Extraesophageal

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Apnea

Apnea is a frequently cited extraesophageal manifestation of reflux in infants, but the causal relationship is controversial, despite being examined by multiple investigators. Most episodes of apnea of prematurity occur in the post-prandial period, and likely follow bouts of regurgitation, and yet studies using impedance and monitoring cardiorespiratory events have been contradictory [52], [53]. In 21 infants with a history of intermittent reflux and apnea, 81% of apneic events did not follow episodes of reflux [52]. However, using pH and impedance testing in 22 infants with a history of irregular breathing and reflux, 29.7% (49 of 165) apneic episodes were associated with reflux, though only 22.4% of these were related to acid reflux [53], (Fig. 1) [54]. Apnea related to reflux has been explained on the basis of a laryngeal chemoreflex causing respiratory pauses and laryngospasm [54], but might also be due to prolongation of normal mechanoreceptor-induced glottic closure [55], or to immaturity of pharyngo-esoph-ageal clearance functions.

Otolaryngologic

Gastroesophageal reflux has been associated with several important otolaryngologic manifestations, includ-

Extraesophageal Reflux Symptoms

Fig. 1. Intraluminal impedance and simultaneous pH probe and pneumogram illustrating non-acid reflux: retrograde esophageal bolus passage with sequential decrease of impedance over time at pH > 4. Temporal association with body movement and central breathing irregularity is apparent on the oronasal and chest wall movement sensors. [Wenzl TG (2202) Investigating esophageal reflux with the intraluminal impedance technique. J Pediatr Gastroenterol Nutr 34(3): 261-268]

Fig. 1. Intraluminal impedance and simultaneous pH probe and pneumogram illustrating non-acid reflux: retrograde esophageal bolus passage with sequential decrease of impedance over time at pH > 4. Temporal association with body movement and central breathing irregularity is apparent on the oronasal and chest wall movement sensors. [Wenzl TG (2202) Investigating esophageal reflux with the intraluminal impedance technique. J Pediatr Gastroenterol Nutr 34(3): 261-268]

ing stridor, chronic cough, hoarseness, and "lump in the throat" [56]. Several laryngoscopic and broncho-scopic findings have been described as predictive of reflux. These include post glottic edema, vocal cord edema, nodules, arytenoid edema, tracheal cobble-stoning, and sub-glottic stenosis [57]. Significant associations in adults may be limited to posterior commisure erythema (in 76% of GERD, 0% of normals), vocal cord erythema (in 70% of GERD, 2% of normals), and arytenoid medial wall erythema (in 82% of GERD, 30% of normals) [58]. Airway abnormalities such as tracheomalacia and laryngomalacia are often diagnosed in infants and children with stri-dor, and notably associated with laryngopharyngeal reflux [59], [60], though it is possible that the airway obstruction promotes the reflux. The prevalence of reflux as diagnosed by barium studies and pH metry was 70% in 54 children with laryngotracheomalacia compared with 39% in a control group. Gas reflux episodes with mild acidity have been demonstrated in adults with reflux laryngitis on concurrently performed impedance and pH studies, suggesting a contrast in the quality and quantity of refluxate involved in esophageal and extraesophageal presentations [61]. In 20 adults with laryngitis, a three month open label trial of high dose omeprazole (60 mg/day) resulted in significant improvement in laryngoscopic findings, including in all those patients who had a positive pharyngeal pH study. Symptoms of laryngitis and quality of voice as outcomes did not improve significantly [62]. In 90 of 100 children diagnosed with GERD based on the results of pH metry, the common laryngeal abnormalities were erythema and edema of the posterior laryngeal mucosa, vocal nodules and granulomas. A significant improvement in voice quality and laryngeal status occurred in those with laryngeal abnormalities in response to 12 weeks of anti-reflux therapy [63]. Possible mechanisms underlying these associations are neural reflexes mediated by intraesophageal acid, stimulation of laryngeal chemoreceptors, aspiration, and direct acid related inflammation [64]. Exacerbation of reflux possibly occurs as a consequence of negative intrapleural pressure and altered thoraco-abdominal pressures that allow acid to breach the anti-reflux barrier [65]. In a case-control study, neurologically normal children with GERD were found to be significantly more often affected by sinusitis, laryngitis, asthma, pneumonia, and bronchiectasis, but not by otitis media, than those without GERD [66]. Esophageal clearance was significantly delayed in 89 children with chronic respiratory symptoms when compared with those with primarily gastrointestinal symptoms (n = 83) or mixed symptoms (n = 64) in a study determining the severity of acid reflux by pH metry [67].

Asthma

Asthma and reflux commonly co-exist, but the contributions of each to the pathogenesis and symptoms of the other remain debatable, mainly due to differences in the selection criteria of study participants, and outcome measures evaluated [68]. Adult asthmatics report reflux symptoms more frequently than non-asthmatics, and experience more nocturnal awakening in relation to their late eating habits [69]. Children with asthma experience a high prevalence of reflux [70]—[72], but both are common conditions and thus could be associated by a chance in some children. One recent study described a 75% prevalence of reflux in 36 asthmatic children; reflux episodes were more frequent in upright versus supine positioning, but the overall reflux duration was not significantly different between positions [73]. Nuclear scintigraphy, used to detect clinical correlation between reflux symptoms and asthma episodes in asthmatic children, revealed scintigraphic evidence of reflux in 10 of 26 (38.5%) with GER symptoms, compared with 23 of 100 (23%) children without GER symptoms, but did not provide support for a direct causal effect of reflux on asthma [74]. A randomized controlled trial, rare in pediatric reflux-respiratory disease literature, evaluated asthma outcome in 37 children (10-20 years old, mean 14 years), using ranitidine for only four weeks as the intervention. A positive outcome was reported for nocturnal asthma symptoms but not for pulmonary functions [75]. Proposed mechanisms for reflux-induced asthma symptoms are acid-stimulated vagal nerve afferents triggering bron-chospasm, or aspiration of gastric contents.

Dental erosions

A limited number of studies have examined the role of acid reflux in producing dental erosions in children [76], [77]. In 37 children evaluated for GERD, 20 of them were identified to have dental erosions, and all of them also had an endoscopic diagnosis of GERD [77]. As in adults, dental erosions in association with acid reflux affect the posterior dentition along the lingual surfaces. Ingestion of acidic (juices) and caffeinated beverages, consumption of ascorbic acid, and poor oral hygiene are other contributory factors.

Sandifer's syndrome

Sandifer's syndrome is characterized by hyperextended posturing involving the head, neck and upper torso. Originally the syndrome was thought to be a manifestation of reflux accompanied by hiatal herniation, but subsequent reports have identified cases in children without a diagnosis of a hiatal hernia [78], [79]. Many of these children are also diagnosed to have a neurological disorder. The majority of children with Sandifer's syndrome respond well to anti-reflux therapy.

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Herbal Remedies For Acid Reflux

Herbal Remedies For Acid Reflux

Gastroesophageal reflux disease is the medical term for what we know as acid reflux. Acid reflux occurs when the stomach releases its liquid back into the esophagus, causing inflammation and damage to the esophageal lining. The regurgitated acid most often consists of a few compoundsbr acid, bile, and pepsin.

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