Chronic cough due to gastroesophageal reflux. Clinical, diagnostic, and pathogenetic aspects
Authors
Irwin, Richard S.French, Cynthia L.
Curley, Frederick J.
Zawacki, John K.
Bennett, Frederick M.
UMass Chan Affiliations
Department of Medicine, Division of GastroenterologyDepartment of Medicine, Division of Pulmonary, Allergy, and Critical Care
Document Type
Journal ArticlePublication Date
1993-11-01Keywords
AdultAnalysis of Variance
Chronic Disease
Cough
Double-Blind Method
Esophagus
Female
Gastric Acid
Gastroesophageal
Reflux
Humans
Hydrogen-Ion Concentration
Male
Middle Aged
Monitoring, Physiologic
Prospective Studies
Life Sciences
Medicine and Health Sciences
Metadata
Show full item recordAbstract
BACKGROUND: Gastroesophageal reflux (GER) is a common cause of chronic cough. Moreover, chronic cough can be the sole presenting manifestation of GER disease (GERD). It has been suggested recently that GER most often causes chronic cough by stimulating the distal esophagus. To gain further diagnostic and pathophysiologic knowledge, we prospectively evaluated a group of patients with chronic cough likely to be due to GER with extensive gastrointestinal and respiratory studies and then observed their response to antireflux therapy. METHODS: We prospectively characterized 12 subjects whose chronic cough was likely to be due to GER by chest radiographs, barium esophagography, 24-h esophageal pH monitoring (EPM) with probes in the distal and proximal esophagus, esophagoscopy, and bronchoscopy. Then, prior to instituting antireflux therapy, we objectively counted coughs during the distal esophageal infusion of 0.1 N HCl or 0.9 percent saline solution administered in a randomized, double-blind, standardized fashion (ie, Bernstein acid-perfusion test). RESULTS: Gastroesophageal reflux was determined to cause cough in all subjects based on disappearance of cough with antireflux therapy. It was clinically "silent" in 75 percent. The EPM was the test most frequently abnormal (sensitivity, 92 percent). Distal esophageal data revealed that 10 of 12 subjects had GER-induced coughs (12 +/- 12) while only 7 of 12 had an abnormal esophageal pH conventional parameter (eg, percent time pH < 4). Compared with the distal esophagus, GER to the proximal esophagus occurred (p = 0.017) and induced cough (p = 0.004) less often. Compared with baseline (9.3 +/- 17.6), there were no differences in coughs induced by the infusion of saline solution (9.2 +/- 15.9) or acid (15.1 +/- 26.7); the number of coughs induced by acid was negatively correlated with distal esophageal acid-GER events during EPM (r = -0.64, p = 0.01). Neither bronchoscopy nor chest radiographs were consistent with aspiration. CONCLUSIONS: There is a clinical profile that prospectively predicts which patients have chronic cough due to GER. The cough was most likely due to stimulation of the distal esophagus, not aspiration. Intraesophageal acid is unlikely to be the sole mediator in gastric juice causing the cough. While EPM is the single most helpful diagnostic test, conventionally utilized diagnostic indices of GERD can be misleadingly normal; observing GER-induced coughs is more frequently helpful.Source
Chest. 1993 Nov;104(5):1511-7.
DOI
10.1378/chest.104.5.1511Permanent Link to this Item
http://hdl.handle.net/20.500.14038/41560PubMed ID
8222816Related Resources
ae974a485f413a2113503eed53cd6c53
10.1378/chest.104.5.1511