Gastroesophageal reflux disease (
GERD) is a condition that develops when there is reflux of stomach contents, which typically manifests as
heartburn and regurgitation. These esophageal symptoms are well recognized; however, there are extra-esophageal manifestations of
GERD, which include
asthma,
chronic cough,
laryngitis and
sinusitis. With the rising incidence of
asthma, there is increasing interest in identifying how
GERD impacts
asthma development and
therapy. Due to the poor sensitivity of endoscopy and pH monitoring, empiric
therapy with
proton pump inhibitors (PPIs) is now considered the initial diagnostic step in patients suspected of having
GERD-related symptoms. If unresponsive, diagnostic testing with pH monitoring off
therapy and/or impedance/pH monitoring on
therapy, may be reasonable in order to assess for baseline presence of reflux with the former and exclude continued
acid or weakly
acid reflux with the latter tests. PPI-unresponsive asthmatics, without overt regurgitation, usually have either no reflux or causes other than
GERD. In this group, PPI
therapy should be discontinued. In those with
GERD as a contributing factor
acid suppressive
therapy should be continued as well as optimally treating other etiologies requiring concomitant treatment. Surgical
fundoplication is rarely needed but in those with a large
hiatal hernia, moderate-to-severe reflux by pH monitoring surgery might be helpful in eliminating the need for high-dose
acid suppressive
therapy.