Extraesophageal manifestations (non-cardiac chest pain, asthma)

Alan Cutler MD: Proton pump inhibitor use by ENT doctors and pulmonologists is definitely on the rise. It appears that many symptoms seen by the ENT physician - hoarseness, laryngitis, maybe even sinusitis-is a direct result of acid reflux up into the upper pharyngeal area. It's also been shown recently that asthma, in some patients, may be induced by reflux disease into the esophagus.

When acid refluxes up into the esophagus, there are two possible scenarios that can occur which may induce extraesophageal symptoms. One is that the acid can stimulate the vagus nerve, causing such things as bronchospasm and asthma. The other possibility is that the acid can splash all the way up into the pharynx, causing either injury to that area or even microaspiration into the lungs.

If a patient has chest pain and the cardiac workup is negative, about half the patients have reflux disease and the physician should think about it. Patients with hoarseness and laryngitis that's persistent may very well be reflux disease. Adult-onset asthma that is not well controlled with traditional agents, such as beta agonists or steroids, is probably reflex related. The prevalence of reflux disease as the etiology for chest pain that is not cardiac is not truly known. We suspect that 30% of patients with chest pain are reflux related. If you then look at patients with normal heart catheterizations and continued symptoms, probably 50% of this group has their symptoms related to reflux disease.

When a patient has chest pain and cardiac etiology's been ruled out and we suspect GERD or reflux disease, we treat the patient with BID proton pump inhibitors for weeks to months. In the first couple of weeks, we should see an improvement in symptoms if they are reflux related. That is the main diagnostic and therapeutic maneuver for chest pain related to reflux.

Alan Cutler MD: The PPI test runs about an 80% sensitivity and specificity for determining whether the chest pain is induced by reflux disease.

Malcolm Robinson MD: Asthma and GERD are related. They're certainly related numerically. As many as 90% of asthmatic patients may have pathological reflux disease. Patients who have pathological reflux disease in asthma, when treated with effective treatment, can be demonstrated to have very significant effects on their symptoms of asthma and on other medication used, although it has been more difficult to show effects on the actual pulmonary functions in asthma, even by pretty aggressive treatment.

At one time it was thought that asthma was exacerbated in reflux disease because of direct reflux of acidic gastric contents through the esophagus, through the larynx and into the tracheobronchial tree. We now know that this can occur, but in most asthmatics, that is not the mechanism. Instead, there is a reflex that is present between the esophagus and the bronchial tree in which acid, even in the distal esophagus, can cause bronchospasm. So this is the mechanism that we now believe takes place in asthmatic patients.

It means that the acid in the esophagus in asthma needs much more complete control than we have previously thought to be present because you not only need to control proximal acid reflux, but even distal reflux, which can also exacerbate asthma.

Alan Cutler MD: GERD and asthma have a unique relationship. Adults who present with first-time asthma probably have it caused by reflux disease, especially if there's no history of asthma in themselves or their family. Especially if their symptoms are made worse with things that might make reflux worse, such as exercising after eating, certain food triggers.

These patients are generally resistant to traditional therapies for asthma.

Additionally, patients with simple asthma may also have reflux disease. The straining of the diaphragm for moving air back and forth will also push acid up. The medications that are utilized to treat asthma, beta agonists, will relax the lower esophageal sphincter and make reflux disease worse.

While there have been symptomatic improvements in patients with asthma and reflux disease, measured factors - such as lung volume and the amount of air a patient can put out in the first second - have not been as successful or as encouraging as we would have liked.