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Invited Commentary |

Antireflux Surgery, a Cough Medicine Difficult to Swallow for Most Physicians Comment on “Antireflux Surgery in Patients With Chronic Cough and Abnormal Proximal Exposure as Measured by Hypopharyngeal Multichannel Intraluminal Impedance”

Marco G. Patti, MD1
[+] Author Affiliations
1Center for Esophageal Diseases, University of Chicago Pritzker School of Medicine, Chicago, Illinois
JAMA Surg. 2013;148(7):615-616. doi:10.1001/jamasurg.2013.1387.
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This study by Hoppo and colleagues1 stresses many important aspects of the diagnosis and treatment of patients with chronic cough of unknown origin.

  • Some of these patients have abnormal proximal reflux of gastric contents.

  • For some of these patients cough is the primary symptom, and they do not experience typical symptoms of gastroesophageal reflux disease, such as heartburn or regurgitation. Therefore, testing for reflux is of paramount importance to detect abnormal proximal reflux and establish an association between symptoms and episodes of reflux.

  • Although an empirical trial with proton pump inhibitors is the initial approach followed by most primary physicians, it is mostly useless since it fails in most patients from both a diagnostic and therapeutic point of view.

  • Conventional pH testing may fail to detect the proximal extent of the refluxate when it is weakly acid or nonacid. Hypopharyngeal multichannel intraluminal impedance is the most sensitive test available today.

  • Once a cause-and-effect relationship between reflux and respiratory symptoms has been established, antireflux surgery should be the primary form of treatment. Impedance technology has in fact shown that proton pump inhibitors just change the pH of the gastric refluxate, but reflux still occurs through an incompetent lower esophageal sphincter. As shown in this study in a highly selected group, a properly performed fundoplication stops instead any type of reflux, resolving or improving symptoms in most patients.

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