Irwin R S, French C L, Curley F J, Zawacki J K, Bennett F M
Department of Medicine, University of Massachusetts Medical School, Worcester.
Chest. 1993 Nov;104(5):1511-7. doi: 10.1378/chest.104.5.1511.
Gastroesophageal reflux (GER) is a common cause of chronic cough. Moreover, chronic cough can be the sole presenting manifestation of GER disease (GERD). It has been suggested recently that GER most often causes chronic cough by stimulating the distal esophagus. To gain further diagnostic and pathophysiologic knowledge, we prospectively evaluated a group of patients with chronic cough likely to be due to GER with extensive gastrointestinal and respiratory studies and then observed their response to antireflux therapy.
We prospectively characterized 12 subjects whose chronic cough was likely to be due to GER by chest radiographs, barium esophagography, 24-h esophageal pH monitoring (EPM) with probes in the distal and proximal esophagus, esophagoscopy, and bronchoscopy. Then, prior to instituting antireflux therapy, we objectively counted coughs during the distal esophageal infusion of 0.1 N HCl or 0.9 percent saline solution administered in a randomized, double-blind, standardized fashion (ie, Bernstein acid-perfusion test).
Gastroesophageal reflux was determined to cause cough in all subjects based on disappearance of cough with antireflux therapy. It was clinically "silent" in 75 percent. The EPM was the test most frequently abnormal (sensitivity, 92 percent). Distal esophageal data revealed that 10 of 12 subjects had GER-induced coughs (12 +/- 12) while only 7 of 12 had an abnormal esophageal pH conventional parameter (eg, percent time pH < 4). Compared with the distal esophagus, GER to the proximal esophagus occurred (p = 0.017) and induced cough (p = 0.004) less often. Compared with baseline (9.3 +/- 17.6), there were no differences in coughs induced by the infusion of saline solution (9.2 +/- 15.9) or acid (15.1 +/- 26.7); the number of coughs induced by acid was negatively correlated with distal esophageal acid-GER events during EPM (r = -0.64, p = 0.01). Neither bronchoscopy nor chest radiographs were consistent with aspiration.
There is a clinical profile that prospectively predicts which patients have chronic cough due to GER. The cough was most likely due to stimulation of the distal esophagus, not aspiration. Intraesophageal acid is unlikely to be the sole mediator in gastric juice causing the cough. While EPM is the single most helpful diagnostic test, conventionally utilized diagnostic indices of GERD can be misleadingly normal; observing GER-induced coughs is more frequently helpful.
胃食管反流（GER）是慢性咳嗽的常见原因。此外，慢性咳嗽可能是胃食管反流病（GERD）的唯一表现。最近有人提出，GER最常通过刺激食管远端引起慢性咳嗽。为了获得更多的诊断和病理生理学知识，我们对一组可能因GER导致慢性咳嗽的患者进行了前瞻性评估，进行了广泛的胃肠道和呼吸方面的研究，然后观察他们对抗反流治疗的反应。
我们通过胸部X线片、食管钡餐造影、使用置于食管远端和近端的探头进行24小时食管pH监测（EPM）、食管镜检查和支气管镜检查，对12名慢性咳嗽可能由GER引起的受试者进行了前瞻性特征分析。然后，在开始抗反流治疗之前，我们以随机、双盲、标准化的方式（即伯恩斯坦酸灌注试验），在食管远端注入0.1N盐酸或0.9%盐水溶液期间客观计数咳嗽次数。
根据抗反流治疗后咳嗽消失，确定所有受试者的胃食管反流均导致咳嗽。其中75%在临床上为“隐匿性”。EPM是最常出现异常的检查（敏感性为92%）。食管远端数据显示，12名受试者中有10名有GER诱发的咳嗽（12±12次），而12名受试者中只有7名食管pH的传统参数异常（如pH<4的时间百分比）。与食管远端相比，GER发生至食管近端的情况较少（p = 0.017），诱发咳嗽的情况也较少（p = 0.0
