Therapy Insight: treatment of gastroesophageal reflux in adults with chronic cough

Laparoscopic Nissen Fundoplication: An Excellent Treatment of GERD-Related Respiratory Symptoms in Children-Results of a Multicentric Study

INTRODUCTION

Respiratory manifestations of gastroesophageal reflux disease (GERD), particularly chronic cough, are being recognized with increased frequency in children. This survey aimed to investigate the efficacy of laparoscopic Nissen fundoplication for treatment of GERD-related respiratory symptoms not responsive to medical therapy in neurological normal children.

MATERIALS AND METHODS

We collected data of children with GERD-related respiratory complaints not responsive to medical therapy who underwent laparoscopic Nissen fundoplication in four European centers of Pediatric Surgery over a 10-year period. We excluded children with neurological impairment.

RESULTS

A total of 220 laparoscopic Nissen procedures were performed in the period 2005-2015. Twenty-four (12 boys and 12 girls, average age 9.5 years) out of the 220 patients (10.9%) presented with chronic cough and other respiratory manifestations, including asthma, reactive airway disease, and recurrent pneumonia. Average operative time was 65 minutes (range 45-100). As for postoperative complications, two tight wraps requiring endoscopic dilatation (IIIb Clavien) and two relapses of GERD for slipped Nissen requiring reoperation (IIIb Clavien) were recorded. None of these complications occurred in the group of patients with GERD-related respiratory symptoms. At follow-up evaluation, respiratory symptoms disappeared with a significant improvement of quality of life scoring (I Grade Visick) in 22/24 patients (91.6%).

CONCLUSION

Our results confirm that GERD should be investigated as one of the possible etiologic factors in any child with persistent respiratory complaints. In patients with symptoms not responsive to medical therapy, laparoscopic Nissen fundoplication is the treatment of choice with a very high success rate (>90% in our series), a very low morbidity, a significant improvement in airway symptoms, and a marked reduction in the need for medications.

Refractory chronic cough due to gastroesophageal reflux: Definition, mechanism and management

Refractory chronic cough due to gastroesophageal reflux is a troublesome condition unresponsive to the standard medical anti-reflux therapy. Its underlying mechanisms may include incomplete acid suppression, non-acid reflux, transient lower esophageal sphincter relaxations and esophageal hypersensitivity. The diagnosis of this disorder depends on both the findings of multi-channel intraluminal impedance-pH monitoring and the subsequent intensified anti-reflux therapy. The strategies of pharmacological treatment for refractory chronic cough due to reflux include the optimization of proton pump inhibitors and add-on therapies with histamine H₂ receptor antagonists, baclofen and gabapentin. However, the further study is needed to satisfy its management.

Dental erosions and other extra-oesophageal symptoms of gastro-oesophageal reflux disease: Evidence, treatment response and areas of uncertainty

Extra-oesophageal symptoms of gastro-oesophageal reflux disease (GORD) are often studied, but remain a subject of debate. It has been clearly shown that there is a relationship between the extra-oesophageal symptoms chronic cough, asthma, laryngitis and dental erosion and GORD. Literature is abundant concerning reflux-related cough and reflux-related asthma, but much less is known about reflux-related dental erosions. The prevalence of dental erosion in GORD and vice versa, the prevalence of GORD in patients with dental erosion is high but the exact mechanism of reflux-induced tooth wear erosion is still under review.

Recent additions in the treatment of cough

BACKGROUND

Worldwide, cough is regarded as a challenging clinical problem due to its frequency and often limited therapeutic options. Chronic cough that remains refractory to usual medical treatment causes significant quality of life impairment in people with this problem.

METHODS

We have examined current evidence on recent additions in the treatment of cough, specifically treatment of refractory chronic cough with speech pathology and gabapentin. Relevant randomised control trials, reviews and case reports were identified through a PubMed and SCOPUS search of English-language literature referring to these concepts over the last eight years.

SUMMARY

Of the one hundred and two articles comprising this review the majority investigated the role of the transient receptor potential (TRP) receptors TRP Vanilloid 1 (TRPV1) and TRPA1 in cough and the potential of TRP antagonists as effective anti-tussives. However, these have only been tested in the laboratory and therefore their clinical effectiveness is unknown. Behavioural treatments such as speech pathology have gained momentum and this was evident in the increasing number of articles investigating its positive effect on cough. Investigation on the effectiveness of neuromodulating medications in the treatment of cough have been supported primarily through case series reports and prospective reviews however; their use (particularly gabapentin) has been significantly advanced through recently conducted randomised controlled trials.

CONCLUSIONS

Recent additions in the treatment of chronic cough have been significant as they consider cough to have a unifying diagnosis of cough hypersensitivity with or without the presence of a neuropathic basis. Primarily, effective treatments for chronic cough target these areas and include behavioural treatment such as speech pathology and pharmaceutical treatment with neuromodulating medications such as gabapentin.

Gastroesophageal reflux in chronic cough and cough syncope and the effect of antireflux treatment: case report and literature review

OBJECTIVE

This study aimed to evaluate the efficacy of antireflux treatment on gastroesophageal reflux (GER)-related cough syncope.

METHODS

The method used was a retrospective review of the outcomes of antireflux treatment with proton pump inhibitor (PPI), Stretta radiofrequency (SRF), or laparoscopic fundoplication (LF) of 8 patients with chronic cough and cough syncope that was clinically evaluated to be GER related over a period of 2 to 5 years.

RESULTS

In the 8 selected cases, the typical GER symptoms disappeared in 7 cases and were significantly eased in 1 case. The chronic cough diminished to mild and occasional occurrence in 6 cases and was completely relieved in 2 cases. Meanwhile, the cough syncope disappeared in all cases. Seven of the patients resumed physical and social functions after the antireflux treatments, except for 1 person, who had a stroke due to other causes.

CONCLUSION

For chronic cough and cough syncope of unknown cause, the GER assessment could be valuable. In treating well-selected GER-related chronic cough and cough syncope, PPI, SRF, and LF can be considered. Moreover, satisfactory restoration of physical and social functions could be achieved after effective antireflux 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.

Fundoplication in chronic intractable cough

Background

Airway reflux is a common cause of chronic cough and this is often refractory to medical therapy. Surgery in the form of Nissen fundoplication has been highly successful in the treatment of the classic reflux symptoms of heartburn and dyspepsia. There is a paucity of data regarding response to fundoplication in patients presenting with chronic cough.

Methods

We retrospectively reviewed the case notes of patients from the Hull Cough Clinic who had undergone Nissen fundoplication over the past 6 years. Demographic details, duration of symptoms, presence of other symptoms, results of oesophageal studies, outcome and complications were recorded. Patients were contacted by post and asked to complete a questionnaire detailing current symptoms. In a subgroup with continued troublesome cough 24 hour pharyngeal pH measurements were undertaken.

Results

Forty seven patients underwent fundoplication. The average duration of pre-operative cough was 8 years. Gastro intestinal symptoms were present in the majority. In 30 (64%) patients a positive response to treatment was recorded. Mild dysphagia or bloating was seen in 18 patients following surgery. Four patients needed repeat surgical intervention for modification of fundoplication. One patient developed aspiration pneumonia eight weeks following surgery and died of a myocardial infarction. Two thirds of patients with persisting cough had evidence of airway reflux on pharyngeal pH monitoring.

Conclusion

In these patients with intractable cough a long term response rate of 63% represents a useful therapeutic option. Treatment failure is more frequent than for classic peptic symptoms and may be related to persistent gaseous reflux.

Chronic cough, reflux, postnasal drip syndrome, and the otolaryngologist

Objectives. Chronic cough is a multifactorial symptom that requires multidisciplinary approach. Over the last years, general practitioners refer increasingly more chronic cough patients directly to the otolaryngologist. The aim of this paper is to highlight the issues in diagnosis and management of chronic cough patients from the otolaryngologist perspective. Design. Literature review. Results. Gastroesophageal reflux and postnasal drip syndrome remain one of the most common causes of chronic cough. Better diagnostic modalities, noninvasive tests, and high technology radiological and endoscopic innovations have made diagnosis of these difficult-to-treat patients relatively easier. Multidisciplinary assessment has also meant that at least some of these cases can be dealt with confidently in one stop clinics. Conclusions. As the number of referrals of chronic cough patients to an Ear Nose Throat Clinic increases, the otolaryngologist plays a pivotal role in managing these difficult cases.

Gastro-oesophageal reflux treatment for prolonged non-specific cough in children and adults

BACKGROUND

Gastroesophageal reflux disease (GORD) is said to be the causative factor in up to 41% of adults with chronic cough. Treatment for GORD includes conservative measures (diet manipulation), pharmaceutical therapy (motility or prokinetic agents, H(2)-antagonist and proton pump inhibitors (PPI)) and fundoplication.

OBJECTIVES

To evaluate the efficacy of GORD treatment on chronic cough in children and adults with GORD and prolonged cough that is not related to an underlying respiratory disease, i.e. non-specific chronic cough.

SEARCH STRATEGY

We searched the Cochrane Airways Group Specialised Register, the Cochrane Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, review articles and reference lists of relevant articles. The date of last search was 8 April 2010.

SELECTION CRITERIA

All randomised controlled trials (RCTs) on GORD treatment for cough in children and adults without primary lung disease.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. We contacted study authors for further information.

MAIN RESULTS

We included 19 studies (six paediatric, 13 adults). None of the paediatric studies could be combined for meta-analysis. A single RCT in infants found that PPI (compared to placebo) was not efficacious for cough outcomes (favouring placebo OR 1.61; 95% CI 0.57 to 4.55) but those on PPI had significantly increased adverse events (OR 5.56; 95% CI 1.18 to 26.25) (number needed to treat for harm in four weeks was 11 (95% CI 3 to 232)). In adults, analysis of H(2) antagonist, motility agents and conservative treatment for GORD was not possible (lack of data) and there were no controlled studies of fundoplication. We analysed nine adult studies comparing PPI (two to three months) to placebo for various outcomes in the meta-analysis. Using intention-to-treat, pooled data from studies resulted in no significant difference between treatment and placebo in total resolution of cough (OR 0.46; 95% CI 0.19 to 1.15). Pooled data revealed no overall significant improvement in cough outcomes (end of trial or change in cough scores). We only found significant differences in sensitivity analyses. We found a significant improvement in change of cough scores at end of intervention (two to three months) in those receiving PPI (standardised mean difference -0.41; 95% CI -0.75 to -0.07) using generic inverse variance analysis on cross-over trials. Two studies reported improvement in cough after five days to two weeks of treatment.

AUTHORS' CONCLUSIONS

PPI is not efficacious for cough associated with GORD symptoms in very young children (including infants) and should not be used for cough outcomes. There is insufficient data in older children to draw any valid conclusions. In adults, there is insufficient evidence to conclude definitely that GORD treatment with PPI is universally beneficial for cough associated with GORD. Clinicians should be cognisant of the period (natural resolution with time) and placebo effect in studies that utilise cough as an outcome measure. Future paediatric and adult studies should be double-blind, randomised controlled and parallel-design, using treatments for at least two months, with validated subjective and objective cough outcomes and include ascertainment of time to respond as well as assessment of acid and/or non-acid reflux.

Comparative analysis of gastroesophageal reflux disease in patients with and without cough

AIM: To compare the clinical features of gastroesophageal reflux disease (GERD) between patients with and without cough.

METHODS: The clinical data for 42 GERD patients with cough and 30 GERD patients without cough, who were positive for 24-h esophageal pH and bile monitoring, were analyzed in this study.

RESULTS: The majority of GERD patients with cough had irritating cough. Of all the GERD patients with cough, 76.2% (32/42) had throat discomfort, such as foreign body sensation, pharyngeal itching, and sound dumb, and 69.0% (29/42) had substernal discomfort, such as feeling of chest tightness, chest congestion and chest pain. Typical reflux symptoms such as acid reflux, heartburn and upper abdominal pain were seen only in 11.9% (5/42), 19.0% (8/42) and 9.5% (4/42) of the patients, respectively. There was a significant difference in symptoms between GERD patients with and without cough (P < 0.05). No significant differences were noted in the reflux time and reflux contents between the two groups of patients (P > 0.05). After acid suppression therapy, the symptoms were relieved or disappeared in 14 d in 73.8% of patients with cough and in 90.0% of patients without cough. There is a significant difference in the percentage of patients achieving symptom improvement between the two groups (P < 0.05).

CONCLUSION: GERD patients with cough have unique clinical features. Besides cough, the majority of GERD patients with cough have no typical reflux symptoms. GERD patients with cough are less responsive to acid suppression treatment than those without cough.

Extraesophageal manifestations of gastroesophageal reflux disease: real or imagined?

PURPOSE OF REVIEW

Extraesophageal reflux disease is a common clinical presentation to gastroenterology as well as ear, nose and throat, allergy, and asthma clinics. The diagnosis and management of this condition is challenging. We review the current dilemma in this area and discuss the latest studies which help guide our therapies for patients with suspected extraesophageal reflux.

RECENT FINDINGS

Diagnostic approach to patients with extraesophageal reflux disease involved the use of insensitive tools, which have hampered the ability to correctly identify patients at risk. Empiric trial using proton pump inhibitors is still the recommended initial approach to those suspected of having reflux as the cause for extraesophageal symptoms such as asthma, chronic cough, or laryngitis. Diagnostic testing should be reserved to those unresponsive to therapy. Most recent studies suggest that ambulatory impedance/pH monitoring performed on therapy may be most likely to help exclude reflux as the cause for persistent symptoms. Recent randomized placebo-controlled studies on chronic laryngitis, cough, and asthma have been disappointing in showing benefit of acid suppressive therapy.

SUMMARY

Gastroduodenal reflux may cause symptoms such as chronic cough, asthma, or laryngitis. However, we are currently limited in our diagnostic ability to identify the subgroup of patients who might respond to acid suppressive therapy. Impedance/pH monitoring may be a step in the right direction; however, outcome studies are needed to better understand the role of acid or nonacid reflux in patients with extraesophageal symptoms.

Long-term therapeutic outcome of patients undergoing ambulatory pH monitoring for chronic unexplained cough

BACKGROUND AND AIM

Ambulatory pH monitoring is frequently performed to determine temporal associations between reflux events and chronic unexplained cough. We further explored the clinical value of ambulatory pH monitoring in predicting long-term symptomatic outcome of therapy in chronic cough.

METHODS

Symptom scores and reflux indicators from ambulatory pH study [acid exposure time, symptom association probability (SAP), and symptom index] were extracted from records of subjects undergoing esophageal evaluation for chronic cough. Intensity of antireflux therapy administered and symptomatic outcome were determined by telephone interview. Univariate and logistic regression analysis were performed to identify predictors of a high degree response (HDR), defined as sustained, durable symptom improvement lasting >3 months.

RESULTS

Fifty-three subjects (mean age 63+/-2 y, 42 females) fulfilled the inclusion criteria. Reflux parameters were abnormal on ambulatory pH monitoring in 54.7%. After a mean interval of 3+/-0.3 years, cough intensity improved significantly, 19 subjects (35.8%) achieving HDR. Only female sex and positive SAP predicted HDR on univariate analysis; SAP and intensity of antireflux therapy were retained as independent predictors (P<or=0.03) on logistic regression analysis. Sequential use of acid exposure time, SAP, and symptom index had the best value, with the highest likelihood of HDR when all three were positive (85.7%, P<0.01).

CONCLUSIONS

Reflux disease is a frequent cause of chronic unexplained cough and aggressive antireflux therapy forms a vital component of management. Positive SAP is an independent predictor of outcome, but hierarchical or sequential use of abnormal gastroesophageal reflux disease parameters on ambulatory pH testing has value in predicting long-term symptomatic response.

Extraesophageal GERD

The manifestations of gastroesophageal reflux disease (GERD) have been classified into either esophageal or extraesophageal syndromes. Cough, reflux laryngitis, and asthma have been classified as extraesophageal syndromes, whereas reflux chest pain has been classified as a symptomatic syndrome of GERD. In extraesophageal syndromes, patients usually do not display the classic symptoms of reflux, such as heartburn and regurgitation. Upper gastrointestinal endoscopy and pH monitoring, when used to diagnose reflux in patients with symptoms not classic for GERD, have proved to have poor sensitivity and are often not diagnostically helpful. In contrast, an empiric trial of proton pump inhibitors is a well-established, cost-effective tool.

ENT manifestations of gastroesophageal reflux

Gastroesophageal reflux (GER) has been associated with a variety of supraesophageal symptoms or diseases, including chronic cough, laryngeal disorders, rhinosinusitis, otitis media, and oral cavity lesions. In this article, we review the relationship between GER and ear, nose, and throat (ENT) symptoms. Data in the published literature are frequently conflicting. Only a few studies are controlled, and an evidence-based approach provides weak support for a causal association between GER and ENT manifestations. The GER diagnostic method should be standardized utilizing new parameters, and the definition and diagnostic accuracy of ENT pathologies also must be better specified. A firm connection remains controversial, and further randomized trials are needed.

Advances in roles of prokinetic agents in the treatment of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is characterized by the reflux of gastric content into esophagus with or without histological changes. Pathogenesis of GERD is lower esophageal sphincter (LES) dysfunction, abnormal clearing capacity of refluxed materials, delayed gastric emptying and abnormal resistance of esophageal mucosa to gastric acid, but the primary upper gastrointestinal motility dysfunction is regarded as the most important factor in general. Therefore, prokinetic agents which can restore gastric motility with increasing of LES and esophageal motility have been developed and used frequently in the treatment of GERD. There are several prokinetic agents such as metoclopramide, domperidone, cisapride and mosapride that facilitate acetylcholine release from the enteric cholinergic neurons through a selective 5-HT₄ receptor agonistic action. It is considered that prokinetic agents have the same effect as H2 blocker in the treatment of patients with mild GERD. Additionally, it was reported that a combination therapy with prokinetic agents and proton pump inhibitors (PPI) or H2 receptor antagonists (H2RAs) is more effective than monotherapy in patients with severe GERD. This article reviews the recent advances in the role of prokinetic agents in the treatment of gastroesophageal reflux disease.

Environmental factors in the etiology of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is currently one of the most common health problems in the Western world, affecting up to 20% of the adult population weekly and 50% monthly. It generates substantial suffering among patients as well as significant costs to both patients and society in general. GERD can further result in serious complications such as esophageal strictures, Barrett's esophagus and esophageal adenocarcinoma. This review discusses the current knowledge on risk factors and potential protective factors in the development of GERD.

Gastro-oesophageal reflux treatment for prolonged non-specific cough in children and adults

BACKGROUND

Cough is a very common symptom presenting to medical practitioners. Gastroesophageal reflux disease (GORD) is said to be the causative factor in up to 41% of adults with chronic cough. However cough and GORD are common ailments and their co-existence by chance is high. Also cough can induce reflux episodes. Treatment for GORD includes conservative measures (diet manipulation), pharmaceutical therapy (motility or prokinetic agents, H(2) antagonist and proton pump inhibitors (PPI)) and fundoplication.

OBJECTIVES

To evaluate the efficacy of GORD treatment on chronic cough in children and adults with GORD and prolonged cough that is not related to an underlying respiratory disease i.e. non-specific chronic cough.

SEARCH STRATEGY

The Cochrane Register of Controlled Trials (CENTRAL), the Cochrane Airways Group Specialised Register Collaboration and Cochrane Airways Group, MEDLINE and EMBASE databases, review articles and reference lists of relevant articles were searched. The date of last search was 7th April 2006.

SELECTION CRITERIA

All randomised controlled trials on GORD treatment for cough in children and adults without primary lung disease.

DATA COLLECTION AND ANALYSIS

Results of searches were reviewed against pre-determined criteria for inclusion. Two independent reviewers selected, extracted and assessed data for inclusion. Authors were contacted for further information. Data was analysed as "intention to treat" as well as "treatment received". Paediatric and adults data were considered separately. Sensitivity analyses were performed.

MAIN RESULTS

Thirteen studies (3 paediatric, 10 adults) were included. Data from six were available for analysis. None of the paediatric studies could be included in meta-analysis. In adults, analysis on use of H(2) antagonist, motility agents and conservative treatment for GORD were not possible (from lack of data) and there were no controlled studies on fundoplication as an intervention. Six adult studies comparing PPI (2-3 months) to placebo were analysed for various outcomes in the meta-analysis. Enrolment of subjects for two studies were primarily from medical clinics and another 4 studies were otolaryngology clinic patients or patients with laryngitis. Using "intention to treat", pooled data from 4 studies resulted in no significant difference between treatment and placebo in total resolution of cough, Odds Ratio 0.46 (95% CI 0.19 to 1.15). Pooled data revealed no overall significant improvement in cough outcomes (end of trial or change in cough scores). Significant differences were only found in sensitivity analyses. A significant improvement in change of cough scores was found in end of intervention (2-3 months) in those receiving PPI with a standardised mean difference of -0.41 (95%CI -0.75, -0.07) using GIV analysis on cross over trials. Two studies reported improvement in cough after 5 days to 2 weeks of treatment.

AUTHORS' CONCLUSIONS

There is insufficient evidence to definitely conclude that GORD treatment with PPI is universally beneficial for cough associated with GORD in adults. The beneficial effect was only seen in sub-analysis and its effect was small. The optimal duration of such a trial of therapy to evaluate response could not be ascertained in the meta-analysis although two RCTs reported significant change by 2 weeks of therapy. Clinicians should be cognisant of a period (natural resolution with time) and placebo effect in studies that utilise cough as an outcome measure. Data in children are inconclusive. Future paediatric and adult studies are needed whereby studies should be double blind, randomised controlled, parallel design, using treatments for at least two months, with validated subjective and objective cough outcomes and include ascertainment of time to respond as well as assessment of acid and/or non acid reflux whilst on therapy.