The overlap syndrome of urticaria and gastroesophageal reflux disease

Abstract

BackgroundOne-quarter of systemic symptoms associated with chronic spontaneous urticaria (CSU) are related to gastrointestinal complaints (GICs).ObjectivesTo investigate the prevalence and features of urticaria-overlapping GICs.MethodsIn this retrospective cross-sectional survey, 1426 consecutive outpatients were observed at our University Department. Only patients suffering from urticaria or GICs with a complete diagnostic work-up including serum total IgE level (Tot-IgE), differential blood count and urticaria activity score (UAS), were evaluated.ResultsAmong different GICs, gastroesophageal reflux disease (GERD) was the most frequent syndrome observed (15.4%; 95%CI: 13.6–17.3). The prevalence of overlap syndrome for urticaria and GERD was 5.9% (95%CI: 4.7–7.2). In urticaria-patients, the prevalence of GERD was four-fold higher than in patients without hives (44% vs. 11%, p<0.001). UAS was significantly higher in urticaria and GERD overlap syndromes vs. isolated urticarias. In patients with GERD or acute/chronic urticaria or overlap syndrome, Tot-IgE and eosinophil blood count (EBC) differed significantly, with a stepwise increase in their values; from the subgroup of patients with GERD only, to that with overlap of CSU to GERD. Prevalence values for urticaria overlapping with GERD were three- and two-fold higher in CSU and in long-duration GERD cases respectively compared to acute urticaria or short-duration GERD cases. Similar to Th2 pathology models, CSU and GERD overlap syndrome was significantly and independently associated with Total-IgE ≥100IU/ml or EBC ≥250/mmc compared to CSU or GERD. Endoscopic/bioptic findings of non-erosive reflux disease (NERD) or Barrett’s esophagus (BE) were more frequent in chronic overlap syndrome than in GERD-patients.ConclusionsGERD was the most frequent GIC in patients with urticaria. Overlap syndrome was more frequent among patients with CSU, where this syndrome was associated with higher values of UAS, Tot-IgE, EBC and frequencies of NERD and BE. These results suggest that overlap syndrome is frequently a chronic syndrome with a Th2-like profile.

The global burden of chronic urticaria for the patient and society*

“…13,20,109,110 An association between CSU and headaches has been reported, which can affect QoL, particularly in children. 111 There is a discussed link between CSU and Helicobacter pylori infection, 112 parasitic infections 113 and chronic viral infections including hepatitis B and C virus and human herpesvirus 6 114,115 Rarely, reports have linked CSU to papillary thyroid, lung and haematological malignancies. 116,117 Chronic urticaria comes with high costs for patients and society Direct costs of CSU (e.g.…”

Total IgE as a Marker for Chronic Spontaneous Urticaria

“… 17 Mean IgE values in CSU patients vary from 66 to 1,037 IU/mL ( Supplementary Table S1 ), regardless of whether comorbid atopic dermatitis was excluded. 18 19 The highest levels of IgE were found in atopic patients with CSU, 20 CSU with concomitant gastroesophageal reflux disorder, 21 and CSU patients with high interleukin (IL)-33 serum levels, 22 indicating that atopic status and concomitant disorders may influence serum total IgE levels of CSU patients.…”

Consecutive Severe Orofacial Complications in Intensive Care Unit Patients: Quincke’s Disease and Macroglossia due to Prolonged Prone Positioning for Management of Acute Respiratory Distress Syndrome

“…We first observed Quincke's disease; this is a rare presentation of angioneurotic oedema affecting only the upper airway. Various etiological factors such as gastroesophageal reflux disease, sleep apnoea, inhalation exposure, drug reactions, and trauma have been implicated, thus provoking orofacial oedema [5]. Moreover, it can be a lethal complication of ACE inhibitors therapy and the emergency physician should focus on airway evaluation and management when treating patients with ACEi-induced angioedema [6] .…”