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ENDGAMES: Atul Gupta, Donald S Urquhart, Sarah Donovan, and Andrew Bush A 4 year old boy with recurrent wheeze and chest infections BMJ 2009; 338: b1255 [Full text]

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What came first: egg or hen? The long story of GORD and asthma.

Giovanna Ventura, Gianluca Tornese, Alessandro Ventura   (20 May 2009)

What came first: egg or hen? The long story of GORD and asthma. 20 May 2009
Giovanna Ventura, MD Institute of Child Health IRCCS Burlo Garofolo, University of Trieste, via dell'Istria 65/1 34137 IT, Gianluca Tornese, Alessandro Ventura Send response to journal: Re: What came first: egg or hen? The long story of GORD and asthma.	Since causal relation between GORD and asthma is not demonstrated, we consider that presenting the Picture Quiz “A 4 year old boy with recurrent wheeze and chest infections”(1) through a pH monitoring image could be misleading. Even though two recent metanalysis confirmed a higher prevalence of GOR in patients with asthma (2,3), none of the studies could demonstrate the causal relation between the two conditions, nor the effectiveness of anti- reflux therapy in controlling the symptoms of asthma. A prospective 35 year study of 710 children with gastro-oesophageal incompetence published in 1984 already suggested that “the discovery of reflux in a patient [with asthma, recurrent bronchitis, etc.] does not necessarily establish a causal relation with the disorder under investigation” (4). In the following years, evidence hasn’t lead elsewhere: too few randomized, double-blinded, placebo-controlled clinical trials regarding this issue have been conducted and none showed a clear association (5). Infact, the only paediatric RCT by Størdal and colleagues (6) showed that in children with asthma and GORD, PPIs do not change respiratory symptoms, which means that asymptomatic GORD (diagnosed through 24-hour pH monitoring) could not be called into question in poorly controlled asthma. Moreover, it’s noteworthy that in children with cerebral palsy (who frequently have a severe GORD with respiratory complications such as bronchopneumonia) asthma doesn’t occur with undue frequency (7). Some Authors suggest that in patients with asthma increased pressure gradient between the abdomen and thorax may cause herniation of the lower sphincter of the oesophagus into the chest (8,9). Therefore, GOR may be considered a consequence rather than a cause of asthma. In our opinion, visually associating a history of recurrent wheeze with an image of pH monitoring may improperly support the unproven causal relationship between asthma and GORD. (1) Gupta A, Urquhart DS, Donovan S, Bush A. A 4 year old boy with recurrent wheeze and chest infections. BMJ 2009; 338: b1255. (2) Tolia V, Vandenplas Y. Systematic review: the extra-oesophageal symptoms of gastro-oesophageal reflux disease in children. Aliment Pharmacol Ther. 2009 Feb 1;29(3):258-72. (3) Havemann BD, Henderson CA, El-Serag HB. The association between gastro -oesophageal reflux disease and asthma: a systematic review. Gut. 2007 Dec;56(12):1654-64. (4) Carré SJ. Clinical significance of gastro-oesophageal reflux. Arch Dis Child. 1984; 59(10):911-2. (5) American Lung Association Asthma Clinical Research Centers, Mastronarde JG, Anthonisen NR, Castro M, Holbrook JT, Leone FT, Teague WG, Wise RA. Efficacy of esomeprazole for treatment of poorly controlled asthma N Engl J Med. 2009 Apr 9;360(15):1487-99. (6) Størdal K, Johannesdottir GB, Bentsen BS, Knudsen PK, Carlsen KC, Closs O, Handeland M, Holm HK, Sandvik L. Acid suppression does not change respiratory symptoms in children with asthma and gastro-oesophageal reflux disease. Arch Dis Child. 2005 Sep;90(9):956-60. (7) Spiroglou K, Xinias I, Karatzas N, Karatza E, Arsos G, Panteliadis C. Gastric emptying in children with cerebral palsy and gastroesophageal reflux. Pediatr Neurol. 2004 Sep;31(3):177-82. (8) Choy D, Leung R. Gastro-oesophageal reflux disease and asthma. Respirology 1997;2:163-8. (9) Zerbib F, Guisset O, Lamouliatte H, Quinton A, Galmiche JP, Tunon-De- Lara JM. Effects of bronchial obstruction on lower esophageal sphincter motility and gastroesophageal reflux in patients with asthma. Am J Respir Crit Care Med 2002; 166:1206-11. Competing interests: None declared