Extraoesophageal GERD

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Extraoesophageal GERD
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Extraoesophageal GERD

• A large number of extraoesophageal abnormalities
  have been attributed to GER.
• Only laryngeal and pumonary manifestations of
  GERD will be presented.

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Some of the proposed extraoesophageal
complications of GERD.

• Dental erosions
• Buccal burning
• Dry or sore throat
• Hoarseness
• Globus sensation
• Asthma, aspiration
• Lung abscess
• Pulmonary fibrosis
• Chronic cough
• Lateral cervical pain
• Laryngospasm, otalgia.
• Pharyngeal tightness

• Contact granuloma of TVC
• Cricopharyngeal dysfunction
• Torticollis
• Dental structure loss
• Posterior laryngitis
• Recurrent resp disease
• Apneic episodes, voice loss
• Subglotic tracheal stenosis
• Non cardiac chest pain
• Bad breath
• Choking sensation.
• Otitis media

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Association of GERD with non-seasonal Bronchial
asthma and Pulmonary diseases

• Bronchial asthma is characterized by inflammation
  and irreversible constrictions of the airways.
• Reports have described an association between
  abnormal pulmonary function and GER, this is
  supported by improvement or even disappearance of
  asthmatic state in some patients with either
  medical or surgical management of GERD.

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Association of GERD with non-seasonal Bronchial
asthma and Pulmonary diseases

• Two different mechanisms of GERD associated
  asthma have been postulated
• Aspiration of gastric contents into lung
  resulting in exudative mucosal reaction leading
  to inflammation and narrowing of bronchial tree.
• Neuorohumoral mechanism caused by activation of
  vagovagal reflex arc from esophagus to the lung
  by entry of gastric acid into the esophagus and
  resulting in bronchial constriction.

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Association of GERD with non-seasonal Bronchial
asthma and Pulmonary diseases

• Bronchodilator therapy may potentially predispose
  to more GER by decreasing the LESP.GER barrier is
  weakened in asthmatics (flattening of diaphragm,
  change in thoraco-abdominal pressure ratio).
• Prevalence of hiatal hernia in asthmatic is
  increased
• These predispose to overt macroscopic
  oesophagitits, that is more prevalent in
  asthmatics.

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Association of GERD with non-seasonal Bronchial
asthma and Pulmonary diseases

• Diurnal variation in airway resistance with its
  peak at early morning hours has been found to be
  exaggerated in nocturnal asthmatics.
• Night time reflux through a vagovagal reflex
  arc may add to this increased airway resistance
  and contribute to development of symptoms of
  asthma.
• Theory of micro aspiration of gastric contents
  especially gastric acid into the lung, requires
  that contents reach the pharynx, then enter the
  airway.
• Depending on extent of invasion, it can
  potentially contribute to airway diseases such as
  asthma if acid is carried deep into airways,
  subglottic stenosis if it is confined to trachea,
  vocal cord granuloma, nodules or inflammation of
  posterior cords and commissure (posterior acid
  laryngitis) if extent of spread is limited to
  glottis.

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Association of GERD with non-seasonal Bronchial
asthma and Pulmonary diseases

• Asthmatics who demonstrate GER symptoms need to
  be treated adequately for their reflux disease.
  In addition asthmatics in whom control of
  bronchospasm is difficult to achieve the
  possibility of GERD needs to be considered.

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Association of GERD with non-seasonal Bronchial
asthma and Pulmonary diseases

• GERD has been implicated in pathogenesis of
  bronchitis, bronchiectasis, hemoptysis, pulmonary
  consolidation, purulent pleurisy, pulmonary
  fibrosis, recurrent pulmonary diseases.
• Clinical outcome of aspiration depends on volume
  and composition of aspirate but probably more
  important on mucocilliary function of
  tracheobronchial tree.

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Association of GERD with non-seasonal Bronchial
asthma and Pulmonary diseases

• The possibility of underlying and causative
  esophageal lesion should be considered in every
  case of pulmonary infiltration of obscure
  etiology.
• Several studies suggest an association between
  GERD and chronic persistent cough.
• Distal esophageal acid infusion has been reported
  to increase frequency and amplitude of cough
  compared to saline infusion in patients with
  chronic cough.

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Association of pharyngeal/laryngeal reflux of
gastric contents with benign lesions of aero
digestive tract

• Laryngeal tissue is not normally adapted to acid
  exposure, it has been suggested that frequent and
  longstanding exposure to gastoesophageal
  refluxate may result in benign as well as
  malignant changes at these sites.
• Contact ulcer, contact granuloma, vocal cord
  nodule or polyp, post commissure erythema,
  subglottic stensosis have been attributed in part
  to GER.

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Association of pharyngeal/laryngeal reflux of
gastric contents with benign lesions of aero
digestive tract

• Role of GER in laryngeal malignancy is supported
  by observation that some patients with laryngeal
  malignancy do not have obvious risk factors(
  smoking, drinking, FH, exposure to noxious
  material).
• Hypothesis that stomach acid is etiological
  factor in cancer larynx is similar to observation
  that refluxed acid is causative factor in ca
  esophagus in patients with Barrett's esophagus.
• It is a prevalent clinical observation that use
  of acid suppressing agents results in improvement
  of a number of benign inflammatory laryngeal
  lesions such as vocal cord granuloma, posterior
  contact ulcer, posterior laryngitis.
• Etiologic role of GER in pathogenesis of benign
  and malignant laryngopharyngeal diseases has not
  been completely studied although strong clinical
  evidence for such association exists.

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Association of pharyngeal/laryngeal reflux of
gastric contents with benign lesions of aero
digestive tract

• Consumption of alcohol and use of tobacco are
  both known to increase the risk of Carcinoma of
  aero digestive tract. Alcohol and tobacco can
  both predispose an individual to develop GER as
  both are reported to decrease LES pressure.
• This may lead to the postulation that GER may
  play a primary or secondary role in pathogenesis
  of aero digestive benign and malignant lesions
  among smokers and drinkers.