Transcript GERD

GERD and its
supraesophageal or
extraesophageal
manafestations
Yousif A. Qari
Ass.prof,Consultant
Gastroenterologist KAUH
What is GERD
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A condition that occurs
when the lower esophageal
sphincter (LES) does not
close properly and stomach
contents leak back, or
reflux, into the esophagus.
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The LES is a ring of muscle
at the bottom of the
esophagus that acts like a
valve between the
esophagus and stomach.
Prevalence of GERD
Approximately 20% of adults have frequent
"classic" symptoms of gastroesophageal reflux
(GER):
► Heartburn
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Regurgitation.
What causes GERD?
► No
one knows why
people get GERD.
►A
hiatal hernia may
contribute.
Other factors that may contribute to GERD
► Alcohol
use
► Overweight
► Pregnancy
► Smoking
Certain foods can be associated with reflux events
Citrus fruits
► Chocolate
► Drinks with caffeine
► Fatty and fried foods
► Garlic and onions
► Mint flavorings
► Spicy foods
► Tomato-based foods, like spaghetti sauce, chili, and pizza
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What are the symptoms of GERD
Persistent heartburn and acid
regurgitation.
► Belching
► Waterbrash (sudden excess of
saliva)
► Sour taste in the mouth
► Food stuck in throat
► Difficulty or pain when swallowing
► Chest pain
► Hoarseness
► Choking or throat tightness.
► Chronic sore throat
► Dry cough
► Bad breath
► Inflammation of the gums
► Erosion of tooth enamel (the
surface of the teeth)
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How is GERD diagnosed?
► Review
of symptoms and a complete
physical examination, with Special
attention to alarming symptoms.
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Duration & severity of symptoms
Anemia
Dysphagia (Difficulty in swollowing)
Weight loss
Diagnosis of supraesophageal Reflux
1.
Heartburn and regurgitation
many of these patients fail to demonstrate the typical symptoms
of heartburn and regurgitation
2.
The response of symptoms to an empirical trial of
antireflux therapy
3.
Ambulatory, esophageal pH monitoring
4.
Upper gastrointestinal endoscopy
Most do not have esophagitis when looked at endoscopically.
A normal upper esophagoscopy
The Los Angeles Classification System for the
endoscopic assessment of reflux oesophagitis
GRADE A:
One or more mucosal breaks no
longer than 5 mm, non of which
extends between the tops of the
mucosal folds
The Los Angeles Classification System for the
endoscopic assessment of reflux oesophagitis
GRADE B:
One or more mucosal
breaks more than 5 mm
long, none of which
extends between the tops
of two mucosal folds
The Los Angeles Classification System for the
endoscopic assessment of reflux oesophagitis
GRADE C:
Mucosal breaks that extend
between the tops of two or
more mucosal folds, but which
involve less than 75% of the
oesophageal circumference
The Los Angeles Classification System for the
endoscopic assessment of reflux oesophagitis
GRADE D:
Mucosal breaks which
involve at least 75% of the
oesophageal circumference
Endoscopic view of GERD complications
Limitations of esophsgeal pH monitoring
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Not accepted by patients easily
Optimal site of probe placement (ie, pharyngeal vs upper
esophageal)
What is a normal vs abnormal amount of acid reflux.
False-negatives may occur
A positive test does not prove a causative relationship to
the symptoms
Normal pH testing in the upper and lower esophagus is
strong evidence against acid-related symptoms
Nonacidic reflux may also play a pathophysiologic role in
the symptoms of some patients (which may only resolve
with fundoplication
Catheter-Free pH-Monitoring System
BRAVO Catheter-Free ph Testing
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Bravo can be placed during endoscopy
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Allows 24-hour or 48-hour pH
monitoring to record more clinical data
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Patients maintain normal diet and
routine activities
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Minimizes throat and nasal discomfort
associated with transnasal catheters
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Transmits data to pager-sized reciever
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Uploads easily to pH analysis software
1.
C, DeMeester T, Peters J, et al. Clinical evaluation of the BRAVOTM probe - a catheter-free
ambulatory esophageal pH monitoring system. Gastroenterology. 2001;120:A-35. [Abstract
#177]
Catheter-Free pH-Monitoring System
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In a controlled study of only 7 asymptomatic subjects
 the small amounts of measured acid reflux appeared comparable to
that obtained with the conventional pH probe.
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Additional head-to-head trials of the micro-probe and
conventional catheter systems are needed in symptomatic
patients to determine the accuracy, reliability, and patient
acceptance of this technique.
How is GERD treated?
► Lifestyle
Changes
► Medications
► Surgery
► Endoscopic options
Lifestyle Changes
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If you smoke, stop.
Do not drink alcohol.
Lose weight if needed.
Eat small meals.
Wear loose-fitting clothes.
Avoid lying down for 3 hours after a meal.
Raise the head of your bed 6 to 8 inches by
putting blocks of wood under the bedposts-just using extra pillows will not help.
Medications
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Antacids:
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Maalox,
Mylanta
Pepto-Bismol
Rolaids
Foaming agents
 Gaviscon
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H2 blockers
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Cimetidine (Tagamet )
Famotidine (Pepcid)
Nizatidine (Axid)
Ranitidine (Zantac 75)
Magnesium salt can lead to diarrhea, and
aluminum salts can cause constipation
Medications
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Proton pump inhibitors
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omeprazole (Prilosec)
lansoprazole (Prevacid)
pantoprazole (Protonix)
rabeprazole (Aciphex)
esomeprazole (Nexium)
Prokinetics
 Bethanechol (Urecholine)
 Metoclopramide (Primpran)
 Domperidone (Motilium)
Surgery
Nissen Fundoplication
Nissen Fundoplication
Endoscopic view of Nissen Fundoplication
Long-term complications of GERD?
Inflammation of the esophagus
► Bleeding or ulcers
► strictures
► Barrett's esophagus and adenoarcinoma
► Supraesphageal manafestations
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Asthma
chronic cough
pulmonary fibrosis
ENT manafestations
Endoscopic pictures of GERD
Extraesophageal disorders in GERD
Extraesophageal manifestations of gastroesophageal reflux disorder
(GERD) are frequent, and consist broadly of
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Noncardiac chest pain
pulmonary diseases
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laryngeal diseases
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Asthma
chronic cough
recurrent bronchitis
sleep apnea
pulmonary fibrosis
Laryngitis
subglottic stenosis
laryngeal cancer
other ENT (ear, nose, throat) disorders
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Sinusitis
Otitis media
Pharyngitis
dental erosion
Noncardiac chest pain is associated with GERD
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Among patients with angina-like chest pain
 30% will have normal coronary arteries; of these, 40% to 50% have
objective evidence of GERD by endoscopy or ambulatory pH monitoring
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Prevalence of GERD symptoms is 23% to 100%
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Esophagitis is seen in 0% to 47%
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Abnormal ambulatory pH recordings noted in 20% to 63%
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Empiric trial of PPI
 78% sensitivity and 86% specificity , for diagnosing GERD association with
noncardiac chest pain.
GERD and Chronic Cough
► Direct
mucosal injury and/or
► Triggering vagally mediated mechanisms
 Increased airway secretions
 Bronchospasm
Nonacid Gastroesophageal Reflux
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Reflux of gastric contents
 Food
 Nonacidic material.
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Symptoms that fail to respond to aggressive therapy with
proton-pump inhibitors may still improve after antireflux
surgery
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Traditional pH testing (which detects reductions in
intraesophageal pH from a baseline of pH 6-7) cannot
detect nonacidic reflux.
Nonacid Gastroesophageal Reflux
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Nonacidic reflux was seen in both normal (healthy controls) subjects and GERD
patients
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Measured by multichannel intraluminal impedance (MII) monitoring
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Accounted for one third of all reflux events
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Occurred more commonly after meals and in recumbency
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Only 4% of nonacidic reflux events were due to bile reflux
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Three fourths of bile reflux episodes occurred in conjunction with acid reflux
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Compared with acid reflux events, nonacidic reflux typically did not extend as
far proximally and was cleared more quickly from the esophagus.
importance of nonacidic reflux
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The true importance of nonacidic reflux in the
pathogenesis of both esophageal and extraesophageal
symptoms remains to be established.
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may be a factor in:
 Functional heartburn (ie, heartburn with normal esophageal pH
measurements)
 Nonerosive reflux disorders
 Extraesophageal disorders, whose symptoms persist despite
aggressive proton-pump inhibitor therapy.
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MII may be used to test for nonacidic reflux
GERD and Chronic Cough
The mechanisms remain controversial.
 Microaspiration
 Stimulation of a vagally mediated esophageal-bronchial
reflex. That may also involve brainstem centers.
GERD and Chronic Cough
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Establishing a definite cause-and-effect relationship
between GER and chronic cough is difficult.
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A normal esophageal pH study argues against acid GER as
a cause of chronic cough
An abnormal pH study does not prove that acid reflux is
the cause of chronic cough.
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Only a minority of patients with proven GER have
improvement of cough after proton-pump inhibitor therapy.
GERD and Chronic Cough
Empirical trial of high-dose therapy with PPI
 Uncontrolled trials
► 70%
to 100% improvement
 The only published placebo-controlled trial reported
► 35%
response rate.
GERD and Chronic Cough
75 patients with chronic cough prospectively evaluated
 GER symptoms in 72%
 abnormal pH testing in 56% (42 of 75)
 20/42 had minimal or no reflux symptoms.
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Omeprazole was given to a subset of patients (n = 55)
with either GER symptoms and/or abnormal pH testing.
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After 3-6 months, significant improvement was noted 45%
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No symptom or pH parameter was predictive of
improvement.
Garrigues V, Bastida G, Bau I, et al. Gastroenterology. 2001;120:A-430. [Abstract #2195]
GERD and Chronic Cough
Conclusions
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ambulatory esophageal pH testing still is of limited utility in the evaluation of patients
with chronic cough.
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A normal pH study with a low SI (symptom index) , probably excludes acid-related
cough, but a positive pH study does not prove a causal relationship.
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Many clinicians may choose to treat all patients with chronic cough with an empirical trial
of high-dose proton-pump inhibitors (eg, omeprazole 40 mg twice daily), even if
symptoms of reflux are absent.
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Cough usually responds within 2 weeks of therapy.
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An empirical trial is more cost-effective than formal evaluation with manometry and pH
testing.
Laryngopharyngeal reflux
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81% will have a normal-appearing esophagus
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40% may have symptoms of heartburn
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Symptoms consistent with this diagnosis
Dysphonia
Globus sensation
Throat clearing
Halitosis
Sore throat
Cough.
Hoarseness is a majer coplaint in 92% of patients with GERD-related
laryngitis
 > 50% of patients presenting to ENT specialists with hoarsness will
have a component of GERD contributing to their symptoms
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Reflux Laryngitis
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Posterior laryngitis at laryngoscopy is a typical finding of reflux
laryngitis
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Niether laryngoscopic findings nor positive pH studies have been found
to be of predictive value in identifying patients likely to respond to
proton-pump inhibitors.
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No agreement as to the optimal site of pharyngeal probe placement or
normal values of esophagopharyngeal reflux (EPR).
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EPR is also is detected in up to 20% of normal controls.
Reflux Laryngitis
Study involved 62 cadidates
19 healthy controls
43 patients with suspected reflux laryngitis
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17 with symptoms but a normal ENT exam
26 with posterior laryngitis.
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Videolaryngoscopy was performed in all subjects
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Dual-probe pH testing was performed, with the proximal probe located 1 cm above the
upper esophageal sphincter in the pharynx.
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Pharyngeal acid reflux occurred in
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26% of controls
53% patients with ENT symptoms alone
69% in patients with ENT symptoms and findings of posterior laryngitis
However, there was no difference in symptoms between patients with abnormal and
normal pH values, or between patients with an abnormal or normal-appearing larynx.
Ylitalo R et al , Gastroenterology. 2001;120:A-426. [Abstract #2175]
Reflux Laryngitis
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49 patients with chronic ENT symptoms and abnormal laryngoscopic
examination underwent a questionnaire and dual-probe esophageal
(not pharyngeal) pH testing.
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After initial evaluation, patients were treated in an uncontrolled fashion
with either
 high-dose proton-pump inhibitors
 high-dose proton-pump-inhibitor therapy and bedtime ranitidine.
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At 4 months, improvement was noted in 32 of 49 (65%) of patients
treated with proton-pump inhibitors (with or without ranitidine).
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Symptoms, ENT findings, and pH parameters were not predictive of
response to proton-pump inhibitor therapy.
1. Vaezi M et al. Gastroenterology. 2001;120:A-118. [Abstract #636]
Management of suspected
reflux-laryngitis
Laryngeal symptoms
The laryngoscopic finding of
"posterior laryngitis"
Advise
•Smooking
•Overuse of voice
ENT consultation
Resolution of symptoms
Trial of PPI BID
For 3 m
Gradual “”step- down””
To define
Maintenace dose
Persitent symptoms
Refer patient for 24h
pH-metry on PPI therapy
Increase dose / consider surgery
Richter Gasroenterol clin north Am 1996 : 25; 75
Reflux Laryngitis
Conclusions
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lack of predictive value for
 Symptoms
 ENT findings
 pH testing
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In uncontrolled trials, improvement is seen in 60% to 90%
of selected patients.
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The efficacy, optimal dose, and duration of proton-pump
inhibitors for reflux laryngitis have not been established in
controlled trials.
Other GERD-Associated ENT conditions
► Subglottic stenosis
► laryngeal carcinoma
► Globus
► Otitis media
► Sleep apnea
Proving a cause-and-effect relationship
between GER and these conditions is
difficult.
GER in Otitis Media
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GER may cause chronic otitis media
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Reflux of gastric contents into the nasopharynx and middle ear might
precipitate infections and/or chronic effusions.
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Assessed 50 middle-ear effusions for pepsin and pepsinogen levels
using an enzyme-linked immunosorbent assay (ELISA).
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Pepsin and pepsinogen were detected in 41 of 50 effusions (82%)
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provocative observation, but proof of causation is lacking.
1.
Tasker A, et al. Gastroenterology. 2001;120:A-119. [Abstract #638]
GER and Sleep Apnea
Obstructive sleep apnea (OSA)
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A condition that occurs as a result of the loss of normal
pharyngeal muscle tone while sleeping, which allows the
pharynx to collapse during inspiration.
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It is most common in:
 Obese
 anatomically narrowed upper airways due to macroglossia,
micrognathia
 redundant pharyngeal or tonsillar soft tissue.
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Strong association between OSA and GER was suggested
GER and Sleep Apnea
101 patients undergoing sleep studies for suspected OSA
were evaluated for symptoms of GER
 Sleep apnea was diagnosed in 71 of 101 patients
 GER symptoms:
► 50%
in patients with OSA
► 33% in patients without OSA.
 GER symptoms were not related to the severity of OSA.
Guda N, et al .Gastroenterology. 2001;120:A-429. [Abstract #2190]
GER and Sleep Apnea
Coclusions
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Observations so far do not prove symptom causality.
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Patients with OSA may be predisposed to GER
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Obesity
sedentary lifestyle
alcohol use
smoking.
Obstructed breathing patterns (with negative intrathoracic pressure) also may
predispose to GER
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A controlled trial of GER therapy in patients with OSA is needed.
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Patients with OSA should be assessed for GER symptoms pre- and post-OSA
treatment.
Coclusions
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Gastroesophageal reflux is extremely common and may
manifest with typical and atypical symptoms.
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At present it is extremely difficult to establish a definite
diagnosis of extraesophageal GERD.
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Typical esophageal symptoms (heartburn, regurgitation)
may be absent in a large number of patients.
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Neither the type of ENT symptoms nor the ENT findings
are of predictive value in determining underlying GER.
Coclusions
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Although interesting new modalities for reflux testing are available
(capsule pH monitoring, impedance testing) it remains to be seen
whether these modalities improve diagnostic accuracy
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Currently, the most cost-effective approach for most patients with
suspected reflux-related symptoms is a trial of a high-dose protonpump inhibitor for 3 monthes.
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pH testing reserved to confirm adequate acid suppression in those with
refractory symptoms.
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Although improvement in cough symptoms may be evident within 2
weeks of treatment, improvement in other ENT disorders may require
3 or more months of therapy.
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The place of Fundoplication is yet to be defined
Diagnosis
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The majority of patients with extraesophageal
manifestations of GER do not have the classic symptoms of
heartburn or regurgitation
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less than 30% have endoscopic evidence of reflux
esophagitis
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Twenty-four-hour pH monitoring has been commonly used
to look for evidence of acid reflux into the lower
esophagus, upper esophagus, and pharynx. However, this
test is not comfortable for most patients
GER and Sleep Apnea
41 consecutive patients with suspected OSA
undergoing sleep exams were prospectively
evaluated with a GERD symptom questionnaire.
 22/41 enrolled patients, reported heartburn or acid
regurgitation.
 17/22 patients with heartburn reported that this
symptom awakened them at night.
 Regression analysis suggested that GER severity was
correlated to the apnea-hypoventilation index.