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Gastroesophageal reflux in asthmatic children not responding to asthma medication
Journal of Clinical Imaging 27 (2003) 333 – 336
Gastroesophageal reflux in asthmatic children not responding to asthma medication A scintigraphic study in 126 patients with correlation between scintigraphic and clinical findings of reflux E.J. Thomasa, R. Kumara,*, J. Bharathi Dasana, S.K. Kabrab, C.S. Bala, Shaji Menonb, A. Malhotraa a
Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India b Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India Received 10 March 2002
Abstract Gastroesophageal reflux (GER) is frequently found in association with asthma. Successful control of GER in these patients may improve in their asthma symptoms. The present retrospective analysis was undertaken to find out the incidence of GER in asthmatic children not responding to routine antiasthmatic medications and to find out if there is a clinical correlation between the symptoms of GER and scintigraphic evidence of GER in these patients. A total of 126 children with a mean age of 2.31 years and range 6 months to 6 years were evaluated. The children were divided into two groups. Group I (n = 100) consisted of children with asthma but no clinical symptoms of GER. Group II (n = 26) consisted of those children with asthma and clinical symptoms of GER. Radionuclide scintigraphy was performed with 100 – 200 mCi (3.7 – 7.4 MBq) of Tc99m-sulphur colloid. All 33 out of 126 (26%) children had GER on scintigraphy. In Group I, only 23 (23%) had reflux while in Group II, 10 (38.5%) had reflux. In conclusion, esophageal scintiscanning can be used to detect GER in asthmatic children refractory to routine antiasthmatic medication irrespective of the presence or absence of symptoms suggestive of GER. D 2003 Elsevier Inc. All rights reserved. Keywords: Gastroesophageal reflux; Asthma; Radionuclide GER scintigraphy
1. Introduction The prevalence of asthma is increasing worldwide. It has increased from 3.5% to 5% in the United States between 1982 and 1992 [1]. Gastroesophageal reflux (GER) is frequently found in association with asthma [2,3]. A review of the existing literature by Stephen et al. revealed that, with medical antireflux therapy, asthma symptoms improved in 69% of the subjects. Further, such therapy resulted in a reduction in asthma medication in 62% of the subjects [4]. Approximately one-half of adult asthmatics attending an asthma clinic experience symptomatic GER on a regular basis [3]. However, in asthmatic children underlying GER * Corresponding author. F-74, Ansari Nagar (West), AIIMS Campus, New Delhi 110029, India. Tel.: +91-11-6259597; fax: +91-11-6862663. E-mail address: [email protected] ( R. Kumar ). 0899-7071/03/$ – see front matter D 2003 Elsevier Inc. All rights reserved. doi:10.1016/S0899-7071(02)00555-7
may remain largely asymptomatic [5]. Therefore, timely detection of GER is important in asthmatic subjects. Various modalities have been found to be useful in the diagnosis of GER. Twenty-four-hour probe monitoring, widely seen as the standard for evaluating reflux, is sensitive and specific in the detection and quantification of acid GER. However, the study may not be reliable in young infants or postprandially when the acid levels tend to be lower. Contrast radiography is useful in the assessment of the swallowing mechanism and esophageal motor function. The results from contrast radiography correlate poorly with the 24-h pH probe study and the radiation exposure resulting from these studies is quite high. Esophageal manometry provides detailed information on esophageal motor function but provides no direct information about GER. Scintiscans are very sensitive and specific in the detection of individual GER episodes, and can accurately
334
E.J. Thomas et al. / Journal of Clinical Imaging 27 (2003) 333–336
assess gastric emptying with negligible radiation exposure to the subject [6– 8]. In our institute, radionuclide scintigraphy is the screening test for children with recurrent respiratory problems in whom GER is suspected as a cause. We undertook a retrospective study of the scintigrams performed on 126 asthmatic children to find out the incidence of GER in those not responding to routine medications. We also sought to find out the correlation between the occurrence of GER symptoms and the presence of scintigraphic evidence for GER in this patient population.
2. Materials and methods 2.1. Patients subgroup Studies performed on 126 children (65 male and 51 female, mean age 2.31 years with a range of 6 months to 6 years), with asthma not responding to routine medications, were reviewed. The children were divided into two groups, depending on the presence or absence of typical symptoms suggestive of GER. Group I consisted of 100 children with asthma but no clinical symptoms of GER. Group II consisted of 26 children with asthma and clinical symptoms of GER. Symptoms such as regurgitation, vomiting, irritability, refusal of feeds, apnoea or bradycardia during feeding, retrosternal burning pain, epigastric pain, dysphagia and failure to thrive were taken to be indicative of GER. Children with associated congenital or acquired abnormalities of upper gastrointestinal (GI) tract (structural/motility), those with neurological disorders, congenital cardiac anomalies and those who underwent any upper gastrointestinal surgical procedures were excluded from the study.
Fig. 2. GER dynamic study showing proximal reflux (solid arrow) in a Group II patient. The activity is seen to appear in the oropharynx during the course of the study.
administered through a nasogastric tube into the stomach in younger children. Adequate intragastric volume was ensured by instilling water of 50-ml volume for children less than 6 months and 100-ml volume for children between 6 and 12 months of age. The nasogastric tube was removed with the patient held in erect position and a small volume of water was pushed to avoid any contamination. In older children, the isotope was administered in a capsule, which they swallowed with 150 – 300 ml of water. Sedation or other restraining measures were not routinely used, instead parents were encouraged to restrain the child. No provocative
2.2. Scintigraphic procedure All studies were performed using a dose of 100– 200 mCi (3.7 – 7.4 MBq) of Tc99m-sulphur colloid, which was
Fig. 1. Sketch diagram showing proximal and distal grading of reflux.
Fig. 3. GER dynamic study showing distal reflux in a Group II patient. Appearance (solid arrow pointing right) of activity in the distal third of the esophagus is noted followed by disappearance (solid arrow pointing to left) during the course of the study.
E.J. Thomas et al. / Journal of Clinical Imaging 27 (2003) 333–336 Table 1 Table showing incidence of proximal and distal reflux in symptomatic and asymptomatic patients in scintigraphic studies
Group I Group II Total
Total no. of pts.
Incidence of GER no. of pts. (%)
Distal GER no. of pts. (%)
Proximal GER no. of pts. (%)
100 26 126
23 (23%) 10 (38.5%) 33 (26%)
10 (43.5%) 03 (30%) 13 (39.4%)
13 (56.5%) 07 (70%) 20 (60.6%)
measures like abdominal compression, posterior tilt of table, which may disrupt the physiological nature of test, were used. A dynamic study was acquired using a low energy allpurpose collimator with the patient in supine position and the camera placed anteriorly. Sixty-four frames of 16-s duration each were acquired in a 64 64 matrix. Twentyfour-hour delayed images were not acquired routinely. Antiasthmatic medications were not withheld prior to the study and feeding was not restricted for the purposes of the study. 2.3. Image analysis All studies were visually analysed for evidence of reflux. Cine-mode was used for confirmation of results and to rule out child movement during the study. The reflux was graded as distal if the tracer was seen reaching the lower one-third of esophagus, and as proximal if the tracer was seen in the upper two-third of esophagus with or without visualization of oropharynx (Fig. 1).
3. Results Out of 126 children, 33 (26%) had GER on scintigraphy. Twenty-three (23%) in Group I and 10 (38.5%) in Group II had positive scintigraphic studies for reflux. Of the 100 Group I patients, 13 (56.5%) had proximal reflux and 10 (43.5%) had distal reflux, whereas in 26 Group II patients, 7 (70%) had proximal reflux (Fig. 2) and 3 (30%) had distal reflux (Fig. 3) (Table 1.).
4. Discussion The prevalence of GER in asthmatics has been reported to vary from 32% to 80% [9 –12]. In these patients, there may be exacerbation in airflow obstruction and increased requirement for antiasthmatic medications during symptomatic episodes of GER [3]. It has been shown that the usage of antiasthmatic medications by themselves does not affect the incidence of GER [10 – 12]. Antireflux barrier incompetence is significantly more prevalent among asthmatics, independent of the use of theophylline, (b)-agonists or corticosteroids [10]. It is hypothesized that regurgitation with aspiration may be the mechanism by which reflux can
335
aggravate asthma. Case reports of anesthetized patients and animal studies have consistently demonstrated that endotracheal/endobronchial aspiration of gastric content precipitate and exacerbate asthma [13,14]. However, aspiration has not been demonstrated by several studies using radioisotope meals in ambulatory patients with asthma [15]. In the absence of aspiration, vagally mediated reflexes and neurogenic inflammation may exacerbate asthma. Intraesophageal acid instillation studies in humans and dogs are consistent with the hypothesis of a vagal reflex triggered by exposure to acid or mechanical distention of the lower esophagus [16,17]. Additional studies suggest that neuropeptides of the nonadrenergic, noncholinergic system are released in the bronchi following esophageal acid reflux or instillation [18,19]. These observations are further supported by embryologic evidence that the distal esophagus originates from the lung bud and that the lower esophagus and airway share innervation by the vagus nerve [20]. Hence, GER with or without associated aspiration may be contributory in a number of patients with bronchial asthma and the treatment of GER in these children may result in alleviation of their symptoms. Toni et al. reported pathological GER in 53% of their 107 patients. Further in their study, one-third of the patients with GER had no typical reflux symptoms [5]. This study suggested that clinically silent GER might be present in patients with asthma. In keeping with this, 70% of the patients with scintigraphic evidence for reflux in our study had no clinical symptoms suggestive of GER. Therefore, the absence of clinical symptoms alone does not rule out GER in asthmatics and GER must be actively sought out even in asymptomatic patients. Scintiscanning has been used in the past to detect of GER in asthmatics. Chopra et al. studied 80 asthmatic children and 10 controls for GER using radionuclide gastroesophagography. Thirty-nine percent of their patients had esophageal reflux, and the presence of reflux was found to correlate strongly with nocturnal exacerbation of symptom [21]. A similar study by Karaman et al. using radionuclide scintigraphy showed a 21.1% incidence of GER in 74 children with recurrent wheezing [22]. The incidence of GER in our study was similar to that in other studies performed with scintigraphy. The incidence of GER found is lower when compared to studies using pH probe. However, most studies, showing a high incidence of GER, were performed in patients with a high a priori probability of GER. In these studies, no mention is made of the incidence of CNS disorders and other similar diseases having a high prevalence of co-existing GER. We selectively excluded all those children with CNS disorders, known congenital or acquired structural and motility disorders of upper GI tract, and children with a history of upper GI interventions. This may account for the lower incidence of GER in our study when compared to other studies. In conclusion, esophageal scintiscanning can be used to detect GER in asthmatic children refractory to routine
336
E.J. Thomas et al. / Journal of Clinical Imaging 27 (2003) 333–336
antiasthmatic medication irrespective of the presence or absence of symptoms suggestive of GER.
References [1] Theodoropoulos DS, Lockey RF, Boyce HW. Gastroesophageal reflux in asthma: a review of pathogenesis, diagnosis, and therapy. Allergy 1999;54:651 – 61. [2] Centers for Disease Control and Prevention. Asthma — United States, 1982 – 1992. Morb Mortal Wkly Rep 1995;43:952 – 3. [3] Field SK, Underwood M, Brant R, Cowie RL. Prevalence of gastroesophageal reflux symptoms in asthma. Chest 1996;109:316 – 22. [4] Stephen K. Field does medical antireflux therapy improve asthma in asthmatics with gastroesophageal reflux? A critical review of the literature. CHEST 1998;114:275 – 83. [5] Kiljander TO, Salomaa E-RM, Hietanen EK, Terho EO. Gastroesophageal reflux IN asthmatics: a double-blind, placebo-controlled crossover study with omeprazole. CHEST 1999;116:1257 – 64. [6] Arasu TS, Wyllie R, Fitzgerald JF, Franken EA, Siddiqui AR, Lehman GA, Eigen H, Grosfeld JL. Gastroesophageal reflux in infants and children-comparative accuracy of diagnostic methods. J Pediatr 1980;96:798 – 803. [7] Blumhagen JD, Rudd TG, Christie DL. Gastroesophageal reflux in children: radionuclide gastroesophagography. AJR 1980;135: 1001 – 4. [8] Castronovo FP. Gastroesophageal scintiscanning in a pediatric population: dosimetry. J Nucl Med 1986;27:1212 – 4. [9] Vincent D, Cohen-Jonathan AM, Leport J, Merrouche M, Geronimi A, Pradalier A, Soule JC. Gastro-oesophageal reflux prevalence and relationship with bronchial reactivity in asthma. Eur Respir J 1997; 10:2255 – 9. [10] Sontag SJ, O’Connel S, Khandelwal S, Miller T, Nemchausky B, Schnell TG, Serlovsky R. Most asthmatics have gastroesophageal reflux with or without bronchodilator therapy. Gastroenterology 1990;99:613 – 20.
[11] Stein MR, Towner TG, Weber RW, Mansfield LE, Jacobson KW, McDonnell JT, Nelson HS. The effect on theophylline on the lower esophageal sphincter pressure. Ann Allergy 1980;45:238 – 41. [12] Berquist WE, Rachelefsky GS, Rowshan N, Siege SI, Katz R, Welch M. Quantitative gastroesophageal reflux and pulmonary function in asthmatic children and normal adults receiving placebo, theophylline, and metaproterenol sulfate therapy. J Allergy Clin Immunol 1984;73: 253 – 8. [13] Bannister WK, Sattilaro AJ, Otis RP. Therapeutic aspects of aspiration pneumonitis in experimental animals. Anesthesiology 1961;22:440 – 3. [14] Jack CIA, Calverley PMA, Donnelly RJ. Simultaneous tracheal and esophageal pH measurements in asthmatic patients with gastroesophageal reflux. Thorax 1995;50:201 – 4. [15] Ghaed N, Stein MR. Assessment of a technique for scintigraphic monitoring of pulmonary aspiration of gastric contents in asthmatics with gastroesophageal reflux. Ann Allergy 1979;42:306 – 8. [16] Mansfield LE, Hameister HH, Spaulding HS, Smith NJ, Glab N. The role of the vagus nerve in airway narrowing caused by intraesophageal hydrochloric acid provocation and esophageal distention. Ann Allergy 1981;47:431 – 4. [17] Mansfield LE, Stein MR. Gastro-esophageal reflux and asthma: a possible reflex mechanism. Ann Allergy 1978;41:224 – 6. [18] Hamamoto J, Kohrogi H, Kawano O, Iwagoe H, Fujii K, Hirata N, Ando M. Esophageal stimulation by hydrochloric acid causes neurogenic inflammation in the airways of guinea pigs. J Appl Physiol 1997;82:738 – 45. [19] James DE, Nijkamp FP. Neuro-immune interactions in the lung. Clin Exp Allergy 1999;29:1309 – 19. [20] Crisera CA, Connelly PR, Marmureanu AR, Li M, Rose MI, Longaker MT, Gittes GK. TTF-1 and HNF-38 in the developing tracheoesophageal fistula: further evidence for the respiratory origin of the distal esophagus. J Pediatr Surg 1999;34:1322 – 6. [21] Chopra K, Matta SK, Madan N, Iyer S. Association of gastroesophageal reflux (GER) with bronchial asthma. Indian Pediatr 1995;32: 1083 – 6. [22] Karaman O, Uzuner N, Degirmenci B, Uguz A, Durak H. Results of the gastroesophageal reflux assessment in wheezy children. Indian J Pediatr 1999;66:351 – 5.
Gastroesophageal reflux in asthmatic children not responding to asthma medication A scintigraphic study in 126 patients with correlation between scintigraphic and clinical findings of reflux E.J. Thomasa, R. Kumara,*, J. Bharathi Dasana, S.K. Kabrab, C.S. Bala, Shaji Menonb, A. Malhotraa a
Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India b Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India Received 10 March 2002
Abstract Gastroesophageal reflux (GER) is frequently found in association with asthma. Successful control of GER in these patients may improve in their asthma symptoms. The present retrospective analysis was undertaken to find out the incidence of GER in asthmatic children not responding to routine antiasthmatic medications and to find out if there is a clinical correlation between the symptoms of GER and scintigraphic evidence of GER in these patients. A total of 126 children with a mean age of 2.31 years and range 6 months to 6 years were evaluated. The children were divided into two groups. Group I (n = 100) consisted of children with asthma but no clinical symptoms of GER. Group II (n = 26) consisted of those children with asthma and clinical symptoms of GER. Radionuclide scintigraphy was performed with 100 – 200 mCi (3.7 – 7.4 MBq) of Tc99m-sulphur colloid. All 33 out of 126 (26%) children had GER on scintigraphy. In Group I, only 23 (23%) had reflux while in Group II, 10 (38.5%) had reflux. In conclusion, esophageal scintiscanning can be used to detect GER in asthmatic children refractory to routine antiasthmatic medication irrespective of the presence or absence of symptoms suggestive of GER. D 2003 Elsevier Inc. All rights reserved. Keywords: Gastroesophageal reflux; Asthma; Radionuclide GER scintigraphy
1. Introduction The prevalence of asthma is increasing worldwide. It has increased from 3.5% to 5% in the United States between 1982 and 1992 [1]. Gastroesophageal reflux (GER) is frequently found in association with asthma [2,3]. A review of the existing literature by Stephen et al. revealed that, with medical antireflux therapy, asthma symptoms improved in 69% of the subjects. Further, such therapy resulted in a reduction in asthma medication in 62% of the subjects [4]. Approximately one-half of adult asthmatics attending an asthma clinic experience symptomatic GER on a regular basis [3]. However, in asthmatic children underlying GER * Corresponding author. F-74, Ansari Nagar (West), AIIMS Campus, New Delhi 110029, India. Tel.: +91-11-6259597; fax: +91-11-6862663. E-mail address: [email protected] ( R. Kumar ). 0899-7071/03/$ – see front matter D 2003 Elsevier Inc. All rights reserved. doi:10.1016/S0899-7071(02)00555-7
may remain largely asymptomatic [5]. Therefore, timely detection of GER is important in asthmatic subjects. Various modalities have been found to be useful in the diagnosis of GER. Twenty-four-hour probe monitoring, widely seen as the standard for evaluating reflux, is sensitive and specific in the detection and quantification of acid GER. However, the study may not be reliable in young infants or postprandially when the acid levels tend to be lower. Contrast radiography is useful in the assessment of the swallowing mechanism and esophageal motor function. The results from contrast radiography correlate poorly with the 24-h pH probe study and the radiation exposure resulting from these studies is quite high. Esophageal manometry provides detailed information on esophageal motor function but provides no direct information about GER. Scintiscans are very sensitive and specific in the detection of individual GER episodes, and can accurately
334
E.J. Thomas et al. / Journal of Clinical Imaging 27 (2003) 333–336
assess gastric emptying with negligible radiation exposure to the subject [6– 8]. In our institute, radionuclide scintigraphy is the screening test for children with recurrent respiratory problems in whom GER is suspected as a cause. We undertook a retrospective study of the scintigrams performed on 126 asthmatic children to find out the incidence of GER in those not responding to routine medications. We also sought to find out the correlation between the occurrence of GER symptoms and the presence of scintigraphic evidence for GER in this patient population.
2. Materials and methods 2.1. Patients subgroup Studies performed on 126 children (65 male and 51 female, mean age 2.31 years with a range of 6 months to 6 years), with asthma not responding to routine medications, were reviewed. The children were divided into two groups, depending on the presence or absence of typical symptoms suggestive of GER. Group I consisted of 100 children with asthma but no clinical symptoms of GER. Group II consisted of 26 children with asthma and clinical symptoms of GER. Symptoms such as regurgitation, vomiting, irritability, refusal of feeds, apnoea or bradycardia during feeding, retrosternal burning pain, epigastric pain, dysphagia and failure to thrive were taken to be indicative of GER. Children with associated congenital or acquired abnormalities of upper gastrointestinal (GI) tract (structural/motility), those with neurological disorders, congenital cardiac anomalies and those who underwent any upper gastrointestinal surgical procedures were excluded from the study.
Fig. 2. GER dynamic study showing proximal reflux (solid arrow) in a Group II patient. The activity is seen to appear in the oropharynx during the course of the study.
administered through a nasogastric tube into the stomach in younger children. Adequate intragastric volume was ensured by instilling water of 50-ml volume for children less than 6 months and 100-ml volume for children between 6 and 12 months of age. The nasogastric tube was removed with the patient held in erect position and a small volume of water was pushed to avoid any contamination. In older children, the isotope was administered in a capsule, which they swallowed with 150 – 300 ml of water. Sedation or other restraining measures were not routinely used, instead parents were encouraged to restrain the child. No provocative
2.2. Scintigraphic procedure All studies were performed using a dose of 100– 200 mCi (3.7 – 7.4 MBq) of Tc99m-sulphur colloid, which was
Fig. 1. Sketch diagram showing proximal and distal grading of reflux.
Fig. 3. GER dynamic study showing distal reflux in a Group II patient. Appearance (solid arrow pointing right) of activity in the distal third of the esophagus is noted followed by disappearance (solid arrow pointing to left) during the course of the study.
E.J. Thomas et al. / Journal of Clinical Imaging 27 (2003) 333–336 Table 1 Table showing incidence of proximal and distal reflux in symptomatic and asymptomatic patients in scintigraphic studies
Group I Group II Total
Total no. of pts.
Incidence of GER no. of pts. (%)
Distal GER no. of pts. (%)
Proximal GER no. of pts. (%)
100 26 126
23 (23%) 10 (38.5%) 33 (26%)
10 (43.5%) 03 (30%) 13 (39.4%)
13 (56.5%) 07 (70%) 20 (60.6%)
measures like abdominal compression, posterior tilt of table, which may disrupt the physiological nature of test, were used. A dynamic study was acquired using a low energy allpurpose collimator with the patient in supine position and the camera placed anteriorly. Sixty-four frames of 16-s duration each were acquired in a 64 64 matrix. Twentyfour-hour delayed images were not acquired routinely. Antiasthmatic medications were not withheld prior to the study and feeding was not restricted for the purposes of the study. 2.3. Image analysis All studies were visually analysed for evidence of reflux. Cine-mode was used for confirmation of results and to rule out child movement during the study. The reflux was graded as distal if the tracer was seen reaching the lower one-third of esophagus, and as proximal if the tracer was seen in the upper two-third of esophagus with or without visualization of oropharynx (Fig. 1).
3. Results Out of 126 children, 33 (26%) had GER on scintigraphy. Twenty-three (23%) in Group I and 10 (38.5%) in Group II had positive scintigraphic studies for reflux. Of the 100 Group I patients, 13 (56.5%) had proximal reflux and 10 (43.5%) had distal reflux, whereas in 26 Group II patients, 7 (70%) had proximal reflux (Fig. 2) and 3 (30%) had distal reflux (Fig. 3) (Table 1.).
4. Discussion The prevalence of GER in asthmatics has been reported to vary from 32% to 80% [9 –12]. In these patients, there may be exacerbation in airflow obstruction and increased requirement for antiasthmatic medications during symptomatic episodes of GER [3]. It has been shown that the usage of antiasthmatic medications by themselves does not affect the incidence of GER [10 – 12]. Antireflux barrier incompetence is significantly more prevalent among asthmatics, independent of the use of theophylline, (b)-agonists or corticosteroids [10]. It is hypothesized that regurgitation with aspiration may be the mechanism by which reflux can
335
aggravate asthma. Case reports of anesthetized patients and animal studies have consistently demonstrated that endotracheal/endobronchial aspiration of gastric content precipitate and exacerbate asthma [13,14]. However, aspiration has not been demonstrated by several studies using radioisotope meals in ambulatory patients with asthma [15]. In the absence of aspiration, vagally mediated reflexes and neurogenic inflammation may exacerbate asthma. Intraesophageal acid instillation studies in humans and dogs are consistent with the hypothesis of a vagal reflex triggered by exposure to acid or mechanical distention of the lower esophagus [16,17]. Additional studies suggest that neuropeptides of the nonadrenergic, noncholinergic system are released in the bronchi following esophageal acid reflux or instillation [18,19]. These observations are further supported by embryologic evidence that the distal esophagus originates from the lung bud and that the lower esophagus and airway share innervation by the vagus nerve [20]. Hence, GER with or without associated aspiration may be contributory in a number of patients with bronchial asthma and the treatment of GER in these children may result in alleviation of their symptoms. Toni et al. reported pathological GER in 53% of their 107 patients. Further in their study, one-third of the patients with GER had no typical reflux symptoms [5]. This study suggested that clinically silent GER might be present in patients with asthma. In keeping with this, 70% of the patients with scintigraphic evidence for reflux in our study had no clinical symptoms suggestive of GER. Therefore, the absence of clinical symptoms alone does not rule out GER in asthmatics and GER must be actively sought out even in asymptomatic patients. Scintiscanning has been used in the past to detect of GER in asthmatics. Chopra et al. studied 80 asthmatic children and 10 controls for GER using radionuclide gastroesophagography. Thirty-nine percent of their patients had esophageal reflux, and the presence of reflux was found to correlate strongly with nocturnal exacerbation of symptom [21]. A similar study by Karaman et al. using radionuclide scintigraphy showed a 21.1% incidence of GER in 74 children with recurrent wheezing [22]. The incidence of GER in our study was similar to that in other studies performed with scintigraphy. The incidence of GER found is lower when compared to studies using pH probe. However, most studies, showing a high incidence of GER, were performed in patients with a high a priori probability of GER. In these studies, no mention is made of the incidence of CNS disorders and other similar diseases having a high prevalence of co-existing GER. We selectively excluded all those children with CNS disorders, known congenital or acquired structural and motility disorders of upper GI tract, and children with a history of upper GI interventions. This may account for the lower incidence of GER in our study when compared to other studies. In conclusion, esophageal scintiscanning can be used to detect GER in asthmatic children refractory to routine
336
E.J. Thomas et al. / Journal of Clinical Imaging 27 (2003) 333–336
antiasthmatic medication irrespective of the presence or absence of symptoms suggestive of GER.
References [1] Theodoropoulos DS, Lockey RF, Boyce HW. Gastroesophageal reflux in asthma: a review of pathogenesis, diagnosis, and therapy. Allergy 1999;54:651 – 61. [2] Centers for Disease Control and Prevention. Asthma — United States, 1982 – 1992. Morb Mortal Wkly Rep 1995;43:952 – 3. [3] Field SK, Underwood M, Brant R, Cowie RL. Prevalence of gastroesophageal reflux symptoms in asthma. Chest 1996;109:316 – 22. [4] Stephen K. Field does medical antireflux therapy improve asthma in asthmatics with gastroesophageal reflux? A critical review of the literature. CHEST 1998;114:275 – 83. [5] Kiljander TO, Salomaa E-RM, Hietanen EK, Terho EO. Gastroesophageal reflux IN asthmatics: a double-blind, placebo-controlled crossover study with omeprazole. CHEST 1999;116:1257 – 64. [6] Arasu TS, Wyllie R, Fitzgerald JF, Franken EA, Siddiqui AR, Lehman GA, Eigen H, Grosfeld JL. Gastroesophageal reflux in infants and children-comparative accuracy of diagnostic methods. J Pediatr 1980;96:798 – 803. [7] Blumhagen JD, Rudd TG, Christie DL. Gastroesophageal reflux in children: radionuclide gastroesophagography. AJR 1980;135: 1001 – 4. [8] Castronovo FP. Gastroesophageal scintiscanning in a pediatric population: dosimetry. J Nucl Med 1986;27:1212 – 4. [9] Vincent D, Cohen-Jonathan AM, Leport J, Merrouche M, Geronimi A, Pradalier A, Soule JC. Gastro-oesophageal reflux prevalence and relationship with bronchial reactivity in asthma. Eur Respir J 1997; 10:2255 – 9. [10] Sontag SJ, O’Connel S, Khandelwal S, Miller T, Nemchausky B, Schnell TG, Serlovsky R. Most asthmatics have gastroesophageal reflux with or without bronchodilator therapy. Gastroenterology 1990;99:613 – 20.
[11] Stein MR, Towner TG, Weber RW, Mansfield LE, Jacobson KW, McDonnell JT, Nelson HS. The effect on theophylline on the lower esophageal sphincter pressure. Ann Allergy 1980;45:238 – 41. [12] Berquist WE, Rachelefsky GS, Rowshan N, Siege SI, Katz R, Welch M. Quantitative gastroesophageal reflux and pulmonary function in asthmatic children and normal adults receiving placebo, theophylline, and metaproterenol sulfate therapy. J Allergy Clin Immunol 1984;73: 253 – 8. [13] Bannister WK, Sattilaro AJ, Otis RP. Therapeutic aspects of aspiration pneumonitis in experimental animals. Anesthesiology 1961;22:440 – 3. [14] Jack CIA, Calverley PMA, Donnelly RJ. Simultaneous tracheal and esophageal pH measurements in asthmatic patients with gastroesophageal reflux. Thorax 1995;50:201 – 4. [15] Ghaed N, Stein MR. Assessment of a technique for scintigraphic monitoring of pulmonary aspiration of gastric contents in asthmatics with gastroesophageal reflux. Ann Allergy 1979;42:306 – 8. [16] Mansfield LE, Hameister HH, Spaulding HS, Smith NJ, Glab N. The role of the vagus nerve in airway narrowing caused by intraesophageal hydrochloric acid provocation and esophageal distention. Ann Allergy 1981;47:431 – 4. [17] Mansfield LE, Stein MR. Gastro-esophageal reflux and asthma: a possible reflex mechanism. Ann Allergy 1978;41:224 – 6. [18] Hamamoto J, Kohrogi H, Kawano O, Iwagoe H, Fujii K, Hirata N, Ando M. Esophageal stimulation by hydrochloric acid causes neurogenic inflammation in the airways of guinea pigs. J Appl Physiol 1997;82:738 – 45. [19] James DE, Nijkamp FP. Neuro-immune interactions in the lung. Clin Exp Allergy 1999;29:1309 – 19. [20] Crisera CA, Connelly PR, Marmureanu AR, Li M, Rose MI, Longaker MT, Gittes GK. TTF-1 and HNF-38 in the developing tracheoesophageal fistula: further evidence for the respiratory origin of the distal esophagus. J Pediatr Surg 1999;34:1322 – 6. [21] Chopra K, Matta SK, Madan N, Iyer S. Association of gastroesophageal reflux (GER) with bronchial asthma. Indian Pediatr 1995;32: 1083 – 6. [22] Karaman O, Uzuner N, Degirmenci B, Uguz A, Durak H. Results of the gastroesophageal reflux assessment in wheezy children. Indian J Pediatr 1999;66:351 – 5.