DELAYED ONSET OF POST-FUNDOPLICATION COUGHING, GAGGING, AND CHOKING IS TEMPORALLY ASSOCIATED WITH GASTROESOPHAGEAL REFLUX (GER)

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Background: Early onset of post-fundoplication coughing, gagging and chocking is reported to be related to poor gastric compliance and accommodation. Delayed onset of such symptoms is of unclear etiology. Aims: 1) assess the role of GER in causing post-fundoplication gagging, choking or coughing 2) evaluate the effects of pH status on the GER in its temporal relation to these symptoms. Methods: Ten children (4M/6F, median age 17.3 months), were referred to our facility for delayed onset of coughing, gagging, and choking 26.1 ± 10.8 months after fundoplication. All patients underwent 24 hour combined pH and multichannel intraluminal impedance monitoring (pH/MII) monitoring. Symptom events (SEs): coughing, choking and gagging were recorded by a constant attendant and considered temporally associated with GER if occurred within 5 min of a GER event. Strengths of association were assessed using symptom indices (SI) and symptom sensitivity indices (SSI). Significance of SI and SSI values were at >50% and >10%, respectively. Results: Of the combined measuring time of 13,055 min, 85.2 min were spent in reflux; 38.0 min (44.6%) were acid-GER (AGER) and 47.2 min (55.4%) were non-acid-GER (NAGER). During the studies we detected 188 GER episodes, 54 (28.7%) AGER and 134 (71.3%) NAGER. Patients had 871 SEs; 769 (88.3%) coughing, 91 (10.4%) gagging, and 11 (1.3%) choking events. Of the total 871 SEs, 60 (6.9%) were found to be temporally-linked with GER by pH/MII; 48 (80%) coughing, 11 (18.3%) gagging, and 1 (1.7%) choking event. SI was <50% in all patients. 7/10 patients had a positive SSI; 1 (14.3%) with AGER only, 4 (57.1%) with NAGER only, and 2 (28.6%) with both AGER and NAGER. More patients had a positive SSI using pH/MII than would have been detected by pH monitoring alone (7/10 [70%] vs 3/10 [30%]). Conclusions: 1. in the delayed post-fundoplication phase coughing, gagging, and choking are temporally associated with either acid or non acid GER 2. pH/MII is superior to the standard pH monitoring in evaluating the etiology of post-fundoplication symptoms.