Nonacid reflux in patients with chronic cough on acid-suppressive therapy

It is generally accepted that extraesophageal gastroesophageal reflux disease (GERD) symptoms and their persistence despite acid-suppressive therapy are poor prognostic factors for antireflux surgery. Recent studies indicating that cough can be temporally associated with reflux episodes of pH 4 to 7 (ie, nonacid reflux) reinvigorates the need for a more careful workup in patients with cough suspected to be due to GERD.

To evaluate the frequency of chronic cough associated with nonacid reflux and the response of these patients to laparoscopic Nissen fundoplication.

We retrospectively reviewed data from patients with persistent cough despite twice-daily proton pump inhibitor (PPI) with or without the use of nighttime regimens of histamine-2 receptor antagonist (H2RA), who had undergone combined multichannel intraluminal impedance and pH monitoring. The association of cough and reflux was evaluated by calculating the symptom index (SI) [positive if > or = 50%]. A subset of patients with positive SI values for impedance-detected reflux with therapy was referred for laparoscopic Nissen fundoplication.

Of 50 patients (38 female patients; mean age, 43 years; age range, 6 months to 84 years) who were monitored while receiving therapy, 13 patients (26%) had a positive SI for cough. The SI-positive group had a lower percentage of female patients and patients of younger age compared to the SI-negative group. Laparoscopic Nissen fundoplication was performed in six SI-positive patients who became asymptomatic and stopped receiving acid-suppressive therapy during follow-up evaluations (median time, 17 months; range, 12 to 27 months).

Impedance pH monitoring should be performed while receiving therapy in patients with persistent symptoms who are receiving PPI therapy. A positive SI for nonacid reflux may be helpful in selecting patients who will benefit from antireflux surgery.