Chest
Volume 106, Issue 6, December 1994, Pages 1793-1796
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Clinical Investigations: Miscellaneous: Articles
Frequency and Site of Gastroesophageal Reflux in Patients With Chest Symptoms: Studies Using Proximal and Distal pH Monitoring

https://doi.org/10.1378/chest.106.6.1793Get rights and content

Prolonged ambulatory pH monitoring was performed on 89 patients with previous diagnosis of asthma (27 patients), chronic cough (28 patients), noncardiac chest pain (34 patients), and on 27 healthy control subjects. The extent of gastroesophageal reflux (GER) was determined using a catheter containing two antimony pH electrodes positioned 5 cm and 20 cm above the superior border of the manometrically determined lower esophageal sphincter. Reflux was defined as a drop in pH to <4 in the distal esophagus. We compared both pH <4 and pH <5 as the beginning of reflux episodes for the proximal esophagus. Considering the confidence interval of 95% in healthy control subjects as a normality criterion, we found a prevalence of abnormal distal GER in 44% of asthmatics, 50% of patients with cough, and 53.8% of patients with noncardiac chest pain. Abnormal proximal acid exposure was found in 24% of asthmatics, 10.7% of patients with cough and 44.1% of patients with chest pain. Distal acid exposure was significantly longer than proximal esophageal acid exposure in all patient groups (p<0.05). There were no differences in the evaluation of proximal GER comparing pH <4 with pH <5. The data also indicate a tendency toward upright, rather than supine acid exposure. These results support the use of 24-h pH monitoring in patients with chest complaints and indicate that GER may frequently be involved in the pathogenesis. They do not support the theory that proximal GER is a specific etiologic factor in chronic cough or asthma.

Section snippets

Patients

We studied 87 patients referred to the esophageal diagnostic laboratory for evaluation of possible GER associated with asthma (25 patients; 9 male/16 female; mean age, 54 years), chronic cough (28 patients; 10 male/18 female; mean age, 58 years), noncardiac chest pain (34 patients; 15 female/19 male; mean age, 50 years), and compared the results with those obtained in asymptomatic volunteers (27 subjects; 13 male/14 female; mean age, 30 years). All patients with the diagnosis of chest pain had

RESULTS

Figures 1 and 2 illustrate the percent time pH <4.0 at the distal and proximal pH electrodes for all groups during the total study. Median values and quartiles for percent time pH <4 distally (upright, supine, and total) and proximally (total) for all groups are contained in Table 1. All groups showed a statistically significant (p<0.01) longer percent time of acid exposure in the distal esophagus than in the proximal esophagus. All patient groups showed a significant (p<0.01) increase in

DISCUSSION

The effects of refluxed gastric contents may extend beyond the esophagus itself, and may include a number of remote manifestations through anatomic or neural connections to the esophagus.23,31,33 Often termed the “extraesophageal” or atypical manifestations of GER disease, these include asthma, chronic cough, and noncardiac chest pain.8,33

The mechanisms by which GER might precipitate asthma, cough, or substernal chest pain have not been fully clarified. Experimental studies have suggested that

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