Publication

Abstract : RATIONALE: We report the case of an 18 month old girl who presented with emesis, gagging, chronic cough, and wheezing. Despite the use of aggressive anti-reflux and asthma controller medications, her symptoms persisted. This case exemplifies the need to utilize a combined multichannel intraluminal impedance and pH study (MII-pH) to evaluate both acidic and non-acidic reflux as potential contributors to the supra-esophageal morbidity found in some cases of persistent respiratory distress. METHODS & RESULTS: The patient underwent an upper GI series which showed spontaneous gastroesophageal reflux. Ranitidine/metoclopramide orally and nebulized albuterol and budesonide respules were started. Symptoms continued and an ambulatory esophageal pH study showed continued acid reflux. Lansoprazole was added, but symptoms persisted. A repeat 24-hour pH study showed the acid reflux was well controlled. A scintiscan demonstrated delayed gastric emptying without evidence of aspiration. A trial of baclofen was unsuccessful. Albuterol nebulizations (during wheezing episodes) and nebulized budesonide respules had little effect on her respiratory status. A MII-pH demonstrated full control of the acid reflux but also evidence of multiple non-acid reflux episodes with positive symptom correlation for cough (66.7%) and regurgitation (66.7%). The infant, after 7 months of anti-inflammatory therapy (budesonide), underwent laparoscopic Nissen fundoplication at 8 months of age and became essentially symptom free without the need for bronchodilators, asthma controller medications, or anti-reflux therapy. CONCLUSIONS: This case demonstrates the need to evaluate both acidic and non-acidic reflux as potential contributors to the pathogenesis of supra-esophageal morbidity such as persistent respiratory distress, even in very young infants.