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Krause AJ, Yadlapati R. Review article: Diagnosis and management of laryngopharyngeal reflux. Aliment Pharmacol Ther 2024; 59:616-631. [PMID: 38192086 PMCID: PMC10997336 DOI: 10.1111/apt.17858] [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: 10/17/2023] [Revised: 11/30/2023] [Accepted: 12/19/2023] [Indexed: 01/10/2024]
Abstract
BACKGROUND Laryngopharyngeal reflux has classically referred to gastroesophageal reflux leading to chronic laryngeal symptoms such as throat clearing, dysphonia, cough, globus sensation, sore throat or mucus in the throat. Current lack of clear diagnostic criteria significantly impairs practitioners' ability to identify and manage laryngopharyngeal reflux. AIMS To discuss current evidence-based diagnostic and management strategies in patients with laryngopharyngeal reflux. METHODS We selected studies primarily based on current guidelines for gastroesophageal reflux disease and laryngopharyngeal reflux, and through PubMed searches. RESULTS We assess the current diagnostic modalities that can be used to determine if laryngopharyngeal reflux is the cause of a patient's laryngeal symptoms, as well as review some of the common treatments that have been used for these patients. In addition, we note that the lack of a clear diagnostic gold-standard, as well as specific diagnostic criteria, significantly limit clinicians' ability to determine adequate therapies for these patients. Finally, we identify areas of future research that are needed to better manage these patients. CONCLUSIONS Patients with chronic laryngeal symptoms are complex due to the heterogenous nature of symptom pathology, inconsistent definitions and variable response to therapies. Further outcomes data are critically needed to help elucidate ideal diagnostic workup and therapeutic management for these challenging patients.
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Affiliation(s)
- Amanda J Krause
- Department of Medicine, Division of Gastroenterology & Hepatology, University of California San Diego, La Jolla, California, USA
| | - Rena Yadlapati
- Department of Medicine, Division of Gastroenterology & Hepatology, University of California San Diego, La Jolla, California, USA
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Vance D, Park J, Alnouri G, Turner RR, Daggumati S, Ferster APO, Ahmad A, Lyons K, Ross J, Russell K, Wu W, Sataloff RT. Diagnosing Laryngopharyngeal Reflux: A Comparison between 24-hour pH-Impedance Testing and Pharyngeal Probe (Restech) Testing, with Introduction of the Sataloff Score. J Voice 2023; 37:737-747. [PMID: 34092465 DOI: 10.1016/j.jvoice.2021.04.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 04/07/2021] [Accepted: 04/07/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVE The purpose of this study was to compare the diagnostic utility of pH monitoring using 24-hour esophageal pH-Impedance (HEMII-pH) testing versus pharyngeal pH (Restech) testing (Respiratory Technology Corporation, Houston, Texas) for diagnosing laryngopharyngeal reflux (LPR). METHODS Retrospectively, patients were reviewed who had completed a Reflux Symptom Index (RSI) survey and stroboscopy within 60 days before or after undergoing simultaneous esophageal pH-Impedance monitoring and Restech testing. Reflux Finding Score (RFS) was determined by 4 blinded observers. 80.45% of patients were on anti-reflux medications at the time of study and had incomplete response to treatment for reflux. Improvement on reflux treatment was determined by evaluating presenting pre-pH monitoring RFS, post treatment RFS, and improvement of symptoms. Pearson correlation coefficients were calculated to assess relationships among RSI, RFS, and test results from HEMII-pH and Restech tests. RESULTS Eighty-seven patients were included in the analysis. The inter-rater reliability of the RFS determination was 74.57%, and the intra-rater reliability was 67.00%. Subjects who had a positive RYAN Score had a significant correlation with RFS (r of 0.222 and p-value of 0.0492). There was no correlation between RFS and number or percent time of reflux events, longest event, total number of events, or percent of time at alkaline pH for either HEMII-PH or Restech test. RSI correlated better with HEMII-pH test than with Restech for percent time spent in both upright (r of 0.226 and p-value of 0.029) and supine position (r of 0.261 and a p-value of 0.032). Restech correlated better with total patient symptom Scores including cough, heartburn, burping, and throat clearing, with a r of 0.242 and a p-value of 0.048. Restech detected more percent time in reflux for total reflux, supine reflux, and upright reflux (p-value less than 0.0001). Restech also detected longer event times than Impedance (p-value of less than 0.0001). When diagnosis of LPR is based on the definition of CRC, the Sataloff Score test had 70.45% sensitivity and 80.95% specificity. The RYAN Score had a sensitivity of 72%, and a specificity of 56.45%, and the Wu Score had a sensitivity of 62.16%, and specificity of 54.05%. When the Sataloff and Wu Score were used together, the sensitivity was 71.45%, specificity 100%, positive predictive value of 100%, and a negative predictive value of 59.46%. CONCLUSION The amount of time of reflux events correlates with symptoms better than the number of events. The HEMII-pH test was able to detect more events of pH<4 than Restech, possibly because there might have been more acid events below than above the upper esophageal sphincter, while Restech detected more total events. Restech recorded longer event times than HEMII-pH test. Since length of time correlates with RFS (probably reflecting laryngeal inflammation), and since laryngeal clearance of acid is more similar to pharyngeal than esophageal clearance, this finding might prove valuable clinically. The Sataloff Score has a sensitivity of 70.45%, and a specificity of 80.95% and appears useful clinically to detect mild to moderate that is missed by the RYAN Score. A combination of Sataloff Score and Wu Score may be clinically valuable to identify LPR with an increased sensitivity of 71.45% and increased specificity of 100%. The Wu Score is not yet available for the general clinical use, but the Sataloff Score is.
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Affiliation(s)
| | - Jin Park
- Drexel University College of Medicine
| | - Ghiath Alnouri
- Department of Otolaryngology, Head and Neck Surgery, Drexel University College of Medicine
| | | | - Srihari Daggumati
- Department of Otolaryngology, Head and Neck Surgery, Virginia Commonwealth University
| | | | - Asyia Ahmad
- Division of Gastroenterology, Drexel University College of Medicine
| | - Karen Lyons
- Department of Otolaryngology, Head and Neck Surgery, Drexel University College of Medicine
| | - Justin Ross
- Department of Otolaryngology, Head and Neck Surgery, Philadelphia College of Osteopathic Medicine
| | - Karissa Russell
- Division of Gastroenterology, Drexel University College of Medicine
| | - Wei Wu
- Department of Otorhinolaryngology, Head and Neck Surgery, PLA Strategic Support Force Characteristic Medical Center; Director of the State Environmental Protection Key Laboratory of Environmental Sense Organ Stress and Health, China
| | - Robert T Sataloff
- Department of Otolaryngology, Head and Neck Surgery, Senior Associate Dean for Clinical Academic Specialties, Drexel University College of Medicine; Director of Otolaryngology and Communication Sciences Research, Lankenau Institute for Medical Research; Drexel University College of Medicine.
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Liu K, Evans J, Clayton S. Proximal reflux frequency not correlated with atypical gastroesophageal reflux disease (GERD) symptoms. Dis Esophagus 2023; 36:doac106. [PMID: 36572402 DOI: 10.1093/dote/doac106] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 12/01/2022] [Indexed: 07/04/2023]
Abstract
Though most known for heartburn and regurgitation, gastroesophageal reflux disease (GERD) is attributed to countless atypical, extra-esophageal (EE) manifestations like cough and throat clearing. While GERD has been studied extensively, the relationship between reflux character and symptom manifestation remains poorly understood. The aim of this study was to examine proximal reflux frequency and its relationship with typical or atypical symptoms. 540 (75.1% female, 24.9% male) pH-impedance monitoring studies from the last 3-years were divided by symptom indication and retrospectively reviewed for proximal reflux frequency, total acid exposure time, mean nocturnal baseline impedance, and total reflux episodes in both abnormal and normal, and borderline studies. Baseline characteristics were also collected. Both total reflux events and mean proximal reflux frequency were found to differ significantly between those with typical versus atypical symptoms. Total reflux events [median (IQR)] were 43.5 (24.0-74.0) in typical patients and 35.0 (20.0-57.0) in atypical patients (P-value 0.0369). Proximal reflux frequency [median (IQR)] was 12.0 (4.0-19.0) typical and 7.0 (3.0-17.0) atypical (P-value 0.0348). Results for exclusively abnormal studies also favored typical patients but not significantly. Baseline characteristics and use of gastric acid control did not differ significantly. Proximal reflux frequency was observed to increase among those with typical GERD symptoms. Total acid reflux events were also significantly higher on average with typical patients. Our findings that proximal reflux frequency is reduced in patients with atypical symptoms compared with patients with typical symptoms suggest that proximal reflux exposure may play a significant role in the symptom presentation of typical classic heartburn and regurgitation symptoms. The differential diagnosis for atypical EE symptoms is vast and can be multifactorial. Our results indicate proximal reflux events may contribute to atypical EE symptoms less than previously reported.
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Affiliation(s)
- Kelli Liu
- Department of Internal Medicine, University of California San Diego Medical Center, San Diego, USA
- Wake Forest School of Medicine, Winston-Salem, USA
| | - Joni Evans
- Department of Biostatistics and Data Science, Atrium Health-Wake Forest Baptist Medical Center, Winston-Salem, USA
| | - Steven Clayton
- Section of Gastroenterology, Department of Internal Medicine, Atrium Health-Wake Forest Baptist Medical Center, Winston-Salem, USA
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Eiamkulbutr S, Dumrisilp T, Sanpavat A, Sintusek P. Prevalence of gastroesophageal reflux disease in children with extraesophageal manifestations using combined-video, multichannel intraluminal impedance-pH study. World J Clin Pediatr 2023; 12:151-161. [PMID: 37342455 PMCID: PMC10278077 DOI: 10.5409/wjcp.v12.i3.151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 04/13/2023] [Accepted: 05/06/2023] [Indexed: 06/08/2023] Open
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) might be either a cause or comorbidity in children with extraesophageal problems especially as refractory respiratory symptoms, without any best methods or criterion for diagnosing it in children.
AIM To evaluate the prevalence of extraesophageal GERD using conventional and combined-video, multichannel intraluminal impedance-pH (MII-pH), and to propose novel diagnostic parameters.
METHODS The study was conducted among children suspected of extraesophageal GERD at King Chulalongkorn Memorial Hospital between 2019 and 2022. The children underwent conventional and/or combined-video MII-pH. The potential parameters were assessed and receiver operating characteristic was used for the significant parameters.
RESULTS Of 51 patients (52.9% males), aged 2.24 years were recruited. The common problems were cough, recurrent pneumonia, and hypersecretion. Using MII-pH, 35.3% of the children were diagnosed with GERD by reflux index (31.4%), total reflux events (3.9%), and symptom indices (9.8%) with higher symptom recorded in the GERD group (94 vs 171, P = 0.033). In the video monitoring group (n = 17), there were more symptoms recorded (120 vs 220, P = 0.062) and more GERD (11.8% vs 29.4%, P = 0.398) by symptom indices. Longest reflux time and mean nocturnal baseline impedance were significant parameters for diagnosis with receiver operating characteristic areas of 0.907 (P = 0.001) and 0.726 (P = 0.014).
CONCLUSION The prevalence of extraesophageal GERD in children was not high as expected. The diagnostic yield of symptom indices increased using video monitoring. Long reflux time and mean nocturnal baseline impedance are novel parameters that should be integrated into the GERD diagnostic criteria in children.
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Affiliation(s)
- Sutha Eiamkulbutr
- Department of Pediatrics, King Chulalongkorn Memorial Hospital, Bangkok 10330, Thailand
| | - Termpong Dumrisilp
- Department of Pediatrics, Bhumibol Adulyadej Hospital, Bangkok 10220, Thailand
| | - Anapat Sanpavat
- Department of Pathology, Chulalongkorn University, Bangkok 10330, Thailand
| | - Palittiya Sintusek
- Thai Pediatric Gastroenterology, Hepatology and Immunology Research Unit, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
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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: 9] [Impact Index Per Article: 9.0] [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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Mahmud Mohayuddin N, Azman M, Wan Hamizan AK, Zahedi FD, Carroll TL, Mat Baki M. Reflux Finding Score Using HD Video Chromoendoscopy: A Diagnostic Adjunct in Suspected Laryngopharyngeal Reflux? J Voice 2022:S0892-1997(22)00164-3. [PMID: 35896429 DOI: 10.1016/j.jvoice.2022.06.008] [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: 04/10/2022] [Revised: 06/04/2022] [Accepted: 06/08/2022] [Indexed: 10/16/2022]
Abstract
OBJECTIVE To explore the use of real-time virtual chromoendoscopy (i-scan) in characterizing the mucosal changes present in subjects with suspected laryngopharyngeal reflux (LPR) and to compare the inter-rater and intra-rater agreement of Reflux Finding Scores (RFS) from both laryngologists and general otolaryngologists (ORL) observing exams using both white light endoscopy (WLE) and i-scan. METHODS This is a cross-sectional study that included 66 subjects: 46 symptomatic and 20 asymptomatic of suspected LPR based on the reflux symptom index (RSI). Subjects underwent flexible video laryngoscopic evaluation of the larynx utilising both WLE and i-scan during one continuous exam. Subjects also underwent 24-hour oropharyngeal pH-monitoring (Dx-pH). Two laryngologists and two general otolaryngologists evaluated the anonymized videos independently using RFS. Dx-pH results were interpreted using the pH graph, report and RYAN score. Subjects were then designated into one of three groups: no reflux, acid reflux and alkaline reflux. RESULTS For the symptomatic group, no mucosal irregularities or early mucosal lesions were observed except in one subject who had granulation tissue. The mean RFS using WLE and i-scan were, respectively: 11.8 (SD 6.1) and 11.3 (SD 5.6) in symptomatic and 7.3 (SD 5.7) and 7.3 (SD 5.2) in asymptomatic group. The inter-rater agreement of RFS using WLE and i-scan for both groups were good with intraclass correlation, ICC of 0.84 and 0.88 (laryngologists); and 0.85 and 0.81 (ORL). The intra-rater agreement among all four raters were good to excellent and similar for both WLE and i-scan (ICC of 0.80 to 0.99). 47 of 66 subjects had evidence of LPR on Dx-pH results which more specifically showed 39 subjects had "acid reflux" and 8 had "alkaline reflux". Sixteen subjects demonstrated a positive RYAN score but showed none were significantly correlated with their RFS. CONCLUSIONS This study reports the first utilization of real-time video chromoendoscopy with i-scan technology through high-definition flexible endoscopes to attempt to characterize laryngopharyngeal findings in patients suspected of having LPR. Both general otolaryngologists and laryngologists were equally capable of reliably calculating the RFS using both WLE and i-scan, however no significant improvement in agreement or change in RFS was found when i-scan technology was employed. LEVEL OF EVIDENCE Level 2.
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Affiliation(s)
- Nurhamizah Mahmud Mohayuddin
- Universiti Kebangsaan Malaysia Medical Centre, Hospital Canselor Tuanku Muhriz, Department of Otorhinolaryngology, Head and Neck Surgery, Kuala Lumpur, Malaysia
| | - Mawaddah Azman
- Universiti Kebangsaan Malaysia Medical Centre, Hospital Canselor Tuanku Muhriz, Department of Otorhinolaryngology, Head and Neck Surgery, Kuala Lumpur, Malaysia
| | - Aneeza Khairiyah Wan Hamizan
- Universiti Kebangsaan Malaysia Medical Centre, Hospital Canselor Tuanku Muhriz, Department of Otorhinolaryngology, Head and Neck Surgery, Kuala Lumpur, Malaysia
| | - Farah Dayana Zahedi
- Universiti Kebangsaan Malaysia Medical Centre, Hospital Canselor Tuanku Muhriz, Department of Otorhinolaryngology, Head and Neck Surgery, Kuala Lumpur, Malaysia
| | - Thomas Leigh Carroll
- Brigham and Women's Hospital, Division of Otolaryngology-Head and Neck Surgery and Harvard Medical School, Department of Otolaryngology-Head and Neck Surgery, Boston Massachusetts
| | - Marina Mat Baki
- Universiti Kebangsaan Malaysia Medical Centre, Hospital Canselor Tuanku Muhriz, Department of Otorhinolaryngology, Head and Neck Surgery, Kuala Lumpur, Malaysia.
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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: 265] [Impact Index Per Article: 132.5] [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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Babic B, Müller DT, Gebauer F, Schiffmann LM, Datta RR, Schröder W, Bruns CJ, Leers JM, Fuchs HF. Gastrointestinal function testing model using a new laryngopharyngeal pH probe (Restech) in patients after Ivor-Lewis esophagectomy. World J Gastrointest Oncol 2021; 13:612-624. [PMID: 34163577 PMCID: PMC8204358 DOI: 10.4251/wjgo.v13.i6.612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 02/11/2021] [Accepted: 05/18/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND There is no established correlation between 24-h esophageal pH-metry (Eso-pH) and the new laryngopharyngeal pH-monitoring system (Restech) as only small case series exist. Eso-pH was not designed to detect laryngopharyngeal reflux (LPR) and Restech may detect LPR better. We have previously published a dataset using the two techniques in a large patient collective with gastroesophageal reflux disease. Anatomically, patients after esophagectomy were reported to represent an ideal human reflux model as no reflux barrier exists.
AIM To use a human reflux model to examine our previously published correlation in these patients.
METHODS Patients after Ivor Lewis esophagectomy underwent our routine follow-up program with surveillance endoscopies, computed tomography scans and further exams following surgery. Only patients with a complete check-up program and reflux symptoms were offered inclusion into this prospective study and evaluated using Restech and simultaneous Eso-pH. Subsequently, the relationship between the two techniques was evaluated
RESULTS A total of 43 patients from May 2016 - November 2018 were included. All patients presented with mainly typical reflux symptoms such as heartburn (74%), regurgitation (84%), chest pain (58%), and dysphagia (47%). Extraesophageal symptoms such as cough, hoarseness, asthma symptoms, and globus sensation were also present. Esophageal 24-hour pH-metry was abnormal in 88% of patients with a mean DeMeester Score of 229.45 [range 26.4-319.5]. Restech evaluation was abnormal in 61% of cases in this highly selective patient cohort. All patients with abnormal supine LPR were also abnormal for supine esophageal reflux measured by conventional Eso-pH.
CONCLUSION Patients following esophagectomy and reconstruction with gastric interposition can ideally serve as a human reflux model. Interestingly, laryngopharyngeal reflux phases occur mainly in the upright position. In this human volume-reflux model, results of simultaneous esophageal and laryngopharyngeal (Restech) pH-metry showed 100% correlation as being explicable by one of our reflux scenarios.
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Affiliation(s)
- Benjamin Babic
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Cologne 50931, Germany
| | - Dolores T Müller
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Cologne 50931, Germany
| | - Florian Gebauer
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Cologne 50931, Germany
| | - Lars Mortimer Schiffmann
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Cologne 50931, Germany
| | - Rabi R Datta
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Cologne 50931, Germany
| | - Wolfgang Schröder
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Cologne 50931, Germany
| | - Christiane J Bruns
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Cologne 50931, Germany
| | - Jessica M Leers
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Cologne 50931, Germany
| | - Hans F Fuchs
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Cologne 50931, Germany
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Abstract
Laryngopharyngeal reflux (LPR) is defined as backflow of gastral or gastroduodenal content into the upper aerodigestive tract and characterized by a variety of unspecific symptoms such as chronic cough, globus sensation, or mucus hypersecretion. Due to the lack of a gold standard and the heterogeneity of studies, the diagnosis of LPR is still problematic and challenging. However, in patients with characteristic symptoms and endoscopic findings, with an increased reflux symptom index, a pathologic reflux finding score (RFS), pathologic 24 h esophageal or oropharyngeal pH monitoring, and without any other underlying condition, the diagnosis of LPR is probable. In the following review, we critically discuss the abovementioned methods as well as more recent tools such as measurements of pepsin concentrations in the saliva for diagnosis of LPR.
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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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11
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Clinical utility of salivary pepsin measurement in patients with proton pump inhibitor-refractory gastroesophageal reflux disease symptoms: a prospective comparative study. Esophagus 2020; 17:339-347. [PMID: 31982992 DOI: 10.1007/s10388-020-00714-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 01/12/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Salivary pepsin measurement has been reported to be useful for diagnosing gastroesophageal reflux disease (GERD). This study aimed to clarify the usefulness of salivary pepsin measurement in patients with proton pump inhibitor (PPI)-refractory GERD symptoms without erosive esophagitis. METHODS One hundred and two patients were included. Over seven days after terminating PPI treatment, all patients underwent a 24-h pH-impedance test and salivary pepsin measurement. In patients whose main symptoms included laryngopharyngeal symptoms, a hypopharyngeal multichannel intraluminal impedance (HMII) test was performed, whereas in other patients, a conventional combined multichannel intraluminal impedance-pH (MII-pH) test was performed. In the HMII tests, patients were divided into abnormal proximal exposure (APE) and non-APE groups. Salivary pepsin concentrations were compared according to acid exposure time (AET) values and were also compared between the APE and non-APE groups. RESULTS The median salivary pepsin concentration in patients with AET > 6% was significantly higher than that in patients with AET ≤ 6% (345.0 [170.0-469.3] ng/mL vs. 120.0 [97.0-290.1] ng/mL, p < 0.01). The sensitivity, specificity, positive predictive value, and negative predictive value of a positive test (> 109 ng/mL) to diagnose patients with AET > 6% were 75.0%, 51.3%, 32.1%, and 86.9%, respectively. There was no significant difference between concentrations in the APE group and concentrations in the non-APE group. CONCLUSIONS In patients with PPI-refractory nonerosive reflux disease, salivary pepsin measurement may help diagnose patients who have conclusive evidence of reflux, whereas it is not adequate for identifying patients with APE.
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12
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Müller DT, Schulte E, Babic B, Knepper L, Fuchs C, Schröder W, Bruns CJ, Leers JM, Fuchs HF. Software improvement for evaluation of laryngopharyngeal pH testing (Restech) – a comparison between DataView 3 and 4. World J Gastrointest Surg 2020; 12:236-246. [PMID: 32551029 PMCID: PMC7289646 DOI: 10.4240/wjgs.v12.i5.236] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 04/09/2020] [Accepted: 05/05/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND When gastroesophageal reflux contents reach above the upper esophageal sphincter, patients may, in addition to typical reflux symptoms, present with atypical, extraesophageal symptoms related to laryngopharyngeal reflux (LPR). Surgical treatment of LPR has shown to lead to 70% symptom improvement, however no gold standard for the diagnosis of LPR exists. In 2007, the Restech Dx-pH was released as a valid method to measure acid exposure above the upper esophageal sphincter. Recently, a new software update was introduced for analysis of measured pH data and calculation of composite scores. The effect of the changes applied to the new software version have not yet been analyzed.
AIM To compare results generated by DataView 3 to the most recently released DataView 4.
METHODS All patients with gastroesophageal reflux disease symptoms were seen in a specialized surgical outpatient clinic for gastrointestinal function testing. Retrospective chart review was performed of all patients presenting with suspected gastroesophageal reflux disease and extraesophageal reflux symptoms, who underwent laryngopharyngeal pH monitoring using the Restech Dx-pH system (Respiratory Technology Corp., Houston, TX, United States) and simultaneous esophageal pH monitoring. DataView 3 and DataView 4 were used to evaluate Restech studies obtained. Diary entries such as mealtimes, supine and upright periods, and symptoms were entered manually to ensure accuracy and precise conversion of data between both software versions. Paired t test was performed for statistical analysis of results.
RESULTS A total of 174 patients (63.8% female) met inclusion criteria, all suffering from extraesophageal reflux symptoms as well as typical gastroesophageal reflux disease symptoms. Mean RYAN score upright was 48.77 in DataView 3 compared to 22.17 in DataView 4, showing a significant difference (aP = 0.0001). Similar results were shown for supine period (mean RYAN Score DataView 3 5.29 vs 1.42 in DataView 4, cP = 0.0001). For upright periods 80 patients showed a decrease of value of the RYAN score with a mean of -58.9 (mean 51.1% decrease). For supine position 25 patients showed a decrease of value of the RYAN score with a mean of -15.13 [range (-153.44)–(-0.01)], which equals a mean decrease of value of 44.5%. Ten patients showed no oropharyngeal acid exposure in DataView 3, but mild/moderate (n = 7) or severe (n = 3) acid exposure in DataView 4. Correlation with positive esophageal pH measurement was improved in all 10 patients.
CONCLUSION Results of both software versions cannot be compared to each other. However, our data suggests that DataView 4 may be an improvement of the Restech pH measurement in the evaluation of LPR.
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Affiliation(s)
- Dolores Thea Müller
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Köln 50937, Germany
| | - Elena Schulte
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Köln 50937, Germany
| | - Benjamin Babic
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Köln 50937, Germany
| | - Laura Knepper
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Köln 50937, Germany
| | - Claudia Fuchs
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Köln 50937, Germany
| | - Wolfgang Schröder
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Köln 50937, Germany
| | - Christiane J Bruns
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Köln 50937, Germany
| | - Jessica M Leers
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Köln 50937, Germany
| | - Hans Friedrich Fuchs
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Köln 50937, Germany
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13
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Weitzendorfer M, Antoniou SA, Schredl P, Witzel K, Weitzendorfer IC, Majerus A, Emmanuel K, Koch OO. Pepsin and oropharyngeal pH monitoring to diagnose patients with laryngopharyngeal reflux. Laryngoscope 2019; 130:1780-1786. [PMID: 31603541 PMCID: PMC7318637 DOI: 10.1002/lary.28320] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 08/29/2019] [Accepted: 09/05/2019] [Indexed: 12/11/2022]
Abstract
Objectives The aim of this study was to compare the diagnostic accuracy of salivary pepsin with oropharyngeal pH monitoring using the Restech measurement system (Dx‐pH) for the diagnosis of laryngopharyngeal reflux (LPR). Study Design Prospective cohort study. Methods Seventy patients with primary symptoms related to LPR underwent gastroscopy, high‐resolution manometry, pH throughout 24‐hour monitoring (MII‐pH), and barium esophagography between October 2015 and May 2018. In addition, an ear, nose, and throat examination was performed, including assessment of Belafsky Reflux Finding Score (RFS). Clinical symptoms were evaluated with the Belafsky Reflux Symptom Index (RSI) and the Gastrointestinal Quality of Life Index (GIQLI). Simultaneous to MII‐pH, pepsin determination and Dx‐pH were performed. Results Of 70 patients, 41 (58.6%) subjects with a pathological DeMeester score showed higher mean values of pepsin (mean value: 216 ng/mL, 95% confidence interval [CI]: 172 to 260), compared to patients with a normal DeMeester score (mean value: 161 ng/mL, 95% CI: 115 to 207). Salivary pepsin showed a specificity of 86.2% and sensitivity of 41.5% for diagnosing LPR using the optimal cutoff value of 216 ng/mL. Furthermore, a significant correlation between the values of salivary pepsin and the RSI score was seen in patients with pathological results in MII‐pH (r = 0.344; P = 0.046). However, elevated Dx‐pH measurements showed no significant correlation with either MII‐pH, RSI score, RFS score, or GIQLI score, or with the results of pepsin measurement. Conclusion Pepsin measurement in saliva could be an alternative tool to assist office‐based diagnosis of LPR, whereas Dx‐pH does not seem to be an adequate test. Level of Evidence 2B Laryngoscope, 130:1780–1786, 2020
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Affiliation(s)
- Michael Weitzendorfer
- Department of SurgeryParacelsus Medical UniversitySalzburgAustria
- Department of SurgeryOrdensklinikum Linz Sisters of Charity HospitalLinzAustria
| | - Stavros A. Antoniou
- Department of SurgerySchool of Medicine, European University CyprusNicosiaCyprus
| | - Philipp Schredl
- Department of SurgeryParacelsus Medical UniversitySalzburgAustria
| | - Kai Witzel
- Department of SurgeryParacelsus Medical UniversitySalzburgAustria
- Minimal Invasiv CenterHuenfeldGermany
| | | | | | - Klaus Emmanuel
- Department of SurgeryParacelsus Medical UniversitySalzburgAustria
| | - Oliver O. Koch
- Department of SurgeryParacelsus Medical UniversitySalzburgAustria
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14
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Mesallam TA, Baqays AA. Characteristics of upright versus supine reflux pattern in patients with laryngopharyngeal reflux. Braz J Otorhinolaryngol 2019; 87:200-204. [PMID: 31708431 PMCID: PMC9422475 DOI: 10.1016/j.bjorl.2019.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 04/07/2019] [Accepted: 08/10/2019] [Indexed: 10/27/2022] Open
Abstract
INTRODUCTION Many laryngeal-related problems have been attributed to laryngopharyngeal reflux including dysphonia, frequent throat clearing, chronic cough, and globus sensation. However, there is still controversy regarding diagnosis and clinical presentation of this disorder. OBJECTIVE The main objective of this study is to describe laryngopharyngeal reflux characteristics of different reflux position patterns in laryngopharyngeal reflux patients diagnosed with oropharyngeal pH monitoring. METHODS A retrospective chart review was conducted for 161 laryngopharyngeal reflux patients diagnosed with 24h oro-pharyngeal pH monitoring. Study subjects were categorized into upright and supine laryngopharyngeal reflux groups based on the pH results. The two groups were compared regarding the clinical presentation and pH characteristics. RESULTS Significant higher rates of upright laryngopharyngeal reflux position than supine laryngopharyngeal reflux position (P<0.0001) were reported among the study group. Reflux symptoms index results were significantly higher in the upright larybgopharyngeal reflux group compared to the supine laryngopharyngeal reflux group. 24h oropharyngeal pH measurements composite Ryan score was significantly higher in the upright group compared to the supine group (P<0.0001). No significant difference was found between the upright and supine laryngopharyngeal reflux groups regarding the frequency of clinical presentation or voice handicap index ratings. CONCLUSION Laryngopharyngeal reflux was found to be more prevalent occurring in the upright position among the study group. Reflux-related characteristics including pH parameters were more evident in the upright laryngopharyngeal reflux position.
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Affiliation(s)
- Tamer A Mesallam
- King Saud University, Department of Otolaryngology, Head and Neck Surgery, Riyadh, Saudi Arabia; King Saud University, Otolaryngology Department, Research Chair of Voice, Communication, and Swallowing Disorders, Riyadh, Saudi Arabia.
| | - Abdulsalam A Baqays
- King Saud University, Department of Otolaryngology, Head and Neck Surgery, Riyadh, Saudi Arabia
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15
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Esophageal Impedance-pH Monitoring and Pharyngeal pH Monitoring in the Diagnosis of Extraesophageal Reflux in Children. Gastroenterol Res Pract 2019; 2019:6271910. [PMID: 30944563 PMCID: PMC6421743 DOI: 10.1155/2019/6271910] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 11/21/2018] [Indexed: 12/14/2022] Open
Abstract
Various clinical symptoms are attributed to extraesophageal reflux disease (EERD). Multichannel intraluminal impedance-pH monitoring (MII-pH) is considered to correlate symptoms with acid and nonacid gastroesophageal reflux (GER) events. Pharyngeal pH monitoring (Dx-pH) is considered to correlate the decrease in the pH level in the oropharynx with reported symptoms and to diagnose supraesophageal reflux. We aimed to assess the correlation between acid reflux episodes recorded by Dx-pH and GER detected via MII-pH in children with suspected EERD. The study enrolled 23 consecutive children (15 boys and 8 girls; median age 8.25 [range 3-16.5] years) with suspected EERD. MII-pH and Dx-pH were conducted concurrently in all patients. A total of 1228 reflux episodes were recorded by MII-pH. With the antimonic sensor placed inside the impedance probe, 1272 pH-only reflux episodes were recorded. Of these, 977 (76.81%) were associated with a retrograde bolus transit. Regarding GER, 630 full-column episodes extended to the most proximal pair of impedance sensors; 500 (83.33%) demonstrated an acidic character. The following acid reflux numbers were determined by the Dx-pH system: for pH < 4, n = 126; pH < 4.5, n = 136; pH < 5, n = 167; and pH < 5.5, n = 304, and for a decrease in pH > 10% relative to the baseline, n = 324. There was no significant correlation between the number of pharyngeal reflux episodes detected by Dx-pH and that of GERs identified by MII-pH. The proportion of oropharyngeal pH events that were temporally related to a GER episode increased with the extended pH criteria. The highest proportion was observed for a pH decrease of ≥10% from the baseline and did not exceed 5.2%. The application of the extended pH criteria in the Dx-pH system resulted in an increase in the number of diagnosed laryngopharyngeal refluxes; most were not temporally associated with GER episodes confirmed by MII-pH. Thus, the efficacy of the exclusive application of Dx-pH for supraesophageal gastric reflux diagnosis is uncertain.
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16
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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: 205] [Impact Index Per Article: 41.0] [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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17
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Fuchs HF, Müller DT, Berlth F, Maus MK, Fuchs C, Dübbers M, Schröder W, Bruns CJ, Leers JM. Simultaneous laryngopharyngeal pH monitoring (Restech) and conventional esophageal pH monitoring-correlation using a large patient cohort of more than 100 patients with suspected gastroesophageal reflux disease. Dis Esophagus 2018. [PMID: 29534167 DOI: 10.1093/dote/doy018] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
24-hour esophageal pH-metry is not designed to detect laryngopharyngeal reflux (LPR). The new laryngopharyngeal pH-monitoring system (Restech) may detect LPR better. There is no established correlation between these two techniques as only small case series exist. The aim of this study is to examine the correlation between the two techniques with a large patient cohort. All patients received a complete diagnostic workup for gastroesophageal reflux including symptom evaluation, endoscopy, 24-hour pH-metry, high resolution manometry, and Restech. Consecutive patients with suspected gastroesophageal reflux and disease-related extra-esophageal symptoms were evaluated using 24-hour laryngopharyngeal and concomitant esophageal pH-monitoring. Subsequently, the relationship between the two techniques was evaluated subdividing the different reflux scenarios into four groups. A total of 101 patients from December 2013 to February 2017 were included. All patients presented extra-esophageal symptoms such as cough, hoarseness, asthma symptoms, and globus sensation. Classical reflux symptoms such as heartburn (71%), regurgitation (60%), retrosternal pain (54%), and dysphagia (32%) were also present. Esophageal 24-hour pH-metry was positive in 66 patients (65%) with a mean DeMeester Score of 66.7 [15-292]. Four different reflux scenarios were detected (group A-D): in 39% of patients with abnormal esophageal pH-metry, Restech evaluation was normal (group A, n = 26, mean DeMeester-score = 57.9 [15-255], mean Ryan score = 2.6 [2-8]). In 23% of patients with normal pH-metry (n = 8, group B), Restech evaluation was abnormal (mean DeMeester-score 10.5 [5-13], mean Ryan score 63.5 [27-84]). The remaining groups C and D showed corresponding results. Restech evaluation was positive in 48% of cases in this highly selective patient cohort. As demonstrated by four reflux scenarios, esophageal pH-metry and Restech do not necessarily need to correspond. Especially in patients with borderline abnormal 24-hour pH-metry, Restech may help to support the decision for or against laparoscopic anti-reflux surgery.
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Affiliation(s)
- H F Fuchs
- Department of General, Visceral and Cancer Surgery, University of Cologne, Cologne, Germany
| | - D T Müller
- Department of General, Visceral and Cancer Surgery, University of Cologne, Cologne, Germany
| | - F Berlth
- Department of General, Visceral and Cancer Surgery, University of Cologne, Cologne, Germany
| | - M K Maus
- Department of General, Visceral and Cancer Surgery, University of Cologne, Cologne, Germany
| | - C Fuchs
- Department of General, Visceral and Cancer Surgery, University of Cologne, Cologne, Germany
| | - M Dübbers
- Department of General, Visceral and Cancer Surgery, University of Cologne, Cologne, Germany
| | - W Schröder
- Department of General, Visceral and Cancer Surgery, University of Cologne, Cologne, Germany
| | - C J Bruns
- Department of General, Visceral and Cancer Surgery, University of Cologne, Cologne, Germany
| | - J M Leers
- Department of General, Visceral and Cancer Surgery, University of Cologne, Cologne, Germany
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18
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The development of new clinical instruments in laryngopharyngeal reflux disease: The international project of young otolaryngologists of the International Federation of Oto-rhino-laryngological Societies. Eur Ann Otorhinolaryngol Head Neck Dis 2018; 135:S85-S91. [DOI: 10.1016/j.anorl.2018.05.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 05/18/2018] [Accepted: 05/22/2018] [Indexed: 12/27/2022]
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19
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Rosen R, Vandenplas Y, Singendonk M, Cabana M, DiLorenzo C, Gottrand F, Gupta S, Langendam M, Staiano A, Thapar N, Tipnis N, Tabbers M. Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr 2018; 66:516-554. [PMID: 29470322 PMCID: PMC5958910 DOI: 10.1097/mpg.0000000000001889] [Citation(s) in RCA: 436] [Impact Index Per Article: 72.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
This document serves as an update of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) 2009 clinical guidelines for the diagnosis and management of gastroesophageal reflux disease (GERD) in infants and children and is intended to be applied in daily practice and as a basis for clinical trials. Eight clinical questions addressing diagnostic, therapeutic and prognostic topics were formulated. A systematic literature search was performed from October 1, 2008 (if the question was addressed by 2009 guidelines) or from inception to June 1, 2015 using Embase, MEDLINE, the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Clinical Trials. The approach of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) was applied to define and prioritize outcomes. For therapeutic questions, the quality of evidence was also assessed using GRADE. Grading the quality of evidence for other questions was performed according to the Quality Assessment of Studies of Diagnostic Accuracy (QUADAS) and Quality in Prognostic Studies (QUIPS) tools. During a 3-day consensus meeting, all recommendations were discussed and finalized. In cases where no randomized controlled trials (RCT; therapeutic questions) or diagnostic accuracy studies were available to support the recommendations, expert opinion was used. The group members voted on each recommendation, using the nominal voting technique. With this approach, recommendations regarding evaluation and management of infants and children with GERD to standardize and improve quality of care were formulated. Additionally, 2 algorithms were developed, 1 for infants <12 months of age and the other for older infants and children.
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Affiliation(s)
- Rachel Rosen
- Center for Motility and Functional Gastrointestinal Disorders, Division of Gastroenterology, Children's Hospital Boston, Boston, MA
| | - Yvan Vandenplas
- KidZ Health Castle, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | | | - Michael Cabana
- Division of General Pediatrics, University of California, San Francisco, CA
| | - Carlo DiLorenzo
- Division of Pediatric Gastroenterology, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Frederic Gottrand
- CHU Lille, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Lille, France
| | - Sandeep Gupta
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Illinois, Peoria, IL
| | - Miranda Langendam
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center/University of Amsterdam, Amsterdam, The Netherlands
| | - Annamaria Staiano
- Department of Translational Medical Science, Section of Pediatrics, University of Naples ‘‘Federico II,’’ Naples, Italy
| | - Nikhil Thapar
- Great Ormond Street Hospital for Children, London, UK
| | - Neelesh Tipnis
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS
| | - Merit Tabbers
- Emma Children's Hospital/AMC, Amsterdam, The Netherlands
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Roman S, Gyawali CP, Savarino E, Yadlapati R, Zerbib F, Wu J, Vela M, Tutuian R, Tatum R, Sifrim D, Keller J, Fox M, Pandolfino JE, Bredenoord AJ. Ambulatory reflux monitoring for diagnosis of gastro-esophageal reflux disease: Update of the Porto consensus and recommendations from an international consensus group. Neurogastroenterol Motil 2017; 29:1-15. [PMID: 28370768 DOI: 10.1111/nmo.13067] [Citation(s) in RCA: 204] [Impact Index Per Article: 29.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 02/20/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND An international group of experts evaluated and revised recommendations for ambulatory reflux monitoring for the diagnosis of gastro-esophageal reflux disease (GERD). METHODS Literature search was focused on indications and technical recommendations for GERD testing and phenotypes definitions. Statements were proposed and discussed during several structured meetings. KEY RESULTS Reflux testing should be performed after cessation of acid suppressive medication in patients with a low likelihood of GERD. In this setting, testing can be either catheter-based or wireless pH-monitoring or pH-impedance monitoring. In patients with a high probability of GERD (esophagitis grade C and D, histology proven Barrett's mucosa >1 cm, peptic stricture, previous positive pH monitoring) and persistent symptoms, pH-impedance monitoring should be performed on treatment. Recommendations are provided for data acquisition and analysis. Esophageal acid exposure is considered as pathological if acid exposure time (AET) is greater than 6% on pH testing. Number of reflux episodes and baseline impedance are exploratory metrics that may complement AET. Positive symptom reflux association is defined as symptom index (SI) >50% or symptom association probability (SAP) >95%. A positive symptom-reflux association in the absence of pathological AET defines hypersensitivity to reflux. CONCLUSIONS AND INFERENCES The consensus group determined that grade C or D esophagitis, peptic stricture, histology proven Barrett's mucosa >1 cm, and esophageal acid exposure greater >6% are sufficient to define pathological GERD. Further testing should be considered when none of these criteria are fulfilled.
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Affiliation(s)
- S Roman
- Digestive Physiology, Hospices Civils de Lyon and Lyon I University, Inserm U1032, LabTAU, Lyon, France
| | - C P Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
| | - E Savarino
- Division of Gastroenterology, Department of Surgical, Oncological and Gastroenterological Sciences, Padua, Italy
| | - R Yadlapati
- Division of Gastroenterology, Department of Medicine, Northwestern University, Chicago, IL, USA
| | - F Zerbib
- Department of Gastroenterology, Bordeaux University Hospital, and Université de Bordeaux, Bordeaux, France
| | - J Wu
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
| | - M Vela
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ, USA
| | - R Tutuian
- Division of Gastroenterology, University Clinics for Visceral Surgery and Medicine, Bern University Hospital, Bern, Switzerland
| | - R Tatum
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - D Sifrim
- Center for Digestive Diseases, Bart's and the London School and Dentistry, London, UK
| | - J Keller
- Department of Internal Medicine, Israelitic Hospital, University of Hamburg, Hamburg, Germany
| | - M Fox
- Department of Gastroenterology, Abdominal Center, St. Claraspital, Basel, Switzerland
| | - J E Pandolfino
- Division of Gastroenterology, Department of Medicine, Northwestern University, Chicago, IL, USA
| | - A J Bredenoord
- Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
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Weitzendorfer M, Pfandner R, Antoniou SA, Langsteger W, Witzel K, Emmanuel K, Koch OO. Role of Pepsin and Oropharyngeal pH-Monitoring to Assess the Postoperative Outcome of Patients with Laryngopharyngeal Reflux: Results of a Pilot Trial. J Laparoendosc Adv Surg Tech A 2017; 27:937-943. [DOI: 10.1089/lap.2017.0360] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
| | - Richard Pfandner
- Department of Surgery, Ordensklinikum Linz Barmherzige Schwestern, Linz, Austria
| | | | - Werner Langsteger
- Department of Nuclear Medicine, Ordensklinikum Linz Barmherzige Schwestern, Linz, Austria
| | - Kai Witzel
- Department of Surgery, Paracelsus Medical University, Salzburg, Austria
- Minimal Invasiv Center, Huenfeld, Germany
| | - Klaus Emmanuel
- Department of Surgery, Paracelsus Medical University, Salzburg, Austria
| | - Oliver O. Koch
- Department of Surgery, Paracelsus Medical University, Salzburg, Austria
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Impact of Laryngopharyngeal Reflux on the Levels of Depression and Anxiety in Patients With Obstructive Sleep Apnea Syndrome. J Craniofac Surg 2017; 28:e121-e124. [DOI: 10.1097/scs.0000000000003302] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
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Akst LM, Haque OJ, Clarke JO, Hillel AT, Best SR, Altman KW. The Changing Impact of Gastroesophageal Reflux Disease in Clinical Practice. Ann Otol Rhinol Laryngol 2017; 126:229-235. [DOI: 10.1177/0003489416686586] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Objectives: The National Ambulatory Medical Care Survey (NAMCS) database was utilized to understand evolving national trends in diagnosis and management of reflux. Methods: The NAMCS database was queried for visits related to gastroesophageal reflux diagnosis and management. Analysis performed for time periods 1998-2001, 2002-2005, and 2006-2009 was weighted to provide national estimates of care. Results were compared to previously reported time periods from 1990 to 2001 to evaluate patterns in overall visits, age and ethnicity of patients, provider type, and prescriptions provided. Results: The number of ambulatory visits for reflux increased from 8 684 000 in 1998-2001 to 15 750 000 in 2006-2009. Visits increased across each time period for internal medicine, family, and gastroenterology physicians. Among otolaryngologists, absolute visits increased from 1998-2001 to 2002-2005 but decreased in 2006-2009; difference between these time periods did not reach statistical significance. From 1998-2001 to 2006-2009, reflux medication use increased 233%, with continuing trends toward increased proton pump inhibitor use. Conclusions: Reflux visits have increased across all demographic subgroups studied. Knowledge of these trends may inform further paradigm shifts in diagnosis and management of reflux.
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Affiliation(s)
- Lee M. Akst
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - John O. Clarke
- Department of Medicine, Division of Gastroenterology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Alexander T. Hillel
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Simon R.A. Best
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kenneth W. Altman
- Department of Otolaryngology-Head & Neck Surgery, Baylor College of Medicine, Houston, Texas, USA
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Herbella FAM, Andolfi C, Vigneswaran Y, Patti MG, Pinna BR. Importance of esophageal manometry and pH monitoring for the evaluation of otorhinolaryngologic (ENT) manifestations of GERD. A multicenter study. J Gastrointest Surg 2016; 20:1673-8. [PMID: 27456014 DOI: 10.1007/s11605-016-3212-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 07/11/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND/AIMS Patients with otorhinolaryngologic (ear, nose, and throat-ENT) symptoms attributed to gastroesophageal reflux disease (GERD) are usually treated with medication based on the findings of nasal endoscopy and laryngoscopy only. This study aims to determine sensitivity and specificity of symptoms, nasal endoscopy, and laryngoscopy for the diagnosis of GERD as compared to pH monitoring. METHODS We studied 79 patients (mean age 53 years, 38 % males) in whom ENT symptoms were assumed to be secondary to GERD. All patients underwent a transnasal laryngoscopy by the ENT team and upper endoscopy and esophageal function tests by the surgical team. GERD was defined by a pathological pH monitoring. RESULTS Pathologic reflux by pH monitoring was documented in 36 of the 79 patients (46 %), with a mean DeMeester score of 44. In 25 of the 36 patients (69 %), distal and proximal reflux was present. Among patients with negative pH monitoring, one patient was diagnosed with achalasia. ENT symptom sensitivity for globus, hoarseness and throat clearing was respectively 11, 58, and 33 %; specificity was respectively 77, 42, and 58 %. Positive predictive value for nasal endoscopy and laryngoscopy was 46 %. Among patients with positive pH monitoring, 13 (36 %) had a hypotensive lower esophageal sphincter (p < 0.01) and 27 (34 %) had abnormal peristalsis (p < 0.01). CONCLUSIONS In conclusion, the results of this study showed that (a) ENT symptoms were unreliable for the diagnosis of GERD and (b) laryngoscopy had a low positive predictive value for the diagnosis of GERD. These data confirm the importance of esophageal manometry and pH monitoring in any patient with suspected ENT manifestations of GERD before starting empiric therapy with acid-reducing medications since pathologic reflux by pH monitoring was confirmed in less than half of the patients with suspected GERD.
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Affiliation(s)
- Fernando A M Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Rua Diogo de Faria 1087, cj 301, São Paulo, SP, 04037-003, Brazil.
| | - Ciro Andolfi
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Yalini Vigneswaran
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Marco G Patti
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Bruno R Pinna
- Department of Otorhinolaryngology, Escola Paulista de Medicina, Federal University of Sao Paulo, São Paulo, Brazil
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de Bortoli N, Martinucci I, Bertani L, Russo S, Franchi R, Furnari M, Tolone S, Bodini G, Bolognesi V, Bellini M, Savarino V, Marchi S, Savarino EV. Esophageal testing: What we have so far. World J Gastrointest Pathophysiol 2016; 7:72-85. [PMID: 26909230 PMCID: PMC4753191 DOI: 10.4291/wjgp.v7.i1.72] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2015] [Revised: 12/02/2015] [Accepted: 01/04/2016] [Indexed: 02/06/2023] Open
Abstract
Gastroesophageal reflux disease (GERD) is a common disorder of the gastrointestinal tract. In the last few decades, new technologies have evolved and have been applied to the functional study of the esophagus, allowing for the improvement of our knowledge of the pathophysiology of GERD. High-resolution manometry (HRM) permits greater understanding of the function of the esophagogastric junction and the risks associated with hiatal hernia. Moreover, HRM has been found to be more reproducible and sensitive than conventional water-perfused manometry to detect the presence of transient lower esophageal sphincter relaxation. Esophageal 24-h pH-metry with or without combined impedance is usually performed in patients with negative endoscopy and reflux symptoms who have a poor response to anti-reflux medical therapy to assess esophageal acid exposure and symptom-reflux correlations. In particular, esophageal 24-h impedance and pH monitoring can detect acid and non-acid reflux events. EndoFLIP is a recent technique poorly applied in clinical practice, although it provides a large amount of information about the esophagogastric junction. In the coming years, laryngopharyngeal symptoms could be evaluated with up and coming non-invasive or minimally invasive techniques, such as pepsin detection in saliva or pharyngeal pH-metry. Future studies are required of these techniques to evaluate their diagnostic accuracy and usefulness, although the available data are promising.
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Wilhelm D, Jell A, Feussner H, Schmid RM, Bajbouj M, Becker V. Pharyngeal pH monitoring in gastrectomy patients - what do we really measure? United European Gastroenterol J 2015; 4:541-5. [PMID: 27536364 DOI: 10.1177/2050640615617637] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 10/24/2015] [Indexed: 12/19/2022] Open
Abstract
AIM Diagnosis of laryngopharyngeal reflux (LPR) has dramatically increased over the last years. For diagnosis of gastroesophageal reflux, a newly designed pharyngeal probe (Dx-pH) was recently introduced. It is also recommended to guide therapy decision in antireflux surgery. However, diagnostic results are questionable. Therefore, we establish a reliable reference group with asymptomatic patients after total gastrectomy and, thus, complete extinction of gastric acid production. METHODS Pharyngeal pH monitoring was performed in 10 consecutive patients with history of total gastrectomy. All patients were off proton pump inhibitor (PPI) therapy and followed a non-acid diet during the complete measurement period. RESULTS All procedures were performed without any complication. Six of the 10 asymptomatic gastrectomy patients (60%) had pathological results derived from the validated reference values (Ryan score) in pharyngeal pH monitoring. CONCLUSION Pathological pH values assessed by the Dx-pH device, usually interpreted as pathological aerosolized acidic gastroesophageal and/or laryngopharyngeal reflux, are obviously dissociated from gastric acid production. Further studies are required to determine diagnostic value of the new system. Therefore, the pharyngeal pH monitoring system seems currently not to be useful to guide any diagnostic or therapeutic decisions, in particular if surgical therapy is considered.
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Affiliation(s)
- Dirk Wilhelm
- Chirurgische Klinik, Klinikum rechts der Isar, Technische Universität München, Germany
| | - Alissa Jell
- Chirurgische Klinik, Klinikum rechts der Isar, Technische Universität München, Germany
| | - Hubertus Feussner
- Chirurgische Klinik, Klinikum rechts der Isar, Technische Universität München, Germany
| | - Roland M Schmid
- Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Germany
| | - Monther Bajbouj
- Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Germany
| | - Valentin Becker
- Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Germany
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Preoperative assessment and classification of benign laryngotracheal stenosis: a consensus paper of the European Laryngological Society. Eur Arch Otorhinolaryngol 2015; 272:2885-96. [DOI: 10.1007/s00405-015-3635-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 04/19/2015] [Indexed: 12/19/2022]
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