Extraesophageal presentations of GERD: where is the science?

Association Between Chronic Rhinosinusitis and Reflux Diseases in Adults: A Systematic Review and Meta-Analysis

BACKGROUND

Over the last few decades, reflux diseases, such as laryngopharyngeal reflux (LPR) and gastroesophageal reflux disease (GERD), have been identified as significant contributors to inflammatory upper aerodigestive tract diseases. Establishing a direct relationship between reflux disease and chronic rhinosinusitis (CRS) is challenging due to the high prevalence of both diseases and their potential for independent coexistence.

OBJECTIVE

The purpose of this study is to review the existing literature and evaluate the evidence of an association between reflux diseases and CRS.

METHODS

A comprehensive electronic search was conducted across multiple databases to identify all studies that investigated the relationship between LPR, GERD, and CRS from January 1, 1950, to June 16, 2022. Only studies with English manuscripts involving adult populations were included, while case series, case reports, and in vitro studies were excluded. The risk of bias was evaluated using The Newcastle-Ottawa Scale for case-control studies and the NIH quality assessment tool for observational cohort and cross-sectional studies.

RESULTS

The search strategy yielded a total of 427 articles, out of which 25 studies examined the correlation between reflux diseases and CRS. The meta-analysis indicated a significant association between the presence of GERD and CRS compared to control groups (P < .001; CI 3.56 [2.25, 5.65]), as well as significantly higher pH values and pepsin detection in CRS patients when compared to healthy individuals (P = .003). Furthermore, all studies that evaluated proton pump inhibitor (PPI) therapy in CRS patients reported positive outcomes, with 93% of CRS patients showing improvement on PPIs.

CONCLUSION

The existing literature provides suggestive evidence of an association between reflux diseases and CRS, with regards to both prevalence and treatment. Nonetheless, further studies are required to confirm this relationship.

Chronic Cough and Causes in Children

Coughing is a natural means to clear the airway [...].

The Effect of Bariatric Surgery and Endoscopic Procedures on Gastroesophageal Reflux Disease

Obesity is a global epidemic posing a significant burden on patients and healthcare systems. Gastroesophageal reflux disease is associated with obesity and its prevalence is also growing worldwide. Numerous bariatric surgeries and endoscopic procedures have arisen to assist with weight loss and management of obesity-related conditions. However, the effect of these interventions on reflux is variable and the evidence is often conflicting. To date, Roux-en-Y gastric bypass remains the gold-standard for attaining both reflux and weight loss management, however novel endoscopic techniques are quickly becoming more prevalent as an alternative to surgery. This review aims to summarize currently available endoscopic and surgical weight loss procedures and their impact on reflux symptoms while emphasizing areas requiring additional investigation.

Diagnosis and management of chronic cough: similarities and differences between children and adults

Cough is a natural process that protects the airway. Cough can occur spontaneously or voluntarily. It is considered chronic when it is present for longer than 4 weeks in children or 8 weeks in adults. In both, chronic cough causes patient distress and increased healthcare utilization. Etiologies of pediatric chronic cough include asthma, protracted bacterial bronchitis, tracheomalacia, habit cough, and various systemic disorders. While some diagnoses are identifiable by careful history alone, others require testing guided by specific pointers. Flexible fiberoptic bronchoscopy has been an important tool to identify etiologies of chronic cough that were not otherwise apparent. In adults, asthma and bronchitis are well-defined etiologies of chronic cough, but much chronic cough in adults is largely a conundrum.

Reviews of adult chronic cough report that at least 40% of adults with chronic cough have no medical explanation. Gastroesophageal reflux and upper airway cough syndrome (a.k.a. post-nasal drip) have been common diagnoses of chronic cough, but those diagnoses have no support from controlled clinical trials and have been subjected to multiple published critiques. Cough hypersensitivity is considered to be an explanation for chronic cough in adults who have no other confirmed diagnosis. Gabapentin, a neuromodulator, has been associated with a modest effect in adults, as has speech pathology. While habit cough has not generally been a diagnosis in adults, there is evidence for a behavioral component in adults with chronic cough. Treatment for a specific diagnosis provides a better outcome than trials of cough suppression in the absence of a specific diagnosis. More data are needed for chronic cough in adults to examine the hypothesized cough hypersensitivity and behavioral management. This article reviews etiologies and the treatment of chronic cough in children and the conundrum of diagnosing and treating chronic cough in adults.

Gastroesophageal Reflux Disease: A Cause for Eustachian Tube Dysfunction in Obstructive Sleep Apnea

OBJECTIVES

To explore the effect of gastroesophageal reflux disease (GERD) on Eustachian tube function in patients with obstructive sleep apnea (OSA).

METHODS

This was a cross-sectional study. The patients were divided into 4 groups according to OSA and GERD: OSA+GERD group; OSA-only group; GERD-only group; and normal control group.

RESULTS

There were no differences among the 4 groups regarding age, sex, smoking history, and alcohol history (all P > .05). The patients in the OSA and OSA+GERD groups had a significantly larger body mass index than those in the control and GERD-only groups (all P < .05). The proportions of patients with abnormal ETS-7 and ETD-Q results were higher in the GERD and OSA+GERD groups compared to the control group (P < .008). There were no significant differences in ETS-7 and ETD-Q between the control and the OSA-only groups (P > .008). The multivariable analysis showed that only GERD was independently associated with abnormal ETS-7 results (odds ratio = 3.090, 95% CI: 1.332-7.169, P = .009).

CONCLUSION

Given the high concomitance rate in patients with OSA, GERD might be an important association factor of Eustachian tube dysfunction in patients with OSA.

[Gastroesophageal reflux disease with cardial manifistations: perspectives of non-pharmacological treatment methods]

In this article we present the review of the literature and our own research regarding gastroesophageal reflux disease (GERD) with cardiac manifestations. The methods of treatment of patients with GERD using mineral waters, physio- and balneotherapeutic factors, as well as acupuncture are discussed. The conclusion is drawn about the effectiveness of the use of non-pharmacological methods in mono- and complex therapy of GERD and the need for further research in this direction.

Long-term patient satisfaction and durability of laparoscopic anti-reflux surgery in a large Danish cohort: study protocol for a retrospective cohort study with development of a novel scoring system for patient selection

INTRODUCTION

Laparoscopic anti-reflux surgery is standard of care in surgical treatment of gastro-oesophageal reflux disease and is not without risks of adverse effects, including disruption of the fundoplication and postfundoplication dysphagia, in some cases leading to reoperation. Non-surgical factors such as pre-existing anxiety or depression influence postoperative satisfaction and symptom relief. Previous studies have focused on a short-term follow-up or only certain aspects of disease, such as reoperation or postoperative quality of life. The aim of this study is to evaluate long-term patient-satisfaction and durability of laparoscopic anti-reflux surgery in a large Danish cohort using a comprehensive multimodal follow-up, and to develop a clinically applicable scoring system usable in selecting patients for anti-reflux surgery.

METHODS AND ANALYSIS

The study is a retrospective cohort study utilising data from patient records and follow-up with patient-reported quality of life as well as registry-based data. The study population consists of all adult patients having undergone laparoscopic anti-reflux surgery at The Department of Surgery, Kolding Hospital, a part of Lillebaelt Hospital Denmark in an 11-year period. From electronic records; patient characteristics, preoperative endoscopic findings, reflux disease characteristics and details on type of surgery, will be identified. Disease-specific quality of life and dysphagia will be collected from a patient-reported follow-up. From Danish national registries, data on comorbidity, reoperative surgery, use of pharmacological anti-reflux treatment, mortality and socioeconomic factors will be included. Primary outcome of this study is treatment success at follow-up.

ETHICS AND DISSEMINATION

Study approval has been obtained from The Danish Patient Safety Agency, The Danish Health Data Authority and Statistics Denmark, complying to Danish and EU legislation. Inclusion in the study will require informed consent from participating subjects. The results of the study will be published in peer-reviewed medical journals regardless of whether these are positive, negative or inconclusive.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov (NCT03959020).

[Pharyngeal acid load and different functional endoscopy findings]

The findings of functional endoscopy (upper esophageal sphincter insufficiency, cardia insufficiency, esophagitis, gastric heterotopia, axial sliding hernia, and visible aerosols) can be traced back to pharyngeal acid exposure by oropharyngeal pH measurement. Significantly increased pharyngeal acid loads are seen in gastric heterotopy and axial sliding hernia. For all measured statistics, the pharyngeal acid load is in the pathological or even very pathological range. The value of functional endoscopy in the context of laryngopharyngeal reflux diagnosis is clearly documented. The findings "heterotopic gastric mucosa" and "axial sliding hernia" may cause marked airway symptoms and a pathogenetic relationship with otorhinolaryngologic reflux-associated symptoms must be postulated for these entities.

Aerodigestive disorders in dogs evaluated for cough using respiratory fluoroscopy and videofluoroscopic swallow studies

Aerodigestive diseases, hybrid disorders representing a pathologic link between respiratory and alimentary tracts, may manifest with respiratory signs without gastrointestinal signs. These are underdiagnosed in dogs due to poor clinical recognition and diagnostic limitations. We hypothesize that a subset of dogs presenting for cough without gastrointestinal signs would have occult aerodigestive disorders identified using videofluoroscopic swallow study (VFSS). Data were retrospectively obtained from 31 client-owned dogs presenting for cough, with thoracic radiographs, and a VFSS between April 2015 and December 2017. Exclusion criteria were cough of cardiac origin or gastrointestinal signs within 6 months. Swallow study parameters included pharyngeal/esophageal motility, laryngeal obstruction/defects, penetration-aspiration, reflux, excessive aerophagia, megaesophagus (ME), lower-esophageal sphincter achalasia-like syndrome (LES-AS), and sliding hiatal hernia (HH). The median (interquartile range) duration of cough was 4 (2-8) months. Thoracic radiographs were unremarkable in 11 dogs, with aspiration pneumonia suspected in seven. In 25/31 dogs (81%), VFSS abnormalities were detected and some dogs had more than one defect: pharyngeal (n=10) or esophageal hypomotility (n=10), reflux (n=9), penetration-aspiration (n=8), excessive aerophagia (n=6), laryngeal obstruction (n=3), ME (n=3), HH (n=2), and LES-AS (n=1). A respiratory disorder causing cough was identified in 17 dogs with VFSS abnormalities (laryngeal obstruction/defect and airway disease including chronic or eosinophilic bronchitis, tracheal/mainstem bronchial collapse, bronchiectasis, and bronchomalacia). An alimentary disorder identified on VFSS in absence of a discrete respiratory disorder causing cough was diagnosed in eight dogs. In conclusion, canine aerodigestive disorders can manifest as cough without alimentary signs. VFSS is a useful diagnostic to determine the contribution of esophageal/gastrointestinal pathology in dogs with cough.

Matrix association region/scaffold attachment region: the crucial player in defining the positions of chromosome breaks mediated by bile acid-induced apoptosis in nasopharyngeal epithelial cells

Background

It has been found that chronic rhinosinusitis (CRS) increases the risk of developing nasopharyngeal carcinoma (NPC). CRS can be caused by gastro-oesophageal reflux (GOR) that may reach nasopharynx. The major component of refluxate, bile acid (BA) has been found to be carcinogenic and genotoxic. BA-induced apoptosis has been associated with various cancers. We have previously demonstrated that BA induced apoptosis and gene cleavages in nasopharyngeal epithelial cells. Chromosomal cleavage occurs at the early stage of both apoptosis and chromosome rearrangement. It was suggested that chromosome breaks tend to cluster in the region containing matrix association region/scaffold attachment region (MAR/SAR). This study hypothesised that BA may cause chromosome breaks at MAR/SAR leading to chromosome aberrations in NPC. This study targeted the AF9 gene located at 9p22 because 9p22 is a deletion hotspot in NPC.

Methods

Potential MAR/SAR sites were predicted in the AF9 gene by using MAR/SAR prediction tools. Normal nasopharyngeal epithelial cells (NP69) and NPC cells (TWO4) were treated with BA at neutral and acidic pH. Inverse-PCR (IPCR) was used to identify chromosome breaks in SAR region (contains MAR/SAR) and non-SAR region (does not contain MAR/SAR). To map the chromosomal breakpoints within the AF9 SAR and non-SAR regions, DNA sequencing was performed.

Results

In the AF9 SAR region, the gene cleavage frequencies of BA-treated NP69 and TWO4 cells were significantly higher than those of untreated control. As for the AF9 non-SAR region, no significant difference in cleavage frequency was detected between untreated and BA-treated cells. A few breakpoints detected in the SAR region were mapped within the AF9 region that was previously reported to translocate with the mixed lineage leukaemia (MLL) gene in an acute lymphoblastic leukaemia (ALL) patient.

Conclusions

Our findings suggest that MAR/SAR may be involved in defining the positions of chromosomal breakages induced by BA. Our report here, for the first time, unravelled the relation of these BA-induced chromosomal breakages to the AF9 chromatin structure.

Electronic supplementary material

The online version of this article (10.1186/s12920-018-0465-4) contains supplementary material, which is available to authorized users.

Saliva Pepsin Detection and Proton Pump Inhibitor Response in Suspected Laryngopharyngeal Reflux

OBJECTIVES/HYPOTHESIS

To evaluate the prediction value of saliva pepsin detection for an 8-week proton pump inhibitor (PPI) response in patients with a Reflux Symptoms Index (RSI) score ≥13, which indicates possible laryngopharyngeal reflux.

STUDY DESIGN

Prospective individual single-cohort study.

METHODS

Patients were recruited who had experienced chronic laryngopharyngeal symptoms (RSI score ≥13) for more than 3 months after excluding other etiologies. The patients received PPI (40 mg of esomeprazole once daily) treatment for 8 weeks. Prior to treatment, the patients submitted saliva/sputum samples that were collected during the time symptoms were observed. The samples were taken for pepsin detection, and performed using the commercially available Peptest lateral flow device. The association of the Peptest results and PPI response were statistically analyzed with the χ² test.

RESULTS

Seventy-four patients completed the study, and upon completion of PPI treatment, the mean RSI score was significantly reduced from 19.22 ± 5.18 to 8.99 ± 5.69. Forty-four (59.5%) patients exhibited a good response as defined by an RSI score reduction ≥50%. The results of the Peptest were semiquantitatively graded as 0, 1, 2, 3 (negative, weak positive, moderate positive and strong positive, respectively) based upon the visual intensity of the test sample line as compared to the control line. Twenty-four patients (32.4%) exhibited grade 3 strong positive results. The Peptest strong positive results (P < .05) were significantly associated with a good PPI response, with the positive predictive value being 79.2%.

CONCLUSIONS

Analysis of strong positive results for pepsin detection in saliva/sputum samples may be a useful, noninvasive method for predicting better PPI response in patients with suspected reflux induced chronic laryngopharyngeal symptoms.

LEVEL OF EVIDENCE

2 Laryngoscope, 129:709-714, 2019.

Bile acids at neutral and acidic pH induce apoptosis and gene cleavages in nasopharyngeal epithelial cells: implications in chromosome rearrangement

BACKGROUND

Chronic rhinosinusitis (CRS) increases the risk of developing nasopharyngeal carcinoma (NPC) while nasopharyngeal reflux is known to be one of the major aetiological factors of CRS. Bile acid (BA), the component of gastric duodenal contents, has been recognised as a carcinogen. BA-induced apoptosis was suggested to be involved in human malignancies. Cells have the potential and tendency to survive apoptosis. However, cells that evade apoptosis upon erroneous DNA repair may carry chromosome rearrangements. Apoptotic nuclease, caspase-activated deoxyribonuclease (CAD) has been implicated in mediating translocation in leukaemia. We hypothesised that BA-induced apoptosis may cause chromosome breaks mediated by CAD leading to chromosome rearrangement in NPC. This study targeted the AF9 gene located at 9p22 because 9p22 is one of the most common deletion sites in NPC.

METHODS

We tested the ability of BA at neutral and acidic pH in inducing phosphatidylserine (PS) externalisation, reactive oxygen species (ROS) production, mitochondrial membrane potential (MMP) disruption, and caspase 3/7 activity in normal nasopharyngeal epithelial (NP69) and NPC (TWO4) cells. Inverse-PCR (IPCR) was employed to detect AF9 gene cleavages. To investigate the role of CAD in mediating these cleavages, caspase inhibition was performed. IPCR bands representing AF9 cleaved fragments were sequenced.

RESULTS

BA-treated cells showed higher levels of PS externalisation, ROS production, MMP loss and caspase 3/7 activity than untreated control cells. The effect of BA in the induction of these intracellular events was enhanced by acid. BA at neutral and acidic pH also induced significant cleavage of the AF9 gene. These BA-induced gene cleavages were inhibited by Z-DEVD-FMK, a caspase-3 inhibitor. Intriguingly, a few chromosome breaks were identified within the AF9 region that was previously reported to participate in reciprocal translocation between the mixed lineage leukaemia (MLL) and AF9 genes in an acute lymphoblastic leukaemia (ALL) patient.

CONCLUSIONS

These findings suggest a role for BA-induced apoptosis in mediating chromosome rearrangements in NPC. In addition, CAD may be a key player in chromosome cleavages mediated by BA-induced apoptosis. Persistent exposure of sinonasal tract to gastric duodenal refluxate may increase genomic instability in surviving cells.

SWALLOWING IN PATIENTS WITH LARYNGITIS

BACKGROUND

Dysphagia is described as a complaint in 32% of patients with laryngitis.

OBJECTIVE

The objective of this investigation was to evaluate oral and pharyngeal transit of patients with laryngitis, with the hypothesis that alteration in oral-pharyngeal bolus transit may be involved with dysphagia.

METHODS

Videofluoroscopic evaluation of the swallowing of liquid, paste and solid boluses was performed in 21 patients with laryngitis, 10 of them with dysphagia, and 21 normal volunteers of the same age and sex. Two swallows of 5 mL liquid bolus, two swallows of 5 mL paste bolus and two swallows of a solid bolus were evaluated in a random sequence. The liquid bolus was 100% liquid barium sulfate and the paste bolus was prepared with 50 mL of liquid barium and 4 g of food thickener (starch and maltodextrin). The solid bolus was a soft 2.2 g cookie coated with liquid barium. Durations of oral preparation, oral transit, pharyngeal transit, pharyngeal clearance, upper esophageal sphincter opening, hyoid movement and oral-pharyngeal transit were measured. All patients performed 24-hour distal esophageal pH evaluation previous to videofluoroscopy.

RESULTS

The evaluation of 24-hour distal esophageal pH showed abnormal gastroesophageal acid reflux in 10 patients. Patients showed longer oral preparation for paste bolus and a faster oral transit time for solid bolus than normal volunteers. Patients with laryngitis and dysphagia had longer preparation for paste and solid boluses, and a faster oral transit time with liquid, paste and solid boluses.

CONCLUSION

A longer oral preparation for paste and solid boluses and a faster transit through the mouth are associated with dysphagia in patients with laryngitis.

Respiratory manifestations of gastro-oesophageal reflux in children

Gastro-oesophageal reflux disease (GORD) is a complex problem in children. Suspected respiratory manifestations of GORD, such as asthma, chronic cough and laryngitis, are commonly encountered in the paediatric practice, but continue to be entities with more questions than answers. The accuracy of diagnostic tests (ie, pH or pH-impedance monitoring, laryngoscopy, endoscopy) for patients with suspected extraoesophageal manifestations of GORD is suboptimal and therefore whether there is a causal relationship between these conditions remains largely undetermined. An empiric trial of proton pump inhibitors can help individual children with undiagnosed respiratory symptoms and suspicion of GORD, but the response to therapy is unpredictable, and in any case what may be being observed is spontaneous improvement. Furthermore, the safety of these agents has been called into question. Poor response to antireflux therapy is an important trigger to search for non-gastro-oesophageal reflux causes for patients' symptoms. Evidence for the assessment of children with suspected extraoesophageal manifestations of GORD is scanty and longitudinal studies with long-term follow-up are urgently required.

Review article: gastro-oesophageal reflux disease in asthma and chronic obstructive pulmonary disease

BACKGROUND

When gastro-oesophageal reflux is causing symptoms or lesions in the oesophagus, this is referred to as gastro-oesophageal reflux disease (GERD). GERD can manifest itself through typical symptoms (heartburn, regurgitation) or may lead to extra-oesophageal symptoms. Extra-oesophageal manifestations of GERD gained increasing attention over the last decade, especially respiratory disorders, because of the prevalent co-occurrence with GERD. The role of GERD in the pathogenesis of respiratory disorders has become a topic of intense discussion.

AIM

To provide an overview of the current knowledge on the role of GERD in asthma and chronic obstructive pulmonary disease (COPD).

METHODS

PubMed was searched for relevant articles using the keywords: GERD, asthma, COPD, prevalence, treatment. Case reports were excluded, only English language articles were considered.

RESULTS

Estimates for the prevalence of GERD in asthma range from 30% to 90%, compared to an average of 24% in controls. In COPD patients, the prevalence of GERD ranges from 19% to 78% compared to an average of 18% in controls. These data indicate an increased prevalence of GERD in patients with asthma and COPD, although causality is not established and GERD treatment yielded inconsistent effects. Literature supports GERD as a risk factor for COPD-exacerbations and a predictor of the 'frequent-exacerbator'-phenotype.

CONCLUSIONS

Despite the high prevalence of GERD in asthma and COPD, a causal link is lacking. The results of anti-reflux therapy on pulmonary outcome are inconsistent and contradictory. Future studies will need to identify subgroups of asthmatics and COPD patients that may benefit from anti-reflux therapy (nocturnal or silent reflux).

Chronic Rhinosinusitis and Extraesophageal Reflux: Who is the Candidate for Antireflux Treatment?

Background

During the past decade, extraesophageal reflux (EER) has been hypothesized to be one of the possible factors that contribute to the worsening of chronic rhinosinusitis (CRS). However, the relationship remains indeterminate due to its complexity, and it is not clear whether antireflux treatment is indicated for patients with recurrent CRS and who would benefit from it.

Objective

The aim of the study was to determine the severity of EER in patients with variable durations of CRS and different numbers of previous endoscopic endonasal surgeries (EES).

Methods

Ninety patients with CRS were recruited for the prospective case series. The age, sex, body mass index, reflux symptom index, duration of treatment of CRS with corticosteroids, and the number of ESS within the previous 5 years were ascertained. The severity of EER was evaluated by oropharyngeal pH monitoring by using the Restech system (the presence of EER, value of the RYAN score) and compared among the groups with varying durations of treatment of CRS (≤10 years, 11–20 years, >20 years) and different numbers of ESS within the previous 5 years (no ESS, 1–2 ESS, >2 ESS).

Results

Pathologic EER was present significantly more often in patients with CRS treated for >10 years (p = 0.0054) and in patients who underwent >2 ESS within the previous 5 years (p = 0.0001).

Conclusion

Patients with CRS treated for >10 years and those who had undergone >2 ESS within the previous 5 years had significant EER. Antireflux therapy (e.g., proton pump inhibitors) can be recommended for these patients. However, its effect has to be confirmed in further studies.

The management of gastro-oesophageal reflux disease

If there are no features of serious disease, suspected gastro-oesophageal reflux disease can be initially managed with a trial of a proton pump inhibitor for 4-8 weeks. This should be taken 30-60 minutes before food for optimal effect. Once symptoms are controlled, attempt to withdraw acid suppression therapy. If symptoms recur, use the minimum dose that controls symptoms. Patients who have severe erosive oesophagitis, scleroderma oesophagus or Barrett's oesophagus require long-term treatment with a proton pump inhibitor. Lifestyle modification strategies can help gastro-oesophageal reflux disease. Weight loss has the strongest evidence for efficacy. Further investigation and a specialist referral are required if there is no response to proton pump inhibitor therapy. Atypical symptoms or signs of serious disease also need investigation.

Patients with chronic rhinosinusitis and simultaneous bronchial asthma suffer from significant extraesophageal reflux

BACKGROUND

The aim of this study was to determine the severity of extraesophageal reflux (EER) in patients with various degrees of chronic rhinosinusitis (CRS), and particularly in patients with simultaneous bronchial asthma.

METHODS

Patients with different severity of CRS were invited to participate in the study. Group I consisted of patients with CRS without nasal polyps or bronchial asthma; group II consisted of patients with CRS with nasal polyps but without bronchial asthma; group III consisted of patients with CRS with nasal polyps and bronchial asthma. The age, gender, Reflux Symptom Index, severity of EER evaluated using the Restech system, and number of previous functional endoscopic sinus surgeries (FESSs) were compared between groups.

RESULTS

A total of 90 patients (30 in each group) were recruited for the study. Pathological EER was significantly often present in group III when compared with group I and group II in all parameters analyzed (RYAN score, number of EER episodes, total percentage of time below pH 5.5). Furthermore, patients from group III had undergone more surgeries in the past.

CONCLUSION

Patients with CRS with nasal polyps and simultaneous bronchial asthma suffer from significant EER. Antireflux therapy can be recommended for these patients. However, the effect has to be confirmed in further studies.

Hypopharyngeal pepsin and Sep70 as diagnostic markers of laryngopharyngeal reflux: preliminary study

INTRODUCTION

The management of laryngopharyngeal reflux (LPR) has been challenging. Hypopharyngeal multichannel intraluminal impedance (HMII) has shown to increase the sensitivity in diagnosing LPR. The objective of this study is to investigate the potential use of pepsin and Sep70 as diagnostic tools for detection of LPR in combination with HMII.

MATERIALS AND METHODS

Tissue samples of hypopharynx, distal esophagus, and gastric cardia were collected from patients with LPR symptoms regardless of gastroesophageal reflux (GERD) diagnosis and underwent HMII to detect LPR and high esophageal reflux (HER: reflux 2 cm distal to upper esophageal sphincter) events. Patients were classified into two groups based on the presence of abnormal proximal exposure (APE), which was defined as LPR ≥1/day and/or HER ≥5/day: (1) positive-APE and (2) negative-APE. Patients with typical GERD symptoms without LPR symptoms who did not undergo HMII were used as a "control" GERD group. Protein was isolated from tissue samples and Western blot analysis of pepsin and Sep70 was performed. Pepsinogen was used as a control to differentiate pepsin from pepsinogen. Relative quantitation was performed using Image Studio Lite Software with normalization against the internal actin of each blot.

RESULTS

From October 2012 to September 2013, 55 patients underwent HMII. Of 55, 20 patients underwent biopsies from hypopharynx (17 positive-APE and 3 negative-APE). Ten patients with typical GERD symptoms were identified from tissue bank as a "control" GERD group. Pepsin was detected in distal esophagus and hypopharynx in all groups without significant difference among groups. However, Sep70 in distal esophagus and hypopharynx was significantly depleted in the positive-APE group compared to the other groups (p = 0.032 and 0.002, respectively).

CONCLUSION

Depletion of Sep70 with the presence of pepsin in the hypopharynx may indicate cellular injury in laryngopharynx due to constant proximal reflux. However, the normative data for these markers have to be validated.