a combination of these factors. PPIs do not prevent the development of refluxes, since they do not reduce the number of spontaneous relaxations of the LES, but only increase the pH of gastric juice. Since most patients have normal visceral perception, an increase in the proportion of weak acid refluxes with PPI administration does not cause the development of symptoms, which is considered a positive result of therapy. In patients with impaired visceral perception and/or increased migration of reflux in the proximal direction, weak acid refluxes cause the development of symptoms, which is considered as a manifestation of resistance to PPI therapy.

Diagnostic Algorithm and Management of PPI Refractory Patients

In the case of persistence of GERD symptoms during PPI therapy, it is first necessary to make sure that the diagnosis is correct. If the diagnosis of GERD was based on symptoms alone, then the patient should have an evaluation that includes upper gastrointestinal endoscopy and esophageal impedance-pH monitoring (see figure).

Patients who have developed refractoriness to therapy should be subjected to a thorough questioning, which should include clarification of the PPI dosing regimen, the time of their intake and the relationship with food intake. If the patient adhered to the recommended regimen (using PPI once a day) and the other conditions were observed (taking the drug depending on the time of the meal), then he should be asked to double the dose and / or divide it into two parts - before breakfast and before dinner. Taking PPIs twice a day is associated with a better pharmacodynamic effect, since the antisecretory effect is more stable under these conditions for 24 hours, especially at night. Increasing the dose of PPI gives a positive effect in patients with refractoriness to therapy in 25% of cases; this approach is especially effective in patients with NERD who have esophageal hypersensitivity to an acid stimulus.

Approach to the diagnosis and treatment of patients with symptoms of GERD refractory to ongoing PPI therapy.

After exclusion of pathology not associated with damage to the digestive system, and clarification of adherence to therapy, esophagogastroduodenoscopy (EGDS) of the upper gastrointestinal tract with a biopsy should be performed. If the results of endoscopy indicate the presence of pathology, the etiology is assumed to be associated with damage to the esophagus by reflux contents or not associated with gastroesophageal refluxes. If the results of endoscopy do not reveal any changes, impedance-pH-metry is performed to study the nature of the reflux and the need for esophageal manometry is considered. If esophageal impedance-pH-metry confirms the presence of excess acid production in the lumen of the esophagus or the presence of non-acid refluxes, and the patient is refractory to PPI therapy, it is possible to either intensify medical therapy or consider the need for surgical treatment. In the case of a normal amount of acid in the esophagus, but a strong correlation between symptoms and episodes of physiological reflux, esophageal hypersensitivity is diagnosed. If the number of refluxes in the lumen of the esophagus is within the physiological norm and there is no correlation with symptoms, the patient is diagnosed with functional heartburn. In the last two situations, visceral analgesics are usually prescribed.

The use of 24-hour impedance pH-metry allows the identification of acidic and non-acidic refluxes and may thus be a useful method for diagnosing the causes of PPI refractoriness. In this regard, weak acid refluxes, the appearance of which correlates with the persistence of symptoms in patients receiving PPIs, are responsible for the development of the refractoriness phenomenon. For this category of patients, antireflux surgery is recommended, the successful implementation of which determines the control of both acid and non-acid reflux. Impedance-pH-metry makes it possible to distinguish among patients with refractoriness to PPI therapy a subgroup of patients with functional heartburn, in whom symptoms disappear after the appointment of visceral analgesics or central modulators of pain sensitivity, as well as to differentiate individuals in need of drug therapy or surgical correction.

Baclofen, a GABAB receptor agonist, reduces the number of PRNPS and duodenogastric reflux and, accordingly, reduces symptoms that persist during PPI use. Unfortunately, the side effects of centrally derived baclofen limit its use in most patients.

Certain hopes are associated with the introduction into clinical practice of peripherally acting GABAB receptor agonists, which are practically devoid of side effects.

Sucralfate, by binding bile acids and salts, improves the condition of the esophageal mucosa in patients with GERD resistant to therapy, which allows us to consider this drug as a means of overcoming refractoriness. Prokinetics reduce the manifestations of BPH by increasing gastric emptying and, therefore, can be considered for the treatment of patients resistant to PPI therapy, in which the mechanism of generation of symptoms is due to reflux of bile contents.

Thus, the diagnosis of the reasons for the development of refractoriness in GERD patients to PPI therapy allows us to optimize approaches to overcoming it by choosing an adequate way of correction.

GERD?

When the lower esophageal sphincter relaxes in an uncoordinated or very weak manner, the acidic contents of the stomach can be thrown back into the esophagus. This reflux is called gastroesophageal (gastroesophageal) reflux and often causes heartburn, which is a burning sensation behind the sternum, where the ribs converge. In addition to heartburn, symptoms of GERD may include: persistent sore throat, hoarseness, chronic cough, choking attacks, heart-like chest pains, and a feeling of a lump in the throat. If acidic contents from the stomach regularly enter the esophagus, GERD can become chronic.

Various factors influence the occurrence and severity of gastroesophageal reflux and heartburn, including:

• the ability of the muscles of the lower esophageal sphincter to open and close properly
• composition and volume of gastric juice that enters the esophagus during reflux
• the quality and speed of cleansing the esophagus from harmful substances that have fallen on its mucosa
• neutralizing effect of saliva and more.

Symptoms

• burning in the retrosternal region
• burning behind the sternum and manifestations of reflux, which are aggravated if the patient lies down or bends over.

How common is heartburn?

Although heartburn is common, it is rarely life-threatening. However, heartburn can severely limit daily activities and work efficiency. With a proper understanding of the causes of heartburn and targeted treatment, most patients achieve improvement.

Does hiatal hernia cause heartburn?

Patients with severe heartburn, or heartburn that does not improve despite the measures described above, may need a more complete evaluation. Various tests and diagnostic procedures are currently used to determine the causes of heartburn and decide on further treatment.

Surgery. A small number of patients with heartburn, possibly due to severe reflux and poor medical outcomes, will require surgery. To reduce the number of refluxes, a fundoplication operation is performed. Patients who are unwilling to take the medication needed to relieve heartburn are also candidates for surgery.

Medicines to relieve heartburn

Various antacids
foaming agent and H2 blocker Kvamatel(famotidine)
Prescription in Russia Ultop and OTC in the USA Prilosec OTC (both PPIs omeprazole)
. They are sold without a prescription. Patients taking antacids may experience a variety of side effects, including diarrhea and constipation. Some antacids can be an additional source of calcium.

The most common topic of questions on this "direct line" was heartburn. Heartburn, bitterness in the mouth, pain in the tongue- the main symptoms of gastroesophageal reflux disease. And it has become more and more common in recent years - up to 20 percent of the inhabitants of our country suffer from pathology and its consequences. The American Gastroenterological Association notes that the number of patients with gastroesophageal reflux disease is increasing in the world. 2 percent per year. The main factor that contributes to the development of this pathology is overweight, obesity(this increases the pressure in the stomach), abuse of carbonated drinks(even carbonated mineral water), coffee. An important role is played by the hereditary factor, as well as iron deficiency anemia, the frequent use of antispasmodic drugs (no-shpa, duspatalin and others).

Esophageal reflux- this is throwing into the esophagus what has already got into the stomach. Still happens reflux duodenogastric when what has already been in the duodenum returns to the stomach. This happens because between the esophagus and stomach, stomach and duodenum there is sphincters, which are normally in a closed state and open only during the movement of food into the lower sections of the gastrointestinal tract. And with a disease, the sphincter is not able to close as it should be, so the contents of the stomach return “back”, more precisely, up. This does not go unnoticed by the patient. After all, the contents of the stomach are acidic (which is necessary for normal digestion), but this is not what the esophagus needs, the epithelium of which suffers from acid. In the case of the duodenum, the contents are alkaline, and the bile that enters the intestine from the gallbladder makes it so. But the contents of the duodenum are very irritating to the gastric mucosa. It happens that there is insufficiency of two sphincters at once - gastroesophageal and duodenogastric. However, the first option is the most common. It is known that the gradual destruction of the esophageal mucosa forms erosions, ulcers, and later a precancerous condition - Barrett's esophagus.

And more about reflux and other diseases of the gastrointestinal tract were told by associate professors of the 2nd Department of Internal Diseases of the Belarusian State Medical University, candidates of medical sciences, gastroenterologists of the highest qualification category Nikolai Kapralov And Irina Sholomitskaya.

Gastritis

- Olga, Minsk. Concerned about heaviness in the stomach, nausea, belching, flatulence ... The diagnosis is chronic gastritis of the body of the stomach with atrophy of a pronounced degree of activity. Doubtful - 2 mm polyp of the gallbladder. After the prescribed treatment, as well as following a strict diet, I feel better, but sometimes there is discomfort in the left and right hypochondrium, a sour taste in the mouth. What can you advise me? How often do fibrogastroduodenoscopy? At what size of a polyp is it recommended to remove the gallbladder?

Sour taste and belching may be associated with gastroesophageal reflux disease, which may be associated with gastritis. It is necessary to continue treatment with prescribed antisecretory drugs. Control studies should be repeated only in the presence of unpleasant painful symptoms. Regular examinations are more important if there are morphological changes - erosions and ulcers. Continue therapy, the more the effect is. Reflux treatment can generally last three to four months or more. Gallbladder polyps larger than 7 mm must be removed.

- Marina, Kletsk. Can gastritis be cured? What will be the lifestyle, nutrition of a child who was diagnosed with such a diagnosis somewhere at the age of 5?

Gastritis has no clinical manifestations, it is simply visible during gastroscopy. This examination allows you to take a biopsy of the mucosa, to establish the presence of a Helicobacter pylori infection that supports the inflammatory process of the mucosa. If such a study was not performed, then it is impossible to talk about such a diagnosis. Maybe we are talking about functional dyspepsia? Then you will need to stick to the diet.

Heartburn

- Nikolai Nikolaevich, Korelichi district. 64 years old. I suffer from heartburn. There is gastritis, cholecystitis, and for a long time. I take omeprazole, mezim and allochol. I don’t stick to a diet, I eat absolutely everything, because how in the countryside, where there is so much hard physical labor, you don’t eat meat and lard? Maybe in my case I need to drink some other medicines? How to relieve symptoms of heartburn?

You have a classic symptom of gastroesophageal reflux disease - heartburn. The disease is very common among the adult population. For treatment, it is necessary to use special drugs -. This includes the medication you are taking, omeprazole. Its average therapeutic dose is 20 mg 2 times a day, morning and evening, 30-40 minutes before meals. But I would recommend that you actively engage in non-drug treatments for the disease - eat only small portions, do not overeat. After eating, you need to move, walk for 30-40 minutes until the food falls below the stomach. You need to sleep with your head elevated, which also helps to ensure that the acidic contents of the stomach are not thrown into the esophagus. Antispasmodics are not recommended. no-shpy, papaverine, duspatalina, which further reduce the tone of the lower esophageal sphincter. All this should give relief. You need to take into account the fact that hard physical work also contributes to unpleasant symptoms - by increasing intra-abdominal pressure.

It is necessary to do all of the above so that heartburn does not occur. If it has arisen, then an antacid drug belonging to the group of fast-acting drugs can be used to relieve the symptom: gefal, almagel, phosphalugel. Under no circumstances should they be abused. They contain salts of heavy metals, and they are toxic to internal organs. Therefore, the course of taking such drugs is 3-5 days. Foreign experts point out that their can not be taken more than 2 weeks a year! Otherwise, other serious conditions may develop, including osteoporosis.

- Galina Feliksovna, Minsk. 76 years old. Almost all life - erosive gastritis, low acidity. I have been suffering from heartburn for a year now - my palate and tongue are very hot ... The doctor also sent me to the dentist. I take immortelle, it seems to help a little, but you can’t drink it all the time. How to get rid of bitterness?

It looks like you have gastroesophageal reflux disease, which is accompanied by similar symptoms. Gastritis with erosion requires its own treatment - medication and long enough. Herbal treatment does not work. There are several groups of gastric drugs, one of them is proton pump inhibitors ( omeprazole, lansoprazole, rabeprazole, esomeprazole), and they should be basic in treatment. The duration of the course will be prescribed by the doctor after esophagogastroduodenoscopy. Therapy should be individual and multi-month.

- Maria Stepanovna, Logoisk. Son is 52 years old. He often has heartburn. Last year, during the examination, they said that his stomach was too small, but no pathology was revealed. He doesn't eat well. Takes baking soda for heartburn. And one more thing: how to be examined, if the intestines do not work well, there are constipations ...

Most likely, your son has gastroesophageal reflux disease. One of its clinical manifestations is heartburn. Treatment with soda is undesirable, because its single use can still have some effect, but repeated intake of alkali further increases the acidity of gastric juice. Soda reduces acidity, but our stomach is acidic, and its glands begin to produce acid again. Finally, the acidity will gradually become even higher. In addition, when soda dissolves in the stomach, a large amount of carbonic acid is formed, which increases the distention of the stomach and increases reflux. Long-term treatment with special drugs - proton pump inhibitors is required. Within months, these drugs will create a physiological atrophy of the acid-producing glands. Heartburn, by the way, most often occurs with high acidity of gastric juice, and high acidity often provokes constipation.

- Svetlana Nikolaevna, Grodno region. 52 years old. A 16 mm stone was found in the gallbladder last year. Is it possible to dissolve such a stone if you use beet juice? And one more thing: there are signs of gastritis, I suffer from heartburn and therefore I take omeprazole. How long can it be taken? What can cause heartburn?

You have gastroesophageal reflux disease - very common right now, as we see even in our hotline questions. This condition is associated with the reflux of gastric contents into the esophagus. Gallstone disease can also provoke the development and maintenance of reflux disease. It is necessary to treat cholelithiasis, and the treatment here is only surgical.

Gastroesophageal reflux disease (GERD)

What are the symptoms of GERD?

Heartburn, sour taste in the mouth, sour belching, pain in the esophagus, tongue, bad breath. Heartburn and belching are aggravated if you take a horizontal position immediately after eating.

Coughing and breathlessness are associated with GERD

Since the oropharynx is anatomically connected with the larynx and trachea, the contents that are thrown up from the esophagus can reach the bronchopulmonary system. And in the gastric contents there are a lot of bacteria that can cause chronic obstructive pulmonary disease or even bronchial asthma. At the same time, the symptomatology of gastroesophageal reflux disease changes - the patient experiences not just heartburn, but also asthma attacks, cough, he has mucus. If the vocal cords are also involved in the process, the voice will become hoarse.

How are they examined?

Diagnosis of the disease is to conduct instrumental studies. With the help of esophagogastroduodenoscopy, the esophagus, stomach and duodenum are examined. The endoscopist sees that the lower esophageal sphincter is relaxed, does not close.

The refluxate itself is also examined using intraesophageal or intragastric daily pH-metry. A thin gastric tube with three capsules capable of perceiving the concentration of hydrogen ions characterizing the acidity of the environment is inserted through the nose into the esophagus and stomach. The probe is attached behind the ear, and a special measuring device is attached to the belt. This method allows you to determine the onset of reflux, its duration, duration of action, the relationship of reflux with food intake, lying position, etc.

What is the treatment?

Proton pump inhibitors that reduce the acidity of gastric juice, blocking acid production in the stomach. We are talking about many months of treatment under the supervision of a doctor. In addition, you need:

• maintain optimal weight;
• do not overeat, eat 4-5 times a day in small portions;
• daily consume 600-800 g (depending on weight) of fruits and vegetables;
• after eating, do not lie down, but walk for 30-40 minutes;
• give up carbonated drinks and coffee;
• sleep with your head elevated by 30 cm;
• Do not smoke;
• do not use uncontrolled antispasmodics.