GERB – gastroezofagealna refluksna bolest
Osećaj gorušice, gorak ukus u ustima kao i spontano vraćanje hrane predstavljaju tipične simptome veoma čestog oboljenja koji se naziva gastroezofagealna refluksna bolest – GERB. GERB predstavlja jedan od najznačajnijih zdravstvenih problema današnjice. Gorušicu, kao najčešći simptom GERB-a, svakodnevno oseća 7% svetske populacije, 14% jednom nedeljno a čak 36% jednom mesečno.
Gorušica se najčešće javlja nakon jela, savijanja ili napinjanja trbušnih mišića. U slučaju da se ovaj problem ne leči i da postoji dugo vremena, GERB može dovesti do značajnih zdravstvenih problema.
U početku se javlja oštećenje i zapaljenje sluzokože jednjaka (ezofagitis), koje vremenom može dovesti do nastanka čira ili suženja jednjaka kao i problema sa disanjem. U retkim slučajevima kod ovih bolesnika mogu nastati i teške komplikacije.
UZROCI NASTANKA
Hrana iz usta preko jednjaka ulazi u želudac. Tokom ovog puta ona prolazi kroz jednosmernu valvulu, koja se naziva donji stezač .(sfinkter) jednjaka (DES) i nalazi se na samom spoju jednjaka i želuca. Kod bolesnika sa GERB-om, DES je oslabljen i dozvoljava želudačnom i duodenalnom sadržaju da se vraćaju (refluks) u jednjak. Najčešći razlog za oslabljenost DES-a je postojanje želudačne kile. Više od 85% bolesnika sa GERB-om imaju herniju hijatusa jednjaka (želudačnu kilu).
Kod bolesnika sa hernijom hijatusa, otvor na dijafragmi, gde se spajaju jednjak i želudac, značajno je proširen. Gornji deo želuca klizi u grudni koš, olakašavajući vraćanje svog sadržaja u jednjak, izazivajući na taj način njegovo oštećenje.
SIMPTOMI
Najtipičniji simptomi GERB-a su gorušica (osećaj pečenja iza grudne kosti) i spontano vraćanje hrane iz želuca. Ostali simptomi GERB-a su: gorak ukus u ustima, podrigivanje, bolno i otežano gutanje hrane, bol u gornjem delu trbuha, mučnina, pojačano lučenje pljuvačke i trnjenje zuba. Gore navedene tegobe se pojačavaju tokom napinjanja, savijanja ili ležanja, a javljaju se i hronični kašalj I promuklost.
DIJAGNOSTIKA
Da bi se postavila tačna dijagnoza GERB-a neophodno je sprovesti detaljno kliničko ispitivanje u visoko specijalizovanim ustanovama. Kod svih bolesnika, sa simptomima GERB-a, potrebno je uzeti detaljnu anamnezu i načiniti sledeće dijagnostičke procedure: barijumsku radiografiju, gornju fleksibilnu endoskopiju i biopsiju.
Takođe je neophodno načiniti funkcionalnu dijagnostiku jednjaka u vidu manometrije i 24h pH-metrije, kako bi se odredio precizan i adekvatan dalji tok lečenja.
PROMENE ŽIVOTNIH NAVIKA
Jednostavne promene životnih navika ponekad mogu značajno pomoći u smanjenju simptoma GERB-a i ubrzati izlečenje i oporavak.
ISHRANA
Ishranu je potrebno organizovati tako da u toku dana postoji 5 obroka u jednakim vremenskim intervalima (3 bazična i 2 užine). Uzimati umerene količine hrane i tečnosti koje neće rastezati želudac. Jesti polako, smireno, žvakati barem 20 puta svaki zalogaj. Održavati dobru higijenu usta i zuba.
Ne počinjati dan stimulansima (čaj, kafa, cigarete) i doručkovati 1 sat posle buđenja. Za užinu uzimati hranu na bazi žitarica i voća ili tost od integralnog raženog hleba. Ne konzumirati previše vruća ili hladna jela i pića. Žvakaće gume i tvrde bombone povećavaju unos progutanog vazduha tako da ih treba izbegavati.
Nakon jela šetnja pomaže varenju. Izbegavati savijanje i ležanje nakon obroka. Od poslednjeg obroka u toku dana do odlaska u krevet potrebno je da prođe najmanje 3 sata.
PODIGNUTO UZGLAVLJE
Refluks se mnogo češće javlja kad se leži na ravnom. Potrebno je podići uzglavlje jastucima ili samo uzglavlje kreveta (preporučuje se) za 15 do 20 cm.
ALKOHOL I NIKOTIN
Značajno pogoršavaju GERB I treba ih apsolutno izbegavati. Alkohol slabi i opušta DES, dok nikotin još i pojačava lučenje želudačne kiseline.
SMANJENJE TRBUŠNOG PRITISKA
Velika količina pritiska na želudac značajno pogoršava refluks. Potrebno je održavati normalnu i značajno smanjiti povećanu telesnu težinu.Uvek olabaviti kaiš i ne nositi usku odeću nakon obroka. Izbegavati nošenje teških predmeta kao i savijanje i naprezanje.
MEDIKAMENTNO LEČENJE
U slučajevima kada samo promene životnih navika nisu dovoljne ili kada se radi o težim oblicima GERB-a potrebno je uzimati lekove koji neutrališu ili smanjuju lučenje želudačne kiseline i koji pomažu u radu jednjaka i ojačavanju DES-a. Svi lekovi se uzimaju 15 minuta pre jela. Izbegavati antiinflamatorne lekove (ibuprofen, aspirin) jer oni pogoršavaju simptome GERB-a.
ANTACIDI
Dejstvo antacida (aluminijum hidroksid i kombinacije aluminijumskih, kalcijumskih i magnezijumskih jedinjenja) se sastoji u privremenom neutralisanju želudačne kiseline. Najčešći lekovi u upotrebi kod nas su: Rupurut®, Kompensan®, Rennie® i Alfogel®. Koriste se 3-4 puta dnevno.
LEKOVI KOJI SMANJUJU LUČENJE ŽELUDAČNE KISELINE
Blokatori H2 receptora
Delimično smanjuju lučenje želudačne kiseline i korisni su u izuzetno blagim oblicima GERB-a kada ne postoji oštećenje sluzokože. Najčešći lekovi su: Famotidin, Ranitidin,Galitidin. Koriste se 2-3 puta dnevno.
Inhibitori protonske pumpe
Skoro u potpunosti smanjuju lučenje želudačne kiseline i predstavljaju lekove izbora u neutralisanju kiseline GERB-a. Najčešći lekovi su: Omeprazol (Omeprol®), Pantoprazol (ControloC®) i Esomeprazol (Nexium®). Koriste se 1-2 puta dnevno,a doziranje zavisi od težine bolesti.
PROKINETICI
Lekovi koji ubrzavaju pražnjenje jednjaka i želuca i pojačavaju pritisak DES-a. Najčešći i najkvalitetniji lekovi su: Domperidon (Motilium®); Metoklopramid (Klometol®, Reglan®). Koriste se 2-3 puta dnevno.
HIRURŠKO LEČENJE
GERB se ponekad može kontrolisati promenama životnih navika i lekovima. U slučaju da simptomi i dalje postoje, hirurgija predstavlja najsigurniji vid lečenja. Hirurška procedura u cilju definitivnog rešavanja ove bolesti se preporučuje u slučajevima kada bolesnici, koji su redovno koristili lekove više nedelja, i koji pored ili neposredno po prestanku terapije, i dalje imaju tegobe. Takođe se ova intervencija preporučuje mlađim bolesnicima, sa izrazitim tegobama, kao i bolesnicima koji više vole da se operišu nego da neizvesno uzimaju lekove, u dugom vremenskom periodu. Danas se smatra da je hirurška intervencija apsolutno primarna metoda lečenja kod bolesnika sa težim oblicima GERB-a, odnosno komplikacijama ove bolesti, ili bolesnicima sa velikim hernijama hijatusa jednjaka (većim od 3 cm).
Najčešća hirurška procedura (antirefluksna operacija), u cilju rešavanja GERB-a i njenih komplikacija, se naziva Nissen-ova operacija.
Ova procedura se sastoji u vraćanju celog želuca u svoju anatomsku poziciju u trbuhu, sužavanju otvora jednjaka na dijafragmi, i ojačavanju donjeg sfinktera jednjaka (DES-a) obmotavanjem oslobođenog gornjeg dela želuca oko donjeg dela jednjaka. Najčešće se ova operacija izvodi kroz trbuh (otvoreno ili laparoskopski) ali kod jako gojaznih, osoba sa prethodnim mnogobrojnim operacijama u trbuhu kao i kad postoji veće skraćenje ukupne dužine jednjaka, odnosno velikih hiatus hernija, ova procedura se izvodi kroz grudni koš. Sama procedura ima mali rizik od operativnih komplikacija. U određenim slučajevima, u zavisnosti od preoperativne dijagnostike ili intraoperativnog nalaza, moguće je načiniti i neke druge antirefluksne procedure.
OPORAVAK
Nakon same operacije, može se kod manjeg broja bolesnika javiti otok unutar jednjaka, koji daje osećaj otežanog gutanja ili rane sitosti. Ovi procesi u potpunosti spontano prolaze za 6 do 8 nedelja. Kada se započne sa uzimanjem čvrste hrane neophodno je uvek svu hranu dobro sažvakati i maksimalno izbegavati gazirana pića u periodu od 3 do 4 nedelje.
Nakon uspešno izvršene operacije i adekvatnog oporavka, osoba se može vratiti svojim svakodnevnim životnim obavezama, bez bojazni od eventualnih komplikacija. Više od 90% bolesnika, nakon uspešno načinjene antirefluksne procedure, nema subjektivne tegobe i zadovoljno je uspehom operacije. Svega oko 4% bolesnika postoperativno zahteva dodatnu terapiju. Po dolasku kući, prvih par nedelja, apsolutno treba izbegavati bilo kakav fizički napor ili podizanje težih predmeta.
Neophodno je kontaktirati svog lekara u sledećim slučajevima: ako postoji telesna temepratura veća od 38°C praćena drhtavicom, ako postoji krvarenje iz operativne rane, mučnina i povraćanje, učestao kašalj i otežano gutanje, koje ne prestaje nakon par nedelja.
KONTROLNI PREGLEDI
Nakon operacije neophodno je redovno se kontrolisati kod svog lekara i to u prvih godinu dana, 4 puta (mesec, tri, šest i godinu dana, nakon operacije), a nakon toga, jednom godišnje. I pored toga što sam operativni zahvat eliminiše tegobe i dalje je potrebno pridržavati se zdravog režima života i ishrane.
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