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Malattia da reflusso gastroesofageo

maggio 30th, 2011

La malattia da reflusso gastroesofageo, (MRGE), è una malattia causata dal reflusso nell’esofago del contenuto gastrico. Essa non va confusa con il reflusso gastroesofageo, che è un fenomeno fisiologico; si parla invece di “malattia” (MRGE) in presenza di sintomi di reflusso (pirosi, rigurgito) ed evidenza endoscopica di esofagite o delle sue complicanze.
Infatti l’acido gastrico e la bile che vengono a contatto in questo modo con la mucosa dell’esofago ne provocano l’infiammazione con la conseguente insorgenza di dolori cronici. Anche se occasionali piccoli reflussi sono considerati fisiologici, in alcuni casi la frequenza e l’intensità dei reflussi può assumere valenza patologica. Col tempo l’infiammazione può evolvere in danni al tessuto dell’esofago, sotto forma di erosioni e piccole ulcere, e si parla quindi di esofagite.
Generalmente la causa del reflusso e’ dovuta ad una diminuzione del tono del cardias (lo sfintere esofageo inferiore – SEI/LES), cioè la valvola che separa l’esofago dallo stomaco, in seguito all’assunzione di sostanze diverse, come cibi grassi, nicotina, caffeina, agrumi, alcolici ed anche alcuni tipi di farmaci; in casi più rari è dovuta al prolungato ristagno del bolo nello stomaco (si può ipotizzare una stenosi o preudo-occlusione ileare o del tenue), per via di discinesie (disturbi motori) che rallentano il normale svuotamento dello stesso; altre volte la causa è da ricercare nell’assunzione di pasti troppo abbondanti; infine sono predisponenti tutte quelle condizioni che determinano un aumento della pressione gastrica, come l’obesità e la gravidanza.

I sintomi associati al reflusso si distinguono in
1) esofagei
2) extraesofagei.

Sintomi esofagei: si suddividono ulteriormente in tipici e atipici. Fra i primi, sono particolarmente frequenti la pirosi (sensazione di bruciore retrosternale, talora irradiata al collo oppure posteriormente, tra le scapole) e il rigurgito (risalita non forzata del contenuto gastrico fino al cavo orale). Tra i sintomi atipici, si ricordano la disfagia (sensazione di difficoltà nella deglutizione, spesso legata ad alterazioni motorie correlate al reflusso), l’odinofagia (dolore legato alla deglutizione) ed il dolore toracico simil-anginoso, che può indurre erroneamente a sospettare un infarto del miocardio.
Sintomi extraesofagei: la MRGE può manifestarsi con sintomi oro-faringei (tosse cronica, scialorrea, raucedine), laringei (laringite cronica, disfonia, ulcere e granulomi delle corde vocali) e bronco-polmonari (asma cronico soprattutto notturno, polmonite ab ingestis). Tra questi abbiamo: Ipersecrezione catarrale (aumentata produzione di muco, ben visibile sul piano glottico), tosse stizzosa o cronica, asma o difficoltà respiratoria, sensazione di nodo in gola (bolo ipofaringeo), Emoftoe (sputare sangue tipico di stati tubercolari), raucedine, disfonia, dolore retrosternale irradiato al mento, alla mandibola, alle braccia e tra scapole, apnee notturne, faringite (con o senza mal di gola), laringite posteriore (edema e rossore), granulomi sulle corde vocali, prolasso dei tessuti molli (velopendulo), patina bianca sulla tonsilla linguare, alitosi e raclage (sensazione di dover raschiare continuamente la gola per un forte presenza di muco che in realtà si rivela essere scarso e di difficile estrazione), vellicchio faringeo, disfagia orofaringea e odinofagia.

La diagnosi di reflusso gastroesofageo patologico si effettua con la ph-metria esofagea 24 ore che consente di differenziare i reflussi fisiologici da quelli patologici. In alcuni casi, anche reflussi “fisiologici” possono provocare sintomi (“esofago irritabile o ipersensibile”).

Per una diagnosi più coerente e certificabile soprattutto in casi di reflusso atipico, alcuni centri mettono a disposizione la Ph-metria con impedenziometria multicanale intraluminale, che permette di valutare se il refluito giunge fino in gola, in che entità ed in quale forma (liquido, gassoso o biliare).

Nel caso in cui si rilevino solo reflussi gastro-esofagei (solitamente si verificano entro i 120 minuti dal pasto), la manometria gastro-esofagea può definire la tonia del cardias.

Per valutare il danno subìto dalla mucosa esofagea è fondamentale la gastroscopia, soprattutto nei pazienti con sintomi atipici o con “segni di allarme” (disfagia, mancata risposta alla terapia con antisecretori), anche per escludere altre patologie soprattutto neoplastiche.
Secondo la classificazione di Savary e Miller, si distinguono quattro gradi di lesioni endoscopiche:

Grado 0: mucosa normale.
Grado 1: presenza di erosioni di forma ovalare o lineare non confluenti, singole o multiple, su una plica longitudinale.
Grado 2: erosioni situate su più pliche longitudinali, ma non circonferenziali.
Grado 3: erosioni confluenti ad estensione circonferenziale.
Grado 4: presenza di complicanze come stenosi, ulcere o esofago di Barrett.
È utile inoltre ricercare la presenza dell’Helicobacter pylori a livello gastrico, per stabilire la condotta terapeutica più adeguata. Per quanto sia stata lungamente studiata una possibile associazione tra l’infezione da Helicobacter e la MRGE, essa non è mai stata accertata da studi epidemiologici, né è stato individuato un possibile meccanismo patogenetico con il quale il virus provocherebbe la malattia.
Nei casi più gravi, il danno tissutale evolve verso forme di metaplasia dell’epitelio cellulare interno, provocando la condizione detta di Epitelio di Barrett (o Esofago di Barrett), che è a sua volta considerato un possibile fattore facilitante dello sviluppo di carcinomi esofagei.

La terapia della MRGE è solitamente basata su alcune norme igienico-dietetiche di base, e sull’assunzione (per periodi più o meno prolungati) di farmaci appartenenti alle classi degli inibitori di pompa protonica/IPP (che inibiscono notevolmente la produzione acida nello stomaco), degli anti-H2 (in gran parte però soppiantati dai più moderni e potenti IPP), degli antiacidi, degli alginati e dei procinetici.

Per quanto riguarda la terapia del reflusso in genere, il primo passo riguarda una modificazione della dieta e dello stile di vita: vanno infatti evitati i cibi reflussogeni (in particolare i pasti grassi, l’alcool, la cioccolata, il pomodoro, il caffè, il the, la menta, gli agrumi) inoltre si consigliano al paziente pasti piccoli e frequenti, e va evitato di coricarsi nelle prime 2-3 ore dopo i pasti. È utile anche la cessazione del fumo.
Il secondo passo è la terapia farmacologica, e solo in casi estremi si interviene chirurgicamente. Il diffondersi della chirurgia laparoscopica ha parzialmente cambiato l’atteggiamento e le indicazioni della chirurgia del reflusso. Questa, in precedenza, era indicata solo nei casi con coesistente ernia iatale di cospicue dimensioni. Attualmente, alcune linee guida propongono il trattamento chirurgico laparoscopico anche per i pazienti che rispondono discretamente alla terapia medica, ma che abbiano severe recidive dopo la sospensione della stessa, o che siano giovani e non vogliano sottoporsi ad una terapia medica continuativa.
La scelta della terapia chirurgica deve comunque essere attentamente valutata, e preceduta da una completa valutazione anatomopatologica e fisiopatologica di stomaco e esofago (gastroscopia, ph-metria esofagea, oppure, nel caso della malattia da reflusso faringo laringeo è meglio parlare di ph metria multicanale intraluminale con impedenziometria o manometria esofagea).

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