Jeannette Y. Wick, RPh, MBA, FASCP
Extrasophageal symptoms of acid reflux can confound diagnosis as they are very different from those that occur in and around the esophagus.
Acid reflux typically causes heartburn and regurgitation, symptoms that occur in and around the esophagus. Some patients, however, develop extraesophageal symptoms mediated by either direct (aspiration) or indirect (vagally-mediated) mechanisms. Symptoms for these patients can be far different from the typical presentation and often confound diagnosis. A review
published online on March 22, 2012, in Swiss Medical Weekly
concisely summarizes the extraesophageal manifestations of acid reflux, reminding clinicians that common diagnostic tests are less useful when dealing with these syndromes.
The review’s authors describe 4 extraesophageal manifestations as they present in patients who have acid reflux: chronic cough, laryngitis, asthma, and non-cardiac chest pain.
The most frequent causes of chronic cough in non-smoking patients are post-nasal drip, asthma, and acid reflux. These patients frequently have atypical presentations; their cough may occur during the day, while talking or when in an upright position—and with no endoscopic findings.
Acid reflux also causes laryngitis that resembles that caused by post-nasal drip and exposure to allergens. Laryngeal erythema and swelling accompanied by hoarseness, a sore or burning throat, frequent throat clearing, a “lump in the throat” feeling, cough, spasm, or post-nasal drip is often induced by acid reflux.
Asthma and acid reflux can each induce the other. Acid reflux tends to cause asthma either by aspiration or vagally-mediated mechanisms. Asthma can cause acid reflux by several mechanisms, including by medication-induced lowered esophageal sphincter pressure. Theophylline, steroids, and beta-agonists have all been implicated.
When non-cardiac chest pain is present, acid reflux is always a likely cause. Cardiac and esophageal chest pain are often burning, pressure-like, substernal, or exercise-induced or exacerbated. Acid reflux is the most likely cause if cardiac origins have been ruled out and chest pain occurs after meals, lasts for hours, is retrosternal without radiation, is diminished after antacids, or disturbs the patient’s sleep. Acid reflux patients often have no esophageal scarring, making endoscopy less useful.
The authors report that prescribing empiric therapy with proton pump inhibitors (PPIs) after ruling out other possible causes of these manifestations can help diagnose and treat acid reflux–related symptoms. Additionally, they report that empiric therapy with PPIs is less costly than traditional diagnostics, including ambulatory pH or impedance monitoring and esophageal motility testing, and can save $454 per patient under appropriate conditions.
Ms. Wick is a visiting professor at the University of Connecticut School of Pharmacy and a freelance writer from Virginia.