Review Question - QID 106299

The patient's symptoms are most consistent with gastroesophageal reflux disease (GERD) and he should be started on a trial of an anti-reflux medication, such as omeprazole (a proton pump inhibitor).

The most common causes of persistent cough include asthma, upper airway cough syndrome (post-nasal drip), and GERD. Clues that point toward GERD in this patient include obesity, going to bed immediately after dinner, sore throat and laryngitis, and chest pain unrelated to exertion. The pathophysiology of GERD is centered around intrinsic weakness of the lower esophageal sphincter that allows for reflux of acidic gastric contents up in to the esophagus. GERD is very prevalent among asthmatics and can exacerbate airflow obstruction via aspiration of small quantities of gastric contents into the upper airway, increased vagal tone, and heightened bronchial reactivity. Management begins with initiation of an anti-reflux medication such as omeprazole and and avoidance of triggers such as spicy foods. Obesity is a contributing factor and patients should be counseled on weight loss. More recent data suggests that long-term use of proton pump inhibitors may increase the risk of pneumonia and osteoporosis, so caution should be used.

Kellerman et. al review the pathophysiology, diagnosis and management of GERD. They further detail the mechanism by which aspiration of gastric contents leads to bronchoconstriction and cough. They recommend initiating treatment with proton pump inhibitors such as omeprazole.

Illustration A is a table of atypical GERD symptoms.
Illustration B is an illustration showing mechanisms of GERD-induced bronchoconstriction.

Incorrect answers:
Answer 1: Adding dextromethorphan, an NMDA receptor antagonist and cough suppressant, may help control this patient's cough. However, it will not treat the underlying cause of this patient's cough.

Answer 3: Adding salmeterol, a long-acting beta agonist, would be appropriate if this patient's symptoms were due to worsening asthma. However, this patient's presentation is suggestive of GERD.

Answer 4: Discontinuing lisinopril would be appropriate if this patient's cough was thought to be related to lisinopril use. While cough is a common side effect of lisinopril use, this patient's presentation is more suggestive of GERD.

Answer 5: Switching to a high-dose fluticasone inhaler would be appropriate if this patient's symptoms were due to worsening asthma. However, this patient's presentation is suggestive of GERD.

Bullet Summary:
Gastroesophageal reflux disease is a common cause of cough and is managed with the initiation of a proton pump inhibitor such as omeprazole.