Dear Dr. B: I have asthma and my doctor thinks it is caused by gastro-esophageal reflux disease although I have no history of heartburn. Can you please explain this to me?
Answer: Heartburn and regurgitation are classical symptoms of gastro-esophageal reflux disease (GERD). But GERD may present in atypical ways. Atypical presentation may be in the form of diseases of the lungs, ear, nose and throat or in some other ways. In atypical presentation, majority of the patients do not have classical heartburn or acid regurgitation.
Asthma, chronic bronchitis, aspiration pneumonia, bronchiectasis and pulmonary fibrosis may be some of the lung problems a person may have with atypical GERD.
Atypical GERD may affect ear, nose and throat in the form of chronic cough, laryngitis, hoarseness, pharyngitis and sinusitis.
Non-cardiac chest pain, dental erosions and sleep apnea are other conditions related to atypical presentation of GERD.
These patients are suspected to have atypical presentation of GERD when they fail to respond to conventional therapy for their medical condition. For example, all patients with non-allergic asthma in which wheezing is poorly controlled should be evaluated for GERD.
Studies have shown that 30 per cent or more patients undergoing cardiac angiogram for chest pain will have normal findings. Of these 40 to 50 per cent will have abnormal findings in the esophagus on endoscopy and pH monitoring.
Finding a cause for various conditions mentioned here can be frustrating. Heartburn is often absent. Endoscopy is often negative. It may be worth trying gastric acid suppression therapy using proton pump inhibitors (PPI) to see if the symptoms affecting the lungs, ear, nose and throat and other conditions are relieved by these medications. Trial of medications twice a day for two to three months may be effective.
If the patient does not respond to this therapy then the next line of investigation would be 24-hour pH study while on PPI.
So, it is not easy to come to a diagnostic conclusion when investigating patients who are suspected to have atypical presentation of gastro-esophageal reflux disease. I presume you have had thorough investigation and your doctor has made a diagnosis after taking into consideration all the results.
Are you worried about getting old? Here is a joke I received from a friend:
“Sixty is the worst age to be,” said a 60-year-old man. “You always feel like you have to pee and most of the time you stand there and nothing comes out.”
“Ah, that’s nothing,” said a 70-year-old. “When you’re 70, you don’t have a bowel movement any more. You take laxatives, eat bran and sit on the toilet all day and nothing comes out.”
“Actually,” said the 80-year -old, “Eighty is the worst age of all.”
“Do you have trouble peeing, too?” asked the 60-year old.
“No, I pee every morning at 6:00. I pee like a racehorse on a flat rock, no problem at all.”
“So, do you have a problem with your bowel movement?”
“No, I have one every morning at 6:30.”
Exasperated, the 60-year-old said, “You pee every morning at 6:00 and have a bowel movement every morning at 6:30. So what’s so bad about being 80?”
“I don’t wake up until 7:00,” said the 80-year-old.
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