Study of respiratory disorders in endoscopically negative and positive gastroesophageal reflux disease

Endoscopic reflux esophagitis and decline in pulmonary function in nonsmokers: A retrospective cohort study

BACKGROUND

The association between reflux esophagitis and pulmonary function remains controversial. Thus, evaluating the relationship between endoscopic reflux esophagitis and changes in pulmonary function over time in a nonsmoking population is an important clinical issue.

METHODS

In this single-center retrospective cohort study, a medical examination database at Kameda Medical Center Makuhari was employed to identify nonsmokers who underwent upper gastrointestinal endoscopy and spirometry in 2010 and were followed up in 2015. Gastroenterologists carefully double-checked the diagnosis of reflux esophagitis. Multiple linear regression analyses were performed to compare the decline in the percentage of predicted vital capacity (%VC), forced vital capacity (%FVC), and forced expiratory volume in 1 s (%FEV1) between participants with reflux esophagitis and those without. Furthermore, using multivariable logistic regression analyses, we evaluated the factors associated with rapid decline in %VC, %FVC, and %FEV1, which is defined as a decrease of >10% in each parameter over the 5-year observation period.

RESULTS

We identified 3098 eligible subjects, including 72 and 44 participants who had a Los Angeles classification grade A and B-C (severe) reflux esophagitis in 2010, respectively. The decline in %VC was significantly larger in the participants with severe reflux esophagitis than in the control subjects (standardized coefficient, -0.037; 95% confidence interval, -0.071 to -0.004). Moreover, reflux esophagitis was significantly associated with a rapid decline in %VC and %FVC but not in %FEV1 (P for trend: 0.009, 0.009, and 0.276, respectively).

CONCLUSIONS

Severe reflux esophagitis among nonsmokers had clinical disadvantages in terms of a decline in %VC.

Is There a Potential Link between Gastroesophageal Reflux Disease and Recurrent Respiratory Tract Infections in Children?

BACKGROUND

The implications of gastroesophageal reflux disease in respiratory tract infections have been investigated over time. The aim of our study was to evaluate the relationship between these two pathologic entities and the outcome after proper antireflux treatment.

METHODS

A group of 53 children with recurrent respiratory tract infections admitted in the gastroenterology clinic of a children's hospital in North-East Romania was investigated for gastroesophageal reflux disease through 24 h pH-metry. Those with a Boix-Ochoa score higher than 11.99 received proton pump inhibitor treatment and were reevaluated after 2 months.

RESULTS

A total of 41 children were found with a positive Boix-Ochoa score. After 2 months of antireflux therapy, eight patients still had a positive Boix-Ochoa score.

CONCLUSIONS

Recurrent respiratory tract infections with symptoms resistant to treatment should be considered a reason to investigate for gastroesophageal reflux, because the symptoms may be due to micro- or macro-aspiration of the gastric refluxate or to an esophageal-bronchial reflex mediated through the vagal nerve.

Fewer acute respiratory infection episodes among patients receiving treatment for gastroesophageal reflux disease

Patients with gastroesophageal reflux disease (GERD) present with comorbid complications with implications for healthcare utilization. To date, little is known about the effects of GERD treatment with a proton-pump inhibitor (PPI) on patients’ subsequent healthcare utilization for acute respiratory infections (ARIs). This population-based study compared ARI episodes captured through outpatient visits, one year before and one year after GERD patients received PPI treatment. We used retrospective data from the Longitudinal Health Insurance Database 2005 in Taiwan, comparing 21,486 patients diagnosed with GERD from 2010 to 2012 with 21,486 age-sex matched comparison patients without GERD. Annual ARI episodes represented by ambulatory care visits for ARI (visits during a 7-day period bundled into one episode), were compared between the patient groups during the 1-year period before and after the index date (date of GERD diagnosis for study patients, first ambulatory visit in the same year for their matched comparison counterpart). Multiple regression analysis using a difference-in-difference approach was performed to estimate the adjusted association between GERD treatment and the subsequent annual ARI rate. We found that the mean annual ARI episode rate among GERD patients reduced by 11.4%, from 4.39 before PPI treatment, to 3.89 following treatment (mean change = -0.5 visit, 95% confidence interval (CI) = (-0.64, -0.36)). In Poisson regression analysis, GERD treatment showed an independent association with the annual ARI rate, showing a negative estimate (with p<0.001). The study suggests that GERD treatment with PPIs may help reduce healthcare visits for ARIs, highlighting the importance of treatment-seeking by GERD patients and compliance with treatment.

Association Between Non-erosive Reflux Disease and High Risk of Obstructive Sleep Apnea in Korean Population

Background/Aims

Obstructive sleep apnea is becoming more important in gastroesophageal reflux disease (GERD) patients. This study investigated the prevalence of high risk for obstructive sleep apnea in GERD patients in comparison with that in healthy controls using the Berlin Questionnaire. We also investigated the risk factors for obstructive sleep apnea in GERD patients.

Methods

We enrolled 1,007 subjects: 776 healthy controls, 115 individuals with erosive reflux disease, and 116 with non-erosive reflux disease. GERD was diagnosed and classified using endoscopy and a reflux questionnaire. The Berlin Questionnaire was used to evaluate obstructive sleep apnea.

Results

More patients in the GERD group (28.2%) had higher risk for obstructive sleep apnea than healthy controls (20.4%, P = 0.036). More patients with non-erosive disease (32.8%) had higher risk for obstructive sleep apnea (OSA) than patients with erosive disease (20.9%) and controls (20.4%, P = 0.010). On multivariate analysis, non-erosive disease was a high risk factor for obstructive sleep apnea (odds ratio [OR], 1.82; P = 0.011). Age ≥ 55 years (OR, 1.83; P < 0.001) and a high body mass index (≥ 25 kg/m²) (OR, 2.76; P < 0.001) were also identified as risk factors. Nocturnal GERD was related to high risk for OSA in non-erosive disease patients (OR, 2.97; P = 0.019), but not in erosive disease patients.

Conclusions

High risk for OSA is more prevalent in GERD patients than in controls. Non-erosive reflux disease, age ≥ 55, and a high BMI are associated with high risk for OSA.

Gastro-esophageal reflux induced cough with airway hyperresponsiveness

To investigate the characteristics of gastroesophageal reflux induced cough (GERC) with airway hyperresponsiveness (AHR). Compared to patients with GERC alone and healthy subjects, cough sensitivity, multi-channel intraluminal impedance combined with pH monitoring and airway inflammation were evaluated in patients with GERC and AHR. 23 patients were definitely diagnosed as acid reflux induced GERC, 9 patients developed AHR concomitantly. When compared with GERC patients, patients with AHR had significantly increased number of proximal extent episodes (21.5 (28.6) vs. 7.5 (1.8), Z = -2.038, P = 0.042) and increased proportion of proximal extent episodes to total refluxes episodes (24.5 (13.5)% vs. 4.2 (7.3)%, Z = -2.138, P = 0.032), and the level of IL-8 in the airway of these patients was significantly higher than that in healthy subjects (71.1 (64.0) vs. 24.3 (35.2) pg/ml, Z = -2.013, P = 0.044). Gastroesophageal reflux may cause neutrophilic airway inflammation due to the acid reflux into the airway, which results in AHR. However, AHR is not definitely able to cause chronic cough. Thus differential diagnosis is required in clinical practice.

Esophageal motility, vagal function and gastroesophageal reflux in a cohort of adult asthmatics

BACKGROUND

Asthmatics are known to have esophageal hypomotility. Vagal hypofunction and prolonged intra-esophageal acidification cause esophageal hypomotility. The contribution of gastroesophageal reflux (GER) and vagal function to esophageal motility in asthmatics is unclear. We studied the relationship between esophageal motility, GER and vagal function in a cohort of adult asthmatics.

METHODS

Thirty mild, stable asthmatics (ATS criteria) and 30 healthy volunteers underwent 24-hour ambulatory esophageal monitoring, manometry, autonomic function testing and GER symptom assessment. 27 asthmatics underwent gastroscopy. A vagal function score calculated from 3 tests (valsalva maneuver, heart rate response to deep breathing and to standing from supine position) was correlated with esophageal function parameters.

RESULTS

Asthmatics (mean age 34.8 (SD 8.4), 60% female) had more frequent GERD symptoms than controls (mean age 30.9 (SD 7.7), 50% female). 10/27 asthmatics had esophageal mucosal damage, 22 showed hypervagal response, none had a hyperadrenergic response. 14 asthmatics had ineffective esophageal motility. Higher GERD-score asthmatics had significantly fewer peristaltic and more simultaneous contractions than controls, and higher esophageal acid contact times than those with lower scores. All reflux parameters were significantly higher and acid clearance time prolonged in asthmatics than controls (p < 0.001, Mann-Whitney U test). There was no correlation between vagal function score and esophageal function parameters.

CONCLUSIONS

A cohort of adult asthmatics was found to have peristaltic dysfunction and pathological GER, but otherwise normal esophageal motility. The peristaltic dysfunction seems to be associated with vagal hyperreactivity rather than vagal hypofunction.

Gastroesophageal reflux disease and pulmonary function: a potential role of the dead space extension

BACKGROUND

To evaluate the differences in the existence and size of dead space in patients with and without Gastroesophageal Reflux Disease (GERD and non-GERD) expressed through the size of intrapulmonary shunt (QS/QT).

MATERIAL/METHODS

The study enrolled 86 subjects - 43 patients referred for endoscopy because of symptoms of GERD (heartburn, acid regurgitation, dysfagia) and 43 healthy subjects with similar anthropometric characteristics without GERD symptoms. Based on endoscopy findings, patients were classified into the erosive reflux disease (ERD) group and non-erosive reflux disease (NERD) group. Spirometry values, single-breath diffusing capacity of the lung for carbon monoxide (DLCO) and intrapulmonary shunt (venous shunt - QS/QT) determined by the oxygen method were measured in all participants.

RESULTS

Statistically significant differences between GERD and non-GERD groups in FVC (p=0.034), FEV1 (p=0.002), FEV1/FVC (p=0.001), and PEF (p=0.001) were observed. There were no statistically significant differences in FEF 25% (p=0.859), FEF 50% (p=0.850), and FEF 75% (p=0.058). Values of DLCO (p=0.006) and DLCO/VA (p=0.001) were significantly lower and QS/QT was significantly higher (p=0.001) in the GERD group than in the non-GERD group. However, in both groups the average values of DLCO and DLCO/VA expressed as a percentage of predictive values were within normal range, while the value of QS/QT in the GERD group showed pathological (6.0%) mean value (normal value ≤ 5.0%). There were no significant differences in respiratory function test results between patients with ERD and NERD.

CONCLUSIONS

Our results suggest that microaspiration of stomach contents may cause surfactant damage, development of microatelectasis, and dead space expansion with consequent increase of intrapulmonary (venous) shunt.

Gastroesophageal and laryngopharyngeal reflux profiles in patients with obstructive sleep apnea/hypopnea syndrome as determined by combined multichannel intraluminal impedance-pH monitoring

BACKGROUND

The profiles of gastroesophageal reflux (GER) and laryngopharyngeal reflux (LPR) in patients with obstructive sleep apnea/hypopnea syndrome (OSAHS) have never been explored. The aim of the study was to investigate the reflux profile in OSAHS patients.

METHODS

Consecutive snoring out-patients suspected with having OSAHS and 20 healthy volunteers were included. All subjects underwent simultaneous 24-h combined multichannel intraluminal impedance-pH (MII-pH) monitoring and polysomnography. Obstructive sleep apnea/hypopnea syndrome was defined when the apnea/hypopnea index was over 5. Stepwise multiple logistic regression analysis was performed to determine the predictor for OSAHS.

KEY RESULTS

Fifty-three patients were included, 37 with and 16 without OSAHS. The prevalence of reflux symptoms was similar between OSAHS (35.1%) and non-OSHAS (37.5%) patients. More OSAHS patients, compared with non-OSAHS patients and healthy volunteers, had pathologic acid GER, nocturnal acid GER, and prolonged acid clearance (P < 0.001). However, no difference in non-acid reflux episodes was observed among the three groups. Laryngopharyngeal reflux was detected in 51.4%, 43.8%, and 35.0% of OSAHS, non-OSAHS, and healthy volunteers, respectively (P = 0.034). In OSAHS patients, there was no difference in the sleep parameters between patients with and without LPR. Body mass index was the only predictor of OSAHS in the regression analysis.

CONCLUSIONS & INFERENCES

OSAHS patients have more pathologic acid GER and prolonged acid clearance than non-OSAHS patients whereas non-acid reflux was similar between the two groups. However, BMI, not GER, is the only independent predictor for OSAHS. Laryngopharyngeal reflux occurs in more than half of OSAHS patients despite no significant association with OSAHS.

Reflux and sex: what drives testing, what drives treatment?

Gastroesophageal reflux (GER) affects ∼10-20% of American adults. Although symptoms are equally common in men and women, we hypothesized that sex influences diagnostic and therapeutic approaches in patients with GER. PubMed database between 1997 and October 2011 was searched for English language studies describing symptoms, consultative visits, endoscopic findings, use and results of ambulatory pH study, and surgical therapy for GER. Using data from Nationwide Inpatient Sample, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality, we determined the sex distribution for admissions and reflux surgery between 1997 and 2008. Studies on symptoms or consultative visits did not show sex-specific differences. Even though women are less likely to have esophagitis or Barrett's esophagus, endoscopic studies enrolled as many women as men, and women were more likely to undergo ambulatory pH studies with a female predominance in studies from the US. Surgical GER treatment is more commonly performed in men. However, studies from the US showed an equal sex distribution, with Nationwide Inpatient Sample data demonstrating an increase in women who accounted for 63% of the annual fundoplications in 2008. Despite less common or severe mucosal disease, women are more likely to undergo invasive diagnostic testing. In the US, women are also more likely to undergo antireflux surgery. These results suggest that healthcare-seeking behavior and socioeconomic factors rather than the biology of disease influence the clinical approaches to reflux disease.

Nocturnal gastroesophageal reflux, lung function and symptoms of obstructive sleep apnea: Results from an epidemiological survey

BACKGROUND

Nocturnal gastroesophageal reflux (nGER) has received increasing interest as a predisposing factor for respiratory diseases and sleep disturbances. The possible role of obstructive sleep apnea (OSA) contributing to nGER is of special interest. The aim of this study was to explore the association between nGER and respiratory diseases, lung function and symptoms of OSA.

METHODS

Participants in the Burden of Obstructive Lung Disease (BOLD) initiative in Iceland and Sweden, a random sample from the general population of 1325 adults aged 40+ (>70% response rate), were compared by pre- and post-bronchodilator spirometry, answers to questionnaires about OSA and respiratory symptoms, health, and symptoms of GER.

RESULTS

Altogether 102 (7.7%) reported nGER and 249 had used medication against GER. The participants were divided into three groups: 1) No nGER (n = 1040), 2) treated GER without nGER (n = 183) and 3) nGER (n = 102). The nGER group had a significantly higher prevalence of respiratory and OSA symptoms than subjects without nGER. The nGER group also had a higher prevalence of COPD (GOLD stage 1+), (25.0% vs. 15.6%) (p = 0.02) and lower FEV(1)/FVC ratio (95.9% vs. 98.9% of the predicted, p = 0.01). These associations remained significant after adjusting for smoking, weight and other possible confounders. No independent association was found between having treated GER and lung function, respiratory or OSA symptoms.

CONCLUSIONS

In our cross-sectional epidemiological study, untreated nGER is strongly associated with both respiratory and OSA symptoms as well as airflow obstruction.

Diagnosing GORD in Respiratory Medicine

Gastroesophageal reflux disease (GORD) is increasing in prevalence and is highly associated with several lung diseases such as asthma and COPD. Current diagnostic methods are imperfect, being insensitive, non-specific, expensive, or invasive. An accurate diagnosis of GORD can aid effective treatment and have significant clinical impact. Novel methods such as exhaled breath condensate analysis and electronic nose technology have the potential to improve the accuracy of diagnosing GORD.

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.