Elderly gastroesophageal reflux disease

　　There are many factors that can cause esophageal damage, which can be summarized as:
　　1. Hiatal hernia:For more than 40 years, the role of hiatal hernia in the pathogenesis and pathophysiology of gastroesophageal reflux has been a hot topic of research.
　　2. Obesity:The relationship between obesity and GERD is not clear, and there is no definitive conclusion on whether obese patients are more prone to hiatal hernia. There are many studies on the relationship between obesity and factors such as hiatal hernia, esophagitis, gastric emptying, and pH monitoring.
　　3. Alcohol:Alcohol can suppress the acid clearance ability of the esophagus, damage esophageal motility, and lower LES pressure.
　　4. Smoking:Smoking can prolong the acid clearance time of the esophagus due to reduced saliva production. Even without reflux symptoms, the acid clearance time of smokers is 50% longer than that of non-smokers; the HCO-3 content in the saliva of smokers is only 60% of that of non-smokers of the same age. The reduction in saliva production in smokers is due to anticholinergic effects, similar to patients who apply anticholinergic drugs and experience reduced saliva. Esophageal pressure measurements show that smoking two cigarettes consecutively causes a decrease in LES pressure, which returns to normal within 2 to 3 minutes after smoking cessation.
　　5. Drugs:Many drugs affect the function of the esophagus and stomach, causing reflux to occur. The effects of these drugs are mainly to change the lower esophageal sphincter (LES) pressure, affect esophageal motility, and delay gastric emptying.
　　6. Helicobacter pylori:Many studies have observed the relationship between Helicobacter pylori and GERD. Most studies show that this pathogen is not related to GERD.

　　Common complications of elderly GERD mainly include the following 3 types:

　　1. Upper gastrointestinal bleeding

　　Patients with reflux esophagitis may have hematemesis and/or melena due to esophageal mucosal inflammation, erosion, or ulcers. Continuous minor bleeding from the esophageal mucosa can lead to mild iron deficiency anemia; ulcers can occasionally cause massive bleeding.

　　2. Esophageal stricture

　　Long-term and repeated gastroesophageal reflux can lead to esophagitis, causing fibrous tissue proliferation and loss of compliance in the esophageal wall, resulting in esophageal stricture. Strictures usually occur in the distal part of the esophagus, ranging from 2 to 4 cm or longer. Long-term placement of a nasogastric tube can easily lead to stricture. Endoscopic dilation treatment is required when symptoms are significant. After the stricture appears, there is generally no longer significant heartburn.

　　3. Barrett's esophagus

　　During the process of esophageal mucosal repair, squamous epithelium is replaced by columnar epithelium, which is called Barrett's esophagus. It can develop peptic ulcers, also known as Barrett's ulcers. Barrett's esophagus is the main precancerous lesion of esophageal adenocarcinoma, and the incidence of adenocarcinoma is 30 to 50 times higher than that of normal people.

　　Common clinical manifestations of elderly GERD include heartburn, regurgitation, difficulty swallowing, and chest pain.

　　1. Heartburn and acid regurgitation

　　This is the most common symptom of GER. Gastric contents that surge into the mouth without nausea or effort are called regurgitation. Reflux material may occasionally contain a small amount of food and is often acidic or bitter, at which point it is called acid regurgitation. Acid regurgitation is often accompanied by heartburn, which refers to a burning or uncomfortable sensation behind the sternum. It often extends upwards from the lower part of the sternum and usually appears 1 hour after a meal, especially after a heavy meal, and is exacerbated by lying flat, bending over, or straining. It can awaken a person from deep sleep.

　　2. Swallowing pain and difficulty

　　When inflammation worsens or esophageal ulcers develop, swallowing pain may occur, often during ingestion of acidic or overly hot foods, and some patients may have difficulty swallowing, which is intermittent. Swallowing can occur with both solid and liquid foods, usually at the beginning of a meal, presenting with a feeling of obstruction behind the sternum, which may be due to esophageal spasm or dysfunction. In a small number of patients with esophageal stricture, there is a persistent difficulty in swallowing that progresses, especially with dry food.

　　3. Pain behind the sternum

　　There is often a burning-like discomfort or pain located behind the sternum, which can be severe and stabbing in some cases, and may radiate to the area below the xiphoid process, scapular region, neck, ear, and arm, resembling angina. Most patients develop heartburn, but some patients with gastroesophageal reflux disease (GERD) do not have typical symptoms such as heartburn or acid regurgitation, and it should be noted that鉴别 is important.

　　4. Other

　　Some patients may experience discomfort or a feeling of obstruction in the throat, but without actual swallowing difficulties, which is known as globus syndrome. This is due to the increased pressure in the upper esophageal sphincter caused by acid reflux. Severe reflux esophagitis, due to aspiration of reflux material, can lead to chronic pharyngitis, laryngitis hoarseness, asthma attacks, or aspiration pneumonia.

　　Elderly gastroesophageal reflux disease should be prevented by classification.

　　1. Third-level Prevention of Gastroesophageal Reflux Disease

　　1. First-level Prevention (Etiological Prevention)

　　Any cause that leads to a decrease in the esophageal anti-reflux mechanism and affects the defense function of the esophageal mucosa should be avoided as much as possible, including:

　　(1) Control diet, eat small and frequent meals, do not lie down immediately after meals to reduce reflux; reduce the intake of coffee, chocolate, alcohol, and fatty foods to avoid reducing LES pressure; quit smoking.

　　(2) Raise the head of the bed by 15-20 cm when sleeping to accelerate gastric emptying;

　　(3) Reduce intra-abdominal pressure: such as weight loss, women not wearing tight-fitting underwear, treating elderly constipation, etc.;

　　(4) Elderly patients with related diseases should avoid taking nitrates or calcium channel blockers, as they can worsen reflux.

　　2. Second-level Prevention (Early Diagnosis and Early Treatment)

　　Before the esophageal tissue is damaged, barium meal or endoscopic examination may not show any abnormalities, or only non-specific changes that are difficult to diagnose. Esophageal pH monitoring is limited by conditions and cannot be widely carried out. However, based on detailed questioning, the typical symptoms of heartburn, gastroesophageal reflux, and foreign body sensation in the throat, globus hystericus, regurgitation of acid water, chest pain, paroxysmal cough, asthma, etc., can be used for differential diagnosis and analysis, and a preliminary diagnosis can be made. If antacid drugs can alleviate the symptoms, then the diagnosis can be mostly confirmed. Internal medicine doctors should strengthen their understanding of the symptoms of gastroesophageal reflux, correctly apply various auxiliary examinations, and strive to make early discoveries in outpatients, achieve early diagnosis, and early treatment.

　　3. Third-level Prevention (Correct Diagnosis, Appropriate Treatment, and Rehabilitation)

　　After the diagnosis of gastroesophageal reflux disease is established, comprehensive treatment measures should be taken, with correct guidance and systematic treatment. This disease is prone to recurrence, so maintenance treatment should be continued after the course of treatment, and rational medication should be used.

　　2. Risk Factors and Intervention Measures

　　The incidence of gastroesophageal reflux disease in the elderly is high, and the elderly have physiological characteristics. The elderly have relaxed esophageal sphincter and low LES tension, which are prone to reflux; the esophageal mucosal repair function is poor, and saliva secretion is less; there are more cases secondary to hiatal hernia, and the medication for elderly diseases is complex, and the duration of medication is long, and some drugs have an impact on LES function and esophageal mucosa, etc. It is even more important to provide correct guidance in terms of lifestyle and medication, and to give early treatment to conditions such as esophageal hiatus hernia and constipation.

　　3. Community Intervention

　　This disease is quite common. According to the current characteristics of Chinese society, the proportion of the elderly in the population structure is increasing, and the majority of the elderly live scattered at home. Most of the elderly are not very knowledgeable about medicine and health knowledge, so community medical services are very important. The purpose is to provide the elderly with correct guidance through health consultation and health education, including guidance on the understanding of the disease, daily life, dietary habits, and medication for related diseases, as well as reasonable medication and course supervision for patients with the disease.

　　The clinical manifestations of elderly gastroesophageal reflux disease mainly include acid regurgitation, retrosternal pain, dysphagia, etc. Gastroesophageal reflux disease can be diagnosed by understanding the history of gastroesophageal reflux, esophageal pH monitoring, endoscopy, and trial anti-reflux treatment.

　　1. 24h Esophageal pH Measurement

　　Esophageal pH measurement can understand the pH condition inside the esophagus. The portable pH recorder is used to continuously monitor the esophageal pH for 24 hours under physiological conditions, recording pH levels during the day, night, and throughout the 24-hour period.

　　2. Endoscopy and Biopsy

　　Endoscopy is the most accurate method for diagnosing reflux esophagitis, allowing direct observation of mucosal lesions and determining the severity of reflux esophagitis and the presence of complications. Combined with histological examination, it can differentiate esophagitis caused by other reasons. It is beneficial for clarifying the benign or malignant nature of the lesions. Since the histological findings of the mucosa in the 2.5cm range at the distal end of the normal esophagus can present with mild inflammation, mucosal samples must be taken 5-10cm above the gastroesophageal junction. Endoscopic evidence of reflux esophagitis can confirm the diagnosis of GERD, but even if the esophagus appears normal, GERD cannot be ruled out. In such cases, esophageal pH monitoring and esophageal barium swallowing X-ray examination should be used to make a comprehensive judgment. Endoscopic grading of reflux esophagitis based on the degree of mucosal damage is beneficial for disease determination and treatment guidance. Many grading criteria have been proposed, and the long-standing Savary-Miller grading method divides reflux esophagitis into 4 grades: Grade I consists of single or several non-fused lesions, presenting as erythema or superficial erosion; Grade II features fused lesions but not diffuse or circumferential; Grade III lesions are diffuse and circumferential with erosion but no stenosis; Grade IV presents as chronic lesions, characterized by ulcers, stenosis, esophageal shortening, and Barrett's esophagus. In reflux esophagitis, the dentate line is often blurred, the lower esophagus has hyperplasia of capillaries, and there are often white granules or spots, indicating squamous epithelial hyperplasia. Some patients may have hiatal hernia, presenting as upward displacement of the dentate line and the hernia sac visible between the hernia and the hiatus. The cardia is often in an open state.

　　3. Esophageal Barium Swallowing X-ray Examination

　　A simple method to understand whether there is gastroesophageal reflux is for the patient to lie flat or elevate the foot of the bed for barium X-ray swallowing examination. This examination has low sensitivity for the diagnosis of reflux esophagitis, often showing no positive findings in mild patients. Esophagitis patients may show rough and non-smooth mucosa in the lower esophagus, esophageal shadowing, stenosis, and may also find weakened esophageal peristalsis, irregular movement, or uncoordinated contractions. When swallowing a small dose of barium sulfate (such as 6ml of 200% barium sulfate) in a supine position, most GERD patients show delayed barium excretion in the esophagus and lower esophageal sphincter.

　　4. Esophageal Acid Reflux Test

　　The patient sits with a nasal catheter introduced in a single-blind condition, fixed at a distance of 30cm from the nares, and infused with normal saline at a rate of 10-12ml per minute for 15 minutes. Then, 0.1N hydrochloric acid is infused at the same speed. During the acid infusion process, patients experiencing pain or heartburn behind the sternum are positive, and these symptoms appear more than 1.5 minutes into the acid infusion, indicating the presence of active esophagitis; symptoms gradually improve after switching to normal saline infusion, but severe esophagitis patients may also be insensitive to acid and show a negative reaction; in cases where there is no gastric acid, symptoms are mainly caused by the reflux of alkaline substances such as bile, and may also show a negative reaction; chest pain of cardiac origin or other chest pain not caused by esophagitis or LWS dysfunction will show a negative reaction. This test is beneficial for the differential diagnosis of pain behind the sternum.

　　5. Esophageal manometry examination

　　LES length and location, LES pressure, LES relaxation pressure, upper esophageal sphincter pressure, and esophageal body pressure can be measured. These can show low LES pressure, frequent relaxation of LES, and low or absent amplitude of esophageal peristaltic contraction waves, which are the motor pathophysiological basis of gastroesophageal reflux, such as LES pressure.

　　After elderly patients are diagnosed with gastroesophageal reflux disease (GERD), they need to change their dietary structure, eating habits, and control their weight. GERD patients should eat high-protein, low-fat foods as the mainstay, and reduce the amount of food per meal, avoiding high-fat foods such as fatty meat and fried food. Avoid chocolates and deodorants such as menthol preparations. Eat less rough foods such as corn products, sweets, and acidic foods. Avoid drinking tea and coffee and other beverages, while milk is a good food. Abandon the habit of snacking, especially not eating within 2 to 3 hours before bedtime. Obese patients should try to lose weight to reach a reasonable level, which helps to reduce reflux. Quit smoking and drinking, as smoking and alcohol affect the clearance of acid in the esophagus and reduce esophageal tension. Severe reflux symptoms should strive to quit smoking and drinking, especially the habit of drinking strong alcohol.

　　After systematic examination, different treatment plans should be adopted according to the severity of illness in the elderly.

　　1. Treatment

　　1. General treatment

　　For patients with mild symptoms, medication is not necessarily required. Adjust lifestyle according to individual circumstances to reduce acid reflux, increase LES pressure, and prevent the recurrence of gastroesophageal reflux. It is necessary to develop a habit and persist in it for a long time.

　　(1) Living habits: To reduce lying down and nocturnal reflux, the foot end of the bed can be raised by 15 to 20 cm, to the extent that the patient feels comfortable, to enhance the clearance power of the esophagus, and accelerate the emptying of the stomach. However, sleeping with many pillows is ineffective because it only raises the head, neck, and chest, while the stomach is not lowered, which can instead cause a fold at the junction of the chest and abdomen, making the stomach higher and promoting reflux.

　　(2) Reducing the increase of intraperitoneal pressure: Obesity can increase intraperitoneal pressure, which can promote the exacerbation of incomplete LES function, so it should be actively reduced. Constipation, tight belts, and other factors can increase intraperitoneal pressure, so they should be avoided as much as possible.

　　(3) Diet: Eating after meals can easily cause reflux, so it is not advisable to eat before bedtime, and it is also not advisable to lie down immediately after eating during the day. Control diet, eat less and more often. Quit smoking to enhance the resistance of the esophageal mucosa. Alcohol, strong tea, coffee, chocolate, and other substances can reduce the pressure of the lower esophageal sphincter (LES), so they should be used less or avoided. High-fat diets can promote the secretion of cholecystokinin and gastrin, reducing the pressure of the LES, so the intake of fat should be reduced.

　　(4) Regarding related drugs: It should be avoided to use drugs that reduce the pressure of the LES and those that affect the delay of gastric emptying. For example, some elderly patients are prone to have gastroesophageal reflux due to the decline in LES function; if they have cardiovascular diseases and take nitroglycerin preparations or calcium channel blockers, it may worsen the symptoms of reflux, so it should be avoided appropriately, and necessary medication should be taken under the guidance of a doctor. Some patients with bronchial asthma may exacerbate asthma symptoms if they have gastroesophageal reflux, so it is best to avoid the use of theophylline and beta-2 receptor agonists, and to add anti-reflux treatment. At the same time, anticholinergic drugs, dopamine receptor agonists, and other drugs should be used with caution to avoid reducing the pressure of the IES.

　　2. Drug treatment

　　(1) Prokinetic drugs: Gastroesophageal reflux is a gastrointestinal motility disease, so the first step is to improve the motility. The effect of prokinetic drugs is to increase the pressure of the lower esophageal sphincter (LES), improve the peristalsis function of the esophagus, promote gastric emptying, thereby reducing the reflux of gastric contents into the esophagus and shortening the time of esophageal acid exposure; Cisapride is recognized as an ideal drug after a large number of clinical studies; it is a non-dopamine, non-cholinergic full gastrointestinal motility agent that can selectively stimulate the ganglion cells between the intestinal wall muscles, increase the release of acetylcholine by cholinergic nerves, and promote the activity of the digestive tract. Cisapride is superior to ranitidine in the disappearance of symptoms and the cure of esophagitis, and is suitable for mild to moderate patients. The common dosage is 3 to 5mg, taken orally three times a day, with a course of 8 to 12 weeks. Due to the side effect of diarrhea, the dosage should be individualized. Domperidone and metoclopramide (antinausea) can increase the pressure of the LES and strengthen the peristalsis of the stomach to accelerate emptying, but they have no significant effect on improving esophageal motility. If the dose is increased, it may achieve the efficacy of improving esophageal motility. Metoclopramide can cross the blood-brain barrier and produce ant dopaminergic effects in the central nervous system, causing extrapyramidal reactions in some patients.

　　(2) Acid-suppressing drugs: By inhibiting the acid reflux from the stomach, the acid-suppressing drugs improve the symptoms by reducing the stimulation to the esophageal mucosa. Therefore, anti-secretory drugs are still an important means of treating GERD.

　　①H2 receptor antagonists (H2 receptor antagonist, H2RA) The drugs of H2RA class have good acid-suppressing effects, which can reduce the secretion of gastric acid by 50% to 70% in 24 hours, but they cannot effectively inhibit the secretion of gastric acid stimulated by eating, so they are suitable for mild to moderate patients. Common drugs and dosages: Cimetidine 400mg, twice a day, or 800mg, taken before bedtime; maintenance dose, 400mg, taken before bedtime. Ranitidine 150mg, twice a day, or 300mg, taken before bedtime; maintenance dose, 150mg, taken before bedtime. Famotidine 20mg, twice a day, or 40mg, taken before bedtime; maintenance dose, 20mg, taken before bedtime. Increasing the dose can improve the efficacy, but it can also increase adverse reactions, with a course of 8 to 12 weeks.

　　② Proton pump inhibitors (PPI): These drugs act on the final stage of gastric acid secretion, inhibiting K+-K+-ATPase to produce acid-suppressing effects. With strong acid-suppressing effects, their efficacy in this disease is superior to that of H2RA or cisapride, especially suitable for patients with severe symptoms and severe esophagitis. Including omeprazole (20mg), lansoprazole (30mg), pantoprazole (40mg), and rabeprazole (10mg), taken orally once a day, or twice a day for better effects, with a course of 8 to 12 weeks. For those with poor efficacy, the dose can be doubled or used in combination with cisapride. Rabeprazole (trade name: Politec) is a new-generation proton pump inhibitor with fast and sustained acid-suppressing effects, making it an ideal acid-suppressing drug for the treatment of gastroesophageal reflux disease.

　　(3) Mucosal protective agents: Used for damaged esophageal mucosa, sucralfate combines with positively charged proteins on the eroded ulcer surface to form a charged barrier, which can adsorb bile salts, pepsin, and gastric acid, preventing the mucosa from being digested and reducing the symptoms of gastroesophageal reflux and treating reflux esophagitis. Sucralfate should be ground into powder, mixed with water to form a paste, and taken orally to adhere to the lesion mucosa of the esophagus. Simeticon is a new type of mucosal protective agent for the gastrointestinal tract that has been applied in clinical practice in recent years. It is obtained from natural montmorillonite, with small particles and a large surface area, which unfolds on the surface of the gastrointestinal mucosa when water is added, providing mucosal protection. Bismuth potassium citrate (colloidal bismuth subcitrate) also has mucosal protective effects.

　　Currently, gastroesophageal reflux disease and peptic ulcer are collectively referred to as 'acid-related diseases'. Their common point is that although acid-suppressing drugs can achieve satisfactory short-term efficacy, they cannot change the natural course of the disease. The recurrence rate is high after discontinuation of medication, with a reported recurrence rate of up to 70% to 80% after half a year in Western countries. Therefore, it is necessary to strengthen preventive measures against recurrence of gastroesophageal reflux disease to reduce the recurrence of symptoms, prevent complications caused by recurrent esophagitis, and provide necessary maintenance treatment. Those who quickly relapse after discontinuation of medication and have persistent symptoms often require long-term maintenance treatment; those with complications such as esophageal ulcers, esophageal stenosis, and Barrett's esophagus definitely require long-term maintenance treatment. Cisapride, H2RA, and PPI can all be used for maintenance treatment, with PPI being the most effective. The dose of maintenance treatment varies from patient to patient, and the most appropriate dose is the lowest dose that keeps the patient asymptomatic.

　　3. Surgical Treatment

　　In cases where symptoms are severe, strict medical treatment is ineffective, IES pressure is very low, or symptoms appear quickly after stopping medication, patients cannot tolerate long-term medication; or there are serious complications, such as recurrent esophageal strictures after dilation treatment, or confirmed severe respiratory diseases caused by reflux, anti-reflux surgical treatment should be considered. Generally, gastroesophageal fundoplication is used, and the short-term efficacy may be satisfactory, but the long-term efficacy is yet to be determined.

　　4. Treatment of Complications

　　(1) Esophageal Strictures: In addition to a few severe fibrous strictures that require surgical resection, the vast majority of strictures can be treated regularly with endoscopic esophageal dilation, including probe dilation and endoscopic water balloon dilation. Long-term PPI maintenance treatment after dilation can prevent recurrence of strictures, and anti-reflux treatment can also be considered for young patients.

　　(2) Barrett's Esophagus: Barrett's esophagus often occurs on the basis of severe esophagitis, and the risk of developing esophageal adenocarcinoma is greatly increased. To prevent the occurrence and development of Barrett's esophagus, it is necessary to actively treat the underlying disease, use PPI treatment, and maintain long-term treatment. In patients with indications, anti-reflux surgical treatment can be considered. Once Barrett's esophagus is found, strengthening follow-up is the only method to prevent its canceration. The focus is on early identification of atypical hyperplasia, and timely surgical resection when severe atypical hyperplasia or early esophageal cancer is found.

　　5. Optimal Treatment Plan

　　Esophageal hiatus hernia is more common in the elderly, so medical treatment is mainly used, including avoiding triggering factors, acid suppression, and enhancing gastric motility as anti-reflux measures. For a few younger patients, surgical treatment can be considered on a case-by-case basis to repair the esophageal hiatus and restore the normal angle of His.

　　6. Rehabilitation Treatment

　　Whether the disease is treated surgically or medically, after systemic treatment, rehabilitation treatment is the key to preventing recurrence; the main purpose is to reduce intra-abdominal pressure, regulate diet, and use medication reasonably; for example: elevate the head of the bed when lying down, accelerate gastric emptying, lose weight; treat constipation, and use cardiovascular and cerebrovascular drugs under the guidance of a doctor, etc.

　　II. Prognosis

　　It mainly depends on the duration of the disease, the severity, and whether complications such as hemorrhage and ulcers occur.