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Chandran S, Mohiuddin A, Cash E, Albert C, Kehdy F. The Inclusion of Voice Assessments to Aid Diagnostic and Surgical Decision Making for Patients With Laryngopharyngeal Reflux. J Voice 2024; 38:1170-1176. [PMID: 35537976 DOI: 10.1016/j.jvoice.2022.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 03/04/2022] [Accepted: 03/13/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Patients with suspected laryngopharyngeal reflux (LPR) present with a variety of symptoms, such as cough, hoarseness, and globus sensation, and often do not have the classic features associated with gastroesophageal reflux disease. STUDY DESIGN To achieve greater clarity in the symptom presentation, response to treatment, and the impact on vocal function among patients presenting with signs and symptoms consistent with LPR, we prospectively evaluated initial assessments and outcomes after medication or surgical management. METHODS A sample of 109 patients completed self-report measures of reflux symptoms, voice handicap, and underwent diagnostic workup by both laryngologist and foregut surgeon to include laryngoscopy, esophagogastroduodenoscopy, manometry and pH monitoring. Patients were then followed for at least 3 months, and outcomes of therapy were recorded. RESULTS The most common indicators on initial workup were reflux symptom inventory score ≥ 13 and at least one abnormality on manometry. Male patients were significantly more likely to demonstrate esophagitis on biopsy, abnormal upper esophageal sphincter mean pressure, and acid (vs nonacid) reflux. Older patients were more likely to have normal esophageal distal contractile integral activity. Significantly higher voice handicap ratings were observed among patients with a positive reflux indicator score in addition to abnormal upper esophageal sphincter mean basal pressure and contractile front velocity. Patients with acid versus nonacid reflux were equally as likely to report non-responsivity to antisecretory medications. Among a subset of patients with 3-month follow-up data (N = 39), reflux scores were significantly lower irrespective of treatment modality (surgical vs pharmacological intervention). CONCLUSION Extensive comprehensive workup did not reveal a single predictive indicator for LPR. Voice assessments may be more sensitive to upper esophageal symptomatology or dysfunction compared to reflux assessments, which may be better indicators of inflammation. Our collaborative data confirms the value of assessing vocal quality and impairment, especially in the presence of equivocal reflux indicators, as together these measures may achieve greater sensitivity to reflux issues and may aid in surgical decision making.
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Affiliation(s)
- Swapna Chandran
- Department of Otolaryngology - HNS and Communicative Disorders, University of Louisville, School of Medicine, Louisville, Kentucky.
| | - Asim Mohiuddin
- University of Louisville, School of Medicine, Louisville, Kentucky
| | - Elizabeth Cash
- Department of Otolaryngology - HNS and Communicative Disorders, University of Louisville, School of Medicine, Louisville, Kentucky; UofL Healthcare - Brown Cancer Center, Louisville, Kentucky
| | - Christina Albert
- Department of Otolaryngology - HNS and Communicative Disorders, University of Louisville, School of Medicine, Louisville, Kentucky
| | - Farid Kehdy
- Division of General Surgery, Department of Surgery, University of Louisville, School of Medicine, Louisville, Kentucky
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Krause AJ, Greytak M, Kessler M, Yadlapati R. Pilot study evaluating salivary bile acids as a diagnostic biomarker of laryngopharyngeal reflux. Dis Esophagus 2024; 37:doae021. [PMID: 38525936 PMCID: PMC11220665 DOI: 10.1093/dote/doae021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 02/16/2024] [Accepted: 03/04/2024] [Indexed: 03/26/2024]
Abstract
Bile acids in refluxate contribute to esophageal and laryngeal symptoms and are quantifiable. The aim of this study was to compare salivary bile acid concentrations across healthy controls and symptomatic patients (esophageal or laryngeal) with or without objective gastroesophageal reflux disease (GERD). This prospective study enrolled adults into three groups: esophageal symptoms (heartburn, regurgitation, chest pain); laryngeal symptoms (cough, throat clearing, sore throat, dysphonia); and controls. Symptomatic patients primarily underwent prolonged wireless reflux monitoring off acid suppression and were categorized as symptomatic no GERD (acid exposure time <4%) or esophageal/laryngeal symptoms with GERD (acid exposure time ≥4%). Controls did not undergo reflux monitoring nor upper endoscopy. Saliva samples were provided for bile acid analysis via ultraperformance liquid chromatography tandem mass spectrometry. Thirty-five participants were enrolled (mean age 47.4 years [SD 18.9], 16 [46%] male), including 10 controls and 25 symptomatic: 9 no GERD, 5 esophageal symptoms + GERD, and 11 laryngeal symptoms + GERD. Total salivary bile acids were highest in the laryngeal symptoms + GERD group (24.2 nM [SD 24.7]) compared to other groups (controls: 5.8 [6.0], P = 0.03; symptomatic no GERD: 3.1 [4.4]; P < 0.01; esophageal symptoms + GERD: 7.1 [7.1], P = 0.10). Bile acids were elevated in 45% (5/11) of the laryngeal symptoms + GERD group compared to 0% of the other three groups (P < 0.01). Salivary bile acids were higher among patients with laryngeal symptoms and objective GERD versus other groups. Salivary bile acids are a quantifiable biomarker with diagnostic potential for laryngopharyngeal reflux.
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Affiliation(s)
- Amanda J Krause
- Department of Medicine, Division of Gastroenterology & Hepatology, University of California San Diego, San Diego, CA, USA
| | - Madeline Greytak
- Department of Medicine, Division of Gastroenterology & Hepatology, University of California San Diego, San Diego, CA, USA
| | - Marco Kessler
- Clinical Development Department, Ironwood Pharmaceuticals, Boston, MA, USA
| | - Rena Yadlapati
- Department of Medicine, Division of Gastroenterology & Hepatology, University of California San Diego, San Diego, CA, USA
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Walsh E, Krause AJ, Greytak M, Kaizer AM, Weissbrod PA, Liu K, Taft T, Yadlapati R. Laryngeal Recalibration Therapy Improves Laryngopharyngeal Symptoms in Patients With Suspected Laryngopharyngeal Reflux Disease. Am J Gastroenterol 2024:00000434-990000000-01134. [PMID: 38656937 DOI: 10.14309/ajg.0000000000002839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 04/17/2024] [Indexed: 04/26/2024]
Abstract
INTRODUCTION Laryngopharyngeal symptoms such as cough, throat clearing, voice change, paradoxic vocal fold movement, or laryngospasm are hyper-responsive behaviors resulting from local irritation (e.g., refluxate) and heightened sympathetic tone. Laryngeal recalibration therapy (LRT) guided by a speech-language pathologist (SLP) provides mechanical desensitization and cognitive recalibration to suppress hyper-responsive laryngeal patterns. The aim of this study was to assess symptom response to LRT among patients with chronic laryngopharyngeal symptoms undergoing evaluation of gastroesophageal reflux disease (GERD). METHODS Adults with chronic laryngopharyngeal symptoms referred for evaluation of GERD to a single center were prospectively followed. Inclusion criteria included ≥2 SLP-directed LRT sessions. Data from endoscopy, ambulatory reflux monitoring, and patient-reported outcomes were collected when available. The primary outcome was symptom response. RESULTS Sixty-five participants completed LRT: mean age 55.4 years (SD 17.2), 46 (71%) female, mean body mass index 25.6 kg/m 2 (6.8), and mean of 3.7 (1.9) LRT sessions. Overall, 55 participants (85%) met criteria for symptom response. Specifically, symptom response was similar between those with isolated laryngopharyngeal symptoms (13/15, 87%) and concomitant laryngopharyngeal/esophageal symptoms (42/50, 84%). Among participants who underwent reflux monitoring, symptom response was similar between those with proven, inconclusive for, and no GERD (18/21 [86%], 8/9 [89%], 10/13 [77%]). DISCUSSION Eighty-five percent of patients with chronic laryngopharyngeal symptoms referred for GERD evaluation who underwent LRT-experienced laryngeal symptom response. Rates of symptom response were maintained across patients with or without proven GERD and patients with or without concomitant esophageal reflux symptoms. SLP-directed LRT is an effective approach to incorporate into multidisciplinary management of chronic laryngopharyngeal symptoms/laryngopharyngeal reflux disease.
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Affiliation(s)
- Erin Walsh
- Department of Otolaryngology, University of California San Diego, La Jolla, California, USA
| | - Amanda J Krause
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California San Diego, La Jolla, California, USA
| | - Madeline Greytak
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California San Diego, La Jolla, California, USA
| | - Alexander M Kaizer
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado-Anschutz Medical Campus, Aurora, Colorado, USA
| | - Philip A Weissbrod
- Department of Otolaryngology, University of California San Diego, La Jolla, California, USA
| | - Kelli Liu
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California San Diego, La Jolla, California, USA
| | - Tiffany Taft
- The Rome Foundation Research Institute, Chapel Hill, North Carolina, USA
| | - Rena Yadlapati
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California San Diego, La Jolla, California, USA
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Cohen DL, Richter V, Mari A, Shirin H, Bermont A. Continued PPI use and gastrointestinal evaluations after a negative pH study in patients with throat symptoms from possible extraesophageal GERD. Acta Gastroenterol Belg 2024; 87:255-261. [PMID: 39210757 DOI: 10.51821/87.2.12969] [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] [Indexed: 09/04/2024]
Abstract
Background Recent guidelines have advocated for upfront pH testing in patients with isolated symptoms of extra-esophageal gastrointestinal reflux disease (EE-GERD) under the assumption that a negative pH study will prevent further gastrointestinal (GI) investigations, proton pump inhibitor (PPI) use, and reduce cost. We sought to evaluate if this actually occurs. Methods A retrospective study was performed on patients who underwent 24-hour combined pH-impedance testing off PPI for suspected EE-GERD. A negative study was defined as DeMeester score <14.7. Results 59 patients were included (mean age 53.2; 50.8% women). Most (38, 64.4%) had a negative study. Findings of laryngopharyngoreflux on laryngoscopy did not predict pH results. Those with a negative study had the same number of followup GI appointments, repeat endoscopies, and repeat pH studies compared to those with a positive study (p=NS). While PPIs were more frequently stopped in those with a negative pH study, still 14 (36.8%) were continued on a PPI. At the end of the follow-up period (mean 43.6 months), 18 (47.4%) subjects with a negative pH study were still prescribed PPIs. Patients who were diagnosed with post-nasal drip or rhinits were significantly less likely to still be receiving a PPI (5.6% vs 35.0%, p=0.045). Conclusions Despite a negative pH study, a substantial number of patients with isolated EE-GERD symptoms are continued on a PPI and they undergo GI follow-up at the same rate as those with a positive study. These findings bring into question the recent recommendations for upfront pH testing in suspected EE-GERD and its reported cost savings.
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Affiliation(s)
- D L Cohen
- The Gonczarowski Family Institute of Gastroenterology and Liver Diseases, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel and The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - V Richter
- The Gonczarowski Family Institute of Gastroenterology and Liver Diseases, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel and The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - A Mari
- Gastroenterology and Endoscopy Unit, Nazareth Hospital EMMS, Nazareth, Israel and The Faculty of Medicine, Bar-Ilan University, Israel
| | - H Shirin
- The Gonczarowski Family Institute of Gastroenterology and Liver Diseases, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel and The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - A Bermont
- The Gonczarowski Family Institute of Gastroenterology and Liver Diseases, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel and The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Moraes-Filho JPP, Domingues G, Chinzon D. BRAZILIAN CLINICAL GUIDELINE FOR THE THERAPEUTIC MANAGEMENT OF GASTROESOPHAGEAL REFLUX DISEASE (BRAZILIAN FEDERATION OF GASTROENTEROLOGY, FBG). ARQUIVOS DE GASTROENTEROLOGIA 2024; 61:e23154. [PMID: 38511797 DOI: 10.1590/s0004-2803.24612023-154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 11/29/2023] [Indexed: 03/22/2024]
Abstract
BACKGROUND Gastroesophageal Reflux Disease (GERD) is a prevalent condition in Brazil, affecting 12% to 20% of the urban population, with significant implications for patient quality of life and potential for complications. OBJECTIVE This paper focuses on the recent update of the Brazilian guidelines for GERD, a necessary revision due to advancements in knowledge and practice since the last publication over a decade ago. The update pays particular attention to the role and safety of proton pump inhibitors (PPIs), acknowledging the growing concerns about their long-term use, adverse events, and overprescription. METHODS The methodology of the guideline update involved an extensive literature review in multiple languages (English, French, Italian, Spanish, and Portuguese), drawing from major databases such as Medline, Embase, and SciELO-Lilacs. RESULTS This comprehensive approach resulted in a carefully curated selection of studies, systematic reviews, and meta-analyses, specifically focusing on PPIs and other therapeutic strategies for GERD. The updated guidelines are presented in a user-friendly question-and-answer format, adhering to the PICO system (Population, Intervention, Comparison, Outcomes) for clarity and ease of interpretation. The recommendations are supported by robust scientific evidence and expert opinions, enhancing their practical applicability in clinical settings. To ensure the reliability and clarity of the recommendations, the GRADE system (Grading of Recommendations Assessment, Development, and Evaluation) was employed. This system categorizes the strength of recommendations as strong, weak, or conditional and classifies evidence quality as high, moderate, low, or very low. These classifications provide insight into the confidence level of each recommendation and the likelihood of future research impacting these guidelines. CONCLUSION The primary aim of these updated guidelines is to offer practical, evidence-based advice for the management of GERD in Brazil, ensuring that healthcare professionals are equipped with the latest knowledge and tools to deliver optimal patient care. BACKGROUND •Gastrointestinal specialists rely heavily on guidelines to manage digestive pathologies effectively. The Brazilian clinical guideline for therapeutic management of gastroesophageal reflux disease (GERD) is an invaluable tool for these specialists. BACKGROUND •It critically analyzes practical aspects of therapy through 12 questions covering a wide range of topics, from behavioral measures to surgical and endoscopic indications. BACKGROUND •The recommendations in this guideline are justified using the GRADE system (Grading of Recommendations Assessment, Development, and Evaluation), and experienced experts provide comments and suggestions at the end of each question.
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Affiliation(s)
| | - Gerson Domingues
- Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
| | - Decio Chinzon
- Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brasil
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Olmos JA, Pandolfino JE, Piskorz MM, Zamora N, Valdovinos Díaz MA, Remes Troche JM, Guzmán M, Hani A, Valdovinos García LR, Pitanga Lukashok H, Domingues G, Vesco E, Rivas MM, Ovalle LFP, Cisternas D, Vela MF. Latin American consensus on diagnosis of gastroesophageal reflux disease. Neurogastroenterol Motil 2024; 36:e14735. [PMID: 38225792 DOI: 10.1111/nmo.14735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 12/05/2023] [Accepted: 12/18/2023] [Indexed: 01/17/2024]
Abstract
BACKGROUND Diagnosing gastroesophageal reflux disease (GERD) can be challenging given varying symptom presentations, and complex multifactorial pathophysiology. The gold standard for GERD diagnosis is esophageal acid exposure time (AET) measured by pH-metry. A variety of additional diagnostic tools are available. The goal of this consensus was to assess the individual merits of GERD diagnostic tools based on current evidence, and provide consensus recommendations following discussion and voting by experts. METHODS This consensus was developed by 15 experts from nine countries, based on a systematic search of the literature, using GRADE (grading of recommendations, assessment, development and evaluation) methodology to assess the quality and strength of the evidence, and provide recommendations regarding the diagnostic utility of different GERD diagnosis tools, using AET as the reference standard. KEY RESULTS A proton pump inhibitor (PPI) trial is appropriate for patients with heartburn and no alarm symptoms, but nor for patients with regurgitation, chest pain, or extraesophageal presentations. Severe erosive esophagitis and abnormal reflux monitoring off PPI are clearly indicative of GERD. Esophagram, esophageal biopsies, laryngoscopy, and pharyngeal pH monitoring are not recommended to diagnose GERD. Patients with PPI-refractory symptoms and normal endoscopy require reflux monitoring by pH or pH-impedance to confirm or exclude GERD, and identify treatment failure mechanisms. GERD confounders need to be considered in some patients, pH-impedance can identify supragrastric belching, impedance-manometry can diagnose rumination. CONCLUSIONS Erosive esophagitis on endoscopy and abnormal pH or pH-impedance monitoring are the most appropriate methods to establish a diagnosis of GERD. Other tools may add useful complementary information.
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Affiliation(s)
- Jorge A Olmos
- Neurogastroenterology Sector, Hospital de Clinicas Jose de San Martin, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - John E Pandolfino
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - María M Piskorz
- Neurogastroenterology Sector, Hospital de Clinicas Jose de San Martin, Universidad de Buenos Aires, Buenos Aires, Argentina
| | | | - Miguel A Valdovinos Díaz
- UNAM, Ciudad de Mexico, Mexico
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - José M Remes Troche
- Institute of Medical Biological Research, Universidad Veracruzana, Veracruz, Mexico
| | - Mauricio Guzmán
- Neurogastroenterology Unit, Gastroenterology Service, Hospital San Martín de La Plata, Buenos Aires, Argentina
| | - Albis Hani
- Hospital San Ignacio-Pontificia Universidad Javeriana, Bogotá, Colombia
| | | | - Hannah Pitanga Lukashok
- Digestive Motility Service, Instituto Ecuatoriano de Enfermedades Digestivas-IECED, Guayaquil, Ecuador
| | | | - Eduardo Vesco
- Neuromotility Unit, Clínica Angloamericana, Lima, Peru
- Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Mariel Mejia Rivas
- Internal Medicine, Gastroenterology and Digestive Endoscopy Service, Hospital Vivian Pellas, Managua, Nicaragua
| | - Luis F Pineda Ovalle
- Neurogastroenterology and Motility Service Motility Instituto Gut Médica, Bogotá, Colombia
| | - Daniel Cisternas
- Clínica Alemana de Santiago, School of Medicine, Universidad del Desarrollo, Clínica Alemana, Vitacura, Chile
| | - Marcelo F Vela
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
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Valdovinos Díaz MA, Amieva-Balmori M, Carmona-Sánchez R, Coss-Adame E, Gómez-Escudero O, González-Martínez M, Huerta-Iga F, Morel-Cerda E, Remes-Troche JM, Tamayo-de la Cuesta JL, Torres-Villalobos G, Valdovinos-García LR, Vázquez-Elizondo G, Villar-Chávez AS, Arenas-Martínez JA. Good clinical practice recommendations for the diagnosis and treatment of gastroesophageal reflux disease. An expert review from the Asociación Mexicana de Gastroenterología. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2024; 89:121-143. [PMID: 38580493 DOI: 10.1016/j.rgmxen.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 12/06/2023] [Indexed: 04/07/2024]
Abstract
INTRODUCTION Gastroesophageal reflux disease (GERD) is very prevalent in the general population, with a broad spectrum of clinical manifestations, requiring accurate diagnosis and treatment. AIM The aim of this expert review is to establish good clinical practice recommendations for the diagnosis and personalized treatment of GERD. METHODS The good clinical practice recommendations were produced by a group of experts in GERD, members of the Asociación Mexicana de Gastroenterología (AMG), after carrying out an extensive review of the published literature and discussing each recommendation at a face-to-face meeting. This document does not aim to be a clinical practice guideline with the methodology such a document requires. RESULTS Fifteen experts on GERD formulated 27 good clinical practice recommendations for recognizing the symptoms and complications of GERD, the rational use of diagnostic tests and medical treatment, the identification and management of refractory GERD, the overlap with functional disorders, endoscopic and surgical treatment, and GERD in the pregnant woman, older adult, and the obese patient. CONCLUSIONS An accurate diagnosis of GERD is currently possible, enabling the prescription of a personalized treatment in patients with this condition. The goal of the good clinical practice recommendations by the group of experts from the AMG presented in this document is to aid both the general practitioner and specialist in the process of accurate diagnosis and treatment, in the patient with GERD.
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Affiliation(s)
| | - M Amieva-Balmori
- Laboratorio de Fisiología Digestiva y Motilidad Intestinal, Instituto de Investigaciones Médico-Biológicas de la Universidad Veracruzana, Veracruz, Mexico
| | - R Carmona-Sánchez
- Servicio de Gastroenterología, Práctica privada, San Luis Potosí, Mexico
| | - E Coss-Adame
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - O Gómez-Escudero
- Clínica de Gastroenterología, Endoscopia y Motilidad Gastrointestinal, Endoneurogastro, Hospital Ángeles Puebla, Puebla, Mexico
| | - M González-Martínez
- Departamento de Endoscopia, Hospital de Especialidades del CMN Siglo XXI IMSS, Mexico City, Mexico
| | - F Huerta-Iga
- Servicio de Gastroenterología, Hospital Ángeles Torreón, Torreón, Mexico
| | - E Morel-Cerda
- Departamento de Gastroenterología, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Mexico
| | - J M Remes-Troche
- Laboratorio de Fisiología Digestiva y Motilidad Intestinal, Instituto de Investigaciones Médico-Biológicas de la Universidad Veracruzana, Veracruz, Mexico
| | - J L Tamayo-de la Cuesta
- Servicio de Gastroenterología y Endoscopia Gastrointestinal, Centro de Investigación y Docencia en Ciencias de la Salud, Universidad Autónoma de Sinaloa, Culiacán, Sinaloa, Mexico
| | - G Torres-Villalobos
- Cirugía Experimental, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | - G Vázquez-Elizondo
- Servicio de Gastroenterología, Centro de Enfermedades Digestivas ONCARE, Monterrey, Mexico
| | - A S Villar-Chávez
- Servicio de Gastroenterología, Hospital Ángeles Acoxpa, Mexico City, Mexico
| | - J A Arenas-Martínez
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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Quigley N, Mistry SG, Vasant DH, Vasani S. Practical multidisciplinary framework for the assessment and management of patients with unexplained chronic aerodigestive symptoms. BMJ Open Gastroenterol 2023; 10:e000883. [PMID: 37996120 PMCID: PMC10668155 DOI: 10.1136/bmjgast-2022-000883] [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: 04/02/2023] [Accepted: 10/20/2023] [Indexed: 11/25/2023] Open
Abstract
OBJECTIVE Patients experiencing unexplained chronic throat symptoms (UCTS) are frequently referred to gastroenterology and otolaryngology outpatient departments for investigation. Often despite extensive investigations, an identifiable structural abnormality to account for the symptoms is not found. The objective of this article is to provide a concise appraisal of the evidence-base for current approaches to the assessment and management of UCTS, their clinical outcomes, and related healthcare utilisation. DESIGN This multidisciplinary review critically examines the current understanding of aetiological theories and pathophysiological drivers in UCTS and summarises the evidence base underpinning various diagnostic and management approaches. RESULTS The evidence gathered from the review suggests that single-specialty approaches to UCTS inadequately capture the substantial heterogeneity and pervasive overlaps among clinical features and biopsychosocial factors and suggests a more unified approach is needed. CONCLUSION Drawing on contemporary insights from the gastrointestinal literature for disorders of gut-brain interaction, this article proposes a refreshed interdisciplinary approach characterised by a positive diagnosis framework and patient-centred therapeutic model. The overarching aim of this approach is to improve patient outcomes and foster collaborative research efforts.
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Affiliation(s)
- Nathan Quigley
- Otolaryngology Department, Royal Brisbane and Woman's Hospital Health Service District, Herston, Queensland, Australia
| | - Sandeep G Mistry
- Department of Ear Nose and Throat, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Dipesh H Vasant
- Neurogastroenterology Unit, Gastroenterology Department, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, UK
| | - Sarju Vasani
- Otolaryngology Department, Royal Brisbane and Woman's Hospital Health Service District, Herston, Queensland, Australia
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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: 26] [Impact Index Per Article: 26.0] [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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Lien HC, Lee PH, Wang CC. Diagnosis of Laryngopharyngeal Reflux: Past, Present, and Future-A Mini-Review. Diagnostics (Basel) 2023; 13:diagnostics13091643. [PMID: 37175034 PMCID: PMC10177910 DOI: 10.3390/diagnostics13091643] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/19/2023] [Accepted: 05/05/2023] [Indexed: 05/15/2023] Open
Abstract
Laryngopharyngeal reflux (LPR) is a variant of gastroesophageal reflux disease (GERD) in which gastric refluxate irritates the lining of the aerodigestive tract and causes troublesome airway symptoms or complications. LPR is a prevalent disease that creates a significant socioeconomic burden due to its negative impact on quality of life, tremendous medical expense, and possible cancer risk. Although treatment modalities are similar between LPR and GERD, the diagnosis of LPR is more challenging than GERD due to its non-specific symptoms/signs. Due to the lack of pathognomonic features of endoscopy, mounting evidence focused on physiological diagnostic testing. Two decades ago, a dual pH probe was considered the gold standard for detecting pharyngeal acidic reflux episodes. Despite an association with LPR, the dual pH was unable to predict the treatment response in clinical practice, presumably due to frequently encountered artifacts. Currently, hypopharygneal multichannel intraluminal impedance-pH catheters incorporating two trans-upper esophageal sphincter impedance sensors enable to differentiate pharyngeal refluxes from swallows. The validation of pharyngeal acid reflux episodes that are relevant to anti-reflux treatment is, therefore, crucial. Given no diagnostic gold standard of LPR, this review article aimed to discuss the evolution of objective diagnostic testing and its predictive role of treatment response.
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Affiliation(s)
- Han-Chung Lien
- Division of Gastroenterology, Taichung Veterans General Hospital, Taichung 407219, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 11217, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung 402, Taiwan
| | - Ping-Huan Lee
- Division of Gastroenterology, Taichung Veterans General Hospital, Taichung 407219, Taiwan
| | - Chen-Chi Wang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 11217, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung 402, Taiwan
- Department of Otolaryngology, Taichung Veterans General Hospital, Taichung 407219, Taiwan
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Alrayah M, Alzahrani R, Alghamdi MA, Alghamdi KM, Almutairi FF, Alghamdi AA, Alzahrani RA, Bajaber TA, Alanazi TF, Alnafisah HA. Assessment of the Current Knowledge and Practice of General Practitioners Towards Laryngopharyngeal Reflux in Saudi Arabia. Cureus 2023; 15:e38043. [PMID: 37228524 PMCID: PMC10208014 DOI: 10.7759/cureus.38043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2023] [Indexed: 05/27/2023] Open
Abstract
Background General practitioners (GPs) have a significant role in the diagnosis of patients with laryngopharyngeal reflux (LPR). Some published data revealed a lack of knowledge among GPs about the disease, consequently, this lack of knowledge impacted their performance. This survey aims to assess the current knowledge and practice of general practitioners regarding laryngopharyngeal reflux in Saudi Arabia. Methodology This survey study was conducted to assess the current knowledge and practice of general practitioners regarding laryngopharyngeal reflux in Saudi Arabia using an online questionnaire. The questionnaire was distributed and collected from the five regions in Saudi Arabia, which are The Central Region (Riyadh, Qassim), Eastern Region (Dammam, Al-Kharj, Al-Ahasa), Western Region (Makkah, Madinah, Jeddah), Southern Region (Asir, Najran, Jizan), and Northern Region (Tabuk, Jouf, Hail). Results In the current study, we collected data from 387 general practitioners, 61.8% of whom were aged between 21-30 years old, and 57.4% of the participants were males. Moreover, 40.6% of the participants thought that both LPR and gastroesophageal reflux disease (GERD) share pathophysiology, however, they are two different diseases considering their clinical presentation. Moreover, it was found that heartburn was the most known symptom of LPR among the participants (Mean score 2.14 (SD=1.31), where a lower score indicated more relation). Considering the treatment of LPR, 40.6% and 40.3% of the participants reported using proton pump inhibitors once or twice daily respectively. In contrast, antihistamine/H2 blockers, alginate, and magaldrate were used to a lesser extent as reported by 27.1%, 21.7%, and 12.1%. Conclusion The current study showed limited knowledge among general practitioners considering LPR with a higher rate of referring patients to other departments depending on symptoms which may increase the pressure on other departments of mild cases.
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Affiliation(s)
- Mujtaba Alrayah
- Unit of Otolaryngology, Department of Surgery, Faculty of Medicine, Al-Baha University, Al-Baha, SAU
| | - Rajab Alzahrani
- Unit of Otolaryngology, Department of Surgery, Faculty of Medicine, Al-Baha University, Al-Baha, SAU
| | - Mohammed A Alghamdi
- Unit of Otolaryngology, Department of Surgery, Faculty of Medicine, Al-Baha University, Al-Baha, SAU
| | - Kholoud M Alghamdi
- Department of Medicine, Faculty of Medicine, Al-Baha University, Al-Baha, SAU
| | - Faisal F Almutairi
- Department of Medicine, Unaizah College of Medicine and Medical Sciences, Qassim University, Unaizah, SAU
| | - Anwar A Alghamdi
- Department of Medicine, Faculty of Medicine, Al-Baha University, Al-Baha, SAU
| | - Raghad A Alzahrani
- Department of Medicine, Faculty of Medicine, Al-Baha University, Al-Baha, SAU
| | - Taif A Bajaber
- Department of Medicine, Faculty of Medicine, Fakeeh College of Medical Sciences, Jeddah, SAU
| | - Tahani F Alanazi
- Department of Medicine, Faculty of Medicine, University of Tabuk, Tabuk, SAU
| | - Haya A Alnafisah
- Department of Medicine, Faculty of Medicine, Princess Nourah bint Abdulrahman University, Riyadh, SAU
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Salgado S, Borges LF, Cai JX, Lo WK, Carroll TL, Chan WW. Symptoms classically attributed to laryngopharyngeal reflux correlate poorly with pharyngeal reflux events on multichannel intraluminal impedance testing. Dis Esophagus 2022; 36:6627278. [PMID: 35780323 DOI: 10.1093/dote/doac041] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Revised: 03/17/2022] [Indexed: 01/11/2023]
Abstract
Laryngopharyngeal reflux (LPR) is thought to be a common etiology of throat and airway symptoms. Diagnosis of LPR is challenging, given the variable symptomatology and response to therapy. Identifying symptoms that better correlate with LPR may inform management strategies. We aimed to examine the association between patient-reported symptoms and objectively identified LPR on ambulatory reflux monitoring. This was a retrospective cohort study of consecutive adults with suspected LPR undergoing combined hypopharyngeal-esophageal multichannel intraluminal impedance-pH testing (HEMII-pH) at a tertiary center. All patients completed standardized symptom surveys for presenting symptoms, reflux symptom index (RSI), and voice handicap index (VHI). LPR was defined as >1 full-column pharyngeal reflux event on HEMII-pH over 24 hours. Univariate and multivariable analyses were performed. A total of 133 patients were included (mean age = 55.9 years, 69.9% female). Of this 83 (62.4%) reported concomitant esophageal symptoms. RSI and VHI did not correlate with proximal esophageal or pharyngeal reflux events (Kendall's tau correlations P > 0.05), although the mean RSI was higher in the LPR group (21.1 ± 18.9 vs. 17.1 ± 8.3, P = 0.044). Cough, but not other laryngeal symptoms, was more common among patients with esophageal symptoms (58% vs. 36%, P = 0.014). Neither laryngeal symptoms nor esophageal symptoms of reflux predicted LPR on univariate or multivariable analyses (all P > 0.05). Neither laryngeal symptoms classically attributed to LPR nor typical esophageal symptoms correlated with pharyngeal reflux events on HEMII-pH. Clinical symptoms alone are not sufficient to make an LPR diagnosis. Broad evaluation for competing differential diagnoses and objective reflux monitoring should be considered in patients with suspected LPR symptoms.
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Affiliation(s)
- Sanjay Salgado
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Lawrence F Borges
- Harvard Medical School, Boston, MA, USA.,Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA, USA
| | - Jennifer X Cai
- Harvard Medical School, Boston, MA, USA.,Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA, USA
| | - Wai-Kit Lo
- Harvard Medical School, Boston, MA, USA.,Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA, USA
| | - Thomas L Carroll
- Harvard Medical School, Boston, MA, USA.,Division of Otolaryngology, Brigham and Women's Hospital, Boston, MA, USA
| | - Walter W Chan
- Harvard Medical School, Boston, MA, USA.,Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA, USA
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Esophageal hypervigilance and visceral anxiety contribute to symptom severity of laryngopharyngeal reflux. Am J Gastroenterol 2022; 118:786-793. [PMID: 36693025 DOI: 10.14309/ajg.0000000000002151] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 11/14/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVES Laryngopharyngeal reflux (LPR) is a clinical conundrum without a diagnostic gold standard. The esophageal hypervigilance and anxiety scale (EHAS) is a questionnaire designed for cognitive-affective evaluation of visceral sensitivity. We hypothesized that esophageal hypervigilance and symptom-specific anxiety have an etiopathological role in generation of LPR symptoms, especially when gastroesophageal reflux disease (GERD) cannot explain these symptoms. METHODS Consecutive patients with LPR and/or GERD symptoms lasting >3 months were prospectively enrolled and characterized using the reflux symptom index (RSI), GERD questionnaire (GERDQ), and EHAS. Eligible patients with negative endoscopy underwent 24-hour impedance-pH monitoring off acid suppression for phenotyping GERD, and assessment of reflux burden, using conventional metrics [acid exposure time (AET) and number of reflux episodes] as well as novel metrics [mean nocturnal baseline impedance (MNBI) and post-reflux swallow induced peristaltic wave (PSPW) index]. RESULTS Of 269 enrolled patients (mean age 47.1 years, 21-65 years, 60.6% female), 90 patients with concomitant GERD and LPR symptoms, 32 patients with dominant LPR symptoms, 102 patients with dominant GERD symptoms, and 45 controls. Patients with concomitant GERD and LPR symptoms had higher EHAS than those with dominant GERD symptoms and controls. ( P ≤ 0.001); patients with dominant LPR symptoms had higher EHAS than controls. ( P = 0.007). On Pearson's correlation, EHAS positively correlated with RSI. CONCLUSIONS Esophageal hypervigilance symptom-specific anxiety may be more important than reflux burden in LPR symptom perception.
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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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Liu CP, Jiang AY, Chen F, Wu J, Wang SY, Cao L, Liao T, Zheng YQ. Predictive Value of Laryngeal Mucosa Pepsin in Therapeutic Response of Laryngopharyngeal Reflux. J Voice 2022:S0892-1997(22)00146-1. [PMID: 35760633 DOI: 10.1016/j.jvoice.2022.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 05/19/2022] [Accepted: 05/20/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVES/HYPOTHESIS To investigate the predictive capability of pepsin level in the laryngeal mucosa to the therapeutic effect of proton-pump inhibitors in patients with suspected laryngopharyngeal reflux (LPR), so as to verify whether it can be referred to as a biomarker of LPR. STUDY DESIGN Prospective case study. METHODS Sixty patients with clinical empiric LPR were enrolled, with an reflux symptom index (RSI) ≥ 13 and an reflux finding score (RFS) > 7 as screening criteria. Biopsy specimens from the interarytenoid mucosa were obtained under topical anesthesia for pepsin immunohistochemical staining. Two parameters were observed in these patients with different pepsin levels after the administration of esomeprazole for 12 weeks: the RSI and the RFS. RESULTS Among the 60 cases, 35 cases were negative or weakly positive for pepsin (Pepsin(-) group), and 25 cases were moderately positive or strongly positive for pepsin (Pepsin(+) group). After therapy, the RSI significantly decreased from 17.00 (15.00, 19.00) to 6.00 (5.00, 11.00) in the Pepsin(+) group (Z = -4.38, P < 0.01), but no difference was found in the RFS (T = 1.48, P > 0.05). No significant difference was observed in the RSI (T = 2.01, P > 0.05) or the RFS (T = 2.01, P > 0.05) in the Pepsin(-) group either before or after therapy. An improvement in the RSI ≥ 50% was taken as the standard of effective therapy. The effective rate in the Pepsin(+) group was 72.0% (18/25), while it was 14.3% (5/35) in the Pepsin(-) group. There was a significant difference in the effective rate between the two groups (χ2 = 20.55, P < 0.01). CONCLUSIONS Proton-pump inhibitors exhibited better effects in patients with higher pepsin levels in the laryngeal mucosa. Laryngeal mucosa pepsin may serve as an ideal indicator to screen patients suitable for proton-pump inhibitor therapy and a reliable biomarker to identify patients with LPR.
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Affiliation(s)
- Cai-Peng Liu
- Department of Otorhinolaryngology Head and Neck Surgery, Guangzhou Red Cross Hospital of Jinan University, Guangzhou, China
| | - Ai-Yun Jiang
- Department of Otorhinolaryngology Head and Neck Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Fang Chen
- Department of Otorhinolaryngology Head and Neck Surgery, Guangzhou Red Cross Hospital of Jinan University, Guangzhou, China
| | - Jian Wu
- Department of Otorhinolaryngology Head and Neck Surgery, Guangzhou Red Cross Hospital of Jinan University, Guangzhou, China
| | - Shu-Yue Wang
- Department of Otorhinolaryngology Head and Neck Surgery, Guangzhou Red Cross Hospital of Jinan University, Guangzhou, China
| | - Lei Cao
- Department of Otorhinolaryngology Head and Neck Surgery, Guangzhou Red Cross Hospital of Jinan University, Guangzhou, China
| | - Tao Liao
- Department of Otorhinolaryngology Head and Neck Surgery, Guangzhou Red Cross Hospital of Jinan University, Guangzhou, China
| | - Yi-Qing Zheng
- Department of Otorhinolaryngology Head and Neck Surgery, The First Affiliated Hospital of Jinan University, Guangzhou, China; Department of Otorhinolaryngology Head and Neck Surgery, Sun Yat-sen Memorial Hospital of Sun Yatsen University, Guangzhou, China.
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Snow GE, Dbouk M, Akst LM, Ihde G, Zarnegar R, Janu P, Murray M, Eskarous H, Sohagia A, Dhar SI, Irene Canto M. Response of Laryngopharyngeal Symptoms to Transoral Incisionless Fundoplication in Patients with Refractory Proven Gastroesophageal Reflux. Ann Otol Rhinol Laryngol 2022; 131:662-670. [PMID: 34378427 DOI: 10.1177/00034894211037414] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Patients with laryngopharyngeal reflux (LPR) symptoms may not respond to proton pump inhibitors (PPI) if they have an alternative laryngeal diagnosis or high-volume reflux. Transoral incisionless fundoplication (TIF) or TIF with concomitant hiatal hernia repair (cTIF) are effective in decreasing symptoms of gastroesophageal reflux disease (GERD) but are not well studied in patients with LPR symptoms. This prospective multicenter study assessed the patient-reported and clinical outcomes after TIF/cTIF in patients with LPR symptoms and proven GERD. METHODS Patients with refractory LPR symptoms (reflux symptom index [RSI] > 13) and with erosive esophagitis, Barrett's esophagus, and/or pathologic acid reflux by distal esophageal pH testing were evaluated before and after a minimum of 6 months after TIF/cTIF. The primary outcome was normalization of RSI. Secondary outcomes were >50% improvement in GERD-Health-Related Quality of Life (GERD-HRQL), normalization of esophageal acid exposure time, discontinuation of PPI, and patient satisfaction. RESULTS Forty-nine patients had TIF (n = 26) or cTIF (n = 23) with at least 6 months follow-up. Mean pre- and post TIF/cTIF RSI were 23.6 and 5.9 (mean difference: 17.7, P < .001). Post TIF/cTIF, 90% of patients had improved GERD-HQRL score, 85% normalized RSI, 75% normalized esophageal acid exposure time, and 80% discontinued PPI. No serious procedure-related adverse events occurred. Patient satisfaction was 4% prior to TIF/cTIF and 73% after TIF/cTIF (P < .001). CONCLUSION In patients with objective evidence of GERD, TIF, or cTIF are safe and effective in controlling LPR symptoms as measured by normalization of RSI and improvement in patient satisfaction after TIF/cTIF. LEVEL OF EVIDENCE Level 4.
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Affiliation(s)
- Grace E Snow
- Division of Laryngology, Department of Otolaryngology-Head & Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mohamad Dbouk
- Division of Gastrointestinal and Liver Pathology, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lee M Akst
- Division of Laryngology, Department of Otolaryngology-Head & Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Glenn Ihde
- Department of General Surgery, The Matagorda Regional Medical Group, Bay City, TX, USA
| | | | - Peter Janu
- Department of Surgery, Fox Valley Surgical Associates, Appleton, WI, USA
| | - Michael Murray
- Department of Surgery, Northern Nevada Medical Center, Sparks, NV, USA
| | - Hany Eskarous
- Department of Medicine, Easton Hospital, Easton, PA, USA
| | - Amit Sohagia
- Department of Medicine, Easton Hospital, Easton, PA, USA
| | - Shumon I Dhar
- Division of Laryngology, Department of Otolaryngology-Head & Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Marcia Irene Canto
- Division of Gastroenterology, Department of Medicine and Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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The Effect of Hyaluronic Acid and Chondroitin Sulphate-Based Medical Device Combined with Acid Suppression in the Treatment of Atypical Symptoms in Gastroesophageal Reflux Disease. J Clin Med 2022; 11:jcm11071890. [PMID: 35407497 PMCID: PMC9000081 DOI: 10.3390/jcm11071890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 03/24/2022] [Accepted: 03/28/2022] [Indexed: 11/16/2022] Open
Abstract
Extraesophageal reflux symptoms are increasingly common in the Western population and their clinical management is still controversial. Although therapy with proton-pump inhibitors (PPIs) represents the gold standard, to date, many patients are refractory to this treatment. The aim of this study was to evaluate, in patients with a recent diagnosis of GERD experiencing extraesophageal symptoms, the efficacy and safety of a 6-week treatment with PPI acid suppression in combination with Gerdoff® (a hyaluronic acid and chondroitin sulphate-based medical device) compared to PPI monotherapy. The trial verified the reduction in symptom frequency and severity by evaluating the proportion of Responders and Non-Responder patients after 6 weeks of treatment, compared to baseline. The effects of Gerdoff® + PPI treatment on extraesophageal symptoms were also evaluated after a 12-week follow up only in Responder patients. The analysis of the change in total Reflux Symptoms Index (RSI) score from baseline to the other time points showed that the extent of the decrease from baseline was higher in the Gerdoff® + PPI group than in the PPI group at any time point. However, the comparison between groups did not show statistically significant differences at any time point. A statistically significant difference, in favor of the Gerdoff® + PPI group, was observed for individual RSI items. Even if the trial showed some limitations, this is the first published study on the efficacy of a medical device containing hyaluronic acid and chondroitin sulphate with antacid in the treatment of extraesophageal reflux symptoms.
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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: 308] [Impact Index Per Article: 154.0] [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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Yadlapati R, Pandolfino JE, Greytak M, Cahoon J, Clarke M, Clary M, Fink D, Menard-Katcher P, Vahabzadeh-Hagh AM, Weissbrod P, Gupta S, Kaizer A, Wani S. Upper Esophageal Sphincter Compression Device as an Adjunct to Proton Pump Inhibition for Laryngopharyngeal Reflux. Dig Dis Sci 2022; 67:3045-3054. [PMID: 34275061 PMCID: PMC8286644 DOI: 10.1007/s10620-021-07172-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 07/08/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND The Reflux Band, an external upper esophageal sphincter (UES) compression device, reduces esophago-pharyngeal reflux events. This study aimed to assess device efficacy as an adjunct to proton pump inhibitor (PPI) therapy in patients with laryngopharyngeal reflux (LPR). METHODS This two-phase prospective clinical trial enrolled adults with at least 8 weeks of laryngeal symptoms (sore throat, throat clearing, dysphonia) not using PPI therapy at two tertiary care centers over 26 months. Participants used double dose PPI for 4 weeks in Phase 1 and the external UES compression device nightly along with PPI for 4 weeks in Phase 2. Questionnaire scores and salivary pepsin concentration were measured throughout the study. The primary endpoint of symptom response was defined as reflux symptom index (RSI) score ≤ 13 and/or > 50% reduction in RSI. RESULTS Thirty-one participants completed the study: 52% male, mean age 47.9 years (SD 14.0), and mean body mass index (BMI) 26.2 kg/m2 (5.1). Primary endpoint was met in 11 (35%) participants after Phase 1 (PPI alone) and 17 (55%) after Phase 2 (Device + PPI). Compared to baseline, mean RSI score (24.1 (10.9)) decreased at end of Phase 1 (PPI alone) (21.9 (9.7); p = 0.06) and significantly decreased at end of Phase 2 (Device + PPI) (15.5 (10.3); p < 0.01). Compared to non-responders, responders to Device + PPI had a significantly lower BMI (p = 0.02) and higher salivary pepsin concentration (p = 0.01). CONCLUSION This clinical trial highlights the potential efficacy of the external UES compression device (Reflux Band) as an adjunct to PPI for patients with LPR (ClinicalTrials.Gov NCT03619811).
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Affiliation(s)
- Rena Yadlapati
- Division of Gastroenterology, University of California, San Diego School of Medicine, ACTRI Building 1W517, 9500 Gilman Drive MC 0956, La Jolla, CA 92093 USA
| | - John E. Pandolfino
- Division of Gastroenterology, Northwestern University, Feinberg School of Medicine, Chicago, IL USA
| | - Madeline Greytak
- Division of Gastroenterology, University of California, San Diego School of Medicine, ACTRI Building 1W517, 9500 Gilman Drive MC 0956, La Jolla, CA 92093 USA
| | - Jonathon Cahoon
- Division of Gastroenterology, University of Colorado, Anschutz Medical Campus, Aurora, CO USA
| | - Mary Clarke
- Division of Gastroenterology, University of California, San Diego School of Medicine, ACTRI Building 1W517, 9500 Gilman Drive MC 0956, La Jolla, CA 92093 USA
| | - Matthew Clary
- Division of Otolaryngology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, CO USA
| | - Daniel Fink
- Division of Otolaryngology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, CO USA
| | - Paul Menard-Katcher
- Division of Gastroenterology, University of Colorado, Anschutz Medical Campus, Aurora, CO USA
| | - Andrew M. Vahabzadeh-Hagh
- Division of Otolaryngology, Department of Surgery, University of California San Diego, La Jolla, CA USA
| | - Philip Weissbrod
- Division of Otolaryngology, Department of Surgery, University of California San Diego, La Jolla, CA USA
| | - Samir Gupta
- Division of Gastroenterology, University of California, San Diego School of Medicine, ACTRI Building 1W517, 9500 Gilman Drive MC 0956, La Jolla, CA 92093 USA
| | - Alexander Kaizer
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Anschutz Medical Campus, Aurora, CO USA
| | - Sachin Wani
- Division of Gastroenterology, University of Colorado, Anschutz Medical Campus, Aurora, CO USA
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20
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Krause AJ, Walsh EH, Weissbrod PA, Taft TH, Yadlapati R. An update on current treatment strategies for laryngopharyngeal reflux symptoms. Ann N Y Acad Sci 2021; 1510:5-17. [PMID: 34921412 DOI: 10.1111/nyas.14728] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 10/23/2021] [Accepted: 10/29/2021] [Indexed: 11/25/2022]
Abstract
Laryngopharyngeal reflux (LPR) is a syndrome caused by reflux of gastric contents into the pharynx or larynx, which leads to symptoms of throat clearing, hoarseness, pain, globus sensation, cough, excess mucus production in the throat, and dysphonia. LPR is a challenging condition, as there is currently no gold standard for diagnosis or treatment, and thus this presents a burden to the healthcare system. Strategies for treatment of LPR are numerous. Medical therapies include proton pump inhibitors, which are first line, H2 receptor antagonists, alginates, and baclofen. Other noninvasive treatment options include lifestyle therapy and the external upper esophageal sphincter compression device. Endoscopic and surgical options include antireflux surgery, magnetic sphincter augmentation, and transoral incisionless fundoplication. Functional laryngeal disorders and laryngeal hypersensitivity can present as LPR symptoms with or without gastroesophageal reflux disease. Though there are minimal studies in this area, neuromodulators and behavioral interventions are potential treatment options. Given the complexity of these patients and numerous available treatment options, we propose a treatment algorithm to help clinicians diagnose and triage patients into an appropriate therapy.
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Affiliation(s)
- Amanda J Krause
- Division of Gastroenterology & Hepatology, Department of Medicine, University of California San Diego, La Jolla, California
| | - Erin H Walsh
- Department of Otolaryngology, University of California San Diego, La Jolla, California
| | - Philip A Weissbrod
- Department of Otolaryngology, University of California San Diego, La Jolla, California
| | - Tiffany H Taft
- Division of Gastroenterology & Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Rena Yadlapati
- Division of Gastroenterology & Hepatology, Department of Medicine, University of California San Diego, La Jolla, California
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21
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Snow G, Dhar SI, Akst LM. How to Understand and Treat Laryngopharyngeal Reflux. Gastroenterol Clin North Am 2021; 50:871-884. [PMID: 34717876 DOI: 10.1016/j.gtc.2021.08.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Laryngopharyngeal reflux (LPR) is frustrating, as symptoms are nonspecific and diagnosis is often unclear. Two main approaches to diagnosis are empiric treatment trials and objective reflux testing. Initial empiric trial of Proton pump inhibitors (PPI) twice daily for 2-3 months is convenient, but risks overtreatment and delayed diagnosis if patient complaints are not from LPR. Dietary modifications, H2-antagonists, alginates, and fundoplication are other possible LPR treatments. If objective diagnosis is desired or patients' symptoms are refractory to empiric treatment, pH testing with/without impedance should be considered. Additionally, evaluation for non-reflux etiologies of complaints should be performed, including laryngoscopy or videostroboscopy.
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Affiliation(s)
- Grace Snow
- Division of Laryngology, Department of Otolaryngology-Head & Neck Surgery, Johns Hopkins University School of Medicine, 601 North Caroline Street, 6th Floor, Baltimore, MD 21287, USA
| | - Shumon I Dhar
- Division of Laryngology, Department of Otolaryngology-Head & Neck Surgery, Johns Hopkins University School of Medicine, 601 North Caroline Street, 6th Floor, Baltimore, MD 21287, USA
| | - Lee M Akst
- Division of Laryngology, Department of Otolaryngology-Head & Neck Surgery, Johns Hopkins University School of Medicine, 601 North Caroline Street, 6th Floor, Baltimore, MD 21287, USA.
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22
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Xiao YL, Zhou LY, Hou XH, Li YQ, Zou DW, Chen MH. Chinese expert consensus on gastroesophageal reflux disease in 2020. J Dig Dis 2021; 22:376-389. [PMID: 34105263 DOI: 10.1111/1751-2980.13028] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 06/07/2021] [Indexed: 12/11/2022]
Affiliation(s)
- Ying Lian Xiao
- Department of Gastroenterology, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Li Ya Zhou
- Department of Gastroenterology, Peking University Third Hospital, Beijing, China
| | - Xiao Hua Hou
- Department of Gastroenterology, Union Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Yan Qing Li
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, Shandong Province, China
| | - Duo Wu Zou
- Department of Gastroenterology, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Min Hu Chen
- Department of Gastroenterology, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
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23
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Cosway B, Wilson JA, O'Hara J. The acid test: Proton pump inhibitors in persistent throat symptoms: A systematic review of systematic reviews. Clin Otolaryngol 2021; 46:1263-1272. [PMID: 34170625 DOI: 10.1111/coa.13827] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 05/05/2021] [Accepted: 05/30/2021] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Proton pump inhibitors (PPIs) have evolved to become a frequent treatment option for patients with persistent throat symptoms. The evidence for their use in this context is, however, conflicting. This review assesses the quality of the published systematic reviews and meta-analyses evaluating PPIs in persistent throat symptoms. METHODS Following a literature search, systematic review were evaluated using the Reporting of Bias in Systematic Reviews (ROBIS) tool and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Outcome measures were analysed using the "checklist to operationalize measurement characteristics of patient-reported outcome measures." RESULTS 10 systematic reviews were assessed. All but one were at high risk of bias. No review met the PRISMA checklist criteria. No identified PROM met the checklist requirements for validation. Significant methodological concerns include inappropriate selection of studies for inclusion, poor selection of outcome measures, a lack of appropriate bias assessments and inconsistent reporting of reviews. CONCLUSION The quality of evidence concerning the role of PPIs in persistent throat symptoms gives serious cause for concern. Collectively, nine studies at high risk of bias have been cited 714 times. Systematic reviews typically attract these high numbers of citations and, if their premises and conclusions do not withstand scrutiny, they are open to widespread misinterpretation, perpetuation of misunderstanding and negative clinical impact.
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Affiliation(s)
| | - Janet A Wilson
- Newcastle University and Freeman Hospital, Newcastle, UK
| | - James O'Hara
- Newcastle University and Freeman Hospital, Newcastle, UK
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24
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Mahoney LB, Esther CR, May K, Rosen R. Metabolomic profiling of extraesophageal reflux disease in children. Clin Transl Sci 2021; 14:2025-2033. [PMID: 34058076 PMCID: PMC8504841 DOI: 10.1111/cts.13064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 03/30/2021] [Accepted: 04/12/2021] [Indexed: 11/29/2022] Open
Abstract
Although respiratory symptoms in children are often attributed to gastroesophageal reflux disease, establishing a clear diagnosis of extraesophageal reflux disease (EERD) can be challenging, as there are no sensitive or specific EERD biomarkers. The aim of this study was to evaluate the metabolite profile in bronchoalveolar (BAL) fluid from children with suspected EERD and assess the impact of reflux treatment on these metabolites. In this prospective pilot study, we performed nontargeted global metabolomic profiling on BAL fluid from 43 children undergoing testing with bronchoscopy, upper endoscopy, and multichannel intraluminal impedance with pH (pH-MII) for evaluation of chronic respiratory symptoms. Twenty-three (54%) patients had an abnormal pH-MII study. Seventeen (40%) patients were on proton pump inhibitors (PPIs) for testing. Levels of histamine, malate, adenosine 5'-monophosphate, and ascorbate were significantly lower in subjects with abnormal pH-MII studies compared to those normal studies. Furthermore, in children off PPI therapy, those with abnormal pH-MII studies had robust increases in a number of glycerophospholipids within phospholipid metabolic pathways, including derivatives of glycerophosphorylcholine, glycerophosphoglycerol, and glycerophosphoinositol, compared to those with normal pH-MII studies. These findings offer insight into the impact of reflux and PPIs on the lungs and provide a foundation for future studies using targeted metabolomic analysis to identify potential biomarkers of EERD.
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Affiliation(s)
- Lisa B Mahoney
- Aerodigestive Center, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Charles R Esther
- Pediatric Pulmonology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Kara May
- Aerodigestive Center, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Rachel Rosen
- Aerodigestive Center, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
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25
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O'Hara J, Stocken DD, Watson GC, Fouweather T, McGlashan J, MacKenzie K, Carding P, Karagama Y, Wood R, Wilson JA. Use of proton pump inhibitors to treat persistent throat symptoms: multicentre, double blind, randomised, placebo controlled trial. BMJ 2021; 372:m4903. [PMID: 33414239 PMCID: PMC7789994 DOI: 10.1136/bmj.m4903] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To assess the use of proton pump inhibitors (PPIs) to treat persistent throat symptoms. DESIGN Pragmatic, double blind, placebo controlled, randomised trial. SETTING Eight ear, nose, and throat outpatient clinics, United Kingdom. PARTICIPANTS 346 patients aged 18 years or older with persistent throat symptoms who were randomised according to recruiting centre and baseline severity of symptoms (mild or severe): 172 to lansoprazole and 174 to placebo. INTERVENTION Random blinded allocation (1:1) to either 30 mg lansoprazole twice daily or matched placebo twice daily for 16 weeks. MAIN OUTCOME MEASURES Primary outcome was symptomatic response at 16 weeks measured using the total reflux symptom index (RSI) score. Secondary outcomes included symptom response at 12 months, quality of life, and throat appearances. RESULTS Of 1427 patients initially screened for eligibility, 346 were recruited. The mean age of the study sample was 52.2 (SD 13.7) years, 196 (57%) were women, and 162 (47%) had severe symptoms at presentation; these characteristics were balanced across treatment arms. The primary analysis was performed on 220 patients who completed the primary outcome measure within a window of 14-20 weeks. Mean RSI scores were similar between treatment arms at baseline: lansoprazole 22.0 (95% confidence interval 20.4 to 23.6) and placebo 21.7 (20.5 to 23.0). Improvements (reduction in RSI score) were observed in both groups-score at 16 weeks: lansoprazole 17.4 (15.5 to19.4) and placebo 15.6 (13.8 to 17.3). No statistically significant difference was found between the treatment arms: estimated difference 1.9 points (95% confidence interval -0.3 to 4.2 points; P=0.096) adjusted for site and baseline symptom severity. Lansoprazole showed no benefits over placebo for any secondary outcome measure, including RSI scores at 12 months: lansoprazole 16.0 (13.6 to 18.4) and placebo 13.6 (11.7 to 15.5): estimated difference 2.4 points (-0.6 to 5.4 points). CONCLUSIONS No evidence was found of benefit from PPI treatment in patients with persistent throat symptoms. RSI scores were similar between the lansoprazole and placebo groups after 16 weeks of treatment and at the 12 month follow-up. TRIAL REGISTRATION ISRCTN Registry ISRCTN38578686 and EudraCT 2013-004249-17.
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Affiliation(s)
- James O'Hara
- Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne NE7 7DN, UK James.O'
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Deborah D Stocken
- Clinical Trials Research, Leeds Institute of Clinical Trials Research University of Leeds, Leeds, UK
| | - Gillian C Watson
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle, UK
| | - Tony Fouweather
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Kenneth MacKenzie
- NHS Greater Glasgow and Clyde. Visiting Professor, University of Strathclyde, Glasgow, UK
| | - Paul Carding
- Oxford Institute of Nursing, Midwifery and Allied Health Research, Oxford Brookes University, Oxford, UK
| | | | - Ruth Wood
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle, UK
| | - Janet A Wilson
- Population Health Sciences Institute, Newcastle University and Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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26
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Wilson JA, Stocken DD, Watson GC, Fouweather T, McGlashan J, MacKenzie K, Carding P, Karagama Y, Harries M, Ball S, Khwaja S, Costello D, Wood R, Lecouturier J, O'Hara J. Lansoprazole for persistent throat symptoms in secondary care: the TOPPITS RCT. Health Technol Assess 2021; 25:1-118. [PMID: 33492208 PMCID: PMC7869007 DOI: 10.3310/hta25030] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Persistent throat symptoms are commonly attributed to 'laryngopharyngeal reflux'. Despite a limited evidence base, these symptoms are increasingly being treated in primary care with proton pump inhibitors. OBJECTIVE To assess the value of proton pump inhibitor therapy in patients with persistent throat symptoms. DESIGN This was a double-blind, placebo-controlled, randomised Phase III trial. SETTING This was a multicentre UK trial in eight UK ear, nose and throat departments. PARTICIPANTS A total of 346 participants aged ≥ 18 years with persistent throat symptoms and a Reflux Symptom Index score of ≥ 10, exclusive of the dyspepsia item, were recruited. INTERVENTION Random allocation (1 : 1 ratio) to either 30 mg of lansoprazole twice daily or matched placebo for 16 weeks. MAIN OUTCOME MEASURE Symptomatic response (i.e. total Reflux Symptom Index score after 16 weeks of therapy). RESULTS A total of 1427 patients were screened and 346 were randomised. The mean age was 52 years (standard deviation 13.7 years, range 20-84 years); 150 (43%) participants were male and 196 (57%) were female; 184 (53%) participants had a mild Reflux Symptom Index minus the heartburn/dyspepsia item and 162 (47%) had a severe Reflux Symptom Index minus the heartburn/dyspepsia item. A total of 172 patients were randomised to lansoprazole and 174 were randomised to placebo. MAIN OUTCOMES A total of 267 participants completed the primary end-point visit (lansoprazole, n = 127; placebo, n = 140), of whom 220 did so between 14 and 20 weeks post randomisation ('compliant' group); 102 received lansoprazole and 118 received placebo. The mean Reflux Symptom Index scores at baseline were similar [lansoprazole 22.0 (standard deviation 8.0), placebo 21.7 (standard deviation 7.1), overall 21.9 (standard deviation 7.5)]. The mean Reflux Symptom Index scores at 16 weeks reduced from baseline in both groups [overall 17.4 (standard deviation 9.9), lansoprazole 17.4 (standard deviation 9.9), placebo 15.6 (standard deviation 9.8)]. Lansoprazole participants had estimated Reflux Symptom Index scores at 16 weeks that were 1.9 points higher (worse) than those of placebo participants (95% confidence interval -0.3 to 4.2; padj = 0.096), adjusted for site and baseline severity. SECONDARY OUTCOMES Ninety-five (43%) participants achieved a Reflux Symptom Index score in the normal range (< 12) at 16 weeks: 42 (41%) in the lansoprazole group and 53 (45%) in the placebo group. A total of 226 participants completed the end-of-trial follow-up visit (lansoprazole, n = 109; placebo, n = 117), of whom 181 were 'compliant'. The mean Reflux Symptom Index scores at 12 months reduced from baseline in both groups [lansoprazole 16.0 (standard deviation 10.8), placebo 13.6 (standard deviation 9.6), overall 14.7 (standard deviation 10.2)]. A total of 87 (48%) participants achieved a Reflux Symptom Index score in the normal range at 12 months: 33 (40%) in the lansoprazole group and 54 (55%) in the placebo group. Likewise, the Comprehensive Reflux Symptom Score and Laryngopharyngeal Reflux - Health Related Quality of Life total scores and subscales all showed very similar changes in the lansoprazole and placebo cohorts at both 16 weeks and 12 months. LIMITATIONS Drop-out rate and compliance are issues in pragmatic clinical trials. The Trial Of Proton Pump Inhibitors in Throat Symptoms (TOPPITS) aimed to detect clinically relevant difference with 90% power. The 346 randomised participants reduced to 283 at the primary end point; 267 completed the primary outcome measure, 220 within the protocol time scale. Despite this, the powers to detect the clinically relevant difference in Reflux Symptom Index score at 16 weeks were 82% (compliant comparison) and 89% (pragmatic comparison). The lack of difference between lansoprazole and placebo is generalisable across NHS clinics. CONCLUSIONS Participants on lansoprazole did not report significantly better outcomes than participants on placebo on any of the three patient-reported outcome tools (Reflux Symptom Index, Comprehensive Reflux Symptom Score and Laryngopharyngeal Reflux - Health Related Quality of Life). This multicentre, pragmatic, powered, definitive Phase III trial found no evidence of benefit for patients by treating persistent throat symptoms with lansoprazole. TRIAL REGISTRATION Current Controlled Trials ISRCTN38578686 and EudraCT number 2013-004249-17. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 3. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Janet A Wilson
- Ear, Nose and Throat Department, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Deborah D Stocken
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Gillian C Watson
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Tony Fouweather
- Biostatistics Research Group, Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Julian McGlashan
- Ear, Nose and Throat Department, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Kenneth MacKenzie
- Ear, Nose and Throat Department, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Paul Carding
- Oxford Institute of Nursing, Midwifery and Allied Health Research, Oxford Brookes University, Oxford, UK
| | - Yakubu Karagama
- Ear, Nose and Throat Department, Manchester University NHS Foundation Trust, Manchester, UK
| | - Meredydd Harries
- Ear, Nose and Throat Department, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Stephen Ball
- Ear, Nose and Throat Department, City Hospitals Sunderland NHS Foundation Trust, Sunderland, UK
| | - Sadie Khwaja
- Ear, Nose and Throat Department, Stockport NHS Foundation Trust, Stockport, UK
| | - Declan Costello
- Ear, Nose and Throat Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ruth Wood
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Jan Lecouturier
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - James O'Hara
- Ear, Nose and Throat Department, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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27
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Lin XH, Luo JC, Ting PH, Chang TE, Huang YH, Hou MC, Lee FY. Comparison of the efficiency of two different proton pump inhibitor formula in treatment of patients with atypical gastroesophageal reflux disease: a prospective randomized study. J Gastroenterol Hepatol 2020; 35:2096-2102. [PMID: 32401385 DOI: 10.1111/jgh.15093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 05/02/2020] [Accepted: 05/07/2020] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM The prospective, open-label, randomized study aims to compare the efficacy of lansoprazole, a fast orally disintegrating proton pump inhibitor (PPI), and dexlansoprazole, a dual delayed release PPI, in patients with atypical symptoms of gastroesophageal reflux disease (GERD). METHODS Patients with atypical GERD symptoms with a total reflux symptom index score > 10 were eligible for enrollment. From February 2018 to December 2019, 232 subjects were randomly assigned (1:1 ratio) to receive oral lansoprazole, Takepron OD 30 mg, once daily before breakfast or oral dexlansoprazole, Dexilant 60 mg, once daily before breakfast for 8 weeks. The primary end-point is to compare the symptoms response rate after an 8-week PPI therapy between the two groups. RESULTS There were 232 study subjects enrolling in this study. After the 8-week PPI therapy, dexlansoprazole-treated group had a significantly higher response rate than lansoprazole-treated group in cough (76.5% vs 38.0%) and globus (69.7% vs 30.8%) (P all < 0.05 by intention-to-treat). Multivariate logistic regression analysis showed that the use of dexlansoprazole, presence of dyslipidemia, and typical GERD symptoms (acid reflux and heartburn) were predictors for symptom response for cough; the use of dexlansoprazole and presence of erosive esophagitis were predictors for symptom response for globus (P all < 0.05). No predictor for therapy response to hoarseness was noted. CONCLUSIONS There is a higher response rate for cough and globus symptoms in patients with atypical GERD after the 8-week PPI therapy with dexlansoprazole rather than lansoprazole.
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Affiliation(s)
- Xi-Hsuan Lin
- Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang-Ming University Hospital, Yilan, Taiwan
| | - Jiing-Chyuan Luo
- Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Keelung Hospital, Ministry of Health and Welfare, Keelung, Taiwan
| | - Po-Hsiang Ting
- Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Tien-En Chang
- Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yi-Hsiang Huang
- Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ming-Chih Hou
- Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Fa-Yauh Lee
- Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
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28
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Zhang M, Chia C, Stanley C, Phyland DJ, Paddle PM. Diagnostic Utility of Salivary Pepsin as Compared With 24-Hour Dual pH/Impedance Probe in Laryngopharyngeal Reflux. Otolaryngol Head Neck Surg 2020; 164:375-380. [DOI: 10.1177/0194599820951183] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Objective Laryngopharyngeal reflux (LPR) is defined as the retropulsion of gastric contents into the larynx, oropharynx, and/or nasopharynx. The 24-hour combined hypopharyngeal-esophageal multichannel intraluminal impedance with dual pH probe (24h-HEMII-pH) is currently the gold standard in LPR diagnosis; however, it is invasive, user dependent, and not always tolerated. This study assesses the diagnostic utility of salivary pepsin (Peptest) at different thresholds and during symptomatic periods as compared with the 24h-HEMII-pH probe in diagnosing LPR. Study Design Prospective cohort study. Setting Private laryngology clinic in Melbourne, Australia. Subjects and Methods Thirty-five patients with a clinical history and endoscopic findings of LPR were recruited and simultaneously evaluated for LPR via 24h-HEMII-pH probe and salivary pepsin analysis at 5 key time points over the same 24-hour period. Results Salivary pepsin was 76.9% sensitive and had a positive predictive value (PPV) of 87.0% at a threshold of 16 ng/mL when compared with the 24h-HEMII-pH probe. If the pathologic pepsin threshold was raised to 75 ng/mL, salivary pepsin had a sensitivity of 57.7%, a specificity of 75.0%, and a PPV of 93.8%. Symptomatic testing conferred a superior specificity at 16 ng/mL (66.7%) and 75 ng/mL (100.0%) and a superior PPV at 16 ng/mL (92.3%) and 75 ng/mL (100.0%). Conclusion Salivary pepsin detection is a simpler, more cost-effective, and less traumatic universal first-line alternative to 24h-HEMII-pH probe in diagnosing LPR. Superior specificities conferring greater diagnostic value may be achieved with higher thresholds and symptomatic testing. If clinical suspicion remains high following negative salivary pepsin analysis, a 24h-HEMII-pH study could provide further diagnostic information.
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Affiliation(s)
- Michael Zhang
- Department of Otolaryngology–Head and Neck Surgery, Monash Health, Melbourne, Australia
| | - Clemente Chia
- Department of Otolaryngology–Head and Neck Surgery, Monash Health, Melbourne, Australia
| | - Claire Stanley
- Department of Otolaryngology–Head and Neck Surgery, Monash Health, Melbourne, Australia
| | - Debra J. Phyland
- Department of Otolaryngology–Head and Neck Surgery, Monash Health, Melbourne, Australia
- Department of Surgery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
- Melbourne Swallow Analysis Centre, Melbourne, Australia
| | - Paul M. Paddle
- Department of Otolaryngology–Head and Neck Surgery, Monash Health, Melbourne, Australia
- Department of Surgery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
- Melbourne Swallow Analysis Centre, Melbourne, Australia
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Failed Swallows on High-Resolution Manometry Independently Correlates With Severity of LPR Symptoms. J Voice 2020; 36:832-837. [DOI: 10.1016/j.jvoice.2020.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 09/07/2020] [Accepted: 09/10/2020] [Indexed: 11/23/2022]
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Chen S, Liang M, Zhang M, Tan N, Lin Y, Cao P, Xiao Y. A study of proximal esophageal baseline impedance in identifying and predicting laryngopharyngeal reflux. J Gastroenterol Hepatol 2020; 35:1509-1514. [PMID: 32003045 DOI: 10.1111/jgh.14998] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 01/29/2020] [Accepted: 01/29/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIM Laryngopharyngeal reflux (LPR) is caused by the reflux of gastric contents beyond the esophagus into the larynx and pharynx. However, upper esophageal sphincter (UES) motility and proximal esophagus reflux parameters are poorly studied. This study aims to explore the characteristics of UES motility and reflux parameter among LPR patients. METHODS Patients with laryngopharyngeal symptoms only (L), patients with laryngopharyngeal symptoms and typical esophageal symptoms (L + E), patients with typical esophageal symptoms only (E), and healthy controls (H) were retrospectively included. Physiological profiles were studied and compared among groups using both high-resolution manometry and pH-impedance monitoring, including UES basal pressure, residual pressure, relaxation duration time, recovery time, the time to nadir pressure, UES length, proximal contractile integral, and proximal mean nocturnal baseline impedance (MNBI). Patients' symptom outcomes were also analyzed. RESULTS A total of 242 patients were included. Proximal MNBI was significantly lower in patients with both laryngopharyngeal and esophageal symptoms (17 cm above low esophageal sphincter [LES]: L vs L + E vs E vs H = 3689.7 vs 2500.0 vs 3073.0 vs 3996.0; 15 cm above LES: L vs L + E vs E vs H = 3155.9 vs 2553.4 vs 3198.9 vs 2985.2; P < 0.001). Patients responded to proton pump inhibitor treatment also had lower proximal MNBI than those who did not (17 cm above LES: 1834.0 vs 3500.0; 15 cm above LES: 1946.5 vs 3432.6; P < 0.001). CONCLUSION Decreased proximal MNBI can not only identify LPR patients but also predict patients' symptom outcomes.
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Affiliation(s)
- Songfeng Chen
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Mengya Liang
- Department of Cardiac Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Mengyu Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Niandi Tan
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yuqing Lin
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Peixian Cao
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yinglian Xiao
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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Cho JH, Shin CM, Yoon H, Park YS, Kim N, Lee DH. Efficacy of a high-dose proton pump inhibitor in patients with gastroesophageal reflux disease: a single center, randomized, open-label trial. BMC Gastroenterol 2020; 20:275. [PMID: 32811427 PMCID: PMC7433117 DOI: 10.1186/s12876-020-01410-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 08/07/2020] [Indexed: 11/22/2022] Open
Abstract
Background The extraesophageal manifestations of gastroesophageal reflux disease (GERD) are more difficult to manage than the typical symptoms. The efficacy of high-dose and standard-dose proton pump inhibitors against these atypical symptoms is not yet established. Methods In this single center, randomized, open-label study, patients with GERD received rabeprazole for 8 weeks, either 20 mg once daily (standard-dose group) or 20 mg twice daily (high-dose group). Patients were assessed before treatment and at weeks 4 and 8 with a 5-graded scale questionnaire consisting of 2 typical symptoms (heartburn and acid regurgitation) and 8 atypical symptoms (chest pain, cough, globus, wheezing, laryngopharyngitis, hoarseness, belching, and dysphagia). Sufficient improvement of reflux symptoms was defined as ≥50% reduction from the initial questionnaire score. Results Final analyses included 35 patients in the standard-dose group and 38 patients in the high-dose group. The rate of sufficient improvement for typical symptoms was significantly higher in the high-dose group than in the standard-dose group (100.0% vs. 84.0%, P = 0.040). For atypical symptoms, the rate of sufficient improvement tended to be higher in the high-dose group than in the standard-dose group (82.4% vs. 63.0%, P = 0.087). Scores of typical and some atypical symptoms (cough and globus) improved after treatment, with significant inter-group differences in time-course changes. Conclusions High-dose rabeprazole is more effective for relieving typical GERD symptoms and some atypical symptoms such as cough and globus than a standard-dose regimen. Trial registration This research was enrolled in a registry of clinical trials run by United States National Library of Medicine at the National Institutes of Health (ClinicalTrials.gov Protocol Registration and Results system ID: NCT04001400). This study was registered on June 26, 2019 - Retrospectively registered.
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Affiliation(s)
- Jae Ho Cho
- Department of Internal Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam, Gyeonggi-do, 13620, South Korea
| | - Cheol Min Shin
- Department of Internal Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam, Gyeonggi-do, 13620, South Korea
| | - Hyuk Yoon
- Department of Internal Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam, Gyeonggi-do, 13620, South Korea
| | - Young Soo Park
- Department of Internal Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam, Gyeonggi-do, 13620, South Korea
| | - Nayoung Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam, Gyeonggi-do, 13620, South Korea
| | - Dong Ho Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam, Gyeonggi-do, 13620, South Korea.
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Durazzo M, Lupi G, Cicerchia F, Ferro A, Barutta F, Beccuti G, Gruden G, Pellicano R. Extra-Esophageal Presentation of Gastroesophageal Reflux Disease: 2020 Update. J Clin Med 2020; 9:E2559. [PMID: 32784573 PMCID: PMC7465150 DOI: 10.3390/jcm9082559] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/04/2020] [Accepted: 08/05/2020] [Indexed: 02/07/2023] Open
Abstract
Gastroesophageal reflux disease (GERD) is defined by the presence of symptoms induced by the reflux of the stomach contents into the esophagus. Although clinical manifestations of GERD typically involve the esophagus, extra-esophageal manifestations are widespread and less known. In this review, we discuss extra-esophageal manifestations of GERD, focusing on clinical presentations, diagnosis, and treatment. Common extra-esophageal manifestations of GERD include chronic cough, asthma, laryngitis, dental erosions, and gingivitis. Extra-esophageal involvement can be present also when classic GERD symptoms are absent, making the diagnosis more challenging. Although available clinical studies are heterogeneous and frequently of low quality, a trial with proton pump inhibitors can be suggested as a first-line diagnostic strategy in case of suspected extra-esophageal manifestations of GERD.
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Affiliation(s)
- Marilena Durazzo
- Department of Medical Sciences, University of Turin, C.so A.M. Dogliotti 14, 10126 Turin, Italy; (G.L.); (F.C.); (A.F.); (F.B.); (G.B.); (G.G.)
- 3th Internal Medicine Unit, Città della Salute e della Scienza Hospital, C.so Bramante 88, 10126 Turin, Italy
| | - Giulia Lupi
- Department of Medical Sciences, University of Turin, C.so A.M. Dogliotti 14, 10126 Turin, Italy; (G.L.); (F.C.); (A.F.); (F.B.); (G.B.); (G.G.)
- 3th Internal Medicine Unit, Città della Salute e della Scienza Hospital, C.so Bramante 88, 10126 Turin, Italy
| | - Francesca Cicerchia
- Department of Medical Sciences, University of Turin, C.so A.M. Dogliotti 14, 10126 Turin, Italy; (G.L.); (F.C.); (A.F.); (F.B.); (G.B.); (G.G.)
- 3th Internal Medicine Unit, Città della Salute e della Scienza Hospital, C.so Bramante 88, 10126 Turin, Italy
| | - Arianna Ferro
- Department of Medical Sciences, University of Turin, C.so A.M. Dogliotti 14, 10126 Turin, Italy; (G.L.); (F.C.); (A.F.); (F.B.); (G.B.); (G.G.)
- 3th Internal Medicine Unit, Città della Salute e della Scienza Hospital, C.so Bramante 88, 10126 Turin, Italy
| | - Federica Barutta
- Department of Medical Sciences, University of Turin, C.so A.M. Dogliotti 14, 10126 Turin, Italy; (G.L.); (F.C.); (A.F.); (F.B.); (G.B.); (G.G.)
- 3th Internal Medicine Unit, Città della Salute e della Scienza Hospital, C.so Bramante 88, 10126 Turin, Italy
| | - Guglielmo Beccuti
- Department of Medical Sciences, University of Turin, C.so A.M. Dogliotti 14, 10126 Turin, Italy; (G.L.); (F.C.); (A.F.); (F.B.); (G.B.); (G.G.)
- 3th Internal Medicine Unit, Città della Salute e della Scienza Hospital, C.so Bramante 88, 10126 Turin, Italy
| | - Gabriella Gruden
- Department of Medical Sciences, University of Turin, C.so A.M. Dogliotti 14, 10126 Turin, Italy; (G.L.); (F.C.); (A.F.); (F.B.); (G.B.); (G.G.)
- 3th Internal Medicine Unit, Città della Salute e della Scienza Hospital, C.so Bramante 88, 10126 Turin, Italy
| | - Rinaldo Pellicano
- Unit of Gastroenterology, Città della Salute e della Scienza Hospital, C.so Bramante 88, 10126 Turin, Italy;
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Lien HC, Wang CC, Kao JY, Yeh HZ, Hsu JY, Lee SW, Chuang CY, Tsou YA, Wang JD, Vaezi MF, Chang CS. Distinct Physiological Characteristics of Isolated Laryngopharyngeal Reflux Symptoms. Clin Gastroenterol Hepatol 2020; 18:1466-1474.e4. [PMID: 31546059 DOI: 10.1016/j.cgh.2019.08.064] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 08/30/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with isolated laryngopharyngeal reflux symptoms (LPRS) defined as those without concomitant typical reflux symptoms (CTRS) are clinically challenging to manage due to unclear pathophysiology. We investigated esophageal physiology in patients with isolated LPRS and their response to proton-pump inhibitors (PPI) therapy. METHODS This is a multi-center observational study conducted in referral hospitals in Taiwan. Patients with predominant LPRS, but without common non-reflux causes, underwent esophageal manometry, 24-hr ambulatory esophagopharyngeal pH testing, and Bernstein test, followed by a 12-week esomeprazole 40 mg twice-daily treatment. Participants with pathological reflux were divided into the isolated LPRS group (ie, LPRS without CTRS, n = 40) and the CTRS group (ie, LPRS with CTRS, n = 66). Participants without pathological reflux or esophagitis (n = 132) served as the nonreflux controls. RESULTS The PPI-responsiveness was similar between the isolated LPRS group and CTRS group (63% vs 57%, P = .8), but lower in the nonreflux controls (32%, P = .005). Despite similar distal esophageal acid exposure time (P = .7) when compared to those with CTRS, the isolated LPRS group had a lower prevalence of both positive Bernstein test (P = .001) and ineffective esophageal motility disorder (P = .03), and fewer pharyngeal acid reflux episodes (P < .0001). CONCLUSIONS Our findings indicate similar distal esophageal acid exposure and PPI-responsiveness between LPRS patients with and without CTRS. The lack of CTRS in the isolated LPRS group is likely due to esophageal acid hyposensitivity and fewer pharyngeal acid reflux episodes, thus implicating distinct pathophysiology of isolated LPRS from those with CTRS.
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Affiliation(s)
- Han-Chung Lien
- Division of Gastroenterology, Taichung Veterans General Hospital, Taichung, Taiwan; Department of Internal Medicine, National Yang-Ming University, Taipei, Taiwan; Science College of Tunghai University, Taichung, Taiwan.
| | - Chen-Chi Wang
- Department of Otolaryngology, Taichung Veterans General Hospital, Taichung, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan; School of Speech-Language Pathology and Audiology, Chung Shan Medical University, Taichung, Taiwan
| | - John Y Kao
- Department of Internal Medicine, Division of Gastroenterology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Hong-Zen Yeh
- Division of Gastroenterology, Taichung Veterans General Hospital, Taichung, Taiwan; Department of Internal Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Jeng-Yuan Hsu
- Division of Chest Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; Division of Clinical Research, Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan; School of Medicine, China Medical University, Taichung, Taiwan; School of Physical Therapy, Chung Shan Medical University, Taichung, Taiwan
| | - Shou-Wu Lee
- Division of Gastroenterology, Taichung Veterans General Hospital, Taichung, Taiwan; School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Chun-Yi Chuang
- Department of Internal Medicine, Chung Shan Medical University, Taichung, Taiwan; Department of Otolaryngology, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Yung-An Tsou
- Department of Otolaryngology-Head and Neck Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Jung-Der Wang
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Michael F Vaezi
- Division of Gastroenterology, Hepatology and Nutrition, Center for Swallowing and Esophageal Disorders, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chi-Sen Chang
- Division of Gastroenterology, Taichung Veterans General Hospital, Taichung, Taiwan; School of Medicine, Chung Shan Medical University, Taichung, Taiwan
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Barrett CM, Patel D, Vaezi MF. Laryngopharyngeal Reflux and Atypical Gastroesophageal Reflux Disease. Gastrointest Endosc Clin N Am 2020; 30:361-376. [PMID: 32146951 DOI: 10.1016/j.giec.2019.12.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Laryngopharyngeal reflux and atypical manifestations of gastroesophageal reflux disease have a high economic and social burden in the United States. There is increasing research supporting the reflex theory and hypersensitivity syndrome underlying this disease pathophysiology. Novel diagnostic biomarkers have gained more traction in the search for a more reliable diagnostic tool, but further research is needed. Current standard-of-care treatment relies on proton pump inhibitor therapy. Antireflux surgery is usually not recommended. Neuromodulators and treatments targeting specific neuronal receptors are discussed. A diagnostic algorithm is proposed for the evaluation of laryngeal symptoms suspected to be related to extraesophageal reflux disease.
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Affiliation(s)
- Caroline M Barrett
- Department of Internal Medicine, Vanderbilt University Medical Center, 719 Thompson Lane, Suite 20400, Nashville, TN 37204, USA
| | - Dhyanesh Patel
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, 1301 Medical Center Drive, TVC # 1660, Nashville, TN 37232, USA.
| | - Michael F Vaezi
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, 1301 Medical Center Drive, TVC # 1660, Nashville, TN 37232, USA
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35
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Im NR, Lee DY, Kim B, Kim J, Jung KY, Kim TH, Baek SK. Role of Matrix Metalloproteinases 7 in the Pathogenesis of Laryngopharyngeal Reflux: Decreased E-cadherin in Acid exposed Primary Human Pharyngeal Epithelial Cells. Int J Mol Sci 2019; 20:E5276. [PMID: 31652949 PMCID: PMC6862869 DOI: 10.3390/ijms20215276] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 10/11/2019] [Accepted: 10/22/2019] [Indexed: 12/20/2022] Open
Abstract
Cleavage of E-cadherin and the resultant weakness in the cell-cell links in the laryngeal epithelium lining is induced by exposure to acidic contents of the refluxate. Herein, we aimed to evaluate the role of matrix metalloproteinases (MMPs) in inducing E-cadherin level changes following acid exposure to the human pharyngeal mucosal cells. E-cadherin levels were inversely correlated with the duration of acid exposure. Treatment with actinonin, a broad MMP inhibitor, inhibited this change. Immunocytochemical staining and transepithelial permeability test revealed that the cell surface staining of E-cadherin decreased and transepithelial permeability increased after acid exposure, which was significantly inhibited by the MMP inhibitor. Among the various MMPs analyzed, the mRNA for MMP-7 in the cellular component was upregulated, and the secretion and enzymatic activity of MMP-7 in the culture media increased with the acid treatment. Consequently, MMP-7 plays a significant role in the degradation of E-cadherin after exposure to a relatively weak acidic condition that would be similar to the physiologic condition that occurs in Laryngopharyngeal reflux disease patients.
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Affiliation(s)
- Nu-Ri Im
- Department of Otorhinolaryngology-Head and Neck Surgery, College of Medicine, Korea University, Seoul 02841, Korea.
| | - Doh Young Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University Boramae Medical Center, Seoul 07061, Korea.
| | - Byoungjae Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, College of Medicine, Korea University, Seoul 02841, Korea.
- Neuroscience research institute, College of Medicine, Korea University, Seoul 02841, Korea.
| | - Jian Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, College of Medicine, Korea University, Seoul 02841, Korea.
| | - Kwang-Yoon Jung
- Department of Otorhinolaryngology-Head and Neck Surgery, College of Medicine, Korea University, Seoul 02841, Korea.
| | - Tae Hoon Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, College of Medicine, Korea University, Seoul 02841, Korea.
| | - Seung-Kuk Baek
- Department of Otorhinolaryngology-Head and Neck Surgery, College of Medicine, Korea University, Seoul 02841, Korea.
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Abstract
PURPOSE OF REVIEW Microbiome refers to the genetic potential of resident microorganisms that inhabit a given niche. The exact role of the microbiome and its relation to chronic disease processes remains largely unknown, although various associations have been observed. We reviewed current literature investigating the microbiome of the upper airway by subsite (nasal cavity, sinus cavities, nasopharynx, and larynx) and its relation to chronic inflammatory disease processes. RECENT FINDINGS The disruption of indigenous microbiota at a specific subsite may lead to pathogen overgrowth and increased susceptibility to infection. This has previously been demonstrated in the gastrointestinal tract and lower airways. The role of the microbiome and its relation to pathogenesis of disease in the upper airway, however, is less clearly understood. The present review discusses the recent studies that appear to link dysbiosis to upper airway chronic inflammatory diseases. SUMMARY Despite mounting research, the role of microbiota in the upper airway remains poorly understood. Based on review of the current literature comparing healthy versus diseased patients with site-specific inflammatory conditions, a complex consortium of microbial communities inhabits the upper airway. Fluctuations in the baseline microbiome may contribute to disease pathogenesis, and improved understanding of the dynamics between shifting microbiota may be critical to guiding future medical therapy.
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Sobrino-Cossío S, Teramoto-Matsubara O, Mateos-Pérez G, Abdo-Francis JM, Tawil J, Olguín-Ramírez C, Orozco-Gamiz A, Galvis-García ES. In search of the grail: A race for acid suppression. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2019; 84:344-356. [PMID: 31239096 DOI: 10.1016/j.rgmx.2019.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 03/26/2019] [Accepted: 04/30/2019] [Indexed: 06/09/2023]
Abstract
Proton pump inhibitors are the reference standards for the treatment of acid-related diseases. Acid suppression in gastroesophageal reflux disease is associated with a high rate of mucosal cicatrization, but symptom response differs among endoscopic phenotypes. Extraesophageal manifestations have a good clinical response in patients that present with abnormal acid exposure (diagnostic test) in the esophagus. Proton pump inhibitors have shown their effectiveness for reducing symptom intensity in nighttime reflux and sleep disorders, improving quality of life and work productivity. That can sometimes be achieved through dose modifications by splitting or increasing the dose, or through galenic formulation. Proton pump inhibitors are not exempt from controversial aspects related to associated adverse events. Technological development is directed at improving proton pump inhibitor performance through increasing the half-life, maximum concentration, and area under the curve of the plasma concentrations through galenic formulation, as well as creating safer and more tolerable drugs. The present review is focused on the mechanisms of action, pharmacokinetic properties, and technological advances for increasing the pharmacologic performance of a proton pump inhibitor.
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Affiliation(s)
- S Sobrino-Cossío
- Hospital Ángeles del Pedregal, Ciudad de México, México; Gástrica, Centro Avanzado en Endoscopia y Estudios Funcionales, Ciudad de México, México.
| | - O Teramoto-Matsubara
- Gástrica, Centro Avanzado en Endoscopia y Estudios Funcionales, Ciudad de México, México; Centro Médico ABC, Ciudad de México, México
| | - G Mateos-Pérez
- Hospital Ángeles del Pedregal, Ciudad de México, México; Hospital Ángeles Acoxpa, Ciudad de México, México
| | - J M Abdo-Francis
- Gástrica, Centro Avanzado en Endoscopia y Estudios Funcionales, Ciudad de México, México; Hospital Ángeles Acoxpa, Ciudad de México, México
| | - J Tawil
- Departamento de Trastornos Funcionales Digestivos, Gedyt-Gastroenterología Diagnóstica y Terapéutica, Buenos Aires, Argentina
| | - C Olguín-Ramírez
- Gástrica, Centro Avanzado en Endoscopia y Estudios Funcionales, Ciudad de México, México
| | - A Orozco-Gamiz
- Gastrolab Laboratorio de Fisiología Gastrointestinal, Guadalajara, Jalisco, México
| | - E S Galvis-García
- Gástrica, Centro Avanzado en Endoscopia y Estudios Funcionales, Ciudad de México, México; Hospital General de México «Dr. Eduardo Liceaga», Ciudad de México, México
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Sobrino-Cossío S, Teramoto-Matsubara O, Mateos-Pérez G, Abdo-Francis J, Tawil J, Olguín-Ramírez C, Orozco-Gamiz A, Galvis-García E. In search of the grail: A race for acid suppression. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2019. [DOI: 10.1016/j.rgmxen.2019.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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39
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Proton Pump Inhibitors for the Treatment of Laryngopharyngeal Reflux. A Systematic Review. J Voice 2019; 34:918-929. [PMID: 31160182 DOI: 10.1016/j.jvoice.2019.05.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 05/10/2019] [Accepted: 05/10/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND To give, if possible, an answer in the long-standing debate of the efficacy of proton pump inhibitors (PPIs) in treating laryngopharyngeal reflux (LPR) through published systematic reviews and meta-analyses. METHOD PubMed, Cochrane Library, and EMBASE were searched from 1984, the year the term LPR first appeared in the literature, until October 2018. Systematic reviews and meta-analyses comparing the treatment response of PPI therapy in patients with LPR were included in our study. RESULTS Nine eligible studies, two systematic reviews and seven meta-analyses, were identified and analyzed in our study. Three of these were published in 2006, one in 2007, one in 2013, and four in 2016. Five studies published before 2016 and one in 2016 showed no benefit from PPI therapy for LPR patients while the three remaining meta-analyses of 2016 showed a significant improvement in LPR symptoms but no significant difference in response rate and reflux finding scores (RFS) between PPI therapy and placebo treatment. CONCLUSIONS Based on the existing data, the use of PPI therapy for the treatment of LPR remains questionable. Six out of the nine systematic reviews/meta-analyses concluded that PPI therapy is not superior to placebo and three concluded that PPI therapy significantly improved LPR symptoms although they did not identify any difference in the post-treatment laryngoscopic findings. There is still a long way to go until we can give a definite answer to this question but in the meantime, the use of PPI therapy for the treatment of LPR will continue even though existing evidence is poor and weak, coming mainly from individual uncontrolled studies.
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Agrawal N, Yadlapati R, Shabeeb N, Price CP, Lidder A, Shintani-Smith S, Bové M, Pandolfino J, Tan B. Relationship between extralaryngeal endoscopic findings, proton pump inhibitor (PPI) response, and pH measures in suspected laryngopharyngeal reflux. Dis Esophagus 2019; 32:5067901. [PMID: 30101358 DOI: 10.1093/dote/doy072] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 04/23/2018] [Accepted: 07/16/2018] [Indexed: 12/11/2022]
Abstract
Laryngopharyngeal reflux (LPR) is a clinical entity diagnosed by history laryngoscopic findings that has a variable response to empiric proton-pump inhibitor (PPI) therapy. While the reflux finding score (RFS), an endoscopic scoring scheme, has been advanced as a measure of LPR, it has not been externally validated against symptom severity in practice. Extralaryngeal pharyngeal endoscopic findings may have diagnostic utility but remain underexplored. This study assesses the correlation between extralaryngeal findings and (1) 24-hour oropharyngeal pH & (2) PPI response in patients with suspected LPR. Subjects presented to a tertiary care center with laryngeal symptoms ≥1 month and reflux symptom index (RSI) ≥13. Following baseline questionnaires, laryngoscopy, and a 24-hour oropharyngeal pH probe study, subjects were prescribed 8-12 week omeprazole trials. Baseline endoscopic findings were scored in a blinded fashion using the RFS and extralaryngeal score criteria, summatively the 'ELS.' PPI response was defined as ≥50% improvement in RSI. Thirty-three subjects with flexible endoscopic recordings completed baseline and follow-up questionnaires. The cohort's baseline mean RSI was 23.0 ± 7.2 with a ΔRSI = 9.8 after PPI therapy. The baseline RFS score averaged 5.3 ± 2.7. 45% of our subjects was found to be PPI responsive. The Cohen's kappa for the ELS but not the RFS was significant. There were no significant differences between the RFS (P = 0.10) or ELS (P = 0.07) for PPI responders & nonresponders. Oropharyngeal pH measures did not correlate with the RFS or ELS. In conclusion, endoscopic scores of laryngeal and extralaryngeal findings did not predict PPI response or oropharyngeal acid exposure in suspected LPR.
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Affiliation(s)
- N Agrawal
- Department of Otolaryngology - Head and Neck Surgery
| | - R Yadlapati
- Division of Medicine - Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - N Shabeeb
- Indiana University School of Medicine, Indianapolis, Indiana
| | - C Pe Price
- Department of Otolaryngology - Head and Neck Surgery
| | - A Lidder
- University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | | | - M Bové
- Department of Otolaryngology - Head and Neck Surgery
| | - J Pandolfino
- Division of Medicine - Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - B Tan
- Department of Otolaryngology - Head and Neck Surgery
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Jetté ME, Clary MS, Prager JD, Finger TE. Chemical receptors of the arytenoid: A comparison of human and mouse. Laryngoscope 2019; 130:423-430. [PMID: 30908677 DOI: 10.1002/lary.27931] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 02/25/2019] [Indexed: 01/01/2023]
Abstract
OBJECTIVES/HYPOTHESIS The larynx is a highly responsive organ exposed to mechanical, thermal, and chemical stimuli. Chemicals elicit responses both in intraepithelial nerve fibers and in specialized chemosensory cells, including scattered solitary cells as well as taste cells organized into taste buds. Activation of both chemosensory cells and taste buds in the larynx elicit cough, swallow, or apnea with exposure to sour or bitter substances, and even by water or sweet-tasting chemicals. In an effort to begin understanding their function, we sought to compare the distribution, density, and types of chemosensory cells and chemoresponsive nerve fibers in laryngeal epithelium of humans and mice. STUDY DESIGN Animal and human laboratory analysis. METHODS Using immunohistochemistry, we identified taste cells and polymodal nociceptive nerve fibers in the arytenoid area of the laryngeal epithelium of the following: 1) infants undergoing supraglottoplasty for laryngomalacia, and 2) a cadaveric specimen procured from a 34-year-old donor. We then compared these findings to both preweanling and mature mouse tissue. RESULTS Arytenoid tissue from both human and mouse contained many taste buds containing type II taste cells-bitter, sweet, or umami sensing-which were innervated by nerve fibers expressing P2X3 type adenosine triphosphate receptors. Type III cells (acid responsive) were also present, but they were fewer in human tissue than in equivalent tissue from mice. In both species, the epithelium was densely innervated by free nerve endings. CONCLUSIONS Our findings suggest that from a standpoint of chemosensation, human and mouse larynges are biologically similar. This suggests that a murine model can be used effectively in laryngeal chemosensory research. LEVEL OF EVIDENCE NA Laryngoscope, 130:423-430, 2020.
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Affiliation(s)
- Marie E Jetté
- Department of Otolaryngology, in the School of Medicine at the University of Colorado, Aurora, Colorado, U.S.A.,Rocky Mountain Taste and Smell Center, Aurora, Colorado, U.S.A
| | - Matthew S Clary
- Department of Otolaryngology, in the School of Medicine at the University of Colorado, Aurora, Colorado, U.S.A
| | - Jeremy D Prager
- Department of Otolaryngology, in the School of Medicine at the University of Colorado, Aurora, Colorado, U.S.A.,Children's Hospital Colorado, Aurora, Colorado, U.S.A
| | - Thomas E Finger
- Department of Cell and Developmental Biology, Aurora, Colorado, U.S.A.,Rocky Mountain Taste and Smell Center, Aurora, Colorado, U.S.A
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Lechien JR, Akst LM, Hamdan AL, Schindler A, Karkos PD, Barillari MR, Calvo-Henriquez C, Crevier-Buchman L, Finck C, Eun YG, Saussez S, Vaezi MF. Evaluation and Management of Laryngopharyngeal Reflux Disease: State of the Art Review. Otolaryngol Head Neck Surg 2019; 160:762-782. [PMID: 30744489 DOI: 10.1177/0194599819827488] [Citation(s) in RCA: 215] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To review the current literature about the epidemiology, clinical presentation, diagnosis, and treatment of laryngopharyngeal reflux (LPR). DATA SOURCES PubMed, Cochrane Library, and Scopus. METHODS A comprehensive review of the literature on LPR epidemiology, clinical presentation, diagnosis, and treatment was conducted. Using the PRISMA statement, 3 authors selected relevant publications to provide a critical analysis of the literature. CONCLUSIONS The important heterogeneity across studies in LPR diagnosis continues to make it difficult to summarize a single body of thought. Controversies persist concerning epidemiology, clinical presentation, diagnosis, and treatment. No recent epidemiologic study exists regarding prevalence and incidence with the use of objective diagnostic tools. There is no survey that evaluates the prevalence of symptoms and signs on a large number of patients with confirmed LPR. Regarding diagnosis, an increasing number of authors used multichannel intraluminal impedance-pH monitoring, although there is no consensus regarding standardization of the diagnostic criteria. The efficiency of proton pump inhibitor (PPI) therapy remains poorly demonstrated and misevaluated by incomplete clinical tools that do not take into consideration many symptoms and extralaryngeal findings. Despite the recent advances in knowledge about nonacid LPR, treatment protocols based on PPIs do not seem to have evolved. IMPLICATIONS FOR PRACTICE The development of multichannel intraluminal impedance-pH monitoring and pepsin and bile salt detection should be considered for the establishment of a multiparameter diagnostic approach. LPR treatment should evolve to a more personalized regimen, including diet, PPIs, alginate, and magaldrate according to individual patient characteristics. Multicenter international studies with a standardized protocol could improve scientific knowledge about LPR.
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Affiliation(s)
- Jerome R Lechien
- 1 Laryngopharyngeal Reflux Study Group of Young Otolaryngologists, International Federation of Oto-rhino-laryngological Societies, Paris, France.,2 Department of Anatomy and Experimental Oncology, Mons School of Medicine, UMONS Research Institute for Health Sciences and Technology, University of Mons, Mons, Belgium.,3 Laboratory of Phonetics, Faculty of Psychology, Research Institute for Language Sciences and Technology, University of Mons, Mons, Belgium.,4 Department of Otorhinolaryngology and Head and Neck Surgery, CHU Saint-Pierre, Faculty of Medicine, University Libre de Bruxelles, Brussels, Belgium
| | - Lee M Akst
- 5 Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Abdul Latif Hamdan
- 1 Laryngopharyngeal Reflux Study Group of Young Otolaryngologists, International Federation of Oto-rhino-laryngological Societies, Paris, France.,6 Department of Otorhinolaryngology and Head and Neck Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Antonio Schindler
- 1 Laryngopharyngeal Reflux Study Group of Young Otolaryngologists, International Federation of Oto-rhino-laryngological Societies, Paris, France.,7 Department of Biomedical and Clinical Sciences, Phoniatric Unit, L. Sacco Hospital, University of Milan, Milan, Italy
| | - Petros D Karkos
- 1 Laryngopharyngeal Reflux Study Group of Young Otolaryngologists, International Federation of Oto-rhino-laryngological Societies, Paris, France.,8 Department of Otorhinolaryngology and Head and Neck Surgery, Thessaloniki Medical School, Thessaloniki, Greece
| | - Maria Rosaria Barillari
- 1 Laryngopharyngeal Reflux Study Group of Young Otolaryngologists, International Federation of Oto-rhino-laryngological Societies, Paris, France.,9 Division of Phoniatrics and Audiology, Department of Mental and Physical Health and Preventive Medicine, University of Naples SUN, Naples, Italy
| | - Christian Calvo-Henriquez
- 1 Laryngopharyngeal Reflux Study Group of Young Otolaryngologists, International Federation of Oto-rhino-laryngological Societies, Paris, France.,10 Department of Otorhinolaryngology and Head and Neck Surgery, Hospital Complex of Santiago de Compostela, Santiago de Compostela, Spain
| | - Lise Crevier-Buchman
- 1 Laryngopharyngeal Reflux Study Group of Young Otolaryngologists, International Federation of Oto-rhino-laryngological Societies, Paris, France.,11 Department of Otorhinolaryngology and Head and Neck Surgery, Foch Hospital, Paris, France
| | - Camille Finck
- 1 Laryngopharyngeal Reflux Study Group of Young Otolaryngologists, International Federation of Oto-rhino-laryngological Societies, Paris, France.,2 Department of Anatomy and Experimental Oncology, Mons School of Medicine, UMONS Research Institute for Health Sciences and Technology, University of Mons, Mons, Belgium.,12 Department of Otorhinolaryngology and Head and Neck Surgery, CHU de Liège, Faculty of Medicine, University of Liège, Liège, Belgium
| | - Young-Gyu Eun
- 1 Laryngopharyngeal Reflux Study Group of Young Otolaryngologists, International Federation of Oto-rhino-laryngological Societies, Paris, France.,13 Department of Otorhinolaryngology and Head and Neck Surgery, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Sven Saussez
- 1 Laryngopharyngeal Reflux Study Group of Young Otolaryngologists, International Federation of Oto-rhino-laryngological Societies, Paris, France.,2 Department of Anatomy and Experimental Oncology, Mons School of Medicine, UMONS Research Institute for Health Sciences and Technology, University of Mons, Mons, Belgium.,4 Department of Otorhinolaryngology and Head and Neck Surgery, CHU Saint-Pierre, Faculty of Medicine, University Libre de Bruxelles, Brussels, Belgium
| | - Michael F Vaezi
- 14 Division of Gastroenterology, Hepatology, Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Establishment of a novel and effective reflux laryngitis model in rabbits: a preliminary study. Eur Arch Otorhinolaryngol 2018; 276:175-183. [PMID: 30535974 DOI: 10.1007/s00405-018-5234-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 12/01/2018] [Indexed: 01/30/2023]
Abstract
PURPOSE To establish a novel and effective reflux model with a modified nasogastric aspiration tube and to investigate the association between different types of nasogastric aspiration tubes and reflux laryngitis, we conducted this study. METHODS Thirty-eight healthy New Zealand albino rabbits (2.5-3.5 kg) were divided into three groups: control (CTR, n = 6)-non-intubated; normal nasogastric intubation (NNI, n = 16)-intubated with 4#, 6#, 8#, and 10# normal nasogastric aspiration tubes; and modified nasogastric intubation (MNI, n = 16)-intubated with 4#, 6#, 8#, and 10# modified nasogastric aspiration tubes. The laryngoscopy, body weight, and pH values at the esophageal entrance were recorded before and 1, 2, and 4 weeks after intubation. After the final laryngoscopy, the animals in groups with a pH below 4 were sacrificed to obtain histological and gene expression analysis results. RESULTS The reflux finding score (RFS) after 4 weeks showed that there was a statistically significant difference in the 8# NNI group (7 ± 0.816, P < 0.001), the 8# MNI group (11.5 ± 2.517, P < 0.001) and the 10# MNI (12.75 ± 1.893, P < 0.001) group compared with the control group (1.83 ± 1.602). The pH values of these three groups were lower than 4. However, the weight loss of the rabbits in the 10# NNI and 10# MNI groups was more obvious. Submucous gland hyperplasia and inflammation were significantly increased in the 8# NNI group, 8# MNI group and the 10# MNI group, but in the level of some pro-inflammatory cytokines and COX-2, the MNI group was significantly higher than the NNI group (8# NNI × 8# MNI, P < 0.01; 8# MNI × 10# MNI, P < 0.01). CONCLUSION This study showed that 8# modified nasogastric intubation (MNI) produces effective reflux laryngitis in the rabbits.
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Carter D, Dickman R. Practice styles, knowledge and attitudes of general practitioners and gastroenterology specialists who treat gastroesophageal reflux disease. Medicine (Baltimore) 2018; 97:e13781. [PMID: 30593157 PMCID: PMC6314753 DOI: 10.1097/md.0000000000013781] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
As little is known on the subject, our aim was to compare practice styles, knowledge and attitudes of general practitioners (GPs), and gastroenterology specialists (GIs) regarding the treatment of gastroesophageal reflux disease (GERD).An internet survey designed by the authors was sent nationwide and randomly to 290 GIs and 1312 GPs. We assessed for the burden of GERD, indications for referral for a GI consultation, criteria for proton pump inhibitors (PPIs) selection, and main unmet treatment needs.Forty (14%) GIs and 132 (10%) GPs returned the questionnaire. Both groups treat 13 to 14 GERD patients weekly (mean age 41-50 years). The most common first and second line drug of choice in both groups was omeprazole and esomeprazole, respectively. GIs stated that the most important consideration for the selection of treatment was high safety profile, whereas GPs considered it to be a rapid symptomatic relief. In the case of first and second line PPI failures, GIs tended to prescribe a non PPI treatment, whereas GPs restarted esomeprazole. GIs stated that the most prevalent conceived limitations of PPI treatment were nighttime heartburn and undesirable side effects, whereas GPs considered treatment inflexibility and drug interactions.GIs and GPs hold different practice styles, knowledge, and attitudes on the treatment of GERD. Our findings ascertain the need for the development of updated National Clinical Guidelines focusing on GERD.
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Affiliation(s)
- Dan Carter
- Department of Gastroenterology, Chaim Sheba Medical Center, Tel Hashomer, Medical Center
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ram Dickman
- Division of Gastroenterology, Rabin Medical Center, Beilinson Hospital
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Schneider SL, Clary MS, Fink DS, Wang SX, Chowdhury FN, Yadlapati R, Jetté ME, Courey MS. Voice therapy associated with a decrease in the reflux symptoms index in patients with voice complaints. Laryngoscope 2018; 129:1169-1173. [PMID: 30444264 DOI: 10.1002/lary.27583] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 08/19/2018] [Accepted: 08/28/2018] [Indexed: 01/01/2023]
Abstract
OBJECTIVES/HYPOTHESIS Patients with muscle tension dysphonia often demonstrate an elevation in Reflux Symptom Index (RSI) and 10-item Voice Handicap Index (VHI-10) scores, and may be erroneously diagnosed with laryngopharyngeal reflux disease. In this study we assessed the effects of voice therapy on RSI and VHI-10 scores in patients with voice complaints not responsive to antireflux medications. STUDY DESIGN Retrospective cohort study. METHODS A study of patients was conducted at a single tertiary-care center over 1 year (January 2012-January 2013). Patients were included if they had dysphonia not responsive to proton pump inhibition, did not have neurologic or neoplastic disease, and participated in at least three voice-therapy sessions in the absence of antireflux therapy. Primary analysis assessed change in RSI scores between the initial and follow-up visits with a laryngologist. RESULTS A total of 18 patients were included (mean age = 49.9 ± 14.5 years, 89% female, 83% with a primary complaint of dysphonia). From initial to follow-up visit, the median RSI score (18.5 [interquartile range {IQR}, 9.5-22.8] vs. 10.5 [IQR, 4.5-14]; P = .02) and median VHI-10 score (25.5 [IQR, 11.3-30.0] vs. 13.5 [IQR, 9.5-20.8]; P = .03) significantly decreased. A significant inverse correlation was found between the number of voice therapy sessions/month and change in RSI score (r = -0.4; P = .05). CONCLUSIONS In this study of patients with muscle tension dysphonia or vocal hyperfunction not responsive to antireflux therapy, RSI and VHI-10 scores improved following voice therapy. Results suggest that self-reported symptoms typically attributed to laryngopharyngeal reflux disease may actually be secondary to inefficient voice use patterns or anxiety about dysphonia that are responsive to voice therapy. LEVEL OF EVIDENCE 4 Laryngoscope, 129:1169-1173, 2019.
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Affiliation(s)
- Sarah L Schneider
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California
| | - Matthew S Clary
- Department of Otolaryngology, University of Colorado School of Medicine, Aurora, Colorado
| | - Daniel Steven Fink
- Department of Otolaryngology, University of Colorado School of Medicine, Aurora, Colorado
| | | | - Farshad N Chowdhury
- Department of Otolaryngology, University of Colorado School of Medicine, Aurora, Colorado
| | - Rena Yadlapati
- Division of Gastroenterology and Hepatology, University of Colorado School of Medicine, Aurora, Colorado
| | - Marie E Jetté
- Department of Otolaryngology, University of Colorado School of Medicine, Aurora, Colorado
| | - Mark S Courey
- Department of Otolaryngology-Head and Neck Surgery, Mount Sinai Health System, New York, New York, U.S.A
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Abdul-Hussein M, Khalaf M, Castell D. Throat Clearing, Frequently Reported, But is it GERD Related? J Clin Gastroenterol 2018; 52:869-872. [PMID: 29356788 DOI: 10.1097/mcg.0000000000000985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
GOALS To identify the association of throat clearing (TC) with gastroesophageal reflux disease (GERD) during objective reflux monitoring in a large number of patients studied in our esophageal testing laboratory. BACKGROUND TC is frequently reported and considered to be an atypical symptom of GERD. Atypical GERD symptoms have been widely investigated and empirically treated with proton pump inhibitors. STUDY We reviewed ambulatory impedance-pH studies of 186 patients referred for evaluation of possible GERD from January 2011 to December 2015 to evaluate the symptom association (SA) of TC with both an abnormal number of reflux episodes and also abnormal esophageal acid exposure (EAE). Patients were divided into 2 groups; group 1: TC is the only reported symptom, group 2: TC is one of the symptoms. All patients were studied off proton pump inhibitors therapy. RESULTS Group 1 where TC was the only symptom in 27/186 (14.5%) patients. There was no significant difference in positive SA between this group (6/27; 22%) and group 2 (43/159; 27%) (Z score P=0.59). There was also no significant association between SA and abnormal EAE whether TC was the only presenting symptom (χ, P=0.7) or one of the reported symptoms (χ, P=0.10). None of the 6/27 had abnormal EAE. CONCLUSION Although TC is often considered a possible GERD-related symptom, we found a low probability of objective association. TC is not likely to be the only presenting symptom, and if it happens, it is unlikely to be associated with GERD. Perhaps, TC should not be considered as a GERD symptom, even as an atypical one.
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Adamiak T, Plati KF. Pediatric Esophageal Disorders: Diagnosis and Treatment of Reflux and Eosinophilic Esophagitis. Pediatr Rev 2018; 39:392-402. [PMID: 30068740 DOI: 10.1542/pir.2017-0266] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Gastroesophageal reflux (GER) occurs frequently in infants, generally at its worst at 4 months of age, with approximately two-thirds of infants spitting up daily. GER typically improves after 7 months of age, with only ∼5% of infants continuing to have reflux at 1 year of age. The diagnosis can often be made based on clinical symptoms. Upper GI (UGI) study has low sensitivity and specificity and should not be ordered as a diagnostic test for reflux. UGI study is best for evaluating other anatomic causes of vomiting. GER becomes problematic gastroesophageal reflux disease (GERD) when complications are present, including feeding difficulties and poor weight gain. Conservative treatment and thickened formula can be helpful for treating GERD. Proton pump inhibitors (PPIs) are frequently prescribed for treating reflux. However, studies do not show a definite benefit in infants, and there are potential side effects. Older children with GERD may present with regurgitation, heartburn, chest discomfort, dysphagia, abdominal pain, vomiting, poor appetite, or poor weight gain. Upper endoscopy is considered for children with concerning symptoms, persistent symptoms despite treatment, and relapse of symptoms after treatment. Other esophageal disorders can have a similar clinical presentation as GERD, notably eosinophilic esophagitis (EoE). EoE is a chronic immune-mediated disorder of the esophagus, which may present as dysphagia, food impaction, heartburn, vomiting, abdominal pain, feeding difficulties, or failure to thrive. Diagnosis is made histologically by the presence of esophageal eosinophilia on endoscopic biopsies in the correct clinical setting.
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Affiliation(s)
- Tonya Adamiak
- Department of Pediatrics, Sanford Children's Hospital, Sioux Falls, SD
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Gaviscon® Advance alone versus co-prescription of Gaviscon® Advance and proton pump inhibitors in the treatment of laryngopharyngeal reflux. Eur Arch Otorhinolaryngol 2018; 275:2515-2521. [PMID: 30062580 DOI: 10.1007/s00405-018-5079-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 07/26/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Management of laryngopharyngeal reflux (LPR) typically comprises alginates and proton pump inhibitors (PPIs) alone or in combination, yet evidence to support any particular treatment regimen is lacking. We sought to evaluate the efficacy of Gaviscon® Advance alone versus co-prescription with a PPI in treating LPR. METHODS One hundred consecutive LPR patients with a reflux symptom index (RSI) score > 10 attending our joint voice clinic (JVC) were studied prospectively. All were treated with Gaviscon® Advance four times daily. If patients had been started on a PPI prior to their JVC attendance, this was optimised to a twice-daily dosing regimen and continued. RSI scores were recorded at first attendance and 3 months post-treatment via postal questionnaire. Scores were analysed using t tests and Levene's test for equality of variances. RESULTS Follow-up RSI scores were returned by 72 patients, 39 of whom were treated with Gaviscon® Advance only (group A) and 33 with Gaviscon® Advance + PPI (group B). Mean pre-treatment RSI scores were similar between groups [group A: 19.2, 95% confidence interval (CI) ± 2.4; group B: 21.3, 95% CI ± 3.2 (p = 0.65)]. No significant differences were observed with respect to 3-month post-treatment RSI scores [group A: 9.9, 95% CI ± 2.8; group B: 12.6, 95% CI ± 4.2 (p = 0.82)] and change in RSI scores [group A: 9.3, 95% CI ± 3.0; group B: 8.7, 95% CI ± 2.9 [p = 0.75]). CONCLUSIONS Gaviscon® Advance alone is effective in treating symptoms of LPR, while co-prescription with a high-dose PPI offers no additional benefit.
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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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Koop H. Medical Therapy of Gastroesophageal Reflux Disease Beyond Proton Pump Inhibitors: Where Are We Heading? Visc Med 2018; 34:110-115. [PMID: 29888239 DOI: 10.1159/000486692] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Proton pump inhibitors (PPI) have greatly improved the treatment of gastroesophageal reflux disease. However, recent investigations have revealed that reflux symptoms persist in a substantial number of patients. Therefore, treatment strategies beyond PPI are urgently required. One such strategy may involve more reliable acid suppression, e.g., with new acid inhibitory drugs. Furthermore, the rapid appearance of an acidic compartment in the proximal stomach after a meal, which is largely responsible for postprandial heartburn, requires a specific kind of therapy in addition to PPI which still needs to be established. Pharmacological augmentation of the lower esophageal sphincter may represent another approach to diminish reflux, but the clinical efficacy of compounds tested so far is limited. Altered e-sophageal perception represents a major component involved in the generation of reflux symptoms, particularly in non-erosive reflux disease, but effective pharmacological intervention is largely lacking. Presumed reflux-induced respiratory symptoms (cough, laryngitis, etc.) in the absence of typical esophageal symptoms (e.g., heartburn) remain a hot topic, but recent research points towards a hypersensitivity syndrome and only a minor role of gastroesophageal reflux. Treatment options for this condition are still pending.
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Affiliation(s)
- Herbert Koop
- formerly Department of General Internal Medicine and Gastroenterology, Helios Klinikum Berlin-Buch, Berlin, Germany
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