Extra-esophageal gastroesophageal reflux disease and asthma: understanding this interplay

Abstract

Gastroesophageal reflux disease (GERD) is a condition that develops when there is reflux of stomach contents, which typically manifests as heartburn and regurgitation. These esophageal symptoms are well recognized; however, there are extra-esophageal manifestations of GERD, which include asthma, chronic cough, laryngitis and sinusitis. With the rising incidence of asthma, there is increasing interest in identifying how GERD impacts asthma development and therapy. Due to the poor sensitivity of endoscopy and pH monitoring, empiric therapy with proton pump inhibitors (PPIs) is now considered the initial diagnostic step in patients suspected of having GERD-related symptoms. If unresponsive, diagnostic testing with pH monitoring off therapy and/or impedance/pH monitoring on therapy, may be reasonable in order to assess for baseline presence of reflux with the former and exclude continued acid or weakly acid reflux with the latter tests. PPI-unresponsive asthmatics, without overt regurgitation, usually have either no reflux or causes other than GERD. In this group, PPI therapy should be discontinued. In those with GERD as a contributing factor acid suppressive therapy should be continued as well as optimally treating other etiologies requiring concomitant treatment. Surgical fundoplication is rarely needed but in those with a large hiatal hernia, moderate-to-severe reflux by pH monitoring surgery might be helpful in eliminating the need for high-dose acid suppressive therapy.

Hospitalizations for asthma among adults exposed to the September 11, 2001 World Trade Center terrorist attack

“…Research suggests that GERS may lead to or exacerbate asthma and be associated with poor asthma control [34][35][36]. Proposed underlying mechanisms fall into two camps: reflex theory and reflux theory [35].…”

“…Proposed underlying mechanisms fall into two camps: reflex theory and reflux theory [35]. Reflex theory suggests that esophageal acid induces a vagally mediated reflex leading to bronchoconstriction.…”

“…The reflux theory posits the direct microaspiration of gastric and duodenal contents into the lungs via the esophagus. Conversely, asthma may lead to GERS due to a resulting increase in the pressure gradient between the thorax and abdomen, relaxation of smooth muscles including the lower esophageal sphincter, and the use of certain asthma medications [35]. The co-occurrence of these two diseases is well documented [7,9,13] and adding proton pump inhibitor treatment for GERS to an asthma regimen may reduce asthma symptoms and medication use, and improve pulmonary function [37].…”

Nordic consensus statement on the systematic assessment and management of possible severe asthma in adults

“…Although the causal link is unclear, co-existence of gastroesophageal reflux is very common in patients with asthma [89]. As the diagnosis of GERD may be difficult, with limited sensitivity of both gastric pH monitoring and endoscopy, a trial treatment with PPI may be used as the initial diagnostic step in symptomatic patients [90]. Of note, high use of beta 2 -agonist has been shown to relax the sphincter between the oesophagus and the ventricle, which increases the tendency to reflux, potentially inducing a vicious cycle of high SABA use, reflux and increasing asthma symptoms leading to high SABA use.…”

“…The effect of treating GERD in severe asthma is uncertain: Whereas some studies have demonstrated an effect on symptoms, quality of life and exacerbations, no convincing effect has been demonstrated on lung function and airway hyperresponsiveness [90,150]. Hence, PPI treatment may be considered in the individual patient.…”