Disease GERD (Gastroesophageal reflux disease, GERD) (Final).

Diagnosis of acid reflux.
In Western countries. Patients with symptoms of chest burning and acid regurgitation. With no other symptoms. Of the stomach or intestines with a chance. Acid reflux disease as much as 77. If you have other symptoms. Of the gastrointestinal tract associated with acid reflux likely to have less The burning pain in the chest is less common than in Western countries 59. The benefits of burning chest pain patients diagnosed with acid reflux have less. Belching as a symptom of the common symptoms found in Thai patients. In patients with GERD patients without reflux symptoms that are more useful than burning chest. However, it is a little disturbing for patients and Thai patients, often patients with symptoms of non-specific symptoms such as a stomach (reflux like dyspepsia), chest pain is not caused by heart disease, ear nose and throat or cough. Chronic etc., so that the patient was diagnosed with acid reflux or not of the same symptoms of Thai patients will be more difficult than those in Western countries. The trial may require special treatment and monitoring. To help in diagnosis.

The test that can aid in the diagnosis and differential diagnosis of acid reflux. Causes or complications of the disease including acid reflux.

A. Of endoscopy in upper gastrointestinal (upper gastrointestinal endoscopy).

Two. To measure the acidity in the esophagus for 24 hours (24 hr esophageal pH monitoring) or to measure the flow of digestive juices and acid from the stomach into the esophagus for 24 hours (multichannel intraluminal impedance-pH monitoring).

Three. The movement of the esophagus (esophageal monometry).

Four. To swallow barium powder (barium esophagogram).


A. Of endoscopy in upper gastrointestinal (upper gastrointestinal endoscopy).
Endoscopic examination of the esophagus. Stomach and small intestine is considered the standard for detecting abnormalities or inflammation of the esophagus. This can be useful: 1) You can tell whether a patient with esophageal inflammation from acid reflux disease, or 2) can tell whether a patient has complications of acid reflux disease or not, Barrett?? S esophagus Esophageal stricture or cancer. of the esophagus, 3) to help diagnose or exclude other diseases that may cause the patient a diet similar to acid reflux disease, such as ulcers in the stomach and small intestine (peptic ulcer), and 4) can detect abnormalities that can be found together. The risk of acid reflux disease, such as a hiatal hernia.

Endoscopic diagnosis of GERD can be. With specificity. (Specificity) in the diagnosis of acid reflux, approximately 90 to 9578 if found to have inflammation of the esophagus (erosive esopha-gitis), but the downside is more sensitive. (Sensitivity) lower because only a few patients have been found. Inflammation of the esophagus. (Less than 10 per cent in Thai).


Of the distal esophagus and inflammation can be useful in the diagnosis and the severity of esophageal inflammation can help determine prognosis and guide treatment of patients in the long run. When endoscopy showed inflammation of the esophagus, endoscopy should indicate the severity of inflammation was detected. Should be based on principles of Los Angeles Classification79. The severity of the disease can be classified into four grades A, B, C and D with A and B grade inflammation are considered to have a grade C and D will have more inflammation and more severe complications.
The Barrett?? S esophagus to the distal esophageal epithelium from normal mucosa, which is a white, pink, red (reddish pink).

Typically, patients with symptoms like acid reflux disease can be treated by lowering your medication, do not need to look inside the gastrointestinal endoscopy at the beginning. Except for patients with warning symptoms, including pain, difficulty swallowing, swallowing, and then I shoot black and pale, vomiting blood, weight loss or symptoms for over five years to have a higher risk of Barrett 's esophagus80 which patients are at risk. to experience complications from acid reflux disease and Barrett?? s esophagus patients are. We look inside the esophagus, endoscopy should be performed beginning from the start.

Two. To measure pH in the esophagus at 24 hours (24 hr esophageal pH moni-toring) or the measurement of acid and the flow of digestive juices from the stomach into the esophagus for 24 hours (multichannel intraluminal impedance-pH monitoring).
Measurement of pH in the esophagus (ambulatory esophageal pH monitoring).
Measurement of pH in the esophagus. Considered the standard for diagnosing GERD. There is a saying that 1) patients with acid reflux in the esophagus and a longer period than normal or not. (The acidity in the esophagus is less than 4, more than 4.5 percent of the time, make sure all is normal) 2) the occurrence of acid reflux associated with symptoms of the patient or not, and 3) to treat patients. acid reflux acid reflux control is adequate or not.

Indications include the measurement of pH in the esophagus.
A. To confirm the diagnosis in patients with diagnostic uncertainty, such as patients with non-specific symptoms (atypical symptoms) and patients with chest pain is not caused by heart disease, chronic cough or chronic hoarseness.

Two. To assess treatment outcome. The patients receiving the symptoms have not improved.

Three. Before surgery, antireflux surgery.

Measurements of acid in the esophagus over time can be two ways to put the check through the nose and hold for 24 hours or measured by the capsule, the acid to the esophagus without the need for a then record the pH is around. 48 hours (wireless pH monitoring or Bravo pH monitoring).

Measurement of pH and flow of digestive juices from the stomach into the esophagus for 24 hours (multichannel intraluminal impedance-pH monitoring, MII-pH monitoring) as a way to make a new one that is likely to be the standard in the patient. Acid reflux and esophageal acid substitution measurement (24 hr esophageal pH monitoring) can be measured as well as acid reflux and reflux of gastric acid into the esophagus is not. Currently used in many institutions in Thailand and Chulalongkorn Hospital.

Three. The movement of the esophagus (esophageal manometry).
The movement of the esophagus is not useful in the diagnosis of acid reflux. However, the benefit of patients, acid reflux are: 1) The location of the measuring tube in the esophagus with acid for 24 hours or the tube. Measurement of acid and digestive juices from the stomach reflux into the esophagus for 24 hours, 2) assist in the assessment of movement disorders. Esophageal sphincter of the esophagus and the lower part. Before surgery, acid reflux disease (antireflux surgery) 3) to diagnose patients with solid leather. (Scleroderma) early on, but no obvious symptoms of the skin with symptoms of acid reflux. Or in patients without symptoms of the skin (sine scleroderma) 4) allows the diagnosis of esophageal disorders (esophageal dysmotility) that have similar symptoms of acid reflux into the esophagus, such as contracting with each other (diffuse esophageal spasm).

Four. The esophagus by swallowing barium powder (barium esophagogram).
To evaluate the incidence of esophageal reflux disease, or narrowing of the openings were loose diaphragm (hiatal hernia), but less useful in helping to diagnose diseases or detect esophageal reflux disease. And in case of abnormalities often requires diagnosis by endoscopy.



The differential diagnosis.
Burning chest pain (heartburn) may be separated from the chest or epigastric pain that was burning. Of ulcers in the stomach or small intestine. In patients with functional gastrointestinal disorders (functional dyspepsia) in patients who have swallowed it and it should be isolated from patients with gastric inflammation caused by infection (infectious esophagitis) or drug (pill induced esophagitis).

If you have chest pain or pain in tight areas. Epigastric with coronary heart disease should think about before. The chest pain can be caused by other non-acid reflux include esophageal peristalsis disorders (esophageal motility disorder), or diseases of the biliary tract. In the case of suspected coronary artery disease. Routine cardiovascular system more before the diagnosis of diseases of the digestive tract.


The nature of acid reflux disease and prognosis (natural history and prognosis).
Acid reflux disease often have a good prognosis. The mortality rate of acid reflux disease is very low. The cause of death in patients with acid reflux is. Cancer of the esophagus ends. The laryngeal cancer, although it has increased in patients with acid reflux. It is a very small proportion and probability factors and other causes. Rather than as a primary factor. The problem in most patients with reflux symptoms, it is only disturbed patients. And complications. Inflammation of the esophagus and the Barrett?? S esophagus does not cause interference, but the risk of esophageal cancer is increasing.


The treatment of acid reflux.
The current treatment for acid reflux disease can be helpful in terms of symptom control for the quality of life and reduce complications. The benefit in reducing mortality from this disease have no proof of 0.81.


The classification of patients with acid reflux. To treatment.
Acid reflux disease can be classified into several types according to the patient's clinical and pathological conditions. However, the patients according to the following will be useful in planning treatment.

A. Consider that a patient who had been searching for the cause or complication of acid reflux by endoscopy or upper gastrointestinal source or not. This makes it possible to divide patients into 2 groups: 1) those who had been searching for the cause by gastrointestinal endoscopy in the previous section. (Investigated GERD) and 2) those that do not have surveillance cameras. (Uninvestigated GERD).

Two. If the patient had been searching for the cause before a colonoscopy. These patients can be classified into 4 groups: 1) those who have esophageal inflammation or infection only slightly (non-erosive reflux disease) 2) group with esophageal disease (erosive reflux disease) 3) group with esophageal stenosis or complications of esophageal disease, and 4) a group with Barrett?? s esophagus.

Patients with GERD have not been searched for the cause of the symptoms.
In patients with symptoms of acid reflux is a symptom and a warning (alarm feature) to patients with significant abnormalities of the telescope. The majority of patients 82. It is best to treat these patients with patients who have esophageal reflux disease or complications. No need to get the latest endoscopic examination.

A) treatment by medication or behavior modification.
All patients should be instructed about Behavioral change to reduce the incidence of acid reflux and symptoms include.
A. The head lying on the bed, his head high and your head up and lie about 6-8 inches left. To help the less acid reflux .83,84.

Two. Avoid sleeping immediately after a meal (within 3 hours after I finished eating) due to sleep immediately after a meal can cause acid reflux during sleep and sleep more than 2-3 hours after eating .85,87.

Three. Avoid a big meal.

Four. Avoid foods that are high in fat, tomatoes, tea, coffee, chocolate, beverages containing caffeine, alcohol and foods containing mint and fruit juice or citrus fruit.

Five. To avoid drugs. That may have resulted in more acid reflux medications such as meperidine, morphine, calcium channel blockers, diazepam, barbiturates, theophylline, prostaglandin E2, and anticholinergic medications, although no study. Effect of treatment of such disease or acid reflux.

6. To lose weight because of heavier than normal effect on acid reflux disease. The weight loss acid reflux into the esophagus at 0.88.

Seven. For Smoking Cessation. Although it is generally recommended due to cigarette smoking results in more acid reflux, as described above. However, the advantages of Tobacco and Tobacco found that the effect is not clear what causes acid reflux was 0.89.


Will see that there is only practical in accordance with Article 1 and 2 that there is clear evidence that there are benefits in reducing the occurrence of acid reflux. The behavioral change by 3-7 despite being on a popular topic. However, evidence from research studies that support such instructions have been less. However, in clinical practice that often leads to better patient should be recommended in all patients with GERD.

Treatment by medication.
The treatment of patients with GERD typically have two phases. The initial phase of treatment. And long-term treatment.
In patients without warning signs and symptoms compatible with reflux disease. Can provide treatment for acid reflux disease to it. The drug should be used first proton pump inhibitor drug is in early stage of treatment should be administered in a standard size one day last week. The drugs currently available in five types of omeprazole, lansoprazole, rabeprazole, pantoprazole and esomeprazole in this early stage should be approximately 4 weeks after treatment, then consider To maintain in the long run.

The long-term treatment. Even patients who received endoscopy. There may be diseases of the esophagus is inflamed or inflammation of the esophagus. Since more than 90 percent of patients with esophageal reflux disease is often not Thai. The long-term treatment in patients with GERD who have not had endoscopy in the digestive tract for themselves and have no symptoms to warn the people of Thailand are advised to maintain a step-down therapy by gradually reducing the dose of the standard size. half the size. After that, if the symptoms are controlled, so it is taking to meet the needs of the patient (on demand).
Patients who had been searching for the cause of the symptoms of acid reflux by endoscopic examination of the gastrointestinal tract it. (Investigated GERD).

After the endoscopic GERD patients can be divided into four groups above. But here are the only two major groups. Group without esophageal inflammation. And the esophageal inflammation.




Caring for patients who have esophageal reflux disease (non-erosive reflux disease, NERD).
Patients with esophageal reflux disease patients who do not have the acid reflux symptoms, but it does not cause inflammation of the esophagus. By endoscopy in the esophagus will not see the disease 16. Or less inflammation (LA classification grade AB) these patients are likely to cause complications from acid reflux less.

The start of treatment. Found that the proton pump inhibitors are more effective treatment in reducing the symptoms of patients compared to antacid group, 0.90.

In the long run, these patients should be treated. By giving the patient a drug to a patient that needs medication to control symptoms (on demand) found that patients with the drug itself can cause symptoms. Lower than placebo 91.92. And cost-efficiency by controlling the symptoms was not reduced. Compared with patients on a daily basis.

Treatment the patient the medication is not recommended for patients with inflammation of the esophagus, large (LA grade CD esophagitis or erosive esophagitis) was considered a taboo, because the incidence of esophageal inflammation, it has a percentage. When the 42 patients for a period of 6 months, 93 of which can cause complications.


Caring for patients with inflammation of the esophagus (erosive reflux disease, ERD).
Patients with esophageal reflux disease refers to patients who have inflammation of the esophagus is a significant level of C or D (LA classification grade CD), which are at high risk for complications such as esophageal stenosis. Early treatment is aimed at reducing the symptoms of inflammation of the esophagus and the patient recovered. Found that the proton pump inhibitor and antacid group of symptoms and inflammation of the esophagus is much faster than the other 94 patients. The usual starting dose for 4-8 weeks, then repeat endoscopy may be considered to evaluate the healing of the inflammation of the esophagus and the Barrette 's esophagus with or not because of the esophagus can cause inflammation of the assessment. The Barrette 's esophagus in endoscopy of the inaccuracy. After treatment if the patient has no symptoms, it is recommended that these patients should receive long-term treatment to prevent recurrent inflammation of the esophagus from acid reflux. The proton pump inhibitors as a standard in the long run. Be careful to keep a long-term antacid drug omeprazole on clopidogrel platelet drug clopidogrel reduced the effectiveness of the risk of coronary artery obstruction by chance. It also may have other side effects. Such as infection. In the digestive tract more easily. And calcium absorption from the gastrointestinal tract is less risk of osteopenia. (Osteoporosis) and fractures easily.
The treatment of patients with esophageal disease or patients with Barrett 's esophagus is not mentioned in the medical care should be forwarded to the next.



The surgical treatment of GERD. (Fundoplication).
Patients the best treatment is surgery. Patients with chest pain or a burning sensation is a symptom Belching. And has been confirmed as a true acid reflux disease, endoscopy, or measurement of acid in the esophagus. And was treated with antacids, then this works well and no abnormal compression of the esophagus. While patients with non-specific symptoms of disease, acid reflux, and has not been confirmed as a true acid reflux disease and esophageal or gastric slow motion with systolic dysfunction is likely. It does not react well to the surgery is high. The most popular surgery is Nissen fundoplication. The results of surgery depend on many factors. It is the expertise of the surgeon. Side effects of surgery include cutting the vagus nerve injury, the spleen is splenectomy. The band of operation. dysphagia and gastroesophageal junction packed. Can not vomit or burp out to have very slow distension. The surgery should be considered carefully.


Summary.
Acid reflux disease is a common disorder in clinical practice. In the past, that are rarely found in the clinical features of Thai patients with chest pain less burning than patients in Western countries. Belching is a common symptom that patients trusted in Thailand. Patients with signs or symptoms and Belching is a burning chest pain or chest pain, not only as a heart attack or symptoms of ear, nose and throat and an unknown disease.

The initial diagnosis based on clinical trials and treatment with proton pump inhibitors reduce acid group. The endoscopy in upper gastrointestinal tract is useful in assessing the severity of esophageal inflammation and complications. The separation of the upper gastrointestinal tract that can cause. Acid reflux symptoms are similar to that. The other measurements such as measuring the pH in the esophagus or gastric acid and non-acid reflux into the esophagus. (Multichannel intraesophageal impedance-pH monitoring) is useful in patients who do not know the exact diagnosis. Patients like symptoms. Acid reflux treatment, but not better. GERD patients are treated by surgery.

Treatment and behavior modification. The risk of causing acid reflux, and antacids increase the crease proton pump inhibitor. The sphincter covering the esophagus treated by surgery to tighten up or down. fundoplication. Should be considered as a last resort, surgeons who specialize in those with only