Refractory chronic cough due to gastroesophageal reflux: Definition, mechanism and management

Biopsies also may be obtained. effects of gravity, reflux occurs more easily, and acid is returned to the stomach more slowly.

GERD has been linked to a variety of respiratory and laryngeal complaints such as laryngitis, chronic cough, pulmonary fibrosis, earache, and asthma, even when not clinically apparent. These atypical manifestations of GERD are commonly referred to as laryngopharyngeal reflux (LPR) or as extraesophageal reflux disease (EERD). GER, gastroesophageal reflux; MII-pH, combined multichannel intraluminal impedance and pH; PPI, proton pump inhibitor.


However, accumulating evidence does not support a significant role of nocturnal acid breakthrough in the failure of PPIs treatment. How to define refractory GERC remains to be controversial. There is no consensus on the refractory gastroesophageal reflux disease which GERC can refer to.

GERD is a major burden to western societies and it was a major breakthrough when omeprazole – the first proton pump inhibitor (PPI) – was marketed in 1989. Since then, the acid component of GERD can be sufficiently treated; PPIs are the gold standard treatment for patients with GERD (1).

The second option is to go ahead without 24 hour pH testing and to increase the dose of PPI. Another alternative is to add another drug to the PPI that works in a way that is different from the PPI, for example, a pro-motility drug or a foam barrier. If necessary, all three types of drugs can be used. If there is not a satisfactory response to this maximal treatment, 24 hour pH testing should be done.

Heartburn / GERD Guide

A new (Porto) classification separates gastroesophageal reflux detected by MII into acid, if the pH drops from above to below 4.0, weakly acidic if the pH is between 4.0 and 7.0, and weakly alkaline if the intraesophageal pH during an MII-detected reflux episode remains above 7.0. Although this new classification offers a better compromise for the chemical and classic gastrointestinal physiology definition of acid and nonacid, the traditional classification using the pH 4.0 cutoff underscores better the concept that for the detection of reflux episodes with a pH above 4.0 a method other than conventional pH monitoring is required. Data are recorded with a sample frequency of 50 Hz and stored on the flash card of a data logger (Sleuth System, Sandhill Scientific Inc., Highland Ranch, CO). During the monitoring period patients are instructed to reproduce as much as possible the daily scenarios during which they experience symptoms. Patients are provided with diaries and asked to record the timing and consistency of ingested meals, timing of the intake of acid-suppressive medication, periods of upright and recumbent position, and the time of symptoms.

In addition to patients not responding to PPI treatment being a significant problem, establishing the diagnosis is poorly developed and the tools needed to make this diagnosis are only available at tertiary referral centres. With new therapies on the horizon, this may change and require that nonacid reflux is confirmed before specific treatment is initiated. The clinical significance of multichannel impedance measurement combined with pH monitoring in patients who fail or insufficiently respond to PPI treatment is undoubted because it is currently the only technique that can reliably quantify nonacid reflux into the esophagus. Manometry, pH monitoring and radiological techniques cannot diagnose disease or quantify nonacid reflux and, thus, are used for other indications. pH monitoring is helpful in diagnosing acid reflux when the study is performed while the patient is off antacid medication, or in diagnosing ongoing acid reflux in patients who are on an antacid medication.

non acid reflux definition

antireflux surgery [76]. In one earlier study comparing the clinical outcome of antireflux surgery between patients with erosive esophagitis and NERD, it was demonstrated that 91% versus 56% reported heartburn resolution, 24% versus 50% reported dysphagia after surgery, and 94% versus 79% were satisfied with surgery, respectively [76]. Visit our Acid Reflux / GERD category page for the latest news on this subject, or sign up to our newsletter to receive the latest updates on Acid Reflux / GERD.

They are abnormal in that they do not accompany swallows and they last for a long time, up to several minutes. These prolonged relaxations allow reflux to occur more easily. The transient LES relaxations occur in patients with GERD most commonly after meals when the stomach is distended with food. Transient LES relaxations also occur in individuals without GERD, but they are infrequent. The first part of the small intestine attached to the stomach.

Moreover, biopsies are the only means of diagnosing the cellular changes of Barrett’s esophagus. More recently, it has been suggested that even in patients with GERD whose esophagi appear normal to the eye, biopsies will show widening of the spaces between the lining cells, possibly an indication of damage. It is too early to conclude, however, that seeing widening is specific enough to be confidently that GERD is present. The usual way that GERD is by its characteristic symptom, heartburn. Heartburn is most frequently described as a sub-sternal (under the middle of the chest) burning that occurs after meals and often worsens when lying down.


In a study of 22 infants with primarily respiratory symptoms who underwent pH-MII testing, the standard pH probe failed to detect 88% of reflux episodes that were associated with breathing problems. Non-acid reflux is measured using a new tool called multi-channel intra-luminal impedance (pH-MII).

non acid reflux definition

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