Gastroesophageal Reflux Disease

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Various associations between asthma and gastroesophageal reflux disease (GERD) have been elucidated in recent clinical investigations: The prevalence of GERD in people with asthma is generally higher than in people without asthma. Patients who have asthma with GERD have a higher risk of hospitalization for asthma symptoms. Asthma medications such as albuterol decrease lower esophageal sphincter pressure and esophageal contraction amplitude, while oral prednisone results in increased esophageal acid contact times, and respiratory symptoms correlate with esophageal acid introduction events.8 These findings suggest the possibility of asthma medications acting as promoting factors in the development of GERD in patients with asthma. It is estimated that incidence of GERD in children with asthma reaches nearly 50%-60% and is higher than in the general population.9 This is not a newly discovered association; however, many studies are underway to determine the relationships between asthma and GERD because it is not clearly known which is the cause and which is the result. Several hypotheses surrounding the GERD-asthma connection focus on how GERD can lead to bronchial obstruction and how obstruction can exacerbate GERD. The esophagus and lungs interact by way of various mechanisms; esophageal acid-induced bronchospasm may be provoked by a vagally mediated reflex in which distal esophageal acid causes airway reactivity; by neural enhancement of bronchial reactivity, whereby esophageal acid augments airway hyper-responsiveness; and by microaspiration, in which miniscule amounts of esophageal acid are inhaled, leading to airway reactivity.10 Possibilities that asthma may predispose patients to GERD include autonomic dysregulation, an increased pressure gradient between the thorax and abdomen, bronchodilator medications, hiatal hernia, and abnormalities in diaphragm function. Clinical trials utilizing antireflux medical therapy (e.g., histamine-2 receptor antagonists) have been largely inconclusive, producing no benefit to only modest reduction of only nocturnal asthma symptoms.11 Other studies that have investigated the use of proton-pump inhibitors and antireflux surgery are currently in progress. Despite the mixed results from these studies, the medical literature is flush with studies that demonstrate a definite link between GERD and asthma. Treating asthma with H-2 blockers and proton-pump inhibitor medications brings to light the possibility of leaving patients with inadequate amounts of digestive acid to properly break food proteins down, potentially leading to increased allergenicity of foods and decreased nutrient absorption.12

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