Questions and Complications
Is all reflux abnormal?
No, reflux is actually a normal event that we all experience. Fortunately, the episodes are so brief that they neither cause damage nor symptoms. Normal reflux usually occurs right after we eat, strain or lift and lasts a few minutes at most. It always occurs during the day and never at night. Nighttime reflux is always abnormal.
Does everyone who has abnormal reflux need surgery?
Can GERD affect my voice?
Yes. The constant bathing of the vocal cords in refluxed material, especially at night, can result in chronic hoarseness. In addition, it may lead to inflammatory vocal cord polyps and even laryngeal cancer. GERD can also contribute to poor dentition.
Can GERD affect my breathing?
Yes. The reflux of acid or stomach contents into the back of your throat can enter your lungs leading to wheezing, asthma and pneumonia. In addition, it can produce a chronic cough, especially at night. Recent studies have shown that many patients with asthma also have GERD and that surgical treatment of the reflux improves many of these patients' symptoms. Unfortunately, it is not yet possible to predict which patients with asthma and GERD will have a significant reduction in their asthma after anti-reflux surgery.
Complications which may require surgery include:
- Esophageal stricture
An esophageal stricture is a narrowing-usually at the very end of the esophagus-that is the result of chronic scarring. It results in painful and difficult swallowing and often weight loss. It is usually first diagnosed by an upper GI x-ray series. A stricture must be distinguished from a narrowing caused by cancer. This is done by an upper endoscopy and biopsy.
How is an esophageal stricture treated?
Strictures are treated by dilation. Tubes of increasing diameters or an inflatable balloon are passed down the throat, through the esophagus and into the stomach until the desired size of the esophagus is reached. This is almost always successful in restoring swallowing, but it may offer only temporary relief. The stricture often will recur, especially if the reflux is not eliminated.
- Reflux esophagitis
Reflux esophagitis is the term for a reddened esophagus that results from acid burning the esophagus and inflaming it. One can think of it as a second or third degree burn of the esophagus. Bleeding, usually of a chronic nature, can result from this inflammation and irritation.
- Esophageal ulcers
Esophageal ulcers are craters or erosions in the esophagus, similar to a cigarette burn on the skin. They result from a high amount, or long duration, of acid contact on the esophagus in a particular place. They are usually diagnosed by endoscopy, and will resolve if the reflux disorder is treated. They can cause significant pain, especially when swallowing, and can also be the source of significant bleeding.
- Barrett's esophagus
Barrett's esophagus is a pre-cancerous change of the internal lining of the esophagus from thin, flat cells (squamous cells) to a taller type of cell (columnar cells). For unknown reasons, these cells have a high rate of deterioration into cancer-approximately 1% per year. As a result, every six months endoscopies and biopsies are performed on people with Barrett's to watch for further deterioration into unusual but not cancerous cells (dysplasia). When severe dysplasia is present, removal and replacement of the esophagus is performed.
- Does everyone with GERD have Barrett's esophagus? No, but up to 40% of people with GERD will develop it. In addition, 10-20% of people have Barrett's when they are first diagnosed with GERD. This is because most patients do not seek medical attention for GERD until the symptoms are severe. They think it's just heartburn, but by the time they see a doctor, Barrett's esophagus has already developed.
- Does Barrett's go away with treatment? There is no known treatment for Barrett's esophagus. Spontaneous regression or disappearance has been reported after surgery or medicine, but it is rare. The best treatment is to prevent it from occurring. Once present, aggressive treatment of GERD may limit or stop the progression of the Barrett's esophagus. This can be done with medications or surgery. Recent efforts in the treatment of Barrett's are focused on removing the abnormal cells with a laser, and then performing an anti-reflux operation. It is too early to tell if this will help.