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Physician Update - Curing the Nonacid Reflux Cough

Physician Update Fall 2009

Curing the Nonacid Reflux Cough

Date: October 15, 2009

John Clarke
John Clarke

The 57-year-old had battled a severe cough accompanied by reflux for five years and had undergone various tests to check for asthma or allergy correlations, all to no avail. When she was referred to gastroenterologist John Clarke, director of esophageal motility at The Johns Hopkins Hospital, he was determined to find the cause of her cough.

What makes chronic coughs so challenging, Clarke says, is that they can be due to anything from asthma and lung disease to gastroesophageal reflux disease or thyroid disorders. After ruling out just about all of these, Clarke was left with the high probability that acid reflux was the underlying culprit.

After four months of acid-suppression treatment didn’t alleviate the patient’s symptoms, Clarke turned to combined pH/impedance, a test that measures the flow, consistency and extent of reflux. The impedance catheter, which contains flow-measuring metal rings, is placed for 24 hours after localization of landmarks by high-resolution esophageal manometry. Unlike standard catheters that measure only pH, the impedance catheter also detects both acid and nonacid reflux.

In Clarke’s patient, the test confirmed the presence of nonacid reflux disease and helped clarify the treatment options: “We either wanted to try to block the reflux with medical therapy,” he says, “or we could do surgery.”

Clarke first chose baclofen, a muscle relaxant commonly used to treat spasticity that’s been shown to decrease the number of daily reflux events (Clarke’s patient was experiencing up to 96 a day.) The downsides are frequent daily administration and side effects that include dizziness and weakness.

After a few weeks, the patient’s cough did improve, and the number of reflux episodes decreased, but she also became chronically tired and weak. Only then did Clarke recommend a Nissen fundoplication to tighten the junction between the sphincter and the stomach—and basically cut off the reflux. Two weeks after the laparoscopic procedure, the patient’s cough began improving significantly.

Though Clarke might have gone straight for surgery, “you want to be as certain as possible,” he says, “that there’s going to be a benefit.” And for that, he credits the pH impedance system:  “Without it, we wouldn’t have gotten the information we needed to recommend surgery.”

Call 410-955-4166 to refer a patient.

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