Gastro-oesophageal reflux disease (GERD) is among the most common diseases in Western countries: prevalence is around 10-20% of the adult population

One speaks of gastro-oesophageal reflux disease (GERD) whenever the rising acid content from the stomach into the oesophagus causes symptoms

The clinical manifestations can be classified into typical or atypical symptoms and very often it is not so easy to recognise them.

One of these is a wheezing cough.

Typical and atypical symptoms of gastro-oesophageal reflux

As mentioned, there are 2 different types of clinical manifestations of reflux:

• typical symptoms, including retrosternal burning (heartburn) and regurgitation;
• atypical symptoms, which may be ear-nose-throat, pulmonary (chronic cough or asthma) or cardiac (non-cardiac chest pain).

Wheezing cough among atypical symptoms of gastro-oesophageal reflux disease

Among the atypical symptoms, which are more difficult to diagnose, is the constipated cough, which requires not only the advice of a specialist, but also a specific diagnostic procedure.

With regard to a constipated cough, there are 2 categories of patients with different symptoms:

• the former, in addition to having the typical symptoms of reflux, i.e. heartburn (retrosternal burning) and regurgitation that tend to be prevalent, also complain of a cough;
• the latter complain only of a cough in the absence of typical GERD symptoms and, unfortunately, tend to be less responsive to medical therapy with antacid medications or proton pump inhibitors.

Causes

The most frequent cause of chronic cough, defined as persisting for more than 8 weeks, is traditionally attributed to asthma or RGE.

However, there are no clinical features that allow us to differentiate cough associated with reflux from cough due to other causes, such as chronic bronchitis from cigarette smoking.

It is reported in the literature that more than 25% of patients suffering from chronic cough also have RGE.

When reflux cough occurs

Reflux cough tends to occur at particular times of the day and in certain situations

• after a meal and/or during the night;
• in a lying position, which favours the rise of acid from the stomach towards the oesophagus;
• when there appears to be no common cause for this type of disorder (e.g. colds).

How chronic cough manifests itself in relation to RGE

The diagnosis of MRGE must be considered when, in addition to the chronic cough, the patient collaterally reports typical reflux symptoms.

Two mechanisms of association between RGE and chronic cough have been proposed.

The most intuitive one according to which acid reflux reaching the upper oesophageal sphincter may lead to the inhalation of certain microparticles that may reach the larynx or bronchi, activating the cough reflex to protect the airways.

The other hypothesis is based on the common embryological origin of the digestive and respiratory tracts: a small reflux can stimulate an oesophagobronchial reflex that determines the onset of coughing. In addition, the cough itself may aggravate the reflux leading to a vicious circle (cough-reflux-reflux).

Oesophagogastroduodenoscopy for the diagnosis of MRGE

Oesophagogastroduodenoscopy (EGDS) is the gold standard examination for the evaluation of patients with MRGE.

It allows evaluation of the presence of:

• erosive oesophagitis;
• Barrett’s oesophagus;
• oesophageal stenosis;
• diagnose neoplasia of the oesophago-gastric district.

oesophageal pH impedance measurement

Another examination is oesophageal pH impedanceometry, nowadays considered the most reliable method for identifying gastro-oesophageal reflux (GORD) because it allows any episode to be recognised and its composition (acidic, basic, neutral), duration, location and nature (solid, liquid, gaseous) to be defined.

It is the diagnostic examination that allows the presence of gastro-oesophageal reflux to be assessed by placing a tube in the oesophagus and recording these events for 24 hours on a laptop computer.

The examination makes it possible to

• identify the presence of acid and non-acid gastro-oesophageal reflux,
• indirectly assess oesophageal motor function;
• ascertain whether there is a correlation between the patient’s symptoms and any reflux.

Conservative treatment of reflux cough

Since reflux cough is a symptom, its treatment consists of treating the pathology that caused it, i.e. gastro-oesophageal reflux disease.

In adults with a wheezing cough attributable to reflux, it is advisable to improve lifestyle through a few simple measures:

• modify diet in order to lose weight (overweight/obese patients are more likely to develop MRGE)
• stop smoking;
• turn up the bedside and avoid going to bed until at least 3 hours after a meal;
• eat slowly and chew a lot;
• avoid tight clothing.

Drug therapy

Among the drugs most commonly used to combat gastro-oesophageal reflux disease are

• proton pump inhibitors, which can reduce acid secretion from the stomach by inhibiting the activity of the proton pump located on the parietal cells of the gastric mucosa;
• antacids, which neutralise the excessive acid environment in the stomach. Their duration of action, however, is very short (a few hours) and they do not affect the stomach’s acid secretion;
• prokinetics: they facilitate gastric emptying by reducing the time food stays in the stomach. They are often used in combination with drugs that intervene on the stomach’s acid secretion.

In addition to implementing these precautions, it should be emphasised that in subjects with a constipated cough and RGE who do not manifest heartburn and regurgitation, PPIs (proton pump inhibitors) are often not decisive.

In fact, symptomatic treatment with antitussive drugs normally indicated for dry cough is generally ineffective in cases of reflux cough.

Surgery

In cases where, despite treatment, symptoms persist and have a severe impact on the patient’s quality of life, a surgical strategy may be considered.

This consists of a minimally invasive laparoscopic operation that can be performed using different techniques tailored to the patient, depending on the presence or absence of factors predisposing to reflux, such as the presence of a hiatal hernia.

It is really a tailor-made surgery, whereby the patient will be offered the most suitable intervention for his or her clinical condition: for example, the placement of LINX or the fitting of an anti-reflux plastic.

A recent study, which evaluated the resolution of atypical symptoms with surgical technique, showed that surgery is associated with a high probability of success, especially with regard to a wheezing cough (around 83%).

It is emphasised that it is imperative, before considering surgery, that all other pathological conditions that could be the cause of the chronic cough are excluded.

The respiratory system will then be investigated through a specialist pulmonary examination, ENT examination, chest X-ray and possible spirometry.

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Source:

GSD