Reflux disease (reflux esophagitis)

Reflux esophagitis (reflux disease) is an inflammation of the esophagus. The disease is caused by the reflux of acidic gastric juice (acid reflux) into the oesophagus. A common cause of acid reflux is failure of the esophageal sphincter (sphincter muscle at the entrance to the stomach). The condition is also known colloquially as chronic heartburn.

The inflammation mainly affects the lower section of the oesophagus, as this part opens directly into the stomach. Chronic reflux esophagitis (recurrent esophagitis) carries the risk of developing esophageal cancer over time due to the ongoing inflammatory process.

About one in five people in western industrialised countries suffer from reflux disease. All age groups - including babies and children - can be affected. According to observations, both the frequency of reflux esophagitis and the frequency of the rare secondary disease esophageal cancer are increasing.

The cause of reflux disease is a failure of the esophageal sphincter (sphincter between the stomach and esophagus), which allows the acidic contents of the stomach to flow back into the esophagus. Chronic inflammation of the esophageal mucosa develops as a result of the constant exposure to stomach acid.

Reflux esophagitis can have several underlying causes:

• The esophageal sphincter (sphincter between the stomach and esophagus) is too weak and therefore does not close sufficiently.
• The opening of the oesophagus through the diaphragm is too large.
• The closure of the stomach towards the oesophagus is prevented by anatomical conditions.

The exact reason why the sphincter between the stomach and the oesophagus is too weak in some people is not yet known. However, it is known that additional factors such as obesity, nicotine, alcohol and special medications increase the risk of reflux esophagitis.

In addition, reflux disease can occur in women towards the end of pregnancy, as the stomach is pushed upwards by the unborn baby, causing some stomach contents to flow back into the oesophagus. About one in two women suffer from reflux esophagitis during the last trimester of pregnancy.

A characteristic symptom of reflux esophagitis is heartburn. This is understood as burning pain radiating from the bottom to the top behind the breastbone. The heartburn occurs especially often at night when sleeping, because the affected person lies flat in bed, which makes it easier for the gastric juice to flow back into the esophagus.

In addition, the following complaints can be a sign of reflux disease:

• A feeling of pressure in the chest (behind the breastbone)
• Belching of air
• A soapy or salty taste in the mouth after regurgitation
• Discomfort when swallowing
• Nausea and vomiting
• Heartburn
• Reflux of food residues

Stomach acid can also pass through the esophagus into the airways, causing conditions such as:

• Sinusitis (inflammation of the paranasal sinuses)
• Pharyngitis (inflammation of the larynx)
• hoarseness
• chronic cough
• chronic bronchitis

During the anamnesis (medical consultation), the description of the characteristic symptoms of reflux esophagitis gives the doctor a first indication of the disease. However, chest pain can also be caused by numerous other diseases, which must first be excluded by various examinations.

With the help of a gastroscopy , the mucosal changes of the oesophagus can be made visible, whereby a reliable diagnosis of reflux oesophagitis can be made. In addition, tissue samples can be taken during gastroscopy (biopsy), the microscopic examination of which further consolidates the diagnosis.

In rare cases, a so-called long-term pH-metry is performed. This is an acid measurement in the oesophagus over a period of 24 hours. To carry out the measurement, a capsule approximately three centimetres long is inserted into the mucous membrane of the oesophagus during a gastroscopy. The capsule then measures the acid concentration and transmits the values via radio to a recording device.

Own measures

Before initiating therapy for reflux disease, or for other stomach complaints in general, it makes sense to first reduce the risk of reflux esophagitis by taking general measures:

• In case of overweight a weight reduction
• Avoidance of coffee, alcohol and nicotine
• No large meals before going to bed
• Instead of a few large meals, it is better to eat several small portions throughout the day.
• No strongly spiced or acidic foods
• Sleep in a bed with the head end raised

Stages of reflux esophagitis

The treatment of reflux disease depends on the stage of the disease:

• Non-erosive reflux disease: this is a reflux disease in which there is not yet any injury to the esophageal mucosa. Proton pump inhibitors, antacids and prokinetics are recommended for therapy. Non-erosive reflux disease is the most common form of the disease.
• Erosive reflux disease: If there are already lesions of the oesophageal mucosa, proton pump inhibitors are the drug of choice. In most cases, the symptoms disappear within two weeks.
• Barrett's oesophagus: If cell changes have already occurred in the mucous membrane of the oesophagus, this is known as Barrett's oesophagus. In this case, the risk of developing esophageal cancer is increased. Patients without symptoms do not require any special treatment, but the oesophageal mucosa must be examined regularly for malignant changes. Proton pump inhibitors can be used to alleviate any symptoms, but the risk of cancer is not affected.

Drug therapy

Stomach acid inhibitors can be used to effectively alleviate the symptoms:

• Antacids: Antacids are used to neutralize stomach acid, providing temporary relief of symptoms. These preparations are available over the counter and may also be suitable for the treatment of pregnancy reflux disease. Because the stomach compensates for antacid therapy over time by increasing stomach acid production, long-term therapy is not indicated.
• Histamine H2 receptor blockers: These agents block the histamine receptor, which the body uses to regulate the production and release of stomach acid. In this way, the acid in the stomach is reduced.
• Proton pump inhibitors: These drugs inhibit an enzyme in the stomach lining that is responsible for transporting stomach acid to the inside of the stomach. Since this enzyme is mainly produced in the morning, the preparations must be taken in the morning. Since proton pump inhibitors act specifically on the gastric mucosa and cause relatively few side effects, these agents represent the standard in long-term therapy.

Taking prokinetics stimulates the peristalsis (muscle movements) of the stomach and intestines, which results in faster removal of gastric acid from the stomach to the intestines. In addition, the function of the esophageal sphincter (sphincter between the stomach and esophagus) is improved. Prokinetics are mainly used for nausea and vomiting.

Stomach discomfort is often accompanied by flatulence as well as a feeling of fullness . These complaints can be alleviated by numerous active substances available over the counter, for example by drops or teas with mixtures of anise, caraway and fennel.

If chronic reflux disease cannot be adequately treated with medication, the symptoms can be remedied by surgery. This involves a procedure known as hiatoplasty, in which the function of the sphincter between the oesophagus and the stomach is restored, thus preventing the backflow of gastric acid. This procedure is normally performed in a minimally invasive manner during laparoscopic surgery.

In radiofrequency therapy , the sphincter muscle between the oesophagus and stomach is heated using a special catheter with the aid of radio waves. This heating causes a permanent thickening of the connective tissue, which prevents the stomach acid from flowing back into the oesophagus. In some cases, however, patients must continue to take antacid medication despite radiofrequency therapy.

Consistent adherence to therapy can in most cases alleviate the symptoms of reflux esophagitis.

If cell changes have already occurred in the oesophageal mucosa due to the ongoing inflammatory process (Barrett's oesophagus), the risk of developing oesophageal cancer is increased. As a rule, a gastroscopy is then performed every three years as part of a check-up in order to detect any malignant cell changes at an early stage.

Adhering to the following measures can reduce the risk of reflux disease:

• No smoking
• Alcohol consumption only in small quantities
• Weight reduction in case of overweight
• No fatty foods
• Eating only small portions before going to bed
• Avoid strongly spiced or acidic foods