Esophageal Reflux: What Are The Implications For Your Patients?
There is a causal-relationship between gastroesophageal reflux disease (GERD), Barrett’s esophagus, and laryngeal cancer.
GERD is a condition marked by the reflux of stomach contents that causes troublesome symptoms and/or complications.
Chronic GERD can lead to Barrett’s esophagus, a condition in which any extent of the metaplastic columnar epithelium that predisposes to cancer development replaces the stratified squamous epithelium that normally lines the distal esophagus.
Esophageal columnar metaplasia predisposes to the development of adenocarcinoma whereby malignant tumors are formed from glandular structures in the epithelial tissue of the larynx.
Regurgitation and/or aspiration of gastric content due to GERD is associated with several extraesophageal complications, including Barrett’s esophagus.
Barrett’s esophagus develops through the process of metaplasia as a consequence of chronic GERD. In most patients, mucosal squamous cell damage due to reflux is repaired by the regeneration of more squamous cells. In some patients, however, the reflux-damaged esophagus is repaired through columnar metaplasia in which columnar cells replace the reflux-damaged squamous cells.
- Patients with Barrett’s esophagus often have few or no symptoms and signs of GERD
- Because of this, Barrett’s can only be diagnosed with an upper endoscopy and biopsy
- Guidelines from the American Gastroenterological Association recommend screening in people who have multiple risk factors for Barrett’s esophagus
- Chronic GERD that exposes the larynx to gastric contents can lead to Barrett’s esophagus
- Those over the age of 50 have the highest number of cases
- The majority of Barrett’s esophagus cases are found in men
- Whites are at a higher risk than other groups
- Having a history of a hiatal hernia elevates one’s risk
- Being overweight elevates your risk, especially if the weight is carried around the middle
- Smoking has been associated with an increased risk of Barrett’s esophagus; the condition is 1.7 times greater in smokers than in nonsmokers without GERD and 1.6 times greater in smokers than in nonsmokers with GERD
- Barrett’s esophagus develops through the process of metaplasia as a consequence of chronic GERD
- Because Barrett’s esophagus presents with little or no symptoms, screening individuals with multiple risk factors is highly recommended
- White males over the age of 50 have the highest risk, along with those who smoke, or who have a history of chronic GERD, hiatal hernia or who carry extra weight around their middle
- Only a small percentage of people with GERD, less than one out of every 10 people, will develop Barrett’s esophagus
The worst potential risk of GERD and Barrett’s esophagus is the development of squamous cell cancer of the larynx. The larynx is the most common site of head and neck squamous cell carcinoma. It accounts for 26 percent of all cases.
Cancers due to Barrett’s esophagus evolve through a sequence of DNA alterations that give the cells certain growth advantages. This causes morphological changes in the tissue that the pathologist can recognize as dysplasia, histological abnormalities where one or more clones of cells have acquired genetic damage rendering them neoplastic and predisposed to malignancy.
- A change in your voice, such as hoarseness, lasting longer than 3 weeks
- Trouble swallowing or a sore throat lasting longer than 6 weeks
- A lump in the neck
- Trouble breathing
- A cough that will not go away
- An earache that will not go away
- Smoking tobacco causes most laryngeal cancers and heavy smokers who have smoked tobacco for an extended period of time are most at risk
- Heavy drinkers are more likely to develop laryngeal cancer than people who don’t drink alcohol; the risk increases with the amount of alcohol a person drinks
- Chronic GERD that exposes the larynx to gastric contents can lead to Barrett’s esophagus and laryngeal cancer
- The larynx is the most common site of head and neck squamous cell carcinoma accounting for 26 percent of all cases
- Laryngeal cancer can evolve from Barrett’s esophagus through a sequence of DNA alterations causing morphological changes in the tissue of the larynx, rendering them neoplastic and predisposed to malignancy
- Between 0.1 to 2.0 percent of those with Barrett’s esophagus each year go on to develop esophageal cancer
- Smoking, drinking alcohol, and GERD are the major risk factors for laryngeal cancer
Implications for Primary Care Physicians:
- Consider screening patients at age 50 (unless symptoms arise prior) for those adults with associated risk factors for GERD
- Educate patients on reducing risk factors for GERD with avoidance of water beds, diet choices (less coffee, citrus drinks, tomato-based products, chocolate, peppermint, and fatty food are not good), weight management, lifestyle choices, smoking cessation, and moderate alcohol consumption
Dr. Irfan Firdaus, an OHC medical oncologist and principal investigator for OHC gastrointestinal clinical trials, practices in our Blue Ash, Eden Park, an West offices. His specific interests include gastrointestinal cancer, prostate cancer, and gynecological cancer. For more information on this topic, visit: www.asge.org