Refluxo ou Doença do Refluxo Gastroesofágico (DRGE)

13 de março de 2017

O que é?

É uma condição crônica decorrente do retorno de conteúdo do estômago e duodeno para o esôfago, acarretando sinais ou sintomas esofagianos variados que podem estar associados ou não a lesões nos tecidos.

Quais são as causas?

O refluxo ocorre quando o músculo localizado no fim do esôfago, chamado de esfíncter inferior do esôfago, não funciona adequadamente. Este músculo deveria estar fechado na maior parte do tempo, abrindo apenas para a entrada de alimentos no estômago. Mas ele pode apresentar uma certa incapacidade e não se fechar completamente, o que permite o retorno do conteúdo do estômago para o esôfago.

Outras situações podem contribuir para o refluxo, como a elevada produção de ácido gástrico, obesidade, gravidez, hérnia de hiato, síndrome de Zollinger-Ellison, hipercalcemia e esclerose sistêmica.

O que sente o portador desta condição?

Pirose (azia): sensação de queimação no peito, atrás do esterno, que pode chegar até a garganta. Este é o sintoma mais comum do refluxo, podendo piorar quando a pessoa come, agacha ou deita. Às vezes ela é confundida com infarto do miocárdio ou angina
Sensação de plenitude gástrica: relatada pelos pacientes como inchaço no estômago ou má digestão
Dor em queimação na “boca do estômago” (abdome superior), que normalmente acorda a pessoa no meio da noite
Eructação (arrotos)
Náuseas
Excesso de salivação
Regurgitação ácida: refluxo de líquidos ou alimentos do estômago à boca
Disfagia (dificuldade para engolir): manifestada por engasgos
Sensação de asfixia noturna
Rouquidão, principalmente pela manhã
Dor de garganta
Pigarro ou necessidade de limpar a garganta repetidamente
Tosse crônica, pneumonias de repetição, asma, sinusite crônica
Desgaste do esmalte dentário, halitose (mau-hálito)
A intensidade e a freqüência dos sintomas não são sinais de gravidade da esofagite. Mas existe correlação entre o tempo de duração dos sintomas e o aumento do risco para o desenvolvimento do Esôfago de Barrett e do adenocarcinoma (câncer) do esôfago.

Alguns sintomas são considerados “manifestações de alarme” e devem ser investigados mais rapidamente. São eles: dificuldade para engolir, dor de garganta, anemia, hemorragia digestiva, emagrecimento, história familiar de câncer, náuseas e vômitos, além de sintomas de grande intensidade e/ou de ocorrência noturna.

Como o médico faz o diagnóstico?

O diagnóstico é realizado a partir de uma história clínica detalhada. Os pacientes que apresentam sintomas com freqüência mínima de duas vezes por semana, ao longo de 4 a 8 semanas, devem ser considerados possíveis portadores da DRGE.

Como as manifestações clínicas são variadas, podem ser necessários exames complementares como a endoscopia digestiva alta, exame radiológico contrastado do esôfago, cintilografia, manometria, pHmetria de 24 horas ou teste terapêutico para auxiliar no diagnóstico.

A endoscopia digestiva alta é particularmente importante nos pacientes com mais de 40 anos de idade, bem como nos que apresentam “manifestações de alarme”. Ela permite ver diretamente a mucosa. Mas é importante saber que uma endoscopia normal não exclui o diagnóstico de DRGE, pois pode estar presente em 25-40% dos pacientes com DRGE.

Procure um especialista em gastroenterologia para avaliar os seus sintomas e a necessidade de realizar exames complementares para o diagnóstico.

No Brasil, pelo baixo custo do exame endoscópico, ele faz parte da propedêutica inicial para pacientes com história clínica e sintomas de DRGE, mesmo em idade abaixo de 40 anos.

Quais as opções de tratamento disponíveis?

Existem dois tipos de tratamento: as medidas comportamentais (mudanças de hábitos) e as farmacológicas (uso de medicamentos). Elas devem ser implementadas simultaneamente em todas as fases da doença.

Pacientes conscientes da importância de modificar o seu estilo de vida ajudam muito no tratamento.

Fazem parte das medidas comportamentais:

Elevação da cabeceira da cama em 15 centímetros para dificultar o refluxo de alimentos do estômago para o esôfago.
Moderada ingestão de alimentos gordurosos, café, bebidas alcoólicas, bebidas gasosas, menta, hortelã, produtos de tomate, condimentos e leite integral. Estes alimentos são irritantes da mucosa gástrica.
Cuidados especiais para o uso de medicamentos que podem piorar o refluxo, como anticolinérgicos, teofilina, antidepressivos tricíclicos, bloqueadores de canais de cálcio, agonistas ß adrenérgicos e alendronato.
Evitar comer até duas horas antes do horário de dormir (deitar).
Evitar refeições copiosas. O melhor é fazer refeições fracionadas, mais vezes ao dia.
Parar de fumar.
Emagrecimento.
Evitar o uso de roupas apertadas, pois elas aumentam a pressão no abdome, piorando o refluxo.
A presença de esofagite à endoscopia indica o uso de medicamentos inibidores da bomba de prótons (IBP), por um tempo mínimo de 6 semanas, embora 4 semanas também possam ser utilizadas.

Aqueles que não apresentarem resposta satisfatória ao tratamento com IBP por 12 semanas, devem ter a dose dobrada por mais 12 semanas antes de serem considerados como insucesso terapêutico.

Por vezes, o tratamento cirúrgico pode ser recomendado pelo médico, dependendo das indicações.

Quais as opções para prevenir esta doença?

São as mesmas medidas comportamentais adotadas para o tratamento do refluxo.

Quais são as complicações da doença?

As complicações mais comuns são:

Esofagite: inflamação do esôfago
Estenose: redução do calibre do esôfago, tornando difícil a deglutição de alimentos sólidos
Úlcera: aparecimento de uma ferida aberta no esôfago
Esôfago de Barrett: substituição do epitélio estratificado e escamoso do esôfago por epitélio colunar com células intestinalizadas ou mistas, em qualquer extensão do órgão. É uma alteração na qual o tecido rosado normal do esôfago é substituído por um tecido de cor “salmão” que mais se assemelha ao revestimento do estômago e afeta primariamente indivíduos do sexo masculino, de raça branca, com idade superior a 40 anos
Sangramento esofágico: costuma ser lento e insidioso, sendo muitas vezes responsável por quadros de anemia crônica. O tratamento clínico constitui a melhor opção de tratamento
Câncer de esôfago: o Esôfago de Barrett pode evoluir para o câncer de esôfago em 2 a 5 por cento das pessoas com esta condição

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