Complications of gastroesophageal reflux in adults

INTRODUCTION — 

Gastroesophageal reflux disease (GERD) may result in esophageal or extraesophageal complications. These complications may result from direct inflammation due to the refluxate or as a consequence of the reparative process (eg, peptic stricture and Barrett's metaplasia). This topic will review the complications of GERD. The pathophysiology, clinical manifestations, diagnosis, and management of GERD are discussed separately. (See "Clinical manifestations and diagnosis of gastroesophageal reflux in adults" and "Initial management of gastroesophageal reflux disease in adults".)

ESOPHAGEAL COMPLICATIONS

Erosive esophagitis — Erosive esophagitis occurs when excessive reflux of acid and pepsin results in necrosis of surface layers of esophageal mucosa, causing erosions and ulcers. Patients with erosive esophagitis can be asymptomatic or present with heartburn, regurgitation, dysphagia, and odynophagia [1]. The diagnosis and management of erosive esophagitis are discussed separately. (See "Clinical manifestations and diagnosis of gastroesophageal reflux in adults", section on 'Endoscopic findings' and "Initial management of gastroesophageal reflux disease in adults", section on 'Severe or frequent symptoms'.)

Barrett's esophagus — Barrett's esophagus is a condition in which metaplastic columnar epithelium replaces the stratified squamous epithelium that normally lines the distal esophagus [2]. The metaplastic epithelium is acquired as a consequence of chronic gastroesophageal reflux disease (GERD) and predisposes to the development of esophageal cancer. The specialized intestinal columnar metaplasia typical of Barrett's esophagus causes no symptoms. Most patients are seen initially for symptoms of associated GERD, such as heartburn, regurgitation, and dysphagia. GERD associated with long-segment Barrett's esophagus is frequently complicated by esophageal ulceration, stricture, and hemorrhage. (See "Barrett's esophagus: Epidemiology, clinical manifestations, and diagnosis", section on 'Clinical features'.)

Esophageal stricture — Peptic strictures are a result of the healing process of ulcerative esophagitis. Collagen is deposited during this phase and, with time, the collagen fibers contract, narrowing the esophageal lumen. These strictures are usually short in length and contiguous with the gastroesophageal junction; endoscopy may also reveal adjacent areas of reflux esophagitis (picture 1 and image 1). Patients may have solid food dysphagia and episodic food impaction. The management of benign esophageal strictures involves dilation combined with acid-suppressive therapy with a proton pump inhibitor or potassium-competitive acid blocker to prevent stricture recurrence [3,4]. (See "Endoscopic interventions for nonmalignant esophageal strictures in adults" and "Initial management of gastroesophageal reflux disease in adults".)

Esophageal cancer — GERD with erosive esophagitis is associated with a two- to threefold increased risk of esophageal adenocarcinoma relative to the general population [5]. In a population-based cohort of 56,139 individuals, severe reflux was associated with an increased risk of mortality from esophageal adenocarcinoma in men (hazard ratio 6.1, 95% CI 2.3-15.9) [6]. However, mortality rates from esophageal adenocarcinoma were low (0.27 per 1000 person-years in men). Severe reflux was not associated with an increased risk of all-cause mortality, cancer-specific mortality, or mortality from lung or head-and-neck cancer.

Gastric reflux is also associated with an increased risk of laryngeal cancer; however, it is unclear if GERD is causal [7]. (See "Barrett's esophagus: Surveillance and management", section on 'Cancer risk'.)

EXTRAESOPHAGEAL COMPLICATIONS — 

Regurgitation and/or aspiration of gastric juice have been associated with several extraesophageal complications. However, the role of gastroesophageal reflux disease (GERD) in the pathogenesis of these disorders is often overestimated.

Asthma — GERD has a prevalence of 30 to 80 percent in individuals with asthma and can potentially trigger asthma symptoms [8,9]. Symptom overlap between GERD and asthma (eg, chest pain and cough) may lead patients to confuse reflux-induced symptoms with an asthma exacerbation [10]. Three potential mechanisms have been proposed whereby esophageal acid may produce bronchoconstriction and therefore exacerbate airflow obstruction in asthmatics: increased vagal tone, heightened bronchial reactivity, and microaspiration of gastric contents into the upper airway. The association between reflux and asthma, as well as the management of GERD in patients with asthma, are discussed separately. (See "Gastroesophageal reflux and asthma".)

Otolaryngologic complications — Laryngopharyngeal reflux (LPR), the reflux of gastric contents into the laryngopharynx, can cause contact injury to the pharyngeal and laryngeal mucosa and lead to otolaryngologic complications, such as chronic laryngitis, laryngeal and tracheal stenosis, laryngospasm, and vocal cord dysfunction. However, the prevalence of LPR in otolaryngologic injury and its precise relation to laryngeal symptoms is unclear, particularly given the paucity of accurate diagnostic criteria for LPR [11]. (See "Laryngopharyngeal reflux in adults".)

Chronic laryngitis — LPR can also cause laryngitis, or a change in voice quality or hoarseness. Other symptoms associated with LPR include throat clearing, persistent cough, globus sensation (sensation of a lump or foreign body in the throat), laryngospasm, or choking sensation. The potential cause of laryngeal symptoms is multifactorial and includes LPR, primary laryngeal pathology, postnasal drip, sinus and allergic disorders, and pulmonary conditions. Symptom-scoring questionnaires can evaluate symptom burden and therapeutic response; however, they do not accurately determine that LPR is causing these symptoms [12]. The diagnosis and management of laryngitis, globus sensation, and LPR are discussed separately. (See "Hoarseness in adults" and "Globus sensation" and "Laryngopharyngeal reflux in adults".)

Laryngeal and tracheal stenosis — LPR can result in laryngeal and tracheal stenosis. Presenting symptoms in patients with central airway obstruction are nonspecific and can be subacute or acute. The clinical manifestations typically depend upon the degree of luminal obstruction, as well as the location and length of time that obstruction has been present. Symptoms include dyspnea, cough, hemoptysis, and wheezing. (See "Clinical presentation, diagnostic evaluation, and management of malignant central airway obstruction in adults", section on 'Etiology and pathophysiology'.)

LPR may also play an important role in the development of subglottic stenosis in patients intubated for prolonged periods [13]. The vocal process of the arytenoids and the posterior cricoid are the sites most often injured by intubation. Following initial disruption of the mucosa, periodic exposures of the exposed cartilage to gastric secretions results in inflammation and a hyperplastic reparative process [14].

Other complications — Other potential chronic complications of GERD include chronic cough, dental erosions, chronic sinusitis, chronic tonsilitis, recurrent pneumonitis, and interstitial lung disease [15-18]. (See "Causes and epidemiology of subacute and chronic cough in adults" and "Chronic rhinosinusitis: Clinical manifestations, pathophysiology, and diagnosis" and "Cryptogenic organizing pneumonia".)

SOCIETY GUIDELINE LINKS — 

Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Gastroesophageal reflux in adults".)

INFORMATION FOR PATIENTS — 

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Acid reflux and GERD in adults (The Basics)" and "Patient education: Esophageal stricture (The Basics)")

●Beyond the Basics topics (see "Patient education: Gastroesophageal reflux disease in adults (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Pathophysiology – Gastroesophageal reflux disease (GERD) may result in esophageal or extraesophageal complications. These complications may result from direct inflammation due to the refluxate or as a consequence of the reparative process (eg, peptic stricture and Barrett's metaplasia). (See 'Introduction' above.)

●Esophageal complications

•Erosive esophagitis – Erosive esophagitis occurs when excessive reflux of acid and pepsin results in necrosis of surface layers of esophageal mucosa, causing erosions and ulcers. Patients with erosive esophagitis can be asymptomatic or present with heartburn, regurgitation, dysphagia, and odynophagia. (See 'Erosive esophagitis' above.)

•Barrett's esophagus – Barrett's esophagus is the replacement of the stratified squamous epithelium that normally lines the distal esophagus with metaplastic columnar epithelium. The metaplastic epithelium results from chronic GERD and predisposes to the development of esophageal cancer. (See 'Barrett's esophagus' above.)

•Peptic stricture – Peptic strictures result from the healing process of ulcerative esophagitis. Patients may have solid food dysphagia and episodic food impaction. Management usually involves dilation combined with acid-suppressive therapy. (See 'Esophageal stricture' above.)

•Esophageal cancer – Erosive esophagitis is associated with a two- to threefold increased risk of esophageal cancer. (See 'Esophageal cancer' above and "Barrett's esophagus: Surveillance and management", section on 'Cancer risk'.)

●Extraesophageal complications

•Asthma – GERD is common in patients with asthma and has been identified as a potential trigger for asthma symptoms. Bronchospasm may result from increased vagal tone, heightened bronchial reactivity, and microaspiration of gastric contents into the upper airway. (See 'Asthma' above.)

•Otolaryngologic complications – Otolaryngologic complications of GERD can result from laryngopharyngeal reflux (LPR) of gastric contents with subsequent contact injury of the pharyngeal and laryngeal mucosa. (See 'Otolaryngologic complications' above.)

LPR can cause chronic laryngitis, a change in voice quality or hoarseness. Because the etiology of laryngitis is multifactorial, its presence does not necessarily implicate LPR. (See 'Chronic laryngitis' above.)

LPR can lead to laryngeal and tracheal stenosis, which commonly presents with dyspnea, cough, hemoptysis, and/or wheezing. The acuity and clinical manifestations typically depend upon the location, degree, and duration of luminal obstruction. (See 'Laryngeal and tracheal stenosis' above.)

●Other complications – Other chronic complications of GERD include chronic cough, dental erosions, chronic sinusitis, and recurrent pneumonitis. (See 'Other complications' above.)