P0464 - Iatrogenic GERD With Extraesophageal Manifestations Proven by Impedance Testing

Jake S. Jacob, MD, Ankur Patel, MD, Milena Gould, MD
Baylor College of Medicine, Houston, TX

Introduction: Transient lower esophageal sphincter (LES) relaxation (TLESR) is a major mechanism of reflux in patients with gastroesophageal reflux disease (GERD). Several agents are theorized to increase the rate of TLESRs. One class, calcium channel blockers (CCBs), promote smooth muscle relaxation, thereby inducing pressure reduction in the LES. We present a patient with severe reflux proven with impedance testing that resolved with cessation of her CCB.

Case Description/Methods: A 45-year-old woman with a history of essential hypertension presented to the gastroenterology clinic for evaluation of reflux. She had been seen by her PCP regularly for health maintenance and was started on lisinopril for hypertension 3 years prior to the visit. For additional blood pressure control, her PCP added diltiazem. 2 months afterwards, the patient developed severe reflux and nocturnal coughing episodes limiting her quality of life and was referred to gastroenterology for evaluation. She was started on a proton pump inhibitor (PPI) that was escalated to twice daily without relief of symptoms. Esophagogastroduodenoscopy did not find evidence of erosive esophagitis. Esophageal manometry showed normal contractility and normal LES pressures.

Ambulatory pH impedance was done after holding proton pump inhibitor therapy that showed a proximal acid exposure time of 10.4% (normal < 4.2%), with 9.0% in the upright position (normal < 6.3%) and 12.4% in the supine position (normal < 1.2%). 94.4% of her coughing episodes were related to acid or weakly acidic reflux. Afterwards, to maximize medical management prior to surgical evaluation, she was asked to discontinue her diltiazem and lisinopril and switch to chlorthalidone for hypertension management. At her one month follow up, the patient described resolution of her reflux sensations and cough. Proton pump inhibitor therapy was discontinued. The patient had durable resolution of her symptoms 6 months after discontinuation of her CCB.

Discussion: Medications used for common issues such as hypertension can significantly impact esophageal physiology. In this case, we objectively demonstrate how a patient’s antihypertensive regimen led to increased acid exposure in the proximal esophagus and was even associated with cough. Thankfully, discontinuation led to rapid improvement in symptoms. An improved understanding of pharmacomodulation of the LES tone has potential to both prevent iatrogenic pathology such as GERD and serve as treatment for disorders of impaired LES relaxation.




Disclosures:


Jake S. Jacob, MD, Ankur Patel, MD, Milena Gould, MD. P0464 - Iatrogenic GERD With Extraesophageal Manifestations Proven by Impedance Testing, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.