Abstract
Objectives:The role of gastroesophageal reflux disease (GERD) in the aetiology of laryngopharyngeal reflux (LPR) is poorly understood and remains a controversial issue. The 24-hour impedance monitoring has shown promise in the evaluation of LPR but is problematic in pharyngeal recording. We have shown the utility of scintigraphic studies in the detection of LPR and lung aspiration of refluxate. Correlative studies were obtained in patients with a strong history of LPR and severe GERD.Methods:A highly selected sequential cohort of patients with a high pre-test probability of LPR/severe GERD who had failed maximal medical therapy were evaluated with 24-hour impedance/pH, manometry and scintigraphic reflux studies.Results:The study group comprised 34 patients (15 M, 19 F) with a mean age of 56 years (range: 28-80 years). The majority had LPR symptoms (mainly cough) in 31 and severe GERD in 3. Impedance bolus clearance and pH studies were abnormal in all patients in the upright and supine position. A high rate of non-acid GERD was detected by impedance monitoring. LOS tone and ineffective oesophageal clearance were found in the majority of patients. Scintigraphic studies showed strong correlations with impedance, pH and manometric abnormalities, with 10 patients showing pulmonary aspiration.Conclusion:Scintigraphic studies appear to be a good screening test for LPR and pulmonary aspiration as there is direct visualisation of tracer at these sites. Impedance studies highlight the importance of non-acidic reflux and bolus clearance in the causation of cough and may allow the development of a risk profile for pulmonary aspiration of refluxate.
Highlights
The pathophysiology of proximal gastrooesophageal reflux disease (GERD) causing laryngopharyngeal reflux (LPR) is poorly understood [1,2]
Impedance studies highlight the importance of non-acidic reflux and bolus clearance in the causation of cough and may allow the development of a risk profile for pulmonary aspiration of refluxate
It has brought the issue of non-acidic reflux into focus and increased the understanding of how symptoms can persist while patients are on maintenance high-dose pump inhibitor (PPI) therapy
Summary
The pathophysiology of proximal gastrooesophageal reflux disease (GERD) causing laryngopharyngeal reflux (LPR) is poorly understood [1,2]. It is an important consideration in the aetiology of chronic cough which remains undiagnosed after eight weeks of specialist investigation [1,2,3,4]. A high placebo response in treatment of cough makes the matter more complex when evaluating therapy [7] Investigation of this situation by 24-hour pH reflux testing has been bedevilled by artefacts in the pharynx [9], leading to attempts to modify instrumentation to increase accuracy and reproducibility. The issue of an episode of reflux changing acidity during ascent in the oesophagus confounds proximal pH measurements, as does the recognition of symptoms associated with nonacid reflux [10,12]
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