[Pathological physiology of gastroesophageal reflux disease. Hypothesis (Literature review)].

UNLABELLED

Currently prolonged pH-monitoring is considered as Gold standard for diagnosis of Gastro Esophageal Reflux Disease (GERD). Criteria and norms based on prolonged pH-monitoring were the basic concepts of pathophysiology of GERD. For example, it is accepted that esophageal hernia (EG) can be present without GERD, as well as GERD without EG. X-ray diagnosis compared to the pH- monitoring has a low sensitivity (70%) and specificity (74%). Meanwhile, in recent decades, it has been found that the pH-metry is not effective in a non-erosive reflux disease. We figured that the criteria and norms of pH-monitoring are not accurate. The purpose of this study is to determine the radiological norms of gastroesophageal junction (EGJ) and, to clarify the pathological physiology of GERD according to the new criteria and analysis of the literature.

MATERIAL AND METHOD

The analysis of the survey of 452 patients was done. Among them were 263 children aged from 1 day to 15 years who have applied to the Belarusian Center of Pediatric Surgery (BCPS) in 1983-1987 and 189 patients aged 15-92 years surveyed in the BCPC, as well as in the Government Geriatric Center (Israel) in 1994-2004. The standard radiography of the upper digestive tract was supplemented by provocative tests. In 21 children and 36 adults survey was carried out to locate space-occupying lesions of the chest or abdomen. Other patients had symptoms of GERD.

RESULTS

The 21 children and 17 of 34 adult patients without of GERD symptoms had the same radiographic picture, indicating of the normal LES function: the width of the esophagus was the same all over and no more than 1.5 cm; in a horizontal position a peristaltic wave opens the LES and pushes its contents into the stomach without delay, despite the provocative tests. In 15 out of 34 adults with no symptoms of GERD radiographic findings show signs of LES weakness. In these patients, with a mild GERD, abdominal compression caused contraction of the GEJ with length of (3.60 +/- 0.8 cm) in adults which corresponds to the length of the LES, according to the manometric studies. A rounded cavity (phrenic ampoule) is formed above the contracted LES when the functional'proximal sphincter' (PS) is closed cranially. When, during the am ampoule contraction the pressure in it reaches a threshold level, LES is opened, and the ampoule injects its contents into the stomach. Inflammation of the esophageal wall leads to the gradual ampoule expansion. With a width of the ampulla 2 cm and more we found no evidence of the displacement of the stomach into the chest cavity. The radiological symptoms of GERD are described, the identification of which at rest and during provocation, can be used for grading the antireflux function impairment of LES.

CONCLUSION

1. In GERD the last peristaltic wave expands, forming a phrenic ampoule, which is closed cranially by the PS. 2. The width of the ampoule is proportional to the stages of GERD. This means that ampoule as well as the so-called esophageal hernia are symptoms of GERD. 3. During the ampoule formation the inner surface of it increases by at least to 11 cm2. The deficit of the mucosa is compensated by the motion of the mucosa from GEJ. The shortening of the longitudinal muscle during the ampulla contraction does not significantly affect the length of the esophagus. 4. Transient LES relaxation is caused by a deficiency of the LES capacity.