Refractory chronic cough due to gastroesophageal reflux: Definition, mechanism and management

[8, 17]. Nonacid reflux disease is a newly understood type of GER that has been more easily identified using 24-hour MII pH monitoring. Cough is the most common symptom for which medical treatment is sought in the outpatient setting. Chronic dry cough poses a great diagnostic and management challenge due to myriad etiologies.

Relaxation of the crura and LES is a normal physiological process that takes place during swallowing. Relaxations not initiated by swallowing are termed transient lower esophageal relaxations (TLESRs); when they occur more frequently or last longer, they result in reflux of gastric fluid through the esophagogastric junction (EGJ), sometimes accompanied by gas (belch). TLESRs contribute to almost 90% of reflux episodes; more severe reflux-induced esophageal damage (esophagitis) results from persistently hypotensive LES [2, 3]. Gastroesophageal reflux disease is a common condition encountered in clinical practice.

non acid reflux definition

Processed foods and sugars can cause inflammation in your stomach, decrease acid activity, and trigger acid reflux symptoms. Surgery for GERD may involve a procedure to reinforce the lower esophageal sphincter called Nissen fundoplication.

NERD patients are also less likely to have a hiatus hernia and more likely to have Helicobacter pylori [22]. Further studies in patients with NERD and erosive esophagitis indicate that both groups of the patients appear to have distinct differences regarding clinical and physiological characteristics (Table 2) [22, 25, 55]. The potential explanations for the symptom generation in NERD include microscopic inflammation, visceral hypersensitivity (stress and sleep), and sustained esophageal contractions [35]. It has been observed that acid exposure disrupts intercellular connections in the esophageal mucosa, producing dilated intercellular spaces (DIS) and increasing esophageal permeability, allowing refluxed acid to penetrate the submucosa and reach chemosensitive nociceptors [36]. DIS has been observed in both NERD and erosive disease without a significant specificity as is also found in 30% of asymptomatic individuals [37].

Some people develop Barretts esophagus, where cells in the esophageal lining take on an abnormal shape and color, which over time can lead to cancer. Also, studies have shown that asthma, chronic cough, and pulmonary fibrosis may be aggravated or even caused by GERD. Because drugs work in different ways, combinations of drugs may help control symptoms. People who get heartburn after eating may take both antacids and H2 blockers.

have proposed the symptom association probability (SAP), arguing that this parameter overcomes some of the limitations of the symptom index and symptom sensitivity index. The SAP tries to evaluate if, from a statistical approach, the pattern of reflux and symptoms during the monitoring period may have occurred by chance, or if the association of symptoms and reflux episodes is not by chance. Commercially available software programs have the ability to report the SAP in percentage based on the original methodology described by Weusten et al.

Chronic cough has been commonly considered to be caused by gastroesophageal reflux, post-nasal drip or asthma. However, recent evidences suggest that many patients with these conditions do not have cough, and in those with cough, the response to specific treatments is unpredictable at best.

This approach, however, has the same problems as discussed above, that result from using the response to treatment to confirm GERD. Many nerves are in the lower esophagus.

This lack of response to treatment could be caused by ineffective treatment. This means that the medication is not adequately suppressing the production of acid by the stomach and is not reducing acid reflux. Alternatively, the lack of response can be explained by an incorrect diagnosis of GERD.

A US study on subjects who had their reflux symptoms controlled by antacids alone has shown that 53% of those subjects had no erosive esophagitis on upper endoscopy [23]. From the previous studies, the prevalence of NERD is therefore estimated to be between 50% and 70% of the GERD population in western countries.

Reflux is worse following meals. This probably is so because the stomach is distended with food at that time and transient relaxations of the lower esophageal sphincter are more frequent. Therefore, smaller and earlier evening meals may reduce the amount of reflux for two reasons. First, the smaller meal results in lesser distention of the stomach.

In this case, PPIs are preferred over H2 antagonists because they are more effective for healing. Clues to the presence of diseases that may mimic GERD, such as gastric or duodenal ulcers and esophageal motility disorders, should be sought. There are several ways to approach the evaluation and management of GERD. The approach depends primarily on the frequency and severity of symptoms, the adequacy of the response to treatment, and the presence of complications. Transient LES relaxations appear to be the most common way in which acid reflux occurs.

non acid reflux definition

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