Detecting laryngopharyngeal reflux in patients with upper airways symptoms: Symptoms, signs or salivary pepsin?

The Consistency Between Symptom Scales and Multi-time Point Salivary Pepsin Test for Diagnosing Laryngopharyngeal Reflux Disease

OBJECTIVE

To investigate the screening diagnostic value of reflux symptom index (RSI) and reflux symptom score (RSS) for laryngopharyngeal reflux disease (LPRD).

METHODS

Fifty-two patients hospitalized in the Department of Otolaryngology-Head and Neck Surgery at The Sixth Medical Center of PLA General Hospital between October 2022 and April 2023 were enrolled in the study. These patients completed the RSS, RSI scales, as well as underwent the multi-time point salivary pepsin test (MTPSPT). Cohen's kappa test and receiver operating characteristic analysis were utilized to assess and compare the diagnostic values of the RSI and RSS.

RESULTS

A total of 52 patients, comprising 37 males and 15 females, with a mean age of 44 ± 12 years, were enrolled in the study. The Kappa values between RSS, RSI, and MTPSPT were found to be 0.403 (P < 0.05) and 0.192 (P < 0.05), respectively. When considering MTPSPT as the diagnostic criterion, the sensitivity and specificity of RSS were determined to be 76.70% and 76.90%, respectively, while those of RSI were 41.10% and 42.30%. Additionally, the negative predictive values for RSS and RSI stood at 77.70% and 64.70%, respectively, and their positive predictive values were 94.20% and 57.10%. Furthermore, the area under the curves (AUC) for RSS and RSI were calculated to be 0.677 (95% confidence interval [CI]: 0.464-0.742) and 0.609 (95% CI: 0.533-0.800), respectively.

CONCLUSIONS

RSS had a better concordance with multi-time point salivary pepsin test results and AUC values when screening for LPRD.

Adaptation and Validation of Reflux Symptom Index into Hindi Language (RSI-H®)

OBJECTIVE

The current study aimed to translate, culturally adapt, and validate the Reflux Symptomatic Index in the Hindi language. Secondly, we aimed to compare its outcomes between normal individuals and people suffering from laryngopharyngeal reflux.

STUDY DESIGN

Cross-sectional study design.

MATERIAL AND METHODS

The original Reflux Symptom Index was translated into Hindi language using the forward-backward translation method. A total of 192 participants were included in the study. Among 192 participants, 57 were healthy controls, and 135 were individuals with laryngopharyngeal reflux. Internal consistency, test-retest reliability, and clinical validity were measured.

RESULTS

The majority of the population reported the presence of globus sensation. Results revealed that the Hindi version of the Reflux Symptom Index exhibited an excellent internal consistency (ie, 0.829). A significant difference was found between the mean scores of both groups, and the excellent test-retest reliability score (ie, 0.94 & 0.96) was obtained.

CONCLUSION

We can conclude that the Hindi version of the Reflux Symptom Index exhibited a similar psychometric functional property as the Original version of the Reflux Symptom Index. So, the developed tool is a quick, reliable, and valid tool to assess laryngopharyngeal reflux.

Laryngopharyngeal reflux disease: Updated examination of mechanisms, pathophysiology, treatment, and association with gastroesophageal reflux disease

Laryngopharyngeal reflux disease (LPRD) is an inflammatory condition in the laryngopharynx and upper aerodigestive tract mucosa caused by reflux of stomach contents beyond the esophagus. LPRD commonly presents with sym-ptoms such as hoarseness, cough, sore throat, a feeling of throat obstruction, excessive throat mucus. This complex condition is thought to involve both reflux and reflex mechanisms, but a clear understanding of its molecular mechanisms is still lacking. Currently, there is no standardized diagnosis or treatment protocol. Therapeutic strategies for LPRD mainly include lifestyle modifications, proton pump inhibitors and endoscopic surgery. This paper seeks to provide a comprehensive overview of the existing literature regarding the mechanisms, patho-physiology and treatment of LPRD. We also provide an in-depth exploration of the association between LPRD and gastroesophageal reflux disease.

Narrative review of relationship between chronic cough and laryngopharyngeal reflux

Gastroesophageal reflux disease (GERD) as a possible cause of chronic cough is known for decades. However, more than 75% of patients with extraoesophageal symptoms do not suffer from typical symptoms of GERD like pyrosis and regurgitations and have negative upper gastrointestinal endoscopy. For such a condition term laryngopharyngeal reflux (LPR) was introduced and is used for more than two decades. Since the comprehensive information on relationship between chronic cough and LPR is missing the aim of this paper is to summarize current knowledge based on review of published information during last 13 years. Laryngopharyngeal reflux is found in 20% of patients with chronic cough. The main and recognized diagnostic method for LPR is 24-h multichannel intraluminal impedance-pH (MII-pH) monitoring, revealing reflux episodes irritating the upper and lower respiratory tract mucosa. The treatment of LPR should be initiated with dietary and lifestyle measures, followed by proton pump inhibitor (PPI) therapy and other measures. Despite progress, more research is needed for accurate diagnosis and targeted therapies. Key areas for exploration include biomarkers for diagnosis, the impact of non-acid reflux on symptom development, and the efficacy of new drugs. Further studies with a focused population, excluding other causes like asthma, and using new diagnostic criteria for LPR are essential. It's crucial to consider LPR as a potential cause of unexplained chronic cough and to approach diagnosis and treatment with a multidisciplinary perspective.

Ocular Surface Disease as Extraesophageal Gastroesophageal Reflux Disease Manifestation: A Specific Therapeutic Strategy

PURPOSE

Gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux (LPR) are common gastrointestinal disorders with extraesophageal manifestations (EGERD). Studies showed a correlation between GERD/LPR and ocular discomfort. Our aim was to report the prevalence of ocular involvement in patients with GERD/LPR, describe clinical and biomolecular manifestations, and provide a treatment strategy for this novel EGERD comorbidity.

METHODS

Fifty-three patients with LPR and 25 healthy controls were enrolled in this masked randomized controlled study. Fifteen naive patients with LPR were treated with magnesium alginate eye drops and oral therapy (magnesium alginate and simethicone tablets) with a 1-month follow-up. Clinical ocular surface evaluation, Ocular Surface Disease Index questionnaire, tear sampling, and conjunctival imprints were performed. Tear pepsin levels were quantified by ELISA. Imprints were processed for human leukocyte antigen-DR isotype (HLA-DR) immunodetection and for HLA-DR, IL8, mucin 5AC (MUC5AC), nicotine adenine dinucleotide phosphate (NADPH), vasoactive intestinal peptide (VIP), and neuropeptide Y (NPY) transcript expression (PCR).

RESULTS

Patients with LPR had significantly increased Ocular Surface Disease Index ( P < 0.05), reduced T-BUT ( P < 0.05), and higher meibomian gland dysfunction ( P < 0.001) compared with controls. After treatment, tear break-up time (T-BUT) and meibomian gland dysfunction scores improved to normal values. Pepsin concentration increased in patients with EGERD ( P = 0.01) and decreased with topical treatment ( P = 0.0025), significantly. HLA-DR, IL8, and NADPH transcripts were significantly increased in the untreated versus controls and comparable significant values were obtained after treatment ( P < 0.05). MUC5AC expression significantly increased with treatment ( P = 0.005). VIP transcripts were significantly higher in EGERD than in controls and decreased with the topical treatment ( P < 0.05). No significant changes were observed in NPY.

CONCLUSIONS

We report an increase in prevalence of ocular discomfort in patients with GERD/LPR. The observations of VIP and NPY transcripts demonstrate the potential neurogenic nature of the inflammatory state. Restoration of the ocular surface parameters suggests the potential usefulness of topical alginate therapy.

Clinical relevance of salivary pepsin detection in diagnosing gastroesophageal reflux disease subtypes

Background

Gastroesophageal reflux disease (GERD) is heterogeneous with a varied symptom spectrum and reflux profiles. Its definite diagnosis often requires invasive tools including endoscopy or reflux monitoring. The aim of this study was to investigate the clinical relevance of salivary pepsin detection as a non-invasive screening tool to diagnose GERD of different subtypes.

Methods

A total of 77 patients with suspected GERD symptoms and 12 asymptomatic controls were analysed. All participants performed symptom evaluation, upper endoscopy, esophageal manometry, and 24-hour multichannel intraluminal impedance-dual pH probe monitoring. Saliva was self-collected across three different time points: at early fasting, postprandially, and at symptom occurrence. Salivary pepsin levels were measured via Peptest. The optimal threshold of salivary pepsin for diagnosing distal or proximal reflux was determined according to a receiver-operating characteristic curve.

Results

The average salivary pepsin concentration of suspected GERD patients was significantly higher than that of controls (100.63 [68.46, 141.38] vs 67.90 [31.60, 115.06] ng/mL, P = 0.044), although no difference was found among patients with different symptom spectrums. The distal reflux group had a higher average pepsin concentration than non-reflux patients (170.54 [106.31, 262.76] vs 91.13 [63.35, 127.63] ng/mL, P = 0.043), while no difference was observed between the distal reflux group and the proximal reflux group. The optimal cut-off value of salivary pepsin concentration for diagnosing pathological distal reflux was 157.10 ng/mL, which was higher than that for diagnosing pathological proximal reflux (122.65 ng/mL). The salivary pepsin concentration was significantly correlated with distal and proximal reflux parameters.

Conclusions

Salivary pepsin measurement can help in identifying true GERD with pathological distal reflux or proximal reflux, regardless of different symptom spectrums. A higher threshold should be applied for diagnosing distal reflux than for proximal reflux.

Multidisciplinary management of inducible laryngeal obstruction and breathing pattern disorder

We provide an overview of the assessment and management of inducible laryngeal obstruction and breathing pattern disorder. We highlight the multidisciplinary team members involved and their essential roles within a complex breathlessness service. We discuss treatments initiated by physiotherapy and speech and language therapy, the importance of joint working, and discuss the high incidence of comorbidities and the association with other respiratory disorders.

Educational aims

Inducible laryngeal obstruction and breathing pattern disorder are common causes of breathlessness.Inducible laryngeal obstruction is an inappropriate, transient, reversible narrowing of the laryngeal area that causes breathlessness and laryngeal symptoms.Breathing pattern disorder is an alteration in the normal biomechanical patterns of breathing that results in intermittent or chronic symptoms, which may be respiratory and/or non-respiratory.People with inducible laryngeal obstruction or breathing pattern disorder often have other comorbidities that will also need addressing.Multidisciplinary assessment and treatment is essential for comprehensive workup and holistic care.Timely assessment and diagnosis can prevent unnecessary medication use and hospital admissions and facilitate effective management of the condition using reassurance, advice, education, breathing retraining and vocal exercises.

GERD-related chronic cough: Possible mechanism, diagnosis and treatment

GERD, or gastroesophageal reflux disease, is a prevalent medical condition that affects millions of individuals throughout the world. Chronic cough is often caused by GERD, and chronic cough caused by GER is defined as GERD-related chronic cough (GERC). It is still unclear what the underlying molecular mechanism behind GERC is. Reflux theory, reflex theory, airway allergies, and the novel mechanism of esophageal motility disorders are all assumed to be linked to GERC. Multichannel intraluminal impedance combined with pH monitoring remains the gold standard for the diagnosis of GERC, but is not well tolerated by patients due to its invasive nature. Recent discoveries of new impedance markers and new techniques (mucosal impedance testing, salivary pepsin, real-time MRI and narrow band imaging) show promises in the diagnosis of GERD, but the role in GERC needs further investigation. Advances in pharmacological treatment include potassium-competitive acid blockers and neuromodulators (such as Baclofen and Gabapentin), prokinetics and herbal medicines, as well as non-pharmacological treatments (such as lifestyle changes and respiratory exercises). More options have been provided for the treatment of GERC other than acid suppression therapy and anti-reflux surgery. In this review, we attempt to review recent advances in GERC mechanism, diagnosis, and subsequent treatment options, so as to provide guidance for management of GERC.

Analysis of Helicobacter pylori in Saliva of Patients with Laryngopharyngeal Reflux and Non-Laryngopharyngeal Reflux

BACKGROUND : Helicobacter pylori is a gram-negative bacteria known as the causative agent of chronic gastritis, peptic ulcer, gastric adenocarcinoma, and gastric mucosa-associated lymphoid tissue lymphoma. Several studies have correlated H. pylori in the pathogenesis of upper airway diseases. H. pylori can be detected in saliva, oropharyngeal aphthae, nasal and sinus mucosa, secretions from the tympanic cavities, larynx, and pharyngeal lymphoid tissue. The diagnosis of LPR can be made simply by examining saliva. AIM : The aim of the study is to analyze the presence of H.pylori in the saliva of LPR and non LPR patients. METHODS : This study is an analytic observational study with a case control design. The research was conducted in the ENT-KL Department of Dr. M. Djamil Hospital, Padang, Indonesia. PCR examination was carried out at the Biomedical Laboratory of the Faculty of Medicine, Andalas University on saliva samples to detect the presence of H.Pylori. The study was conducted on 22 LPR patients and 22 control subjects. RESULT : LPR patients are more common in women than men, which were 12 women and 10 men. The average age of LPR patients is 43.7 years. The presence of H.pylori in LPR patients was 86.4%, while in the non-LPR group was 50%.  After being tested using the Chi-square test, a significant difference was found between the presence of H. Pylori and the incidence of LPR (P = 0.010). CONCLUSION : There was an increase in the frequency of the presence of Helicobacter Pylori in patients with LPR compared to Non LPR patients after statistical analysis.  

Diagnostic utility of salivary pepsin in laryngopharyngeal reflux: a systematic review and meta-analysis

OBJECTIVES

Salivary pepsin has emerged as a biomarker for Laryngopharyngeal Reflux (LPR), which, however, has been questioned for its efficacy due to a lack of supporting medical data. Therefore, this study analyzed the diagnostic value of salivary pepsin for LPR and assessed a better cutoff value.

METHODS

Studies were searched in PubMed, Embase, and Cochrane Library from their receptions to October 1, 2021. Then, RevMan 5.3 and Stata 14.0 were utilized to summarize the diagnostic indexes for further meta-analysis. Data were separately extracted by two reviewers according to the trial data extraction form of the Cochrane Handbook. The risk of bias in Randomized Control Trials (RCTs) was evaluated with the Cochrane Risk of Bias Tool.

RESULTS

A total of 16 studies matched the criteria and were subjected to meta-analysis. The results revealed a pooled sensitivity of 61% (95% CI 50%-71%), a pooled specificity of 67% (95% CI 48%-81%), a positive likelihood ratio of 2 (95% CI 1.2-2.8), a negative likelihood ratio of 0.58 (95% CI 0.47‒0.72), and the area under the receiver operating characteristic curve of 0.67 (95% CI 0.63‒0.71). Subgroup analyses indicated that the cutoff value of pepsin at 50 ng/mL had a higher degree of diagnostic accuracy than that of pepsin at 16 ng/mL in cohort studies.

CONCLUSION

The review demonstrated low diagnostic performance of salivary pepsin for LPR and that the cutoff value of 50 ng/mL pepsin had superior diagnostic accuracy. Nevertheless, the diagnostic value may vary dependent on the utilized diagnostic criteria. Therefore, additional research is needed on the improved way of identifying salivary pepsin in the diagnosis of LPR, and also longer-term and more rigorous RCTs are warranted to further assess the effectiveness of salivary pepsin.

ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) continues to be among the most common diseases seen by gastroenterologists, surgeons, and primary care physicians. Our understanding of the varied presentations of GERD, enhancements in diagnostic testing, and approach to patient management have evolved. During this time, scrutiny of proton pump inhibitors (PPIs) has increased considerably. Although PPIs remain the medical treatment of choice for GERD, multiple publications have raised questions about adverse events, raising doubts about the safety of long-term use and increasing concern about overprescribing of PPIs. New data regarding the potential for surgical and endoscopic interventions have emerged. In this new document, we provide updated, evidence-based recommendations and practical guidance for the evaluation and management of GERD, including pharmacologic, lifestyle, surgical, and endoscopic management. The Grading of Recommendations, Assessment, Development, and Evaluation system was used to evaluate the evidence and the strength of recommendations. Key concepts and suggestions that as of this writing do not have sufficient evidence to grade are also provided.

How I Approach Laryngopharyngoesophageal Reflux (LPR)

The purpose of this article is to review the cornerstone and most recent literature regarding laryngopharynoesophageal reflux (LPR) including epidemiological characteristics, pathophysiology, symptoms, diagnosis, and management. The role of pepsin in the pathophysiology of LPR is highlighted in addition to new diagnostic modalities and pharmacologic therapies that target pepsin.

Usefulness of matrix metalloproteinase-7 in saliva as a diagnostic biomarker for laryngopharyngeal reflux disease

Several diagnostic methods are currently being used to diagnose LPRD (laryngopharyngeal reflux disease), but have the disadvantage of being invasive, subjective, or expensive. Our purpose in this study was to investigate the correlation between pepsin and MMP-7 (Matrix Metalloproteinase-7) in pharyngeal secretions of subjects according to RSI (Reflux Symptom Index) score to find out the diagnostic value of MMP-7. We recruited 173 subjects aged between 19 and 85 years who completed the RSI scale. All samples were taken after waking up, and the amount of the pepsin and MMP-7 in saliva were measured by means of an enzyme activity assay. There was a significant increase of pepsin and MMP-7 activity in the study group with an RSI score of 13 or higher. The sensitivity and specificity of MMP-7 for predicting the possibility of an RSI of 13 or more was higher than that of pepsin. When MMP-7 and pepsin were combined, this sensitivity and specificity increased. An enzyme assay of MMP-7 in saliva may be a noninvasive and easy technique for diagnosing LPRD.

Salivary peptest for laryngopharyngeal reflux and gastroesophageal reflux disease: A systemic review and meta-analysis

BACKGROUND

A rapid lateral flow test (Peptest) to detect pepsin in saliva/sputum has been considered as a valuable method for diagnosing laryngopharyngeal reflux (LPR) and gastroesophageal reflux disease (GERD). The aim of this meta-analysis is to analyze the utility of Peptest for diagnosis of LPR and GERD.

METHODS

PubMed, EMBASE, and the Cochran Library (from January 1980 to 26 January 2020) were searched for pepsin in saliva for LPR/GERD diagnosis. Sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio, and area under the curve data were summarized to examine the accuracy.

RESULTS

A total of 16 articles that included 2401 patients and 897 controls were analyzed. The pooled sensitivity and specificity for the diagnosis of GERD/LPR with Peptest were 62% (95% confidence interval [CI] 49%-73%) and 74% (95% CI 50%-90%), respectively. The summarized diagnostic odds ratio and area under the curve were 5.0 (95% CI 2-19) and 0.70 (95% CI 0.66-0.74), respectively.

CONCLUSION

Peptest shows moderate diagnostic value for LPR and GERD. More studies with standard protocols should be done to verify its usefulness.

Gastro-oesophageal reflux disease

Gastro-oesophageal reflux disease (GERD) is a common disorder in adults and children. The global prevalence of GERD is high and increasing. Non-erosive reflux disease is the most common phenotype of GERD. Heartburn and regurgitation are considered classic symptoms but GERD may present with various atypical and extra-oesophageal manifestations. The pathophysiology of GERD is multifactorial and different mechanisms may result in GERD symptoms, including gastric composition and motility, anti-reflux barrier, refluxate characteristics, clearance mechanisms, mucosal integrity and symptom perception. In clinical practice, the diagnosis of GERD is commonly established on the basis of response to anti-reflux treatment; however, a more accurate diagnosis requires testing that includes upper gastrointestinal tract endoscopy and reflux monitoring. New techniques and new reflux testing parameters help to better phenotype the condition. In children, the diagnosis of GERD is primarily based on history and physical examination and treatment vary with age. Treatment in adults includes a combination of lifestyle modifications with pharmacological, endoscopic or surgical intervention. In refractory GERD, optimization of proton-pump inhibitor treatment should be attempted before a series of diagnostic tests to assess the patient's phenotype.

Are Multiple Tests Necessary for Salivary Pepsin Detection in the Diagnosis of Laryngopharyngeal Reflux?

OBJECTIVES

To evaluate the necessity of multiple salivary pepsin tests within a day when diagnosing laryngopharyngeal reflux.

STUDY DESIGN

Prospective cohort study.

SETTING

Tertiary hospitals.

METHODS

A total of 138 patients with signs and/or symptoms associated with laryngopharyngeal reflux were included. Salivary pepsin was detected on the day of 24-hour pH monitoring, and the results of salivary pepsin detected once in the morning and multiple times in 1 day were compared with the results of pH monitoring.

RESULTS

Among the 138 patients, pH monitoring results were positive in 112. Salivary pepsin was positive in 47 cases in the morning, which was not consistent with the results of pH monitoring (kappa value = 0.117). With the pH monitoring results as the standard, the salivary pepsin detected once in the morning had a sensitivity of 38.4% (43/112) and a specificity of 84.6% (22/26) for the diagnosis of laryngopharyngeal reflux. When salivary pepsin was detected multiple times per day, 102 patients tested positive. The consistency with pH monitoring was moderate (kappa value = 0.587). The sensitivity was 86.6% (97/112), and the specificity was 80.8% (21/26). Of the 97 patients with positive results from pH monitoring and salivary pepsin detected multiple times a day, 54 had negative findings for a single detection in the morning, indicating that 55.7% (54/97) of the true positive cases were missed.

CONCLUSION

Although a single detection of salivary pepsin in the morning is more economical, the sensitivity is too low, and it is necessary to detect it multiple times a day.

Diagnostic Value of the PeptestTM in Detecting Laryngopharyngeal Reflux

BACKGROUND

The Peptest^TM is a non-invasive diagnostic test for measuring the pepsin concentration in saliva, which is thought to correlate with laryngopharyngeal reflux (LPR). The aim of this study was to investigate the diagnostic value of the Peptest in detecting LPR based on 24-h multichannel intraluminal impedance-pH (MII-pH) monitoring using several hypopharyngeal reflux episodes as criterion for LPR.

METHODS

Patients with suspected LPR were examined with the Reflux Symptom Index (RSI), Reflux Finding Score (RFS), fasting Peptest, and MII-pH monitoring. We calculated the accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the Peptest, RSI, and RFS based on the threshold of one and six hypopharyngeal reflux episodes.

RESULTS

Altogether, the data from 46 patients were analyzed. When one hypopharyngeal reflux episode was used as a diagnostic threshold for LPR, the accuracy, sensitivity, specificity, PPV, and NPV were, respectively, as follows: 35%, 33%, 100%, 100%, and 3%, for the Peptest; 39%, 40%, 0%, 95%, and 0%, for the RSI; and 57%, 58%, 0%, 96%, and 0%, for the RFS. The accuracy, sensitivity, specificity, PPV, and NPV of the Peptest for diagnosing gastroesophageal reflux disease (GERD) were 46%, 27%, 63%, 40.0%, and 48%, respectively.

CONCLUSIONS

A positive Peptest is highly supportive of a pathological LPR diagnosis. However, a negative test could not exclude LPR.

Irritant-Induced Chronic Cough Triggers: A Scoping Review and Clinical Checklist

Purpose The primary aim of this review was to identify environmental irritants known to trigger chronic cough through the life span and develop a comprehensive clinically useful irritant checklist. Method A scoping review was conducted using the Preferred Reporting Items for Systematic Review and Meta-Analysis Extension for Scoping Reviews, checklist, and explanation. English-language, full-text resources were identified through Medline, PsycINFO, SPORTDiscus, Web of Science, and ProQuest Dissertations and Theses Global. Results A total of 1,072 sources were retrieved; of these, 109 were duplicates. Titles of abstracts of 963 articles were screened, with 295 selected for full-text review. Using the exclusion and inclusion criteria listed, 236 articles were considered eligible and 214 different triggers were identified. Triggers were identified from North America, Europe, Africa, Asia, and Australia. Occupational exposures were also delineated. Conclusions A clinically useful checklist of both frequently encountered triggers and idiosyncratic or rare triggers was developed. The clinical checklist provides a unique contribution to streamline and standardize clinical assessment of irritant-induced chronic cough. The international scope of this review extends the usefulness of the clinical checklist to clinicians on most continents.

Endoscopic evaluation of pharyngeal and laryngeal sensation in patients with chronic obstructive pulmonary disease (COPD): A cross-sectional study

OBJECTIVE

To describe and compare the findings of endoscopic sensory assessment in COPD patients and healthy controls.

DESIGN

A prospective cross-sectional study.

SETTING

Otorhinolaryngology outpatient clinic at a university hospital.

PARTICIPANTS

27 adults with COPD and 11 age-matched healthy controls.

MAIN OUTCOME MEASURES

Group differences in light touch endoscopic tests of pharyngeal and laryngeal sensation, controlling for pooled salivary secretions in the pharynx and laryngo-pharyngeal reflux as measured by the Reflux Finding Score (RFS).

RESULTS

A significant difference in laryngeal sensation was found between the study groups (P = .047), with reduced laryngeal sensation in the COPD patients. Additionally, a significant relationship was found between impaired oropharyngeal sensation and the presence of pooled salivary secretions in the pharynx (P = .018), especially in the pyriform sinuses (P = .012). No differences in the frequency of abnormal RFSs were found between groups.

CONCLUSION

Individuals with COPD were significantly more likely to present with impaired laryngeal sensation. Additionally, impaired sensation in the oropharynx was associated with pooled salivary secretions in the pharynx.

Lansoprazole for persistent throat symptoms in secondary care: the TOPPITS RCT

BACKGROUND

Persistent throat symptoms are commonly attributed to 'laryngopharyngeal reflux'. Despite a limited evidence base, these symptoms are increasingly being treated in primary care with proton pump inhibitors.

OBJECTIVE

To assess the value of proton pump inhibitor therapy in patients with persistent throat symptoms.

DESIGN

This was a double-blind, placebo-controlled, randomised Phase III trial.

SETTING

This was a multicentre UK trial in eight UK ear, nose and throat departments.

PARTICIPANTS

A total of 346 participants aged ≥ 18 years with persistent throat symptoms and a Reflux Symptom Index score of ≥ 10, exclusive of the dyspepsia item, were recruited.

INTERVENTION

Random allocation (1 : 1 ratio) to either 30 mg of lansoprazole twice daily or matched placebo for 16 weeks.

MAIN OUTCOME MEASURE

Symptomatic response (i.e. total Reflux Symptom Index score after 16 weeks of therapy).

RESULTS

A total of 1427 patients were screened and 346 were randomised. The mean age was 52 years (standard deviation 13.7 years, range 20-84 years); 150 (43%) participants were male and 196 (57%) were female; 184 (53%) participants had a mild Reflux Symptom Index minus the heartburn/dyspepsia item and 162 (47%) had a severe Reflux Symptom Index minus the heartburn/dyspepsia item. A total of 172 patients were randomised to lansoprazole and 174 were randomised to placebo.

MAIN OUTCOMES

A total of 267 participants completed the primary end-point visit (lansoprazole, n = 127; placebo, n = 140), of whom 220 did so between 14 and 20 weeks post randomisation ('compliant' group); 102 received lansoprazole and 118 received placebo. The mean Reflux Symptom Index scores at baseline were similar [lansoprazole 22.0 (standard deviation 8.0), placebo 21.7 (standard deviation 7.1), overall 21.9 (standard deviation 7.5)]. The mean Reflux Symptom Index scores at 16 weeks reduced from baseline in both groups [overall 17.4 (standard deviation 9.9), lansoprazole 17.4 (standard deviation 9.9), placebo 15.6 (standard deviation 9.8)]. Lansoprazole participants had estimated Reflux Symptom Index scores at 16 weeks that were 1.9 points higher (worse) than those of placebo participants (95% confidence interval -0.3 to 4.2; padj = 0.096), adjusted for site and baseline severity.

SECONDARY OUTCOMES

Ninety-five (43%) participants achieved a Reflux Symptom Index score in the normal range (< 12) at 16 weeks: 42 (41%) in the lansoprazole group and 53 (45%) in the placebo group. A total of 226 participants completed the end-of-trial follow-up visit (lansoprazole, n = 109; placebo, n = 117), of whom 181 were 'compliant'. The mean Reflux Symptom Index scores at 12 months reduced from baseline in both groups [lansoprazole 16.0 (standard deviation 10.8), placebo 13.6 (standard deviation 9.6), overall 14.7 (standard deviation 10.2)]. A total of 87 (48%) participants achieved a Reflux Symptom Index score in the normal range at 12 months: 33 (40%) in the lansoprazole group and 54 (55%) in the placebo group. Likewise, the Comprehensive Reflux Symptom Score and Laryngopharyngeal Reflux - Health Related Quality of Life total scores and subscales all showed very similar changes in the lansoprazole and placebo cohorts at both 16 weeks and 12 months.

LIMITATIONS

Drop-out rate and compliance are issues in pragmatic clinical trials. The Trial Of Proton Pump Inhibitors in Throat Symptoms (TOPPITS) aimed to detect clinically relevant difference with 90% power. The 346 randomised participants reduced to 283 at the primary end point; 267 completed the primary outcome measure, 220 within the protocol time scale. Despite this, the powers to detect the clinically relevant difference in Reflux Symptom Index score at 16 weeks were 82% (compliant comparison) and 89% (pragmatic comparison). The lack of difference between lansoprazole and placebo is generalisable across NHS clinics.

CONCLUSIONS

Participants on lansoprazole did not report significantly better outcomes than participants on placebo on any of the three patient-reported outcome tools (Reflux Symptom Index, Comprehensive Reflux Symptom Score and Laryngopharyngeal Reflux - Health Related Quality of Life). This multicentre, pragmatic, powered, definitive Phase III trial found no evidence of benefit for patients by treating persistent throat symptoms with lansoprazole.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN38578686 and EudraCT number 2013-004249-17.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 3. See the NIHR Journals Library website for further project information.

Relationship Between Pepsin Expression and Dysplasia Grade in Patients With Vocal Cord Leukoplakia

OBJECTIVE

To measure pepsin expression in patients with vocal fold leukoplakia and elucidate its clinical significance.

STUDY DESIGN

Retrospective analysis of pathologic archive specimens.

SETTING

Affiliated university hospital.

SUBJECTS AND METHODS

The study included 45 patients with vocal fold leukoplakia and 19 with vocal fold polyps who underwent surgical treatment between December 2013 and July 2016. Masses were detected on both vocal cords in 5 patients with vocal fold leukoplakia and in 1 patient with vocal fold polyps. Immunohistochemistry was used to assess pepsin expression. In addition, the relationship of pepsin expression level with clinical characteristics of vocal fold leukoplakia was assessed.

RESULTS

The rate of pepsin expression was high in the polyp group (75%) and the leukoplakia group (68%); however, the difference between groups was not significant (P > .05). Pepsin expression significantly increased according to grade of dysplasia (mild, 57.1%; moderate, 88.9%; severe, 100.0%; P = .034). Similarly, the percentage of lesions that exhibited strongly positive pepsin expression increased with the grade of dysplasia (mild, 37.1%; moderate, 66.7%; severe, 100.0%; P = .005). The leukoplakia recurrence rate was higher in patients with positive pepsin expression than in patients with negative pepsin expression but without a significant difference (P > .05).

CONCLUSION

Our study suggests that pepsin was associated with the grade of dysplasia of vocal cord leukoplakia. Further investigation with appropriate control groups and controlling for other risk factors, such as smoking or alcohol consumption, is needed.

Laryngopharyngeal Reflux: Symptoms, Signs, and Presence of Pepsin in Saliva - A Reliable Diagnostic Triad

Introduction  Twenty-four-hour multichannel intraluminal impedance with double probe pH monitoring (MII-pH), though considered the most sensitive tool for the diagnosis of gastroesophageal reflux disease (GERD), is invasive, time consuming, not widely available, and unable to detect non-acid reflux. In contrast, the presence of pepsin in the saliva would act as a marker for reflux, considering that pepsin is only produced in the stomach.

Objective  To evaluate the predictive value of salivary pepsin in diagnosing laryngopharyngeal reflux (LPR) as suggested by the results of reflux symptom index (RSI > 13), reflux finding score (RFS > 7), and positive response to treatment with a 4-week course of proton-pump inhibitors.

Methods  This prospective study was done at a tertiary care hospital on 120 adult patients attending ENT OPD with clinical diagnosis of LPR. The presence of pepsin in their pharyngeal secretions and saliva using a lateral flow device, the Peptest, was compared with RSI, RFS, and with the response to medical treatment using the Chi-squared test.

Results  Salivary pepsin was found to be positive in 68% of the patients, with 87.5% of them showing positive response to treatment. Chi-squared analysis showed a significant association between positive salivary pepsin and RFS > 7, RSI >13, a combination of RFS > 7 and RSI > 13 as well as with response to treatment ( p  < 0.0001).

Conclusion  When considered along with the clinical indicators of RFS and RSI of more than 7 and 13, respectively, and/or with a response to treatment, a positive salivary pepsin test indicates statistically significant chance of presence of LPR.

Adaptation and Validation of Reflux Symptom Index Into Kannada Language

OBJECTIVE

The present study aimed to translate, validate the Reflux Symptom Index in Kannada language and to compare its outcomes between normal individuals and individuals with laryngopharyngeal reflux.

STUDY DESIGN

Cross sectional study design MATERIALS AND METHOD: : The English version of Reflux Symptom Index was translated into Kannada language using standard procedures. A total of 162 participants participated in the study, 81 with laryngopharyngeal reflux and 81 controls. Internal consistency, test-retest reliability, and clinical validity were calculated.

RESULTS

Results revealed that the Kannada Reflux Symptom Index exhibited an excellent internal consistency (α = 0.87). The average intra-class correlation coefficient was 0.90 and 0.92, indicating excellent test-retest reliability. Independent sample t test revealed a statistically significant difference between the total scores of both the groups, thereby exhibiting good clinical validity of RSI-K (t = 42.71, df = 158, P < 0.001).

CONCLUSION

The Kannada Reflux Symptom Index is a reliable and valid tool for use in patients with laryngopharyngeal reflux. It can be used as a quick tool to assess laryngopharyngeal reflux.

Assessment and Diagnostic Accuracy Evaluation of the Reflux Symptom Index (RSI) Scale: Psychometric Properties using Optimal Scaling Techniques

OBJECTIVES

To investigate the psychometric properties of the reflux symptom index (RSI) as short screening approach for the diagnostic of laryngopharyngeal reflux (LPR) in patients with confirmed diagnosed regarding the 24-hour multichannel intraluminal impedance-pH monitoring (MII-pH).

METHODS

From January 2017 to December 2018, 56 patients with LPR symptoms and 71 healthy individuals (control group) were prospectively enrolled. The LPR diagnosis was confirmed through MII-pH results. All subjects (n = 127) fulfilled RSI and the Reflux Finding Score (RFS) was performed through flexible fiberoptic endoscopy. The sensitivity and the specificity of RSI was assessed by ROC (Receiver Operating Characteristic) analysis.

RESULTS

A total of 15 LPR patients (26.8%) of the clinical group met MII-pH diagnostic criteria. Among subjects classified as positive for MII- pH diagnoses, RSI and RFS mean scores were respectively 20 (SD ± 10.5) and 7.1 (SD ± 2.5), values not significantly different compared to the negative MII-pH group. The metric analysis of the items led to the realization of a binary recoding of the score. Both versions had similar psychometric properties, α was 0.840 for RSI original version and 0.836 for RSI binary version. High and comparable area under curve (AUC) values indicate a good ability of both scales to discriminate between individuals with and without LPR pathology diagnosis. Based on balanced sensitivity and specificity, the optimal cut-off scores for LPR pathology were ≥ 5 for RSI binary version and ≥ 15 for RSI original version. Both version overestimated LPR prevalence. The original version had more sensitivity and the RSI Binary version had more specificity.

CONCLUSIONS

It would be necessary to think about modifying the original RSI in order to improve its sensitivity and specificity (RSI binary version, adding or changing some items), or to introduce new scores in order to better frame the probably affected of LPR patient.

A Multicentre Study in UK Voice Clinics Evaluating the Non-invasive Reflux Diagnostic Peptest in LPR Patients

Questionnaires and invasive diagnostic tests are established for diagnosing gastro-esophageal reflux disease (GERD) but shown not to be sensitive or specific for diagnosing laryngopharyngeal reflux (LPR) where vast majority of reflux events are weakly acidic or non-acidic. The research question addressed in the current multicentre study was to determine if the measurement of salivary pepsin is a sensitive, specific and reliable diagnostic test for LPR. Five UK voice clinics recruited a total of 1011 patients presenting with symptoms of LPR and a small group of subjects (n = 22) recruited as asymptomatic control group. Twenty-six patients failed to provide demographic information; the total patient group was 985 providing 2927 salivary pepsin samples for analysis. Study participants provided 3 saliva samples, the first on rising with two samples provided post-prandial (60 min) or post-symptom (15 min). The control group provided one sample on rising and two post-prandial providing a total of 66 samples. Pepsin analysis was carried out using Peptest as previously described. High prevalence of pepsin in patient groups (75%) represents a mean pepsin concentration of 131 ng/ml. The greatest prevalence for pepsin was in the post-prandial sample (155 ng/ml) and the lowest in the morning sample (103 ng/ml). The mean pepsin concentration in the control group was 0 ng/ml. Patients across all 5 clinics showed high prevalence of salivary pepsin (ranging from 69 to 86%), and the overall sensitivity was 76.4% and specificity 100%. Pepsin was shown to be an ideal biomarker for detecting airway reflux and LPR.

Magnetic sphincter augmentation is an effective treatment for atypical symptoms caused by gastroesophageal reflux disease

BACKGROUND

The purpose of this study was to determine whether magnetic sphincter augmentation (MSA) could effectively treat patients with gastroesophageal reflux disease (GERD) who suffer primarily from atypical symptoms due to laryngopharyngeal reflux (LPR). MSA has been shown to treat typical symptoms of GERD with good success, but its effect on atypical symptoms is unknown.

METHODS

A retrospective review of a prospectively maintained institutional review board-approved database was conducted for all patients who underwent MSA between January 2015 and December 2018. All patients had objective confirmation of GERD from ambulatory pH monitoring off anti-reflux medications (DeMeester score > 14.7). Symptoms were assessed preoperatively and at 1 year postoperatively using GERD Health-Related Quality of Life (GERD-HRQL) and Reflux Symptom Index (RSI) questionnaires.

RESULTS

There were 86 patients (38 males; 48 females) with a median age of 51.5 years. Total GERD HRQL scores improved from a mean of 38.79 to 6.53 (p < 0.01) and RSI scores improved from a mean of 20.9 to 8.1 (p < 0.01). Atypical symptoms evaluated from the RSI questionnaire include hoarseness, throat clearing, postnasal drip, breathing difficulties, and cough. All atypical symptoms were significantly improved at 1 year following MSA (p < 0.01). All three typical symptoms of heartburn, dysphagia, and regurgitation were significantly improved based on pre and postoperative GERD HRQL questionnaires (p < 0.02). Ninety-one percent of patients were off their PPI and dissatisfaction with their current therapy decreased from 95% preoperatively to 13% postoperatively.

CONCLUSION

MSA is an effective treatment for typical and atypical GERD symptoms.

Detection of Pepsin in Oral Secretions of Infants with and without Laryngomalacia

Objectives:

Laryngomalacia is a common cause of stridor in infants and is associated with laryngopharyngeal reflux (LPR). Although pepsin in operative supraglottic lavage specimens is associated with severe laryngomalacia, detection of pepsin in oral secretions has not been demonstrated in an outpatient setting.

Methods:

Children <2 years old with laryngomalacia diagnosed by flexible laryngoscopy and children without stridor were selected. Oral secretion samples were obtained in clinic from all subjects. Pepsin, IL-1β, and IL-8 enzyme-linked immunosorbent assays were performed to determine presence of LPR.

Results:

Sixteen laryngomalacia and sixteen controls were enrolled. Pepsin was detected more frequently in oral secretions of patients with laryngomalacia (13/16) than in controls (2/16; P < .001). Four patients with laryngomalacia developed symptoms requiring supraglottoplasty. Presence and level of salivary pepsin was not significantly associated with need for surgical management, nor were the levels or presence of IL-1β or IL-8 significantly associated with presence or level of pepsin, diagnosis of laryngomalacia, or need for operative management.

Conclusion:

Pepsin in saliva appears to be associated with laryngomalacia, suggesting a role for salivary pepsin as a noninvasive marker of LPR in patients with laryngomalacia. Future studies will determine the utility of this test in laryngomalacia.

Reflux characteristics in patients with gastroesophageal reflux-related chronic cough complicated by laryngopharyngeal reflux

Background

This study aimed to investigate the reflux characteristics in patients with gastroesophageal reflux-related chronic cough (GERC) complicated by laryngopharyngeal reflux (LPR).

Methods

Patients with chronic cough were recruited. Reflux symptom index (RSI) scoring, cough symptom scoring, assessment of capsaicin cough sensitivity, and multichannel intraluminal impedance and pH monitoring (MII-pH) were performed.

Results

RSI score in GERC patients was significantly higher than that in patients with atopic cough (AC), cough variant asthma, eosinophilic bronchitis (EB), and upper airway cough syndrome (UACS) (P<0.05). The RSI score in non-acid GERC patients was significantly higher than that in acid GERC patients (P=0.003). The cut-off value of the RSI score was defined as 19 during diagnosis of non-acid GERC. In the RSI ≥19 group, there was more proximal reflux and more significant gas and non-acid reflux, and the efficacy of a combined use of baclofen or gabapentin was better than that of the RSI <19 group (P<0.05). The efficacy of proton pump inhibitor (PPI) at a routine dosage together with prokinetic agents in the RSI <19 group was better than that in the RSI ≥19 group (P=0.009).

Conclusions

LPR overlaps with GERC in part. GERC patients with higher RSI scores may present more proximal reflux, non-acid reflux, and gas reflux, and get better efficacy with neuromodulators (gabapentin or baclofen) used as an add-on therapy.

Evaluation of Important Analytical Parameters of the Peptest Immunoassay that Limit its Use in Diagnosing Gastroesophageal Reflux Disease

GOAL

To evaluate the analytical parameters of a lateral flow (LF) pepsin immunoassay (Peptest) and assess its suitability in the diagnostics of gastroesophageal reflux disease (GERD).

BACKGROUND

Peptest is a noninvasive assay to analyze pepsin in saliva, intended for use in GERD diagnostics. Although commercialized, fundamental studies on its performance are missing. The assay therefore requires basic analytical parameter evaluation to assess its suitability in clinical practice.

STUDY

Assay reaction's time dependence, reader device repeatability, and individual LF devices and longitudinal pepsin concentration reproducibility in individual subjects was evaluated. Salivary pepsin was analyzed in 32 GERD patients with extraesophageal reflux symptoms and 13 healthy individuals.

RESULTS

The assay's signal increase is not completed at the recommend readout time and continues to increase for another 25 minutes. The relative standard deviation of measurement was good when using the same LF device, ranging from 2.3% to 12.9%, but the reproducibility of 10 different individual LF devices was poor. The random error when analyzing the same saliva sample on 10 LF devices was as high as 36 ng/mL and this value is thus suggested as the positivity cut-off. Pepsin concentration in individual subjects during a 10-day period varied significantly. The sensitivity of the Peptest was 36.8% in the group with acid reflux and 23.1% in the group with weakly acid reflux. The specificity was 61.5%.

CONCLUSIONS

The Peptest assay's sensitivity and specificity is low, the results are highly variable and it should not be used as a near-patient diagnostic method in primary care.

Pepsin in Saliva as a Diagnostic Marker for Gastroesophageal Reflux Disease: A Meta-Analysis

BACKGROUND Gastroesophageal reflux disease (GERD) is very common. Salivary pepsin detection has previously been considered as a method for GERD diagnosis. We performed a meta-analysis to investigate the utility of salivary pepsin assay as a diagnostic tool of GERD. MATERIAL AND METHODS PubMed, Web of Science, the Cochran Library, and EMBASE (from January 1980 to 23 October 2018) were searched for pepsin in saliva for GERD diagnosis. We summarized the retrieved specificity, sensitivity, negative likelihood ratio (NLR), positive likelihood ratio (PLR), diagnostic odds ratio (DOR), and receiver operating characteristic (ROC) curves data in the meta-analysis. RESULTS In final analysis, a total of 5 studies were included. The summary sensitivity, specificity, NLR, and PLR were 0.60 (95% CI 0.41-0.76), 0.71 (95% CI 0.51-0.86), 0.56 (95% CI 0.34-0.93), and 2.1 (95% CI 1.1-4.1), respectively. The pooled DOR was 4 (95% CI 1.0-11.0) and area under the ROC was 0.70 (95% CI 0.66-0.74). CONCLUSIONS The meta-analysis showed that pepsin in saliva has moderate diagnostic value for GERD, and is not as helpful as previously thought.

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.

Extraesophageal Symptoms and Diseases Attributed to GERD: Where is the Pendulum Swinging Now?

The purpose of this review is to outline the recent developments in the field of extraesophageal reflux disease and provide clinically relevant recommendations. The recommendations outlined in this review are based on expert opinion and on relevant publications from PubMed and EMbase. The Clinical Practice Updates Committee of the American Gastroenterological Association proposes the following recommendations: Best Practice Advice 1: The role of a gastroenterologist in patients referred for evaluation of suspected extra esophageal symptom is to assess for gastroesophageal etiologies that could contribute to the presenting symptoms. Best Practice Advice 2: Non-GI evaluations by ENT, pulmonary and/or allergy are essential and often should be performed initially in most patients as the cause of the extraesophageal symptom is commonly multifactorial or not esophageal in origin. Best Practice Advice 3: Empiric therapy with aggressive acid suppression for 6-8 weeks with special focus on response of the extraesophageal symptoms can help in assessing association between reflux and extraesophageal symptoms. Best Practice Advice 4: No single testing methodology exists to definitively identify reflux as the etiology for the suspected extra esophageal symptoms. Best Practice Advice 5: Constellation of patient presentation, diagnostic test results and response to therapy should be employed in the determination of reflux as a possible etiology in extra esophageal symptoms. Best Practice Advice 6: Testing may need to be off or on proton pump inhibitor (PPI) therapy depending on patients' presenting demographics and symptoms in assessing the likelihood of abnormal gastroesophageal reflux. A. On therapy testing may be considered in those with high probability of baseline reflux (those with previous esophagitis, Barrett's esophagus or abnormal pH). B. Off therapy testing may be considered in those with low probability of baseline reflux with the goal of identifying moderate to severe reflux at baseline. Best Practice Advice 7: Lack of response to aggressive acid suppressive therapy combined with normal pH testing off therapy or impedance-pH testing on therapy significantly reduces the likelihood that reflux is a contributing etiology in presenting extraesophageal symptoms. Best Practice Advice 8: Surgical fundoplication is discouraged in those with extra esophageal reflux symptoms unresponsive to aggressive PPI therapy. Best Practice Advice 9: Fundoplication should only be considered in those with a mechanical defect (e.g., hiatal hernia), moderate to severe reflux at baseline off PPI therapy who have continued reflux despite PPI therapy and have failed more conservative non-GI treatments.

Assessing Old and New Diagnostic Tests for Gastroesophageal Reflux Disease

A detailed critique of objective measurements of gastroesophageal reflux disease (GERD) would improve management of patients suspecting of having reflux, leading to rational selection of treatment and better outcomes. Many diagnostic tests for GERD have been developed over the past decades. We analyze their development, positive- and negative-predictive values, and ability to predict response to treatment. These features are important for development of medical, surgical, and endoscopic therapies for GERD. We discuss the value of available diagnostic tests and review their role in management of patients with persistent reflux symptoms despite adequate medical or surgical treatment. This is becoming a significant health economic problem, due to the widespread use of proton pump inhibitors. GERD is believed to cause nonesophageal symptoms, such as those provoked by ear, nose, throat, or respiratory disorders. We analyze the value of GERD diagnostic tests in evaluation of these troublesome, nonesophageal symptoms.

The diagnostic value of pepsin detection in saliva for gastro-esophageal reflux disease: a preliminary study from China

Background

None of current diagnostic methods has been proven to be a reliable tool for gastro-esophageal reflux disease (GERD). Pepsin in saliva has been proposed as a promising diagnostic biomarker for gastro-esophageal reflux. We aimed to determine the diagnostic value of salivary pepsin detection for GERD.

Methods

Two hundred and fifty patients with symptoms suggestive of GERD and 35 asymptomatic healthy volunteers provided saliva on morning waking, after lunch and dinner for pepsin determination using the Peptest lateral flow device. All patients underwent 24-h multichannel intraluminal impedance pH (24-h MII-pH) monitoring and upper gastrointestinal endoscopy. Based on 24-h MII-pH and endoscopy study, patients were defined as GERD (abnormal MII-pH results and/or reflux esophagitis) and non-GERD otherwise.

Results

Patients with GERD had a higher prevalence of pepsin in saliva and higher pepsin concentration than patients with non-GERD and healthy controls (P < 0.001 for all). The pepsin test had a sensitivity of 73% and a specificity of 88.3% for diagnosing GERD using the optimal cut-off value of 76 ng/mL. Postprandial saliva samples collected when the symptoms occurred had a more powerful ability to identify GERD.

Conclusions

Salivary pepsin test had moderate diagnostic value for GERD. It may be a promising tool to replace the use of currently invasive tools with advantages of non-invasive, easy to perform and cost effective.

Trial registration

ChiCTR-DDD-16009506 (date of registration: October 20, 2016).

Facts and Fantasies on Extraesophageal Reflux: A Gastroenterologist Perspective

Gastroesophageal reflux disease encompasses a wide spectrum of disorders related to the reflux of gastric contents into the esophagus. Extraesophageal reflux (EER) may be suspected in patients with unexplained chronic cough, pharyngolaryngeal symptoms, and asthma. For physicians, suspected EER is challenging as there is currently no tool that can reliably make a definitive diagnosis. Endoscopic signs are not specific, pharyngeal and proximal reflux monitoring are not reliable, and if distal pH or pH-impedance monitoring can identify patients with abnormal reflux, they cannot predict the response to therapy. Controlled randomized trials have failed to reliably demonstrate any benefit of high-dose proton-pump inhibitors over placebo in patients with laryngeal symptoms, chronic cough, and asthma. Overall, the role of gastroesophageal reflux has been largely overestimated in patients with suspected EER. Especially when proton-pump inhibitors failed to improve symptoms, other diagnosis should be considered, such as functional laryngeal disorders which are probably much more prevalent in these patients than pathologic gastroesophageal reflux.

Salivary Pepsin Test: Useful and simple tool for the laryngopharyngeal reflux diagnosis

INTRODUCTION AND OBJECTIVES

Laryngopharyngeal Reflux (LPR) is a disease characterized by the presence of symptoms, signs and tissue damage caused by retrograde flow of gastric contents to the upper aerodigestive tract. It represents up to 10% of otolaryngology consultations. The aim of the study is to describe the findings obtained by applying the salivary pepsin test (PEP-test) in a sample of patients with the clinical suspicion of LPR.

MATERIAL AND METHODS

Our descriptive clinical study included 142 subjects with symptoms suggestive of LPR and a score above 13 on the RSI scale. The subjects underwent laryngeal endoscopy to rule out other pathologies that could justify the symptoms and the salivary pepsin test (PEP-test). The latter was carried out on fasting subjects and a second test one hour after eating, only on those with negative results.

RESULTS

The results obtained in the tests performed on the 142 patients included in the study were: 105 (73.94%) presented positive results in some of the salivary pepsin tests and the results of both tests were negative in 37 subjects (26.06%).

CONCLUSION

The salivary pepsin test is a simple, low-cost, non-invasive and easily repeatable tool which could minimize empirical treatments and invasive tests for LPR diagnosis, although further research is needed for its validation.

Pepsin in saliva as a biomarker for oropharyngeal reflux compared with 24-hour esophageal impedance/pH monitoring in pediatric patients

BACKGROUND

Pepsin in saliva is a proposed biomarker for oropharyngeal reflux. Pepsin may be prevalent in saliva from subjects with gastro-esophageal reflux and may correlate with proximal reflux by intraluminal impedance/pH monitoring (MII/pH).

METHODS

Patients (3 days to 17.6 years, n=90) undergoing 24-hour MII/pH monitoring and asymptomatic controls (2 months to 13.7 years, n=43) were included. Salivary pepsin was determined using a pepsin enzyme-linked immunosorbent assay. Eight saliva samples were collected from patients undergoing 24-hr MII/pH: (i) before catheter placement, (ii) before and 30 minutes after each of three meals, and (iii) upon awakening. One sample was collected from each control.

KEY RESULTS

In MII/pH subjects, 85.6% (77/90) had at least one pepsin-positive sample compared with 9.3% (4/43) in controls. The range of pepsin observed in individual subjects varied widely over 24 hours. The average pepsin concentration in all samples obtained within 2 hours following the most recent reflux event was 30.7±135 ng/mL, decreasing to 16.5±39.1 ng/mL in samples collected more than 2 hours later. The frequency of pepsin-positive samples correlated significantly with symptom index (r_S =0.332, P=.0014), proximal (r_S =0.340, P=.0010), and distal (r_S =0.272, P=.0095) MII events.

CONCLUSIONS & INFERENCES

Concentration of salivary pepsin may not be an accurate measure of severity of reflux because of the wide range observed in individuals over 24 hours. Saliva samples must be obtained soon after a reflux event. Defining a regimen for optimal saliva collection may help to achieve the goal of using salivary pepsin as a biomarker for oropharyngeal reflux.

CLINICAL TRIAL REGISTRY

NCT01091805.

Combined Multichannel Intraluminal Impedance and pH Measurement in Detecting Gastroesophageal Reflux Disease in Children

OBJECTIVE

The aim of the study was to evaluate and compare multichannel intraluminal impedance-pH (MII-pH) monitoring with standard investigations including pH testing for detecting gastroesophageal reflux disease (GERD) in children.

METHODS

A retrospective review of all MII-pH studies performed between July 2007 and March 2013 at Sydney Children's Hospital. Results from MII-pH testing, esophagogastroduodenoscopy (EGD), barium meal and pepsin assay, symptoms, underlying comorbidities, age, and medication usage were evaluated.

RESULTS

An additional 47.18% of children had GERD detected by MII-pH testing, which would have been missed by pH testing alone. Based on symptomatology, 50.49% of children with respiratory symptoms as a result of GERD and 47.54% of those with gastrointestinal symptoms would have been missed by pH testing alone. GERD was detected in an additional 39.47% of children with neurological impairment, 44.44% for those with cystic fibrosis, and 52.17% for those with esophageal atresia-tracheoesophageal fistula by MII-pH. In patients with persistent symptoms on anti-reflux medication, GERD would have been missed by pH testing alone in 50.40%. GERD was detected in an additional 62.79% of infants and 42.76% of older children by MII-pH compared with pH testing alone. With reference to MII-pH, the sensitivity of other standard investigations, pH testing (32.35%), barium meal (25.00%), EGD (45.26%), and pepsin assay (48.89%) was significantly lower in the detection of GERD in children. Of all abnormal MII-pH results, 51.1% were abnormal because of symptom association alone.

CONCLUSIONS

Combined MII-pH testing is superior to standard investigations such as 24-hour pH testing, barium meal, EGD, and pepsin assay in detecting GERD in children, particular because of its ability to associate symptoms with acid and non-acid reflux events.

The Ability of Patient-Symptom Questionnaires to Differentiate PVFMD From Asthma

OBJECTIVES

Goals of the current study were to (1) conduct initial validation of a new Paradoxical Vocal Fold Movement Disorder Screening Questionnaire (PVFMD-SQ); (2) determine if symptom-based questionnaires can discriminate between patients with confirmed PVFMD and those with diagnosed uncontrolled asthma without clinical suspicion for PVFMD; and (3) determine if a new questionnaire with diagnostic specificity could be created from a combination of significant items on previously validated questionnaires.

METHODS

This is a prospective, case-controlled study of patients with PVFMD only and asthma only, who completed five questionnaires: Dyspnea Index, Reflux Symptom Index, Voice Handicap Index-10, Sino-Nasal Questionnaire, and PVFMD-SQ. Factor analysis was completed on the new PVFMD-SQ, and the discrimination ability of selected factors was assessed by receiver operating characteristics curve. The factor with the greatest discriminatory ability was selected to create one diagnostic questionnaire, and scores for each participant were calculated to estimate how well the factor correlated with a PVFMD or asthma diagnosis. Mean scores on all questionnaires were compared to test their discriminatory ability.

RESULTS

Patients with PVFMD showed greater voice handicap and reflux symptoms than patients with asthma. A 15-item one-factor questionnaire was developed from the original PVFMD-SQ, with a sensitivity of 89% and specificity of 73% for diagnosing asthma versus PVFMD. The combined questionnaires resulted in four factors, none of which showed discriminatory ability between PVFMD and asthma.

CONCLUSION

This study represents the first time that a patient symptom-based screening tool has shown diagnostic sensitivity to differentiate PVFMD from asthma in a cohort of symptomatic patients.