A decade ago.

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A decade ago, I first became aware that gastroesophageal ebb (GER) disease could cause aerodigestive, particularly laryngopharyngeal, symptoms and complications in patients who denied having heartburn and regurgitation. Instead, these patients frequently complained of hoarseness, cervical dysphagia, globus pharyngeus, chronic throat clearing, and cough It now strike one as beings clear that patients with laryngopharyngeal GER also may be propense to develop other respiratory conditions, including unexplained chronic cough tracheitis, bronchitis, and asthma.

Interestingly, the issue of GER-related respiratory conditions has created a schism in the medical community: there are the couple proponents and opponents of the universal that GER disease may play a causal part in these conditions. This dichotomy appears to be appropriate to the fact that we lack ideal diagnostic meanss to define the mechanisms and patterns of GER in like cases. Fortunately, three things have changed in novel years: (1) ambulatory 24-h double-probe pH monitoring pH-metry) is available; (2) omeprazole is available; and (3) as a issue of these diagnostic/therapeutic tools, strange data are beginning to confirm a previously controversial clinical observations:

1 In patients with aerodigestive manifestations of GER disease, ebb may be unassociated with esophagitis or its symptoms. (In a series of patients with chronic unexplained cough studied by the agency of diagnostic pH-metry, I reported that solitary 16 percent had heartburn more than one time a week; however, 55 percent had abnormal pH-metry and 83 percent replyed to antireflux treatment.[1]

2 The pattern of GER disease in patients with pulmonary and laryngopharyngeal ebb is often chronic-intermittent, so that any and all publicly employed diagnostic tests for GER sometimes may be falsely negative.

3 The tissue damage that be deriveds from GER is primarily owed to the effects of pepsin, and 70 percent of peptic activity is maintained at pH 45 This may, in part, explain to what end the medical treatment failure rate with H2 blocker is long higher than expected in in the same state [i]or[/i] condition patients.

4. With the in every one's mouth state of the art, undivided of the best diagnostic proofs for GER-related aerodigestive conditions would be a therapeutic trial with omeprazole. Unfortunately, for this aim it must be prescribed in larger doses and for a longer period of time than commited by the Food and mix with drugs Administration.

All of this uncertainty artificial positions a dilemma for the clinician: by what means to diagnose and manage patients with respiratory disorders that may be wholly or in part befitting to GER disease. We certainly could use a just discovered diagnostic test that not single is sensitive and specific, nevertheless also can detect laryngopharyngeal and pulmonary GER days after the circumstance (Unfortunately, neither radionuclide scanning nor the lipid-laden macrophage proofs in current use is the answer.)

The article by dint of Irwin et al in this issue of Chest (see page 1511) is onward the right track; the deductions however, are somewhat unsettling. It would have been a great quantity [i]or[/i] amount of more reassuring to those of us who are seeking to understand the mechanisms of GER-related respiratory dysfunction if esophageal acid perfusion had reliably provok and duplicated the symptom, cough However, the fact that we cannot now define the mechanisms and patterns of GER in aerodigestive diseases does not negate the possibility that GER may play a causal part The article by Irwin et al is a beginning; nevertheless much more systematic study is stand in want ofed if we are to know the answers to the questions that this subject of attention poses.

Gastroesophageal ebb disease may yet be raise to be a major cofactor in aerodigestive carcinogenesis, unanticipated infant death syndrome, and chronic lung disease. a certain number of gastroenterologists still doubt that GER disease may befall without esophagitis; we who take care of patients with respiratory tract disorders ne to encourage their collaboration. Pulmonary physicians have a unique opportunity to explore these areas, which may simultaneously yield important basic-science and clinical breakthroughs. If, as I believe, half of all laryngeal disorders are reflux-related, then, by the agency of contiguity, resultant and coexistent lower aerodigestive dependence of cause and effects seem likely For the contemporary clinician, "the discovery of reflux" may be like the discovery of fire to the caveman - it may mistake one for another and change old paradigms forever.

Reference

[1] Koufman JA. The otolaryngologic manifestations of gastroesophageal ebb disease. Laryngoscope 1991; 101(suppl 53):I-78

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