Gastro-oesophageal reflux disease and respiratory disease

Abstract An epidemiological survey showed that respiratory symptoms with gastro-oesophageal reflux (GER) were twice as high as those without GER symptoms. In 46 cases of unknown chronic cough or asthma, 67% had positive oesophageal pH monitoring. Of 34 patients with snoring and reflux symptoms, 16 (47.1%) were confirmed as positive for obstructive sleep apnoea (OSA) and GER. Anti-reflux therapy significantly improved both GER and OSA.     

Gastro-oesophageal reflux disease and asthma

Abstract Gastro-oesophageal reflux disease (GOR) and asthma are both common medical conditions that often co-exist. Studies using oesophageal manometry and 24 h ambulatory pH monitoring have shown that up to 80% of asthmatics have abnormal GOR. A number of mechanisms whereby GOR may trigger asthma have been proposed, and it is believed that acid reflux may stimulate vagal receptors in the lower oesophagus causing reflex bronchoconstriction. However, GOR may be worsened by asthma causing abnormal diaphragm mechanics and by its treatment. Formal evaluation of GOR should be considered a part of asthma assessment, particularly if asthmatic symptoms are precipitated by factors known to trigger GOR such as reclining, alcohol ingestion, and the use of theophylline. Twenty-four hour ambulatory intra-oesophageal pH monitoring remains the gold standard for the diagnosis of GOR. Medical therapy with anti-refux medications, such as acid suppressive agents and prokinetic agents may improve both GOR and asthma control. In those who fail medical therapy, anti–reflux surgery may be warranted in some.     

Gastro-oesophageal reflux disease in Asia

Gastro-oesophageal reflux disease (GORD) occurs more frequently in Europe and North America than in Asia but its prevalence is now increasing in many Asian countries. Many reasons have been given for the lower prevalence of GORD in Asia. Low dietary fat and genetically determined factors, such as body mass index and maximal acid output, may be important. Other dietary factors appear to be less relevant. Increased intake of carbonated drinks or aggravating medicines may influence the increasing rates of GORD in some Asian countries but no strong evidence links other factors, such as the age of the population, smoking or alcohol consumption, to GORD. The management of GORD in Asia is similar to that in Europe and North America but the lower incidence of severe oesophagitis in Asia may alter the approach slightly. Also, because Asians tend to develop stomach cancer at an earlier age, endoscopy is used routinely at an earlier stage of investigation. Gastro-oesophageal reflux disease is essentially a motility disorder, so short-term management of the disease can usually be achieved using prokinetic agents (or histamine (H2)-receptor antagonists). More severe and recurrent GORD may require proton pump inhibitors (PPI) or a combination of prokinetic agents and PPI. The choice of long-term treatment may be influenced by the relative costs of prokinetic agents and PPI.     

Gastro-oesophageal reflux and interstitial lung disease

BACKGROUND: Interstitial lung disease is a heterogeneous entity, which encompasses a large number of pulmonary disorders, including idiopathic pulmonary fibrosis. Gastro-oesophageal reflux appears to be more prevalent in idiopathic pulmonary fibrosis than in controls and in patients with secondary pulmonary fibrosis, but its contribution to interstitial lung disease remains unsettled. AIMS: To prospectively evaluate gastro-oesophageal reflux in patients with interstitial lung disease and to define acid reflux patterns in patients with idiopathic and secondary forms of pulmonary fibrosis. MATERIALS AND METHODS: Twenty-eight patients (15M, median age 66 years, interquartile range 60-71) were studied by history taking, pulmonary function tests, high resolution computed tomography, oesophageal manometry and 24h oesophago-gastric pH monitoring. RESULTS: Sixteen patients (57%) had typical reflux symptoms. All patients completed 24h pH metry and 14 underwent oesophageal manometry. An abnormal oesophageal acid exposure was observed in 19 patients (68%), 13 of which complained of predominant typical reflux symptoms. A diagnosis of idiopathic pulmonary fibrosis was made in 18 patients, while the remaining 10 patients were classified as secondary pulmonary fibrosis. Secondary pulmonary fibrosis patients had more restrictive lung defect, as expressed as Tiffeneau index (p<0.05) and greater acid reflux at nighttime (p<0.05) than idiopathic pulmonary fibrosis patients. CONCLUSIONS: The prevalence of abnormal acid reflux in interstitial lung disease patients is high and, in particular, patients with secondary pulmonary fibrosis show higher oesophageal acid exposure than those with idiopathic form.     

Gastro-oesophageal reflux disease and motility disorders

Gastro-oesophageal reflux (GOR) is a common phenomenon occurring at any age with a benign prognosis in the majority of cases, but requiring prompt evaluation and treatment when presenting with alarm symptoms or when persisting. Complications of GOR disease (GORD) may be severe. This chapter will discuss the epidemiology, natural course, pathophysiology, clinical presentation, diagnostic and therapeutic approach towards GORD and motility disorders according to different ages. Similarities and differences between infants, children and adults will be highlighted. The superior efficacy and safety of proton pump inhibitors have recently changed the diagnostic and therapeutic recommendations in adults, and possible indications in children are discussed. Only in patients unresponsive to optimal medical treatment are further investigations to exclude other aetiologies for GORD needed (e.g. eosinophilic oesophagitis in infants, scleroderma in adults). Special patient groups such as those with congenital malformations (e.g. oesophageal atresia) are not considered, whereas neurological, respiratory and allergy-affected patients as well as Helicobacter pylori infection are briefly discussed.     

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胃食管反流性咳嗽(gastroesophagealrefluxcough,GERC)也有人称为“胃食管反流相关性咳嗽”,是慢性咳嗽常见的原因之一。不同作者报道,GERC约占慢性咳嗽病因的10%～40%。1概念GERC是因胃酸和其他胃内容物反流进入食管,导致以慢性咳嗽为主要临床表现,超过8周以上,胸部X线检查正常的慢性咳嗽。胃食管反流(gastro-oesophagealreflux,GOR)是指胃内容物反流入食管。GOR可以引起临床症状,甚至组织病理学的改变。当出现胃烧灼、反酸、胸骨后疼痛等临床症状和(或)组织病理学的改变时,也被称为胃食管反流病(gastro-esophagealrefluxdisease,G…     

Gastro-oesophageal reflux disease and Helicobacter pylori

The interaction between gastro-oesophageal reflux disease (GERD) and Helicobacter pylori (H. pylori) infection has been the subject of intense scrutiny in recent years. Although the evidence base is incomplete it is now sufficient to clarify a number of key questions. H. pylori is not a risk factor for reflux disease. Similarly, H. pylori infection, in most patients, is not 'protective' against the risk of developing reflux and oesophagitis. Furthermore, reflux and oesophagitis are not more likely to develop or to worsen after H. pylori eradication therapy and eradication does not make control of reflux symptoms with proton pump inhibitor (PPI) therapy more difficult. Long term PPI therapy in the presence of H. pylori infection does increase the rate at which gastric mucosal atrophy and intestinal metaplasia develop. Eradication therapy has been shown to reduce this risk. In the uninfected stomach, PPIs are associated with a low likelihood of these adverse histological changes. PPI therapy reduces the accuracy of diagnostic tests for H. pylori. The decision to test for and treat H. pylori infection in the context of reflux must be individualised based on patient factors including co-morbidity, age, gastric histology, family history and informed choice. Distinction must be made between treating symptoms and potentially reducing risks. A decision not to test for and treat H. pylori is now just as active a choice as is the decision to test and treat. Recent international consensus statements recommend eradication of H. pylori prior to long term PPI therapy in reflux disease, although there is not a universal agreement on this. Further research to clarify the risk and benefits of such an approach is required.     

Gastro-oesophageal reflux in infancy

Gastro-oesophageal reflux (GOR) is a common phenomenon in infants, which may occur with or without accompanying symptoms. Although most infants presenting with regurgitation have a normal physical examination, it is now recognized that infants may also present with a wide variety of symptoms. Oesophagitis is associated with increased oesophageal acid exposure. The determination of cause and effect is difficult, as there are many aspects of reflux disease where cause and effect relationships are cyclic. Reflux disease is present when there is an imbalance between a number of factors that can contribute to a decrease, as well as an increase, of GOR. Oesophageal pH monitoring with a semi-disposable monocrysant antimony pH catheter with three sensors is very good at documenting oesophageal acidification and gastric buffering and, therefore, quantifies acid reflux frequency and duration. However, the interpretation of the data is complex as they are influenced by numerous factors, such as position, activity (sleep, crying), feeding (frequency and composition) or medication. The duration of buffering of gastric acidity during pH monitoring might, in the future, appear to be a relevant factor in the interpretation of oesophageal pH data.     

Gastro-oesophageal reflux and severity of pulmonary disease in cystic fibrosis

The correlation between oesophageal dysfunction (OD), pathologic gastro-oesophageal reflux (GOR), and severity of pulmonary disease was studied in 12 patients with cystic fibrosis (CF). They were interviewed about symptoms of OD and underwent 24-h pH recording in the oesophagus, oesophageal manometry combined with reflux provocation tests, the acid perfusion test, the acid clearance test, lung function tests, and scoring of the chest radiograph. Six of the 12 patients reported symptoms of OD. Abnormal GOR, as shown by 24-h pH monitoring of the oesophagus, was found in eight of them. Altogether 9 of the 12 participants had at least one pathologic oesophagus test result. Results of radiologic examinations of the oesophagus, performed in six patients, were pathologic. The four patients with the best chest radiograph scores and the best lung function had significantly less signs and symptoms of OD and GOR than the other eight patients. We conclude that OD, GOR, and pulmonary disease covariate in CF.     

Gastro-oesophageal reflux disease in obesity: pathophysiological and therapeutic considerations

Gastro‐oesophageal reflux disease (GERD) is common in obese patients. Apart from the physical discomfort and the economic burden, GERD may increase morbidity and mortality through its association with oesophageal carcinoma. The pathophysiology of GERD differs between obese and lean subjects. First, obese subjects are more sensitive to the presence of acid in the oesophagus. Second, hiatal hernia, capable of promoting GERD by several mechanisms, is more prevalent among the obese. Third, obese subjects have increased intra‐abdominal pressure that displaces the lower oesophageal sphincter and increases the gastro‐oesophageal gradient. Finally, vagal abnormalities associated with obesity may cause a higher output of bile and pancreatic enzymes, which makes the refluxate more toxic to the oesophageal mucosa. The altered body composition associated with obesity affects the pharmacokinetics of drugs. There are no data regarding the efficacy of any of the drugs used for GERD treatment. The dosages of cimetidine and ranitidine should be calculated according to the patient’s ideal body weight, not their actual weight. Of the operative procedures used for weight loss, Roux‐en‐Y gastric bypass was found to be most effective for GERD, while gastric banding was associated with a high prevalence of reflux. This review outlines the pathophysiology and the treatment of GERD in obesity with emphasis on the therapeutic considerations in this population of patients.     

Gastro-oesophageal reflux and nocturnal asthma

Gastro-oesophageal (GO) reflux is believed to be a possible cause of nocturnal asthma. The aim of this study was to see if there is any correlation between the incidence of GO-reflux at night and nocturnal asthma. Thirty-seven adult patients with a history of nocturnal asthma for more than one hundred days a year and of reflux disease were evaluated using 24 h pH-monitoring of the oesophagus and measurement of peak expiratory flow (PEF) rate every hour when awake. Half of the patients suffered from severe GO-reflux at night, whilst the other half had no nocturnal reflux. Respiratory symptoms and inhalation of beta-2 agonists were recorded during the night and PEF was recorded when the patients awoke in the morning. A significant correlation was found between reflux at night and the degree of bronchial obstruction in the early morning, but not between night-time reflux and nocturnal respiratory symptoms. It would appear that GO-reflux in most asthmatics is neither a strong nor immediate trigger factor in nocturnal asthma, although it does seem to influence bronchial obstruction during the night as was demonstrated by a low morning-PEF value.     

Gastro-oesophageal reflux disease and obesity: Pathogenesis and response to treatment

The link between obesity and GERD is clear on all measures of the disease: clinical symptoms, erosive oesophagitis, acid esophageal exposure, and complications. The pathogenesis of this link may be due to general factors such as visceral adiposity, oestrogen levels, or decrease of Helicobacter pylori infection with increased gastric acid secretion. Increased abdominal pressure leads to disruption of the esophago-gastric junction and hiatal hernia, and esophageal motility may be modified by obesity. Weight loss does improve GERD, but lifestyle modifications and diet are usually insufficient in the long-term for morbid obesity. GERD and hiatal hernia are key issues in bariatric surgery, and are widely discussed because of important implications. It is not currently certain which procedure should be favoured in case of GERD; yet gastric bypass offers the best guarantee of success. Hiatal hernia repair is also deemed necessary by some authors at the same time of the bariatric surgery. Minimally invasive techniques pose a new challenge to this issue, both technically and theoretically.