Backward flow gastro-œsophagien

The backward flow gastro-œsophagien is defined by the passage in the esophagus of part of the gastric contents , acid. It is about a normally intermittent and asymptomatic phenomenon which occurs at all the subjects, in particular in period postprandiale (after the meals). In certain cases however, an excessively frequent and/or prolonged backward flow can be responsible for occurred for awkward symptoms (burns rétrosternales, acid régurgitations) and sometimes for complications, defining a pathological backward flow gastro-œsophagien.

The pathological backward flow gastro-œsophagien is a frequent reason for consultations in medicine.

Physiopathology

Operation of the œso-gastric junction

Under the normal conditions the sealing of the œso-gastric junction is ensured by:

the permanent tonicity of the lower Sphincter of the œesophage, Smooth muscle whose relieving occurs automatically with each Déglutition and is particularly marked during the food catch and of the period postprandiale;
the strict intra-abdominal position of the Cardia, higher portion of the Stomach, which ensures mechanically the closing of the sphincter (closing of the angle of His), because of a difference in pressure between the thoracic area (hyper) and the abdominal area (hypo).

The pathological backward flow gastro-œsophagien occurs consequently:

in the event of insufficiency sphinctérienne (the most frequent case), which results in spontaneous relievings of the lower sphincter of the esophagus, apart from any swallowing. Such relievings would have a genetic cause, like showed it a américano-Swedish study undertaken among twins ;
in the event of anatomical anomaly (more rarely): the protrusion of the cardia in the thorax through the hiatus œsophagien of the diaphragmatic muscle, called Hernia hiatale, takes part in the failure of the lower sphincter of the esophagus.

Physiopathology of the RGO

The too frequent passage or too prolonged acid gastric contents has a corrosive effect on the mucous membrane œsophagienne which is not protected from acidity. By decreasing order of frequency, a repeated aggression of the mucous membrane œsophagienne is responsible:

Frequently: of a simple irritation of the mucous membrane responsible for the most frequent symptom (Pyrosis);
Sometimes of an ignition of the mucous membrane œsophagienne (œsophagite) (responsible for pains, or sometimes asymptomatic), sometimes complicated of digestive hemorrhage (Hématémèse) or of contracting of the diameter œsophagien (peptic Sténose);
Exceptionally of major deteriorations of the cellular structure of the mucous membrane being able to lead to a Métaplasie: one speaks about Endobrachyoesophage; then with a dysplasy and a canceration.

Epidemiology

Occurred of a feeling of burn on the level of the chest (Pyrosis) is frequent in the Western populations (nearly 25% of the latter complains occasionally about this pain). This sign is rarer at the Asian ones.

On the other hand, nearly one the third of the patients having a œsophagite with the fibroscopy never complained about pyrosis.

Helicobacter pylori , germ responsible for number of gastric ulcers, does not cause more backward flow and seems even sometimes relatively protective.

Semiology

The typical shape of the adult

In the adult, the most frequent symptom is the Pyrosis, a feeling of ascending burn rétrosternale. The pyrosis occurs readily when the subject is lengthened or leans ahead. Association with régurgitations acid S is Pathognomonique backward flow gastro-œsophagien and is enough to pose the diagnosis. A epigastric pain without pyrosis and a bad breath (Halitose) are frequent.

The atypical shapes of the adult

Sometimes the symptoms are indirect and the recourse to the complementary examinations can be necessary to pose the diagnosis.

thoracic Pains being able to impose some for a Angina pectoris;
pulmonary Demonstrations: Cough irritating chronicle, Dyspnea asthmatiforme;
Demonstrations ORL: enrouement;
stomatologic Demonstrations: Dental carie, Gingivite;
Complications: to see will infra.

Backward flow gastro-œsophagien of the infant and the child

It can appear in an atypical way:

Break of the staturo-ponderal Curve;
repeating Rhino-pharyngo-bronchitis;
Asthma and Bronchiolite;
Anemia.

Complications

They are rather rare (considering the frequency of the pyrosis) and are not correlated with the severity of the symptoms.

œsophagite peptic, with risk of bleedings (weakens occults ferriprive), of sténose
contracting of the esophagus, particularly in the child;
Endobrachyœsophage : intestinal metaplasy of the esophagus (also called esophagus of Barett), occurring especially at the old patient, diagnosed on the microscopic analysis of a taking away carried out during a fibroscopy, being able to evolve/move in the second time in Cancer of the esophagus.
Cancer of the esophagus, rare and late complication.

It is necessary to be wary of occurred of the one of these complications if there exists:

a Dysphagie
a Hématémèse (vomiting of blood) or a Maelena (diarrhea noirâtre correspondent with digested blood)

Diagnosis

Fibroscopy

The high digestive endoscopy does not pose the diagnosis of backward flow but makes it possible to determine the existence or not secondary lesion œsophagienne with this one, such as a œsophagite or a sténose (contracting) for example. This examination can be completely normal, even in the event of proven backward flow.

the manometry œsophagienne

It explores the cause of the backward flow. It consists in measuring the pressure in various zones of the esophagus by means of a tube flexible and hollow, that the patient swallows and who is connected to a pressure pick-up. A fall of the tonicity of the lower sphincter of the esophagus, or an associated driving disorder will be sought.

the pH-métrie œsophagienne

It consists in collecting the pH of the esophagus by a small probe whose end is positioned with a few cm above the lower sphincter of the esophagus. This probe is introduced by the nose and is connected to a recording case. It is only examination which confirms in an unquestionable way a backward flow gastro-œsophagien, while determining its acidity (pH lower than 4), its frequency (remains normal if the backward flow occupies less than 5% of the 24:00), its schedule, etc the examination is however unpleasant and remains held with the dubious cases.

A recording capsule without wire was developed: it is fixed at the low esophagus during a fibroscopy and communicates outside by electromagnetic waves. It is detached spontaneously from the wall at the end of 24 to 48 H and is then ejected by the natural ways. it is techic expensive, still at the stage of the evaluation.

Other examinations

the Scintiscanning: it makes it possible to seek a residual radioactivity inhaled following a backward flow on the level of the lungs. This examination is done in hospital medium and can be interesting in the infant or the small child.
the test of Bernestein is a test psychophysiologic, indicated in the thoracic pains of origin œsophagienne; it requires the full co-operation of the patient.
the transit œsophagien consists in making swallow with the patient a radiopaque paste and to follow its progression in the digestive tract. This examination makes it possible to visualize certain complications (contractings) or certain supporting grounds (hernia hiatale).

Classification of Los Angeles

Rank 0: anamnèse typical of backward flow without detectable mucous lesions to the endoscopy.
Rank a: One or more mucous lesions, lower or equal to 5 mm
Rank b: At least a mucous lesion of more than 5 mm but without any junction enters the tops of the 2 folds.
Rank C: At least an erosion continues between the tops of 2 folds or more, but noncircumferential.
Rank D: circumferential mucous lesion.

Treatment

The treatment can be medical or surgical. The drugs (aluminum salts, antihistamines anti-H₂, IP) very effective, are often well tolerated and especially make it possible to pass in addition to or, in any case, to reduce of the painful and antisocial Régime S.

Prevention: to avoid the worsening factors

Certain food and lifestyles tend to support the backward flow gastro-œsophagien: fatty food and nicotinism inhibit the sphincter lower esophagus and must thus be decreased or proscribed.

The coffee, alcoholic drinks, Vitamine C increase the acid secretion of the stomach and must be appreciably decreased.

It is advised with the patient to lie down at least an hour after its last food catch.

An appearance slightly more frequent is noticed at the people being regularly brought to be leaning forwards, the curved back, lasting a work, a regular physical-activity or a constant posture (to be sitted on a chair can suffir if the posture is not healthy and if that is prolonged during many years). The stress is also a worsening factor, even release. In the same way the fizzy drinks can increase the frequency of the backward flows.

It is in all the cases good to preserve a hygiene of correct life, at least during the period of re-establishment.

Medicamentous treatment

the Antacid catch of S before the meals or symptomatically after the appearance of the symptoms can reduce the gastric acidity (by increasing pH).
the catch of antihistamines anti-H₂ 2 receptor blockers--> gastric the such Ranitidine or the Famotidine can reduce the secretion of gastric juice acid. Antihistamine S. They relieve complaints in butt 50% off patient all GERD. -->
IP (inhibiters of the pump with protons) the such Oméprazole are in general more effective as regards reduction of the secretion of gastric acid.
the agents Prokinétique S, . The Cisapride, a member of this class was withdrawn from the market in certain countries (risk of Bloc of branch and Torsades of point), in others (for example the Belgium), it is the subject of a regulation and an heightened surveillance. One more easily uses nerve sedatives like the Dompéridone or it].

Surgical treatment

The fundoplicature remains reserved with the serious cases and rebels with the treatments by drugs, or repeating with the stop of those. It consists in folding up the stomach of such kind to reinforce the junction between this last and the esophagus. This surgery can be made by Laparotomie or Cœlioscopie.

Therapeutic prospects

Treatments by fibroscopic way were proposed but remain to be evaluated and are reserved for quite particular cases:

application of a radio frequency in the low esophagus causing a mini burn of this last;
injection in the muscular sphincter of a probably acting product in a mechanical way by thickening this last;
joining partial of the low-esophagus, in order to restrict the passage.

Reference

'' Gastro-oesophageal backward flow disease '', P Moayyedi, NR Talley, Lancet 2006; 367:2086 - 100

Slang synonym

The Backward flow gastro-œsophagien is called a “deleuze” in Jargon normalien.

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