Official reprint from UpToDate® www. uptodate.com
Complications of gastroesophageal reflux in adults
Author Peter J Kahrilas, MD Section Editor Nicholas J Talley, MD, PhD Deputy Editor Peter A L Bonis, MD
Last literature review for version 16.2: mayo 31, 2008 | This topic last updated: abril 23, 2007 INTRODUCTION — The complications ofgastroesophageal reflux disease (GERD) can be broadly divided into three categories:
Esophagitis, which can be associated with a variety of symptoms, including heartburn, regurgitation, and dysphagia. (See "Clinical manifestations and diagnosis of gastroesophageal reflux in adults");
Consequences of the reparative process of esophagitis — peptic stricture and Barrett's metaplasia);and Extraesophageal manifestations of reflux, such as asthma, laryngitis, and cough.
This topic review will discuss the complications of reflux other than esophagitis, each of which occurs in a continuum of severity. The pathophysiology of this disorder, the consequences of Barrett's metaplasia, and the medical and surgical management of esophagitis are presented separately. PEPTICSTRICTURE — 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. The strictures are usually short in length and contiguous with the gastroesophageal junction; endoscopy may also reveal adjacent areas of reflux esophagitis (show endoscopy 1 and show radiograph 1). Themain symptoms that they produce are solid food dysphagia and episodic esophageal obstruction. Treatment — Many reports have confirmed the benefit of conservative management of benign strictures by dilation [1,2]. Dramatic relief of dysphagia can be attained by
http://www.utdol.com/online/content/topic.do?topicKey=eso_dis/5875&view=print (1 of 9)27/10/2008 06:35:06 p.m.
Complications ofgastroesophageal reflux in adults
mechanical dilation with mercury-filled, rounded, or tapered dilators. This generally requires dilation to a lumen diameter ≥14 mm (44 French). Unyielding, tortuous, or tight strictures may require an endoscopically positioned balloon dilator or a dilator passed over an endoscopically or fluoroscopically positioned metal guide wire (show endoscopy 2). (See "Managementof benign esophageal strictures"). Severe strictures invariably require several dilations. The schedule for serial dilations should be based upon the type of stricture, its response to initial and subsequent dilation, and the patient's tolerance of the procedure. Treatment with a proton pump inhibitor can prevent the recurrence of strictures once they have been adequately dilated [3,4]; thebenefit is greater than that achieved with H2 blockers . (See "Medical management of gastroesophageal reflux disease in adults"). Although effective, surgery is only rarely required for peptic strictures. One report evaluated 160 patients who underwent an antireflux operation and dilation for peptic stricture; the results of early operation appeared to be comparable to, or better than, those ofconservative treatment by dilation alone . However, this conclusion was obtained prior to the availability of proton pump inhibitors. COMPLICATIONS OF EXTRAESOPHAGEAL REFLUX — Gastroesophageal reflux followed by regurgitation and/or aspiration of gastric juice has been associated with several extraesophageal complications including asthma, posterior laryngitis, chronic cough , dental erosions, chronic sinusitis [8,9], recurrent pneumonitis, nocturnal choking, chronic hoarseness, pharyngitis, subglottic stenosis, and laryngeal cancer. Convincing evidence exists linking each of these entities to reflux in some patients. (See "Evaluation of subacute and chronic cough in adults"). However, it remains difficult to establish a causal relationship in an individual patient because, even if...