Ambulatory pH-impedance-pressure monitoring as a diagnostic tool for the reflux-cough syndrome

Guidelines for the management of chronic cough in adults. Endorsed by the French speaking society of respiratory diseases (Société de Pneumologie de Langue Française, SPLF), the Société Française d'Oto-Rhino-Laryngologie et de Chirurgie de la Face et du Cou (SFORL), the Société Française de Phoniatrie et de Laryngologie (SFPL), the Société Nationale Française de Gastro-entérologie (SNFGE)

Patients with chronic cough experience a high alteration of quality of life. Moreover, chronic cough is a complex entity with numerous etiologies and treatments. In order to help clinicians involved in the management of patients with chronic cough, guidelines on chronic cough have been established by a group of French experts. These guidelines address the definitions of chronic cough and the initial management of patients with chronic cough. We present herein second-line tests that might be considered in patients with cough persistence despite initial management. Experts also propose a definition of unexplained or refractory chronic cough (URCC) in order to better identify patients whose cough persists despite optimal management. Finally, these guidelines address the pharmacological and non-pharmacological interventions useful in URCC. Thus, amitryptilline, pregabalin, gabapentin or morphine combined with speech and/or physical therapy are a mainstay of treatment strategies in URCC. Other treatment options, such as P2 × 3 antagonists, are being developed.

[Guidelines for the management of chronic cough in adults]

Patients with chronic cough experience major alteration in their quality of life. Given its numerous etiologies and treatments, this disease is a complex entity. To help clinicians involved in patient management of patients, guidelines have been issued by a group of French experts. They address definitions of chronic cough and initial management of patients with this pathology. We present herein the second-line tests that might be considered in patients whose coughing has persisted, notwithstanding initial management. The experts have also put forward a definition of unexplained or refractory chronic cough (URCC), the objective being to more precisely identify those patients whose cough persists despite optimal management. Lastly, these guidelines indicate the pharmacological and non-pharmacological interventions of use in URCC. Amitriptyline, pregabalin, gabapentin or morphine combined with speech and/or physical therapy are mainstays in treatment strategies. Other treatment options, such as P2X3 antagonists, are being developed and have generated high hopes among physicians and patients alike.

GERD-related chronic cough: Possible mechanism, diagnosis and treatment

GERD, or gastroesophageal reflux disease, is a prevalent medical condition that affects millions of individuals throughout the world. Chronic cough is often caused by GERD, and chronic cough caused by GER is defined as GERD-related chronic cough (GERC). It is still unclear what the underlying molecular mechanism behind GERC is. Reflux theory, reflex theory, airway allergies, and the novel mechanism of esophageal motility disorders are all assumed to be linked to GERC. Multichannel intraluminal impedance combined with pH monitoring remains the gold standard for the diagnosis of GERC, but is not well tolerated by patients due to its invasive nature. Recent discoveries of new impedance markers and new techniques (mucosal impedance testing, salivary pepsin, real-time MRI and narrow band imaging) show promises in the diagnosis of GERD, but the role in GERC needs further investigation. Advances in pharmacological treatment include potassium-competitive acid blockers and neuromodulators (such as Baclofen and Gabapentin), prokinetics and herbal medicines, as well as non-pharmacological treatments (such as lifestyle changes and respiratory exercises). More options have been provided for the treatment of GERC other than acid suppression therapy and anti-reflux surgery. In this review, we attempt to review recent advances in GERC mechanism, diagnosis, and subsequent treatment options, so as to provide guidance for management of GERC.

Impedance in the evaluation of the esophagus

The aim of this paper is to review esophageal electrical impedance technologies and to discuss the use of these technologies for physiological measurements, diagnostics, and therapy of esophageal disease. In order to develop a better understanding of the pathophysiology of and improve the diagnosis of esophageal disorders, such as gastroesophageal reflux disease (GERD) and achalasia, several new diagnostic tests, including intraluminal impedance, esophageal mucosal impedance, and the functional luminal imaging probe, have been developed. These technologies have proven valuable for assessment of the esophagus in recent years. They provide information on esophageal flow properties, mucosal integrity, lumen shape, and distensibility in esophageal disorders, in particular for GERD and achalasia. Despite their promise and novel clinical studies, the potential of these technologies has been far from realized. New multidisciplinary approaches will contribute to our understanding and interpretation of esophageal impedance data and disease mechanisms.

Salivary Pepsin as an Intrinsic Marker for Diagnosis of Sub-types of Gastroesophageal Reflux Disease and Gastroesophageal Reflux Disease-related Disorders

Background/Aims

To determine the value of salivary pepsin in discriminating sub-types of gastroesophageal reflux disease (GERD) and GERD-related disorders.

Methods

Overall, 322 patients with different sub-types of GERD and 45 healthy controls (HC) were studied. All patients took Gastroesophageal Reflux Disease Questionnaire (GerdQ) and underwent endoscopy and 24-hour esophageal pH monitoring and manometry. Salivary pepsin concentration (SPC) was detected by using colloidal gold double-antibody immunological sandwich assay. Oral esomeprazole treatment was administrated in the patients with non-erosive reflux disease (NERD) and extra-esophageal symptoms (EES).

Results

Compared to HC, patients with erosive esophagitis, NERD, EES, EES plus typical GERD symptoms, or Barrett’s esophagus had a higher prevalence of saliva and SPC (all P < 0.001). There was no significant difference in the positive rate for pepsin in patients with functional heartburn or GERD with anxiety and depression, compared to HC. After esomeprazole treatment, the positive rate and SPC were significantly reduced in NERD (both P < 0.001) and in EES (P = 0.001 and P = 0.002, respectively). Of the 64 NERD patients, 71.9% (n = 46) were positive for salivary pepsin, which was significantly higher than the rate (43.8%, n = 28) of pathological acid reflux as detected by 24-hour esophageal pH monitoring (P = 0.002).

Conclusions

Salivary pepsin has an important significance for the diagnosis of GERD and GERD-related disorders. Salivary pepsin and 24-hour esophageal pH monitoring may complement with each other to improve the diagnostic efficiency.

Gastroesophageal reflux disease and chronic cough: A possible mechanism elucidated by ambulatory pH-impedance-pressure monitoring

BACKGROUND

The pathophysiological mechanism(s) of gastroesophageal reflux disease (GERD)-related chronic cough (CC) is unclear. We aimed to determine the mechanism of reflux-induced cough by synchronous monitoring of reflux episodes, esophageal motility, and cough.

METHODS

Patients with GERD were prospectively enrolled and classified into GERD with CC (GERD-CC) and without CC (GERD) groups. Twenty-four-hour ambulatory pH-impedance-pressure monitoring was performed; the reflux patterns, esophageal motility during prolonged exposure to acid and characteristics of reflux episodes that induced coughing paroxysms were analyzed.

KEY RESULTS

Thirty-one patients with GERD-CC and 47 with GERD were enrolled; all of whose monitoring results fulfilled the criteria for diagnosis of GERD. Patients with GERD-CC had higher reflux symptom scores, longer exposure to acid, higher DeMeester scores, and more frequent reflux episodes, proximal extent reflux detected by impedance, and higher percentage of strongly acidic reflux than patients in the GERD group (all P < .05). Of 63 reflux-cough episodes identified in the GERD-CC group, 74.6% of distal reflux and 67.0% of proximal reflux episodes were acidic. More patients had low pan-esophageal pressure in primary peristalsis (48.5% vs 11.8%, P = .000) and synchronous contraction in secondary peristalsis during prolonged exposure to acid in the GERD-CC than in the GERD group (63.9% vs 9.1%, P = .000).

CONCLUSIONS & INFERENCES

Proximal acidic reflux and distal reflux-reflex are jointly associated with reflux-induced cough in patients with GERD. Low pan-esophageal pressure in primary peristalsis and synchronous contraction in secondary peristalsis may play important roles in GERD-associated chronic cough.

The role of esophageal pH-impedance testing in clinical practice

PURPOSE OF REVIEW

Ambulatory reflux monitoring is typically performed when esophageal symptoms do not respond to usual antireflux medications, or prior to invasive antireflux therapy. Although pH-based metrics have been the standard in defining esophageal reflux burden, novel impedance parameters have been introduced in recent years that can either be extracted from pH-impedance monitoring or obtained directly from esophageal mucosa. This review evaluates the clinical role of esophageal pH-impedance monitoring in clinical practice in the present day.

RECENT FINDINGS

Elevated acid exposure time in the distal esophagus remains the primary metric that predicts symptom improvement from antireflux therapy. Although conventional impedance-based metrics (numbers of reflux episodes, reflux-symptom association) provide complementary evidence, novel impedance-based metrics show promise in documenting reflux-induced damage to esophageal mucosal integrity, and in potentially predicting treatment outcome. The postreflux swallow-induced peristaltic wave measures integrity of primary peristalsis triggered by a reflux episode. Baseline impedance values reflect histopathological damage to mucosal integrity, and improve following successful antireflux therapy. Mucosal impedance assessed at endoscopy is a new diagnostic tool that is currently being evaluated in multinational research studies.

SUMMARY

Esophageal pH-impedance monitoring has potential to augment confidence in a reflux diagnosis beyond that provided by pH-monitoring alone.

Rabeprazole combined with trimebutine for treatment of patients with gastroesophageal reflux cough: Clinical efficacy and impact on serum levels of motilin and gastrin

AIM

To investigate the clinical effect of rabeprazole combined with trimebutine in the treatment of patients with gastroesophageal reflux cough and the impact on serum levels of motilin (MOT) and gastrin (GAS).

METHODS

Ninety-two patients with gastroesophageal reflux cough treated at our hospital from December 2015 to September 2017 were randomly divided into either a control group or a study group. Both groups were treated treated with routine treatment and rabeprazole, and the study group was additionally treated with trimebutine. The total effective rate, cough symptom score, gastroesophageal reflux disease questionnaire (GERDQ) score, and adverse effects were compared between the two groups.

RESULTS

The total effective rate was significantly higher in the study group than in the control group (95.7% vs 80.4%, P < 0.05). Before treatment, there was no significant difference in either day cough symptom score (4.14 ± 0.76 vs 4.28 ± 0.69) or night cough symptom score (4.11 ± 0.81 vs 4.07 ± 0.72) between the study group and the control group (P > 0.05). After treatment, both day cough symptom score and night cough symptom score were significantly lower in the study group than in the control group (P < 0.05). Before treatment, there was no significant difference in GERDQ score between the study group and control group (15.74 ± 3.26 vs 15.81 ± 3.32, P > 0.05). After treatment, the GERDQ score was significantly lower in the study group than in the control group (P < 0.05). Before treatment, serum levels of MOT and GAS did not differ significantly between the two groups (P > 0.05). After treatment, serum levels of MOT and GAS were significantly higher in the study group than in the control group (P < 0.05). There were no adverse effects in either group.

CONCLUSION

Rabeprazole combined with trimebutine can effectively improve clinical symptoms in patients with gastroesophageal reflux cough, without adverse effects.