Chronic cough question from Pulmonologist to GI doctors

[NewYorkDoctors]

Hello GI doctors

I have an honest question about community GI setups regarding getting esophageal manometry and 24 hour pH probe Bravo studies.

As a pulmonologist I see a lot of chronic cough.
After I have gone through the checklist of asthma/COPD/bronchiectasis/structural lung disease and done all of my PFTs, FENOs, bronchoprovocation testing, and CT chests, I am often still confronted with GERD

I barium esophagrams and at times I get lucky with GERD but this is not always the case.

Once UACS is ruled out, I am confronted with GERD

These patients have usually seen a community GI and had EGD done and there might be some gastritis or intestinal metaplasia but not necessarily esophagitis.

I am often ordering hospital beds or doing discussions on intensive lifestyle modifications for these patients or trying to get them to be adherent to their PPIs (which the PCP should be doing but I digress)

The "by the book" workup next would be to evaluate for non-erosive reflux disease . But for the life of me I have never seen a community GI doctor (at least in my neck of the woods in NYC) do esophageal manometry or Bravo studies. From what I understand this is an academic GI only thing?
I mean I would assume that community GIs would refer to their academic colleagues? (Because I know leaving the profitable office for a hospital anesthesia procedure is not profitable or a good use of business time - I Try not to do bronchs and leave my office unless its clearly not something for thoracic surgery to do and it's like a TB case or sarcoidosis case and only I should do it) but this does not seem to happen in my neck of the woods.


This is not a GI bashing thread at all. I just wanted to know if community GI docs should be finding someone to treat their refractory GERD patients by arranging for these tests in a hospital endoscopy suite?

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[Suprep]

Half of our community GI dept does esophageal manometry, bravo, etc. We do need the hospital to budget for upfront costs of these equipment and maintenance when they break. We have a robust upper GI surgery team so ability to do Bravo, manometry is key for their procedures. But I would say setup like ours is not typical of community practice. Blame it on poor reimbursement, lack of training for older docs for manometry, etc. Many community setups around us do not do the above tests.

 

[NewYorkDoctors]

so if my chronic cough patients keep bothering me then I should take the initiative to find them an academic GI then?
if I ever write recommendations for PCP to do these things... it does NOT get done.

what often happens is when I tell them the by the books approach (and then tell them I am using Internal Medicine MKSAP level knowledge here) is to do these test and I show them a youtube video of the Bravo, they instantly stop bothering me lol

 

[Suprep]

so if my chronic cough patients keep bothering me then I should take the initiative to find them an academic GI then?
if I ever write recommendations for PCP to do these things... it does NOT get done.

what often happens is when I tell them the by the books approach (and then tell them I am using Internal Medicine MKSAP level knowledge here) is to do these test and I show them a youtube video of the Bravo, they instantly stop bothering me lol

my ENT colleagues have no issues with the reflux testing and diagnose most ppl with LPR

 

[NewYorkDoctors]

my ENT colleagues have no issues with the reflux testing and diagnose most ppl with LPR

right. the ENTs I refer to will do laryngoscopy. but those reflux findings tend to be more specific than sensitive?
I have had patients tell me "the ENT doctor said nothing was seen so it's not GERD!"
then the same patient whom I eventually get a barium esophagram on shows GERD and then really pushing the "take PPI twice a day standing. that's right standing . Not PRN. This is not TUMS" and "buy a GERD Pillow or i'll order you a semi automatic bed" and "you really have to cut out these food groups and stop eating for 4 hours before laying down." etc.... and they ultimately get better over the following 2 months

 

[Suprep]

right. the ENTs I refer to will do laryngoscopy. but those reflux findings tend to be more specific than sensitive?
I have had patients tell me "the ENT doctor said nothing was seen so it's not GERD!"
then the same patient whom I eventually get a barium esophagram on shows GERD and then really pushing the "take PPI twice a day standing. that's right standing . Not PRN. This is not TUMS" and "buy a GERD Pillow or i'll order you a semi automatic bed" and "you really have to cut out these food groups and stop eating for 4 hours before laying down." etc.... and they ultimately get better over the following 2 months

by the way, barium esophagogram is neither sensitive or specific test for diagnosing GERD.

There is the whole issue of NERD(Non erosive reflux disease) which can still happen on those taking PPI. It is due to mechanical issue with the GE junction laxity(hiatal hernia or just lax sphincter) that can still trigger cough.

 

[NewYorkDoctors]

right. there is no real gold standard for laryngeal reflux diagnosis.

when all the lung etiologies are ruled out, I say follow up PCP and then PCP gaslights the patient back to me, i'm often trying to get an academic GI referral done but there are too many barriers for this (usually the patient's impatience of waiting for a hospital based physician's wait time. patients like their community doctors for the "ease and quickness." But once the resources of an academic physician is required, the patients suddenly become very irritable and moody at the wait time... at least that's the New Yorker problem)

Often i just get them a hospital bed and/or do some empiric baclofen for the LES tightening effect. many patients do get better

i just lament how hard it is to do a "full proper workup" in the community.

 

[Gastrapathy]

Keep your own functional patients. We have plenty. Seriously, if a PPI doesn’t work, there’s no point in all this nonsense.

 

[NewYorkDoctors]

Keep your own functional patients. We have plenty. Seriously, if a PPI doesn’t work, there’s no point in all this nonsense.

technically they are not "my patients" as I have already ruled out lung disease in these patients but I am unable to "get them go to go away" because their PCPs keep gaslighting them back to me. bad PCP bad. so I am just trying to be helpful for these patients in which all the PCPs can do is gaslight and agitate. it's a cruel world out there.

 

[Gastrapathy]

So your solution is to pass them to another specialist? And you don’t see the irony in that.

 

[NewYorkDoctors]

edit posted this in DM to you. no need to make the forums full of mud.

I thank you Suprep for your insightful answers.

I will not post publicly on this thread any further. Happy New year to everyone here.

 

[slopes23]

This thread is deteriorating fast. NewYorkDoctor I don’t know who the community doctors are in your area but it’s a small sample of what the entire community looks like in your region let alone the country. If you think recommending FODMAPS to an IBD patient is a panacea and that GI doctors don’t know how to manage IBS then I would posit that you simply haven’t seen the much more severe and refractory cases of IBS and those patients are hard to manage. I think the point that was being made was that there are some patients/diagnosis that are just frankly difficult to manage, not because of their complexity but the fact that they are functional disorders that have no physiologic or very little physiologic correlate making it frustrating to manage for people that go into specialities that are otherwise know for having much more logical and solvable physiologies. Most if not all specialities, especially in medicine have their own subset of functional patients. Yours happens to be functional cough, among others I’m sure. Ours is functional dyspepsia, IBS, functional diarrhea among others. I think the point is that you make it seem like you were trying to punt off your functional patients to the PCP and then later to GI under a facade that it’s for patient care when the style of your writing implies it’s more likely to get them off your panel. No one wants to manage these patients but it was being pointed out as ironic that you were speaking poorly of a PCP for not wanting to manage a patient that you yourself didn’t want to manage for a condition that arguably is equally in your territory as it in the PCP’s. If you think there was so much to be added by a GI for cough then order the procedure that you think is indicated like a Bravo, we’ll be glad to do the procedure and interpret it for you and send the patient back to you with that information in hand so you can continue to manage them.

But don’t act like you punting off patients is in the name of this being a team sport or under the guise of its best for the patient. At least have the gull to call a spade a spade.

But I think this tangent should likely stop here as I suspect it’s only going to deteriorate further and for what. I myself don’t want/mean to insult you because at the end of the day it’s just a matter of feeling frustrated or unsatisfied by seeing these patients (for most of us).