Relationship between asthma and gastro-oesophageal reflux: significance of endoscopic grade of reflux oesophagitis in adult asthmatics

[Effects of proton pump inhibitors in asthmatics with gastroesophageal reflux disease]

BACKGROUND/AIMS

Gastroesophageal reflux disease (GERD) is common in asthma patients. Proton pump inhibitor (PPI) therapy improves symptoms of asthma in some patients. The objective of this study was to investigate endoscopic findings of GERD in asthma patients and to assess the effect of gastric acid suppression with the PPIs on symptom improvement and pulmonary function.

METHODS

From 105 consecutive patients with GERD symptoms during follow up for asthma, 45 patients were enrolled. Patients enrolled to this study were asked about GERD symptoms before and after treating with PPI. Endoscopic findings were described according to Los Angeles classification. The improvement of asthma symptoms and follow-up pulmonary function test were investigated after administration of PPIs.

RESULTS

Esophageal symptoms such as heartburn and acid reflux were present in 25 patients (55.6%), and patients without esophageal symptoms were 20 (44.4%). The degree of endoscopic abnormality was not significantly different between groups with or without esophageal symptoms. The improvement of symptoms was seen in 44 patients (97.8%) except 1 patient after administration of PPIs. The number of patients classified to the low-dose group was 7 patients (15.6%) and that of patients classified to the standard-dose group was 38 patients (84.4%). The follow-up pulmonary function test, peak expiratory flow rate (L/sec) was improved in 3 patients (3 of 7, 42.9%) of the low-dose group, and in 24 patients (24 of 38, 63.2%) of the standard-dose group. The improvement of ventilatory function was not significantly different according to dose of PPIs.

CONCLUSIONS

Treatment with PPIs is expected to improve subjective symptoms and ventilatory function in asthma patients.

Gastroesophageal reflux in children with refractory asthma

OBJECTIVES

To investigate the association between clinical and macroscopic findings of GER and severity of refractory asthma (statistical study).

METHODS

A prospective study in a university-based practice of 75 children who were diagnosed with refractory asthma because they exhibited no satisfactory response for at least three months of treatment. Medical history, physical examination, spirometrical measurements and prick skin test were conducted on all patients. Endoscopic and macroscopic evaluations for esophagitis were performed on all patients regardless of the presence of GER symptoms.

RESULTS

Endoscopy was done for 75 children with refractory asthma. GER was symptomatic in 65% of all patients with no statistical significance (p>0.05) and the most frequent symptom was abdominal pain (67%). The frequency of these symptoms was 50% in mild asthma, 58% in moderate asthma and 72% in severe asthma with no statistical significance (p>0.05). The frequency of macroscopic esophagitis was 71%, distributed in three asthmatic groups as in order of 75% in mild asthma, 58.3% in moderate asthma and 76.6% in severe asthma (p>0.05). Regarding the relationship between GER and nocturnal attacks or spasmodic cough, the frequency of the latest was 66.7%. The differences have no statistical significance regarding GER symptoms (p>0.05), but they are statistically significant regarding the reflux esophagitis (p<0.05). Also endoscopic reflux was as frequent as76.3% in non allergic patients, and this result is statistically significant (p<0.05).

CONCLUSION

In spite of the fact that there was no relationship between the severity of asthma and the symptoms of GER, or its endoscopic findings, the frequency of GER in asthmatic children was higher than its frequency in other children.

Patients with gastroesophageal reflux disease and respiratory manifestations do not present lung function disorders during cardiopulmonary exercise test

Gastroesophageal reflux disease (GERD) has been associated with a variety of pulmonary manifestations, but it is unclear if gastroesophageal reflux causes any abnormality in pulmonary function. Cardiopulmonary exercise test (CPET) is a specialized method that is used to evaluate respiratory function during exercise. The aim of this study was to reveal any abnormality of pulmonary function in patients with GERD and respiratory symptoms. We evaluated 34 patients with GERD (24 men and 10 women, aged 21-63) and extraesophageal respiratory symptoms (wheezing and/or cough) before therapy and after a 12-week treatment with double dose of omeprazole. No patient presented abnormal spirometry. CPET was performed in all the patients at baseline and after completion of the 12-week treatment. CPET parameters including VO(2) rest, VO(2) max, VCO(2) rest, VCO(2) max, O(2)-puls rest, O(2)-puls max, HR (heart rate) rest, HRmax, PETCO(2) rest, PETCO(2) max, and VE/VCO(2) slope were recorded pretreatment and posttreatment. Twenty-four patients (70.6%) had esophagitis (grade A-D), 16 patients had hiatal hernia (47.1%), and 13 patients (38.2%) tested positive for Helicobacter pylori. All of the patients completed the CPET. No one presented shortness of breath or respiratory symptoms. CPET parameters were within normal limits in all of the patients. Twenty-eight patients were reevaluated. No improvement in any CPET parameter posttreatment was observed despite remission of esophageal and extraesophageal respiratory symptoms in all patients. No statistically significant difference was observed pretreatment and posttreatment between the patients older and younger than 40 years, smokers and nonsmokers, Hp(+) and Hp(-) patients, and those with and without hiatal hernia and esophagitis. The patients with GERD and respiratory manifestations and normal spirometry present no pulmonary dysfunction during CPET. No alterations in CPET values posttreatment or differences in CPET values according to age, smoking, Hp status, presence of esophagitis, or hiatal hernia were observed.

Epidemiology of gastroesophageal reflux disease in Asia: a systematic review

Ethnic and geographical differences are important factors in studying disease frequencies, because they may highlight the environmental or genetic influences in the etiology. We retrieved the studies which have been published regarding the epidemiologic features of gastroesophageal reflux disease (GERD) in Asia, based on the definitions of GERD, study settings, publication years and geographical regions. From the population-based studies, the prevalence of symptom-based GERD in Eastern Asia was found to be 2.5%-4.8% before 2005 and 5.2%-8.5% from 2005 to 2010. In Southeast and Western Asia, it was 6.3%-18.3% after 2005, which was much higher than those in Eastern Asia. There were robust epidemiologic data of endoscopic reflux esophagitis in medical check-up participants. The prevalence of endoscopic reflux esophagitis in Eastern Asia increased from 3.4%-5.0% before 2000, to 4.3%-15.7% after 2005. Although there were only limited studies, the prevalence of extra-esophageal syndromes in Asia was higher in GERD group than in controls. The prevalence of Barrett's esophagus was 0.06%-0.84% in the health check-up participants, whereas it was 0.31%-2.00% in the referral hospital settings. In summary, the prevalence of symptom-based GERD and endoscopic reflux esophagitis has increased in Asian countries. However, the prevalence of Barrett's esophagus in Asia has not changed and also still rare.

Prevalence of gastro-oesophageal reflux disease symptoms and reflux-associated respiratory symptoms in asthma

Background

Gastro-oesophageal reflux disease (GORD) symptoms are common in asthma and have been extensively studied, but less so in the Asian continent. Reflux-associated respiratory symptoms (RARS) have, in contrast, been little-studied globally. We report the prevalence of GORD symptoms and RARS in adult asthmatics, and their association with asthma severity and medication use.

Methods

A cross-sectional analytical study. A validated interviewer-administered GORD scale was used to assess frequency and severity of seven GORD symptoms. Subjects were consecutive asthmatics attending medical clinics. Controls were matched subjects without respiratory symptoms.

Results

The mean (SD) composite GORD symptom score of asthmatics was significantly higher than controls (21.8 (17.2) versus 12.0 (7.6); P < 0.001) as was frequency of each symptom and RARS. Prevalence of GORD symptoms in asthmatics was 59.4% (95% CI, 59.1%-59.6%) versus 28.5% in controls (95% CI, 29.0% - 29.4%). 36% of asthmatics experienced respiratory symptoms in association with both typical and atypical GORD symptoms, compared to 10% of controls (P < 0.001). An asthmatic had a 3.5 times higher risk of experiencing a GORD symptom after adjusting for confounders (OR 3.5; 95% CI 2.5-5.3). Severity of asthma had a strong dose-response relationship with GORD symptoms. Asthma medication use did not significantly influence the presence of GORD symptoms.

Conclusions

GORD symptoms and RARS were more prevalent in a cohort of Sri Lankan adult asthmatics compared to non-asthmatics. Increased prevalence of RARS is associated with both typical and atypical symptoms of GORD. Asthma disease and its severity, but not asthma medication, appear to influence presence of GORD symptoms.

[Relationship between comorbidity and asthma control]

INTRODUCTION

The coexistence of potentially aggravating processes is common in asthmatics, particularly in patients with difficult control. The primary aim of this study is to ascertain whether comorbidity id more common in uncontrolled patients. As a secondary aim, we propose to evaluate the correlation between the asthma control test (ACT) and the fraction of exhaled nitric oxide (FENO).

PATIENT AND METHODS

A prospective, observational study comparing the function and clinical picture of two groups of asthmatics: controlled (ACT≥20) and uncontrolled (ACT<20). They were all assessed for, smoking, rhinosinusitis, obesity, anxiety, depression, vocal cord dysfunction, gastro-oesophageal reflux (GORD), allergic bronchopulmonary aspergillosis (ABPA), COPD and nasal polyps.

RESULTS

A total of 50 patients with controlled asthma and 102 with suboptimal control were included. The patients with an ACT≥20 had better lung function, less variation in PEF, less bronchial hyper-reactivity and lower FENO values. Comorbidities were found in 95% of the controlled asthmatics and in 97% of the uncontrolled. Only the presence of nasal polyps, GORD and ABPA was more frequent in the uncontrolled group. However, the simultaneous presence of 3 or more comorbidity factors was significantly more frequent in patients with sub-optimal control (P=0.01). There was no significant correlation between the FENO and the ACT values (rho=-0.08; P=0.32).

CONCLUSIONS

Aggravating comorbidities are more common in patients with sub-optimal control. There was no correlation between the FENO and the ACT values.

Epidemiology and clinical characteristics of GERD in the Japanese population

We reviewed articles on the epidemiology and clinical characteristics of gastroesophageal reflux disease (GERD) in Japan to clarify these features of GERD in this country. Although the definition of GERD depends on the individual study, the prevalence of GERD has been increasing since the end of the 1990s. The reasons for the increase in the prevalence of GERD may be due to increases in gastric acid secretion, a decrease in the Helicobacter pylori infection rate, more attention being paid to GERD, and advances in the concept of GERD. More than half of GERD patients had non-erosive reflux disease, and the majority (87%) of erosive esophagitis was mild type, such as Los Angeles classification grade A and grade B. There were several identified risk factors, such as older age, obesity, and hiatal hernia. In particular, mild gastric atrophy and absence of H. pylori infection influence the characteristics of GERD in the Japanese population. We also discuss GERD in the elderly; asymptomatic GERD; the natural history of GERD; and associations between GERD and peptic ulcer disease and H. pylori eradication. We examined the prevalence of GERD in patients with specific diseases, and found a higher prevalence of GERD, compared with that in the general population, in patients with diabetes mellitus, those with obstructive sleep apnea syndrome, and those with bronchial asthma. We provide a comprehensive review of GERD in the Japanese population and raise several clinical issues.

Gastro-oesophageal reflux disease in Asia : birth of a 'new' disease?

Gastro-oesophageal reflux disease (GORD) is one of the most common gastrointestinal diseases in the Western world and imposes a heavy burden on society. Although its prevalence in Asia is much lower, there is evidence that this is rapidly rising in Asia. The reported population prevalence of GORD in Eastern Asia ranges from 2.5% to 6.7% for at least weekly symptoms of heartburn and/or acid regurgitation. In general, Asians tend to have a milder spectrum of the disease. Most Asian patients have non-erosive GORD; erosive oesophagitis is less commonly seen than in the Western population. Complicated GORD, such as oesophageal stricture and Barrett's oesophagus, is seldom encountered. The mechanisms of GORD may be different in the Chinese population compared with the Western population. Chest pain is the most predominant extra-oesophageal manifestation of GORD in China, whereas an association with asthma has been shown in Japanese patients. The prevalence of GORD appears to be increasing and possible factors for GORD in Asian populations include Helicobacterpylori infection, obesity and increasing dietary fat intake. The adoption of a Western lifestyle in many developing Asian countries may account for the increasing prevalence of GORD. Proton pump inhibitors remain the most effective medical treatment for GORD. GORD will undoubtedly be a great challenge to clinicians both in primary care and in gastroenterology practice in the Asia-Pacific region in the coming years.

Gastroesophageal reflux disease in Asia: a condition in evolution

Widespread epidemiological changes, rising prevalence and gradual shifts in patterns of disease manifestations: this is the changing face of gastroesophageal reflux disease (GERD) in Asia. Are we witnessing a disease in evolution or merely the result of increased and more accurate case reporting that comes with advancing diagnostic technology, better medical facilities and heightened awareness of the disease? Do the figures reported really reflect the actual scenario or is there more to it than meets the eye? In this article, we take you back in time to review relevant developments over the past decade or so. We will draw on findings from across Asia, take an in-depth look at prevailing trends and patterns and examine some of the most plausible explanations behind the dynamics of this epidemiological transition.

Immunoglobulin E blockade in the treatment of asthma

Patients with moderate-to-severe asthma often have persistent symptoms despite aggressive pharmacotherapy, enthusiastic patient compliance, and proper technique in using delivery devices. Persistent symptoms have detrimental effects on patients' quality of life and result in a tremendous financial burden because of an increased utilization of health care resources. Guidelines from the National Asthma Education and Prevention Program list symptom prevention, near-normal lung function, and participation in activities (e.g., school, work) as goals of successful asthma therapy. The development of pharmacologic and biologic therapies that target different aspects of airway inflammation will help patients with persistent asthma symptoms achieve these goals. Immunoglobulin E (IgE) is increasingly recognized as a key component of asthma pathophysiology and contributes to both the early- and late-phase inflammatory cascade of the airways by inhibiting allergen-induced activation of mast cells. Both epidemiologic and clinical evidence support the use of IgE blockade for asthma treatment. Omalizumab is currently the only IgE-targeted therapy approved by the United States Food and Drug Administration for asthma treatment. The drug improves symptoms, reduces exacerbations, and improves quality of life in certain patient populations.

Not asthma, but GERD: case report

Asthma is a disorder of the lungs characterized by increased responsiveness of the airways, as manifested by episodes of wheezing and increased resistance to expiratory airflow because of varying degrees of smooth muscle contraction, edema of the mucosa, and mucus in the lumen of the bronchi and bronchioles. The stimuli vary widely and include antigens, infection, air pollutants, respiratory tract irrtants, exercise, and emotional factors. This condition is completely different from distress breathing because of laryngotracheal spasm. One of its causes is the gastric content reflux through the pharynx to the larynx because of gastroesophageal reflux disease (GERD), in addition to the typical human avian flu that may cause immediate suffocation by laryngospasm owing to acute larygotrachitis. A patient suffered from GERD without esophageal symptoms, which was diagnosed and treated as bronchial asthma during his five emergency admissions. The admissions were because of episodic attacks of severe air hunger owing to an extreme throat tightening. The patient was being treated for as long as two years. After the correct diagnosis was made and treatment of laporascopic fundaplication was performed, the longstanding "bronchial asthma", after all, completely disappeared. The concept of "not asthma, but GERD" seems undervalued, unappreciated, even misunderstood among patients with intractable asthma. Therefore, such a case is reported in detail, similar cases are mentioned briefly as well, and a mechanism responsible for GERD-originated larryngo-or laryngotracho-spasm is proposed.

Gastroesophageal reflux disease in Asian countries: disorder of nature or nurture?

Gastroesophageal reflux disease (GERD) is less prevalent in Asia than in the West, but there is now evidence to suggest that its frequency is rapidly rising in Asia. The different prevalence rates reported in various Asian studies may represent different points in the 'rising' phase of GERD. The cause for the lower but increasing prevalence of GERD in Asia is not known, but genetics and to some extent environmental factors, may have initially protected Asians against GERD. However, with the recent globalization of economies, the associated lifestyle changes in many developing Asian countries may have tipped the balance in favor of the development of GERD.

A proton-pump inhibitor, rabeprazole, improves ventilatory function in patients with asthma associated with gastroesophageal reflux

BACKGROUND

Treatment of gastroesophageal reflux (GER) with proton-pump inhibitors (PPI) improves symptoms of asthma in some patients. However, the effects of a PPI on ventilatory function are still controversial. In this study, we measured ventilatory function in asthma patients treated with a PPI in order to identify those in whom a therapeutic effect on asthma can be expected from the acid suppression.

METHODS

From a cohort of 114 consecutive patients with bronchial asthma, 53 patients agreed to participate in the study and were treated with rabeprazole 20mg daily for 8 weeks during an asymptomatic, stable period with no exacerbations of their asthma. Of the 53 patients, 22 were diagnosed as GER on the basis of the QUEST questionnaire and endoscopic examination. The patients were monitored for improvement in ventilatory function.

RESULTS

Four patients dropped out because of adverse drug reactions. All the patients with GER noted an improvement in reflux symptoms with PPI treatment. An improvement of more than 20% in peak expiratory flow (PEF) was observed in 8 of 21 GER patients but in none of the non-GER patients. Factors predictive of improvement in PEF with rabeprazole therapy were the QUEST score (odds ratio: 1.47, 95% CI: 1.06-2.04, P = 0.022) and steroid-dependency of asthma (odds ratio: 0.01, 95% CI: 0.001-0.31, P = 0.008).

CONCLUSIONS

Treatment with rabeprazole is expected to ameliorate asthma in non-steroid-dependent patients who have symptomatic GER defined by the QUEST score.

Refractory asthma

Treating patients with refractory asthma remains an ongoing challenge. Although most patients respond to large doses of systemic corticosteroid, the adverse effects associated with such a treatment limit its general use. Clinicians treating patients with refractory asthma must consider tapering systemic corticosteroid at every opportunity. Recent advances in the understanding of the pathogenesis of refractory asthma and corticosteroid resistance have fueled further study in the mechanisms of these processes and have prompted consideration of new treatment approaches. Unfortunately, most alternative approaches require more rigorous evidence to support their regular use.