Acid Reflux (GERD) and the Esophagus
Nearly everyone has an attack of heartburn at some point in their lives. In the vast majority of cases the condition is temporary and mild, causing only short-term discomfort. If patients develop persistent gastroesophageal reflux disease with frequent relapses, and it remains untreated, serious complications may develop over time. Complications can include:
- Erosive esophagitis
- Severe narrowing (stricture) of the esophagus
- Barrett's esophagus
- Problems in other areas, including the teeth, throat, and airways leading to the lungs
Older people are at higher risk for complications from persistent GERD. The following conditions also put individuals at risk for recurrent and serious GERD:
- Very inflamed esophagus
- Severe symptoms
- Symptoms that continue in spite of treatments to heal the esophagus
- Severe muscle abnormalities
Despite the complications that can occur with the condition, GERD does not appear to shorten life expectancy.
Erosive Esophagitis and its Complications
Erosive esophagitis develops in chronic GERD patients when acid irritation and inflammation cause extensive injuries to the esophagus. The longer and more severe the GERD, the higher the risk for developing erosive esophagitis.
Bleeding. Bleeding may occur in about 8% of patients with erosive esophagitis. In very severe cases, people may have dark-colored, tarry stools (indicating the presence of blood) or may vomit blood, particularly if ulcers have developed in the esophagus. This is a sign of severe damage and requires immediate attention.
Sometimes long-term bleeding can result in iron-deficiency anemia and may even require emergency blood transfusions. This condition can occur without heartburn or other warning symptoms, or even without obvious blood in the stools.
Barrett's Esophagus and Esophageal Cancer
Barrett's esophagus. Barrett's esophagus (BE) leads to abnormal changes in the cells of the esophagus, which puts a patient at risk for esophageal cancer.
About 10% of patients with symptomatic GERD have BE. In some cases, BE develops as an advanced stage of erosive esophagitis. While obesity, alcohol use, and smoking have all been implicated as risk factors for Barrett's esophagus, their role remains unclear. Only the persistence of GERD symptoms indicates a higher risk for BE.
Not all patients with BE have either esophagitis or symptoms of GERD. In fact, studies suggest that more than half of people with BE have no GERD symptoms at all. BE, then, is likely to be much more prevalent and probably less harmful than is currently believed. (BE that occurs without symptoms can only be identified in clinical trials or in autopsies, so it is difficult to determine the true prevalence of this condition.)
The incidence of esophageal cancer is higher in patients with Barrett's esophagus. Most cases of esophageal cancer start with BE, and symptoms are present in less than half of these cases. Still, only a minority of BE patients develop cancer. When BE patients develop abnormalities of the mucus membrane cells lining the esophagus (dysplasia), the risk of cancer rises significantly. There is some evidence that acid reflux may contribute to the development of cancer in BE.
Complications of Stricture
If the esophagus becomes severely injured over time, narrowed regions called strictures can develop, which may impair swallowing (a condition known as dysphagia). Stretching procedures or surgery may be required to restore normal swallowing. Strictures may actually prevent other GERD symptoms, by stopping acid from traveling up the esophagus.
Asthma and Other Respiratory Disorders
Asthma. Asthma and GERD often occur together. Some theories about the connection between GERD and asthma are:
- Small amounts of stomach acid backing up into the esophagus can lead to changes in the immune system that trigger asthma.
- Acid leaking from the lower esophagus stimulates the vagus nerves, which run through the gastrointestinal tract. These stimulated nerves cause the nearby airways in the lung to constrict, producing asthma symptoms.
- Acid backup that reaches the mouth may be inhaled (aspirated) into the airways. Here, the acid triggers a reaction in the airways that causes asthma symptoms.
There is some evidence that asthma triggers GERD, but in patients who have both conditions, treating GERD does not appear to improve asthma.
Other Respiratory and Airway Conditions. Studies indicate an association between GERD and various upper respiratory problems that occur in the sinuses, ear and nasal passages, and airways of the lung. People with GERD appear to have an above-average risk for chronic bronchitis, chronic sinusitis, emphysema, pulmonary fibrosis (lung scarring), and recurrent pneumonia. If a person inhales fluid from the esophagus into the lungs, serious pneumonia can occur. It is not yet known whether treating GERD would also reduce the risk for these respiratory conditions.
Dental erosion (the loss of the tooth's enamel coating) is a very common problem among GERD patients, including children. It results from acid backing up into the mouth and wearing away the tooth enamel.
Chronic Throat Conditions
An estimated 20 - 60% of patients with GERD have symptoms in the throat (hoarseness, sore throat) without any significant heartburn. A failure to diagnose and treat GERD may lead to persistent throat conditions, such as chronic laryngitis, hoarseness, difficulty speaking, sore throat, cough, constant throat clearing, and granulomas (soft, pink bumps) on the vocal cords.
GERD commonly occurs with obstructive sleep apnea, a condition in which breathing stops temporarily many times during sleep. It is not clear which condition is responsible for the other, but GERD is particularly severe when both conditions occur together. Both conditions may also have risk factors in common, such as obesity and sleeping on the back. Studies suggest that in patients with sleep apnea, GERD can be markedly improved with a continuous positive airway pressure (CPAP) device, which opens the airways and is the standard treatment for severe sleep apnea.
Complications in Infants and Children
Feeding Problems. Children with GERD tend to refuse food and may be late in eating solid foods.
Associations with Asthma and Infections in the Upper Airways. In addition to asthma, GERD is associated with other upper airway problems, including ear infections and sinusitis.
Rare Complications in Infants. Although GERD is very common, the following complications only occur in rare cases:
- Failure to thrive
- Anemia resulting from feeding problems and severe vomiting
- Acid backup that is inhaled into the airways and causes pneumonia
The infant's life may be in danger if acid reflux causes spasms in the larynx severe enough to block the airways. Some experts believe this chain of events may contribute to sudden infant death syndrome (SIDS). More research is needed to determine whether this association is valid.