Complications and Prognosis of GORD

Complications for 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) (50% of people with GERD present with oesophagitis). 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
The normal squamous epithelium lining of the esophagus is replaced by metaplastic columnar epithelium. The medical significance of Barrett’s esophagus is its strong association with esophageal adenocarcinoma, a particularly lethal cancer. It is considered to be a premalignant condition because it is associated with an increased risk of esophageal cancer (more specifically, adenocarcinoma) of about 0.5% per patient-year. Barrett esophagus is present in 8-15% of patients with gastroesophageal reflux disease (GERD) and may progress to adenocarcinoma.
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.
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.




Some Stats
• White males are at a greater risk for Barrett esophagus and adenocarcinoma than other populations.
• Gastroesophageal reflux disease (GERD) is as common in men as in women.
• The male-to-female incidence ratio for esophagitis is 2:1-3:1. The male-to-female incidence ratio for Barrett esophagus is 10:1.
• Gastroesophageal reflux disease (GERD) occurs in all age groups.
• The prevalence of gastroesophageal reflux disease (GERD) increases in people older than 40 years.
• Deaths: 1,000 (USA annual deaths calculated from this data: 1,000 deaths in the USA 1984-88 for "GERD and related esophageal disorders" (Digestive diseases in the United States: Epidemiology and Impact – NIH Publication No. 94-1447, NIDDK, 1994))
• Incidence: 8,160,000 (USA prevalence calculated from this data: 3-7% of the population in the USA 1985 for "GERD and related esophageal disorders" (Digestive diseases in the United States: Epidemiology and Impact – NIH Publication No. 94-1447, NIDDK, 1994)
• 0.012% (ratio of deaths to prevalence).