Gastroesophageal Reflux Disease (GERD) (cont.)
What are the complications of GERD?
Ulcers
The liquid from the stomach that refluxes into the esophagus damages the
cells lining the esophagus. The body responds in the way that it usually
responds to damage, which is with inflammation (esophagitis). The purpose of
inflammation is to neutralize the damaging agent and begin the process of
healing. If the damage goes deeply into the esophagus, an ulcer forms. An ulcer
is simply a break in the lining of the esophagus that occurs in an area of
inflammation. Ulcers and the additional inflammation they provoke may erode into
the esophageal blood vessels and give rise to bleeding into the esophagus.
Occasionally, the bleeding is severe and may require:
- blood transfusions,
- an endoscopic procedure (in which a tube is inserted through the mouth into the esophagus to visualize the site of bleeding and to stop the bleeding), or
- surgical treatment.
Strictures
Ulcers of the esophagus heal with the formation of scars (fibrosis). Over
time, the scar tissue shrinks and narrows the lumen (inner cavity) of the
esophagus. This scarred narrowing is called a stricture. Swallowed food may get stuck in the esophagus once the narrowing becomes severe enough (usually when it restricts the esophageal lumen to a diameter of one centimeter). This
situation may necessitate endoscopic removal of the stuck food. Then, to prevent
food from sticking, the narrowing must be stretched (widened). Moreover, to
prevent a recurrence of the stricture, reflux also must be prevented.
Barrett's esophagus
Long-standing and/or severe GERD causes changes in the cells that line the esophagus in some patients. These cells are pre-cancerous and finally become cancerous. This condition is referred to as Barrett's esophagus and occurs in approximately 10% of patients with GERD. The type of esophageal cancer associated with Barrett's esophagus (adenocarcinoma) is increasing in frequency. It is not clear why some patients with GERD develop Barrett's esophagus, but most do not.
Barrett's esophagus can be recognized visually at the time of an endoscopy and confirmed by microscopic examination of biopsies of the lining cells. Then, patients with Barrett's esophagus may require periodic surveillance endoscopies with biopsies. The purpose of surveillance is to detect pre-cancerous changes so that cancer-preventing treatment can be started. It is also believed that patients with Barrett's esophagus should receive maximum treatment for GERD to prevent further damage to the esophagus. Procedures are being studied that remove the abnormal lining cells. Several endoscopic, non-surgical techniques can be used to remove the cells. These techniques are attractive because they do not require surgery; however, there are associated complications, and the long-term effectiveness of the treatments has not yet been determined. Surgical removal of the esophagus is always an option. For more, please read the
Barrett's Esophagus article.
Cough and asthma
Many nerves are in the lower
esophagus. Some of these nerves are stimulated by the refluxed acid, and this
stimulation results in pain (usually heartburn). Other nerves that are
stimulated do not produce pain. Instead, they stimulate yet other nerves that
provoke coughing. In this way, refluxed liquid can cause coughing without ever
reaching the throat! In a similar manner, reflux into the lower esophagus can
stimulate esophageal nerves that connect to and can stimulate nerves going to
the lungs. These nerves to the lungs then can cause the smaller breathing tubes
to narrow, resulting in an attack of asthma.
So, GERD is a common cause of unexplained coughing. Although GERD also may be
a cause of asthma, it is more likely that it precipitates asthmatic attacks in
patients who already have asthma. Although
chronic cough and asthma are common
ailments, it is not clear just how often they are aggravated or caused by GERD.
Inflammation of the throat and larynx
If refluxed liquid gets past the upper esophageal sphincter, it can enter the
throat (pharynx) and even the voice box (larynx). The resulting inflammation can
lead to a sore throat and hoarseness. As with coughing and asthma, it is not
clear just how commonly GERD is responsible for otherwise unexplained
inflammation of the throat and larynx.
Inflammation and infection of the lungs
Refluxed liquid that passes the larynx can enter the lungs. The reflux of
liquid into the lungs (called aspiration) often results in coughing and choking.
Aspiration, however, can also occur without producing these symptoms. With or
without these symptoms, aspiration may lead to infection of the lungs and result
in pneumonia. This type of pneumonia is a serious problem requiring immediate
treatment. When aspiration is unaccompanied by symptoms, it can result in a
slow, progressive scarring of the lungs (pulmonary
fibrosis) that can be seen on chest
x-rays. Aspiration is more likely to occur at night because that is when the
processes (mechanisms) that protect against reflux are not active and the
coughing reflex that protects the lungs also is not active.
Fluid in the sinuses and middle ears
The throat communicates with the nasal passages. In small children, two
patches of lymph tissue, called the adenoids, are located where the upper part
of the throat joins the nasal passages. The passages from the sinuses and the
tubes from the middle ears (Eustachian tubes) open into the rear of the nasal
passages near the adenoids. Refluxed liquid that enters the upper throat can
inflame the adenoids and cause them to swell. The swollen adenoids then can
block the passages from the sinuses and the Eustachian tubes. When the sinuses
and middle ears are closed off from the nasal passages by the swelling of the
adenoids, fluid accumulates within them. This accumulation of fluid can lead to
discomfort in the sinuses and ears. Since the adenoids are prominent in young
children, and not in adults, this fluid accumulation in the
ears and sinuses is
seen in children and not adults.
Next: How is GERD diagnosed and evaluated? »
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