Long-term clinical course of extra-oesophageal manifestations in patients with gastro-oesophageal reflux disease. A prospective follow-up analysis based on the ProGERD study

Irritant-Induced Chronic Cough Triggers: A Scoping Review and Clinical Checklist

Purpose The primary aim of this review was to identify environmental irritants known to trigger chronic cough through the life span and develop a comprehensive clinically useful irritant checklist. Method A scoping review was conducted using the Preferred Reporting Items for Systematic Review and Meta-Analysis Extension for Scoping Reviews, checklist, and explanation. English-language, full-text resources were identified through Medline, PsycINFO, SPORTDiscus, Web of Science, and ProQuest Dissertations and Theses Global. Results A total of 1,072 sources were retrieved; of these, 109 were duplicates. Titles of abstracts of 963 articles were screened, with 295 selected for full-text review. Using the exclusion and inclusion criteria listed, 236 articles were considered eligible and 214 different triggers were identified. Triggers were identified from North America, Europe, Africa, Asia, and Australia. Occupational exposures were also delineated. Conclusions A clinically useful checklist of both frequently encountered triggers and idiosyncratic or rare triggers was developed. The clinical checklist provides a unique contribution to streamline and standardize clinical assessment of irritant-induced chronic cough. The international scope of this review extends the usefulness of the clinical checklist to clinicians on most continents.

The diagnostic value of GerdQ in subjects with atypical symptoms of gastro-esophageal reflux disease

BACKGROUND

Symptoms are essential in the clinical diagnosis of gastro-esophageal reflux disease (GERD). Questionnaires such as GerdQ have been developed as diagnostic aids. GerdQ has been thoroughly validated in well-characterized GERD patients, but has not yet been fully evaluated in a population that includes subjects with atypical symptoms.

AIM

To evaluate GerdQ in a population with typical and/or atypical symptoms of GERD, defined by 24-h pH monitoring. The secondary aim was to investigate the outcome of GerdQ depending on the response to proton pump inhibitor (PPI) treatment.

METHODS

The study included 646 subjects referred for 24-h pH monitoring due to a clinical suspicion of GERD. All subjects completed GerdQ before performing a 24-h pH monitoring.

RESULTS

In total, 377 (58%) subjects were diagnosed with GERD based on symptoms and 24-h pH monitoring (GERD_pH). Of these, 46% had atypical main symptoms. Overall, GerdQ (at cut-off 8) predicted GERD_pH with a sensitivity and specificity of 62% and 74%, respectively. A high specificity but poor sensitivity for diagnosis of GERD_pH was found for atypical main symptoms such as cough, dysphagia and globus. GerdQ had a relatively high sensitivity and specificity in predicting PPI response and a PPV of 99% at cut-off 8.

CONCLUSIONS

GerdQ has a diagnostic value in an unselected population presenting with typical and/or atypical symptoms of GERD, but a low sensitivity for diagnosis of GERD_pH was found in subjects with predominant symptoms such as cough, dysphagia and globus.

Medical Therapy of Gastroesophageal Reflux Disease Beyond Proton Pump Inhibitors: Where Are We Heading?

Proton pump inhibitors (PPI) have greatly improved the treatment of gastroesophageal reflux disease. However, recent investigations have revealed that reflux symptoms persist in a substantial number of patients. Therefore, treatment strategies beyond PPI are urgently required. One such strategy may involve more reliable acid suppression, e.g., with new acid inhibitory drugs. Furthermore, the rapid appearance of an acidic compartment in the proximal stomach after a meal, which is largely responsible for postprandial heartburn, requires a specific kind of therapy in addition to PPI which still needs to be established. Pharmacological augmentation of the lower esophageal sphincter may represent another approach to diminish reflux, but the clinical efficacy of compounds tested so far is limited. Altered e-sophageal perception represents a major component involved in the generation of reflux symptoms, particularly in non-erosive reflux disease, but effective pharmacological intervention is largely lacking. Presumed reflux-induced respiratory symptoms (cough, laryngitis, etc.) in the absence of typical esophageal symptoms (e.g., heartburn) remain a hot topic, but recent research points towards a hypersensitivity syndrome and only a minor role of gastroesophageal reflux. Treatment options for this condition are still pending.

Evaluation of treatment pattern and symptom control in patients with gastroesophageal reflux disease: multihospital questionnaire survey on the current situation in Korea

Proton pump inhibitors (PPIs) are the most effective treatment for gastroesophageal reflux disease (GERD); however, a considerable number of patients fail to respond to PPI therapy and complain of nocturnal heartburn and sleep disturbance. The aims of this study are to evaluate the treatment pattern of GERD-related medications and their efficacy in relieving nocturnal heartburn. A total of 334 patients with GERD receiving PPI therapy within 6 months were enrolled in a multihospital questionnaire survey from January, 2014 to March, 2015. GERD symptoms and patients' satisfaction were assessed by patient questionnaires, and treatment patterns of GERD-related medications were assessed by investigators. Among the 334 patients, 95.8% used PPI once daily and 58.6% used a half-dose of PPI. The PPI treatment pattern was changed in 26.6% of all patients, of those, 54% of the patients doubled the PPI dose, and 29.2% of the patients switched to another PPI. Approximately 60.3% of all patients were prescribed more than three GERD-related medications. The overall satisfaction rate was 61.8%, and 32.2% of patients experienced nocturnal heartburn and sleep disturbance. In the extended-release PPI group, there were fewer nocturnal symptoms compared with the conventional PPI group (10% vs. 33.7%, respectively, P = 0.027). The use of more than three medications was inversely associated with patients' satisfaction (OR = 0.355, 95% CI; 0.197-0.642, P = 0.001). Most patients were prescribed adjunctive medications other than PPIs; however, patients' satisfaction was inversely associated with multiple drugs. Patients' satisfaction was superior in extended-release PPIs than conventional PPIs for the relief of nocturnal heartburn in Korean patients.

pH/multichannel impedance monitoring in patients with laryngo-pharyngeal reflux symptoms - Prediction of therapy response in long-term follow-up

BACKGROUND AND STUDY AIM

Optimal therapy concepts in patients with laryngo-pharyngeal reflux (LPR) are still under discussion. Aim of this study was to evaluate long term symptom relief according to results in combined pH/multichannel impedance (MII) monitoring to predict therapy response and symptom relief during long term follow-up.

PATIENTS AND METHODS

In patients with predominant LPR symptoms, pH/MII monitoring and subsequent proton pump inhibitor (PPI) therapy were evaluated retrospectively after a minimum follow-up period of 36months. Patients were asked to complete symptom based questionnaires.

RESULTS

45 patients were evaluated and classified according to results of pH/MII. Twenty one patients showed a pathological finding in pH/MII. These patients reported significantly higher LPR-symptom intensity scores and a significantly higher LPR symptom-induced impairment of everyday life scores compared to patients with normal pH/MII monitoring at baseline and at follow-up. PPI associated symptom relief was significantly higher in patients with pathologic pH/MII monitoring (p=0.003).

CONCLUSION

In conclusion, combined pH/MII monitoring can reliably predict therapy response to PPIs in LPR patients. With negative results, PPI therapy should be avoided. This approach should be assessed in future prospective clinical trials.

pH Impedance vs. traditional pH monitoring in clinical practice: an outcome study

BACKGROUND

The addition of impedance to 24-h pH monitoring has allowed detection of weakly acidic reflux, but the extent to which pH-impedance (pH-MII) monitoring improves outcomes is unknown.

METHODS

This was a prospective observational study. Patients referred for pH or pH-MII monitoring completed a standardized questionnaire on improvement in the dominant symptom, their satisfaction, and treatment at 3 and 12 months after the test during a telephone interview.

RESULTS

A total of 184 patients (mean age, 52 years, range, 19-82 years; 35 % with typical symptoms; and 89 % tested off therapy) completed pH (n = 92) or pH-MII monitoring (n = 92) over a period of 15 months. The two arms were similar in terms of demographic, clinical, and endoscopic variables. Ten patients in the pH-MII arm showed evidence of weakly acidic reflux disease. There was no difference in the percentage of patients in the pH and pH-MII monitoring arms who experienced improvement in their dominant symptom after 3 (58 vs. 63 %; p = 0.621) or 12 months (66 vs. 70 %; p = 0.234), and the same was true for patient satisfaction. There were also no between-group difference in the use of proton pump inhibitors (PPIs) after 3 (63 vs. 68.5 %; p = 0.437) or 12 months (47 vs. 60.5 %; p = 0.051). PPIs were prescribed more frequently after a positive test (p < 0.001) although they were used by 45.6 % of the negative patients. Only one patient underwent fundoplication.

CONCLUSIONS

Two-thirds of patients undergoing pH-MII monitoring experience a positive outcome, similarly to what occurs after traditional pH monitoring. Physicians often pay little attention to the test results, especially if they are negative.

Comparison of Stretta procedure and toupet fundoplication for gastroesophageal reflux disease-related extra-esophageal symptoms

AIM: To compare the outcomes between the Stretta procedure and laparoscopic toupet fundoplication (LTF) in patients with gastroesophageal reflux disease (GERD)-related extra-esophageal symptoms.

METHODS: From January 2011 to February 2012, a total of 98 patients diagnosed with GERD-related extra-esophageal symptoms who met the inclusion criteria were enrolled in this study. All patients who either underwent the Stretta procedure or LTF treatment have now completed the 3-year follow-up. Primary outcome measures, including frequency and severity of extra-esophageal symptoms, proton pump inhibitor (PPI) use, satisfaction, and postoperative complications, were assessed. The results of the Stretta procedure and LTF therapy were analyzed and compared.

RESULTS: There were 47 patients in the Stretta group and 51 patients in the LTF group. Ninety patients were available at the 3-year follow-up. The total of the frequency and severity scores for every symptom improved in both groups (P < 0.05). Improvement in symptom scores of cough, sputum, and wheezing did not achieve statistical significance between the two groups (P > 0.05). However, the score for globus hysterics was different between the Stretta group and the LTF group (4.9 ± 2.24 vs 3.2 ± 2.63, P < 0.05). After the Stretta procedure and LTF treatment, 29 and 33 patients in each group achieved PPI therapy independence (61.7% vs 64.7%, P = 0.835). The patients in the LTF group were more satisfied with their quality of life than those in the Stretta procedure group (P < 0.05). Most complications resolved without intervention within two weeks; however, two patients in the LTF group still suffered from severe dysphagia 2 wk after the operation, and it improved after bougie dilation treatment in both patients.

CONCLUSION: The Stretta procedure and LTF were both safe and effective for the control of GERD-related extra-esophageal symptoms and the reduction of PPI use.

Response of chronic cough to acid-suppressive therapy in patients with gastroesophageal reflux disease

BACKGROUND

Epidemiologic and physiologic studies suggest an association between gastroesophageal reflux disease (GERD) and chronic cough. However, the benefit of antireflux therapy for chronic cough remains unclear, with most relevant trials reporting negative findings. This systematic review aimed to reevaluate the response of chronic cough to antireflux therapy in trials that allowed us to distinguish patients with or without objective evidence of GERD.

METHODS

PubMed and Embase systematic searches identified clinical trials reporting cough response to antireflux therapy. Datasets were derived from trials that used pH-metry to characterize patients with chronic cough.

RESULTS

Nine randomized controlled trials of varied design that treated patients with acid suppression were identified (eight used proton pump inhibitors [PPIs], one used ranitidine). Datasets from two crossover studies showed that PPIs significantly improved cough relative to placebo, albeit only in the arm receiving placebo fi rst. Therapeutic gain in seven datasets was greater in patients with pathologic esophageal acid exposure (range, 12.5%-35.8%) than in those without (range, 0.0%-8.6%), with no overlap between groups.

CONCLUSIONS

A therapeutic benefit for acid-suppressive therapy in patients with chronic cough cannot be dismissed. However, evidence suggests that rigorous patient selection is necessary to identify patient populations likely to be responsive, using physiologically timed cough events during reflux testing, minimal patient exclusion because of presumptive alternative diagnoses, and appropriate power to detect a modest therapeutic gain. Only then can we hope to resolve this vexing clinical management problem.

Airway reflux, cough and respiratory disease

It is increasingly accepted that the effects of gastro-oesophageal reflux are not limited to the gastrointestinal tract. The adjacent respiratory structures are also at risk from material ejected from the proximal oesophagus as a result of the failure of anatomical and physiological barriers. There is evidence of the influence of reflux on several respiratory and otorhinological conditions and although in many cases the precise mechanism has yet to be elucidated, the association alone opens potential novel avenues of therapy to clinicians struggling to treat patients with apparently intractable respiratory complaints. This review provides a description of the airway reflux syndrome, its effects on the lung and current and future therapeutic options.

Oral manifestations of gastroesophageal reflux disease

Numerous case-control and other studies involving confirmation of gastroesophageal reflux disease (GERD) by esophageal pH-metry and the assessment of dental erosions have shown significant associations between the two conditions in both adults and children. By contrast, when asked to vote on whether GERD may cause dental erosions, only 42% of physicians strongly agreed that such an association existed in adults, and just 12.5% strongly agreed for children, respectively in two global consensus reports. Part of this divergence between the perceptions of physicians and the findings of research publications may reflect a general lack of oral health education during medical training, and cursory oral examinations being made under less-than-ideal conditions. Adequate salivary secretions are essential for the protection of the teeth and the oropharyngeal and esophageal mucosa. The quantity and quality of the saliva require monitoring as many drugs, including several of the proton pump inhibitors (PPIs), can cause hyposalivation. In addition, PPIs do not always result in adequate acid suppression. Therefore, collaboration between physicians and dentists is strongly advocated to prevent or ameliorate possible adverse oral effects from both endogenous and exogenous acids, and to promote adequate saliva production in patients with GERD.

Diagnostic yield of 96-h wireless pH monitoring and usefulness in patients' management

OBJECTIVE

To get insight into usefulness of 96-h wireless monitoring in diagnosis of gastro-esophageal reflux disease (GERD) and in patients' management.

MATERIAL AND METHODS

51 patients who underwent 96-h wireless and 51 matched patients who underwent 24-h traditional pH monitoring were enrolled and retrospectively contacted with a structured telephone interview.

RESULTS

In the wireless group, the 96-h recording improved (p < 0.05) the diagnostic yield compared with the first 48-h recording by allowing Symptom Association Probability to be measured in eight more patients and by decreasing indeterminate tests from 11 to 5. After pH monitoring, concordance between results of the test and treatment for GERD was higher in the wireless compared with the traditional group, 78% versus 58% of the patients (p < 0.05). Both improvement/disappearance of the clinically relevant symptom and satisfaction (score of 1-10) at time of the telephone interview were however similar in the two groups, 73% versus 65% and 7.0 versus 6.5.

CONCLUSIONS

Wireless pH monitoring prolonged to 96 h increased the likelihood to exclude/confirm GERD as the cause of the clinically relevant symptoms in those patients with an indeterminate result for GERD after the first 48 h. Outcome was however similar to the one of traditional pH monitoring.

Relationship between gastro-oesophageal reflux and airway diseases: the airway reflux paradigm

Our understanding of the relationship between gastro-oesophageal reflux and respiratory disease has recently undergone important changes. The previous paradigm of airway reflux as synonymous with the classic gastro-oesophageal reflux disease (GORD) causing heartburn has been overturned. Numerous epidemiological studies have shown a highly significant association of the acid, liquid, and gaseous reflux of GORD with conditions such as laryngeal diseases, chronic rhinosinusitis, treatment resistant asthma, COPD and even idiopathic pulmonary fibrosis. However, it has become clear from studies on cough hypersensitivity syndrome that much reflux of importance in the airways has been missed, since it is either non- or weakly acid and gaseous in composition. The evidence for such a relationship relies on the clinical history pointing to symptom associations with known precipitants of reflux. The tools for the diagnosis of extra-oesophageal reflux, in contrast to the oesophageal reflux of GORD, lack sensitivity and reproducibility. Unfortunately, methodology for detecting such reflux is only just becoming available and much additional work is required to properly delineate its role.

[Cheilitis: a new manifestation of gastro-oesophageal reflux?]

BACKGROUND

Gastro-oesophageal reflux (GOR) is a common disease. Extra-oesophageal clinical signs associated with the disease and affecting the ENT (otitis media, rhinitis, laryngitis), pulmonary and stomatological spheres have been described for a number of years. We report three cases of cheilitis potentially attributable to GOR.

CASE REPORT

Three female patients consulted for cheilitis present for several months. Screening for an infectious cause was negative, as was allergological investigation using skin tests. However, questioning revealed nocturnal breathing through the mouth in all three patients as well as symptomatic GOR in one patient. Test therapy comprising proton-pump inhibitors was proposed and after 1month symptoms had subsided completely. Gastro-oesophageal endoscopy performed in the subsequent weeks revealed oesophagitis in all patients.

DISCUSSION

Extra-oesophageal signs described during the course of GOR mainly affect the ENT sphere and pulmonary sphere (cough, asthma) and are doubtless due to the direct caustic action of gastric secretions on the mucus membrane. Although gastroenterological investigation (endoscopy, 24-h pHmetry) may be negative, treatment with proton-pump inhibitors results in complete resolution of symptoms. The cases we describe suggest for the first time that extra-oesophageal sites affected by GOR may include the labial semimucosa.

Development and validation of a laryngopharyngeal reflux questionnaire, the Pharyngeal Reflux Symptom Questionnaire

OBJECTIVE

To develop and validate the Pharyngeal Reflux Symptom Questionnaire (PRSQ), a comprehensive, disease-specific, self-administered questionnaire for laryngopharyngeal reflux (LPR) disease.

MATERIAL AND METHODS

The PRSQ was developed based on empirical evidence from a literature review and expert input from physicians and patients and tested in a pilot study. In this validation study, a total of 228 patients were included and classified according to the Reflux Symptom Index (RSI) cut-off score. Patients with an RSI score > 13 were defined as abnormal, i.e. having LPR disease (n = 102), and those with a score between 0 and 13 were defined as normal controls (n = 126). Psychometric properties of the PRSQ were evaluated by exploring the factor structure and by evaluating internal consistency and item convergent and discriminant validity. Convergent and discriminant validity were determined by using the Laryngopharyngeal Reflux-Health Related Quality of Life questionnaire (LPR-HRQL), the RSI and the Short Form-36.

RESULTS

The PRSQ was well accepted by the patients. Compliance was satisfactory and missing item rates were low. After item reduction, due to items not being conceptually relevant or scaling errors and/or low factor loadings, a construct was achieved with no scaling errors and high internal consistency (Cronbach's alpha 0.79-0.93). The correlations between the PRSQ and similar dimensions in the RSI and LPR-HRQL were generally strong. Discriminant validity was satisfactory as the questionnaire discriminated between patients with and without LPR disease.

CONCLUSION

The PRSQ showed good psychometric properties and may become a valuable instrument for assessing LPR disease.

Gastroesophageal reflux in bronchiolitis obliterans syndrome: a new perspective

BACKGROUND

Long-term survival after lung transplantation (LTx) is limited largely by bronchiolitis obliterans syndrome (BOS). Gastroesophageal reflux disease (GERD) is proposed as a risk factor for BOS development. This study investigates the relationship between BOS and GERD measured by esophageal impedance.

METHODS

After the initiation of routine screening for GERD, 59 LTx recipients underwent ambulatory esophageal impedance monitoring. Exposure to acid reflux and non-acid liquid reflux was recorded. Clinical outcomes were reviewed to analyze any effect of reflux on the time to development of BOS.

RESULTS

Thirty-seven (65%) had abnormal acid reflux and 16 (27%) had abnormal non-acid reflux. There was no relationship between acid reflux and BOS. The hazard ratio (HR) for development of BOS in the presence of abnormal non-acid reflux was 2.8 (p = 0.043). The HR for development of BOS increased to 3.6 (p = 0.022) when the number of acute rejection episodes was also taken into account.

CONCLUSIONS

GERD is prevalent in LTx recipients and may represent a modifiable risk factor for BOS. This study found non-acid reflux, measured by esophageal impedance to be associated with the development of BOS. Prospective studies are now required to investigate a causal association between GERD and the development of BOS and to establish the role of surgery for GERD in preventing progression to BOS. The methods used to identify GERD in future studies may be important.

Pulmonary manifestations of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) may cause, trigger or exacerbate many pulmonary diseases. The physiological link between GERD and pulmonary disease has been extensively studied in chronic cough and asthma. A primary care physician often encounters patients with extra esophageal manifestations of GERD in the absence of heartburn. Patients may present with symptoms involving the pulmonary system; noncardiac chest pain; and ear, nose and throat disorders. Local irritation in the esophagus can cause symptoms that vary from indigestion, like chest discomfort and abdominal pain, to coughing and wheezing. If the gastric acid reaches the back of the throat, it may cause a bitter taste in the mouth and/or aspiration of the gastric acid into the lungs. The acid can cause throat irritation, postnasal drip and hoarseness, as well as recurrent cough, chest congestion and lung inflammation leading to asthma and/or bronchitis/ pneumonia. This clinical review examines the potential pathophysiological mechanisms of pulmonary manifestations of GERD. It also reviews relevant clinical information concerning GERD-related chronic cough and asthma. Finally, a potential management strategy for GERD in pulmonary patients is discussed.

Clinical course of laryngo-respiratory symptoms in gastro-oesophageal reflux disease during routine care--a 5-year follow-up

BACKGROUND

Gastro-oesophageal reflux disease (GERD) can be associated with laryngo-respiratory symptoms (LRS) such as chronic cough, asthma or laryngeal symptoms.

AIM

To analyse the long-term clinical course of LRS in a large population with GERD and LRS.

METHODS

ProGERD is a prospective multicentre cohort study of 6215 adult out-patients with GERD. At baseline, the prevalence of LRS was assessed. Initial standardized treatment was esomeprazole for up to 8 weeks. After 5 years of follow-up, patients were interviewed for LRS and a multivariate analysis was performed with resolved vs. persistent symptoms for chronic cough, asthma and laryngeal symptoms.

RESULTS

In all, 2886 patients (46.4%) were available for analysis at baseline and at 5 years. The prevalence of chronic cough and laryngeal disorders had decreased while the prevalence of asthma had increased. Resolution of LRS was independent of clinical reflux characteristics or PPI medication.

CONCLUSIONS

In a large population with GERD, only few patients reported persistent LRS over 5 years. Resolution of LRS was independent of the stage of GERD and PPI treatment. Accordingly, data on the direction of causality between GERD and LRS are lacking and the strength of the association between the two must remain controversial.

Serum gastrin and pepsinogens do not correlate with the different grades of severity of gastro-oesophageal reflux disease: a matched case-control study

BACKGROUND

Gastrin and pepsinogens reflect the functional state of the gastric mucosa.

AIM

To evaluate whether serum gastrin and pepsinogens correlate with the different grades of severity of gastro-oesophageal reflux disease (GERD).

METHODS

In all, 388 patients with heartburn not taking any form of acid suppressive therapy were matched-controlled for age and gender and sub-classified into four groups: group 1 non-erosive reflux disease (NERD); group 2, erosive reflux disease (ERD) Los Angeles (LA) A and B, group 3, ERD LA C and D; group 4 Barrett's oesophagus (BO). Fasting serum was analysed for gastrin 17, pepsinogen I, pepsinogen II und Helicobacter pylori using specific EIA tests (GastroPanel; Biohit, Plc).

STATISTICS

Kruskal-Wallis test and analysis of variance.

RESULTS

There was a significant difference among the four groups with respect for pepsinogen I, but not for pepsinogen II, the pepsinogen I pepsinogen II ratio, H. pylori serology and gastrin levels. Pepsinogen I was the lowest in NERD and the highest in BO (median 91.6, mean +/- standard deviation 106.2 +/- 51.6 vs. median 114.7, mean +/- standard deviation 130.4 +/- 70.6; P = 0.046). Pepsinogen I levels were higher in H. pylori positive subjects. After adjusting for H. pylori status, the differences in pepsinogen I across patient groups were no longer statistically significant (P = 0.298).

CONCLUSIONS

Serum gastrin and pepsinogen I and II do not correlate with the different grades of severity of GERD. The non-invasive GastroPanel is not useful for the differentiation of the various forms of GERD.

Systematic review: gastro-oesophageal reflux disease and dental lesions

BACKGROUND

Dental erosion (DE), which is the irreversible loss of tooth substance that does not involve bacteria ranging from a minimal loss of surface enamel to the partial or complete exposure of dentine by a chemical process, is acknowledged as an established extra-oesophageal manifestation of gastro-oesophageal reflux disease (GERD). However, the real impact of GERD in the genesis of this lesion remains unclear.

AIM

To review the existing literature to assess the relationship between DE and GERD.

METHODS

Studies that assessed the prevalence of DE in individuals with GERD or vice versa were identified in Medline and the Cochrane Controlled Trials Register via a systematic research strategy.

RESULTS

Seventeen studies met the selection criteria. Studies, however, differed greatly as far as design, population methods of diagnosing GERD, duration of follow-up and, consequently, findings. The median prevalence of DE in GERD patients was 24%, with a large range (5-47.5%), and the median prevalence of GERD in DE adults patients was 32.5% (range: 21-83%) and in paediatric population 17% (range: 14-87%). Children with GERD are found by a majority of studies at increased risk of developing DEs in comparison with healthy subjects, as are intellectually disabled people.

CONCLUSIONS

This systematic review shows that there is a strong association between GERD and DE. The severity of DEs seems to be correlated with the presence of GERD symptoms, and also, at least in adults, with the severity of proximal oesophageal or oral exposure to an acidic pH. The inspection of the oral cavity in search for DEs should become a routine manoeuvre in patients with GERD.

Review article: respiratory manifestations of gastro-oesophageal reflux disease

BACKGROUND

Respiratory manifestations represent one of the most prevalent and difficult-to-manage extra-oesophageal syndromes of gastro-oesophageal reflux disease.

AIMS

To review the epidemiology, pathophysiological mechanisms and therapeutic outcomes of reflux-related respiratory disorders.

METHODS

Search of the literature published in English using PubMed database.

RESULTS

There is a discrepancy between the high prevalence of reflux in asthmatics and the limited efficacy of antireflux therapies. Asthma per se may cause reflux. Patients with difficult-to-treat asthma and/or nocturnal symptoms should be screened for reflux. Reflux can induce chronic cough through different mechanisms including micro-aspiration and both local and central reflexes. Cough and reflux may precipitate each other. A meta-analysis found no significant difference between placebo and proton pump inhibitors in the resolution of cough. Encouraging results have been reported, following antireflux surgery in patients selected on the basis of pH-impedance monitoring. Attention has been drawn to obstructive sleep apnoea syndrome.

CONCLUSIONS

The role of gastro-oesophageal reflux disease in the pathogenesis of miscellaneous respiratory disorders has been discussed for decades and established in asthma and cough. However, no major therapeutic advances have been reported recently. Future trials should concentrate on patient selection and the control of efficacy using recently developed technologies, such as pH-impedance monitoring.

Validation of the reflux disease questionnaire for an Italian population of patients with gastroesophageal reflux disease

BACKGROUND/AIMS

The reflux disease questionnaire (RDQ) is a very simple questionnaire based on only 12 questions that can be answered and evaluated quickly in a primary care setting, which was already found to be valid and reliable in the diagnosis of gastroesophageal reflux disease (GERD). As an English and a German version of the RDQ exist, but not an Italian one, we aimed at translating the RDQ into Italian and evaluating its reliability for the use of Italian-speaking GERD patients.

PATIENTS/METHODS

For the purpose of linguistic validation, we translated backward and forward the original RDQ into Italian and again into English. For the purpose of assessing internal consistency, test-retest, and interrater reliability, 130 GERD patients were used, of whom 57 patients had an endoscopic oesophagitis of grade A to C according to the Los Angeles classification and 63 patients had uninvestigated GERD symptoms but with a frequency of heartburn and/or regurgitation at least twice a week.

RESULTS

After professional translation, the Italian RDQ was judged to retain fully the meaning of the original RDQ. Internal consistency, as judged by the (Cronbach's alpha) was satisfactory, with an overall RDQ scale alpha=0.86 (minimum acceptable value=0.70). Test--retest reliability (Spearman coefficient) was again found to be optimal, with individual item values ranging between 0.74 (for 'pain in the upper stomach: frequency') and 0.90 (for 'burning feeling behind breastbone: severity'). Finally, the correlation coefficient was 0.96 for the total scale and a range of 0.85-0.98 for individual items, indicating extremely satisfactory concordance.

CONCLUSIONS

The Italian RDQ appears to be a simple, reproducible, and reliable tool for the diagnosis of GERD. We believe that this questionnaire is well suited for use, both in primary care settings and in epidemiological studies, in particular for the assessment of so-called typical symptoms.

Medical therapy of gastroesophageal reflux disease

PURPOSE OF REVIEW

Proton pump inhibitors remain the mainstay of medical therapy in gastroesophageal reflux disease. Despite their increasing use, up to 40% of patients are not fully satisfied with their antireflux therapy. Recent data on efficacy and safety are reviewed and causes of failure are discussed.

RECENT FINDINGS

Several randomized studies and a metaanalysis have shown marginal differences in efficacy between various proton pump inhibitor regimens. In subgroups, however, such as severe esophagitis, esomeprazole may be superior. Poor compliance is one of the main causes of failure. Nonacid reflux is likely to play an important role, especially in patients with regurgitation or cough persisting on therapy. Genetic polymorphisms involved in proton pump inhibitor metabolism, Helicobacter pylori infection or nocturnal acid breakthrough during therapy are probably less important than initially suspected. Recent pharmacological developments include new proton pump inhibitor isomers, potassium competitive acid blockers and inhibitors of transient lower esophageal sphincter relaxations.

SUMMARY

There are still important unmet needs in the treatment of gastroesophageal reflux disease. Optimizing acid control is unlikely to improve the condition of the majority of patients with incomplete proton pump inhibitor response. Inhibition of transient lower esophageal sphincter relaxations remains the major pharmacological target for future drug development.