**3. Thoracic manifestations**

Thoracic manifestations can occur secondary to the wide range of esophageal disorders: inflammatory process, infections, trauma and perforation, congenital malformations, esophageal motility disorders and benign and malignant neoplasms. Complications associated with these diseases and disorders can involve the mediastinum, tracheobronchial tree, and lungs. Lower respiratory system and esophagus share a common embryological derivation and are anatomically related. Pulmonary complications can be associated with high morbidity and mortality. Such complications can be categorized as:


Gastroesophageal reflux disease has been linked to a variety of respiratory diseases either as a direct cause, or as a risk factor to the inability to control or worsening of the disease. It can cause various pulmonary manifestations and nonspecific complaints: chronic cough and fewer, recurrent pneumonia, noncardiac chest pain, sputum production and dyspnoea, bronchospasm. Epidemiological studies in patients with reflux esophagitis have shown an increased risk for chronic bronchitis, chronic obstructive pulmonary disease, pneumonia, and idiopathic pulmonary fibrosis. Chronic cough and bronchial asthma are more common respiratory manifestations of GERD. Pathological GERD has been described in 30% to 80% of patients with asthma. Micro-aspiration of gastric contents and/or vagal irritation from gastro esophageal reflux may constitute airway irritants and thus represent a potential pathogenic mechanism for acute illness or acute exacerbations of chronic pulmonary diseases. Exacerbations of chronic obstructive pulmonary disease is twice as high in patients with GERD as in those without GERD symptoms. GERD can produce lung disease by two mechanisms: by reflex neural mechanisms occuring during reflux events limited to the lower part of esophagus, and direct from gastric contents refluxed into the pharynx producing upper airway damage and lung disease. While gastroesophageal reflux may increase airways resistance and cause inflammation by releasing pro-inflammatory mediators, esophagopharyngeal reflux creates the potential to aspiration and its consequences which varies depending of the duration, volume and nature of the aspirate [44]. Chronic cough is considered to be a cough that is continuously present for eight weeks and longer. Among the etiological factors, the three most common causes of chronic cough can be singled out: postnasal drip syndrome, asthma and gastroesophageal reflux. In 75% of cases, patients with chronic cough do not have the typical symptoms of

esophagitis or gastroesophageal reflux disease, yet the result of 25% of patients with symptoms of both types speaks in favor of the association of chronic cough and esophageal disease [45]. Namely, the determination of correlation is primarily based on the strength and direction of the correlation, and not only on the frequency and percentage of results.

### **4. Cardiac manifestations**

Coronary heart disease and gastroesophageal reflux disease can interact and produce chest pain. Some recent studies have shown that exposure of the esophageal mucosa to acid can compromise myocardial perfusion and cause chest pain by inducing coronary spasm or cardiac dysrythmia [46–48]. On the other hand, myocardial ischemia can cause esophageal dysmotility or relaxation of the lower esophageal sphincter and exacerbate GERD [49]. GERD can worsen sleep disturbances, and sleep apnea increases the risk of a cardiovascular diseases [50]. These two diseases have a number of common risk factors and comorbidities, such as diabetes, hypertension, hyperlipidemia, smoking and alcoholism, gender and age [51, 52]. Proton pump inhibitors, as a treatment option in GERD therapy can also affect cardiovascular physiology. One of the big population-based study shows that PPI usage can reduce the cardioprotective effects of certain therapies, and it can also reduce the contractility of myocardial tissue and raise the risk of atherosclerosis by increasing the serum levels of homocysteine by impairing the absorption of vitamin B12. This study indicates that GERD is associated with an increased risk of developing coronary heart disease, and PPI therapy that lasts longer than one year might increase the risk of CHD [53].

#### **5. Conclusion**

Esophageal symptoms are common and often overlap between different esophageal disorders, making a diagnosis based solely on patient history, symptoms, and physical presentation challenging. Esophageal motility disorders often manifest with chest pain and dysphagia. Other symptoms are heartburn, regurgitation, weight loss and malnutrition. Chest pain is localized behind the sternum, and does not spread to the shoulders and arms, which distinguishes it from cardiac pain. Gastroesophageal reflux (GER) symptoms have been reported in up to 20% of the adult population, which makes GER one of the common gastrointestinal disorders with a chronic or recurrent nature. Patients often complain of heartburn and acid regurgitation. The presence of this symptoms at least once a week for the last 3 months are considered essential in diagnosis of a clinical disorder called gastroesophageal reflux disease (GERD) [54]. Gastroesophageal reflux is often associated with symptoms of the respiratory tract. Chronic cough of unknown origin, laryngeal complaints, throat discomfort, breathing disorders, bronchitis, pneumonia and even non allergic asthma, resistant to steroid therapy, are suspicious of being reflux related. Other symptoms are haematemesis, eructation, dysphagia, odynophagia, hiccups, changes in the oral, nasal and pharyngeal mucosa, dental erosions and cardiac problems. Laryngopharyngeal reflux (LPR) is present in up to 60% of GERD patients. Symptoms of this multifactorial syndrome are mainly extraesophageal, and are found in the head and neck region. The most common symptoms are cough, hoarseness, dysphonia, sore throat, globus pharyngeus, chronic postnasal drip, and Eustachian tube dysfunction, Some studies have shown that LPR has been associated with vocal cord polyps, vocal cord granulomas,

#### *Extraesophageal Manifestations and Symptoms of Esophageal Diseases DOI: http://dx.doi.org/10.5772/intechopen.96751*

laryngospasm, subglottic stenosis and laryngeal carcinoma [55]. Esophagitis can be caused by reflux mechanism, infections, caustic agents, ionizing radiation, thermal injuries, eating disorders, medications, and as a part of some sistemic diseases. The most common symptoms are dysphagia and odynophagia, heartburn and acid regurgitation, haematemesis. Severe and prolonged vomiting and straining can results in tears in the mucous membrane of the esophagus. This condition is called Mallory-Weiss Syndrome. The main symptoms are hematemesis and melena, and in severe cases heavier bleeding may occur. Ribs and webs are the most common structural abnormalities of the esophagus. Most of them are asymptomatic, but can occasionally present with intermittent dysphagia to solids. They are associated with Zenker's diverticulum and Plummer-Vinson Syndrome which is classically a triad of dysphagia, iron-deficiency anemia, and esophageal webs. Esophageal rings are almost always associated with a hiatal hernia [56]. The esophagus is the most common site of acute foreign body obstruction. The clinical presentation varies from mild to extremely severe, and the most common symptoms are hypersalivation and odynophagia [57]. Esophageal perforation is a rare and potentially life-threatening condition most commonly caused by manipulations with medical instruments, forced strining and foreign bodies. The most common symptoms are odynophagia, chest pain, vomiting and shortness of breath, and in 70% of patients with perforation of the intrathoracic esophagus there are pleuromediastinum and palpable crepitus in the soft tissue of the neck and thorax. Caustic injuries of the esophagus are potentially one of the most challenging clinical situations in gastroenterology. Caustics and corrosives cause tissue injury by a chemical reaction. The severity of injury and the clinical presentation depends on several aspects: Concentration of the substance, amount ingested, duration of tissue contact, location of damage, and pH of the agent: hoarseness, stridor, dysphagia, odynophagia, hematemesis, epigastric pain. Short-term complications include perforation and death [58, 59]. Esophageal cancer is the sixth most common cause of cancer deaths worldwide. In the initial stage it usually shows no symptoms. The most common symptoms are dysphagia, chest pain, pressure or burning, heartburn, coughing or hoarseness, weight loss, bleeding, and hiccups. As can be seen, almost all esophageal diseases shows atypical and extraesophageal symptomatology. Due to proper and accurate diagnosis and treatment, the cooperation of a multidisciplinary team is required.
