The Results From Up-Front Esophageal Testing Predict Proton Pump Inhibitor Response in Patients With Chronic Cough

The Milan Score is an Effective Manometric Tool to Predict Gastroesophageal Reflux in Patients With Laryngopharyngeal Symptoms

INTRODUCTION

According to Lyon 2.0, laryngopharyngeal symptoms (LPS) should undergo upfront pathophysiologic tests. The novel Milan score integrates esophagogastric junction (EGJ) morphology, ineffective esophageal motility, EGJ-contractile integral (EGJ-CI), and straight leg raise (SLR) response. It has been demonstrated to predict abnormal AET. The aim of this study was to assess the value of the Milan score in predicting GERD in these patients.

METHODS

We prospectively enrolled patients with suspected GERD who underwent HRM and MII pH from 12 referral centers. Patients with isolated LPS (reflux symptom index > 13) were compared with typical GERD symptoms (GERD-HRQL ≥ 10). A Milan score > 137 was considered positive. The effectiveness of the Milan score in the identification of patients with pathologic GERD was assessed.

RESULTS

Of 570 patients (49% females, median age 49 years, BMI 24 kg/m2), isolated LPS was found in 30 patients and isolated typical symptoms in 154. An AET > 6% was found in 23% of the LPS group and 43% of the typical symptom group (p = 0.034). The Milan score was higher in the typical symptoms group, with higher scores for EGJ-CI (p = 0.039) and SLR response (p = 0.038) components. The likelihood of concordance of the Milan score and AET on reflux monitoring was similar (83.3% vs. 84.4%, p = 0.532).

CONCLUSIONS

Patients with isolated LPS demonstrated a lower likelihood of EGJ disruption, pathologic GERD, and abnormal Milan score. The Milan score performed similarly well in the identification of GERD in both LPS and typical symptoms and could therefore be used as an upfront test in LPS patients.

Extraesophageal reflux: Clinical manifestations and tools for diagnosis and treatment

Extraesophageal reflux is a complex clinical entity, classically presenting with laryngopharyngeal symptoms including chronic cough and vocal changes, but it is also implicated in conditions such as subglottic stenosis and lung injury. Diagnosis is challenging, in large part due to the oftentimes vague presenting symptoms with multiple possible etiologies, as well as limited consistency of currently available diagnostic tests. Furthermore, effective medical treatment is limited, and acid suppression therapy such as proton pump inhibitors has shown low to mixed efficacy in relieving signs and symptoms of reflux outside the esophagus. In this review, we will address laryngopharyngeal reflux and its diagnosis based on symptoms and exam findings, and diagnostic tools such as impedance monitoring and salivary pepsin testing. A summary of the use and limitations of acid-suppressing therapies for extraesophageal reflux and the rationale for targeting pepsin as a nonacid component of reflux will be presented. Finally, the current literature on the potential role of reflux in subglottic stenosis and lessons learned regarding reflux in the lung transplant surgery field in higher risk patient populations will be discussed.

Exploring the Complex Interplay Between Ineffective Esophageal Motility and Reflux Burden

The role of esophageal motility in determining GERD severity has been widely explored. Kamboj et al. show that IEM diagnosis is associated with increased GERD severity. We aim to further highlight the impact of IEM in reflux burden, as demonstrated by several recent studies in patients with both typical and atypical symptoms.

Baseline Impedance via Manometry Predicts Pathological Mean Nocturnal Baseline Impedance in Isolated Laryngopharyngeal Reflux Symptoms

Background/Aims

Distal mean nocturnal baseline impedance (MNBI) measuring via pH-impedance may be valuable in diagnosing patients with suspected laryngopharyngeal reflux (LPR). However, its wide adoption is hindered by cost and invasiveness. This study investigates whether baseline impedance measured during high-resolution impedance manometry (HRIM-BI) can predict pathological MNBI.

Methods

A cross-sectional study in Taiwan included 74 subjects suspected of LPR, who underwent HRIM (MMS) and pH-impedance testing (Diversatek), after stopping proton pump inhibitors for more than 7 days. Subjects with grade C or D esophagitis or Barrett's esophagus were excluded. The cohort was divided into 2 groups: those with concomitant typical reflux symptoms (CTRS, n = 28) and those with isolated LPR symptoms (ILPRS, n = 46). HRIM-BI measurements focused on both distal and proximal esophagi. Pathological MNBI was identified as values below 2065 Ω, measured 3 cm above the lower esophageal sphincter.

Results

In all subjects, distal HRIM-BI values correlated weakly with distal MNBI(r = 0.34-0.39, P < 0.005). However, in patients with ILPRS, distal HRIM-BI corelated moderately with distal MNBI(r = 0.43-0.48, P < 0.005). The areas under the receiver operating characteristic curve was 0.78 (P = 0.001) with a sensitivity of 0.83 and a specificity of 0.68. No correlation exists between distal HRIM-BI and distal MNBI in patients with CTRS, and between proximal HRIM-BI and proximal MNBI in both groups.

Conclusions

Distal HRIM-BI from HRIM may potentially predict pathological MNBI in patients with ILPRS, but not in those with CTRS. Future outcome studies linked to the metric are warranted.

Link between pharyngeal acid reflux episodes and the effectiveness of proton pump inhibitor therapy

BACKGROUND

Diagnosing laryngopharyngeal reflux (LPR) is challenging due to overlapping symptoms. While proton pump inhibitors (PPIs) are commonly prescribed, reliable predictors of their responsiveness are unclear. Reflux monitoring technologies like dual potential of hydrogen (pH) sensors and multichannel intraluminal impedance-pH (MII-pH) could improve diagnosis. Research suggests that a composite pH parameter, defined by ≥ 2 pharyngeal acid reflux (PAR) episodes and/or excessive esophageal acid reflux (EAR), predicts PPI efficacy. The criteria for PAR episodes, a pharyngeal pH drop of ≥ 2 units to < 5 within 30 seconds during esophageal acidification, showed strong interobserver reliability. We hypothesized that PAR episodes alone might also predict PPI responsiveness.

AIM

To investigate whether PAR episodes alone predict a positive response to PPI therapy.

METHODS

Patients suspected of having LPR were prospectively recruited from otolaryngologic clinics in three Taiwanese tertiary centers. They underwent a 24-hour esophagopharyngeal pH test using either 3-pH-sensor or hypopharyngeal MII-pH catheters while off medication, followed by a 12-week esomeprazole course (40 mg twice daily). Participants were categorized into four groups based on pH results: PAR alone, EAR alone, both pH (+), and both pH (-). The primary outcome was a ≥ 50% reduction in primary laryngeal symptoms, with observers blinded to group assignments.

RESULTS

A total of 522 patients (mean age 52.3 ± 12.8 years, 54% male) were recruited. Of these, 190 (mean age 51.5 ± 12.4 years, 61% male) completed the treatment, and 89 (47%) responded to PPI therapy. Response rates were highest in the PAR alone group (73%, n = 11), followed by EAR alone (59%, n = 68), both pH (+) (56%, n = 18), and both pH (-) (33%, n = 93). Multivariate analysis adjusting for age, sex, body mass index, and endoscopic esophagitis showed that participants with PAR alone, EAR alone, and both pH (+) were 7.4-fold (P = 0.008), 4.2-fold (P = 0.0002), and 3.4-fold (P = 0.03) more likely to respond to PPI therapy, respectively, compared to the both pH (-) group. Secondary analyses using the definition of ≥ 1 PAR episode were less robust.

CONCLUSION

In the absence of proven hypopharyngeal predictors, this post-hoc analysis found that baseline ≥ 2 PAR episodes alone are linked to PPI responsiveness, suggesting the importance of hypopharyngeal reflux monitoring.

The Clinical Spectrum of Gastroesophageal Reflux Disease: Facts and Fictions

BACKGROUND

This review addresses the intricate spectrum of gastroesophageal reflux disease (GERD), a condition affecting 10-30% of the Western population. GERD is characterized by the backflow of gastric contents into the esophagus, causing typical and atypical symptoms. Its pathophysiology involves various factors such as hiatal hernia, esophageal motor disorders, and dietary triggers. The review explores the complexities of GERD spectrum, including nonerosive reflux disease (NERD), reflux hypersensitivity (RH), and functional heartburn (FH).

SUMMARY

The diagnostic process for GERD, based on the Lyon Consensus 2.0 criteria, encompasses clinical evaluation, endoscopy, and functional tests, including pH-impedance and wireless-pH monitoring. NERD, a significant subset of GERD, is defined by reflux symptoms and abnormal reflux burden without mucosal damage. RH, classified under functional esophageal disorders by Rome IV criteria, presents with typical esophageal symptoms associated with reflux but lacks of structural, inflammatory, or motor causes. FH is identified by heartburn with normal endoscopy, reflux testing, and esophageal manometry results. The management of RH and FH, focusing on reducing esophageal hypersensitivity, varies from standard GERD treatments.

KEY MESSAGES

The review emphasizes the necessity of personalized treatment strategies due to the complexity and overlap of GERD subtypes. It highlights the importance of a multidisciplinary approach, involving gastroenterologists, psychologists, and other specialists, to improve patient outcomes and quality of life. The article underscores that understanding the distinctions and overlaps among NERD, RH, and FH is crucial for effective management, and the need for innovative approaches in diagnosis and treatment to address the unique challenges of each subtype.

Update on extraesophageal manifestations of gastroesophageal reflux

PURPOSE OF REVIEW

Symptoms/complications related to extraesophageal reflux (EER) are increasingly prevalent presentations and pose significant challenges for clinicians. We summarize and discuss clinical advances and developments in pathophysiology, testing and treatment algorithms of upper/lower airway manifestations of EER.

RECENT FINDINGS

Growing evidence supports likely multifactorial causes of laryngeal symptoms, including EER, oropharyngeal pathologies, allergic conditions, and cognitive-affective processes (brain-larynx interaction). Diagnostic paradigm for laryngopharyngeal reflux (LPR) is shifting towards a personalized approach with noninvasive strategies/prediction tools to risk-stratify patients for upfront reflux testing over empiric acid suppression trials. Management should be multipronged to include antireflux therapies and treatments targeting other causes. Lower airway complications of EER may result in lung dysfunction and poor transplant outcomes. Esophageal symptoms are often absent and routine esophageal/reflux testing to guide timely antireflux therapies may lead to improved outcomes. Modalities that leverage impedance technology may be important, given the potential role of nonacidic reflux. Novel impedance-based metrics such as mean nocturnal baseline impedance and postreflux swallow-induced peristaltic wave index may provide adjunctive diagnostic values.

SUMMARY

Standardized approach to diagnosis/management of EER should include multidisciplinary care teams and consider different phenotypes, nonreflux contributors, and the complex gut-airway relationships. Prompt antireflux therapies after careful candidate selection may improve outcomes of these airway complications.

Proximal esophageal impedance baseline increases the yield of impedance-pH and is associated with response to PPIs in chronic cough patients

BACKGROUND

Chronic cough significantly impairs the quality of life. Although various studies focused on MNBI as assessed in the distal esophagus, scarce data are available on the clinical value of proximal measurements.

AIM

To investigate the role of proximal MNBI in the workup of patients with chronic cough and its ability to predict PPI response.

METHODS

Demographic, clinical, endoscopy findings, impedance-pH and HRM tracings from consecutive cough patients were evaluated. MNBI was calculated at proximal and distal esophagus.

RESULTS

One hundred and sixty four patients were included. In addition to traditional variables, when considering also the PSPW index or MNBI at 3 cm or 15 cm, the proportion of patients with pathological impedance-pH monitoring significantly increased. 70/164 patients were responders, while 94 (57.3%) were non-responder to double PPI dose (p < 0.05). Patients with pathologic MNBI at 3 cm and/or 15 cm as well as those with pathologic PSPW index were characterized by a significantly higher proportion of responders than that observed among patients with normal impedance-pH variables (p < 0.001). The proportion of responders with pathological MNBI at 15 cm was significantly higher than the proportion of responders with pathological MNBI at 3 cm (82.8% vs. 64.3%, p < 0.05). At multivariable model, pathological MNBI at both 3 cm and 15 cm as well as PSPW index were associated with PPI responsiveness. The strongest association with PPI response was observed for MNBI at 15 cm.

CONCLUSIONS

The assessment of MNBI at proximal esophagus increases the diagnostic yield of impedance-pH monitoring and may represent a useful predictor of PPI responsiveness in the cumbersome clinical setting of suspected reflux-related cough.

Proximal esophageal impedance baseline increases the yield of impedance-pH monitoring for GERD diagnosis and is associated with heartburn response to PPI

BACKGROUND

Impairment of esophageal mucosal integrity as assessed by low mean nocturnal baseline impedance (MNBI) measured in the distal esophagus increases the diagnostic yield of impedance-pH in patients with inconclusive GERD diagnosis as defined by Lyon criteria.

AIM

To assess the diagnostic yield of MNBI measurement in the proximal esophagus, and its relationship with PPI response.

METHODS

Expert review of off-therapy impedance-pH tracings from consecutive patients with heartburn, 80 responders and 80 non-responders to label-dose PPI. Data were compared to those from 36 healthy controls using ROC analysis. Multivariate analysis was performed to measure the strength of association of MNBI with PPI response.

RESULTS

A threshold value of 2665 Ω was defined for proximal MNBI by ROC analysis, affording 91.7% sensitivity and 86.5% specificity. Proximal and distal MNBI were significantly lower in non-responder cases as compared to responders. Adding proximal MNBI positivity to pathologic (>6%) acid exposure time (AET) and positive symptom-reflux association, the proportion of patients with abnormal impedance-pH findings increased from 74/160 (46%) to 106/160 (66.3%) (p = 0.0016). Among the 12 patients with pathologic proximal MNBI as the only positive impedance-pH finding, 9 cases (75%) were PPI responders. According to multivariate analysis, AET and pathological distal and proximal MNBI were significantly associated with PPI response, the strongest association observed for proximal MNBI.

CONCLUSIONS

Impedance baseline assessment in the proximal esophagus may increase the diagnostic yield of impedance-pH monitoring. Heartburn response to PPI is directly related to ultrastructural mucosal damage in the distal and in the proximal esophagus as well.

Encouraging appropriate use of proton pump inhibitors: existing initiatives and proposals for the future

INTRODUCTION

Proton pump inhibitors (PPIs) have revolutionized the management of acid-related disorders, representing today the mainstay treatment of these conditions. However, despite their large range of indications and usefulness, the remarkable expansion of their use in the last two decades cannot be explained by the increasing prevalence of acid-related diseases only. An inappropriate prescription for clinical conditions in which the pathogenetic role of acid has not been documented has been described, with the natural consequence of increasing the costs and the potential risk of iatrogenic harm due to adverse events and complications recently emerged.

AREAS COVERED

In this review, we summarize current indications of PPIs administration, potential adverse events associated with their chronic utilization, and misuse of PPIs. Moreover, we describe existing and possible initiatives for improving the use of PPIs, and some proposals for the future.

EXPERT OPINION

PPI deprescribing is the preferred and most effective approach to reduce the use of PPIs, rather than adopting sharp discontinuation, probably due to fewer withdrawal symptoms. Nonetheless, large knowledge gaps still exist in clinical practice regarding the optimal approach of PPI deprescribing in various clinical scenarios. Further prospective well-designed international studies are eagerly warranted to improve our perspectives on controlling global PPI inappropriate use.

Towards a better diagnosis of gastro esophageal reflux disease

INTRODUCTION

GERD is a common disorder and is characterized by the presence of typical or atypical symptoms. In GERD patients, the presence of mucosal alterations in endoscopy is detected in up to 30% of individuals. The clinical presentation of GERD patients may be complex and their management is challenging, due to the heterogeneous clinical presentation. The present review has been performed searching all relevant articles in this field, over the past years, using PubMed database.

AREAS COVERED

The diagnosis and management of GERD have been significantly improved in the last years due to the increasing availability of reflux monitoring techniques and the implementation of new procedures in the therapeutic armamentarium. Beside traditional impedance-pH variables, new metrics have been developed, increasing the diagnostic yield of reflux monitoring and better predicting the treatment response. Traditional pharmacological treatments include acid-suppressive-therapy and/or anti-acid. On the other hand, surgical treatment and, more recently, endoscopic procedures represent a promising field in the therapeutic approach.

EXPERT OPINION

Diagnosis and treatment of GERD still represent a challenging area. However, we believe that an accurate upfront evaluation is, nowadays, necessary in addressing patients with GERD to a more accurate diagnosis as well as to the best treatment options.

Anxiety correlates with excessive air swallowing and PPI refractoriness in patients with concomitant symptoms of GERD and functional dyspepsia

BACKGROUND

Anxiety may exacerbate GERD and FD symptoms perception and reduce quality of life. As many as 50% of patients with GERD symptoms have incomplete relief with PPI therapy, and psychological factors may influence PPI responsiveness.

AIM

The potential relationship between anxiety, excessive air swallowing, and PPI responsiveness was evaluated.

METHODS

GERD patients with concomitant FD were prospectively evaluated. Validated structured questionnaires were used to evaluate anxiety, GERD, and FD symptoms. All patients were treated, within the previous year, with at least 8 weeks of standard dose PPI therapy.

RESULTS

One hundred sixty-one patients were included. Frequency of non-responders in patients with moderate/severe anxiety was significantly higher compared to patients with mild anxiety (62.7% vs. 37.3%, p < 0.01). Patients with moderate/severe anxiety displayed a significantly higher mean FD symptoms score value compared to patients with mild anxiety. A significantly higher mean number of air swallows were observed in patients with moderate/severe anxiety. At ROC analysis, air swallows and mixed reflux episodes were significantly associated with the presence of PPI refractoriness (AUC: 0.725, 95% CI: 0.645-0.805 and 0.768, 0.692-0.843). According to univariate analysis, an abnormal number of air swallows, mixed reflux episodes and presence of moderate/severe anxiety was significantly associated with PPI refractoriness.

CONCLUSION

Our results, if confirmed in in a larger, prospective clinical and therapeutic study, demonstrate the usefulness of an up-front evaluation with anxiety questionnaire and esophageal testing in patients with a broad spectrum of upper gastrointestinal symptoms who fail to respond to PPI treatment, supporting the option of alternative treatment modalities.

Prospective validation of reflux monitoring by impedance-pH in predicting PPI response in typical GERD

BACKGROUND

The Lyon Consensus proposed a hierarchical approach to GERD diagnosis based on conventional and new impedance-pH metrics, namely acid exposure time (AET), number of reflux episodes, post-reflux swallow-induced peristaltic wave (PSPW) index, and mean nocturnal baseline impedance (MNBI).

AIMS

To define the value of conventional and new impedance-pH parameters as predictors of response to label-dose PPI in typical GERD.

METHODS

Consecutive adult patients with typical esophageal symptoms were prospectively studied with impedance-pH monitoring and treated with 8-week label-dose PPI. At the end of the PPI course, symptoms response was assessed.

RESULTS

Among 255 patients who entered the study, 168 (65.9%) reported symptom remission. At ROC analysis, both MNBI and PSPW index were significantly associated to PPI responsiveness with AUC of 0.783 and 0.801, respectively. Cut-off values of 1747Ω for MNBI and 50% for PSPW index were identified as discriminators between response and non-response to label-dose PPI. At multivariate analysis, MNBI, PSPW index, and AET >6% were efficient predictors of PPI responses (OR 3, 5.4 and 2.3, respectively). Number of reflux episodes did not predict PPI response.

CONCLUSIONS

The novel MII-pH variables together with pathological are highly predictive of response of the typical GERD syndrome to label-dose PPI.

Diagnosis of Laryngopharyngeal Reflux: Past, Present, and Future-A Mini-Review

Laryngopharyngeal reflux (LPR) is a variant of gastroesophageal reflux disease (GERD) in which gastric refluxate irritates the lining of the aerodigestive tract and causes troublesome airway symptoms or complications. LPR is a prevalent disease that creates a significant socioeconomic burden due to its negative impact on quality of life, tremendous medical expense, and possible cancer risk. Although treatment modalities are similar between LPR and GERD, the diagnosis of LPR is more challenging than GERD due to its non-specific symptoms/signs. Due to the lack of pathognomonic features of endoscopy, mounting evidence focused on physiological diagnostic testing. Two decades ago, a dual pH probe was considered the gold standard for detecting pharyngeal acidic reflux episodes. Despite an association with LPR, the dual pH was unable to predict the treatment response in clinical practice, presumably due to frequently encountered artifacts. Currently, hypopharygneal multichannel intraluminal impedance-pH catheters incorporating two trans-upper esophageal sphincter impedance sensors enable to differentiate pharyngeal refluxes from swallows. The validation of pharyngeal acid reflux episodes that are relevant to anti-reflux treatment is, therefore, crucial. Given no diagnostic gold standard of LPR, this review article aimed to discuss the evolution of objective diagnostic testing and its predictive role of treatment response.

Mean Nocturnal Baseline Impedance (MNBI) Provides Evidence for Standardized Management Algorithms of Nonacid Gastroesophageal Reflux-Induced Chronic Cough

BACKGROUND

The clinical management of nonacid gastroesophageal reflux-induced chronic cough (GERC) is challenging, and patient response to standard antireflux therapy (omeprazole 20 mg twice daily plus mosapride 10 mg thrice daily) is suboptimal. This study aimed to identify predictors of standard antireflux therapy efficacy and provide evidence for standardized management algorithms of nonacid GERC.

METHODS

A total of 115 nonacid GERC patients who underwent multichannel intraluminal impedance-pH monitoring (MII-pH) were enrolled between March 2017 and March 2021. Retrospective analysis of general information and MII-pH indications were used to establish a regression analysis model for multiple factors affecting standard antireflux therapy efficacy.

RESULTS

90 patients met the inclusion criteria, and the overall response rate to standard antireflux therapy was 55.5% (50/90). The mean nocturnal baseline impedance (MNBI) (1817.75 ± 259.26 vs. 2369.93 ± 326.35, P = 0.030) and proximal MNBI (1833.39 ± 92.16 vs. 2742.57 ± 204.64, P ≤ 0.001) of responders were lower than those of nonresponders. Weakly acid reflux (56.00 (31.70, 86.00) vs. 14.00 (14.00, 44.20), P = 0.022), nonacid reflux (61.35 (15.90.86.50) vs. 21.60 (0.00, 52.50), P = 0.008), and proximal extent (19.00 (5.04, 24.00) vs. 5.50 (2.56, 11.13), P = 0.011) were markedly higher in responders than nonresponders. Proximal MNBI (OR = 0.997, P = 0.042, and optimal cutoff = 2140 Ω) and weakly acid reflux (OR = 1.051, P = 0.029, and optimal cutoff = 45) were independent predictors of standard antireflux therapy efficacy. The combination predictive value did not show better results than either individual predictor.

CONCLUSIONS

Proximal MNBI < 2140 Ω may be used to screen patients with nonacid GERC suitable for standard antireflux therapy and in standardized management algorithms for nonacid GERC. In the absence of MNBI, weakly acid reflux > 45 can be used as an auxiliary indicator.

Association between post-reflux swallow-induced peristaltic wave index and esophageal mucosal integrity in patients with GERD symptoms

BACKGROUND

Impedance-pH monitoring allows evaluation of esophageal chemical clearance, a response to reflux elicited by the esophago-salivary reflex, by means of the post-reflux swallow-induced peristaltic wave (PSPW) index; mucosal integrity can be evaluated by means of mean nocturnal baseline impedance (MNBI) and is regarded as a GERD marker. Currently, the relationship between PSPW index and MNBI has not yet been fully investigated and represents the aim of the present study.

METHODS

Impedance-pH tracings from consecutive patients were reviewed. ROC analysis and multivariate regression models were generated to evaluate the association between acid exposure time (AET), total refluxes (TRs), PSPW index, and MNBI. Patients were classified by means of AET thresholds and symptom-reflux association indexes into conclusive and inconclusive GERD, reflux hypersensitivity (RH), and functional heartburn (FH). Pathologic MNBI <2292 Ω was defined according to published outcome studies.

KEY RESULTS

Two hundred and thirty patients constituted the study cohort. Overall, a significant direct correlation was observed between PSPW index and MNBI (0.759, p < 0.001). At ROC analysis, a PSPW index cut-off value of 53% was the best discriminator between normal from pathologic MNBI values (sensitivity 88%, specificity 86.4%). Considering AET cut-off of 4% or 6%, a sensitivity of 80.7% and 46% and a specificity of 62.5% and 93.2% were found, respectively. According to multivariate analysis, AET >4% and PSPW index value <53% or <61% were significantly associated with pathologic MNBI values.

CONCLUSIONS AND INFERENCES

Esophageal chemical clearance is a major defense mechanism against reflux and its impairment represents a major determinant of reflux-associated mucosal damage.

Efficacy of laparoscopic fundoplication in patients with chronic cough and gastro-oesophageal reflux

BACKGROUND

The outcome of anti-reflux surgery in patients with suspected gastro-oesophageal reflux-induced cough is frequently uncertain. The aims of this study were to assess the efficacy of laparoscopic fundoplication for controlling cough in patients with chronic cough without asthma, who have pathologic gastro-oesophageal reflux, and to identify predictors of response.

METHODS

From a prospective database of 1598 patients who have undergone laparoscopic fundoplication, 66 (4%) with proven gastro-oesophageal reflux disease (GORD) and chronic cough without asthma were studied. All patients underwent gastroscopy and 24-h pH monitoring before operation. Heartburn and regurgitation were assessed using a modified DeMeester score. Severity of cough before and after surgery was self-assessed by the patient using a visual analog scale at a minimum of 12 months post-operatively (median 43 mo; range: 14-104 mo). Patients were considered to have responded to fundoplication if they had no cough or the cough had improved by 50% or more after operation.

RESULTS

Cough and heartburn/regurgitation were relieved in 61% (40/66) and 90% (44/49) of the patients, respectively. The presence of typical GORD symptoms or oesophagitis, and pH study variables did not predict the response of the cough to fundoplication.

CONCLUSION

Refinement in the aetiological diagnosis of chronic cough due to GORD is necessary for improved outcome. Patients diagnosed with GORD-related chronic cough need to be counseled regarding their expectations from anti-reflux surgery.

Applying Lyon Consensus criteria in the work-up of patients with proton pump inhibitory-refractory heartburn

BACKGROUND

A hierarchical approach for gastro-oesophageal reflux disease (GERD) diagnosis by impedance-pH monitoring was proposed by the Lyon Consensus, based on acid exposure time (AET) and supportive impedance metrics.

AIMS

To establish the clinical value of Lyon Consensus criteria in the work-up of patients with proton pump inhibitory (PPI)-refractory heartburn.

METHODS

Expert review of off-therapy impedance-pH tracings from unproven GERD patients with PPI-refractory heartburn prospectively evaluated at referral centers. Impedance metrics, namely total reflux episodes, postreflux swallow-induced peristaltic wave index, and mean nocturnal baseline impedance, were assessed. Expert review of on-therapy preoperative impedance-pH tracings from a separate cohort of surgically treated erosive/nonerosive GERD cases.

RESULTS

Off-therapy, normal, inconclusive, and abnormal AET was found in 59%, 17%, and 23% of 317 cases. Supportive evidence of GERD was provided by abnormal impedance metrics in up to 22% and 62% of cases in the normal and inconclusive AET groups, respectively. Adding the cases with inconclusive AET and abnormal impedance metrics to the abnormal AET group, a significant increase in GERD evidence was observed (from 23% to 37% of cases, p < 0.0002). At the on-therapy presurgical evaluation, abnormal/inconclusive AET and supraphysiological values of impedance metrics showed ongoing reflux in 21% and 90% of 96 cases, respectively (p < 0.00001); a relationship between on-therapy ongoing reflux and PPI-refractory heartburn was confirmed by the favorable surgical outcome at 3-year follow-up, 88% of cases being in persistent off-PPI heartburn remission.

CONCLUSIONS

Impedance-pH monitoring, off- and on-therapy, is of high clinical value in the work-up of patients with PPI-refractory heartburn.