A recent practice update (MF Vaezi, D Katzka, F Zerbib. Clin Gastroenterol Hepatol 2018; 16: 1018-29) reviews the data and provides up-to-date recommendations for extraesophageal symptoms attributed to gastroesophageal reflux disease (GERD) in adults.
Extraesophageal symptoms attributed to GERD could include cough, asthma, hoarseness, sore throat, sinusitis, dental erosions, and ear pain.
Non-GI evaluations by ENT, pulmonary and/or allergy are essential and often should be performed initially in most patients.
“Abnormalities seen on endoscopy have poor predictive value for determination of GERD as the cause of extraesophageal symptoms”
“Ambulatory pH/impedance monitoring…have limited ability to establish GERD as the cause of an extraesophageal symptom. The main role of testing is to document the absence of GERD.”
Empiric therapy with ‘aggressive’ acid suppression for 6-8 weeks can help in assessing association between reflux and extraesophageal symptoms.
Testing for reflux on therapy should be considered mainly in those with high probability of baseline reflux (eg. previous esophagitis, Barrett’s esophagus, or prior abnormal pH study).
Surgical treatment is discouraged in those with extraesophageal reflux symptoms unresponsive to aggressive PPI therapy
A recent prospective study (A M-L Ong et al. Clin Gastroenterol Hepatol 2018; 16: 407-16) of 36 patients (median age 45) showed that diaphragmatic breathing was helpful for PPI-refractory GERD symptoms/belching. Patients enrolled all had “troublesome belching” for 6 months and GERD. Patients underwent high resolution manometry and pH-impedance study.
9 of 15 (60%) in the diaphragmatic treatment group reduced their belching visual analog score by ≥50%, whereas none of the control group achieved the primary outcome
Treatment also resulted in lower GERD symptoms based on reflux disease questionnaire score -decrease of 12.2 vs 3.1 in the control group (P=.01)
Treatment improved QOL scores, based on Reflux-Qual Short form (15.7 increase for treatment group compared to 2.4 decrease in control group)
Treatment effects were sustained at 4 months after treatment
My take: Diaphragmatic breathing can be a useful adjunct in GERD, particularly in patients with belching.
Gastroenterology published a ‘special issue’ in January 2018 (volume 154; pages 263-451) which reviewed several esophageal diseases in-depth: gastroesophageal reflux disease (GERD), eosinophilic esophagitis (EoE), and esophageal cancer. For me, this issue served as a good review on GERD and EoE.
A couple of items that I picked up:
For both GERD and functional dyspepsia, “estimated prevalence values are approximately 20% for each.” (pg 269)
“15% of healthy individuals may have microscopic esophagitis” (pg 291)
For pH-impedance, the current view of non-acid reflux is unchanged: “unknown clinical relevance of non-acid reflux in the setting of aggressive acid suppression.” (pg 291)
Treatment algorithm for EoE (pg 353):
Induction treatment with any of the three approaches: high dose topical corticosteroids, double dose proton pump inhibitor (PPI) or elimination diet “because no comparative studies have shown any of these to be superior to the others.”
Then, re-evaluation after 2-3 months (clinical, endoscopic, and histologic). Responders should continue on therapy but maintenance treatment suggests low dose topical corticosteroid, lowering PPI to single dose, or continuing elimination diet. For nonresponders, switching to one of the other two treatment approaches is recommended.
The algorithm indicates that followup evaluation of responders to insure ongoing response should be considered 1 year later
As for dilatation, the authors note that this does not control the underlying inflammation and thus should not be used as monotherapy. Also, “after dilatation, 75% of patients have considerable chest pain that may last several days.” (pg 354)
Unrelated twitter post below -IgG allergy testing is NOT a good idea:
It is not uncommon for a pediatric gastroenterologist to see a patient with a chronic cough due to concerns about potential gastroesophageal reflux disease (GERD). As such, a recent clinical practice article (JA Smith, A Woodcock. NEJM 2016; 375: 1544-51) by lung specialists was of interest, even though this article was not targeted to the pediatric population.
The authors define a chronic cough as lasting more than 8 weeks and note that it common with respiratory conditions (eg. chronic obstructive pulmonary disease, asthma, and bronchiectasis) and some non-respiratory conditions (eg. gastroesophageal reflux and rhinosinusitis). Medications, particularly ACE inhibitors, can trigger a chronic cough as well.
Steps in evaluation: 1. H&P, CXR, spirometry. 2. Consider metacholine challenge, ENT evaluation, consider empiric treatment (eg. inhaled glucocorticoids, PPI), and consider GERD evaluation. 3. High-resolution CT and bronchoscopy.
For many patients, there is likely to be an abnormality in neuronal pathways controlling cough and the term “cough hypersensitivity syndrome” has been coined. Figure 2 (below) illustrates the neuronal pathways.
For refractory patients, potential therapies would include low-dose morphine, gabapentin or pregabalin, and speech language therapy.
Guidelines “suggest a trial of treatment with acid-suppression therapy” (eg. twice-daily PPIs for up to 3 months).
“Most randomized, controlled trials of reflux treatment for cough have not shown a significant improvement in association with this type of treatment.”
Subgroups of patients with heartburn, regurgitation, or excessive acid reflux on esophageal pH monitoring “appeared marginally more likely to have a response to PPI treatment.” pH or impedance tests “are poorly predictive of a response of cough to acid suppression.”
My take: In the absence of clinical reflux, reflux therapy is unlikely to help with chronic cough. However, in patients with an adequate workup, an empiric course of a PPI is likely more preferable than empiric morphine or gabapentin.
This post’s title question turns out to be quite tricky. According to a recent study (RL Rosen et al. JPGN 2016; 63: 210-17), reflux burden, even in children that aspirate did not correlate with increased hospitalization.
Here are the details:
Methods: Prospectively recruited cohort of 116 children who had both pH-impedance testing along with modified barium swallow. The authors considered pathologic reflux to have at least 73 episodes on pH-impedance or if pH<4 for >6% of study period.
There was no statistical correlation between pH-impedance study results and total number of admissions even with or without adjusting for aspiration status (and neurologic complications).
When the authors tried to reconcile these findings, they offered three competing potential explanations for these results:
Reflux has little impact on hospitalziations
Our methods for measuring reflux are not good
Even “normal” reflux can be a problem for those prone to complications; therefore, reflux burden is not consequential.
What is clear is that pH-impedance studies cannot predict which patients are at risk for increased complications. This is supported by data showing that ‘reflux-related’ hospitalizations may not improve after fundoplication (Pediatrics 2006; 118: 2326-33; J Pediatr Surg 2008; 43: 59-63). One particularly important limitation was that the cause of hospitalizations was determined by medical record review.
My take: A simple algorithm for preventing aspiration pneumonia does not exist. Even the role of reflux testing is uncertain.
L Laine, A Nagar. Am J Gastroenterol 2016; 111: 913-15.
This reference explains how these clinicians discuss the long-term use of proton-pump inhibitors with their adult patients. Thanks to Ben Gold for this reference. Here are a couple pointers:
“The recent studies about CKD (chronic kidney disease) and dementia, similar to many prior studies assessing PPI risk, are retrospective observational studies…This results in differences between PPI users and non-users in factors that may impact study outcomes and confound results.”
Gastroesophageal reflux disease: The authors suggest that PPIs for GERD can be stopped >2 weeks after symptoms resolve. For infrequent symptoms, H2RAs, lifestyle modifications and intermittent PPIs often suffice.
Barrett’s esophagus: “observational sutdies suggest that PPIs may decrease progression to neoplastic Barrett’s esophagus”
WHAT WE TELL PATIENTS: “Because of inherent risk of bias and low effect sizes we cannot conclude that associations of PPIs and adverse outcomes such as dementia and CKD in recent observational studies are vailid…Nevertheless, we cannot conclude that risks do not exist…we need to ensure that benefits outweigh potential risk. If PPIs are indicated, using the lowest effective dose and, if possible, intermittent rather than daily therapy..should decrease the risk of potential side effects.”
On the same topic, Paul Moayyedi (in Gastroenterology and Endoscopy News, August 2016): “Every study has shown that sicker patients tend to be prescribed PPIs…Sick patients tend to develop other illnesses so PPIs will be associated with about any disease you can imagine in a database.” As such, he asserts that weak associations (OR <2) are usually due to cofounding factors. “The only benefit [these studies]..have is that it is another opportunity to discuss with the patients about stopping their PPI therapy, as there are a significant proportion…on these drugs unnecessarily.”
Every now and then a dentist sends a kid to our GI practice due to eroded teeth because of concerns about reflux damaging the enamel. While it is recognized that reflux may damage teeth, the exact frequency is unclear. Other questions:
Which asymptomatic kids with poor dentition require GI evaluation?
What is the best way to evaluate these children?
If reflux is identified, how long should they remain on treatment? Forever?
How effective is reflux treatment in reducing tooth damage?
While none of these questions have been definitely answered, Rosen et al (JPGN 2016; 62: 309-13) show that acid reflux rather than nonacid reflux is predictive of tooth erosion. In this study, the authors used a prospective cohort of 27 children (age ≥3 years)–ALL of them were ON acid suppression (for >1 year) at the time of pH-MII testing. Key findings:
Prevalence of tooth erosion was 10 or 27 (37%)
There was correlation with acid reflux episodes (& time in reflux) and tooth erosion, r=0.44, P=0.02
There was correlation with reflux index as well, r=0.54, P=0.004, In the tooth erosion group, the mean reflux index was 7.3% compared with 1.6% in no dental erosion group.
There was no correlation with nonacid reflux with tooth erosion
The authors’ discussion highlights many prior relevant studies and indicates that a pH-metry study alone (rather than pH-MII) “may be adequate.” They note some of the limitations of this study which included a small number of patients and potential referral bias, as these children had suspected GERD. In the methods section, the authors state that their standard practice, at the time of the study, was to maintain patients on prior acid suppression medication. It would be useful to acknowledge that many experts, at this time, recommend doing pH-MII studies as well as standard pH studies off all acid suppression due to improved sensitivity/accuracy.
My take: This study shows that in the 10 children with tooth erosion who had suspected GERD, there was correlation with acid reflux but not with nonacid reflux.
Overall, this is a terrific review and intended for a high level audience. Here are a couple of key points from the talk:
Dr. Jennifer Lightdale introduced the webinar. She noted that there has been a tremendous rise in the use of proton pump inhibitors (PPIs) in children over the past 15 years, including in infants.
Preponderance of evidence does not support use of PPIs for reducing GER symptoms or crying in infants.
PPIs are extremely effective at acid suppression.
Excellent discussion by Dr. Rachel Rosen on Nonerosive Reflux Disease (NERD) and distinguishing this entity from erosive reflux disease, hypersensitive esophagus, and functional heartburn.
On a microscopic level, NERD is similar to erosive reflux with microscopic inflammation and dilated intracellular spaces.
With regard to testing, it is recommended that for impedance studies, that acid suppression be stopped prior due to improved sensitivity/accuracy.
For those at odds with their pulmonologists and ENT colleagues, Dr. Ben Gold reviewed the literature on asthma, cough, and laryngeal-pharyngeal pathology related to reflux. The sensitivity of laryngoscopic findings to identify reflux is poor. “There is insufficient evidence to recommend for OR against the use of acid suppression therapy.”
Dr. Jose Garza reviewed the indications for PPI use which include eosinophilic esophagitis/PPI-REE, erosive esophagitis, NSAID prophylaxis, Upper GI bleeding, and H pylori therapy.
Dr. Carlo DiLorenzo provided an in-depth discussion of the potential risks of PPI therapy and explained some of the context as well as absolute risks. He noted that besides the risk of infection, particularly C difficile, other risks demonstrated in adults have not yet been confirmed in children.
“Prolonged acid suppression should be used only when indicated.” Thus, management should include strategies for treatment discontinuation in the majority of those receiving PPI therapy.