The esophageal mucosal resistance: structure and function of an unique gastrointestinal epithelial barrier

The purpose of this review is to delineate the factors that contribute to the innate epithelial resistance of the esophageal mucosa when challenged with potentially damaging intraluminal aggressive factors that are present as a result of gastroesophageal reflux. The ability of this mucosa to act as an effective barrier is dependent on the structural complexity of its 20 to 30 cell layer-thick stratified squamous epithelia, its convoluted intercellular spaces (paracellular resistance), and the cellular ion transport mechanisms that maintain intracellular homoestasis (cellular resistance). Because H+ ion is the most important damaging agent in the gastroesophageal refluxate, we have primarily focused on mechanisms that impede or prevent H+ ion entry into the mucosa ("pre-epithelial" and "mucosal factors"), cellular mechanisms that allow cells to maintain their intracellular pH in the presence of an external acid environment ("cellular factors"), mechanisms that limit continued mucosal and cellular injury ("submucosal factors") and reparative processes that come into play after damage has occurred.