Asthma and gastroesophageal reflux: Difference between revisions

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# '''Vagal reflex:''' Both the esophagus and the bronchial tree are innervated by [[vagus nerve]] as they both share a common embryonic origin. Therefore when there is reflux of acid contents from the stomach into the esophagus, the receptors in esophagus are stimulated causing firing of vagus nerve which results in bronchospasm. This phenomenon was demonstrated by Mansfield and Stein by intraesophageal acid provocation test resulting in increased resistance to airflow<ref name="pmid707849">{{cite journal| author=Mansfield LE, Stein MR| title=Gastroesophageal reflux and asthma: a possible reflex mechanism. | journal=Ann Allergy | year= 1978 | volume= 41 | issue= 4 | pages= 224-6 | pmid=707849 | doi= | pmc= | url= }} </ref> and further strengthened by another series involving 136 subjects<ref name="pmid2344943">{{cite journal| author=Wright RA, Miller SA, Corsello BF| title=Acid-induced esophagobronchial-cardiac reflexes in humans. | journal=Gastroenterology | year= 1990 | volume= 99 | issue= 1 | pages= 71-3 | pmid=2344943 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2344943  }} </ref>. However, many studies failed to demonstrate a significant relationship between acid reflux and pulmonary function<ref name="pmid10084501">{{cite journal| author=Field SK| title=A critical review of the studies of the effects of simulated or real gastroesophageal reflux on pulmonary function in asthmatic adults. | journal=Chest | year= 1999 | volume= 115 | issue= 3 | pages= 848-56 | pmid=10084501 | doi= | pmc= | url= }} </ref><ref name="pmid2350084">{{cite journal| author=Tan WC, Martin RJ, Pandey R, Ballard RD| title=Effects of spontaneous and simulated gastroesophageal reflux on sleeping asthmatics. | journal=Am Rev Respir Dis | year= 1990 | volume= 141 | issue= 6 | pages= 1394-9 | pmid=2350084 | doi= | pmc= | url= }} </ref>.
# '''Vagal reflex:''' Both the esophagus and the bronchial tree are innervated by [[vagus nerve]] as they both share a common embryonic origin. Therefore when there is reflux of acid contents from the stomach into the esophagus, the receptors in esophagus are stimulated causing firing of vagus nerve which results in bronchospasm. This phenomenon was demonstrated by Mansfield and Stein by intraesophageal acid provocation test resulting in increased resistance to airflow<ref name="pmid707849">{{cite journal| author=Mansfield LE, Stein MR| title=Gastroesophageal reflux and asthma: a possible reflex mechanism. | journal=Ann Allergy | year= 1978 | volume= 41 | issue= 4 | pages= 224-6 | pmid=707849 | doi= | pmc= | url= }} </ref> and further strengthened by another series involving 136 subjects<ref name="pmid2344943">{{cite journal| author=Wright RA, Miller SA, Corsello BF| title=Acid-induced esophagobronchial-cardiac reflexes in humans. | journal=Gastroenterology | year= 1990 | volume= 99 | issue= 1 | pages= 71-3 | pmid=2344943 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2344943  }} </ref>. However, many studies failed to demonstrate a significant relationship between acid reflux and pulmonary function<ref name="pmid10084501">{{cite journal| author=Field SK| title=A critical review of the studies of the effects of simulated or real gastroesophageal reflux on pulmonary function in asthmatic adults. | journal=Chest | year= 1999 | volume= 115 | issue= 3 | pages= 848-56 | pmid=10084501 | doi= | pmc= | url= }} </ref><ref name="pmid2350084">{{cite journal| author=Tan WC, Martin RJ, Pandey R, Ballard RD| title=Effects of spontaneous and simulated gastroesophageal reflux on sleeping asthmatics. | journal=Am Rev Respir Dis | year= 1990 | volume= 141 | issue= 6 | pages= 1394-9 | pmid=2350084 | doi= | pmc= | url= }} </ref>.
#'''Heightened Bronchial Reactivity:''' Acid reflux into esophagus, increases the bronchial response to other stimuli. This was demonstrated by increased bronchial response to methacholine challenge test<ref name="pmid3096180">{{cite journal| author=Herve P, Denjean A, Jian R, Simonneau G, Duroux P| title=Intraesophageal perfusion of acid increases the bronchomotor response to methacholine and to isocapnic hyperventilation in asthmatic subjects. | journal=Am Rev Respir Dis | year= 1986 | volume= 134 | issue= 5 | pages= 986-9 | pmid=3096180 | doi= | pmc= | url= }} </ref>.
#'''Heightened Bronchial Reactivity:''' Acid reflux into esophagus, increases the bronchial response to other stimuli. This was demonstrated by increased bronchial response to methacholine challenge test<ref name="pmid3096180">{{cite journal| author=Herve P, Denjean A, Jian R, Simonneau G, Duroux P| title=Intraesophageal perfusion of acid increases the bronchomotor response to methacholine and to isocapnic hyperventilation in asthmatic subjects. | journal=Am Rev Respir Dis | year= 1986 | volume= 134 | issue= 5 | pages= 986-9 | pmid=3096180 | doi= | pmc= | url= }} </ref>.
#'''Microaspiration:''' Microaspiration of acidic contents from stomach into the upper airways and bronchial tree was shown to stimulate bronchial receptors resulting in broncho-constriction in asthmatic patients<ref name="pmid7701464">{{cite journal| author=Jack CI, Calverley PM, Donnelly RJ, Tran J, Russell G, Hind CR et al.| title=Simultaneous tracheal and oesophageal pH measurements in asthmatic patients with gastro-oesophageal reflux. | journal=Thorax | year= 1995 | volume= 50 | issue= 2 | pages= 201-4 | pmid=7701464 | doi= | pmc=PMC473925 | url= }} </ref>. An animal study demonstrated that microaspiration of gastric contents caused immune response similar to that observed in asthma<ref name="pmid18717828">{{cite journal| author=Barbas AS, Downing TE, Balsara KR, Tan HE, Rubinstein GJ, Holzknecht ZE et al.| title=Chronic aspiration shifts the immune response from Th1 to Th2 in a murine model of asthma. | journal=Eur J Clin Invest | year= 2008 | volume= 38 | issue= 8 | pages= 596-602 | pmid=18717828 | doi=10.1111/j.1365-2362.2008.01976.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18717828  }} </ref>. However, a prospective single blinded study failed to demonstrate any significant bronchoconstriction with acid reflux into the airways<ref name="pmid7587420">{{cite journal| author=Harding SM, Schan CA, Guzzo MR, Alexander RW, Bradley LA, Richter JE| title=Gastroesophageal reflux-induced bronchoconstriction. Is microaspiration a factor? | journal=Chest | year= 1995 | volume= 108 | issue= 5 | pages= 1220-7 | pmid=7587420 | doi= | pmc= | url= }} </ref>.
#'''Microaspiration:''' Microaspiration of acidic contents from stomach into the upper airways and bronchial tree was shown to stimulate bronchial receptors resulting in broncho-constriction in asthmatic patients<ref name="pmid7701464">{{cite journal| author=Jack CI, Calverley PM, Donnelly RJ, Tran J, Russell G, Hind CR et al.| title=Simultaneous tracheal and oesophageal pH measurements in asthmatic patients with gastro-oesophageal reflux. | journal=Thorax | year= 1995 | volume= 50 | issue= 2 | pages= 201-4 | pmid=7701464 | doi= | pmc=PMC473925 | url= }} </ref>. A murine study demonstrated that microaspiration of gastric contents caused immune response similar to that observed in asthma<ref name="pmid18717828">{{cite journal| author=Barbas AS, Downing TE, Balsara KR, Tan HE, Rubinstein GJ, Holzknecht ZE et al.| title=Chronic aspiration shifts the immune response from Th1 to Th2 in a murine model of asthma. | journal=Eur J Clin Invest | year= 2008 | volume= 38 | issue= 8 | pages= 596-602 | pmid=18717828 | doi=10.1111/j.1365-2362.2008.01976.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18717828  }} </ref>. However, a prospective single blinded study failed to demonstrate any significant bronchoconstriction with acid reflux into the airways<ref name="pmid7587420">{{cite journal| author=Harding SM, Schan CA, Guzzo MR, Alexander RW, Bradley LA, Richter JE| title=Gastroesophageal reflux-induced bronchoconstriction. Is microaspiration a factor? | journal=Chest | year= 1995 | volume= 108 | issue= 5 | pages= 1220-7 | pmid=7587420 | doi= | pmc= | url= }} </ref>.


==Epidemiology and Demographics==
[[GERD]] is commonly seen among patients with asthma. The prevalence ranges between 34%-89% as reported by various studies<ref name="pmid9149599">{{cite journal| author=Harding SM, Richter JE| title=The role of gastroesophageal reflux in chronic cough and asthma. | journal=Chest | year= 1997 | volume= 111 | issue= 5 | pages= 1389-402 | pmid=9149599 | doi= | pmc= | url= }} </ref><ref name="pmid15579368">{{cite journal| author=Harding SM| title=Gastroesophageal reflux: a potential asthma trigger. | journal=Immunol Allergy Clin North Am | year= 2005 | volume= 25 | issue= 1 | pages= 131-48 | pmid=15579368 | doi=10.1016/j.iac.2004.09.006 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15579368  }} </ref><ref name="pmid15539717">{{cite journal| author=Kiljander TO, Laitinen JO| title=The prevalence of gastroesophageal reflux disease in adult asthmatics. | journal=Chest | year= 2004 | volume= 126 | issue= 5 | pages= 1490-4 | pmid=15539717 | doi=10.1378/chest.126.5.1490 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15539717  }} </ref><ref name="pmid8620699">{{cite journal| author=Field SK, Underwood M, Brant R, Cowie RL| title=Prevalence of gastroesophageal reflux symptoms in asthma. | journal=Chest | year= 1996 | volume= 109 | issue= 2 | pages= 316-22 | pmid=8620699 | doi= | pmc= | url= }} </ref><ref name="pmid10513887">{{cite journal| author=Harding SM| title=Nocturnal asthma: role of nocturnal gastroesophageal reflux. | journal=Chronobiol Int | year= 1999 | volume= 16 | issue= 5 | pages= 641-62 | pmid=10513887 | doi= | pmc= | url= }} </ref>.
==Diagnosis==
===History and Symptoms===
*[[Chest pain]]
*Coughing in supine position
*[[Dyspnea]]
*[[Heartburn]]
*[[Hoarseness]]
*Loss of dental enamel
*Regurgitation of foods/liquids
*Sensation of lump in throat
*[[Sore throat]]
*Water Brash (regurgitation of excessive saliva)
===Physical
==References==
==References==
{{reflist|2}}
{{reflist|2}}

Revision as of 16:05, 29 September 2011

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Varun Kumar, M.B.B.S. [2]

Overview

The underlying gastro-esophageal reflux disease predisposes the patient to have repetitive episodes of acid aspiration, which subsequently causes repeated airway inflammation and results in irritant-induced asthma.[1][2] The incidence of GERD in patients with asthma is approximately 38%. Asthmatics resistant to therapy are commonly associated with GERD, but identification and treatment of GERD has not shown to relate to the improvement in asthmatic control.[3]

Pathophysiology

There are three mechanisms proposed to explain the pathophysiology of development of asthma in patients with GERD:

  1. Vagal reflex: Both the esophagus and the bronchial tree are innervated by vagus nerve as they both share a common embryonic origin. Therefore when there is reflux of acid contents from the stomach into the esophagus, the receptors in esophagus are stimulated causing firing of vagus nerve which results in bronchospasm. This phenomenon was demonstrated by Mansfield and Stein by intraesophageal acid provocation test resulting in increased resistance to airflow[4] and further strengthened by another series involving 136 subjects[5]. However, many studies failed to demonstrate a significant relationship between acid reflux and pulmonary function[6][7].
  2. Heightened Bronchial Reactivity: Acid reflux into esophagus, increases the bronchial response to other stimuli. This was demonstrated by increased bronchial response to methacholine challenge test[8].
  3. Microaspiration: Microaspiration of acidic contents from stomach into the upper airways and bronchial tree was shown to stimulate bronchial receptors resulting in broncho-constriction in asthmatic patients[9]. A murine study demonstrated that microaspiration of gastric contents caused immune response similar to that observed in asthma[10]. However, a prospective single blinded study failed to demonstrate any significant bronchoconstriction with acid reflux into the airways[11].

Epidemiology and Demographics

GERD is commonly seen among patients with asthma. The prevalence ranges between 34%-89% as reported by various studies[12][13][14][15][16].

Diagnosis

History and Symptoms

===Physical

References

  1. ↑ Cuevas Hernández MM, Arias Hernández RM (2008) [Pulmonary gammagraphy study in asthmatic children with gastroesophageal reflux.] Rev Alerg Mex 55 (6):229-33. PMID: 19157219
  2. ↑ Shapiro GG, Christie DL (1983) Gastroesophageal reflux and asthma. Clin Rev Allergy 1 (1):39-56. PMID: 6142759
  3. ↑ Leggett JJ, Johnston BT, Mills M, Gamble J, Heaney LG (2005) Prevalence of gastroesophageal reflux in difficult asthma: relationship to asthma outcome. Chest 127 (4):1227-31. DOI:10.1378/chest.127.4.1227 PMID: 15821199
  4. ↑ Mansfield LE, Stein MR (1978). "Gastroesophageal reflux and asthma: a possible reflex mechanism". Ann Allergy. 41 (4): 224–6. PMID 707849.
  5. ↑ Wright RA, Miller SA, Corsello BF (1990). "Acid-induced esophagobronchial-cardiac reflexes in humans". Gastroenterology. 99 (1): 71–3. PMID 2344943.
  6. ↑ Field SK (1999). "A critical review of the studies of the effects of simulated or real gastroesophageal reflux on pulmonary function in asthmatic adults". Chest. 115 (3): 848–56. PMID 10084501.
  7. ↑ Tan WC, Martin RJ, Pandey R, Ballard RD (1990). "Effects of spontaneous and simulated gastroesophageal reflux on sleeping asthmatics". Am Rev Respir Dis. 141 (6): 1394–9. PMID 2350084.
  8. ↑ Herve P, Denjean A, Jian R, Simonneau G, Duroux P (1986). "Intraesophageal perfusion of acid increases the bronchomotor response to methacholine and to isocapnic hyperventilation in asthmatic subjects". Am Rev Respir Dis. 134 (5): 986–9. PMID 3096180.
  9. ↑ Jack CI, Calverley PM, Donnelly RJ, Tran J, Russell G, Hind CR; et al. (1995). "Simultaneous tracheal and oesophageal pH measurements in asthmatic patients with gastro-oesophageal reflux". Thorax. 50 (2): 201–4. PMC 473925. PMID 7701464.
  10. ↑ Barbas AS, Downing TE, Balsara KR, Tan HE, Rubinstein GJ, Holzknecht ZE; et al. (2008). "Chronic aspiration shifts the immune response from Th1 to Th2 in a murine model of asthma". Eur J Clin Invest. 38 (8): 596–602. doi:10.1111/j.1365-2362.2008.01976.x. PMID 18717828.
  11. ↑ Harding SM, Schan CA, Guzzo MR, Alexander RW, Bradley LA, Richter JE (1995). "Gastroesophageal reflux-induced bronchoconstriction. Is microaspiration a factor?". Chest. 108 (5): 1220–7. PMID 7587420.
  12. ↑ Harding SM, Richter JE (1997). "The role of gastroesophageal reflux in chronic cough and asthma". Chest. 111 (5): 1389–402. PMID 9149599.
  13. ↑ Harding SM (2005). "Gastroesophageal reflux: a potential asthma trigger". Immunol Allergy Clin North Am. 25 (1): 131–48. doi:10.1016/j.iac.2004.09.006. PMID 15579368.
  14. ↑ Kiljander TO, Laitinen JO (2004). "The prevalence of gastroesophageal reflux disease in adult asthmatics". Chest. 126 (5): 1490–4. doi:10.1378/chest.126.5.1490. PMID 15539717.
  15. ↑ Field SK, Underwood M, Brant R, Cowie RL (1996). "Prevalence of gastroesophageal reflux symptoms in asthma". Chest. 109 (2): 316–22. PMID 8620699.
  16. ↑ Harding SM (1999). "Nocturnal asthma: role of nocturnal gastroesophageal reflux". Chronobiol Int. 16 (5): 641–62. PMID 10513887.

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