Acid and non-acid reflux in patients with persistent symptoms despite acid suppressive therapy: a multicentre study using combined ambulatory impedance-pH monitoring

Treatment of GORD: Three decades of progress and disappointments

The treatment of GORD has been revolutionized by the introduction, in the 1980s, of proton-pump inhibitors as the mainstay of medical therapy and by the development of laparoscopic antireflux surgery which has definitively replaced open surgery. However, despite these major advances, many unmet therapeutic needs still persist and justify novel therapeutic approaches. The aim of this historical review is to recall the main discoveries in the treatment of GORD that have occurred during the last three decades and to discuss why some initially promising drugs or techniques have not translated into clinical applications. A careful analysis of these previous disappointing experiences should help to identify high priorities and better research programmes on the management of GORD.

Modern medical and surgical management of difficult-to-treat GORD

Approximately 30-40% of patients taking proton pump inhibitors (PPIs) for presumed gastro-oesophageal reflux (GOR) symptoms do not achieve adequate symptom control, especially when no oesophageal mucosal breaks are present at endoscopy and when extra-oesophageal symptoms are concerned. After failure of optimization of medical therapy, a careful work up is mandatory that aims at determining whether symptoms are related to GOR or not. Most patients with refractory symptoms do not have GOR-related symptoms. Some may have symptoms related to weakly acidic reflux and/or oesophageal hypersensitivity. Baclofen is currently the only antireflux compound available as add-on therapy to PPIs, but its poor tolerability limits its use in clinical practice. There is room for pain modulators in patients with hypersensitive oesophagus and functional heartburn. Antireflux surgery is a suitable option in patients responding to medical therapy who want to avoid taking medication or if persisting symptoms can be clearly attributed to poorly controlled GOR.

Acid-based parameters on pH-impedance testing predict symptom improvement with medical management better than impedance parameters

OBJECTIVES

pH-impedance testing detects reflux events irrespective of pH, but its value in predicting treatment outcome is unclear. We prospectively evaluated subjects treated medically after pH-impedance testing to determine predictors of symptom improvement.

METHODS

Subjects referred for pH-impedance testing completed questionnaires in which dominant symptoms and global symptom severity (GSS) were recorded. Acid-reflux parameters (acid-exposure time, AET; symptom association by Ghillebert probability estimate, GPE; symptom index, SI) and impedance reflux parameters (reflux-exposure time, RET; number of reflux events; GPE and SI with impedance data) were extracted. Symptoms and GSS were prospectively reevaluated after medical therapy. Univariate and multivariate analyses determined predictors of GSS improvement following medical management.

RESULTS

Over 5 years, 128 subjects (mean 53.3±1.3 years, 66.4% female; typical symptoms 57.0%, 53.9% tested on therapy) underwent pH-impedance testing and subsequent medical therapy for reflux symptoms, and completed required questionnaires. On follow-up 3.35±0.14 years later, mean GSS declined by 45.0%, with 42.2% patients reporting ≥50% GSS improvement. On univariate analysis, total AET, AET≥4.0%, and GPE for all reflux events predicted both linear and ≥50% GSS improvement, but RET and number of reflux events did not. On multivariate analysis, controlling for testing on or off therapy, only AET (P=0.003) and GPE for all reflux events (P=0.029) predicted GSS improvement.

CONCLUSIONS

Acid-based reflux parameters offer greater value over impedance-based nonacid-reflux parameters in predicting symptomatic responses to proton pump inhibitor (PPI) therapy. Our findings support conducting pH-impedance studies off PPI therapy to maximize clinical utility in predicting outcome.

Impedance pH Monitoring: Intra-observer and Inter-observer Agreement and Usefulness of a Rapid Analysis of Symptom Reflux Association

BACKGROUND/AIMS

Symptom reflux association analysis is especially helpful for evaluation and management of proton pump inhibitor (PPI) re-fractory patients. An accurate calculation requires manual editing of 24-hour multichannel intraluminal impedance-pH (MII-pH) tracings after automatic analysis. Intra- and inter-observer agreement as well as reliability of rapid editing confined to the time around symptomatic episodes are unknown. Aim of this study was to explore these topics in a prospective multicenter study.

METHODS

Forty consecutive patients who were off PPI therapy underwent MII-pH recordings. After automatic analysis, their tracings were anonymized and randomized. Three experienced observers, each one trained in a different European center, independently per-formed manual editing of 24-hour tracings on 2 separate occasions. Values of symptom index and symptom association proba-bility for acid and non acid reflux were transformed into binary response (i.e., positive or negative).

RESULTS

Intra-observer agreement on symptom reflux association was 92.5% to 100.0% for acid and 85.0% to 97.5% for non-acid reflux. Inter-observer agreement was 100.0% for acid and 82.5% to 95.0% for non-acid reflux. Values for symptom index and symptom association probability were similar. Concordance between 24-hour and rapid (2 minutes-window before each symp-tomatic episode) editings for symptom reflux association occured in 39 to 40 patients (acid) and in 37 to 40 (non-acid), de-pending on the observer.

CONCLUSIONS

Intra- and inter-observer agreement in classifying patients with or without symptom reflux association at manual editing of 24-hour tracings was high, especially for acid reflux. Classifying patients according to a rapid editing showed excellent con-cordance with the 24-hour one and can be adopted in clinical practice.

Esophageal motility abnormalities in gastroesophageal reflux disease

Esophageal motility abnormalities are among the main factors implicated in the pathogenesis of gastroesophageal reflux disease. The recent introduction in clinical and research practice of novel esophageal testing has markedly improved our understanding of the mechanisms contributing to the development of gastroesophageal reflux disease, allowing a better management of patients with this disorder. In this context, the present article intends to provide an overview of the current literature about esophageal motility dysfunctions in patients with gastroesophageal reflux disease. Esophageal manometry, by recording intraluminal pressure, represents the gold standard to diagnose esophageal motility abnormalities. In particular, using novel techniques, such as high resolution manometry with or without concurrent intraluminal impedance monitoring, transient lower esophageal sphincter (LES) relaxations, hypotensive LES, ineffective esophageal peristalsis and bolus transit abnormalities have been better defined and strongly implicated in gastroesophageal reflux disease development. Overall, recent findings suggest that esophageal motility abnormalities are increasingly prevalent with increasing severity of reflux disease, from non-erosive reflux disease to erosive reflux disease and Barrett’s esophagus. Characterizing esophageal dysmotility among different subgroups of patients with reflux disease may represent a fundamental approach to properly diagnose these patients and, thus, to set up the best therapeutic management. Currently, surgery represents the only reliable way to restore the esophagogastric junction integrity and to reduce transient LES relaxations that are considered to be the predominant mechanism by which gastric contents can enter the esophagus. On that ground, more in depth future studies assessing the pathogenetic role of dysmotility in patients with reflux disease are warranted.

EAES recommendations for the management of gastroesophageal reflux disease

BACKGROUND

Gastroesophageal reflux disease (GERD) is one of the most frequent benign disorders of the upper gastrointestinal tract. Management of GERD has always been controversial since modern medical therapy is very effective, but laparoscopic fundoplication is one of the few procedures that were quickly adapted to the minimal access technique. The purpose of this project was to analyze the current knowledge on GERD in regard to its pathophysiology, diagnostic assessment, medical therapy, and surgical therapy, and special circumstances such as GERD in children, Barrett's esophagus, and enteroesophageal and duodenogastroesophageal reflux.

METHODS

The European Association of Endoscopic Surgery (EAES) has tasked a group of experts, based on their clinical and scientific expertise in the field of GERD, to establish current guidelines in a consensus development conference. The expert panel was constituted in May 2012 and met in September 2012 and January 2013, followed by a Delphi process. Critical appraisal of the literature was accomplished. All articles were reviewed and classified according to the hierarchy of level of evidence and summarized in statements and recommendations, which were presented to the scientific community during the EAES yearly conference in a plenary session in Vienna 2013. A second Delphi process followed discussion in the plenary session.

RESULTS

Recommendations for pathophysiologic and epidemiologic considerations, symptom evaluation, diagnostic workup, medical therapy, and surgical therapy are presented. Diagnostic evaluation and adequate selection of patients are the most important features for success of the current management of GERD. Laparoscopic fundoplication is the most important therapeutic technique for the success of surgical therapy of GERD.

CONCLUSIONS

Since the background of GERD is multifactorial, the management of this disease requires a complex approach in diagnostic workup as well as for medical and surgical treatment. Laparoscopic fundoplication in well-selected patients is a successful therapeutic option.

Accuracy of diagnosing gastroesophageal reflux disease by GerdQ, esophageal impedance monitoring and histology

OBJECTIVE

To assess the performance of self-assessment gastroesophageal reflux disease questionnaire (GerdQ), 24-h impedance monitoring, proton pump inhibitor (PPI) test and intercellular space of esophageal mucosal epithelial cells in the diagnosis of gastroesophageal reflux disease (GERD).

METHODS

Patients with symptoms suspected of GERD were administered the GerdQ and underwent endoscopy (measurement of intercellular space in the biopsy specimen sampling at 2 cm above the Z-line) and 24-h impedance pH monitoring, together with a 2-week experimental treatment with esomeprazole.

RESULTS

A total of 636 patients were included for the final analysis, including 352 with GERD. The sensitivity and specificity of GerdQ and 24-h impedance monitoring for diagnosing GERD were 57.7% and 48.9%, and 66.4% and 43.3%, respectively. The sensitivity of 24-h impedance pH monitoring increased to 93.7%. The sensitivity and specificity of dilated intercellular spaces (DIS) (≥0.9 μm) for diagnosing GERD were 61.2% and 56.1%, respectively, whereas those for PPI test were 70.5% and 44.4%.

CONCLUSIONS

GerdQ score or PPI test alone cannot accurately diagnose GERD in a Chinese population suspected of GERD. A definitive diagnosis of GERD still depends on endoscopy or 24-h pH monitoring. 24-h impedance pH monitoring may increase the sensitivity for diagnosing GERD by 20%; however, when used alone, it results in poor specificity in patients without acid suppressive therapy.

The role of pain modulators in esophageal disorders - no pain no gain

Pain modulators have been primarily used for the management of functional esophageal disorders. Recently, these drugs have also been used for the management of other esophageal disorders, such as non-erosive reflux disease, the hypersensitive esophagus, and heartburn that is not responsive to proton pump inhibitor treatment. Several etiologies have been identified in patients with functional esophageal disorders, and these include esophageal hypersensitivity due to peripheral and/or central sensitisation, altered central processing of peripheral stimuli, altered autonomic activity, and psychological comorbidity such as depression and anxiety. Different antidepressants have been used as pain modulators and have demonstrated a beneficial effect on patients with the aforementioned esophageal disorders. Tricyclic antidepressants are the most commonly used class of drugs in clinical practice. Other antidepressants that have been used, some with more clinical success than others, include selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and trazodone. Other medications that have been used as pain modulators in esophageal disorders include adenosine antagonists, serotonin agonists, antiepileptics, and medications that ameliorate peripheral neuropathy. The mechanism by which many of the pain modulators confer their visceral analgesic effect remains to be fully elucidated. Regardless, their role and value in treating esophageal disorders have markedly increased in the last decade.

Chronic pepsin exposure promotes anchorage-independent growth and migration of a hypopharyngeal squamous cell line

OUTCOME OBJECTIVES

(1) Investigate the role of reflux, specifically pepsin, in laryngopharyngeal carcinogenesis. (2) Evaluate effects of chronic pepsin exposure on cell migration, apoptosis, and colony-forming ability in hypopharyngeal cells.

STUDY DESIGN

Translation research.

SETTING

Academic research laboratory.

METHODS

Human hypopharyngeal squamous carcinoma FaDu cells were chronically exposed to nonacidic pepsin (exposed for 24 hours, 4 times over 2 weeks at the following concentrations: 0.01 mg/mL, 0.1 mg/mL, or 1 mg/mL). Precise wounds were created in confluent cell plates, and rates of cell migration into wounds were quantified. Separately, cell viability of chronic pepsin-exposed FaDu cells acutely treated with paclitaxel was measured. Finally, a clonogenic assay was performed on these cells to measure effects of chronic pepsin exposure on colony-forming ability.

RESULTS

An increased rate of relative wound density was observed in chronic pepsin-treated (0.01 mg/mL, 0.1 mg/mL) cells compared with control (P < .001), suggesting greater rates of cell migration. Pepsin-treated (0.1 mg/mL) cells demonstrated on average greater cell viability compared with control after exposure to paclitaxel, suggesting possible apoptotic resistance; however, this was not statistically significant. Chronic pepsin exposure (0.1 mg/mL, 1 mg/mL) was associated with a dose-dependent increase in colony-forming ability relative to control (P < .001).

CONCLUSION

Hypopharyngeal squamous cell line chronically exposed to pepsin demonstrated increased cell migration and colony-forming ability relative to control cells. These experiments indicate that chronic pepsin exposure acts as a promoter of tumorigenesis and metastasis of airway epithelium, suggesting a role for pepsin in laryngopharyngeal carcinogenesis attributed to gastric reflux.

The gastric accommodation response to meal intake determines the occurrence of transient lower esophageal sphincter relaxations and reflux events in patients with gastro-esophageal reflux disease

BACKGROUND

Gastro-esophageal reflux (GER), the retrograde flow of gastric contents into the esophagus is a physiologic phenomenon, which can evoke symptoms and/or lesions in the esophagus (=gastro-esophageal reflux disease or GERD). Proton pump inhibitors (PPIs) reduce gastric acidity; however, as they are unable to control transient lower esophageal sphincter relaxations (TLESRs), the main mechanism for reflux in GERD, they do not abolish reflux. TLESRs occur predominantly in the postprandial period, and they are believed to be triggered by gastric distention. Gastric accommodation (GA) is the physiologic response to gastric distention and serves to prevent a rise in gastric wall tension during food intake. We aimed to study the relationship between GA and TLESRs, as they both are triggered by gastric distention.

METHODS

We studied 12 GERD patients (average age 37 years [range 18-62], 7m/5f) and nine healthy volunteers (average age 27 years [range 22-36], 2m/7f) using high resolution manometry-impedance measurement before and after a mixed meal challenge. We determined the number of TLESRs (with or without reflux) and measured pre- and postprandial IGP. The change in IGP between the pre- and postprandial period (ΔIGP) is used as surrogate for GA. We also measured LES pressure before and after the meal and calculated the change (ΔLESp).

KEY RESULTS

There were no statistical differences between pre- and postprandial IGP in GERD and healthy volunteers and similarly, there was no significant difference between pre- and postprandial LES pressures in GERD patients and healthy volunteers. The number of TLESRs (with or without reflux) was similar in GERD and healthy volunteers. More importantly, we did observe a negative correlation between ΔIGP and the number of TLESRs, irrespective of whether they were associated with reflux or not, in the GERD patients (without reflux r = -0.67, p = 0.017; with reflux r = -0.81, p = 0.0014). The same observations were found in healthy volunteers, where ΔIGP and the number of TLESRs are significantly inversely correlated (without reflux r = -0.87, p = 0.0045; with reflux r = -0.75, p = 0.021). We could not establish a correlation between ΔLESp and the number of TLESRs, neither in GERD patients nor in healthy volunteers.

CONCLUSIONS & INFERENCES

This is the first study showing a clear negative correlation between ΔIGP and the number of TLESRs, irrespective of whether they were associated with reflux or not, both in GERD patients and in healthy subjects. These results suggest that TLESRs and GA are closely linked, probably through activation of mechanoreceptors involved in triggering of TLESRs.

Esophageal baseline impedance levels in patients with pathophysiological characteristics of functional heartburn

BACKGROUND

Recently, it has been suggested that low esophageal basal impedance may reflect impaired mucosal integrity and increased acid sensitivity. We aimed to compare baseline impedance levels in patients with heartburn and pathophysiological characteristics related to functional heartburn (FH) divided into two groups on the basis of symptom relief after proton pump inhibitors (PPIs).

METHODS

Patients with heartburn and negative endoscopy were treated with esomeprazole or pantoprazole 40 mg daily for 8 weeks. According to MII-pH (off therapy) analysis, patients with normal acid exposure time (AET), normal reflux number, and lack of association between symptoms and refluxes were selected; of whom 30 patients with a symptom relief higher than 50% after PPIs composed Group A, and 30 patients, matched for sex and age, without symptom relief composed Group B. A group of 20 healthy volunteers (HVs) was enrolled. For each patient and HV, we evaluated the baseline impedance levels at channel 3, during the overnight rest, at three different times.

KEY RESULTS

Group A (vs Group B) showed an increase in the following parameters: mean AET (1.4 ± 0.8% vs 0.5 ± 0.6%), mean reflux number (30.4 ± 8.7 vs 24 ± 6.9), proximal reflux number (11.1 ± 5.2 vs 8.2 ± 3.6), acid reflux number (17.9 ± 6.1 vs 10.7 ± 6.9). Baseline impedance levels were lower in Group A than in Group B and in HVs (p < 0.001).

CONCLUSIONS & INFERENCES

Evaluating baseline impedance levels in patients with heartburn and normal AET could achieve a better understanding of pathophysiology in reflux disease patients, and could improve the distinction between FH and hypersensitive esophagus.

Esophageal pH and Combined Impedance-pH Monitoring in Children

Esophageal pH monitoring is considered the gold standard for the diagnosis of gastroesophageal reflux disease because of the normal ranges across the pediatric age range. However, this method can only detect acid reflux. Multichannel intraluminal impedance-pH (MII-pH) monitoring has recently been used for the detection of bolus reflux in infants and children. This method allows for the detection of liquid, gas or mixed reflux in addition to acid, weakly acidic or weakly alkaline reflux. MII-pH monitoring can record the direction of flow and the height of reflux, which are useful parameters to identify an association between symptoms and reflux. However, the technique is limited by its high cost and the lack of normative data of MII-pH in the pediatric population. Despite certain limitations, MII-pH monitoring will become more common and gradually replace pH monitoring in the future, because pH monitoring is part of MII-pH.

Esophageal manometry in gastroesophageal reflux disease

High-resolution manometry (HRM) allows nuanced evaluation of esophageal motor function, and more accurate evaluation of lower esophageal sphincter (LES) function, in comparison with conventional manometry. Pathophysiologic correlates of gastroesophageal reflux disease (GERD) and esophageal peristaltic performance are well addressed by this technique. HRM may alter the surgical decision by assessment of esophageal peristaltic function and exclusion of esophageal outflow obstruction before antireflux surgery. Provocative testing during HRM may assess esophageal smooth muscle peristaltic reserve and help predict the likelihood of transit symptoms following antireflux surgery. HRM represents a continuously evolving new technology that compliments the evaluation and management of GERD.

Acid and nonacid reflux monitoring

Detection of acid and nonacid reflux using esophageal reflux monitoring, which includes conventional and wireless pH monitoring and pH impedance, can be a valuable diagnostic tool when used appropriately in the assessment of patients with gastroesophageal reflux disease. Reflux monitoring may be especially helpful if a management change is desired, such as when initial or empirical treatment is ineffective. However, each of these methods has its limitations, which need to be accounted for in their clinical use. Indications, test performance, interpretation, and clinical applications of esophageal reflux monitoring, as well as their limitations, are discussed in this review.

New Approaches to Management of PPI-Refractory Gastroesophageal Reflux Disease

OPINION STATEMENT

"Refractory GERD" is one the most common misnomers in the area of gastroesophageal reflux disease. The term implies reflux as the underlying etiology despite unresponsiveness to aggressive, often twice-daily proton pump inhibitor therapy. The term should be replaced with "refractory symptoms." We must acknowledge that in many patients, symptoms of reflux often overlap with non-GERD causes such as gastroparesis, dyspepsia, hypersensitive esophagus, and functional disorders. Lack of response to aggressive acid suppressive therapy often leads to esophagogastroduodenoscopy followed by pH or impedance monitoring. In the majority of patients these tests are normal. The role of non-acid reflux measured by impedance pH testing in this group is uncertain at best and the results from this test alone should not be used to refer patients to surgical fundoplication. In patients unresponsive to acid suppressive therapy, reflux is most commonly not causal and a search for non-GERD causes must ensue.

Idiopathic pulmonary fibrosis and gastroesophageal reflux. Implications for treatment

BACKGROUND

Even though the pathogenesis of idiopathic pulmonary fibrosis (IPF) is unknown, there is mounting evidence that abnormal reflux (GERD) and aspiration of gastric contents may play a role in the pathogenesis of this disease.

AIMS

The aims of this study were to determine in patients with GERD and IPF: (a) the clinical presentation, (b) the esophageal function, and (c) the reflux profile.

METHODS

We compared the clinical presentation, the esophageal function (as defined by high-resolution manometry), and the reflux profile (by dual sensor pH monitoring) in 80 patients with GERD (group A) and in 22 patients with GERD and IPF (group B).

RESULTS

Heartburn was present in less than 60 % of patients with GERD and IPF. Lower esophageal sphincter pressure and peristalsis were normal in both groups, while the upper esophageal sphincter (UES) was more frequently hypotensive in IPF patients (p = 0.008). In patients with GERD and IPF, the proximal esophageal acid exposure was higher (p = 0.047) and the supine acid clearance was slower as compared with patients with GERD only (p < 0.001).

CONCLUSIONS

The results of this study show that in patients with GERD and IPF: (a) reflux is frequently silent, (b) with the exception of a weaker UES, the esophageal function is preserved, and (c) proximal reflux is more common, and in the supine position, it is coupled with a slower acid clearance. Because these factors predisposing IPF patients to the risk of aspiration, antireflux surgery should be considered early after the diagnosis of IPF and GERD is established.

A randomized trial on endoscopic full-thickness gastroplication versus laparoscopic antireflux surgery in GERD patients without hiatal hernias

BACKGROUND AND GOALS

Endoscopic full-thickness gastroplication by the Plicator instrument has proven to be a safe and effective method to improve symptoms of gastroesophageal reflux disease. This is the first comparative objective data study for endoscopic versus laparoscopic antireflux procedures.

STUDY

In this single-center controlled open trial in 70 adult patients with documented gastroesophageal reflux disease without hiatal hernias, objective and subjective outcome parameters were evaluated prospectively and compared. Patients were randomly assigned to either endoscopic full-thickness gastroplication or laparoscopic antireflux surgery. Patients in the Plicator group received between 1 and 3 transmural-pledgeted sutures to the gastric cardia. Patients in the laparoscopic anti-reflux surgery (LARS) group underwent Nissen or Toupet fundoplication. Esophageal manometry, 24-hour impedance pH monitoring, Gastrointestinal Quality-of-Life Index, and symptom questionnaires were evaluated at baseline and at the 3-month follow-up for significant (P<0.05) changes and differences.

RESULTS

Lower esophageal sphincter pressures were increased in the LARS group and unchanged in the Plicator group. Total reflux numbers, acid, nonacid, proximal, upright, and recumbent reflux events were reduced in both groups, significantly more in the LARS group. Reductions in reflux-related esophageal acid scores were significant only in the LARS group. Similar improvements of Gastrointestinal Quality-of-Life Index were found in both groups. General and gas-related symptom scores were comparably reduced. Greater Reductions in reflux-specific symptom scores were found after LARS. Bowel dysfunction symptom scores were lower after LARS.

CONCLUSIONS

Improvements in the general subjective outcome parameters were similar after endoscopic full-thickness gastroplication compared with LARS despite a stronger reflux control provided by LARS. More effective relief of reflux-related symptoms favors LARS, and differences in side effect symptoms favor endoscopic full-thickness gastroplication.

Proton pump inhibitor resistance, the real challenge in gastro-esophageal reflux disease

Gastro-esophageal reflux disease (GERD) is one of the most prevalent chronic diseases. Although proton pump inhibitors (PPIs) represent the mainstay of treatment both for healing erosive esophagitis and for symptom relief, several studies have shown that up to 40% of GERD patients reported either partial or complete lack of response of their symptoms to a standard PPI dose once daily. Several mechanisms have been proposed as involved in PPIs resistance, including ineffective control of gastric acid secretion, esophageal hypersensitivity, ultrastructural and functional changes in the esophageal epithelium. The diagnostic evaluation of a refractory GERD patients should include an accurate clinical evaluation, upper endoscopy, esophageal manometry and ambulatory pH-impedance monitoring, which allows to discriminate non-erosive reflux disease patients from those presenting esophageal hypersensitivity or functional heartburn. Treatment has been primarily based on doubling the PPI dose or switching to another PPI. Patients with proven disease, not responding to PPI twice daily, are eligible for anti-reflux surgery.

Ambulatory reflux monitoring in GERD--which test should be performed and should therapy be stopped?

Diagnosing gastroesophageal reflux disease (GERD) often entails using a combination of patient symptoms, response to proton pump inhibitors (PPI), upper endoscopy, and ambulatory reflux testing. Each of these has limitations of which the clinician must be aware when managing patients with reflux symptoms. Ambulatory reflux monitoring, in particular, can potentially document the true presence of pathologic GERD. Consequently, reflux testing is often necessary in our evaluation of patients with reflux symptoms, and can be useful in distinguishing etiologies driving a lack of response to PPI therapy. Reflux testing results can be also used to guide appropriate PPI prescribing and clinical decision making for appropriate or unnecessary therapy. This review focuses on the limitations of our current diagnostic paradigm and highlights how reflux testing can be helpful in the diagnosis and management of patients with poor response to PPI therapy.

Extra-esophageal manifestations of GERD: who responds to GERD therapy?

Gastroesophageal reflux disease (GERD) is a common disease that is defined as a condition that develops when the reflux of stomach contents causes troublesome symptoms. In addition to the esophageal manifestations of heartburn and regurgitation, the role of GERD in causing extra-esophageal symptoms, such as laryngitis, asthma, cough, chest pain, and dental erosions, is increasingly recognized with renewed interest. Due to the poor sensitivity of endoscopy and pH monitoring, and the poor specificity of laryngoscopy, empiric therapy with proton pump inhibitors (PPI) is now considered the initial diagnostic step in patients suspected of having GERD-related symptoms. In those who are unresponsive to such therapy, other diagnostic testing such as impedance/pH monitoring may be reasonable in order to exclude continued acid or weakly acid reflux. Recent data suggest that patients with extra-esophageal symptoms who have concomitant typical symptoms, moderate-sized hiatal hernia and moderate reflux on pH testing may respond better to acid suppressive therapy. This group only accounts for 20-30 % of patients commonly referred for suspected GERD. PPI-unresponsive patients usually have causes other than GERD for their extra-esophageal signs and symptoms and continued PPI therapy in this group is not recommended.

The pulmonary side of reflux disease: from heartburn to lung fibrosis

INTRODUCTION

Gastroesophageal reflux disease (GERD) is the most prevalent gastrointestinal disorder in the USA. Heartburn is the symptom most commonly associated with this disease, and the highly commercialized medical treatment directed toward relief of this symptom represents a 10-billion-dollar-per-year industry.

DISCUSSION

Unfortunately, there is often little awareness that GERD can be potentially a lethal disease as it can cause esophageal cancer. Furthermore, there is even less awareness about the relationship between GERD and respiratory disorders with the potential for severe morbidity and even mortality.

The role of impedance monitoring in patients with extraesophageal symptoms

OBJECTIVES/HYPOTHESIS

Ambulatory esophageal impedance monitoring is commonly employed to assess for nonacid reflux in patients with extraesophageal reflux. We aimed to determine if on therapy impedance data can be predicted from off therapy upper endoscopy, manometry, or pH parameters.

STUDY DESIGN

Prospective Cohort Study.

METHODS

Patients with extraesophageal reflux symptoms and either partial- or nonresponders to twice-daily PPI underwent impedance monitoring on twice-daily PPI, as well as manometry, upper endoscopy, and 48-hour wireless pH monitoring off acid-suppressive medications for 1 week. Percent time pH < 4 and number of reflux episodes were obtained. Multivariable linear regression was used to determine association between the impedance data on therapy and upper endoscopy, manometry, and pH parameters measured off therapy.

RESULTS

Seventy-five patients (77% female, median BMI 29, 38% with hiatal hernia, and 19% with esophagitis) were studied both on and off therapy. Thirty-five percent had abnormal impedance monitoring on therapy and 84% had abnormal pH testing off therapy. There was no significant (P = 0.184) overall correlation between total number of impedance events and the baseline physiologic parameters of hiatal hernia, degree of acid reflux, or manometric findings, with only weak correlation (r = 0.54, P = 0.045) with % time pH < 4 among patients with esophagitis.

CONCLUSIONS

In patients with suspected extraesophageal reflux refractory to PPI therapy, impedance measures on therapy cannot be predicted from traditional baseline esophageal physiologic parameters. We recommend caution regarding over-interpretation of impedance data.

LEVEL OF EVIDENCE

2b.

Pharyngeal pH monitoring better predicts a successful outcome for extraesophageal reflux symptoms after antireflux surgery

BACKGROUND

Gastroesophageal reflux disease can be associated with extraesophageal symptoms (hoarseness, cough, asthma, and globus). However, these symptoms may have a multifactorial etiology. Proximal pH monitoring has been proposed as a means of identifying patients where reflux is the cause of the extraesophageal symptoms. The aim of this study was to determine whether proximal esophageal or pharyngeal pH monitoring better identified patients with extraesophageal symptoms that improved after antireflux surgery.

METHODS

A retrospective chart review was performed to identify all patients who had esophageal and pharyngeal pH monitoring before an antireflux operation. A composite score was used to define an abnormal result with each test. A successful outcome was defined as improvement or resolution of extraesophageal symptoms.

RESULTS

There were 20 patients identified. Antireflux surgery led to a successful outcome in 14 patients (70 %). Restech better identified patients with extraesophageal symptoms who had a successful outcome with antireflux surgery (12 of 14 [86 %] based on abnormal Restech versus 5 of 10 [50 %] based on abnormal proximal probe, p = 0.06). Comparing only the 15 patients who had both proximal esophageal and pharyngeal pH monitoring, Restech again better identified those who had a successful outcome with antireflux surgery (9 of 10 [90 %] based on abnormal Restech versus 5 of 10 [50 %] based on abnormal proximal probe, p = 0.05). The positive and negative predictive values for symptomatic improvement after a fundoplication were better for an abnormal Restech score than for an abnormal proximal esophageal score (80 vs. 71 % and 60 vs. 38 %, respectively). In two patients with a successful outcome, Restech was the only positive test.

CONCLUSIONS

In patients with extraesophageal reflux symptoms, proximal esophageal pH monitoring failed to identify half of the patients who had a successful outcome after antireflux surgery. In contrast, an abnormal Restech pH test was present in 90 % of patients with a successful outcome. Further, a negative Restech study more reliably indicated the absence of reflux-induced extraesophageal symptoms. Our results indicate that Restech pharyngeal pH monitoring should be utilized in the evaluation of patients with extraesophageal symptoms that may be associated with reflux disease.

Small volume acid reflux in gastroesophageal reflux disease patients with hiatal hernia is only detectable by pH-metry but not by multichannel intraluminal impedance

Until now, it is uncertain if the so-called pH-only reflux episodes that consist of a pH drop without evidence of retrograde bolus movement in multichannel intraluminal impedance (MII) represent reflux episodes or artifacts. Hiatal hernia (HH) may allow reflux of small volumes to occur that can be detected by pH-metry but not by MII. The aim was to search for a mechanism that can explain pH-only reflux, 20 patients (12 females and 8 males, median age 52 years, interquartile range [IQR]: 40.5-60.75 years) were investigated with MII-pH off PPI. Impedance and pH-metry data were analyzed separately. The differences in detection rate of acid reflux between pH-metry and MII were correlated with the presence of HH. In an in vitro experiment, MII-pH probes were flushed with citric acid in plastic tubes of different size with capillary diameter and diameters of 2.5 mm and 4.5 mm, while recording pH values and impedance. HH was present in six patients and absent in 14 patients. In patients with HH in comparison with patients with absent HH, the difference of acid reflux detection between pH-metry and MII is significantly higher (70%, IQR: 15-88% and 3.6%, IQR: 0-31%, respectively). In vitro all simulated reflux lead to a fall in pH whereas a corresponding decrease in impedance was only recognizable in the 4.5-mm plastic tubes. Acid reflux episodes in patients with HH are more frequently detected by pH-metry than by MII. Small volume reflux that does not lead to a decrease in impedance is the likely explanation for this phenomenon.

Approach to the patient with presumed extraoesophageal GERD

Reflux related cough, asthma and laryngitis are frequently encountered and are considered part of extraoesophageal syndromes. The diagnosis of extraoesophageal reflux is difficult due to the lack of gold standard diagnostic criteria. Esophagogastroduodenoscopy and esophageal pH monitoring are inadequate diagnostic tools for due to poor sensitivity and specificity. For this reason, empirical PPI therapy is recommended as an initial approach to diagnose and treat the potential underlying cause of these symptoms in patients without alarm symptoms. Diagnostic testing with esophageal pH and/or impedance monitoring and esophageal motility testing is usually reserved for those who continue to be symptomatic despite a trial of therapy with PPIs. Recent developments have increased our understanding of this difficult to treat group of patients but more research into reflux related extraoesophageal symptoms are needed to better diagnose and treat this group.

Post-prandial reflux suppression by a raft-forming alginate (Gaviscon Advance) compared to a simple antacid documented by magnetic resonance imaging and pH-impedance monitoring: mechanistic assessment in healthy volunteers and randomised, controlled, double-blind study in reflux patients

BACKGROUND

Alginates form a raft above the gastric contents, which may suppress gastro-oesophageal reflux; however, inconsistent effects have been reported in mechanistic and clinical studies.

AIMS

To visualise reflux suppression by an alginate-antacid [Gaviscon Advance (GA), Reckitt Benckiser, UK] compared with a nonraft-forming antacid using magnetic resonance imaging (MRI), and to determine the feasibility of pH-impedance monitoring for assessment of reflux suppression by alginates.

METHODS

Two studies were performed: (i) GA and antacid (Alucol, Wander Ltd, Switzerland) were visualised in the stomach after ingestion in 12 healthy volunteers over 30 min after a meal by MRI, with reflux events documented by manometry. (ii) A randomised controlled, double-blind cross-over trial of post-prandial reflux suppression documented by pH-impedance in 20 patients randomised to GA or antacid (Milk of Magnesia; Boots, UK) after two meals taken 24 h apart.

RESULTS

MRI visualized a "mass" of GA form at the oesophago-gastric junction (OGJ); simple antacid sank to the distal stomach. The number of post-prandial common cavity reflux events was less with GA than antacid [median 2 (0-5) vs. 5 (1-11); P < 0.035]. Distal reflux events and acid exposure measured by pH-impedance were similar after GA and antacid. There was a trend to reduced proximal reflux events with GA compared with antacid [10.5 (8.9) vs. 13.9 (8.3); P = 0.070].

CONCLUSIONS

Gaviscon Advance forms a 'mass' close to the OGJ and significantly suppresses reflux compared with a nonraft-forming antacid. Standard pH-impedance monitoring is suitable for clinical studies of GA in gastro-oesophageal reflux disease patients where proximal reflux is the primary outcome.

Esophageal chemical clearance is impaired in gastro-esophageal reflux disease--a 24-h impedance-pH monitoring assessment

BACKGROUND

Impedance-pH monitoring allows assessment of retrograde and antegrade intra-esophageal movement of fluids and gas. Reflux is followed by volume clearance and chemical clearance, elicited by secondary and swallow-induced peristalsis, respectively. We aimed to assess whether chemical clearance is impaired in gastro-esophageal reflux disease (GERD).

METHODS

Blinded retrospective review of impedance-pH tracings from patients with erosive reflux disease (ERD) and non-erosive reflux disease (NERD), and from proton pump inhibitor (PPI)-refractory patients before and after laparoscopic fundoplication. The number of refluxes followed within 30 s by swallow-induced peristaltic waves was divided by the number of total refluxes to obtain a parameter representing chemical clearance namely the postreflux swallow-induced peristaltic wave (PSPW) index.

KEY RESULTS

The PSPW index was significantly lower in 31 ERD (15%) and in 44 NERD (33%) off-PPI patients than in 30 controls (75%), as well as in 18 ERD (16%) and in 48 NERD (31%) on-PPI patients than in 26 on-PPI functional heartburn (FH) cases (67%) (P < 0.05 for all comparisons). In 29 PPI-refractory patients, the median PSPW index was unaltered by otherwise effective antireflux surgery (20% postoperatively, 21% preoperatively). The overall sensitivity, specificity, positive, and negative predictive values of the PSPW index in identifying GERD patients were 97%, 89%, 96%, and 93%.

CONCLUSIONS & INFERENCES

Impairment of chemical clearance is a primary pathophysiological mechanism specific to GERD: it is unaffected by medical/surgical therapy, is not found in FH, and is more pronounced in ERD than in NERD. Using the PSPW index could improve the diagnostic efficacy of impedance-pH monitoring.

Novel therapeutics for gastro-esophageal reflux symptoms

Approximately 20-30% of patients with gastro-esophageal reflux symptoms report inadequate symptom relief while on proton-pump inhibitor therapy. The mechanisms involved are failure of the antireflux barrier (transient lower esophageal sphincter relaxations), high proximal extent of the refluxate, esophageal hypersensitivity and impaired mucosal integrity. Persisting acid or nonacid reflux can be demonstrated in 40-50% of cases, suggesting that there is room for antireflux therapy in these patients. New antireflux compounds have been shown to decrease the occurrence of transient lower esophageal sphincter relaxations. The most promising classes of compounds are GABA type B agonists and metabotropic glutamate receptor 5 antagonists, which can reduce both reflux episodes and symptoms, but the development of these compounds has been abandoned for either safety issues or lack of efficacy. Esophageal hypersensitivity and impaired mucosal integrity may prove to be relevant therapeutic targets in the future.

[Updated guidelines 2012 for gastroesophageal reflux disease]

In 2010, a Korean guideline for the management of gastroesophageal reflux disease (GERD) was made by the Korean Society of Neurogastroenterology and Motility, in which the definition and diagnosis of GERD were not included. The aim of this guideline was to update the clinical approach to the diagnosis and management of GERD in adult patients. This guideline was developed by the adaptation process of the ADAPTE framework. Twelve guidelines were retrieved from initial queries through the Appraisal of Guidelines for Research & Evaluation II process. Twenty-seven statements were made as a draft and revised by modified Delphi method. Finally, 24 consensus statements for the definition (n=4), diagnosis (n=7) and management (n=13) of GERD were developed. Multidisciplinary experts participated in the development of the guideline, and the external review of the guideline was conducted at the finalization phase.

Extraesophageal manifestations of gastroesophageal reflux disease

This article discusses the current state of knowledge regarding the relationship between gastroesophageal reflux disease (GERD) and pulmonary and ear/nose/throat manifestations of reflux and outlines the recent developments in the diagnostic and treatment strategies for this difficult group of patients. Upper gastrointestinal endoscopy and pH monitoring are poorly sensitive for diagnosing reflux in this group of patients. Instead it is recommended that in those without warning symptoms, an empiric trial of proton-pump inhibitors be the initial approach to diagnosing and treating the potential underlying cause of these extraesophageal symptoms.

Impedance-pH testing

Pharmacologic treatment of gastroesophageal reflux disease is based upon gastric acid suppression with proton pump inhibitors (PPIs). In many patients, symptoms persist despite PPI treatment. For some, ongoing symptoms may be due to nonacid reflux. Accurate measurement of nonacid reflux is not possible with conventional ambulatory pH monitoring. Impedance-pH monitoring has advanced the ability to assess gastroesophageal reflux, because, in addition to detecting acid reflux, it enables measurement of nonacid reflux. This article discusses the principles of impedance-pH monitoring, catheter characteristics and placement, interpretation of studies, and clinical uses of this form of reflux monitoring.

Effect of proton pump inhibition on acid, weakly acid and weakly alkaline gastro-esophageal reflux in children

BACKGROUND

The effect of proton pump inhibitors on the characteristics of gastroesophageal reflux (GER) in children and adolescents was evaluated.

METHODS

Twenty-one children and adolescents with symptoms suggesting GER disease (GERD) underwent upper endoscopy and a 24-hour multichannel intraluminal impedance/pH (MII-pH) monitoring before and at the end of 2 months of therapy with proton pump inhibitors (PPIs).

RESULTS

Fourteen (67%) patients reported clinically relevant symptom improvement after 2 months of PPIs intake. At the first endoscopy, 8 (38%) patients had macroscopic signs of reflux esophagitis; after two months of therapy, 6/8 (75%) patients had a complete mucosal recovery. There was a significant reduction in the total percentage of mean acid reflux time (from 13.1% to 3.8%), and the De Meester score dropped to normal (from 46.4 to 13.1). The mean number of acid refluxes decreased significantly from 48 to 15 per 24 hours, while inversely, the mean number of weakly acid refluxes increased significantly from 26 to 64 per 24 hours. PPI therapy did not affect the total number of reflux episodes, the number of liquid and mixed refluxes, the duration of esophageal bolus exposure and proximal extent of the reflux.

CONCLUSIONS

In children and adolescents with GERD, PPIs do not affect the total number of reflux episodes. PPIs only decrease the acidity of refluxate. Nevertheless, the majority of patients with typical reflux symptoms may report symptom improvement. Esophagitis can be healed after PPI treatment. The treatment of weakly acid and weakly alkaline reflux remains a challenge for physicians in the future.

The role of the larynx in chronic cough

Cough lasting more than 8 weeks is considered chronic. If the classic causes of chronic cough have been discarded, vagus nerve sensory disturbances are currently considered the most important etiological cause. Patients with chronic cough of laryngeal origin have associated symptoms such as globus, dysphagia, dysphonia, dyspnoea and/or stridor. These patients are more likely to have paradoxical vocal fold movement. There is a higher cough reflex sensibility and neuropathic laryngeal response, mainly caused by viral infection or reflux. The cough associated with reflux has 2 mechanisms: Exposure to acid in the distal oesophagus (gastroesophageal reflux) and microaspiration of oesophageal contents into the larynx and tracheo-bronchial tree (pharyngo-laryngeal reflux). Laryngeal neuropathy hypersensitivity responds well to speech therapy as a treatment for refractory chronic cough. Because chronic cough is a sign of laryngeal sensory, neuropathy can improve with neuroleptic drugs such as amitriptyline and gabapentin.

Investigation of extraesophageal gastroesophageal reflux disease

The most common extraesophageal manifestations of gastroesophageal reflux disease (GERD) include chronic cough, asthma and laryngitis. There are two mechanisms proposed to explain extraesophageal syndromes caused by GERD. The first one is a direct way via irritation and/or microaspiration and the second one is an indirect, vagally mediated way. The investigation of extraesophageal manifestations of GERD is difficult and the empirical therapy with proton pump inhibitors usually double dose for at least three months is still the most common approach.

Prolonged 2-day esophageal pH-metry with impedance monitoring improves symptom-reflux association analysis

BACKGROUND

The day-to-day variability in the number of reflux episodes and symptoms of gastro-esophageal reflux disease is high; therefore, the assessment of reflux disease based on 24-h monitoring may be inaccurate.

AIMS

The aim of the study was to compare prolonged (48 h) and standard (24 h) pH-impedance monitoring (pH-MII).

METHODS

Fifty-four consecutive patients with typical and atypical reflux symptoms underwent 48-h pH-MII. Acid exposure time (AET), total number of reflux episodes (TR), number of symptoms, and symptom association probability (SAP) were analyzed after the first 24 h and compared with the results obtained during 48 h of monitoring.

RESULTS

The differences between the fractions of patients with normal and abnormal total AET and TR on both days were not significant. The percentage of patients with positive SAP was 57.9% at 24 h and 71.9% at 48 h (difference: 14.81%, 95% CI 0.7-21.29, P<0.05). There were ten patients (10/54, 18.5%) with positive SAP after 48 h that had been negative in the first 24 h. In comparison to 24 h monitoring, patients reported a significantly increased number of various symptoms correlated with reflux after 48 h.

CONCLUSIONS

Extending pH-MII monitoring to 48 h does not improve the detection of abnormal acid exposure. However, it does increase the fraction of patients with positive symptom-reflux association by as much as 18.5%.

Step-by-step management of refractory gastresophageal reflux disease

Up to a third of the patients who receive proton pump inhibitor (PPI) once daily will demonstrate lack or partial response to treatment. There are various mechanisms that contribute to PPI failure and they include residual acid reflux, weakly acidic and weakly alkaline reflux, esophageal hypersensitivity, and psychological comorbidity, among others. Some of these underlying mechanisms may coincide in the same patient. Evaluation for proper compliance and adequate dosing time of PPIs should be the first management step before ordering invasive diagnostic tests. Doubling the PPI dose or switching to another PPI is the second step of management. Upper endoscopy and pH testing appear to have limited diagnostic value in patients who failed PPI treatment. In contrast, esophageal impedance with pH testing (multichannel intraluminal impedance MII-pH) on therapy appears to provide the most insightful information about the subsequent management of these patients (step 3). In step 4, treatment should be tailored to the specific underlying mechanism of patient's PPI failure. For those who demonstrate weakly acidic or weakly alkaline reflux as the underlying cause of their residual symptoms, transient lower esophageal sphincter relaxation reducers, endoscopic treatment, antireflux surgery and pain modulators should be considered. In those with functional heartburn, pain modulators are the cornerstone of therapy.

Patients with refractory gastroesophageal reflux disease: diagnostic tools

Patients with refractory to proton pump inhibitors (PPIs) gastroesophageal reflux disease (GERD) symptoms are approximately 40% and represent a very common problem in clinical practice. Many of these patients do not have GERD, but suffer from functional heartburn or hypersensitive esophagus. After thorough clinical evaluation and failure of escalation of PPI dose, diagnostic investigations include endoscopy, esophageal manometry, pH testing, esophageal Bilitec and esophageal impedance with pH monitoring.

Acid-suppressive therapy with esomeprazole for relief of unexplained chest pain in primary care: a randomized, double-blind, placebo-controlled trial

OBJECTIVES

High-quality data regarding the efficacy of acid-suppressive treatment for unexplained chest pain are lacking. The aim of this study was to evaluate the efficacy of esomeprazole in primary-care treatment of patients with unexplained chest pain stratified for frequency of reflux/regurgitation symptoms.

METHODS

Patients with a ≥ 2-week history of unexplained chest pain (unrelated to gastroesophageal reflux) who had at least moderate pain on ≥ 2 of the last 7 days were stratified by heartburn/regurgitation frequency (≤ 1 day/week (stratum 1) vs. ≥ 2 days/week (stratum 2)) and randomized to 4 weeks of double-blind treatment with twice-daily esomeprazole 40 mg or placebo. Chest pain relief during the last 7 days of treatment (≤ 1 day with minimal symptoms assessed daily using a 7-point scale) was analyzed by stratum in keeping with the predetermined analysis plan.

RESULTS

Overall, 599 patients (esomeprazole: 297, placebo: 302) were randomized. In stratum 1, more esomeprazole than placebo recipients achieved chest pain relief (38.7% vs. 25.5%; P=0.018); no between-treatment difference was observed in stratum 2 (27.2% vs. 24.2%; P=0.54). However, esomeprazole was superior to placebo in a post-hoc analysis of the whole study population (combined strata; 33.1% vs. 24.9%; P=0.035).

CONCLUSIONS

A 4-week course of high-dose esomeprazole provided statistically significant relief of unexplained chest pain in primary-care patients who experienced infrequent or no heartburn/regurgitation, but there was no such significant reduction in patients with more frequent reflux symptoms.

Role of non-acid reflux in patients with non-erosive reflux disease

Non-erosive reflux disease (NERD) is the most common presentation of gastroesophageal reflux disease. Although acid reflux is the most important cause of symptom generation in NERD patients, non-acid reflux is also associated with reflux symptoms. The temporal relation between symptoms and reflux episodes is of importance in evaluating the results of combined pH-impedance monitoring in NERD patients. Mucosal hypersensitivity and mechanical stimulation due to great volume of non-acid reflux are among the putative mechanisms of symptom generation.

Findings of impedance pH-monitoring in patients with atypical gastroesophageal reflux symptoms

AIM

This study was designed to investigate about findings of Impedance pH-monitoring in patients with atypical symptoms of GERD.

BACKGROUND

The routine treatment with proton pump inhibitors is not very effective in patients with atypical symptoms of Gastro-Esophageal Reflux Disease (GERD). It may be due to non-acid reflux which cannot be monitored using common methods such as pH-metry. Therefore, in these patients combinational procedure of multi channel intraluminal impedance and pH monitoring has been suggested as a new approach.

PATIENTS AND METHODS

Sixty patients with atypical symptoms of GERD underwent combined impedance pH-monitoring. pH of reflux episodes, type of material refluxant, blous cleaning time, proximal extension and symptoms association probability (SAP) was recorded for each patient.

RESULTS

Globus sensation was reported as the most common atypical symptom. 95% of patients experienced weakly acid reflux. Mixed and pure gas refluxates were more frequent than pure liquid reflux. Bolus clearing time was pathologic in 36.7% of cases and proximal extension was detected in 43 patients (71.7%). Of the 46 symptomatic patients, 33.3% had a positive SAP and 43.3% had a negative SAP.

CONCLUSION

The findings of current study showed that the combinational procedure of MII and pH monitoring could provide important information for resistant to treatment patients' with atypical GERD symptoms.

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.