Respiratory manifestations of gastroesophageal reflux disease

Efficacy and safety of antireflux surgery in gastroesophageal-related cough: a systematic review and meta-analysis

BACKGROUND

Gastroesophageal reflux disease (GERD) is a prevalent condition that manifests a spectrum of symptoms, including gastroesophageal-related cough (GERC). Antireflux procedures have been employed to alleviate these symptoms, yet their efficacy varies. This systematic review and meta-analysis aim to evaluate the improvement in gastroesophageal-related cough and other reflux symptoms following antireflux procedures.

METHODS

A systematic review was performed by searching PubMed, Embase, and Cochrane Library. All observational studies reporting the improvement of GERC and other reflux symptoms after the antireflux procedures. Data were extracted and pooled using a random effects model to assess the overall effect size and heterogeneity between studies. The authors found that antireflux surgery has some clear benefits for common reflux-related symptoms.

RESULTS

Fifty-nine eligible studies with 7431 patients with GERD were included in this study. The pooled cough remission rate was 80.0% (95% CI: 75.4-84.2) and the mean time of follow-up was 35.8 months. Antireflux surgery significantly improved overall reflux-related symptom scores (all P <0.001). The authors also assessed the rate of remission of other reflux symptoms. The pooled heartburn remission rate was 87.7% (95% CI: 82.3-92.2) and the pooled regurgitation remission rate was 91.2% (95% CI: 87.8-94.1).

CONCLUSION

Antireflux procedures significantly improve gastroesophageal-related cough and other reflux symptoms. These findings support the use of antireflux procedures as a viable treatment option for patients with GERD symptoms. Further research is needed to identify predictors of success and to optimize patient selection for antireflux procedures.

Extrapulmonary Comorbidities Associated with Chronic Obstructive Pulmonary Disease: A Review

Most patients with chronic obstructive pulmonary disease (COPD) suffer from at least one additional, clinically relevant chronic disease. To a degree, the high global prevalence and mortality rate of COPD is closely related to its extrapulmonary effects. Moreover, the various of comorbidities of COPD and itself interact with each other, resulting in diverse clinical manifestations and individual differences, and thus further influencing the prognosis as well as healthcare burden of COPD patients. This is closely related to the common risk factors of chronic diseases (aging, smoking, inactivity, etc.). Additionally, some pathophysiological mechanisms caused by COPD, including the systemic inflammatory response, hypoxia, oxidative stress, and others, also have an impact on other systems. But comprehensive management and medical interventions have not yet been established. The clinicians should improve their knowledge and skills in diagnosing as well as treating the comorbidities of COPD, and then aim to develop more individualized, efficient diagnostic and therapeutic strategies for different patients to achieve greater clinical benefits. In this article, we will review the risk factors, mechanisms, and treatment strategies for extrapulmonary comorbidities in chronic obstructive pulmonary disease, including cardiovascular diseases, diabetes, anemia, osteoporosis, emotional disorders, and gastroesophageal reflux disease.

The Causal Relationship Between Gastroesophageal Reflux Disease and Chronic Obstructive Pulmonary Disease: A Bidirectional Two-Sample Mendelian Randomization Study

Background

Gastroesophageal reflux disease (GERD) and Chronic Obstructive Pulmonary Disease (COPD) often coexist and have been associated in observational studies. However, the real potential causal relationship between GERD and COPD is unknown and not well established.

Methods

In this study, we conducted a bidirectional two-sample Mendelian randomization(MR) to estimate whether GERD and COPD are causal. The GERD genetic data is from summary level data of a genome-wide association (GWAS) meta-analysis (Ncases = 71,522, Ncontrol=26,079). The COPD GWAS are available from the FinnGen (Ncases=16,410, Ncontrol=283,589). MR-Egger regression, Weighted Median, and Inverse-variance weighted (IVW) were used for MR analysis from the R package "TwoSampleMR", and IVW was the dominant estimation method. Additionally, the MR pleiotropy residual sum and outlier (MR-PRESSO), Cochran Q statistic, and leave-one-out analysis were used to detect and correct for the effect of heterogeneity and horizontal pleiotropy.

Results

MR analysis indicated that GERD was causally associated with an increased risk of COPD (IVW odds ratio (OR): 1.3760, 95% confidence interval (CI): 1.1565-1.6371, P=0.0003), and vice versa (IVW OR: 1.1728, 95% CI:1.0613-1.2961, P=0.0018). The analyses did not reveal any pleiotropy or heterogeneity.

Conclusion

Our study revealed possible evidence for a bidirectional causal relationship between GERD and COPD. Implementing screening and preventive strategies for GERD in individuals with COPD, and vice versa, will be crucial in future healthcare management. Further studies are needed to elucidate the mechanisms underlying the causal relationship between GERD and COPD.

Is There a Potential Link between Gastroesophageal Reflux Disease and Recurrent Respiratory Tract Infections in Children?

BACKGROUND

The implications of gastroesophageal reflux disease in respiratory tract infections have been investigated over time. The aim of our study was to evaluate the relationship between these two pathologic entities and the outcome after proper antireflux treatment.

METHODS

A group of 53 children with recurrent respiratory tract infections admitted in the gastroenterology clinic of a children's hospital in North-East Romania was investigated for gastroesophageal reflux disease through 24 h pH-metry. Those with a Boix-Ochoa score higher than 11.99 received proton pump inhibitor treatment and were reevaluated after 2 months.

RESULTS

A total of 41 children were found with a positive Boix-Ochoa score. After 2 months of antireflux therapy, eight patients still had a positive Boix-Ochoa score.

CONCLUSIONS

Recurrent respiratory tract infections with symptoms resistant to treatment should be considered a reason to investigate for gastroesophageal reflux, because the symptoms may be due to micro- or macro-aspiration of the gastric refluxate or to an esophageal-bronchial reflex mediated through the vagal nerve.

The link between airway reflux and non-acid reflux in children: a review

OBJECTIVE

Airway reflux, a member of extra-esophageal reflux, has been linked to countless respiratory pathologies amongst children. The advent of novel instrumentation has enabled the discovery of non-acid reflux which was postulated as the main culprit of airway reflux. The objective of this review is to outline the association between non-acid reflux and airway reflux in children.

METHODS

A comprehensive review of recent literature on non-acid reflux and airway reflux in children was conducted. Studies ranged from January 2010 till November 2021 were searched over a period of a month: December 2021.

RESULTS

A total of eleven studies were identified. All studies included in this review revealed a strong link between non-acid reflux and airway reflux in children. 6 of the included studies are prospective studies, 3 retrospective studies, 1 cross-section study, and type of study was not mentioned in 1 study. The most common reported respiratory manifestation of non-acid reflux in children was chronic cough (7 studies). Predominant non-acid reflux was noted in 4 studies. The total number of children in each study ranges from 21 to 150 patients. MII-pH study was carried out in all studies included as a diagnostic tool for reflux investigation.

CONCLUSION

Non-acid reflux is the culprit behind airway reflux as well as other myriads of extra-esophageal manifestations in children. Multicentre international studies with a standardized protocol could improve scientific knowledge in managing non-acid reflux in airway reflux amongst children.

Diagnostic value of reflux episodes in gastroesophageal reflux-induced chronic cough: a novel predictive indicator

Background

Multichannel intraluminal impedance and pH-monitoring (MII-pH) is an essential testing modality for gastroesophageal reflux-induced chronic cough (GERC), while the existing diagnostic criteria still have some inherent defects. This study aimed to explore the diagnostic value of a direct and objective index, reflux episodes, and related parameters in MII-pH in different types of GERC.

Methods

Patients with chronic cough suspected of gastroesophageal reflux disease who successfully received MII-pH were enrolled. The differences in MII-pH parameters were analyzed among patients with different etiologies and the predictive diagnostic value of reflux episodes and related parameters were analyzed in patients with GERC, acid GERC, and non-acid GERC, and compared with existing diagnostic criteria.

Results

A total of 190 patients with suspected GERC who underwent MII-pH were enrolled; 131 of these patients were finally diagnosed with GERC. When the reflux episodes were used to diagnose GERC, the area under the curve (AUC) was 0.684; when the acid reflux episodes and the ratio of acid reflux episodes were used to diagnose acid GERC, the AUCs were 0.769 and 0.854; when the non-acid reflux episodes and the ratio of non-acid reflux episodes were used to diagnose non-acid GERC, the AUCs were 0.735 and 0.705, respectively. When the non-acid reflux episodes > 58 and the proportion of non-acid reflux episodes > 68.18% were used alone or in combination to diagnose non-acid GERC, their diagnostic value was significantly better than SAP or SI (all ps < 0.05).

Conclusion

The number of reflux episodes has a good diagnostic value for GERC, especially in the diagnosis of non-acid GERC.

Sorting out the Relationship Between Esophageal and Pulmonary Disease

The aim of this review is to explore the relationship between esophageal syndromes and pulmonary diseases considering the most recent data available. Prior studies have shown a close relationship between lung diseases such as asthma, chronic obstructive pulmonary disorders (COPD), Idiopathic pulmonary fibrosis (IPF), and lung transplant rejection and esophageal dysfunction. Although the association has long been demonstrated, the exact relationship remains unclear. Clinical experience has shown a bidirectional relationship where esophageal disease may influence the outcomes of pulmonary disease and vice versa. The impact of esophageal dysfunction on pulmonary disorders may also be related to 2 different mechanisms: the reflux pathway leading to microaspiration and the reflex pathway triggering vagally mediated airway reactions. The aim of this review is to further explore these relationships and pathophysiologic mechanisms. Specifically, we discuss the proposed hypotheses for the relationship between the 2 diseases, as well as the pathophysiology and new developments in clinical management.

Upper digestive tract abnormalities in dogs with chronic idiopathic lymphoplasmacytic rhinitis

BACKGROUND

Chronic idiopathic lymphoplasmacytic rhinitis (CILPR) is a common inflammatory disorder of unknown etiology affecting the nasal cavity of dogs. The diagnosis is made by exclusion of other causes of nasal disease and specific therapeutic protocols are lacking. In human medicine, a relationship between CILPR and gastrointestinal clinical signs has been postulated, and remission of respiratory signs after clinical trials with medications for gastrointestinal disorders has been observed.

OBJECTIVES

To describe history, clinical presentation, endoscopic and histopathologic concurrent respiratory and digestive tract abnormalities, and to evaluate improvement of respiratory signs after treatment for gastrointestinal signs.

ANIMALS

Twenty-five dogs with CILPR.

METHODS

Prospective study. For inclusion, following information had to be available: respiratory and digestive clinical signs, airway and digestive tract endoscopic abnormalities, histologic evaluation of respiratory and gastrointestinal tract biopsy specimens, and clinical response to different treatment strategies.

RESULTS

Twenty-two dogs had endoscopic gastrointestinal lesions, whereas 13 dogs had concurrent gastrointestinal signs. Most esophageal and duodenal endoscopic abnormalities were classified as moderate or severe. Respiratory and gastrointestinal tract histologic evaluation identified mostly chronic inflammation. Remission or marked improvement of respiratory signs was observed in the majority of dogs treated only for gastrointestinal signs up to 12 months after endoscopy. No significant associations between treatments and follow-up information were found.

CONCLUSION AND CLINICAL IMPORTANCE

Nasal and upper digestive tract abnormalities coexist in some dogs with CILPR. Lack of standardized therapeutic protocols suggests caution when interpreting improvement in nasal clinical signs. Additional studies are needed to explore the possibility of a cause-effect relationship between the 2 processes.

Assessment of the Acute Effects of Carbonated Beverage Consumption on Symptoms and Objective Markers of Gastric Reflux

Previous studies have suggested that carbonated beverages may cause gastro-oesophageal reflux. Pepsin (the major enzyme secreted by the stomach) has been suggested to be an objective, acute marker of a reflux event. This pilot study aimed to investigate whether intake of carbonated beverages could affect pepsin concentration in saliva or reflux symptoms. This was assessed by a randomised, crossover trial where participants consumed 330 mL of beverage (carbonated cola, degassed cola or water) at separate visits. Saliva samples and symptom questionnaires were collected at baseline and over the 30 min postprandial period. Pepsin was detected in all saliva samples. No difference was found in the salivary pepsin concentrations between treatments at all time points. There were significantly higher scores (p > 0.05) for feelings of fullness, heartburn, urge to belch and frequency of belches after ingestion of carbonated cola than degassed cola and water. The ingestion of carbonated beverages did not appear to increase postprandial pepsin concentration in saliva compared to other beverages but did evoke higher levels of reflux-related symptoms such as fullness, heartburn and belching. This suggests carbonated beverages may cause symptoms associated with reflux but do not drive detectable levels of gastric juice to reach the oral cavity.

Respiratory manifestations of gastro-oesophageal reflux in children

Gastro-oesophageal reflux disease (GORD) is a complex problem in children. Suspected respiratory manifestations of GORD, such as asthma, chronic cough and laryngitis, are commonly encountered in the paediatric practice, but continue to be entities with more questions than answers. The accuracy of diagnostic tests (ie, pH or pH-impedance monitoring, laryngoscopy, endoscopy) for patients with suspected extraoesophageal manifestations of GORD is suboptimal and therefore whether there is a causal relationship between these conditions remains largely undetermined. An empiric trial of proton pump inhibitors can help individual children with undiagnosed respiratory symptoms and suspicion of GORD, but the response to therapy is unpredictable, and in any case what may be being observed is spontaneous improvement. Furthermore, the safety of these agents has been called into question. Poor response to antireflux therapy is an important trigger to search for non-gastro-oesophageal reflux causes for patients' symptoms. Evidence for the assessment of children with suspected extraoesophageal manifestations of GORD is scanty and longitudinal studies with long-term follow-up are urgently required.

Gastroesophageal Reflux in the Intensive Care Unit Patient

The incidence of gastroesophageal reflux disease (GERD) in the critically ill patient in the intensive care unit is unknown. Interventions used in critically ill patients, such as sedation, tracheal tubes, mechanical ventilation, enteral feedings, positioning, and medications, along with specific patient characteristics and comorbid conditions contribute to an increased risk for gastroesophageal reflux (GER) in this population. Critical care nurses have an integral role in helping identify critically ill patients at risk for GER or with known GERD, in preventing complications associated with these conditions.

The Relationship Between Gastroesophageal Reflux and Chronic Unexplained Cough in Children

The aim of this study was to assess the association between chronic cough and acid or weakly acid gastroesophageal reflux (GER) determined by 24-hour multichannel intraluminal impedance-pH monitoring and to assess whether the association is age dependent. Overall 150 children (mean age 7.5 years; range 0.3-18.0 years; male/female 90/60) were enrolled. Median of 87.5% (0% to 100%) of all cough episodes were associated with reflux; 9% (0% to 100%) with acidic and 60% (0% to 100%) with weakly acidic episodes. In 52 children (34.7%), all cough episodes were associated with GER (100% association). Children younger than 2 years had significantly higher number of cough episodes associated with total (P = .03) and weakly acidic GER (P = .01). Binary logistic regression confirmed that only increase in age decreases the risk for complete (100%) association between cough episode and GER. Cough is significantly associated with weakly acidic GER and children of younger age are at higher risk.

[Gastro-esophageal reflux and chronic respiratory diseases]

Gastroesophageal reflux disease (GERD) frequently occurs in association with chronic respiratory diseases although the casual link is not always clear. Several pathophysiological and experimental factors are considered to support a role for GERD in respiratory disease. Conversely, respiratory diseases and bronchodilator treatment can themselves exacerbate GERD. When cough or severe asthma is being investigated, GERD does not need to be systematically looked for and a therapeutic test with proton pump inhibitors is not always recommended. pH impedance monitoring is now the reference diagnostic tool to detect non acid reflux, a form of reflux for which proton pump inhibitor treatment is ineffective. Recent data have shown a potential role of GERD in idiopathic pulmonary fibrosis and bronchiolitis obliterans following lung transplantation, leading to discussions about the place of surgery in this context. However, studies using pH impedance monitoring are still needed to better understand and manage the association between GERD and chronic respiratory diseases.

The association of premorbid diseases with chronic rhinosinusitis with and without polyps

PURPOSE OF REVIEW

To review the recent insights regarding the epidemiology of adult chronic rhinosinusitis (CRS), with particular attention to its association with other premorbid conditions. Identifying premorbid disease associations establishes potential risk factors for developing CRS and helps corroborate current postulates of the various pathophysiologic mechanisms involved with the development and persistence of paranasal sinus inflammation.

RECENT FINDINGS

Recent findings demonstrate that the diagnosis of CRS is associated with a higher premorbid prevalence of upper airway diseases, lower airway diseases, gastroesophageal reflux disease, diseases of epithelial tissues, autoimmune disorders, and psychiatric conditions. Although some of these conditions have long been associated with CRS, improvements in study design and future studies in the general population will more accurately estimate the relative strengths of associations, clinical relevance, and temporal relationship of these various conditions in relation to the development of CRS.

SUMMARY

The predisposing patterns of premorbid illnesses may provide valuable information regarding the underlying causes of CRS and allow for both therapeutic and preventive interventions. There remains conflicting evidence within the literature regarding the association of CRS with some medical conditions, signifying the need for continued research on the subject. Limitations of the current studies include small sample sizes, lack of prospective longitudinal or interventional studies that help establish causality, and variable criteria for diagnosis of CRS in the outpatient setting.

Defining severe asthma - an approach to find new therapies

Asthma is a chronic inflammatory disease that has reached epidemic proportions worldwide. It is treatable in the majority of patients, but there is no cure. Moreover, a proportion of patients suffer from severe, difficult-to-control disease with daily symptoms and high morbidity, making it imperative that we continue to improve our understanding of the underlying mechanisms of this disease. Severe asthma is a heterogeneous condition. A systematic approach to identify specific asthma phenotypes, including clinical characteristics and inflammatory processes, is the first step toward individualized, logical therapy. This review focuses on the need to characterize severe asthma phenotypes and on novel, targeted molecular treatment options currently under development.