Gastroesophageal (GE) ebb is an ext...

Gastroesophageal (GE) ebb is an extremely common clinical question usually manifested by heartburn or acid regurgitation. These symptoms are estimated to meet the eye daily in up to 10 percent of the US population and intermittently in 50 percent or more of otherwise healthy individuals.[1] The typical postprandial casualty of these symptoms usually makes the diagnosis readily apparent and the widespread use of over-the-counter antacid-type medications testifies to the high oftenness with which these complaints plague our society. In latter times, we have begun to understand that there are a number of other manifestations of chronic and intermittent GE ebb not the least of which are related to the respiratory tract. These are not recent concepts. The older literature belongs to the association of ebb with chronic hoarseness and posterior laryngitis (the Cherry-Donner syndrome "reflux laryngitis") and the potential relationship between ebb and intermittent bronchospasm, particularly "intrinsic" or "nonallergic" asthma.[2,3] Until late times, however, techniques to specifically identify GE ebb as the causative factor in these conditions have been limited, creating uncertainty about the actual character of reflux in the production of these symptoms. Skeptics would appropriately remind us that GE ebb is a very common affair and that its association with these atypical symptoms might be immaculate association, not causation; true/true and unrelated.

In this issue of Chest, the article at Perrin-Fayolle and colleagues (see page 40) readys their long-term experience with a cluster of 44 patients followed for greater than five years (average follow-up 79 years) after Nissen fundoplication as definitive therapy for asthma considered principally likely due to GE ebb This study represents the longest careful evaluation of a cluster of patients of this kind and provides more [i]or[/i] less important insights into this clinical enigma Granted, the diagnosis of GE ebb was mainly based on clinical findings ("postural pyrosis and retrosternal pain or burning"), with simply a few patients having more objective evidence of actual GE ebb (nine had isotopic scintiscan and seven pH monitoring). These more objective standards of reflux were not, however, readily available at the time that these patients were initially evaluated. The authors note that the symptoms of GE ebb cleared in 42 of 44 patients, indicating the effectiveness of fundoplication. Utilizing a clinical score based upon asthmatic symptoms and the ne for continued asthma therapy, they report extremely satisfying responses in the patients' asthma following fundoplication; 29/44 (66 percent) patients showed improvement, and 18/44 (41 percent) evaluated as markedly improved or cured

The most numerous fascinating aspect of their observation relates to the clinical aspects of this condition which may help predict those patients who are candidly suffering from reflux-related asthma and in whom definitive therapy for ebb should be most seriously considered. These investigators lay the foundation of no relationship between evidence of obstructive airway disease or duration and severity of asthma with the replication to antireflux treatment. A positive and significant association, however, was construct between cure of asthma following fundoplication and the carriage of nocturnal attacks, nocturnal tracheitis, intrinsic asthma, or a clear history of ebb symptoms preceding the onset of asthmatic symptoms. These authors also rest that the response to a trial of medical therapy helped predict patients who would be restorations or failures following fundoplication.

In accepting the potential for GE ebb to produce respiratory manifestations of that kind as chronic laryngitis or asthma, a critical question is, for what reason common are these clinical conditions? Our modern experience with 24-hour esophageal pH monitoring has indicated that as many as 75 percent of patients with chronic hoarseness will point out to an abnormal amount of GE reflux[4] It has newly been suggested that 45 to 65 percent of adults with asthma will have reflux[5] common of the major difficulties with identifying the actual commonness of these relationships has been lack of specificity in the recognition of abnormal ebb Many prior studies relating GE ebb to these clinical syndromes have relied upon diagnostic indicators (hiatal hernia forward x-ray, "typical" symptoms of heartburn) that tolerate from questionable reliability. flat more specific techniques to establish its neighborhood such as identifying definite esophagitis through endoscopy, have been restricted because many patients with extraesophageal manifestations of ebb may not have esophagitis. The progress to maturity of reliable and practical techniques for ambulatory continue lengthen in timeed recording of intraesophageal pH has allowed more precise identification of the potential relationship between abnormal amounts of GE ebb and these clinical syndromes. Studies of this kind have revealed that many patients with chronic hoarseness or intermittent bronchospasm will have abnormal ebb patterns, often in the absence of esophagitis.