GERD LEADS TO RESPIRATORY SYSTEM DISEASES

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GERD LEADS TO RESPIRATORY SYSTEM DISEASES

• Dr. Remziye TANAÇ
• Ege University School of Medicine Division of
  Pediatric Allergy and Pulmonology

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GERD

• GER is reflux of the gastric contents into the
  esophagus
• At least one regurgitation in a day
• 0-3 months period 50
• In 4th months 67
• 10-12 months period 5
• Decrease after 6-months-old

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REFLUX

• Gastroesophageal Reflux (GERD)
• Physiological
• Functional
• Pathologic (GERD)
• Secondary
• Pharyngolaryngeal reflux (PLR) is to reach up
  the gastric contents to the upper-esophageal
  sphincter with no vomiting and retching

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GERD

• Most common extraesophageal symptom is concerning
  the respiratory system
• Bronchial hyperreactivity (infantile
  wheezing,asthma)
• Recurrent pneumonia
• Chronic cough
• Infantile apnea
• Laryngeal diseases
• Otitis media
• Sinusitis
• Adenoidal hyperplasia

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GERD and Common Pulmonary Symptoms

• Distal esophagus originates from lung pouch
  embryologically
• Vagal nerve innervates distal esophagus and
  airway
• Throughout life association and interaction in
  thoracal cage

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HISTORY

• 12th Century Moses Malmonides horisontal
  position is harmful for dyspnea
• 18th Century Rosenstein stomachic cough
• 1802 Haberden in some people respiration
  becomes fast and forced after meals
• 1892 Osler overeating must be avoided
• 1934 Bray airway obstruction in people who lie
  down right after meals
• 1962 Kennedy silent reflux in airway diseases
• 1970 Barr GERD is one of the causes of bronchial
  obstruction

Ped.Clin. Notrh. Am. 50 (2003) 487-502
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Prevalence

• GERD
• 40 in general population
• Classical reflux symptoms
• 40-50 in asthmatic patients
• 57 patients have URT symptoms
• 43 in chronic cough

Not very Clear
Clinical Cornerstone 2003, vol.5-4
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Prevalence

• In general
• Pulmonary symptoms 42 in children with GERD
• Asthmatic symptoms 60-80 in adults with GERD
• Asthmatic symptoms 56-60 in children with GERD

Ped. Pulm. Supp. 2004 26 194-96 J. Pediatrr.
2005 146s.3-12
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Mechanisms of GER

• Macroaspiration
• Chronic laryngitis,recurrent sinusitis,otitis
  media,recurrent pneumonia,bronchectasis
• Microaspiration
• Chronic cough,bronchospasm
• Esophagolaryngeal/Bronchial vagal reflex,local
  axonal reflex
• Chronic cough,laryngospasm,infantile
  apnea,bronchospasm

Immunol. Allergy. Clin. N. Am. 28 (2005) 131-148
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Macro-Micro Aspiration Theory

• Acid reflux into the trachea
• Increase in total lung resistance
• Decrease in intratracheal pH
• Induce chemo and sensory receptor-vagal
  reflex
• Cough,bronchospazm

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Esophagobronchial/Vagal/Local Axonal Reflex

• Distal esophagus originates from lung pouch
  embryologically
• Vagal nerve innervates distal esophagus and
  airway

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• Gastric contents
• Regurgitation into esophagus
• Induced lower esophageal receptor
• Vagal stimuli
• (Bronchospasm,cough)
• Local axonal reflex
• Esophagus-lung interaction
• (NO)
• (Substance P, neurokinin A)

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• GERD-Reactive Airway Disease
• (Asthma-Wheezy child)

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Association of Asthma and GERD

• 30 gt 80
• 24 - 77
• 45 - 65
• 50 - 60

J.Poelmans.J.Gut
200554492-99 Harding SMThe Am. J.Med.
200315(3A)405-445 Lemaske RF J.Allergy Clin.
Immunol 2006 117 S.445-61
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GERD-Asthma-Risk

• 10.000 children 2-18 years of age
• 7920 children GERD(-) 7 Asthma
• 1980 children GERD() 13 Asthma
• OR 1.9
  plt0.001

El Serag H.B. Gastroenterology 2001 121 1294-9
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• Field SK
• 109 Asthma
  125 Control
• GERD 77
  50
• Pul. Find 41
• Harding SM
• pH monitoring
• Pul. Symptoms in 151 cases 79 Acidic
  reflux

Field S.K. Chest 1996 109 316-22
Hardig S.M.Chest 1999 115 654-59
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Lung Function Test(LFT)-GERD

• 34 Asthmatic children (2.5-17 years of age)
• pH monitoring
• Endoscopy
• LFT
• 87 pathologic reflux
• FEV1/FVC (r -0.67)
• Increase of pathologic reflux in severe asthmatic
  patients

Farcau D. Pneumologia 2004 53(3)127-71
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Nocturnal GERD-Asthma

• 77 Asthmatic children (39-170 months of age)
• More nocturnal GERD in moderate and severe
  asthma than mild group

Cinquetti J.Asthma 2002 39135-42
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Nocturnal GERD-Pul. Symptoms-PEF

• Randomised n 2197 (20-48 years of age)
• GERD (complains of patient)
• FEV1-PEFR-BHR
• Results
• GERD in 101 patients - 4.6
• Wheezing OR 2.5 (95 CI)
• Dyspnea OR2.8
• nGER() 5.4 4.2
• nGER(-) 4.2 3.5
• No change in FEV1

PEF variability plt0.05
Gislason T. Chest 2002 121 158-63
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GERD-Asthma-Morbidity

• 2397 children
  13-14 years of age
• Questionnaire
• Asthmatics n296
  GERD 19.3
• Non- asthmatics n1510 GERD
  2.5

Debley J.S.Ped.Pulmonol 2006 41475-81
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Wheezing-GERD

• pH monitoring in 190 children
• 15.8 wheezing
• 82 children (Med. age 17.4 months)
• Recurrent wheezing
• 21.9 GERD

Goldami H. Arq Gastroenterol 2005,42(3)173-2
Karaman O.Indian J.Peditr. 1999, 66(3)351-5
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Wheezing-GERD

• Non-atopic 25 patients (wheezingcough) 25
  control
• 72 38.1 months of age
• pH monitoring
• Therapy for three months with PPI

Yüksel H. Respiratory Med.2006, 100393-98
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Therapy of Asthma-GERD

• Meta-analysis (Adult)
• 1966-1996 12 studies 326 Patients
• 8 placebo controlled
• 3 open
• 1 untreated control group
• Result
• 69 decrease in asthmatic symptoms
• 62 decrease in antiasthmatics usage
• 26 increase in morning PEF value

Field SK Chest 1998, 114(1),275-83
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Asthma and Therapy of the GERD

• Prospective (Adult)
• 30 Patients 73 GERD()
• Medication with PPI for three months
• Result
• 20 increase in PEF
• 20 improvement in asthmatic symptoms
• Need for 12 week therapy

Harding M.S.. Immunol. Allergy. Clin. North
Amer.25,2005,131-48
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Asthma and Therapy of the GERD

• Multicentric,double-blind placebo controled
• 207 Patients Moderate persistant (Adults)
• PPI 30 mgx2 6 months
• Decrease in asthma attacks
• Improvement in life-quality

Littner M.R. Chest 2005 1281128-35
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Asthma and Therapy of the GERD

• 27 Patients 5-10.5 years of age
• 59 GERD() by Ph Monitoring
• Medicalsurgical treatment
• Result
• After 6 months
• 50 decrease in bronchodilator usage
• 89 decrease in inhaled steroid usage

Khoshoo V.Chest 20031231008-13
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Asthma-GERD SURGERY

• Meta-analysis
• 12 studies 417 Patients
• 90 improvement in GER
• 80 decrease in antiasthmatics usage
• 79 decrease in asthmatic symptoms
• 27 improvement in LFT

Field SK.. Chest 1999, 116760-74
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RESULT

• GERD Leads to Reactive Airway
• DISEASE
• (ASTHMA-WHEEZING)

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GERD-Recurrent Pneumonia

• Pneumonia
• Two or more within one year
• and/or
• Three or more at any time

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GERD-Recurrent Pneumonia

• Patients with neurologic diseases
• Children who have congenital malformation related
  to upper-gastrointestinal system
• Healty children with GERD
• Increase of GERD incidence in recurrent pneumonia
• Improvement in GERD and pneumonia with GERD
  therapy

Euler AR, Byrne WJ, Ament ME. Reccurent
pulmonary disease in childrena complication of
gastroesophageal reflux.Pediatrics
63(1979),pp47-51 Carre IJ. Pulmonary
infections in children with a partial thoracic
stomach(hiatus hernia) Arch Dis Child
35(1960)pp481-484
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GERD-Recurrent Pneumonia

• El-Serag (2-18 years of age, children)
  1996-2000
• n 10.000 GERD 1980
  Control 7920
• OR 2.3 CI1.8-2.9
  plt0.0001

El Serag H.B.Gastroenterology 2001121,1294-9
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GERD-Recurrent Pneumonia

• Çiftçi E
• n788 children 1997-2002
• RP9 GERD15
• Increase risk in lt1 year of age
• Owaged AF
• n 2952 children 1987-1997
• RP 8 GERD5

Çiftçi E..J.Trop.Pediatr 2003. 49(4)
212-5 Owaged A.F.Arch.Pediatr.
2000.154(8) 850
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GERD-Pneumonia-Therapy

• Chen P
• n23 children 3-25 months of age
• pH monitoring
• GERD91 Therapy Improvement64

Chen. J. Pediatr. Gastroenterology. Nutr.
199113(1) 16-22
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• GERD leads to Recurrent pneumonia

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GERD-Idiopathic Pulmonary Fibrosis

• 1952
• Rabbit,dog acid inhalation - fibrosis
• Mays EE
• n131 Tracheobronchial aspiration
• n48 Pulmonary fibrosis in x-ray
• GERD 54 Control 8.5
• Tobin RW
• n17 Idiopathic pulmonary fibrosis
  by biopsy
• n8 Interstitiel pulmonary
  disease
• pH monitoring
• Acid reflux in 16/17
• Acid reflux in 4/8 control

Teabeaut J.R.Am.J.Pathol 19522851-62 Glauser
FL. Am.Rev.resp.Dis. 19701261119-23 Mays EE
Chest. 1976 6951-15 Tobin RV.
Am.J.Resp.Crit.Care Med.19981581804-08 Raghu
G.Am.J.Med. 2003 115(3A) 60-64
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GERD-Cough

• Cough 1.Acute 2.Chronic
  3.Recurrent
• Chronic cough duration gt4 weeks in children
  (3-12)
• Chronic cough duration gt8 weeks in adults
• Recurrent cough 2 attacks, more than gt2 weeks
  duration in a year or attacks, 1-3 weeks
  duration in consecutive months
• GERD-Cough
• Non-productive, long duration in the upright
  position

Chang AB Cough 2005 17
Vaezi MF. Clin. Cornerstone GERD 200354 32-36
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GERD-Cough

• Prevalence
• In general 21-41
• Roka R
• n299 GERD()
• Pulmonary symptoms 18 (56/299)
• Chronic cough 75 (42/56)

Poelmans J.Gut 2005541492-99 Roka R.
Digestion 20057(12)92-6
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GERD-Cough-Therapy

• Poe RH
• n183 31 (56/183) GERD-cough
• 43 (25/56)
  GERD-unique cause
• Therapy
• PPI or PPIProkinetic

Poe Rh. Chest 2003123679-84
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GERD-Cough-Therapy

• Chang AB Meta-analysis
• n763 studies
• 11 Randomised controled studies
• Adults 8
• Children 3

n383
Chang AB. BMS 200633211-17
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Results Treatment with PPI is beneficial for
GERD related cough in adult patients.Needs more
studies for children.
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• GERD leads to Chronic Cough

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GERD-Infantile Apnea-ALTE

• Infants respond to laryngeal stimuli as central
  and/or obstructive apnea
• But response in children as cough

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GERD-Infantile Apnea-ALTE

• Mc Guirth WF Meta-analysis
• 1979-2003 99 studies
• 56 studies (Children) in meta-analysis
• Prevalence
• Premature 33-100
• Infant in term 25-100
• Symptoms control 27-100

Mc Guirth WF. Ped.Clin. North Am 200350
487-502
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GERD-Laryngeal Symptoms-Therapy

• El Serag HB
• Placebo controled study
• PPI for 3 months
• Improvement in 50 patients
• Improvement in 10 placebo group

El Serag HB.Am.J.of Gastroenterology2001(96)199
7
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GERD-Otitis Media

• Pepsin/pepsinogen in the middle ear in 73
  children with otitis media
• High pepsin/pepsinogen level in 59/65 patients
  with otitis media
• Improvement, after anti-reflux therapy for 11
  weeks

Judith EC. 2005 Otholaringology 133357-61
Poelmans J. Gut 200554 1492-1499
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Esophagopulmonary and Pharyngolaryngeal Reflux in
Children with Pulmonary Symptoms

• Betül SÖZERI YENIAY, Figen GÜLEN, Sema
  AYDOGDU, Remziye TANAÇ, Levent MIDYAT, Fatih
  ÖGÜT,Tayfun KIRAZLI,Funda ÖZGENÇ, Rasit V.
  YAGCI, Esen DEMIR
• Ege University School of Medicine Division of
  Pediatric Allergy and Pulmonology, Izmir
• Ege University School of Medicine Department
  of Otorhinolaryngology ,Izmir

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AIM

• To evaluate demographic characteristics,
  follow-up and response to the therapy in
  children with GERD

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METHOD

• Outpatients were admitted to Ege University
  School of Medicine Division of Pediatric
  Gastroenterology and Hepatology with pulmonary
  complaints
• Diagnosis of GERD History,scintigraphy,24 hour
  pH monitoring
• Pharyngolaryngeal reflux Otorhinolaryngologic
  examination
• Statistical analysis SPSS 10.0 Meanful
  plt0.05

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Demographic Characteristics

• n134
• Age 59.648.4 months (2months-18years)
• Sex (M/F) 1/1.4
• Weight 50p 60.9
• 3p 4
• Height 50p 53.7
• 3p 3

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• PATIENTS
• In 85.1 (n114) patients- complaints are
  related to respiratory system only
• In 14.9 (n20) patients -additional complaints
  are related to gastrointestinal system

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Complaints of Respiratory System
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Complaints of GIS

• Vomiting (n17)
• Cant gain weight (n2)
• Pyrosis (n1)

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• RESULT
• GERD Leads to Respiratory System Diseases