Digestive Discomfort: Causes and Remedies - Gastroenterology and Hepatology

Dr. Cai Yaozhou reply Gastroenterology and Hepatology

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The primary examination is endoscopy.
Its purpose is to exclude other potential upper gastrointestinal diseases that the patient may have, as some symptoms of tumors and peptic ulcers often overlap with gastroesophageal reflux disease (GERD), making it difficult to accurately differentiate based solely on symptoms.
Additionally, during the endoscopic examination, attention should be focused on the gastroesophageal mucosal junction to observe for any damage, redness, inflammation, ulcers, strictures, gastric mucosal metaplasia, and hiatal hernias.
The examiner should document the degree of esophagitis as a basis for future healing or lack thereof.
The latest classification of esophagitis uses the Los Angeles classification system established in 1994, which is simple, easy to remember, and has clear boundaries for each grade.
However, more than half of the cases may not show endoscopically visible esophagitis, which can lead to diagnostic challenges, even causing clinicians to question whether a misdiagnosis has occurred.
These cases without esophagitis are referred to as endoscopy-negative gastroesophageal reflux disease.
If other diagnostic tools, such as a 24-hour pH monitoring, are used to analyze the correlation between acid reflux and symptom occurrence, their relationship can still be demonstrated.
It is currently hypothesized that the sensory nerves at the lower esophagus in these patients are more sensitive, easily triggered by the reflux of acidic contents, leading to significant symptoms.
The treatment for these cases should follow the same principles as for patients with esophagitis.

Why do patients with gastroesophageal reflux need treatment? As defined, these patients suffer from the discomfort of acid reflux, which affects their daily lives and causes anxiety, thus requiring treatment to alleviate their symptoms.
Furthermore, long-term severe esophagitis can lead to strictures at the lower esophagus, resulting in dysphagia.
It is now believed that a portion of esophageal adenocarcinoma and gastric cardia cancer is caused by chronic acid reflux, necessitating treatment to prevent these serious complications.
Principles of Gastroesophageal Reflux Treatment
The first focus of treatment should be on lifestyle modifications.
Overweight individuals may increase abdominal pressure, slow gastric emptying, and have a higher likelihood of hiatal hernias, exacerbating reflux symptoms; therefore, patients should aim for appropriate weight loss.
Generally, physiological gastroesophageal reflux occurs less frequently when lying flat at night, so reflux symptoms are also less likely to occur during sleep.
If this phenomenon occurs, patients should avoid sleeping on their right side and elevate their heads with pillows to reduce the frequency of episodes.
When selecting foods, patients should consider the following side effects: those that can increase gastric volume and the likelihood of bloating and acid reflux, delay gastric emptying, decrease lower esophageal sphincter tone, or directly irritate the esophageal mucosa.
Therefore, patients should avoid overeating, especially avoiding binge eating before bedtime, and minimize the intake of fatty foods.
Chocolate, mint, spicy foods, onions, tomatoes, and their products should also be limited.
Various alcoholic beverages, citrus juices, tomato juice, coffee, and even cola are considered irritating to the esophageal mucosa and should be avoided as much as possible.
Smoking can also reduce lower esophageal sphincter tone and should be discontinued.
Excessive exercise may impair esophageal motility and acid clearance, so patients who are not physically trained should be cautious of this effect.
If patients are taking other medications such as progesterone, prostaglandins, anticholinergics, certain antihypertensives, Parkinson's disease medications, sedatives, analgesics, calcium channel blockers, or bronchodilators, they should consider that these medications may lower lower esophageal sphincter tone and increase reflux.
Gastroesophageal reflux disease still requires consideration of pharmacological treatment, as lifestyle modifications alone may not completely eliminate symptoms.
Treatment can also be seen as a means of accurate diagnosis, especially valuable for patients with negative endoscopy findings, as it can alleviate symptoms, reduce patient distress and anxiety, improve quality of life, and decrease the likelihood of various complications.
Currently, there are many available medications, and generally, the symptomatic relief often outweighs the actual healing of esophagitis.
Patients most desire significant symptom relief to improve their quality of life.
Antacids are commonly used by patients attempting self-treatment, but their efficacy is limited, and only a few patients may experience symptom relief.
Gastrointestinal prokinetics like cisapride aim to enhance gastric emptying, promote esophageal motility, and increase lower esophageal sphincter tone, with about half of the patients experiencing significant symptom improvement.
Additionally, direct acid secretion suppression is a treatment trend; H2 receptor antagonists can lead to symptom improvement in 50-70% of patients.
There are also developments in chewable antagonists that not only suppress acid through oral absorption but also increase saliva secretion through chewing, enhancing the protective function of the esophageal mucosa.
Proton pump inhibitors, developed in the 1980s, can completely inhibit acid secretion from parietal cells, significantly improving the efficacy of gastroesophageal reflux treatment.
Generally, the rates of symptom elimination and esophagitis healing can reach over 80%, making them an ideal treatment option.
The laparoscopic surgery introduced in the 1990s allows surgeons to encircle the lower esophagus with the fundus of the stomach via laparoscopy, increasing resistance at this site and reducing reflux.
This surgery is also an effective treatment.
For certain patients who require long-term medication, have respiratory complications, or exhibit columnar cell metaplasia in the esophageal mucosa, surgical treatment may be considered.
However, potential postoperative complications such as upper abdominal fullness, difficulty belching, and significant weight loss must also be taken into account.
Patients deciding whether to undergo surgical treatment should consider and understand the respective advantages and disadvantages of both medication and surgical treatments, obtaining final consent as an effective treatment approach.
With the advancement of social civilization, people's standards for health have increased.
Gastroesophageal reflux disease has become a fashionable civilization disease.
Currently, the most important understanding of this condition is how to accurately diagnose and appropriately treat it with medication, while also closely monitoring potential sequelae such as strictures and tumors.
The goal of any treatment is to improve the patient's quality of life, and whether to ultimately opt for laparoscopic surgery for a permanent solution depends on thorough communication and understanding between the internal medicine and surgical physicians and the patient before making this decision.

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Reply Date: 2007/01/28