Global burden of esophageal diseases: a comprehensive analysis of disease trends and risk factors from 1990 to 2021

Abstract

Background: Esophageal diseases (ED) are a common category of upper gastrointestinal disorders, mainly including gastroesophageal reflux disease (GERD), esophagitis, Barrett's esophagus, achalasia, and esophageal cancer (EC). In recent years, the high recurrence rate of GERD and poor prognosis of EC are paid more attention, collectively contributing to the global burden of ED.

Methods: For this study, we systematically analyzed the global distribution of ED from 1990 to 2021, detailing the burden across different countries, regions, and socio-demographic index (SDI) levels. Furthermore, we explored temporal trends in ED burden over this period and conducted decomposition analysis, health inequality analysis, and frontier analysis. Finally, we projected trends in ED burden from 2022 to 2045, and quantify contributions of associated risk factors to disability-adjusted life years (DALYs) of EC.

Results: The absolute numbers of incidence, mortality, and DALYs for GERD and EC showed increasing trends from 1990 to 2021, while their age-standardized rates (ASRs) demonstrated divergent patterns: stable for GERD and declining for EC. The highest ASRs were observed in low-middle SDI regions for GERD and high-middle SDI regions for EC, respectively, with population as a main driver. If current trends continue, the burden of GERD will continue to rise, whereas that of EC will persistently decline by 2045. In 2021, DALYs of EC were mainly attributed to smoking (36.5%) and alcohol use (16.2%).

Conclusions: For GERD and EC, the global burden continued to rise and decline from 1990 to 2021, respectively. Developing targeted public health strategies in different countries and regions is crucial for alleviating the global burden of ED.

Keywords: Disability-adjusted life years; Esophageal cancer; Gastroesophageal reflux disease; Global burden of diseases; Incidence; Mortality.

Fig. 1

The global burden of esophageal diseases in 204 countries and territories in 2021. a-c The incidence number (a), ASIR (b), and EAPC of ASIR (c) of GERD. d-f The DALYs number (d), ASDR (e), and EAPC of ASDR (f) of GERD. g-i The incidence number (g), ASIR (h), and EAPC of ASIR (i) of EC. j-l The mortality number (j), ASMR (k), and EAPC of ASMR (l) of EC. m-o The DALYs number (m), ASDR (n), and EAPC of ASDR (o) of EC. ASDR: age-standardized DALYs rate; ASIR: age-standardized incidence rate; ASMR: age-standardized mortality rate; DALYs: disability-adjusted life years; EAPC: estimated annual percentage change; EC: esophageal cancer; GERD: gastroesophageal reflux disease

Fig. 2

Relationships between sociodemographic index and age-standardized rates of esophageal diseases in 2021. a, c Relationships between SDI and ASIR (a) and ASDR (c) (per 100,000 persons) of GERD by GBD regions in 2021. b, d Relationships between SDI and ASIR (b) and ASDR (d) (per 100,000 persons) of GERD by countries in 2021. e, g, i Relationships between SDI and ASIR (e), ASMR (g), and ASDR (i) (per 100,000 persons) of EC by GBD regions in 2021. f, h, j Relationships between SDI and ASIR (f), ASMR (h), and ASDR (j) (per 100,000 persons) of EC by countries in 2021. ASDR: age-standardized DALYs rate; ASIR: age-standardized incidence rate; ASMR: age-standardized mortality rate; DALYs: disability-adjusted life years; EC: esophageal cancer; GBD: global burden of diseases; GERD: gastroesophageal reflux disease; SDI: sociodemographic index

Fig. 3

Sex-stratified age distribution of esophageal diseases burden in 2021. a, b Age-specific rates of GERD burden in 2021, including the specific incidence (a) and DALYs (b), stratified by sexes. c-e Age-specific rates of EC burden in 2021, including the specific incidence (c), mortality (d), and DALYs (e), stratified by sexes. DALYs: disability-adjusted life years; EC: esophageal cancer; GERD: gastroesophageal reflux disease

Fig. 4

The joinpoint analysis of age-standardized rates of esophageal diseases from 1990 to 2021. a, d The ASIR (a) and ASDR (d) changes of GERD globally. b, e The ASIR (b) and ASDR (e) changes of GERD by SDI regions. c, f The ASIR (c) and ASDR (f) changes of GERD by sexes. g, j, m The ASIR (g), ASMR (j), and ASDR (m) changes of EC globally. h, k, n The ASIR (h), ASMR (k), and ASDR (n) changes of EC by SDI regions. i, l, o The ASIR (i), ASMR (l), and ASDR (o) changes of EC by sexes. The color gradient represents SDI regions: purple (low SDI regions), light blue (low-middle SDI regions), green (middle SDI regions), red (high-middle SDI regions), and dark blue (high SDI regions) in the Fig. 4b, e, h, k, n. The color gradient represents sexes: dark blue (both), red (male), and green (female) in the Fig. 4c, f, i, l, o. ASDR: age-standardized DALYs rate; ASIR: age-standardized incidence rate; ASMR: age-standardized mortality rate; DALYs: disability-adjusted life years; EC: esophageal cancer; GERD: gastroesophageal reflux disease; SDI: sociodemographic index

Fig. 5

The decomposition analysis of the burden of esophageal diseases from 1990 to 2021. a, b The decomposition analysis of incidence (a) and DALYs (b) number changes of GERD by global and SDI regions in the both, male, and female. c-e The decomposition analysis of incidence (c), mortality (d), and DALYs (e) number changes of EC by global and SDI regions in the both, male, and female. DALYs: disability-adjusted life years; EC: esophageal cancer; GERD: gastroesophageal reflux disease; SDI: sociodemographic index

Fig. 6

The health inequality analysis for the burden of esophageal diseases in 1990 and 2021, globally. a, b The SDI-related health inequality regression and concentration curves for incidence (a) and DALYs (b) of GERD in 1990 and 2021, globally. c-e The SDI-related health inequality regression and concentration curves for incidence (c), mortality (d), and DALYs (e) of EC in 1990 and 2021, globally. DALYs: disability-adjusted life years; EC: esophageal cancer; GERD: gastroesophageal reflux disease; SDI: sociodemographic index

Fig. 7

The frontier analysis of the burden of esophageal diseases in 2021. a, b The frontier analysis based on SDI and ASIR of GERD in 2021. c, d The frontier analysis based on SDI and ASDR of GERD in 2021. e, f The frontier analysis based on SDI and ASIR of EC in 2021. g, h The frontier analysis based on SDI and ASMR of EC in 2021. i, j The frontier analysis based on SDI and ASDR of EC in 2021. The frontier is delineated in solid black color. Countries and territories are represented as dots. The top 15 countries with the largest effective difference are labeled in black. Examples of frontier countries with low SDI (< 0.5) and low effective difference are labeled in blue, and examples of countries and territories with high SDI (> 0.85) and relatively high effective difference for their level of development are labeled in red. Red dots indicate an decrease in ASRs from 1990 to 2021, blue dots indicate a increase in ASRs from 1990 to 2021. ASDR: age-standardized DALYs rate; ASIR: age-standardized incidence rate; ASMR: age-standardized mortality rate; ASRs: age-standardized rates; DALYs: disability-adjusted life years; EC: esophageal cancer; GERD: gastroesophageal reflux disease; SDI: sociodemographic index

Fig. 8

The predicted global burden of esophageal diseases from 2022 to 2045 by sexes. a The predicted the incidence number and ASIR of GERD burden from 2022 to 2045 by sexes globally. b The predicted the DALYs number and ASDR of GERD burden from 2022 to 2045 by sexes globally. c The predicted the incidence number and ASIR of EC burden from 2022 to 2045 by sexes globally. d The predicted the mortality number and ASMR of EC burden from 2022 to 2045 by sexes globally. e The predicted the DALYs number and ASMR of EC burden from 2022 to 2045 by sexes globally. ASDR: age-standardized DALYs rate; ASIR: age-standardized incidence rate; ASMR: age-standardized mortality rate; DALYs: disability-adjusted life years; EC: esophageal cancer; GERD: gastroesophageal reflux disease

Fig. 9

The population attributable fraction analysis of the disability-adjusted life years burden of esophageal diseases in 2021. a-d Contributions to DALYs (%) of EC attributable to smoking (a), alcohol use (b), diet low in vegetables (c), and chewing tobacco (d) by global, SDI regions, and GBD regions in the both, male, and female. DALYs: disability-adjusted life years; EC: esophageal cancer; GBD: global burden of diseases; SDI: sociodemographic index