wèi shí guǎn fǎn liú jí fǎn liú xìng shí guǎn yán
2 Classification of DiseasePediatrics
3 Disease OverviewReflux esophagitis is a digestive inflammation of the esophageal mucosa caused by reflux of gastric and duodenal contents into the esophagus. The main symptoms are acid swallowing, acid spitting, burning discomfort or burning pain behind the sternum, and swallowing disorders.
Treatment:
1. Antacids;
2. Acid suppressants: the main drugs used in the treatment of this disease, (1) cimetidine (2) famotidine (3) omeprazole: (4) ranitidine:
3. Gastric motility medications: (1) domperidone (2) mecaropramide: (3) cisapride:
4. Gastric mucosal protectant: aluminum sulfate: 1g each time, 4 times a day, 2-3 hours after meals, need to be chewed and swallowed.
4 Description of the diseaseGastroesophageal reflux (GER) is the reflux of gastric contents, including bile salts and pancreatic enzymes from the duodenum into the stomach, into the esophagus. The symptoms resolve spontaneously in 60% of children by the age of 2 years with increased upright *** time and solid diets, and in some children the symptoms may persist beyond the age of 4 years. Children with cerebral palsy, trisomy 21, and other causes of developmental delay have a higher incidence of GER.
5 Symptoms1. Vomiting
Vomiting is the main manifestation in newborns and infants, with 85% of children experiencing vomiting in the first week of life, and 10% of children experiencing symptoms within 6 weeks of birth. The degree of vomiting varies, mostly after eating, sometimes at night or on an empty stomach, and in severe cases, it is projectile vomiting. The vomit is stomach contents, sometimes containing a small amount of bile, but also manifested as milk, regurgitation or vomiting foam. Older children with regurgitation, acid reflux, belching and other symptoms are common.
2, reflux esophagitis
The usual symptoms are ① heartburn: seen in expressive older children, located in the lower end of the sternum, drinking acidic beverages can worsen the symptoms, take antacids to reduce the symptoms, ② pain in the throat: infants and young children show difficulty in feeding, irritability, refusal to eat, older children complain of pain in the throat, such as the complication of esophageal stenosis, then there is a serious vomiting and persistent difficulty in swallowing, ③ Vomiting blood and blood in stool: in severe cases of esophagitis, erosion or ulceration may occur, and symptoms of vomiting blood or black stool may occur. Iron deficiency anemia can occur in severe reflux esophagitis.
3, Barrette's esophagus
Due to chronic GER, the squamous epithelium at the lower end of the esophagus is replaced by hyperplastic columnar epithelium, which has an increased resistance to acidity, but is more prone to esophageal ulcers, strictures and adenocarcinomas, and esophagotracheal fistulae can occur in cases where the ulcers are deeper.
4, other systemic symptoms
(1) respiratory diseases: the flow of direct or indirect can trigger recurrent respiratory tract infections, aspiration pneumonia, refractory asthma, preterm infants asphyxia or apnea, and sudden infant death syndrome.
(2) malnutrition: seen in about 80% of the children, mainly manifested in weight gain and growth retardation, anemia.
(3) other: such as hoarseness, otitis media, sinusitis, recurrent oral ulcers, dental caries, etc., some children can appear mental, neurological symptoms: ① Sandifer syndrome: refers to the pathology of GER children present similar to the sloping neck of a special "rooster head" posture, which is a protective mechanism to maintain airway patency. This is a protective mechanism to keep the airway open or reduce the pain caused by acid reflux, accompanied by pestle branch, protein-losing enteropathy and anemia. ② Infantile crying syndrome: manifested as irritability, night terrors, and crying during feeding.
6 Etiology of diseasePhysiological and pathological. Physiological conditions, due to the immaturity of the lower esophageal sphincter (LES) or poor neuromuscular coordination of small infants, reflux can occur, often in the gradual meal or after meals, also known as "breast milk". Pathological reflux is due to dysfunction of the LES and/or abnormalities in the tissue structure related to its function, resulting in reflux under the LES pressure, which often occurs during sleep, supine position, and fasting, causing a series of clinical symptoms and complications, i.e., gastroesophageal reflux disease (GERD).
7 Pathophysiology1. Low function of the anti-reflux barrier
(1) Decreased LES pressure is the main cause of GER. During normal swallowing, the LES reflexively loosens and the pressure drops, which pushes the food into the stomach through esophageal peristalsis, and then the pressure returns to the normal level, and there is a reactive pressure increase to prevent food reflux. When the intravascular pressure and intra-abdominal pressure increase, the LES briefly relaxes, which can lead to the reflux of gastric contents into the esophagus;
(2) weakening of the role of tissues around the LES, for example, the lack of abdominal segment of the esophagus, resulting in the increase of intra-abdominal pressure can not be transmitted to the LES so that the LES contraction to achieve the effect of anti-reflux, the small infants with a large esophageal angle (formed by the esophagus and the cardia of the stomach, i.e., the angle of his angle) (the normal is 30 ℃ ~ 50 ℃), the diaphragm esophageal clamping effect is weakened, the diaphragmatic esophageal ligament and the lower esophageal mucosal flap of the anatomical structure of the presence of organic or functional lesions, as well as the intragastric pressure, intra-abdominal pressure increases, etc., can destroy the normal anti-reflux function.
2, esophageal contouring ability to reduce
Under normal circumstances, the esophageal contouring ability is dependent on the esophagus to promote peristalsis, saliva flushing, degree of acid neutralization, the gravity of the esophageal pills and the esophageal mucosal cell secretion of bicarbonate and other factors to play its role in the removal of reflux to shorten the reflux and the esophageal mucosa of the contact time. When esophageal peristalsis weakens or disappears, or when pathological peristalsis occurs, the ability of the esophagus to remove reflux decreases, which prolongs the residence time of harmful reflux material in the esophagus and increases the damage to the mucosa.
3, the barrier function of the esophageal mucosa is damaged
The barrier function is composed of the mucus layer, intracellular buffer, cellular metabolism and blood supply **** with the composition. Some substances in the reflux, such as gastric acid, pepsin, and bile salts and pancreatic enzymes from the duodenum refluxed into the stomach make the barrier function of the esophageal mucosa impaired, causing inflammation of the esophageal mucosa.
4. Gastric and duodenal malfunction
Low gastric emptying capacity increases gastric contents and its pressure, and when the intragastric pressure increases beyond the LES pressure, it can open the LES. Increased gastric volume in turn leads to gastric dilatation, resulting in the shortening of the cardia-esophageal segment, which reduces its anti-reflux barrier function. In duodenal disease, pyloric dilatation and insufficient closure can lead to duodenal reflux.
8 Diagnostic testsThe clinical manifestations of GER are complex and lack specificity, and it is sometimes difficult to distinguish GER from other diseases that cause vomiting on the basis of clinical evidence alone, and it is difficult to distinguish GER from other diseases that cause vomiting, and it is difficult to distinguish GER from other diseases that cause vomiting from other diseases that cause vomiting from other diseases that cause vomiting from other diseases. Any clinical findings of unexplained recurrent vomiting, dysphagia, recurrent chronic respiratory infections, refractory asthma, growth retardation, malnutrition, anemia, recurrent asphyxia, apnea and other symptoms should be taken into account when the possibility of GER is considered, and for different cases, the necessary auxiliary tests should be selected to clarify the diagnosis.
Ancillary tests:
1. Barium esophagography
It can determine the morphology of the esophagus, its motion, the reflux of barium, and the tissue structure of the esophagus in connection with the stomach, and it can also observe congenital disorders such as hiatal hernia and the inflammatory changes of the esophageal mucosa in severe cases.
2. Dynamic monitoring of esophageal pH
The microelectrode is placed above the sphincter, and the pH of the lower esophagus is continuously monitored for 24 hours, and the pH decreases if acidic GER occurs, and the frequency and duration of GER, the retention of regurgitant material in the esophagus, and the relationship between regurgitation and activities and clinical symptoms can be analyzed by the computer software, and the physiological and clinical symptoms can be differentiated by the help of some scoring criteria. With the help of some scoring criteria, it can distinguish between physiologic and pathologic reflux, which is the most reliable diagnostic method at present. It is the most reliable diagnostic method at present. It is especially used in patients with atypical symptoms to determine GER and duodenal gastroesophageal reflux when the pH of the lower esophagus does not fall.
3, esophageal power function examination
Application of low-compliance perfusion catheter system and endoluminal micro-infection of its catheter system and other pressure measurement equipment, to understand the esophageal movement and LES function, for LES pressure normal children should be continuous pressure, dynamic observation of esophageal motor function.
4, esophageal endoscopy and mucosal biopsy
can determine the presence of esophagitis lesions and Barrette's esophagus, endoscopic esophagitis can be divided into 3 degrees: 1 degree of congestion, 2 degrees of erosions and/or shallow ulcers, and 3 degrees of gastric ulcers and/or strictures.
5. Gastro-esophageal isotope scintigraphy
Oral or intragastric injection of liquid containing 99mTc labeling, the application of γ camera to determine esophageal reflux, can understand the esophageal motor function, and clarify the relationship between respiratory symptoms and GER.
6, ultrasonography
B-mode ultrasound can detect the length of the abdominal segment of the esophagus, the status of the mucosal texture, the anti-reflux effect of the esophageal mucosa, and at the same time, can detect the presence of esophageal hiatal hernia.
9 TreatmentAll children diagnosed with GER, especially those with comorbidities or those who affect growth and development must be treated promptly. This includes *** treatment, dietary therapy, medication and surgery.
1, *** treatment
The best *** for newborns and small infants is to lean forward in the prone position, with the upper body elevated by 30 degrees. The best *** for children in awake state is upright position and sitting position, keep the right side lying position during sleep, raise the head of the bed 20-30cm to promote gastric emptying, reduce the frequency of reflux and reflux material aspiration.
2, dietary therapy
to thick diet, small meals, infants to increase the number of breastfeeding. Shorten the interval between feedings, artificial feeding children can be added to the milk cake dry powder, rice flour or eat cereals, older children should also be a small number of meals, high protein low-fat diet is the main focus of the two hours before bedtime, do not eat, to keep the stomach in a non-full state, avoid eating to reduce the LES tension and increase the secretion of gastric acid food, such as acidic beverages, high-fat diet, chocolate and spicy food.
3, drug therapy? Including three categories, namely, gastrointestinal stimulants, antacids or acid inhibitors, and mucosal protectants
(1) Gastrointestinal stimulants: they can improve LES tone, increase esophageal and gastric peristalsis, improve esophageal contouring ability, and promote gastric emptying, thus reducing the reflux and the retention time of the regurgitant material in the esophagus. ① Dopamine receptor antagonist: domperidone (morphine) is a selective, peripheral dopamine D2 receptor antagonist, which normalizes peristalsis and tone in the upper part of the gastrointestinal tract, promotes gastric emptying, increases gastric sinus and duodenal motility, coordinates pyloric contraction, and enhances esophageal peristalsis and LES tone, with the usual dose of 0.2-0.3 mg/kg each time, three times a day. The usual dose is 0.2-0.3mg/kg per time, 3 times a day, half an hour before meal and at bedtime. ② Drugs acting through acetylcholine: Cisapride (Prevacid) is a new type of total gastrointestinal dynamics agent, which is a derivative of toluramide and has no cholinergic or anti-dopamine effect. It mainly acts on the 5-hydroxytryptamine receptors of the intestinal muscular layer nerves from the motor neuron, increases the release of acetylcholine, and thus induces and strengthens the physiological movement of the gastrointestinal tract, and the usual dosage is 0.1-0.2mg/kg per time, 3 times/day orally.
(2) antacid and acid-suppressing drugs: the main role is to inhibit acid secretion, neutralize gastric acid to reduce the damage of reflux on the esophageal mucosa, improve the LES tension, ① acid-suppressing drugs: H2 receptor antagonists (H2-receptor blockers) commonly used cimetidine, ranitidine, proton pump inhibitor (PPI) omeprazole (Losec) ② neutralize the release of acetylcholine, thus inducing and strengthening the physiological movement of the gastrointestinal tract. Losec) ② neutralization of gastric acid drugs: such as aluminum hydroxide gel, mostly used in older children.
(3) mucosal protective agents: such as aluminum sulfate, aluminum silicate, aluminum phosphate. (2, 3 two drug treatment see this chapter, section V, peptic ulcer disease treatment)
(4) Surgical treatment: the above treatment, most of the children's symptoms can be significantly improved and healed. Surgery can be considered with the following indications: ① 6-8 weeks of medical treatment is ineffective, there are serious complications (gastrointestinal bleeding, malnutrition, growth retardation) ② severe esophagitis with ulcers, stenosis, or found to have an esophageal hiatal hernia, ③ serious respiratory complications, such as respiratory obstruction, recurrent episodes of inhalation pneumonia or asphyxia, accompanied by bronchopulmonary dysplasia, ④ serious neurological disorders. Combined serious neurological diseases.
10 Special tipsPatients with reflux esophagitis should maintain a good psychological state, avoid or overcome worry and anger and other bad ***. Do not smoke or drink, eat regular meals, diet to high protein, high fiber, low fat-based, small meals, avoid satiety, should also pay attention to the postprandial should be upright, should not be lying down, 2 ~ 3 hours before bedtime should not eat, should not eat spicy food, strong tea, coffee and other acidic foods and drinks, in order to reduce the amount of gastric acid secretion.
GERD is a chronic and highly recurrent disease that should be treated over time.
Acupuncture points for GERD and reflux esophagitis Upper Epigastric Pipe, jaundice, running dolphin, dizziness, dizziness, stroke, stroke, gastroptosis, esophageal spasms, coughing and phlegm, accumulation, consumptions and vomiting of blood, spasm of septum, enteritis, etc. ...
Upper epigastric cavity, jaundice, dizziness, dizziness, cardiac pain, stroke, gastroptosis, esophageal spasm, cough and phlegm, accumulation of sputum, consumption and vomiting of blood, spasm of septal muscles, enteritis, etc. ...
The tracheais a long, flat, narrow, muscular tube, the upper end of which is connected to the pharynx at the lower edge of the sixth cervical vertebrae, and to the gastric cardia at the lower end, which is twice as long as the trachea, and the upper esophagus is slightly behind the trachea ...
Shang Ji, jaundice, Ben Dolphin, dizziness, dizziness, stroke, stroke, gastric ptosis, esophageal spasm, cough and phlegm, accumulation, consumption and vomiting of blood, spasm of the septum muscle, intestinal inflammation, etc. ...
Atrium