Esophagogastroduodenoscopy has a role in the evaluation of laryngopharyngeal reflux

Abstract

I read with interest the publication by Vardar et al [1] on diagnosis of laryngopharyngeal reXux (LPR) in patients with typical gastroesophageal reXux disease (GERD). They showed that there were no signiWcant diVerences in the endoscopic Wndings and concluded that esophagogastroduodenoscopy (EGD) has no role in the diagnosis of LPR. While I agree with their conclusion, there are several important issues that I would like to highlight when interpreting this study. First, Vardar et al. assumed that all LPR were secondary to gastroesophageal reXux (GER) with gastric content causing symptoms. In fact, I believe this is a common limitation and misconception to most if not all published studies looking at LPR and extra-esophageal limitation of GERD to date. The role of reXux of purely esophageal contents (esophagolaryngopharyngeal reXux) causing LPR symptoms is largely underappreciated. An important cause of such LPR that is still largely underappreciated is the heterotopic gastric mucosal patch (HGMP) of the proximal esophagus or cervical inlet patch (Fig. 1) commonly located just distal to the upper esophageal sphincter and is frequently missed during endoscopy. Endoscopic studies have reported prevalence as high as 13.8% based on narrow band imaging study, while autopsy studies reported as high as 70% [2]. HGMP is able to secrete acid and being located just within a few centimeters distal to the upper esophageal sphincter, it can cause signiWcant LPR symptoms even if the amount of reXuxate is small and weakly acidic [2]. In fact, reXux of non-acidic content such as mucin is also postulated to cause symptoms [3]. We have previously shown that patients with HGMP have higher prevalence of LPR symptoms (73.1%) even though most were mild [4]. Second, even though EGD has no role in the diagnosis of LPR, it helps to establish the possible causes of LPR. Presence of erosive esophagitis suggests GERD as the underlying etiology, guide management and avoid any further unnecessary investigations. We also showed that patients who were referred with LPR for evaluation, the chances of Wnding HGMP and erosive esophagitis were signiWcantly higher compared to other indications (p = 0.018 for trend) [4]. Finally, establishing or excluding important upper gastrointestinal causes also provides reassurance to patients and in itself may be therapeutic.