Gastroesophageal Reflux Common in Patients With Sleep Apnea Rather Than Snorers Without Sleep Apnea

Abstract

To the Editor: We acknowledge the comments by Teramoto et al regarding our recent article in CHEST (June 2002).1Valipour A Makker HK Hardy R et al.Symptomatic gastroesophageal reflux in subjects with a breathing sleep disorder.Chest. 2002; 121: 1748-1753Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar We agree that there might be an interrelationship between gastroesophageal reflux (GER) and sleep-disordered breathing. Lifestyle features associated with sleep apnea, including obesity and alcohol ingestion, are also risk factors for GER, and apnea-induced transdiaphragmatic pressure swings might promote the reflux of gastric contents. However, it remains less clear whether hypoxia is related to GER episodes. While some have suggested that hypoxia induces a protective mechanism against reflux by increasing the lower esophageal sphincter tone,2Kiatchoosakun P Dreshaj IA Abu-Shaweesh JM et al.Effects of hypoxia on respiratory neural output and lower esophageal sphincter pressure in piglets.Pediatr Res. 2002; 52: 50-55Crossref PubMed Scopus (27) Google Scholar others observed increased GER episodes during hypoxia due to an impaired swallowing function.3Teramoto S Sudo E Ohga E et al.Impaired swallowing reflex in patients with obstructive sleep apnea syndrome.Chest. 1999; 116: 17-21Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar In our report, we did not observe a relationship between nocturnal oxygenation and the occurrence of symptomatic GER in patients with sleep apnea. In their correspondence, Teramoto and colleagues suggested that GER is less common in patients who snore than in those who have obstructive sleep apnea. While this might be true for asymptomatic “silent” reflux episodes, it seems not be true for symptomatic GER, as our data show.1Valipour A Makker HK Hardy R et al.Symptomatic gastroesophageal reflux in subjects with a breathing sleep disorder.Chest. 2002; 121: 1748-1753Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar However, this also might be due to the approach used in the diagnosis of GER. In our report, a validated questionnaire developed by the Mayo Clinic and designed to identify symptomatic GER, was used.4Locke GR Talley NJ Weaver AL et al.A new questionnaire for gastroesophageal reflux disease.Mayo Clin Proc. 1994; 69: 539-547Abstract Full Text Full Text PDF PubMed Scopus (396) Google Scholar We decided to use this diagnostic tool based on the following reasons: (1) pH monitoring is an invasive procedure that is reserved for atypical symptoms of GER5de Castecker JS Blackwell JN Brown J et al.The oesophagus as a cause of recurrent chest pain: which patients should be investigated and which tests should be used.Lancet. 1985; 126: 1143-1146Abstract Scopus (99) Google Scholar6Brzana RJ Koch KL Gastroesophageal reflux disease presenting with intractable nausea.Ann Intern Med. 1997; 126: 704-707Crossref PubMed Scopus (48) Google Scholar; (2) in daily practice, the diagnosis of GER is based on the recognition of symptoms, and a response of reflux symptoms to empirical treatment is considered diagnostic, with a sensitivity for and specificity comparable with pH monitoring7Schenk BE Kuipers EJ Klinkenberg-Knol EC et al.Omeprazole as a diagnostic tool in gastro-oesophageal reflux disease.Am J Gastroenterol. 1997; 92: 1997-2000PubMed Google Scholar; and (3) pH recordings have some considerable limitations with poor reproducibility data.8Mela GS Savarino V Vigneri S et al.Limitations of continuous 24-h intragastric pH monitoring in the diagnosis of duodenogastric reflux.Am J Gastroenterol. 1995; 90: 933-937PubMed Google Scholar However, from our findings we cannot rule out that asymptomatic GER was more prevalent in patients with sleep apnea compared to patients who only snore. Only 5 of 15 patients with sleep apnea and GER, which were documented by abnormal findings of pH monitoring studies, had symptomatic GER in the study by Penzel and colleagues.9Penzel T Becker HF Brandenburg U et al.Arousal in patients with gastro-esophageal reflux and sleep apnoea.Eur Respir J. 1999; 14: 12166-12170Crossref Scopus (111) Google Scholar It also might be considered that patients with a respiratory condition have a different perception of sensing reflux events compared to healthy subjects.10Mokhlesi B Morris AL Huang CF et al.Increased gastroesophageal reflux symptoms in patients with COPD.Chest. 2001; 119: 1043-1048Abstract Full Text Full Text PDF PubMed Scopus (157) Google Scholar If this is the case, do patients with sleep apnea and asymptomatic GER require separate GER treatment? Furthermore, if therapy with continuous positive airway pressure improves nocturnal GER in the absence of sleep apnea,11Kerr P Shoenut JP Steens RD et al.Nasal continuous positive airway pressure: a new treatment for nocturnal gastroesophageal reflux?.J Clin Gastroenterol. 1993; 17: 276-280Crossref PubMed Scopus (76) Google Scholar is GER then necessarily related to apneas? Since these questions are as yet unanswered, new studies are necessary in order to investigate the link between sleep-disordered breathing and GER more thoroughly. Gastroesophageal Reflux Common in Patients With Sleep Apnea Rather Than Snorers Without Sleep ApneaCHESTVol. 124Issue 2PreviewTo the Editor: Full-Text PDF