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Nonacid Reflux in Patients With Chronic Cough on Acid-Suppressive Therapy^*

^* From the Division of Gastroenterology and Hepatology (Drs. Tutuian, Agrawal, and Castell, and Mr. Mainie), Department of Surgery (Dr. Adams), Medical University of South Carolina, Charleston, SC.

Correspondence to: Radu Tutuian, MD, Fellow in Gastroenterology, Division of Gastroenterology/Hepatology, Medical University of South Carolina, 96 Jonathan Lucas St, 210 CSB, Charleston, SC 29425; e-mail: tutuianr{at}musc.edu

Abstract

Background: It is generally accepted that extraesophageal gastroesophageal reflux disease (GERD) symptoms and their persistence despite acid-suppressive therapy are poor prognostic factors for antireflux surgery. Recent studies indicating that cough can be temporally associated with reflux episodes of pH 4 to 7 (ie, nonacid reflux) reinvigorates the need for a more careful workup in patients with cough suspected to be due to GERD.

Aim: To evaluate the frequency of chronic cough associated with nonacid reflux and the response of these patients to laparoscopic Nissen fundoplication.

Methods: We retrospectively reviewed data from patients with persistent cough despite twice-daily proton pump inhibitor (PPI) with or without the use of nighttime regimens of histamine-2 receptor antagonist (H2RA), who had undergone combined multichannel intraluminal impedance and pH monitoring. The association of cough and reflux was evaluated by calculating the symptom index (SI) [positive if 50%]. A subset of patients with positive SI values for impedance-detected reflux with therapy was referred for laparoscopic Nissen fundoplication.

Results: Of 50 patients (38 female patients; mean age, 43 years; age range, 6 months to 84 years) who were monitored while receiving therapy, 13 patients (26%) had a positive SI for cough. The SI-positive group had a lower percentage of female patients and patients of younger age compared to the SI-negative group. Laparoscopic Nissen fundoplication was performed in six SI-positive patients who became asymptomatic and stopped receiving acid-suppressive therapy during follow-up evaluations (median time, 17 months; range, 12 to 27 months).

Conclusion: Impedance pH monitoring should be performed while receiving therapy in patients with persistent symptoms who are receiving PPI therapy. A positive SI for nonacid reflux may be helpful in selecting patients who will benefit from antireflux surgery.

Key Words: extraesophageal manifestation of gastroesophageal reflux disease • multichannel intraluminal impedance • pH monitoring • proton pump inhibitors

This article has been cited by other articles:

				S. Decalmer, A. A. Woodcock, J. A. Smith, R. Tutuian, and D. O. Castell Patient Misreporting May Lead to Underestimation of Cough Events Chest, July 1, 2007; 132(1): 358 - 359. [Full Text] [PDF]