Gastroesophageal Reflux Symptoms in Typical and Atypical GERD

Roles of Gastroesophageal Acid Refluxes and Esophageal Motility

Tanisa Patcharatrakul; Sutep Gonlachanvit

Disclosures

J Gastroenterol Hepatol. 2014;29(2):284-290. 

In This Article

Results

Two-hundred and thirty six patients with GERD-related symptoms (159 females, age 47 ± 14 years, body mass index [BMI] 23.2 ± 3.7 kg/m2) were included. All patients completed standard water perfused esophageal manometry and 24 h lower esophageal pH studies during off therapy. Two hundred and nineteen patients had both upper and lower esophageal pH studies. Seventeen patients had only distal esophageal pH monitoring due to nonavailability of the dual pH catheter at the time of the studies. The patient characteristics and esophageal manometry findings of all patients and the patients with positive and negative 24 h esophageal pH test were demonstrated in Table 1.

Five, 61, 33, 122, and 15 patients had typical GERD, reflux like dyspepsia, noncardiac chest pain, chronic ENT symptoms, and chronic cough as their main problem, respectively. The duration of symptoms was 12(5–36) months. Among 66 patients who had typical reflux or reflux-like dyspepsia as their main problem, 59 patients (89%) previously used acid suppressions, and 80% (47/59) of these patients had unsatisfied response. All of patients with atypical GERD symptoms (noncardiac chest pain, chronic ENT symptoms, and chronic cough) had esophageal manometry and 24 h pH monitoring because of uncertain diagnosis.

Eighty seven and 67 patients had positive pH tests of the lower and upper esophagus, respectively (Table 1). Patients with positive lower esophageal pH test were significantly older than patients with negative lower esophageal pH test (50 ± 13 vs 45 ± 13 years, P < 0.005). Gender and BMI were not significantly different between patients with positive and negative either lower or upper esophageal pH test (P > 0.05) (Table 1).

Abnormal esophageal manometry studies were presented in 93 patients, including ineffective esophageal motility disorders (n = 82), nutcracker esophagus (n = 8), and diffuse esophageal spasm (n = 3). Patients with abnormal esophageal motility were significantly older than patients with normal esophageal manometry (49 ± 14 vs 45 ± 13 years, P < 0.05). Prevalence of esophageal dysmotility between patients with positive and negative lower as well as upper esophageal pH test was similar (P > 0.05).

Among 123 patients who had upper endoscopy within 6 months prior to esophageal manometry and pH monitoring, 111 patients showed no esophagitis. Nine and three patients had esophagitis LA grade A and grade B, respectively. No Barrett's esophagus was found. There was no significant difference of the prevalence of esophagitis in patients with normal and abnormal pH tests (P > 0.05) or patients with normal and abnormal esophageal manometry (P > 0.05).

Associations Between Upper Gastrointestinal/Respiratory Tract Symptoms and 24 h Lower Esophageal pH Monitoring/Esophageal Manometry Results

Patients with positive and negative pH tests of the lower esophagus had similar prevalence of upper gastrointestinal and respiratory tract symptoms (P > 0.05), except acid regurgitation symptom was significantly more prevalent in the pH positive group (56/87 vs 72/149, P < 0.05) (Fig. 1). Prevalence of heartburn symptom was similar between the patients with positive and negative pH tests of lower esophagus (P > 0.05).

Figure 1.

Proportion of each upper gastrointestinal (GI) and respiratory tract symptom between patients with negative and positive lower esophageal pH study (*P < 0.05). ( ) Negative lower pH test (n = 149), ( ) Post-lower pH test (n = 87).

Patients with normal and abnormal esophageal manometry results had similar upper gastrointestinal and respiratory symptom profile. Although patients with abnormal esophageal manometry had higher prevalence of dysphagia symptom than patients with normal esophageal manometry, it did not reach the statistical significant difference (46/93 vs 53/143, P > 0.05) (Fig. 2). Only prevalence of chronic cough symptom was significantly higher in patients with abnormal esophageal manometry than in patients with normal manometry (30/93 vs 26/143, P < 0.05).

Figure 2.

Proportion of each upper gastrointestinal (GI) and respiratory tract symptom between patients with normal and abnormal esophageal manometry (*P < 0.05). ( ) Normal esophageal manometry (n = 143), ( ) Abnormal esophageal manometry (n = 93).

Logistic regression analysis also showed that age more than 45 years and the presence of acid regurgitation symptom were the independent factors that were significantly associated with positive lower esophageal pH result (odds ratio [OR] = 1.2(1.1–1.4), P < 0.005 for age; OR = 1.1(1.004–1.3), P < 0.05 for acid regurgitation symptom). In addition, age more than 45 years old and the presence of chronic cough symptom were the independent factors that were significantly associated with abnormal esophageal manometry (OR = 1.2(1.002–1.3), P < 0.05 for age; OR = 1.2(1.003–1.4), P < 0.05 for chronic cough symptom).

To determine the role of gastroesophageal acid refluxes and esophageal dysmotility on upper gastrointestinal and respiratory tract symptom, the prevalence of each symptom in patients with positive or negative pH tests of the lower esophagus was compared between patients with or without abnormal esophageal manometry tests. In patients with positive pH tests, the prevalence of dysphagia, chronic cough, and hoarseness of voice symptom were significantly higher in patients with abnormal esophageal manometry than in patients with normal esophageal manometry (18/31 vs 18/56, P < 0.05; 12/31 vs 6/56, P < 0.005 and 19/31 vs 18/56, P < 0.01, respectively). The prevalence of acid regurgitation and heartburn symptom were not significantly different between patients with normal and abnormal manometry in patients with positive lower esophageal pH test (P > 0.05). Whereas in patients with negative lower esophageal pH tests, the prevalence of heartburn symptom was significantly lower in patients with normal esophageal manometry than in patients with abnormal esophageal manometry (26/87 vs 30/62, P < 0.05). The prevalence of acid regurgitation and other upper GI as well as respiratory symptoms were not significantly different between patients with normal and abnormal manometry in patients with positive (Fig. 3a) or negative (Fig. 3b) lower esophageal pH test (P > 0.05).

Figure 3.

(a) Proportion of each upper gastrointestinal (GI) and respiratory tract symptom in patients with positive lower esophageal pH monitoring (n = 87) comparing between patients with normal and abnormal esophageal manometry (*P < 0.05,** P < 0.01,*** P < 0.005); ( ) Normal manometry (n = 56), ( ) Abnormal manometry (n = 31); (b) Proportion of each upper GI and respiratory symptom in patients with negative lower esophageal pH monitoring (n = 149) comparing between patients with normal and abnormal esophageal manometry (*P < 0.05). () Normal manometry (n = 87), ( ) Abnormal manometry (n = 62).

Associations Between Upper Respiratory/Gastrointestinal Symptoms and 24 h Upper Esophageal pH Monitoring/Esophageal Manometry Results

Patients with positive upper esophageal pH test results had significantly more prevalence of acid regurgitation symptom than patients with negative upper esophageal pH test results (43/67 vs 74/152, P < 0.05). The other upper gastrointestinal symptoms and upper respiratory symptoms had similar prevalence between patients with positive and negative upper esophageal pH test (Fig. 4).

Figure 4.

Proportion of each upper gastrointestinal (GI) and respiratory symptom in patients with negative and positive upper esophageal pH test (*P < 0.05). ( ) Negative upper pH test (n = 152), ( ) Positive upper pH test (n = 67).

After the prevalence of each respiratory and upper gastrointestinal symptom in patients with positive or negative pH tests of the upper esophagus was compared between patients with or without abnormal esophageal manometry tests, the prevalence of acid regurgitation symptom was not significantly different between patients with normal and abnormal manometry both in patients with negative or positive upper esophageal pH test (50/97 vs 24/55 and 22/36 vs 21/31, P > 0.05, respectively). However, the prevalence of chronic cough and hoarseness of voice symptom was significantly higher in patients with abnormal esophageal manometry than in patients with normal esophageal manometry only in patients with positive upper pH monitoring but not in patients with negative upper esophageal pH test results (chronic cough 12/31 vs 4/36, P < 0.01 and 17/55 vs 18/97, P > 0.05, respectively; hoarseness of voice 17/31 vs 8/36, P < 0.01 and 22/55 vs 41/97, P > 0.05, respectively) (Fig. 5).

Figure 5.

Proportion of each upper gastrointestinal (GI) and respiratory tract symptom in patients with positive upper esophageal pH monitoring (n = 67) comparing between patients with normal and abnormal esophageal manometry (*P < 0.05). ( ) Normal manometry (n = 36), ( ) Abnormal manometry (n = 31).

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