Extra-esophageal manifestations of gastro-esophageal reflux disease, continued. NCCP patients without dysphagia can be treated empirically with PPIs for 8 weeks or until symptoms remit; the PPI dose should, then, be tapered to the lowest dose that controls the symptoms. Diagnostic testing with ambulatory pH or impedance monitoring and esophageal motility testing should usually be reserved for those who continue to be symptomatic despite initial empiric trial of PPI. Surgical treatment Surgical fundoplication should not be considered in patients who are unresponsive to prolonged, high-dose (twice-daily) PPI therapy.18- 19 Fundoplication may be beneficial in patients who respond to anti-secretory agents but require continuous, high-dose PPI therapy to control symptoms, and in those with large hiatal hernia. Extra-esophageal manifestations of GERD: Proposed Oral manifestations of GERD Oral manifestations of GERD include dental erosions, halitosis, water brash, mouth ulceration, taste disturbance and glossodynia. Dental erosions occur due to erosive potential in the oral cavity from intrinsic and extrinsic acid that exceeds the buffering capacity of saliva. Other oto-rhino-pharyngeal manifestations of GERD Other proposed oto-rhino-pharyngeal manifestations of extraesophageal GERD include chronic rhino-sinusitis and otitis media. Nasopharyngeal exposure to reflux has been found in patients with rhino-sinusitis. GERD treatment with PPI may improve the symptoms of sinusitis. Pulmonary fibrosis There is some evidence to suggest that recurrent micro-aspirations of gastric refluxate can lead to pulmonary fibrosis. Sleep disturbances and GERD Nocturnal reflux is associated with esophageal injury as well as a higher prevalence of laryngeal and pulmonary manifestations. GERD can affect the quality of sleep by awakening patients from sleep due to nocturnal heartburn and reflux may result in amnestic arousals. Abnormal esophageal acid exposure is also associated with obstructive sleep apnea.20 Conclusions Extra-esophageal manifestations such as chronic cough, reflux laryngitis syndrome, reflux induced chest pain and reflux-induced bronchial asthma are common in patients with GERD. These manifestations can occur in in patients with co-existent other diseases. A trial of PPI therapy, twice-daily for 2-3 months, and evaluation of their response to therapy, is the preferred initial approach to diagnosis and management. Figure: Treatment algorithm for extra-esophageal manifestations of GERD Figure: Treatment algorithm for extra-esophageal manifestations of GERD Suspected extra‐esophageal GERD Twice‐daily PPI, 4‐8 weeks No improvement in extra‐esophageal symptoms Improvement in symptoms Esophageal‐pH (off therapy) and/or Impedance‐pH (on therapy) Taper to a lower dose of PPI Normal Abnormal Consider other diagnosis Increase PPI dose Ensure compliance References 1. Vakil N, van Zanten SV, Kahrilas P, Dent J, Jones R; Global Consensus Group. The Montreal definition and classification of gastro-esophageal reflux disease: a global evidence-based consensus. Am J Gastroenterol 2006;101:1900-1920. 2. Yuksel ES, vaezi MF. Extraesophageal manifestations of gastroesophagheal reflux disease: cough, asthma, laringitis, chest pain. Schweiz Med Wochenschr 2012;142:w13544. 3. Madanick RD. Extraesophageal presentations of GERD: where is the science? Gastroenterol Clin N Am 2014;43:105- 120. 4. Francis DO, Rymer JA, Slaughter JC, Choksi Y, Jiramongkolchai P, Ogbeide E, et al. High economic burden of caring for patients with suspected extraesophageal reflux. Am J Gastroentrol 2013;108:905-911. 5. Ang D, Ang TL, Teo EK, Hsu PP, Tee A, Poh CH, et al. Is impedance pH monitoring superior to the conventional 24-h pH meter in the evaluation of patients with laryngorespiratory symptoms suspected to be due to gastroesophageal reflux disease? J Dig Dis 2011;12:341-348. 6. Bajbouj M, Becker V, Neuber M, Schmid RM, Meining A. Combined pH-Metry/Impedance monitoring increases the diagnostic yield in patients with atypical gastroesophageal reflux symptoms. Digestion 2007;76:223-228. 7. Sifrim D, Dupont L, Blondeau K, Zhang X, Track J, Janssens J. Weakly acidic reflux in patients with chronic unexplained cough during 24 hour pressure, pH, and impedance monitoring. Gut 2005;54:449-454. 8. Kim TH, Lee KJ, Yeo M, Kim DK, Cho SW. Pepsin detection in the sputum/saliva for the diagnosis of gastro-esophageal reflux disease in patients with clinically suspected atypical gastro-esophageal reflux disease symptoms. Digestion 2008;77:201-206. World Digestive Health Day WDHD May 29, 2015 WGO HANDBOOK HEARTBURN: A GLOBAL PERSPECTIVE 23
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