| Aim The quality of life in patients with refractory gastroesophageal reflux disease and gastroesophageal reflux disease-chronic cough is seriously impaired,which is a big challenge for physician. Our research aimed to explor reflux symptoms and reaveal the relation between psychological and refractory GERD, reflux pattern and esophageal motility in patients with refractory GERD,the potential link between GERD and CC.Methods We prospectively enrolled patients of GERD. Subjects completed GERD symptom questionnaire,hamilton anxiety scale, hamilton depression scale, and then received 24-hour ambulatory p H-impedance-pressure monitoring.Results 60 patients in refractory GERD group and 18 patients in untreated GERD group were selected.The patients had similar age, gender and BMI in two groups. There was no significant difference in score of reflux symptoms between two groups, while refractory GERD patients reported “heartburn” in varied forms and less typical symptoms than GERD patients. The refractory reflux symptoms limit to their eating(43.3% vs.5.6%, P=0.003) and daily life(36.7% vs.11.1%, P=0.039) more frequently than untreated GERD patients. Comorbid anxiety and /or depression in refractory GERD and GERD patients are 48.3% and 33.3% respectively(P=0.262). In p H-impedance monitoring data, there was no significant difference in De Meester score(P=0.991) between two groups. More patients in refractory GERD group had non-acidic reflux events(21.1% vs.16.6%, P=0.000). The proportions of patients with positive symptom index(SI) in refractory GERD and GERD group are 43.6% and76.9% respectively(P=0.031). Long acidic reflux(?5min) was detected in 36 RGERD and 12 GERD patients, which are more frequent episodes in refractory GERD patients than GERD patients(4[1-10] vs. 2[1-4], P=0.015). During long acidic reflux period, the primary peristalses(swallow-evoked) rather than secondary peristalsis(distension-evoked) are the predominant motor of esophageal body in both groups.When long acidic reflux occurred, less primary peristalsis per minute were evoked in refractory RGERD patients than that in GERD group(0.15 vs. 0.32, P=0.019), and similar trend was observed for secondary peristalsis(0.07 vs. 0.13, P=0.057).Furthermore, the effective primary and secondary peristalsis in response to long reflux episodes was significantly decreased in refractory GERD patients comparing with GERD patients(22.53% vs.59.74%, P=0.000; 6.17% vs.24.32%, P=0.012).Age- and sex-matched 31 patients in GERD-CC group(39.7%) and 47 patients in GERD group(60.3%) were selected. Compared with GERD group, GERD-CC patients had higher reflux symptom scores(6.4±2.4 vs. 4.6±3.1, p=0.007). HRM showed no significant difference in UES resting pressure(83.0±42.1mm Hg vs. 93.2±49.4mm Hg,p=0.35) and LES resting pressure(11.8±7.6mm Hg vs. 14.4±7.5mm Hg, p=0.14)between two groups. GERD-CC patients had more IEM( 67.7% vs. 60.6%, p=0.04). In p H-impedance-pressure monitoring, the effective primary peristalsis in GERD-CC group and GERD group was 28.3% vs. 38.2%(p=0.09). Of 206 cough bursts, 61.5%cough events were dependent of reflux, which occurred within 2min of a reflux episode.Half of these were reflux-cough sequences, including acidic(54.0%), weakly acidic(36.5%) and non-acidic(9.5%) reflux. Proximal reflux(22.2% vs. 18.4%) and laryngopharyngeal reflux(4.8% vs. 1.3%) in reflux-cough patients were more prominent than GERD group.Conclusion refractory GERD patients presented atypical reflux symptoms, which limit their daily life, and impact their psychological status. More frequent non-acidic reflux and long acidic reflux, less effective esophageal peristalsis during long period reflux were the pathophysiological basis for refractory GERD.Increased proximal/laryngopharyngeal reflux, weakly acidic/non-acidic reflux and IEM might play important roles in the pathogenesis of GERD-related cough. |
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