Etiopathogenesis and risk factors
GERD is classified as a multifactorial disease. Its trigger factor is gastroesophageal reflux (GER). It is important to distinguish between physiological GER (a variant of normal, occurs after eating, without mucosal damage) and pathological GER (frequent, independent of eating, causes reflux esophagitis).
The pathogenesis is based on an imbalance between "aggression" factors (gastric contents) and "defense" factors (esophageal mucosal resistance). Key mechanisms:
- Incompetence of the cardiac sphincter.
- Impaired esophageal clearance (self-cleaning).
- Dysmotility of the gastroduodenal zone.
These disorders are often caused by autonomic nervous system dysfunction. The disease develops against the background of predisposing factors (obesity, connective tissue dysplasia, sliding hiatal hernia).
Provoking triggers:
- Mechanical: increased intra-abdominal pressure (constipation, bending over).
- Alimentary and toxic: diet errors, alcohol, smoking.
- Respiratory: bronchial asthma, cystic fibrosis, frequent bronchitis.
- Iatrogenic: medications that reduce sphincter tone (anticholinergics, sedatives, beta-blockers, nitrates).
Clinical presentation
The symptoms of GERD are diverse and divided into two major groups:
- Esophageal symptoms: classical manifestations such as heartburn, regurgitation (backflow of food), air eructation, swallowing disorders (dysphagia), periodic retrosternal pain, and the characteristic "wet pillow" sign (stains on the pillow after sleep).
- Extraesophageal symptoms: mask other pathologies. They include dental enamel erosion, bronchopulmonary lesions, ENT disorders, and cardiovascular diseases.
Clinical feature: the severity of reflux is directly related to cerebrasthenic manifestations — sleep disorders, weather sensitivity, and emotional lability.
Instrumental diagnostics and classification
The diagnosis is established based on clinical presentation but requires mandatory instrumental confirmation. The baseline method is EGD (endoscopy). Broadly, there are 3 forms: non-erosive, erosive, and Barrett's esophagus.
Endoscopic grades of esophageal injury:
- Grade I: focal hyperemia in the distal section. Prolapse of the walls by 1–2 cm only upon provocation.
- Grade II: total hyperemia, the appearance of single non-confluent erosions. Wall prolapse up to 3 cm.
- Grade III: multiple confluent erosions. Spontaneous (unprovoked) wall prolapse.
- Grade IV: formation of complications (chronic ulcer, Barrett's esophagus with intestinal metaplasia, stenosis).
Additionally, 24-hour pH monitoring (to assess the severity of episodes), esophagotonokymography (assessment of lower esophageal sphincter tone), and radiography (to exclude anatomical anomalies) are used.
Principles of treatment
Treatment begins with baseline non-pharmacological correction. Postural therapy (sleeping with the head of the bed raised by 10–15 cm, feeding infants at an angle of 45–60°) and diet therapy are used. For children over 1 year of age, whole milk is replaced with low-lactose alternatives, while fermented dairy products are well tolerated.
Pharmacological tactics depend on the endoscopic picture:
- Endoscopically negative variant: emphasis on normalizing motility and relieving symptoms. Liquid antacids (gels, suspensions), anti-reflux agents (alginates), and prokinetics (domperidone, trimebutine) are prescribed.
- GERD with reflux esophagitis: first-line drugs are proton pump inhibitors (PPIs) in age-appropriate dosages. Antacids and prokinetics are used as adjunctive therapy.
Since the nervous system is involved in the genesis of the disease, therapy is often carried out in conjunction with a neurologist using neurotropic agents (vasoactive drugs, nootropics, glycine). In complicated cases in infants with profuse vomiting (risk of dehydration and malnutrition), nutritional support with elements of parenteral nutrition is indicated.
To memorize the provoking triggers of GERD, use the acronym MARP: Mechanical (constipation, bending), Alimentary (diet, smoking), Respiratory (asthma, cystic fibrosis), Pharmacological/Iatrogenic (drugs reducing tone).
Class and exam questions
In which cases is a biopsy mandatory during endoscopy?
Histological examination is indicated when radiography and endoscopy data are discrepant, in atypical esophagitis, suspected metaplasia (Barrett's esophagus), detection of papillomatosis, or suspected malignant transformation.
How does physiological reflux differ from pathological reflux?
Physiological reflux is a variant of normal, occurs after eating, is asymptomatic, and does not damage the mucosa. Pathological reflux is frequent, occurs at any time of day, and consistently leads to the development of reflux esophagitis.
Is H. pylori eradication therapy prescribed for all GERD patients?
No, Helicobacter pylori infection is not critical in the pathogenesis of GERD, so anti-Helicobacter therapy is performed strictly according to individual indications.
What else to study on this topic
- Mechanisms of formation and clinical significance of Barrett's esophagus
- Extraesophageal masks of GERD: differential diagnosis with bronchial asthma and ENT pathology
- The role of autonomic dysfunction in gastroduodenal zone motility disorders
- Features of nutritional support and selection of anti-reflux formulas in infants
- Pharmacodynamics and age restrictions of proton pump inhibitors (PPIs) in pediatrics
Master the entire topic in the Pediatrics course
This is a summary. The course covers everything tested in classes and exams.
- Complete guidelines on "Gastroesophageal reflux disease" and 3,738 more pages of the subject
- Assignments and quizzes after every topic — just like in a colloquium
- AI tutor answers questions on the topic anytime
- 71 video lessons on the subject
Other topics in "Chapter 7. Digestive System Diseases"
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