Chronic cough- Multidiscipline sessionWorkshop: Rotorua GP CME 2016
Dr Alasdair PatrickGastroenterologistMacmurray Center
Dr Julian VyasRespiratory Paediatrician
Starship Hospital
Mr Richard DouglasORL
Gillies Hospital
Dr Alasdair PatrickGastroenterologist
Overview
• Case history of a typical patient
• Respiratory aspects of cough– Dr Julian Vyas
• ORL aspects of cough– Dr Richard Douglas
• Gastroenterology aspects of cough– Dr Alasdair Patrick
• Wrap up– Dr Julian Vyas
Mrs C
• 57 year old European lady with a six month cough– Background history of childhood asthma and
eczema• On no medication for this
– Smoked a packet a day from ages 18-32
– Sinus surgery for recurrent infections aged 38
– Noted to have high blood pressure and mild renal impairment• Started an ACE inhibitor 1 year ago
Mrs C
• Significant weight gain in past 5 years
– Current BMI 32
• Occasional reflux symptoms
– Takes PRN Omeprazole
• What is the cause of her cough?
Julian Vyas
• Put Julian slides in here
Richard Douglas
• Put Richard slides in here
Dr Alasdair Patrick
Gastroenterologist
Symptoms of GORD
• Heartburn– Burning retrosternal painful sensation of short
duration• Poorly understood by patients
– 29.7% think had HB but clinician did not
– 22.8% denied HB but clinician thought had it
– Questionaires may be useful
» Spechler et al APT 2002
• Regurgitation– Retrograde flow gastric contents(bitter taste)
• Without nausea or retching
Extra-oesophgeal symptoms of GORD
Madanick R Gastro Clin NA 2014, 105-120
Extra-oesophgeal symptoms of GORD
• Four key principles from Gastro literature
– An association between GORD and these syndromes exist
– Syndromes are rare in isolation without other reflux symptoms
– Multi-factorial with GORD as one aggravating factor
– Data supporting benefit of anti-reflux therapy is weak
Madanick R Gastro Clin NA 2014, 105-120
Reflux cough syndrome
Madanick R Gastro Clin NA 2014
Diagnosis of EOS- Laryngoscopy
• Accuracy of laryngoscopy uncertain
– 83-93% of normal people have at least 1 sign» Reulbach et al 2001, Hicks et al 2002, Milstein 2005
• Specificity therefore is low
– Inter/Intra rater agreement of findings is low» Branski et al 2002, Eren et al 2013
– 41 patients diagnosed with LPR (RFS & RSI also done)
• OGD, manometry, pH/impedance
– 40% confirmed on gold standard only
» De Bortoli et al WJG 2012 18(32):4363-70
Diagnosis of EOS- Endoscopy
• Value is probably low for the typical patient
– Oesophagitis, Barretts, hiatus hernia
5-30% of LPR patientshave endoscopic abnormalities
-Qua et al APT 2007-de Bortoli et al WJG 2012
PPI challenge
Dent et al Gut 2010;59:714-21
Not a great test for GORD!
More definitive tests to prove GORD
• Established
– pH/Impedance
– BRAVO capsule
• Experimental
– Oropharyngeal pH (REStech)
– Salivary pepsin
pH/Impedance study• Catheter placed via nose to 5cm above LOS
• Measures pH
over 24 hour period
• Event recorder that patient can activate to
correlate symptoms with reflux
– ZepHer
– Digitrapper and Sleuth
Impedanc
eTime
Impedance Contacts
Impedance Technology Fundamentals
Bolus Entry Bolus Exit
Bolus Present
Impedance –pH Catheter
3 cm
5 cm
7 cm
9 cm
15 cm
17 cm
pH - 5 cm
Adult Model6 impedance channels
1 pH channel
20 cm
15 cm
10 cm
5 cm
LES
pH/Impedance
• Advantages
– Detects weak acid/non acid
– Shows direction of bolus
– Detects gas
• Disadvantages
– Uncomfortable• 93% refuse repeat study
– Only 24 hours
– Change lifestyle• 80% off work
Bravo capsule
Bravo advantages
• Increase yield by 50% with 48 hour recording
• >90% carry on with normal activities
• Patients much prefer this option
– 82% would have repeat test (cf 7%)
Diagnosis of EOS- REStech
• Minimally invasive trans-nasal device
– Tear drop shaped tip to maintain moisture saturation from exhaled breath
REStech studies
• 10 patients with chronic cough
– 43.6% of OP reflux episodes were actually swallows on Impedance
Ummarino et al Laryngoscope
123:980-4 2013
REStech studies
• Disparate results
– 30% of refluxate is neutralised by time it reaches upper oesophagus
– Cannot tell what is a swallow
– May not be as accurate at night due to drying of probe (need to exclude sleep?)
• Further studies needed
– Extended criteria
• % drop and lower absolute pH
Mazzoleni et al NGM 2014
Pepsin
• Studies demonstrate damage to pharynx» Samuels et al Otolarng head neck surg 2009
• Pepsin in saliva has been proposed as office based GORD test
Wassenaar et al Surg Endo 2011 25:3870-6
Pepsin
• 111 GORD pts and 100 controls– Impedance and pepsin testing
– 1/3 controls had low level pepsin• If use cut off >210ng/ml
– Sens 44% and spec 96%
• If use cut off >16ng/ml
– Sens 78.6% and spec 64.9%
» Hayat et al Gut 2014
• Small studies suggest sens 94% if done at time of symptoms
» De Bartoli et al Gastro 2013;144:s118
Other possible GI causes of cough:Zenkers diverticulum
• Hernia in Killian triangle– Transverse fibers of crico-pharyngeus and oblique
fibers of inferior
pharyngeal constrictor
– Found in 0.01-0.11%
of population
– Can be a cause of cough• Diagnosed on Barium swallow
» Ferreira et al Dis Eos 2008
Heterotopic gastric mucosa of the proximal oesophagus
Sahin et al Int J of biomed sci 2014; 10(2):129-135
Treatment options for Extra-oesophageal symptoms
• PPI
– Side effects short and long term
• Gabapentin
– GABA agonist
• New options
Madanick R Gastro Clin NA 2014
Gabapentin: Reflux cough syndrome
• Gabapentin in low dose
– Mimic GABA but also works on Ca channels
– RDB PCB on 62 cough patients
• Dose increased from 300mg/day to 1800mg/day– Given for 10 weeks
• Cough specific QOL significantly improved– Side effects in 31%
» Nausea, dizziness, fatigue
Gastroenterologists updatePotential new ways to treat GORD
• Endoscopic or surgical options
– Endocinch
– Stretta
• UES assist device
Device worn when sleeping that applies a standardised external pressure to the cricoid cartilage in order to decrease retrograde reflux of gastroduodenal contents
UES assist device
UES assist device
Summary
• GORD is a cause of chronic cough– Usually they have other reflux symptoms
• Trial a longer course of PPI (2 months)
• pH study useful for diagnosis
• Gabapentin is a new treatment option
Thanks
Dr Alasdair PatrickGastroenterologist
MacMurray Center
