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Zhang M, Wu T, Tan N, Chen S, Zhuang Q, Luo Y, Xiao Y. Clinical relevance of salivary pepsin detection in diagnosing gastroesophageal reflux disease subtypes. Gastroenterol Rep (Oxf) 2023; 11:goad053. [PMID: 37720194 PMCID: PMC10500079 DOI: 10.1093/gastro/goad053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 07/25/2023] [Accepted: 08/09/2023] [Indexed: 09/19/2023] Open
Abstract
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.
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Affiliation(s)
- Mengyu Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Tingting Wu
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Niandi Tan
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Songfeng Chen
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Qianjun Zhuang
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Yu Luo
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Yinglian Xiao
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
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Chen R, Shi L, Huang X, Mao H, Feng B, Wang M, Lin L, Jiang L. The clinical application value of salivary pepsin in the diagnosis of gastroesophageal reflux diseases. Neurogastroenterol Motil 2023; 35:e14627. [PMID: 37332241 DOI: 10.1111/nmo.14627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 05/27/2023] [Accepted: 05/30/2023] [Indexed: 06/20/2023]
Abstract
BACKGROUND Peptest is a noninvasive and convenient diagnostic kit for gastroesophageal reflux disease (GERD). We aimed to explore the application value of Peptest in the diagnosis of GERD. METHODS Patients suspected of GERD all completed 24 h pH-impedance monitoring (24 h MII-pH) and then took proton pump inhibitor (PPI) 2 weeks. The postprandial, post-symptom and random salivary samples were taken. Receiver operating characteristic analysis was used to identify the best cutoff value of Peptest, to differentiate GERD patients from non-GERD patients and the optimal sampling time of Peptest was analyzed. Reflux characteristics and esophageal motility between Peptest (+) group and Peptest (-) group were compared in negative 24 h MII-pH patients. Peptest concentration were compared among non-reflux, distal reflux, and proximal reflux groups according to 24 h MII-pH curve. RESULTS The area under the curve of post-symptom Peptest was highest in three time points and the diagnostic specificity was 81.0% and sensitivity was 53.3% with the diagnostic value of 86 ng/mL. Compared with negative Peptest group, distal mean nocturnal baseline impedance was significantly lower, gastroesophageal junction contractile integral was substantially lower in positive Peptest group in negative 24 h MII-pH patients. The concentration of post-symptom and postprandial Peptest increased gradually in the non-reflux, distal reflux, and proximal reflux groups. CONCLUSIONS & INFERENCES Peptest has a relatively low diagnostic value for GERD. Post-symptom Peptset is the best sampling time with the optimal value of 86 ng/mL and may have auxiliary diagnostic value for negative 24 h MII-pH patients. Peptest may assist 24 h MII-pH in monitoring proximal reflux.
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Affiliation(s)
- Rongrong Chen
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Lin Shi
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- Department of Medical Oncology, Jiangsu Cancer Hospital & Jiangsu Institute of Cancer Research & The Affiliated Cancer Hospital of Nanjing Medical University, Nanjing, China
| | - Xiaoyu Huang
- Department of Gastroenterology, Nanjing Qixia District Hospital, Nanjing, China
| | - Hui Mao
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Benchang Feng
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Meifeng Wang
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Lin Lin
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Liuqin Jiang
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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Chen JW, Vela MF, Peterson KA, Carlson DA. AGA Clinical Practice Update on the Diagnosis and Management of Extraesophageal Gastroesophageal Reflux Disease: Expert Review. Clin Gastroenterol Hepatol 2023; 21:1414-1421.e3. [PMID: 37061897 DOI: 10.1016/j.cgh.2023.01.040] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 12/23/2022] [Accepted: 01/02/2023] [Indexed: 04/17/2023]
Abstract
DESCRIPTION The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update is to review the available evidence and expert advice regarding the clinical management of patients with suspected extraesophageal gastroesophageal reflux disease. METHODS This article provides practical advice based on the available published evidence including that identified from recently published reviews from leading investigators in the field, prospective and population studies, clinical trials, and recent clinical guidelines and technical reviews. This best practice document is not based on a formal systematic review. The best practice advice as presented in this document applies to patients with symptoms or conditions suspected to be related to extraesophageal reflux (EER). This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee (CPUC) and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the CPUC and external peer review through standard procedures of Clinical Gastroenterology and Hepatology. These Best Practice Advice (BPA) statements were drawn from a review of the published literature and from expert opinion. Because systematic reviews were not performed, these BPA statements do not carry formal ratings of the quality of evidence or strength of the presented considerations. BEST PRACTICE ADVICE 1: Gastroenterologists should be aware of potential extraesophageal manifestations of gastroesophageal reflux disease (GERD) and should inquire about such disorders including laryngitis, chronic cough, asthma, and dental erosions in GERD patients to determine whether GERD may be a contributing factor to these conditions. BEST PRACTICE ADVICE 2: Development of a multidisciplinary approach to extraesophageal (EER) manifestations is an important consideration because the conditions are often multifactorial, requiring input from non-gastroenterology (GI) specialties. Results from diagnostic testing (ie, bronchoscopy, thoracic imaging, laryngoscopy, etc) from non-GI disciplines should be taken into consideration when gastroesophageal reflux (GER) is considered as a cause for extraesophageal symptoms. BEST PRACTICE ADVICE 3: Currently, there is no single diagnostic tool that can conclusively identify GER as the cause of EER symptoms. Determination of the contribution of GER to EER symptoms should be based on the global clinical impression derived from patients' symptoms, response to GER therapy, and results of endoscopy and reflux testing. BEST PRACTICE ADVICE 4: Consideration should be given toward diagnostic testing for reflux before initiation of proton pump inhibitor (PPI) therapy in patients with potential extraesophageal manifestations of GERD, but without typical GERD symptoms. Initial single-dose PPI trial, titrating up to twice daily in those with typical GERD symptoms, is reasonable. BEST PRACTICE ADVICE 5: Symptom improvement of EER manifestations while on PPI therapy may result from mechanisms of action other than acid suppression and should not be regarded as confirmation for GERD. BEST PRACTICE ADVICE 6: In patients with suspected extraesophageal manifestation of GERD who have failed one trial (up to 12 weeks) of PPI therapy, one should consider objective testing for pathologic GER, because additional trials of different PPIs are low yield. BEST PRACTICE ADVICE 7: Initial testing to evaluate for reflux should be tailored to patients' clinical presentation and can include upper endoscopy and ambulatory reflux monitoring studies of acid suppressive therapy. BEST PRACTICE ADVICE 8: Testing can be considered for those with an established objective diagnosis of GERD who do not respond to high doses of acid suppression. Testing can include pH-impedance monitoring while on acid suppression to evaluate the role of ongoing acid or non-acid reflux. BEST PRACTICE ADVICE 9: Alternative treatment methods to acid suppressive therapy (eg, lifestyle modifications, alginate-containing antacids, external upper esophageal sphincter compression device, cognitive-behavioral therapy, neuromodulators) may serve a role in management of EER symptoms. BEST PRACTICE ADVICE 10: Shared decision-making should be performed before referral for anti-reflux surgery for EER when the patient has clear, objectively defined evidence of GERD. However, a lack of response to PPI therapy predicts lack of response to anti-reflux surgery and should be incorporated into the decision process.
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Affiliation(s)
- Joan W Chen
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan.
| | - Marcelo F Vela
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona
| | | | - Dustin A Carlson
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Wu J, Ma Y, Chen Y. GERD-related chronic cough: Possible mechanism, diagnosis and treatment. Front Physiol 2022; 13:1005404. [PMID: 36338479 PMCID: PMC9630749 DOI: 10.3389/fphys.2022.1005404] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 10/07/2022] [Indexed: 11/04/2023] Open
Abstract
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.
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Affiliation(s)
| | - Yiming Ma
- Department of Pulmonary and Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yan Chen
- Department of Pulmonary and Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
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Diagnostic utility of salivary pepsin in laryngopharyngeal reflux: a systematic review and meta-analysis. Braz J Otorhinolaryngol 2022; 89:339-347. [PMID: 36347787 PMCID: PMC10071530 DOI: 10.1016/j.bjorl.2022.10.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 09/14/2022] [Accepted: 10/14/2022] [Indexed: 11/22/2022] Open
Abstract
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.
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Zhang J, Wang X, Wang J, Zhao J, Zhang C, Liu Z, Li J. Does hypopharyngeal-esophageal multichannel intraluminal impedance-pH monitoring for the diagnosis of laryngopharyngeal reflux have to be 24 h? Eur Arch Otorhinolaryngol 2022; 279:5323-5329. [PMID: 35864359 DOI: 10.1007/s00405-022-07554-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 07/11/2022] [Indexed: 12/25/2022]
Abstract
PURPOSE To investigate the diagnostic value of combined multi-timepoint salivary pepsin testing (MTPSPT) and hypopharyngeal-esophageal multichannel intraluminal impedance-pH monitoring (HEMII-pH) for laryngopharyngeal reflux (LPR) and whether an appropriate reduction in the duration of HEMII-pH would affect the accuracy of diagnosis of LPR. METHODS Recruited patients were studied with both MTPSPT and HEMII-pH. The diagnosis of LPR was based on the occurrence of > 1 reflux event and/or positive results on any of the MTPSPT. The diagnostic value of combined diagnosis was studied through combining a breakdown of the 24-h HEMII-pH finding and the results of the MTPSPT. The diagnostic value was expressed in terms of sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). RESULTS Based on 24-h HEMII-pH and MTPSPT, the positive rate of LPR was 83.33% and 74.69%, respectively. According to the combined diagnosis, the positive rate of LPR was 90.74%. The sensitivity and specificity of the combined diagnosis both were 89.51% and 100%, when the HEMII-pH intervals were 7 a.m.-6 p.m. and 7 a.m.-7 p.m., respectively. However, when the monitoring time was extended to 8 p.m. and bedtime, the sensitivity, specificity, PPV and NPV of the combined diagnosis both were 100%. CONCLUSIONS The combination of MTPSPT and HEMII-pH increased the sensitivity and accuracy of diagnosis of LPR. For patients with positive MTPSPT results, the duration of HEMII-pH can be appropriately shortened to reduce patient sufferings.
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Affiliation(s)
- Jinhong Zhang
- Department of Otolaryngology, School of Medicine, South China University of Technology, Guangzhou, 510006, China.,Department of Otolaryngology, The Sixth Medical Center of PLA General Hospital of Beijing, Beijing, 100048, China
| | - Xiaoyu Wang
- Department of Otolaryngology, The Sixth Medical Center of PLA General Hospital of Beijing, Beijing, 100048, China
| | - Jiasen Wang
- Department of Otolaryngology, The Sixth Medical Center of PLA General Hospital of Beijing, Beijing, 100048, China
| | - Jing Zhao
- Department of Otolaryngology, The Sixth Medical Center of PLA General Hospital of Beijing, Beijing, 100048, China
| | - Chun Zhang
- Department of Otolaryngology, The Sixth Medical Center of PLA General Hospital of Beijing, Beijing, 100048, China
| | - Zhi Liu
- Department of Otolaryngology, The Sixth Medical Center of PLA General Hospital of Beijing, Beijing, 100048, China
| | - Jinrang Li
- Department of Otolaryngology, School of Medicine, South China University of Technology, Guangzhou, 510006, China. .,Department of Otolaryngology, The Sixth Medical Center of PLA General Hospital of Beijing, Beijing, 100048, China.
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ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease. Am J Gastroenterol 2022; 117:27-56. [PMID: 34807007 PMCID: PMC8754510 DOI: 10.14309/ajg.0000000000001538] [Citation(s) in RCA: 294] [Impact Index Per Article: 147.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 08/30/2021] [Indexed: 01/30/2023]
Abstract
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.
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8
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Guo Z, Jiang J, Wu H, Zhu J, Zhang S, Zhang C. Salivary peptest for laryngopharyngeal reflux and gastroesophageal reflux disease: A systemic review and meta-analysis. Medicine (Baltimore) 2021; 100:e26756. [PMID: 34397878 PMCID: PMC8360476 DOI: 10.1097/md.0000000000026756] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 07/06/2021] [Indexed: 12/19/2022] Open
Abstract
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.
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Affiliation(s)
- Zihao Guo
- Department of Gastroenterology, Beijing Tong Ren Hospital, Capital Medical University, Beijing, China
| | - Jiali Jiang
- Department of Gastroenterology, Beijing Tong Ren Hospital, Capital Medical University, Beijing, China
| | - Hao Wu
- Department of Cardiovascular diseases, Beijing Tong Ren Hospital, Capital Medical University, Beijing, China
| | - Jinxia Zhu
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Capital Medical University, Beijing, China
| | - Shutian Zhang
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing, China
- Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing, China
| | - Chuan Zhang
- Department of Gastroenterology, Beijing Tong Ren Hospital, Capital Medical University, Beijing, China
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Fass R, Boeckxstaens GE, El-Serag H, Rosen R, Sifrim D, Vaezi MF. Gastro-oesophageal reflux disease. Nat Rev Dis Primers 2021; 7:55. [PMID: 34326345 DOI: 10.1038/s41572-021-00287-w] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/22/2021] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Ronnie Fass
- The Esophageal and Swallowing Center, Division of Gastroenterology and Hepatology, MetroHealth Medical System, Case Western Reserve University, Cleveland, OH, USA.
| | - Guy E Boeckxstaens
- Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
| | - Hashem El-Serag
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Rachel Rosen
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel Sifrim
- Wingate Institute of Neurogastroenterology, Royal London Hospital, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Michael F Vaezi
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA
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10
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Yadlapati R, Kaizer A, Greytak M, Ezekewe E, Simon V, Wani S. Diagnostic performance of salivary pepsin for gastroesophageal reflux disease. Dis Esophagus 2021; 34:5974938. [PMID: 33180095 PMCID: PMC9989599 DOI: 10.1093/dote/doaa117] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 10/07/2020] [Indexed: 12/11/2022]
Abstract
Uncertain diagnostic performance has limited clinical adoption of salivary pepsin, a noninvasive diagnostic tool for gastroesophageal reflux disease (GERD). This study aimed to assess diagnostic performance of salivary pepsin, and test validity of thresholds in an external cohort of patients with or without GERD. This two-phase prospective study conducted at two centers enrolled adult asymptomatic volunteers, patients with symptoms of GERD undergoing reflux monitoring, and patients with Barrett's esophagus (BE). Fasting saliva samples were processed for pepsin concentration using Peptest. Phase 1 compared pepsin concentration between No GERD (volunteers/functional heartburn) and GERD (erosive reflux disease/nonerosive reflux disease (NERD)/BE). Phase 2 tested validity of the diagnostic thresholds identified from Phase 1 among external functional heartburn and NERD cohorts. Of 243 enrolled subjects, 156 met inclusion criteria. Phase 1 (n = 114): Pepsin concentrations were significantly higher in GERD (n = 84) versus No GERD (n = 30) (73.8 ng/mL vs. 21.1 ng/mL; P < 0.001). Area under the curve for pepsin concentration was 0.74 (95% CI 0.65, 0.83). A salivary pepsin threshold of 24.9 ng/mL optimized the true negative rate and 100.0 ng/mL optimized the true positive rate. Phase 2 (n = 42): Pepsin concentrations were significantly higher in NERD (n = 22) versus Functional Heartburn (n = 20) (176.0 ng/mL vs. 53.3 ng/mL, P < 0.001). Applying Phase 1 thresholds in this external cohort, salivary pepsin 24.9 ng/mL was 86% sensitive (64%, 97%) and 100.0 ng/mL was 72% specific for distinguishing NERD from functional heartburn. Given modest sensitivity and specificity for GERD, salivary pepsin may have clinical utility as a noninvasive office based diagnostic screening tool for GERD.
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Affiliation(s)
- Rena Yadlapati
- Division of Gastroenterology, University of California, San Diego School of Medicine, La Jolla, CA, USA
| | - Alexander Kaizer
- University of Colorado, Anschutz Medical Campus, Colorado School of Public Health, Department of Biostatistics and Informatics, Aurora, CO, USA
| | - Madeline Greytak
- Division of Gastroenterology, University of California, San Diego School of Medicine, La Jolla, CA, USA
| | - Eze Ezekewe
- Division of Gastroenterology & Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Violette Simon
- Division of Gastroenterology & Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Sachin Wani
- Division of Gastroenterology & Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Guo Z, Wu Y, Chen J, Zhang S, Zhang C. The Role of Salivary Pepsin in the Diagnosis of Gastroesophageal Reflux Disease (GERD) Evaluated Using High-Resolution Manometry and 24-Hour Multichannel Intraluminal Impedance-pH Monitoring. Med Sci Monit 2020; 26:e927381. [PMID: 33220027 PMCID: PMC7687924 DOI: 10.12659/msm.927381] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND The Lyon Consensus classification confirms or rules out gastroesophageal reflux disease (GERD). The refractory symptoms of patients with GERD taking proton pump inhibitors (PPIs) are challenging in clinical practice. Salivary pepsin concentration was proposed as a diagnostic biomarker for GERD. We aimed to determine the diagnostic value of salivary pepsin concentration for patients with conclusive GERD, based on the Lyon classification, and the correlation of salivary pepsin concentration with parameters of high-resolution manometry and 24-h multichannel intraluminal impedance-pH in patients with PPI-refractory symptoms. MATERIAL AND METHODS Saliva samples obtained from 130 patients who were suspicious for GERD and had PPI-refractory symptoms were used for pepsin determination using the enzyme-linked immunosorbent assay. All patients underwent upper gastrointestinal endoscopy, high-resolution manometry, 24-h multichannel intraluminal impedance, and pH recording and were classified as conclusive GERD, inconclusive GERD, and evidence against GERD groups according to Lyon classification. RESULTS Salivary pepsin concentration was 8.2 ng/mL (3.8-17.8 ng/mL), 4.0 ng/mL (2.3-6.1 ng/mL), and 2.4 ng/mL (2.2-3.1 ng/mL) in conclusive GERD, inconclusive GERD, and evidence against GERD groups, respectively (P<0.001), and had a negative correlation with distal mean nocturnal baseline impedance and positive correlations with acid exposure time, total number of reflux events, and esophagogastric junction type. The area under the ROC curve of salivary pepsin for conclusive GERD was 0.76 (0.68-0.84), with a sensitivity of 76.36% and a specificity of 63.41% for conclusive GERD diagnosis at a cut-off value of 4.21 ng/mL. CONCLUSIONS Salivary pepsin test had moderate diagnostic value for conclusive GERD by Lyon classification in patients with PPI-refractory symptoms.
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Affiliation(s)
- Zihao Guo
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing, China (mainland).,Department of Gastroenterology, Beijing Tong Ren Hospital ,Capital Medical University, Beijing, China (mainland)
| | - Yanhong Wu
- Department of Gastroenterology, Beijing Tong Ren Hospital ,Capital Medical University, Beijing, China (mainland)
| | - Jing Chen
- Department of Gastroenterology, Beijing Tong Ren Hospital ,Capital Medical University, Beijing, China (mainland)
| | - Shutian Zhang
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing, China (mainland)
| | - Chuan Zhang
- Department of Gastroenterology, Beijing Tong Ren Hospital ,Capital Medical University, Beijing, China (mainland)
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Plateroti R, Sacchetti M, Magliulo G, Plateroti AM, Pace A, Moramarco A, Lambiase A, Bruscolini A. Evidence of Pepsin-Related Ocular Surface Damage and Dry Eye (PROD Syndrome) in Patients with Laryngopharyngeal Reflux. Life (Basel) 2020; 10:life10090202. [PMID: 32942541 PMCID: PMC7554736 DOI: 10.3390/life10090202] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 09/11/2020] [Accepted: 09/12/2020] [Indexed: 02/07/2023] Open
Abstract
Background: patients with laryngopharyngeal reflux (LPR) showed detectable levels of tear pepsin that explain the nasolacrimal obstruction. The purpose of this study was to determine whether patients with LPR show ocular surface changes and to investigate the relationship between lacrimal pepsin concentration and ocular alterations. Methods: Fifty patients with positive endoscopic signs for LPR and an equal or higher score of 13 and 7 for Reflux Symptom Index and Reflux Finding Score were enrolled. Twenty healthy patients with no reflux disease and dry eye were included as the control group. After evaluation of ocular discomfort symptoms, the tear break-up time test, corneal staining, and tear sampling were performed. Tear pepsin levels were measured using Pep-testTM kit. Results: Patients with LPR showed ocular surface changes including epithelial damage (48%) and impairment of lacrimal function (72%). Tear pepsin levels were detectable in 32 out of 50 (64%) patients with LPR (mean ± SD: 55.4 ± 67.5 ng/mL) and in none of the control subjects. Most of the LPR patients complained of ocular discomfort symptoms, including itching (38%), redness (56%), or foreign body sensation (40%). Tear pepsin levels were significantly correlated with the severity of LPR disease and with ocular surface changes. Conclusions: A multidisciplinary approach, including ophthalmological evaluation, should be considered in order to improve the management of patients with LPR.
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Affiliation(s)
- Rocco Plateroti
- Department of Sense Organs, Sapienza University of Rome, 00161 Rome, Italy; (R.P.); (M.S.); (G.M.); (A.P.); (A.M.); (A.B.)
| | - Marta Sacchetti
- Department of Sense Organs, Sapienza University of Rome, 00161 Rome, Italy; (R.P.); (M.S.); (G.M.); (A.P.); (A.M.); (A.B.)
| | - Giuseppe Magliulo
- Department of Sense Organs, Sapienza University of Rome, 00161 Rome, Italy; (R.P.); (M.S.); (G.M.); (A.P.); (A.M.); (A.B.)
| | - Andrea Maria Plateroti
- NESMOS Department, S. Andrea Hospital, Faculty of Medicine and Psychology, Sapienza University of Rome, 00189 Rome, Italy;
| | - Annalisa Pace
- Department of Sense Organs, Sapienza University of Rome, 00161 Rome, Italy; (R.P.); (M.S.); (G.M.); (A.P.); (A.M.); (A.B.)
| | - Antonietta Moramarco
- Department of Sense Organs, Sapienza University of Rome, 00161 Rome, Italy; (R.P.); (M.S.); (G.M.); (A.P.); (A.M.); (A.B.)
| | - Alessandro Lambiase
- Department of Sense Organs, Sapienza University of Rome, 00161 Rome, Italy; (R.P.); (M.S.); (G.M.); (A.P.); (A.M.); (A.B.)
- Correspondence: ; Tel.: +39-06-4997-5300
| | - Alice Bruscolini
- Department of Sense Organs, Sapienza University of Rome, 00161 Rome, Italy; (R.P.); (M.S.); (G.M.); (A.P.); (A.M.); (A.B.)
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Yin CY, Zhang SS, Zhong JT, Zhou SH. Pepsin and Laryngeal and Hypopharyngeal Carcinomas. Clin Exp Otorhinolaryngol 2020; 14:159-168. [PMID: 32734742 PMCID: PMC8111387 DOI: 10.21053/ceo.2020.00465] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 07/17/2020] [Indexed: 02/08/2023] Open
Abstract
Laryngeal and hypopharyngeal carcinomas are common malignant tumors of the head and neck, and the incidence of both is increasing. Laryngopharyngeal reflux refers to the retrograde flow of gastric contents into the larynx, oropharynx, and/or nasopharynx. It remains controversial whether laryngopharyngeal reflux is a risk factor for laryngeal and hypopharyngeal cancers. The refluxing substances mainly include hydrochloric acid, pepsin, and occasionally bile acids and bile salts, as well as bacteria that colonize the gastrointestinal tract. Loss of epithelium in the mucous membrane of the larynx and hypopharynx is thought to be caused by pepsin. Here, we review the relationships between laryngopharyngeal reflux and both laryngeal and hypopharyngeal carcinomas, as well as the significance of pepsin, methods of clinical detection, and the mechanism of carcinogenesis.
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Affiliation(s)
- Cheng-Yi Yin
- Department of Otolaryngology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,Department of Otolaryngology, The First People's Hospital of Huzhou City, Zhejiang, China
| | - Sha-Sha Zhang
- Department of Otolaryngology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Jiang-Tao Zhong
- Department of Otolaryngology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Shui-Hong Zhou
- Department of Otolaryngology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
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Clinical utility of salivary pepsin measurement in patients with proton pump inhibitor-refractory gastroesophageal reflux disease symptoms: a prospective comparative study. Esophagus 2020; 17:339-347. [PMID: 31982992 DOI: 10.1007/s10388-020-00714-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 01/12/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Salivary pepsin measurement has been reported to be useful for diagnosing gastroesophageal reflux disease (GERD). This study aimed to clarify the usefulness of salivary pepsin measurement in patients with proton pump inhibitor (PPI)-refractory GERD symptoms without erosive esophagitis. METHODS One hundred and two patients were included. Over seven days after terminating PPI treatment, all patients underwent a 24-h pH-impedance test and salivary pepsin measurement. In patients whose main symptoms included laryngopharyngeal symptoms, a hypopharyngeal multichannel intraluminal impedance (HMII) test was performed, whereas in other patients, a conventional combined multichannel intraluminal impedance-pH (MII-pH) test was performed. In the HMII tests, patients were divided into abnormal proximal exposure (APE) and non-APE groups. Salivary pepsin concentrations were compared according to acid exposure time (AET) values and were also compared between the APE and non-APE groups. RESULTS The median salivary pepsin concentration in patients with AET > 6% was significantly higher than that in patients with AET ≤ 6% (345.0 [170.0-469.3] ng/mL vs. 120.0 [97.0-290.1] ng/mL, p < 0.01). The sensitivity, specificity, positive predictive value, and negative predictive value of a positive test (> 109 ng/mL) to diagnose patients with AET > 6% were 75.0%, 51.3%, 32.1%, and 86.9%, respectively. There was no significant difference between concentrations in the APE group and concentrations in the non-APE group. CONCLUSIONS In patients with PPI-refractory nonerosive reflux disease, salivary pepsin measurement may help diagnose patients who have conclusive evidence of reflux, whereas it is not adequate for identifying patients with APE.
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A Multicentre Study in UK Voice Clinics Evaluating the Non-invasive Reflux Diagnostic Peptest in LPR Patients. ACTA ACUST UNITED AC 2019. [DOI: 10.1007/s42399-019-00184-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
AbstractQuestionnaires 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.
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Klimara MJ, Johnston N, Samuels TL, Visotcky AM, Poetker DM, Loehrl TA, Blumin JH, Bock JM. Correlation of salivary and nasal lavage pepsin with MII-pH testing. Laryngoscope 2019; 130:961-966. [PMID: 31329290 DOI: 10.1002/lary.28182] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 06/10/2019] [Accepted: 06/24/2019] [Indexed: 11/12/2022]
Abstract
OBJECTIVES Laryngopharyngeal reflux (LPR) is a common upper airway disease. Salivary pepsin is a proposed marker for LPR; however, the optimal time for collection of specimens for pepsin detection and pepsin's presence in the oral and nasal secretions relative to concurrent multichannel intraluminal impedance-pH (MII-pH) monitoring are unknown. STUDY DESIGN Prospective case-control study with an experimental design. METHODS Patients undergoing MII-pH testing for evaluation of LPR and asymptomatic control subjects were selected. Nasal lavage and saliva samples were collected in the clinic prior to MII-pH probe placement. Additional saliva samples were obtained an hour after each meal and upon waking the following morning. Nasal lavage and salivary pepsin were measured by ELISA. RESULTS Twenty-six patients undergoing MII-pH testing and 13 reflux-free control patients were enrolled. Salivary pepsin was detected in 11 of 26 patients with suspected LPR and 0 of 13 controls. Pepsin was most frequently detected in the specimen provided upon waking at an average concentration of 186.9 ng/mL. A significant correlation was observed between salivary pepsin in waking samples to MII-pH measurements, including reflux bolus duration, and proximal and distal recumbent reflux episodes (P < 0.05). A significant correlation was also observed between salivary pepsin upon waking or sinus lavage and reflux symptom index (P < 0.05). CONCLUSION Pepsin in salivary and nasal lavage samples demonstrated an association with MII-pH-documented LPR. Pepsin detection was most frequent in morning samples, supporting use of morning salivary pepsin levels as a potential noninvasive technique for LPR diagnosis. LEVEL OF EVIDENCE 2 Laryngoscope, 130:961-966, 2020.
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Affiliation(s)
- Miles J Klimara
- Department of Microbiology and Immunology, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Nikki Johnston
- Department of Microbiology and Immunology, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Tina L Samuels
- Institute for Health and Equity, Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Alexis M Visotcky
- Institute for Health and Equity, Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - David M Poetker
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Todd A Loehrl
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Joel H Blumin
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Jonathan M Bock
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
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Duricek M, Banovcin P, Halickova T, Hyrdel R, Kollarik M. Acidic Pharyngeal Reflux Does Not Correlate with Symptoms and Laryngeal Injury Attributed to Laryngopharyngeal Reflux. Dig Dis Sci 2019; 64:1270-1280. [PMID: 30430298 PMCID: PMC10694844 DOI: 10.1007/s10620-018-5372-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 11/08/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Laryngopharyngeal reflux (LPR) is suspected when the symptoms are attributed to the penetration of acidic gastroesophageal reflux (GER) into the larynx. However, the relationships between the intensity of LPR and symptoms and laryngeal injury have not been elucidated. Several factors confound the study of LPR, namely pH is monitored in the pharynx (pharyngeal reflux) but the pharyngeal acidity (pH) required to induce laryngeal injury is unknown, the GER origin of pharyngeal acid is not always established, and a recent treatment with proton pump inhibitors (PPI) confounds the analysis. AIMS We aimed to limit these confounding factors to analyze the relationship between LPR and symptoms and laryngeal injury. METHODS We used dual pharyngeal and distal esophageal 24-h pH/impedance monitoring to establish GER origin of pharyngeal reflux, we used an unbiased approach to analysis by evaluating a whole range of acidity (pH < 6, pH < 5.5, pH < 5.0, pH < 4.5 and pH < 4.0) in patients with suspected LPR without PPI for > 30 days. RESULTS Pharyngeal reflux was (median[IQR]) 14[8-20.5] and 4[1.5-6.5] pharyngeal reflux episodes with pH < 6.0 and pH < 5.5, respectively. Pharyngeal reflux with pH < 5.0 was rare. Comprehensive analysis did not reveal any correlation between symptoms (reflux symptom index) or laryngeal injury (reflux finding score) and the number of pharyngeal reflux episodes or duration of pharyngeal acid exposure at any pH level. CONCLUSION Unbiased comprehensive approach did not reveal any relationship between acidic pharyngeal reflux and the symptoms or laryngeal injury attributed to LPR. Limited clinical usefulness of pharyngeal monitoring reported by others is unlikely due to confounding factors.
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Affiliation(s)
- Martin Duricek
- Gastroenterology Clinic JFM CU, Jessenius Faculty of Medicine in Martin (JFM CU), Comenius University in Bratislava, Kollárova 2, 03659, Martin, Slovakia
| | - Peter Banovcin
- Gastroenterology Clinic JFM CU, Jessenius Faculty of Medicine in Martin (JFM CU), Comenius University in Bratislava, Kollárova 2, 03659, Martin, Slovakia.
| | - Tatiana Halickova
- Clinic of ENT and Head and Neck Surgery, Central Military and Faculty Hospital in Ružomberok, Považská 1380/2, 034 01, Ružomberok, Slovakia
| | - Rudolf Hyrdel
- Gastroenterology Clinic JFM CU, Jessenius Faculty of Medicine in Martin (JFM CU), Comenius University in Bratislava, Kollárova 2, 03659, Martin, Slovakia
| | - Marian Kollarik
- Department of Pathophysiology JFM CU, Jessenius Faculty of Medicine in Martin (JFM CU), Comenius University in Bratislava, Ružomberok, Slovakia
- Department of Molecular Pharmacology & Physiology, University of South Florida, Tampa, FL, USA
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Woodland P, Singendonk MMJ, Ooi J, Nikaki K, Wong T, Lee C, Glasinovic E, Koning R, Lutter R, Benninga MA, van Wijk MP, Sifrim D. Measurement of Salivary Pepsin to Detect Gastroesophageal Reflux Disease Is Not Ready for Clinical Application. Clin Gastroenterol Hepatol 2019; 17:563-565. [PMID: 29782998 DOI: 10.1016/j.cgh.2018.05.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 04/28/2018] [Accepted: 05/15/2018] [Indexed: 02/07/2023]
Abstract
A noninvasive test for gastroesophageal reflux disease (GERD) is desirable for adults and children. Salivary pepsin measurement has been proposed as such a test.1-3 A previous study from our group demonstrated that a maximal salivary pepsin cutoff of >210 ng/mL using the PepTest device (RD Biomed, Hull, United Kingdom) had excellent specificity of 96% but modest sensitivity of 44% to diagnose GERD,4 leading to optimism about its potential use. In this study, we aimed to confirm the previously reported sensitivity and specificity in healthy volunteers and patients with heartburn, evaluate the association between a positive PepTest and response to proton pump inhibitor (PPI) therapy, assess if test-sensitivity can be improved for GERD when samples are taken over a 72-hour sampling period, and establish normal values of salivary pepsin in infants.
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Affiliation(s)
- Philip Woodland
- Wingate Institute for Neurogastroenterology, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Maartje M J Singendonk
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital AMC, Amsterdam, The Netherlands
| | - Joanne Ooi
- Wingate Institute for Neurogastroenterology, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Kornilia Nikaki
- Wingate Institute for Neurogastroenterology, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Terry Wong
- Department of Gastroenterology, St Thomas Hospital, London, United Kingdom
| | - Chung Lee
- Wingate Institute for Neurogastroenterology, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Esteban Glasinovic
- Wingate Institute for Neurogastroenterology, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Romy Koning
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital AMC, Amsterdam, The Netherlands
| | - Rene Lutter
- Department of Experimental Immunology, Academic Medical Centre, Amsterdam, The Netherlands; Department of Respiratory Medicine, Academic Medical Centre, Amsterdam, The Netherlands
| | - Marc A Benninga
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital AMC, Amsterdam, The Netherlands
| | - Michiel P van Wijk
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital AMC, Amsterdam, The Netherlands; Department of Pediatric Gastroenterology, VU University Medical Center, Amsterdam, The Netherlands
| | - Daniel Sifrim
- Wingate Institute for Neurogastroenterology, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom.
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Guo Z, Wu H, Jiang J, Zhang C. Pepsin in Saliva as a Diagnostic Marker for Gastroesophageal Reflux Disease: A Meta-Analysis. Med Sci Monit 2018; 24:9509-9516. [PMID: 30596632 PMCID: PMC6324865 DOI: 10.12659/msm.913978] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- Zihao Guo
- Department of Gastroenterology, Beijing Tong Ren Hospital, Capital Medical University, Beijing, China (mainland)
| | - Hao Wu
- Department of Cardiovascular, Beijing Tong Ren Hospital, Capital Medical University, Beijing, China (mainland)
| | - Jiali Jiang
- Department of Gastroenterology, Beijing Tong Ren Hospital, Capital Medical University, Beijing, China (mainland)
| | - Chuan Zhang
- Department of Gastroenterology, Beijing Tong Ren Hospital, Capital Medical University, Beijing, China (mainland)
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Abstract
Globus is an area of interest for many medical specialists including otorhinolaryngologists, gastroenterologist, allergists, and psychiatrists. It may be caused by an organic disease, but it is not uncommon that an underlying etiology remains unidentified even after a full workup has been performed. Patients who suffer from globus usually visit several physicians from different specialties without finding a solution for their symptoms. Identifying the underlying cause of globus is not always a simple task; therefore, structural or functional abnormalities of the thyroid, larynx, pharynx, and esophagus should be investigated. Gastroesophageal reflux disease is commonly considered to be the underlying cause after being identified in an otorhinolarygeal (ear, nose, and throat) evaluation, which is usually the first diagnostic step. In the last few years, an inlet patch in the proximal esophagus has been shown to be associated with globus, and its elimination has resulted in symptom resolution in some patients. Finally, globus can be associated with psychiatric disorders as well as oropharyngeal hypersensitivity that could be either chemical or mechanical. Treatment is directed toward an identified organic cause; in those with a functional disorder, the mainstay of therapy includes neuromodulators and psychiatric/psychological interventions.
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Vaezi MF, Katzka D, Zerbib F. Extraesophageal Symptoms and Diseases Attributed to GERD: Where is the Pendulum Swinging Now? Clin Gastroenterol Hepatol 2018; 16:1018-1029. [PMID: 29427733 DOI: 10.1016/j.cgh.2018.02.001] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 01/31/2018] [Accepted: 02/02/2018] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Michael F Vaezi
- Division of Gastroenterology, Hepatology, Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - David Katzka
- Department of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Frank Zerbib
- CHU Bordeaux, Department of Gastroenterology, Hepatology and Digestive Oncology, University of Bordeaux, Bordeaux, France
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Gyawali CP, Kahrilas PJ, Savarino E, Zerbib F, Mion F, Smout AJPM, Vaezi M, Sifrim D, Fox MR, Vela MF, Tutuian R, Tack J, Bredenoord AJ, Pandolfino J, Roman S. Modern diagnosis of GERD: the Lyon Consensus. Gut 2018; 67:1351-1362. [PMID: 29437910 PMCID: PMC6031267 DOI: 10.1136/gutjnl-2017-314722] [Citation(s) in RCA: 815] [Impact Index Per Article: 135.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 01/11/2018] [Accepted: 01/14/2018] [Indexed: 12/12/2022]
Abstract
Clinical history, questionnaire data and response to antisecretory therapy are insufficient to make a conclusive diagnosis of GERD in isolation, but are of value in determining need for further investigation. Conclusive evidence for reflux on oesophageal testing include advanced grade erosive oesophagitis (LA grades C and D), long-segment Barrett's mucosa or peptic strictures on endoscopy or distal oesophageal acid exposure time (AET) >6% on ambulatory pH or pH-impedance monitoring. A normal endoscopy does not exclude GERD, but provides supportive evidence refuting GERD in conjunction with distal AET <4% and <40 reflux episodes on pH-impedance monitoring off proton pump inhibitors. Reflux-symptom association on ambulatory reflux monitoring provides supportive evidence for reflux triggered symptoms, and may predict a better treatment outcome when present. When endoscopy and pH or pH-impedance monitoring are inconclusive, adjunctive evidence from biopsy findings (histopathology scores, dilated intercellular spaces), motor evaluation (hypotensive lower oesophageal sphincter, hiatus hernia and oesophageal body hypomotility on high-resolution manometry) and novel impedance metrics (baseline impedance, postreflux swallow-induced peristaltic wave index) can add confidence for a GERD diagnosis; however, diagnosis cannot be based on these findings alone. An assessment of anatomy, motor function, reflux burden and symptomatic phenotype will therefore help direct management. Future GERD management strategies should focus on defining individual patient phenotypes based on the level of refluxate exposure, mechanism of reflux, efficacy of clearance, underlying anatomy of the oesophagogastric junction and psychometrics defining symptomatic presentations.
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Affiliation(s)
- C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Peter J Kahrilas
- Division of Gastroenterology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Edoardo Savarino
- Division of Gastroenterology, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - Frank Zerbib
- Department of Gastroenterology, Bordeaux University Hospital, Université de Bordeaux, Bordeaux, France
| | - Francois Mion
- Digestive Physiology, Hopital E Herriot, Hospices Civils de Lyon, Université de Lyon, Lyon, France,Digestive Physiology, Université de Lyon, Lyon I University, Lyon, France,Université de Lyon, Inserm U1032, Lyon, France
| | - André J P M Smout
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Michael Vaezi
- Division of Gastroenterology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Daniel Sifrim
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Mark R Fox
- Gastroenterology, St. Claraspital, Kleinriehenstrasse 30, Basel, Switzerland,Zürich Neurogastroenterology and Motility Research Group, Clinic for Gastroenterology and Hepatology, University Hospital of Zürich, Zürich, Switzerland
| | - Marcelo F Vela
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Radu Tutuian
- Division of Gastroenterology, University Clinics for Visceral Surgery and Medicine, Bern University Hospital, Bern, Switzerland
| | - Jan Tack
- Department of Gastroenterology, Catholic University of Leuven, Leuven, Belgium
| | - Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - John Pandolfino
- Division of Gastroenterology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Sabine Roman
- Digestive Physiology, Hopital E Herriot, Hospices Civils de Lyon, Université de Lyon, Lyon, France,Digestive Physiology, Université de Lyon, Lyon I University, Lyon, France,Université de Lyon, Inserm U1032, Lyon, France
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23
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Johnston N, Dettmar PW, Ondrey FG, Nanchal R, Lee SH, Bock JM. Pepsin: biomarker, mediator, and therapeutic target for reflux and aspiration. Ann N Y Acad Sci 2018; 1434:282-289. [PMID: 29774546 DOI: 10.1111/nyas.13729] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 03/13/2018] [Accepted: 03/20/2018] [Indexed: 02/06/2023]
Abstract
Extra-esophageal reflux is suspected to cause a wide range of clinical symptoms in the upper airways. Diagnosis and treatment has focused on acid, but realization of the role of nonacid reflux has resulted in research investigating the use of pepsin as a biomarker for gastric reflux and aspiration. Pepsin analysis can complement the use of questionnaires and office-based diagnosis and lessen the dependency on invasive and expensive diagnostic tests. Furthermore, pepsin as a first-line diagnostic biomarker has been shown to improve the accuracy of reflux diagnosis. In addition to its use as a diagnostic biomarker, pepsin has been shown to cause inflammation independent of the pH of the refluxate and thus despite acid suppression therapy. Research is ongoing to develop new therapies for airway reflux that specifically target pepsin.
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Affiliation(s)
- Nikki Johnston
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Frank G Ondrey
- Department of Otolaryngology, University of Minnesota, Minneapolis, Minnesota
| | - Rahul Nanchal
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Sang-Hyuk Lee
- Department of Otolaryngology, Sungkyunkwan University School of Medicine, Kangbuk Samsung Hospital, Seoul, Korea
| | - Jonathan M Bock
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin
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Abstract
INTRODUCTION Gastroesophageal reflux disease (GERD) may present with heartburn, regurgitation, dysphagia, chronic cough, laryngitis, or even asthma. The clinical presentation of GERD is therefore varied and poses certain challenges to the physician, especially given the limitations of the diagnostic testing. DISCUSSION The evaluation of patients with suspected GERD might be challenging. It is based on the evaluation of clinical features, objective evidence of reflux on diagnostic testing, correlation of symptoms with episodes of reflux, evaluation of anatomical abnormalities, and excluding other causes that might account for the presence of the patient's symptoms. CONCLUSIONS The diagnostic evaluation should include multiple tests, in addition to a thorough clinical examination.
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25
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Vaezi MF, Sifrim D. Assessing Old and New Diagnostic Tests for Gastroesophageal Reflux Disease. Gastroenterology 2018; 154:289-301. [PMID: 28774844 DOI: 10.1053/j.gastro.2017.07.040] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 07/05/2017] [Accepted: 07/10/2017] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Michael F Vaezi
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Daniel Sifrim
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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26
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Pepsin in saliva as a diagnostic biomarker in laryngopharyngeal reflux: a meta-analysis. Eur Arch Otorhinolaryngol 2017; 275:671-678. [DOI: 10.1007/s00405-017-4845-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Accepted: 12/08/2017] [Indexed: 01/17/2023]
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27
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Wang J, Yu Z, Ren J, Xu Y, Zhang Y, Lei L, Zheng Y, Huang L, He Z. Effects of pepsin A on heat shock protein 70 response in laryngopharyngeal reflux patients with chronic rhinosinusitis. Acta Otolaryngol 2017; 137:1253-1259. [PMID: 28784015 DOI: 10.1080/00016489.2017.1360515] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES We investigated the relationship between laryngopharyngeal reflux (LPR) and chronic rhinosinusitis (CRS), and explored the effects of pepsin A on the level of heat shock protein 70 (HSP70) in CRS. METHODS We included 23 CRS patients with nasal polyps (CRSwNP), 26 CRS patients without nasal polyps (CRSsNP) and nine normal controls to measure pepsin A levels in nasal secretions, blood plasma and nasal tissues, to measure HSP70 levels in nasal tissues, and to detect pepsinogen A, HSPA5, cyclo-oxygenase-2 (COX-2), and carbonic anhydrase III (CAIII) mRNA expression levels in nasal tissues. RESULTS Pepsin A levels in nasal secretions were significantly higher in CRSwNP/CRSsNP patients than in controls. HSP70 levels were significantly increased in pepsin A-positive turbinate mucosa compared to controls (p < .001). Similarly, HSP70 levels were significantly increased in pepsin A-positive polyp tissues than in pepsin A-negative polyp tissues (p = .016). Furthermore, no association was found between the presence of pepsin A and HSPA5, COX-2, and CAIII mRNA expression levels. CONCLUSIONS These results suggest that LPR may play a role in the development of CRS through pepsin A reflux, and increased HSP70 expression may be associated with the pathogenic mechanism of mucosal injury in CRS.
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Affiliation(s)
- Jing Wang
- Department of Oto-Rhino-Laryngology, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan, China
| | - Zhao Yu
- Department of Oto-Rhino-Laryngology, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan, China
| | - Jianjun Ren
- Department of Oto-Rhino-Laryngology, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan, China
| | - Yang Xu
- Department of Oto-Rhino-Laryngology, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan, China
| | - Yuke Zhang
- Department of Oto-Rhino-Laryngology, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan, China
| | - Lei Lei
- Department of Oto-Rhino-Laryngology, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan, China
| | - Yongbo Zheng
- Department of Oto-Rhino-Laryngology, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan, China
| | - Ligao Huang
- Department of Otolaryngology, Chengdu Renpin Otorhinolaryngological Hospital, Chengdu, Sichuan, China
| | - Zhaoping He
- Department of Biomedical Research, Nemours/Alfred I.duPont Hospital for Children, Wilmington, DE, USA
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28
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Abstract
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.
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29
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Sadeghi MH, Morice AH. The Emerging Role of The Eosinophil and Its Measurement in Chronic Cough. Open Respir Med J 2017; 11:17-30. [PMID: 28761563 PMCID: PMC5510559 DOI: 10.2174/1874306401711010017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 04/29/2017] [Accepted: 05/08/2017] [Indexed: 11/22/2022] Open
Abstract
Although the aetiology of chronic cough in guidelines is clearly stated as asthma and related syndromes, gastro-oesophageal reflux disease (GORD), and upper airways disease, the inflammatory mechanisms underlying these conditions differ. Recent studies on asthma have increasingly focused on its molecular phenotypes instead of clinical characteristics. Here, we proposed the hypothesis that divides cough into two groups; the eosinophilic and neutrophilic. This division will enhance our ability to recognise the type of airway inflammation which, as a consequence will lead us to more targeted and personalized treatment approaches.
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Affiliation(s)
- Mahboobeh H. Sadeghi
- Respiratory Medicine, Castle Hill Hospital, Centre for Cardiovascular and Metabolic Research, Hull York Medical School, Cottingham, UK
| | - Alyn H. Morice
- Respiratory Medicine, Castle Hill Hospital, Centre for Cardiovascular and Metabolic Research, Hull York Medical School, Cottingham, UK
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30
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Calvo-Henríquez C, Ruano-Ravina A, Vaamonde P, Martínez-Capoccioni G, Martín-Martín C. Is Pepsin a Reliable Marker of Laryngopharyngeal Reflux? A Systematic Review. Otolaryngol Head Neck Surg 2017; 157:385-391. [DOI: 10.1177/0194599817709430] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Objective Laryngopharyngeal reflux (LPR) is a common illness of otolaryngology visits. Over the past few years, pepsin has become a promising marker of LPR. The objective of the present research is to analyze the existing literature using pepsin as a diagnostic tool of LPR through a systematic review. Data Sources PubMed (Medline), Trip Database, Cochrane Library, EMBASE, SUMsearch, and Web of Science. Review Methods The outcome assessed was the presence of pepsin in LPR patients. We included articles in which pepsin was studied in LPR patients (clinically suspected or with confirmed diagnosis). Studies with no control group, comparison group, and/or a sample size lower than 20 patients were excluded. Results Twelve studies were included. All included studies, with the exception of 2, found statistically significant differences for pepsin in cases compared with healthy controls. Conclusion Pepsin might be a reliable marker in LPR patients, although questions remain about optimal timing, location, nature, and threshold values for pepsin testing. Future investigations are necessary to clarify the best method to use pepsin in the diagnostic process of LPR.
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Affiliation(s)
- Christian Calvo-Henríquez
- Service of Otolaryngology, Hospital Complex of Santiago de Compostela, Santiago de Compostela, Spain
| | - Alberto Ruano-Ravina
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, Santiago de Compostela, Spain
- CIBER de Epidemiología y Salud Pública, CIBERESP, Santiago de Compostela, Spain
| | - Pedro Vaamonde
- Service of Otolaryngology, Hospital Complex of Santiago de Compostela, Santiago de Compostela, Spain
- Department of Voice and Swallowing Disorders, Service of Otolaryngology, Hospital Complex of Santiago de Compostela, Santiago de Compostela, Spain
| | | | - Carlos Martín-Martín
- Service of Otolaryngology, Hospital Complex of Santiago de Compostela, Santiago de Compostela, Spain
- Department of Otolaryngology, University of Santiago de Compostela, Santiago de Compostela, Spain
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31
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Ren JJ, Zhao Y, Wang J, Ren X, Xu Y, Tang W, He Z. PepsinA as a Marker of Laryngopharyngeal Reflux Detected in Chronic Rhinosinusitis Patients. Otolaryngol Head Neck Surg 2017; 156:893-900. [PMID: 28457223 DOI: 10.1177/0194599817697055] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Objectives We aimed to confirm the presence of pepsinA in the nasal secretions and tissues of chronic rhinosinusitis (CRS) patients and reveal the relationship between CRS and laryngopharyngeal reflux (LPR). Study Design Cross-sectional study. Setting The study was conducted at the Department of Oto-Rhino-Laryngology, West China Hospital, Sichuan University. Subjects and Methods A total of 32 CRS patients with or without nasal polyps (CRSwNP and CRSsNP, respectively) and 10 normal controls were enrolled in our study. We investigated the expression of pepsinA in the nasal tissues, secretions, and blood plasma from the subjects by immunohistochemical staining, Western blot, or ELISA. Additionally, the expressions of MUC4, MUC5AC, MUC5B, MUC8, and pepsinogenA in nasal tissue were evaluated by quantitative real-time polymerase chain reaction. Results Immunohistochemistry and Western blot revealed that the pepsinA expression levels in the turbinate mucosa in CRSwNP/CRSsNP patients, which were largely restricted to the epithelial layer or glandular mucous cells in nasal tissues, were significantly higher than those in controls and in the polyp tissues of CRSwNP patients ( P < .05). In addition, the concentration of pepsinA in nasal secretions was significantly increased in the CRSwNP (147.85 ± 53.69 ng/mL, P < .001) and CRSsNP (134.12 ± 36.23 ng/mL, P < .001) groups as compared with the controls (68.69 ± 19.28 ng/mL). Although MUC5AC, MUC5B, and MUC8 expression differed among the groups, no correlation between pepsinA and mucin genes was found. Conclusion The results of this study provided evidence of an association between LPR and CRS, although no correlation was found to exist between LPR and mucin genes in CRS patients.
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Affiliation(s)
- Jian-jun Ren
- Department of Oto-Rhino-Laryngology, West China Hospital, West China Medical School, Sichuan University, Chengdu, China
| | - Yu Zhao
- Department of Oto-Rhino-Laryngology, West China Hospital, West China Medical School, Sichuan University, Chengdu, China
| | - Jing Wang
- Department of Oto-Rhino-Laryngology, West China Hospital, West China Medical School, Sichuan University, Chengdu, China
| | - Xue Ren
- School of Mathematics and Statistics, Chongqing Technology and Business University, Chongqing, China
| | - Yang Xu
- Department of Oto-Rhino-Laryngology, West China Hospital, West China Medical School, Sichuan University, Chengdu, China
| | - Wenlong Tang
- Shenzhen Key Laboratory of ENT, Institute of ENT & Longgang ENT Hospital, Shenzhen, China
| | - Zhaoping He
- Department of Biomedical Research, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware, USA
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32
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Savarino E, Zentilin P, Marabotto E, Savarino V. Relevance of Measuring Substances in Bronchoalveolar Lavage Fluid for Detecting Aspiration-associated Extraesophageal Reflux Disease. J Neurogastroenterol Motil 2017; 23:318-319. [PMID: 28249378 PMCID: PMC5383128 DOI: 10.5056/jnm17027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
- Edoardo Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Patrizia Zentilin
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Elisa Marabotto
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Vincenzo Savarino
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
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33
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Fortunato JE, D'Agostino RB, Lively MO. Pepsin in saliva as a biomarker for oropharyngeal reflux compared with 24-hour esophageal impedance/pH monitoring in pediatric patients. Neurogastroenterol Motil 2017; 29. [PMID: 27604397 DOI: 10.1111/nmo.12936] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 08/06/2016] [Indexed: 12/13/2022]
Abstract
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 (rS =0.332, P=.0014), proximal (rS =0.340, P=.0010), and distal (rS =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.
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Affiliation(s)
- J E Fortunato
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - R B D'Agostino
- Department of Biostatistical Sciences, Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - M O Lively
- Department of Biochemistry, Wake Forest School of Medicine, Winston-Salem, NC, USA
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Dulery C, Lechot A, Roman S, Bastier PL, Stoll D, de Gabory L, Zerbib F. A study with pharyngeal and esophageal 24-hour pH-impedance monitoring in patients with laryngopharyngeal symptoms refractory to proton pump inhibitors. Neurogastroenterol Motil 2017; 29. [PMID: 27424517 DOI: 10.1111/nmo.12909] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 06/22/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND The role of gastroesophageal reflux in chronic laryngeal symptoms is difficult to establish. The aim of this study was to characterize pharyngeal and esophageal pH-impedance reflux patterns in a group of patients with suspected laryngopharyngeal reflux and to determine predictive factors of response to proton pump inhibitors. METHODS Patients with chronic pharyngolaryngeal symptoms were evaluated with a symptom score questionnaire, laryngoscopy, and 24-hour pharyngeal and esophageal pH-impedance monitoring at baseline and after 8-week treatment with esomeprazole 40 mg b.i.d. Response to treatment was defined by a diminution of more than 50% of the score for the primary symptom. Reflux patterns and baseline impedance values were compared to those obtained in 46 healthy subjects. KEY RESULTS Twenty-four patients were included (17 women, median age 54 years), all previously refractory to antisecretory therapy. Symptom scores were 46 (32-62) and 40 (27-76) off and on therapy, respectively (P=.1). There was no significant difference between patients and controls for pH-impedance reflux parameters and baseline values off and on therapy in distal and proximal esophagus and in the pharynx. Median numbers of pharyngeal reflux were 0 and 0 off and on therapy, respectively. Only two patients were responders to treatment, both with excessive distal reflux but no pharyngeal reflux. Only one patient had abnormal pharyngeal reflux but did not respond to proton pump inhibitors. CONCLUSIONS Patients with suspected laryngopharyngeal reflux refractory to therapy do not exhibit abnormal pharyngeal or esophageal pH-impedance reflux. In these patients, laryngopharyngeal reflux is unlikely.
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Affiliation(s)
- C Dulery
- Gastroenterology Department, Bordeaux University Hospital, Université de Bordeaux, Bordeaux, France
| | - A Lechot
- ENT Department, Bordeaux University Hospital, Université de Bordeaux, Bordeaux, France
| | - S Roman
- LabTAU, Inserm U1032, Univ Lyon, Lyon, France.,Digestive Physiology Department, Hospices Civils de Lyon, Edouard Herriot Hospital, Lyon, France
| | - P-L Bastier
- ENT Department, Bordeaux University Hospital, Université de Bordeaux, Bordeaux, France
| | - D Stoll
- ENT Department, Bordeaux University Hospital, Université de Bordeaux, Bordeaux, France
| | - L de Gabory
- ENT Department, Bordeaux University Hospital, Université de Bordeaux, Bordeaux, France
| | - F Zerbib
- Gastroenterology Department, Bordeaux University Hospital, Université de Bordeaux, Bordeaux, France
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35
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Passaretti S, Mazzoleni G, Vailati C, Testoni PA. Oropharyngeal acid reflux and motility abnormalities of the proximal esophagus. World J Gastroenterol 2016; 22:8991-8998. [PMID: 27833390 PMCID: PMC5083804 DOI: 10.3748/wjg.v22.i40.8991] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 08/29/2016] [Accepted: 09/28/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the relationship between pathological oropharyngeal (OP) acid exposure and esophageal motility in patients with extra-esophageal syndromes.
METHODS In this prospective study we enrolled consecutive outpatients with extra-esophageal symptoms suspected to be related to gastroesophageal reflux disease (GERD). We enrolled only patients with a reflux symptom index (RSI) score-higher than 13 and with previous lung, allergy and ear, nose and throat evaluations excluding other specific diagnoses. All patients underwent 24-h OP pH-metry with the Dx probe and esophageal high-resolution manometry (HRM). Patients were divided into two groups on the basis of a normal or pathological pH-metric finding (Ryan Score) and all manometric characteristics of the two groups were compared.
RESULTS We examined 135 patients with chronic extra-esophageal syndromes. Fifty-one were considered eligible for the study. Of these, 42 decided to participate in the protocol. Patients were divided into two groups on the basis of normal or pathological OP acid exposure. All the HRM parameters were compared for the two groups. Significant differences were found in the median upper esophageal sphincter resting pressure (median 71 mmHg vs 126 mmHg, P = 0.004) and the median proximal contractile integral (median 215.5 cm•mmHg•s vs 313.5 cm•mmHg•s, P = 0.039), both being lower in the group with pathological OP acid exposure, and the number of contractions with small or large breaks, which were more frequent in the same group. This group also had a larger number of peristaltic contractions with breaks in the 20 mmHg isobaric contour (38.7% vs 15.38%, P < 0.0001).
CONCLUSION In patients with suspected GERD-related extra-esophageal syndromes pathological OP acid exposure was associated with weaker proximal esophageal motility.
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Herbella FAM, Andolfi C, Vigneswaran Y, Patti MG, Pinna BR. Importance of esophageal manometry and pH monitoring for the evaluation of otorhinolaryngologic (ENT) manifestations of GERD. A multicenter study. J Gastrointest Surg 2016; 20:1673-8. [PMID: 27456014 DOI: 10.1007/s11605-016-3212-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 07/11/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND/AIMS Patients with otorhinolaryngologic (ear, nose, and throat-ENT) symptoms attributed to gastroesophageal reflux disease (GERD) are usually treated with medication based on the findings of nasal endoscopy and laryngoscopy only. This study aims to determine sensitivity and specificity of symptoms, nasal endoscopy, and laryngoscopy for the diagnosis of GERD as compared to pH monitoring. METHODS We studied 79 patients (mean age 53 years, 38 % males) in whom ENT symptoms were assumed to be secondary to GERD. All patients underwent a transnasal laryngoscopy by the ENT team and upper endoscopy and esophageal function tests by the surgical team. GERD was defined by a pathological pH monitoring. RESULTS Pathologic reflux by pH monitoring was documented in 36 of the 79 patients (46 %), with a mean DeMeester score of 44. In 25 of the 36 patients (69 %), distal and proximal reflux was present. Among patients with negative pH monitoring, one patient was diagnosed with achalasia. ENT symptom sensitivity for globus, hoarseness and throat clearing was respectively 11, 58, and 33 %; specificity was respectively 77, 42, and 58 %. Positive predictive value for nasal endoscopy and laryngoscopy was 46 %. Among patients with positive pH monitoring, 13 (36 %) had a hypotensive lower esophageal sphincter (p < 0.01) and 27 (34 %) had abnormal peristalsis (p < 0.01). CONCLUSIONS In conclusion, the results of this study showed that (a) ENT symptoms were unreliable for the diagnosis of GERD and (b) laryngoscopy had a low positive predictive value for the diagnosis of GERD. These data confirm the importance of esophageal manometry and pH monitoring in any patient with suspected ENT manifestations of GERD before starting empiric therapy with acid-reducing medications since pathologic reflux by pH monitoring was confirmed in less than half of the patients with suspected GERD.
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Affiliation(s)
- Fernando A M Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Rua Diogo de Faria 1087, cj 301, São Paulo, SP, 04037-003, Brazil.
| | - Ciro Andolfi
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Yalini Vigneswaran
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Marco G Patti
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Bruno R Pinna
- Department of Otorhinolaryngology, Escola Paulista de Medicina, Federal University of Sao Paulo, São Paulo, Brazil
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Little RE, Bock JM. Beyond Laryngoscopy: Current Objective Diagnostic Testing and Interpretation for LPR. CURRENT OTORHINOLARYNGOLOGY REPORTS 2016. [DOI: 10.1007/s40136-016-0102-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Strugala V, Woodcock AD, Dettmar PW, Faruqi S, Morice AH. Detection of pepsin in sputum: a rapid and objective measure of airways reflux. Eur Respir J 2015; 47:339-41. [DOI: 10.1183/13993003.00827-2015] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 09/11/2015] [Indexed: 12/23/2022]
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Strugala V, Dettmar PW, Bittenglova R, Fremundova L, Peŝek M. Use of pepsin detection to identify airways reflux in a range of pulmonary diseases. CLINICAL RESPIRATORY JOURNAL 2015; 11:666-667. [DOI: 10.1111/crj.12395] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Vicki Strugala
- RD Biomed Ltd, Daisy Building (2nd Floor), Castle Hill Hospital; Cottingham East Yorkshire UK
| | - Peter W. Dettmar
- RD Biomed Ltd, Daisy Building (2nd Floor), Castle Hill Hospital; Cottingham East Yorkshire UK
| | - Radka Bittenglova
- Department of Pneumology and Phtiseology; Charles University Teaching Hospital; Plzen Czech Republic
| | - Lucie Fremundova
- First Department of Internal Medicine; Charles University Teaching Hospital; Plzen Czech Republic
| | - Milos Peŝek
- Department of Pneumology and Phtiseology; Charles University Teaching Hospital; Plzen Czech Republic
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Spyridoulias A, Lillie S, Vyas A, Fowler SJ. Detecting laryngopharyngeal reflux in patients with upper airways symptoms: Symptoms, signs or salivary pepsin? Respir Med 2015; 109:963-9. [DOI: 10.1016/j.rmed.2015.05.019] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 05/16/2015] [Accepted: 05/19/2015] [Indexed: 12/12/2022]
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Mazzoleni G, Vailati C, Lisma DG, Testoni PA, Passaretti S. Correlation between oropharyngeal pH-monitoring and esophageal pH-impedance monitoring in patients with suspected GERD-related extra-esophageal symptoms. Neurogastroenterol Motil 2014; 26:1557-64. [PMID: 25208949 DOI: 10.1111/nmo.12422] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 08/06/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND 24-hour esophageal pH-impedance (pH-MII) is not totally reliable for laryngopharyngeal reflux (LPR). Oropharyngeal (OP) pH-monitoring with the Dx-pH probe may detect LPR better. The correlation between these two techniques is not thoroughly established. Aim of this study is to examine the correlation between OP pH-metry and esophageal pH-MII monitoring. METHODS Thirty-six consecutive patients with suspected gastroesophageal reflux disease-related extra-esophageal symptoms were evaluated using 24-h OP-pH and concomitant esophageal pH-MII monitoring. OP events were defined as: drop in pH below thresholds of 5.5, 5.0, 4.5, 4.0 or drop in pH of at least 10% from a running baseline. Temporal relationship between OP and esophageal reflux events and outcomes of the two tests were evaluated. KEY RESULTS 2394 refluxes were detected by pH-MII; of these only 120 were detected also by OP Dx-probe. On the other hand, the proportion of OP-pH events which were temporally related to an episode of distal reflux ranged from 0% to 17%, depending on the proximal pH criteria used. In 8/36 patients both tests were pathological, while in 10/36 they were both normal; 14/36 patients had pathological OP reflux, but a normal pH-MII test; 4/36 patients had pathological pH-MII, but a normal OP reflux. CONCLUSIONS & INFERENCES The correlation between OP pH-metry and pH-MII was weak. At present, the absence of a reliable gold standard for the diagnosis of LPR and the uncertain etiology of the pharyngeal pH alterations make it difficult to decide which is the most reliable technique for the diagnosis of true LPR.
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Affiliation(s)
- G Mazzoleni
- Division of Gastroenterology and Gastrointestinal Endoscopy, Vita-Salute San Raffaele University, San Raffaele Scientific Institute, Milan, Italy
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