Gastroesophageal reflux disease: symptoms versus pH monitoring results (original) (raw)
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Typical GERD Symptoms and Esophageal pH Monitoring Are Not Enough to Diagnose Pharyngeal Reflux
Journal of Surgical Research, 2005
Background. Abnormal pharyngeal reflux of acid (PR) (as measured by pH monitoring) is associated with microaspiration, and is a good predictor of airway symptom response to medical and surgical antireflux therapy. However, in clinical practice the link between airway disease and Gastroesophageal reflux disease (GERD) is still based on the presence of typical symptoms (e.g., heartburn) and/or standard esophageal function testing (manometry and 24-pH monitoring). PR is rarely measured directly. We undertook this study to determine if typical symptoms and standard testing could reliably predict the presence of PR. Methods. The study group consisted of 518 patients with suspected reflux induced airway disease evaluated from December 1998 through January 2002. Each patient completed a standardized symptom questionnaire, underwent esophageal manometry, and 24-h esophageal and pharyngeal pH monitoring. Patients were classified having abnormal pharyngeal reflux (PR؉) if they had >1 episode of PR detected during pH monitoring. Results. One hundred eighty-one patients were PR؉ and 337 were PR؊. The most common symptoms, namely cough (PR ؉73%, PR؊ 68%), hoarseness (PR ؉64%, PR؊ 66%), and dyspnea (PR ؉59%, PR؊ 59%) were present with similar incidence in PR؉ and PR؊ patients. The incidence of heartburn was 54% in the PR؉ and 52% in the PR؊ patients. Logistic regression analysis revealed that abnormal esophageal acid exposure was a predictor of PR؉ (P < 0.001). Neither the presence of heartburn or specific respiratory symptoms, the pressure of the lower esophageal sphincter (LES) or upper esophageal sphincter (UES), or amplitude of esophageal contractions predicted PR؉. There was substantial variability in esophageal length (UES to LES), thus the placement of the distal pH probe from the LES varied considerably (median ؍ 13 cm, 2-20 cm). Using established normal values of acid exposure at multiple levels of the esophagus, 24% of PR؉ patients had normal amounts of esophageal acid exposure. Conclusions. Typical GERD symptoms, such as heartburn, and typical symptoms of aspiration such as hoarseness, cough, or dyspnea are not enough to positively identify PR. While patients with abnormal esophageal acid exposure are three times more likely than those with normal values to have PR, abnormal esophageal acid exposure alone does not identify all patients with PR. Therefore, relying on symptoms and standard diagnostic testing may fail to identify patients with extraesophageal reflux. Pharyngeal pH monitoring should be considered for patients with suspected reflux-induced airway disease.
Laryngopharyngeal reflux in patients with symptoms of gastroesophageal reflux disease
Diseases of the Esophagus, 2006
Endoscopic grading of gastroesophageal flap valve (GEFV) is simple and reproducible and offers useful information for reflux activity. To investigate the potential correlation between GEFV grading and reflux finding score (RFS) in patients with laryngopharyngeal reflux disease (LPRD), 225 consecutive Patients with suspected LPRD who underwent both routine upper gastrointestinal endoscopy and laryngoscope were enrolled in our study. Patients with a RFS of more than 7 were diagnosed with LPRD. The GEFV was graded as I through IV according to Hill's classification and was classified into two groups: normal GEFV group (grades I and II) and the abnormal GEFV group (grades III and IV). The percent of GEFV grades I to IV was 39.1%, 39.1%, 12.4%, and 9.3%, respectively. Age was significantly related to an abnormal GEFV (p = 0.002). Gender, BMI, smoke and alcohol were not related to GEFV grade. Fifty-one patients (22.67%) had positive RFS. Reflux finding scores were higher in GEFV grades III and IV than I and II (p < 0.05). Endoscopic grading of GEFV is well correlated with reflux finding score in patients with LPRD. This is a simple and useful technique that provides valuable diagnostic information of LPRD. Gastroesophageal reflux disease GERD is one of the most common GI diseases around the world, with evidence of increasing prevalence in many regions 1. The impairment of the normal antireflux mechanisms is a main cause for GERD. Furthermore, the gastroesophageal flap valve (GEFV) is a dynamic structure that influences gastroesophageal reflux disease (GERD) 2-6. Endoscopic grading of the GEFV as proposed by Hill et al. is easy and provides useful information about the status of gastroesophageal and gastropharyngeal reflux 2. Laryngopharyngeal reflux disease (LPRD), which was first proposed by Koufman et al. 7 , is regarded as different from GERD, because LPRD patients do not necessarily have specific symptoms of GERD such as regurgitation or heartburn. Even though the relationship between GERD and the otolaryngological manifestations is still controversial, the two main theories of laryngopharyngeal reflux (LPR) are characterized by acid reflux. The first theory suggests that the fragile mucosa of the larynx and pharynx, in contrast to the oesophagus, is far more susceptible to injury from acid and activated pepsin 8. The second theory posits that acid stimulates vagally mediated reflexes in the oesophagus, leading to the symptoms of LPR, such as chronic cough and throat clearing sensation 8,9. Tokashiki et al. reported that the LPRD patients showed significantly longer acid reflux time in the upper oesophagus and patients who had LPRD with reflux oesophagitis (RE) experienced more frequent acid exposure in the upper oesophagus than the LPRD without RE 10 .Therefore, there is reason to believe that structural factors, such as GEFV, may affect the pathogenesis of LPRD.
Laryngopharyngeal Symptoms and Gastroesophageal Reflux Disease
Journal of Voice, 2005
The incidence of gastroesophageal reflux disease (GERD) in patients with laryngopharyngeal symptoms is greater than expect. A prospective study was performed to investigate the incidence of gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux (LPR) in patients with laryngopharyngeal symptoms. Laryngologic evaluation with nasopharyngeal and laryngeal endoscopy and gastroenterologic evaluation with esophagogastroduodenoscopy including measurement of pH value were performed in 46 patients. Therapeutic intervention included general antireflux precautions and antireflux medication, and eradication of Helicobacter pylori in selected cases. Posterior laryngitis was present in 33 patients. GERD was present in 25 patients, hiatus hernia in 4 patients, H pylori-positive gastritis in 11 patients, and Barrett's metaplasia in 2 patients. Increasing evidence shows that GERD may cause laryngopharyngeal symptoms. Otherwise laryngopharyngeal symptoms can be predictors of GERD. Medical antireflux treatment is also effective for laryngopharyngeal symptoms.
Patterns of Gastroesophageal Reflux in Health and Disease
Annals of Surgery, 1976
Twenty-four-hour pH monitoring of the distal esophagus quantitates gastroesophageal reflux in a near physiologic setting by measuring the frequency and duration of acid exposure to the esophageal mucosa. Fifteen asymptomatic volunteers were studied with 24-hour pH and esophageal manometry. The normal cardia was more competent supine than in the upright position. Physiologic reflux was unaffected by age, rarely occurred during slumber, and was the rule after alimentation. One hundred symptomatic patients with an abnormal 24-hour pH record (2 S.D. above the mean of controls) could be divided into three patterns of pathological reflux: those who refluxed only in the upright position (9), only in the supine position (37), and in both positions (54). Upright differed from supine refluxers by excessive aerophagia causing reflux episodes by repetitive belching. Compared to controls, they had excessive post-prandial reflux, lower DES pressure, and less DES exposed to the positive pressure of the abdomen. Supine differed from upright refluxers by having a higher incidence of esophagitis and an inability to clear the esophagus of acid after a supine reflux episode. Compared to controls, they had only a lower DES pressure. Combined refluxers had a higher incidence of esophagitis than supine refluxers. Stricture (15%) was seen only in this group. They were similar to supine refluxers in their inability to clear a supine reflux episode. Compared to controls, they had a lower DES pressure and less DES exposed to the positive pressure of the abdomen. Forty of the 100 patients had an antireflux procedure (4 upright, 8 supine, 28 combined). The most severe postoperative flatus and abdominal distention was seen in the upright refluxers. It is concluded that minimal reflux is physiological. Patients with pathological reflux all have lower DES pressure. Patients with upright reflux have less of their DES exposed to the positive pressure environment of the abdomen. Patients with supine reflux have an inability to clear the esophagus of reflux acid and are prone to develop esophagitis. Patients with both upright and supine reflux have the most severe disease and are at risk in developing strictures. In patients with only upright reflux, aerophagia and delayed gastric emptying may be an important etiological factor.
American Journal of Respiratory and Critical Care Medicine, 2001
This study evaluated the prevalence of upper respiratory symptoms (URS) among patients with symptomatic gastroesophageal reflux disease (GERD). Seventy-four subjects with heartburn completed a URS questionnaire before dual-probe, 24-h esophageal pH monitoring. The URS questionnaire was also completed by 74 normal volunteers without previous or current symptoms of GERD. Esophageal pH monitoring results were classified as normal, distal, or proximal and distal gastroesophageal reflux using standardized criteria. Mean URS scores (Ϯ SD) were 8.31 Ϯ 3.98 in the 52 subjects with GERD and 4.57 Ϯ 3.57 in the 22 subjects with negative pH probe studies, p ϭ 0.02. Subjects with negative pH probe studies and normal volunteers scored similarly on the URS questionnaire. Reflux episodes/24 h correlated with URS scores, r ϭ 0.47, p ϭ 0.0001. Seventy-five percent of subjects with upper reflux, 68% of subjects with lower reflux, 36% of subjects with normal esophageal pH studies, and 9% of normal volunteers reported laryngeal symptoms for at least 5 d/mo. Sixty-nine percent of subjects with upper reflux, 50% of subjects with lower reflux, 31% of subjects with normal pH studies, and 14% of normal volunteers reported nasal symptoms for at least 5 d/mo. URS are frequent among subjects with GERD.
Laryngopharyngeal Reflux: An Update
Archives of Otorhinolaryngology-Head & Neck Surgery, 2019
Laryngopharyngeal reflux (LPR), also referred to as extra-esophageal reflux, supra-esophageal reflux, or silent reflux, refers to a condition in which gastroduodenal content rises up the esophagus and affects the throat, specifically the laryngopharynx [1-6]. In some cases, gastric content may even reach the nasal cavities and/or ears via the Eustachian tubes, which can exacerbate rhinitis, sinusitis, or otitis media [7-9]. Otolaryngologists and gastroenterologists differ in their definitions and management of LPR [4,10-12]. Otolaryngologists treat LPR as a relatively new clinical entity, whereas gastroenterologists treat LPR as a rare extra-esophageal manifestation of gastroesophageal reflux disease (GERD) [10,13]. Gastroenterologists have questioned whether reflux contributes to LPR-related symptoms in patients with no GERD-associated manifestations [11]. Otolaryngologists have pointed out that LPR is a multifactorial syndrome that also involves gaseous and/or nonacid refluxate [14,15]. In this article, we examine the clinical manifestations, diagnosis, and current recommended treatments of LPR. Based on the latest findings in LPR research, we propose an algorithm aimed at facilitating the assessment and management of LPR. Differences Between LPR and GERD Despite similarities between LPR and GERD, these are two distinct disease entities. The retrograde flow of gastroduodenal contents into the esophagus and/or adjacent structures can lead to complications or troublesome reflux-associated symptoms, such as throat clearing, heartburn, and globus pharyngeus. Reflux diseases can be categorized as LPR, erosive esophagitis, and nonerosive reflux disease (NERD). Cases of erosive esophagitis and NERD are categorized as GERD [16]. In GERD, the reflux of gastric contents is limited to the esophagus. In LPR, the reflux of gastric content affects the larynx and pharynx [12]. Despite occasional cross-diagnoses of GERD and LPR, there are essential differences (Table 1). GERD is accompanied by acidity and heartburn (retrosternal burning), which is rarely encountered in LPR patients [12]. In GERD, reflux and acidity typically occur during the night (nocturnal refluxers). In LPR, reflux typically occurs during the day (daytime refluxers) [12]. LPR symptoms occur when patients are in an upright position during periods of physical exertion (e.g., bending over, Valsalva, and exercise) [11,12,17], whereas GERD reflux occurs while patients are lying down.