Standard Antireflux Therapy Research Articles

Mean Nocturnal Baseline Impedance (MNBI) Provides Evidence for Standardized Management Algorithms of Nonacid Gastroesophageal Reflux-Induced Chronic Cough.

The clinical management of nonacid gastroesophageal reflux-induced chronic cough (GERC) is challenging, and patient response to standard antireflux therapy (omeprazole 20 mg twice daily plus mosapride 10 mg thrice daily) is suboptimal. This study aimed to identify predictors of standard antireflux therapy efficacy and provide evidence for standardized management algorithms of nonacid GERC. A total of 115 nonacid GERC patients who underwent multichannel intraluminal impedance-pH monitoring (MII-pH) were enrolled between March 2017 and March 2021. Retrospective analysis of general information and MII-pH indications were used to establish a regression analysis model for multiple factors affecting standard antireflux therapy efficacy. 90 patients met the inclusion criteria, and the overall response rate to standard antireflux therapy was 55.5% (50/90). The mean nocturnal baseline impedance (MNBI) (1817.75 ± 259.26 vs. 2369.93 ± 326.35, P = 0.030) and proximal MNBI (1833.39 ± 92.16 vs. 2742.57 ± 204.64, P ≤ 0.001) of responders were lower than those of nonresponders. Weakly acid reflux (56.00 (31.70, 86.00) vs. 14.00 (14.00, 44.20), P = 0.022), nonacid reflux (61.35 (15.90.86.50) vs. 21.60 (0.00, 52.50), P = 0.008), and proximal extent (19.00 (5.04, 24.00) vs. 5.50 (2.56, 11.13), P = 0.011) were markedly higher in responders than nonresponders. Proximal MNBI (OR = 0.997, P = 0.042, and optimal cutoff = 2140 Ω) and weakly acid reflux (OR = 1.051, P = 0.029, and optimal cutoff = 45) were independent predictors of standard antireflux therapy efficacy. The combination predictive value did not show better results than either individual predictor. Proximal MNBI < 2140 Ω may be used to screen patients with nonacid GERC suitable for standard antireflux therapy and in standardized management algorithms for nonacid GERC. In the absence of MNBI, weakly acid reflux > 45 can be used as an auxiliary indicator.

Особливості діагностики й лікування дітей з езофагітом на фоні харчової алергії

Нами обстежено 40 дітей віком 6–18 років, у яких можна було запідозрити езофагіт. Усім дітям проводили ендоскопічну фіброезофагогастродуоденоскопію, під час якої брали біопсійний матеріал із стравоходу для подальшої верифікації діагнозу. Діти були розподілені на 2 групи: основна група — 20 дітей з діагнозом гастроезофагеальної рефлюксної хвороби, у яких на момент огляду або в анамнезі були прояви харчової алергії, і їм призначали стандартну протирефлюксну терапію та елімінаційну або гіпоалергенну дієту, левоцетиризин, пробіотичні бактерії Lactobacillus reuteri; контрольна група — 20 дітей з діагнозом гастроезофагеальної рефлюксної хвороби, які отримували стандартну протирефлюксну терапію. Курс лікування тривав місяць, після чого проводилась повторна ендоскопія з біопсією слизової оболонки стравоходу для визначення ефективності проведеного лікування. Після проведеного лікування ми отримали однонаправлені зміни клінічних, ендоскопічних та морфологічних показників в обох групах, проте в основній групі вони були більш виражені. Множинні білуваті нальоти, виявлені при первинній ендоскопії, повністю регресували в 75 % дітей основної та 50 % дітей контрольної групи, у 25 та 50 % дітей відповідно — частково. Тому при підозрі на алергічний компонент при езофагіті діагностичний алгоритм повинен бути розширений з обов’язковим включенням алергодіагностики.

Gabapentin versus baclofen for treatment of refractory gastroesophageal reflux-induced chronic cough

Refractory gastroesophageal reflux-induced chronic cough (GERC) is a special type of gastroesophageal reflux disease (GERD) with predominant cough resistant to pragmatic standard anti-reflux therapy including antisecretory agents alone or in combination with promotility agents but with a favorable response to intensified anti-reflux treatment. The condition is not rare and is difficult to treat. Neuromodulators such as baclofen and gabapentin are considered potential therapeutic options for refractory GERC. Limited data indicate that gabapentin and baclofen could attenuate the cough symptom in patients with refractory GERC by blockade of gastroesophageal reflux or by direct antitussive effects. However, no study has compared the efficacy of these two drugs in treatment of refractory GERC. In an open-labeled randomized clinical study, we demonstrated that, as add-on therapy, gabapentin and baclofen had a similar prevalence of therapeutic success for suspected refractory GERC but gabapentin may be more preferable because of its fewer central side effects. The efficacy of baclofen and gabapentin was suboptimal, so further studies are needed to select the patients with refractory GERC suitable for precise treatment using these two neuromodulators.

Changes and implications of esophageal function in patients with chronic cough induced by gastroesophageal reflux

Objective: To explore the changes in the esophageal function and their association with the therapeutic outcome in patients with gastroesophageal reflux-induced chronic cough (GERC). Methods: One hundred thirty-five patients with definite GERC consecutively referred to our respiratory clinic were recruited into the study between January 2012 and August 2015.Cough was due to acid reflux in 81 patients and non-acid reflux in 54 patients, with the favorable response to the standard antireflux therapy in 88 patients and to the intensified antireflux treatment in 47 patients. The control groups included 26 patients with gastroesphageal reflux disease without cough and 22 healthy volunteers. All the subjects underwent an esophageal manometry from which the parameters were recorded, including the pressure, length and relaxation rate of lower esophageal sphincter, and the peristaltic contractive amplitude, wave velocity and contractive time of esophagus. The data were combined with the results of multi-channel intraluminal impedance combined with pH monitoring to analyze the changes of esophageal function in the patients with acid or non-acid GERC and their relation to the outcomes of antireflux therapy. Results: Compared with healthy volunteers, patients with GERC presented with a lower pressure [(11±5) mmHg vs (15±5) mmHg (1 mmHg=0.133 kPa), q=3.70, P=0.000], shorter overall length [(2.2±0.5) cm vs (3.0±1.0) cm, q=2.78, P=0.017] and similar relaxation rate of lower esophageal sphincter(q=1.14, P=0.258). Furthermore, they also showed a decrease in esophageal peristaltic contractive amplitude [(33±13) mmHg vs (45±11) mmHg, q=2.19, P=0.030] and wave velocity [(2.6±0.8) cm/s vs (3.4±0.6) cm/s, q=2.91, P=0.010] but an increase in esophageal contractive time of esophagus [(4.9±2.2) s vs (3.1±0.8) s, q=3.25, P=0.001] in addition to a linear negative correlation between esophageal peristaltic wave velocity and bolus clearance (r=-0.603, P=0.000). However, these parameters were not different between patients with GERC and gastroesophageal reflux disease without cough. The patients with GERC due to acid and non-acid reflux presented with a similar esophageal dysmotility but different variables reflecting the acidity of refluxates as indicated by multi-channel intraluminal impedance combined with pH monitoring. The esophageal peristaltic wave velocity was significantly lower in the patients with GERC responsive to the standard antireflux therapy than in those responsive to the intensified antireflux therapy [(2.2±0.6) cm/s vs (3.0±1.0) cm/s, t= 2.066, P= 0.041]. Conclusions: Esophageal dysfunction is present in patients with GERC. Its characteristics and severity are not associated with the types of gastroesophageal reflux inducing cough, but may predict the efficacy of medical antireflux therapy.

A stepwise protocol for the treatment of refractory gastroesophageal reflux-induced chronic cough.

Refractory gastroesophageal reflux-induced chronic cough (GERC) is difficult to manage. The purpose of the study is to evaluate the efficacy of a novel stepwise protocol for treating this condition. A total of 103 consecutive patients with suspected refractory reflux-induced chronic cough failing to a standard anti-reflux therapy were treated with a stepwise therapy. Treatment commences with high-dose omeprazole and, if necessary, is escalated to subsequent sequential treatment with ranitidine and finally baclofen. The primary end-point was overall cough resolution, and the secondary end-point was cough resolution after each treatment step. High-dose omeprazole eliminated or improved cough in 28.1% of patients (n=29). Further stepwise of treatment with the addition of ranitide yielded a favorable response in an additional 12.6% (n=13) of patients, and subsequent escalation to baclofen provoked response in another 36.9% (n=38) of patients. Overall, this stepwise protocol was successful in 77.6% (n=80) of patients. The diurnal cough symptom score fell from 3 [1] to 1 [0] (Z=6.316, P=0.000), and the nocturnal cough symptom score decreased from 1 [1] to 0 [1] (Z=-4.511, P=0.000), with a corresponding reduction in the Gastroesophageal Reflux Diagnostic Questionnaire score from 8.6±1.7 to 6.8±0.7 (t=3.612, P=0.000). Conversely, the cough threshold C2 to capsaicin was increased from 0.49 (0.49) µmol/L to 1.95 (2.92) µmol/L (Z=-5.892, P=0.000), and the cough threshold C5 was increased from 1.95 (2.92) µmol/L to 7.8 (5.85) µmol/L (Z=-5.171, P=0.000). Sequential stepwise anti-reflux therapy is a useful therapeutic strategy for refractory reflux-induced chronic cough.

P151 Laryngopharyngeal Pepsin Reflux in Patients with Upper Airway Symptoms

BackgroundLaryngopharyngeal reflux (LPR) is implicated in inducing laryngeal hyper-responsiveness which is a unifying feature underlying chronic cough and vocal cord dysfunction. A lack of response to standard anti-reflux therapy in...

A Prospective Study of the Effect of Gastroesophageal Reflux Disease Treatment on Children With Otitis Media

To demonstrate improvements in validated quality-of-life measures for otitis media and gastroesophageal reflux disease (GERD) and an objective score for pediatric reflux obtained by fiberoptic laryngoscopy after treatment with antireflux precautions and therapy in children diagnosed as having either recurrent acute otitis media or otitis media with effusion and GERD. Prospective, before-and-after intervention study. Hospital-based pediatric otolaryngology practice. Population-based sample of 47 patients (mean age, 19.5 months). Standard antireflux therapy for 2 consecutive 12-week periods. Otitis Media 6-Item quality-of-life survey, Infant GERD Questionnaire-Revised, GERD Symptom Questionnaire for Young Children, Pediatric Reflux Finding Score, and speech awareness threshold. Follow-up data were available for 37 patients. Mean (SD) change scores for Otitis Media 6-Item quality-of-life survey were 1.6 (1.1) at visit 2 and 1.5 (1.1) at visit 3 (P < .001 and P = .004, respectively). Change scores were significantly improved for Infant GERD Questionnaire-Revised and GERD Symptom Questionnaire for Young Children at visit 2 and for Infant GERD Questionnaire-Revised at visit 3. Mean (SD) change scores for the Pediatric Reflux Finding Score were 6.4 (4.9) at visit 2 and 8.0 (7.2) at visit 3 (P < .001 and P = .03, respectively). Hearing loss was significantly improved following therapy, as were laryngeal findings of reflux on fiberoptic laryngoscopy. Otitis media was considered by the examining physician to be clinically improved in 28 of 37 children (76%; 95% confidence interval, 60%-87%) at visit 2 and in 6 of 10 children (60%; 95% confidence interval, 31%-83%) at visit 3. Nine children (19.1%) required myringotomy tube placement. Children with otitis media with effusion or recurrent acute otitis media and GERD have improved quality of life following treatment with antireflux therapy. Control of gastroesophageal reflux may play a role in the management of otitis media and avoidance of tympanostomy.

Effect of Six-Food Elimination Diet on Clinical and Histologic Outcomes in Eosinophilic Esophagitis

In children, eosinophilic esophagitis (EE) is predominantly, but not exclusively, a food-hypersensitivity disorder. A crystalline amino acid-based elemental diet (ELED) formula currently remains the most effective nutritional treatment in inducing clinical and histologic remission. However, compliance with an exclusive, poor-tasting liquid formulation is difficult. This retrospective observational study assessed the short-term clinical and histologic responses of 2 cohorts of children with EE evaluated during 2 different time periods: one was treated with the standard 6-food elimination diet (SFED) and the other was treated with ELED. Of the 60 children who met the inclusion criteria and were compliant with the dietary protocol, 35 were treated with a diet excluding cow-milk protein, soy, wheat, egg, peanut, and seafood while allowing all other table foods and 25 were treated exclusively with ELED. Repeat esophageal biopsy specimens were obtained at least 6 weeks later. Twenty-six of 35 (74%) in the SFED group and 22 of 25 (88%) in the ELED group achieved significant improvement of esophageal inflammation (</=10 eosinophils/high-power field). The pretreatment and posttreatment peak eosinophil counts for the SFED were 80.2 +/- 44.0 and 13.6 +/- 23.8 (P < .0001) and 58.8 +/- 31.9 and 3.7 +/- 6.5 (P < .001) for the ELED group, respectively. SFED treatment was associated with clinical and histologic improvement in EE in an observational study. It offers advantages of better acceptance, cost, and compliance than ELED and should be considered as an option in the initial management of children with EE.

The Use of Omeprazole in Infants with Gastroesophageal Reflux-induced Wheezing

We evaluated the use of proton pump inhibitor omeprazole to control severe gastroesophageal reflux (GER) in two otherwise healthy infants (ages 4 and 7 months) presenting with respiratory symptoms only. Omeprazole was given when standard antireflux therapy (H2 receptor antagonists [H2RA] and prokinetic agents) for at least 6 weeks failed to improve the wheezing, and prolonged pH probe and infant pulmonary function tests failed to show any significant improvement. Within 6 weeks of omeprazole therapy the cough and wheezing had completely resolved. In otherwise healthy infants with refractory GER-induced wheezing, omeprazole therapy may avoid the need for fundoplication in some children and may be considered prior to any antireflux surgery. Prospective long-term studies in infants and children are warranted to establish safety for long-term use.

Diagnosis and Treatment of Patients With Gastroesophageal Reflux and Noncardiac Chest Pain

Patients with noncardiac chest pain frequently have some evidence of gastroesophageal reflux. Yet there are few formal studies on the treatment of what appears to be reflux-related chest pain. The purpose of this study was to evaluate the effectiveness of intensive antireflux therapy in patients with noncardiac chest pain and gastroesophageal reflux and to determine whether patients who will respond to this therapy can be identified through routine esophageal testing. Thirteen patients with noncardiac chest pain and evidence of gastroesophageal reflux were treated with intensive antireflux therapy featuring high-dose ranitidine. Chest pain symptoms were scored from 0 (none) to 4 (severe) at entry into the study and at 8 weeks. Mean symptom scores were 2.9 +/- 0.3 at entry and 0.7 +/- 0.3 at 8 weeks. All patients had improvement, including those with a normal endoscopic or barium study (nine patients) and those for whom earlier standard antireflux therapy had failed (seven patients). Only one patient had a positive acid perfusion test, and only seven had any correlation of chest pain and reflux episodes during ambulatory monitoring. We concluded that many patients with noncardiac chest pain have gastroesophageal reflux, including those for whom an empiric trial of standard antireflux therapy fails. More aggressive antireflux therapy often leads to improvement in symptoms. Diagnostic studies requiring strict correlation of chest pain symptoms and reflux episodes are insensitive methods of determining which patients will respond to antireflux therapy.

Lack of impact of therapy on extent of Barrett's esophagus in 67 patients

Sixty-seven patients with Barrett's esophagus have been prospectively followed over an average of 36 months (range 6 to 76 months) with standardized endoscopic observation and biopsies of the length of columnar epithelium. The initial length of Barrett's epithelium ranged from 1 to 16 cm, mean 5.5 cm. Specialized columnar epithelium was present in 64 of the 67 patients. Patients were treated predominantly with H2-receptor blocker therapy to relieve symptoms. Eighty-two percent of patients had less than a 1-cm change in length per year. The mean rate of change of length was -0.093 cm per year. These results confirm in a relatively large, prospective study that standard antireflux therapy for Barrett's esophagus does not result in consistent reduction in the extent of Barrett's epithelium over a three-year interval.