Gastro oesophageal reflux

Gastro-oesophageal reflux in bronchiectasis

Gastro-oesophageal reflux (GOR) is the retrograde flow of gastric contents into the oesophagus (Fig. 1). This often occurs commonly after meals and episodes are brief, clear quickly and are well tolerated.
Fig. 1 Gastro-oesophageal reflux into the oesophagus

However, pathological GOR or GORD (GOR disease) develops when the reflux of gastric contents results in troublesome symptoms and/or complications, with episodes occurring more frequently (Howard 2014, DeMeester 1989). Troublesome symptoms may be classed as typical or atypical and are outlined in Box 1.

A diagnosis of GORD may be linked to severe oesophageal complications (e.g. oesophagitis, oesophageal varices or strictures, Barrett’s oesophagus and oesophageal adenocarcinoma), reported in a medical history.

Box 1. Typical and atypical symptoms of GORD
Typical symptomsAtypical symptoms
HeartburnChronic cough
Acid regurgitationEar, nose and throat symptoms (Laryngitis)
Epigastric painChest pain (non-cardiac)

Source: Howard 2014, Ing 1994

Diagnosis of GORD

Diagnosis of GORD is often made from the presence of typical or atypical symptoms.

Questionnaires to identify symptoms of GORD are also available. There are several options to select from:

Structured symptom questionnaire (Carlsson 1998)

Reflux Disease Questionnaire (Shaw 2008)

Mayo Clinic GER questionnaire (Locke et al 1994)

Hull Airway Reflux questionnaire (HARQ) (Belafsky et al 2002)

They may be of limited value in individuals who present with asymptomatic (clinically silent) GORD.

Some patients with typical or atypical symptoms may be prescribed anti-reflux medication. Improvement or a resolution in symptoms, with a trial of therapy, is suggestive of a diagnosis of GORD.

To diagnose GORD, ambulatory 24hr oesophageal pH monitoring may be undertaken, which measures the pH of the lower and upper oesophagus (DeMeester 1980, DeMeester 1989).

Other tests which may be applied are:

oesophageal endoscopy, used to identify oesophageal mucosal injury and oesophagitis

barium swallow, which detects abnormalities in the digestive tract.

Prevalence of GOR in adults and children with bronchiectasis.

GORD may be a co-morbidity in 26% to up to 40% of adults with mild to severe bronchiectasis and may be more common in those with very severe bronchiectasis (Lee 2014). It may be a cause of bronchiectasis or may exacerbate respiratory symptoms in some people, but its effect on lung function is unclear. GORD may be confined to the lower oesophagus or may reach the upper oesophagus. Clinically silent (asymptomatic) GORD may be present in 42% to up to 73% of individuals.

Physiotherapy Implications
As part of assessment, to evaluate GORD, the following should be included:

Enquiry about the presence of typical symptoms of GORD (both after meals and in between meals) or the presence of wheezing or coughing after meals. This may be important for patients demonstrating a decline in lung function which is not believed to be linked to exacerbations or other causes.

Questionnaires to evaluate symptoms and their severity may direct the need for further evaluation of GORD.

For any patient suspected of GORD or presenting with symptoms, this information should be conveyed to their treating physician for potential referral to a gastroenterologist if necessary.

Airway clearance therapy

For those prescribed PEP therapy, this technique (including coughing) does not exacerbate GORD (Lee 2012).

As gravity-assisted drainage (GAD) has been a trigger for GORD in other respiratory diseases (Button 1997, Ledson 1998, Button 2003), any patient prescribed this technique should be assessed for any symptoms of GORD.

For those who may not be symptomatic, a physiotherapist should enquiry about atypical symptoms (wheezing, excess coughing) in the GAD position or immediately after completing the technique

Irrespective of symptoms, ACT should not be undertaken immediately following meals (they should be completed either prior to meals or at least 1 hr following meals).

Although exercise is not considered to be a trigger for GORD (Lee 2012), a physiotherapist should enquire about the presence of any symptoms with respect to activity and exercise. Patients may be advised to avoid exercise if experiencing symptoms or to treat their symptoms with short-term antacid therapy prior to continuing with activity. Alternatively, avoiding exercise or downward dog yoga poses 2 hours before sleeping and minimizing stress can also be helpful.
Medical therapy

Current therapy for GORD focuses on modifying risk factors and inhibiting the production of gastric acid (Katz 2013, Dore 2008).

Lifestyle changes:

Avoid potential dietary triggers (e.g. caffeine, chocolate, spicy food) and meals approximately 2 hrs before lying down.

Other triggers may be butter, whole milk, creamed foods, citrus fruits and juices and carbonated beverages.

Those with nocturnal symptoms may benefit from elevating the head of the bed. This may be important to reinforce in those diagnosed with GORD.

Medications which may be prescribed:

Antacids (short term symptom relief)

Proton pump inhibitors (PPIs), such as Omeprazole, Esomeprazole and Pantoprazole

Histamine antagonists (Ranitidine)

Surgery (Nissen Fundoplication) for uncontrolled, severe reflux not amenable to medication