Laryngopharyngeal reflux: a diagnostic and therapeutic challenge for the otolaryngologist and gastroenterologist

Nocturnal Gastroesophageal Reflux: Assessment and Clinical Implications

Persistent Reflux Symptoms in the Proton Pump Inhibitor Era: The Changing Face of Gastroesophageal Reflux Disease

Gastroesophageal Reflux

After completing this article, readers should be able to: 1. Describe the epidemiology and pathophysiology of gastroesophageal reflux (GER) in preterm neonates. 2. Delineate the associations of GER with apnea, chronic lung disease, behavior, and growth of preterm infants. 3. Review the investigations used to evaluate GER in preterm infants. 4. Describe nonpharmacologic and pharmacologic therapies for GER. Gastroesophageal reflux (GER) is a normal physiologic event occurring across the age spectrum. It may contribute to a variety of disorders, including esophagitis, feeding problems, and airway disease in all age groups. (1) A large number of symptoms and signs have been purported to be caused by GER despite a lack of data showing a clear association between a specific symptom and GER. In preterm infants, empiric therapy often is administered using agents of unproven efficacy and safety to treat symptoms that likely are unrelated to GER. In a survey on management practices for GER in preterm infants, common treatment strategies included positioning (98%) and slopes (96%), histamine 2 (H 2) receptor antagonists (100%), feed thickeners (98%), antacids (96%), prokinetics (79%), proton pump inhibitors (PPIs) (65%), and dopamine receptor antagonists (53%). (2)(3) The safety, efficacy, and appropriate dosing recommendations for most medical therapies remain uncertain in neonates. In this review, we attempt to summarize the current literature regarding physiology, pathophysiology, and diagnostic and management strategies for GER pertinent to the neonate, with an emphasis on the preterm infant. GER describes the retrograde movement of stomach contents (air or feeding, liquid or semisolid, acid or alkaline, enzymes or bile salts) into the esophagus. GER disease (GERD) occurs when GER causes symptoms or signs such as pain, poor weight gain, esophagitis, hematemesis, and airway symptoms, including apnea, aspiration, recurrent pneumonia, chronic lung disease (CLD), or large airway inflammation. However, any of these symptoms or signs …

Introduction: Laryngopharyngeal reflux (LPR) is defined as the reflux of gastroduodenal contents to the laryngopharynx, casuing symptoms such as cough, globus, throat clearing, and hoarseness. Proton pump inhibitors (PPIs) are often used for treatment; however, these are often not effective. Among patients with LPR, nocturnal symptoms are common. Recent studies have demonstrated that use of a positional therapy device (PTD) significantly decreased typical gastroesophageal reflux symptoms; however, use of a PTD for LPR symptoms has not been previously studied. Methods: This is a single center prospective trial of a PTD consisting of a two-component wedge-shaped base and a lateral positioning body pillow (MedCline, Amenity Health, Inc., San Diego, CA) in patients with a clinical diagnosis of LPR and nocturnal symptomology. Patients were supplied the PTD and asked to sleep using the device for at least 6 hours per night for 28 consecutive nights. Patients completed the Nocturnal Gastroesophageal Reflux Symptom Severity and Impact Questionnaire (N-GSSIQ) and Reflux Symptoms Index (RSI) at baseline and after 2 and 4 weeks of PTD use. The primary endpoint of this study was reduction from baseline RSI at 4 weeks. Results: A total of 23 patients (70% female; mean (SD): age 60±12.9; BMI 28.1±8.0) were recruited. 70% patients were on PPI prior to enrollment. At baseline, mean N-GSSIQ was 50.0±7.9 and mean RSI of 22.5±9.6. All patients completed the study protocol. Matched-pair analysis showed that subjects' total N-GSSIQ scores decreased by an average of 24.0 (p=0.0024) points by two weeks and 30.5 points by 4 weeks (p=0.0002). RSI decreased an average of 9.5 points by 2 weeks (p=0.015) and an average of 16.8 points by 4 weeks (p=0.0023). Mean RSI improvement at 2 weeks and 4 weeks was 42% and 75%, respectively. N-GSSIQ subsets all reached statistical significance at 4 weeks of use: nocturnal reflux (p=0.0019), morning impact of nocturnal reflux (p=0.0002) and concern about nocturnal reflux (p=0.0006). No adverse events were reported, no patients withdrew from the study. Conclusion: In patients with LPR, use of a PTD significantly improves self-reported symptoms of typical nocturnal reflux symptoms as well as symptoms specific to LPR. Use of a PTD may be considered as a potential treatment option for patients with nocturnal LPR symptoms.

White Paper AGA: Optimal Strategies to Define and Diagnose Gastroesophageal Reflux Disease.

American Gastroenterological Association Institute Technical Review on the Management of Gastroesophageal Reflux Disease

To evaluate the prevalence of gastroesophageal reflux disease (GERD) in patients presenting with asthma and chronic cough. The charts of 358 consecutive patients who were referred for ambulatory gastroesophageal pH monitoring to the Lung Centre in Vancouver, British Columbia, were reviewed, and the data of 108 (30%) patients with asthma and 134 (37%) patients with chronic cough were analyzed. The maintenance treatment for GERD was discontinued before patients underwent the pH monitoring study. One hundred eighteen (33%) patients were excluded. Reflux episodes identified reflux events as the percentage of time where the pH was less than four. For asthma patients, 70 (64.8%) had distal total reflux, 50 (46.3%) had distal upright reflux, 41 (38.3%) had distal supine reflux and 73 (67.6%) had other distal refluxes. Proximal total reflux in asthmatic patients was present in 56 (52%), proximal upright reflux in 55 (51%) and proximal supine reflux in 56 (52%) patients. For chronic cough patients, 70 (52.6%) had distal total reflux, 59 (44.4%) had distal upright reflux, 45 (34.4%) had distal supine reflux and 75 (56%) patients had other distal refluxes. In chronic cough patients, proximal total reflux was present in 70 (52%), proximal upright reflux in 80 (60%) and proximal supine reflux in 59 (44%). Presenting respiratory and/or reflux symptoms were absent in approximately 25% of patients with asthma and reflux, and in approximately 50% of patients with chronic cough and reflux. During pH monitoring, symptoms did not differ significantly between those with and without distal reflux in both study groups, except for more significant heartburn in patients with chronic cough and reflux (RR 2.0). The data of the present study support the observation that there is a high prevalence of GERD in patients with asthma or chronic cough. The use of different pH parameters for detecting acid reflux during 24 h ambulatory pH monitoring, such as proximal esophageal acid measurement, should be considered as part of the routine interpretation of such testing. A low threshold for diagnosing GERD in patients with asthma or chronic cough is essential, because respiratory and/or reflux symptoms can be absent or atypical in some of these patients.

Sleeping on the Right Side After Esophagectomy

Over-Prescription of Acid-Suppressing Medications in Infants: How It Came About, Why It’s Wrong, and What to Do About It

Notre these est une contribution pour repenser les rapports entre sciences et ethiques, et avancer vers une democratie epistemique. Qu'il s'agisse de demontrer l'insoutenabilite d'une science contre l'Homme ou d'identifier les conditions d'une remontee de l'Homme dans les sciences, la visee nous semble la meme : il s'agit de reunir-sans-unifier ce qui, dans la science, est de l'ordre de l'epistemique, du technique et de l'ethique. Pour ce faire, il nous faut prealablement travailler en profondeur sur deux espaces - epistemologique et ethique -, et ceci sans d'abord les melanger ou les recouvrir l'un sur l'autre. Car si les sciences nous sont effectivement donnees dans leurs melanges (avec le technique, le politique, l'economique, le social ou le philosophique), rendant a la mode les themes de technoscience, de nouveau regime de production des savoirs ou encore de science post-normale, il ne s'agit pas pour nous d'un symptome de la fin de l'epistemologie mais de la necessite de son renouvellement. Celui-ci passera, et il s'agit la de notre these principale, par de nouveaux rapports avec l'ethique. Nous donnons a cette these le nom d'integrite epistemique et ethique des sciences. Afin de definir les conditions et la portee de celle-ci, nous proposons deux hypotheses, respectivement au sein de l'espace epistemologique et ethique : celle d'un pluralisme epistemique ordonne et celle d'une ethique generique. Nous defendons ces hypotheses a la lumiere d'un long travail d'instruction d'un objet des sciences et techniques contemporaines, le poisson genetiquement modifie. In fine, notre travail permet de re-interroger les postulats classiques de l'evaluation et de proposer de nouvelles pistes de recherches.

COMPARED TO OTHER GASTROINTESTINAL (GI) SYMPTOM COMPLEXES, the medical management of gastroesophageal reflux disease (GERD) appears fairly straightforward. Whereas there are few pharmacotherapeutic options for many other GI symptoms for which patients may seek medical advice, the majority of patients with troublesome GERD symptoms can be rendered asymptomatic with a once-daily dose of a proton pump inhibitor (PPI) within 4 to 8 weeks of starting therapy. Thus, many may consider GERD an easily treated problem that can be vanquished with the mere stroke of a pen. Yet as a gastroenterologist, I find my patients with GERD to be some of the most difficult to treat. The patients I see are the relatively small group who do not obtain relief with that PPI prescription. Unfortunately, there are currently few therapeutic options that are effective in alleviating GERD symptoms that persist despite PPI use. While I often recommend that patients take their PPI twice daily instead of once, or switch to another PPI, this decision is based on limited data from uncontrolled open-label trials with significant methodologic flaws.1,2 Stepping down PPI therapy from double-dose to standard doses is successful for most patients.3 There are no other proven therapies, and I am left with limited therapeutic options for patients with refractory GERD. These patients are the proverbial high-hanging fruit that are the most difficult to reach. However, these fruit can grow the largest, rewarding those who develop tools to snare them. It is important to gain a better understanding of GERD pathophysiology to devise better strategies for helping these patients to obtain relief. GERD has been traditionally thought of as the reflux of acidic gastric contents into the esophagus, resulting in symptoms and/or esophageal injury. The gold standard diagnostic criteria for GERD involves 24-hour esophageal pH monitoring, requiring an intra esophageal pH of less than 4 for more than 4% of the time over a 24-hour period. It is generally believed that if there is no gastric acid production, there can be no reflux symptoms. However, reflux symptoms often persist. Studies confirm that the majority of patients with GERD-like symptoms, despite high-intensity (double-dose or greater) PPI therapy, have a very low prevalence of reflux by the gold standard definition.4 So what are the mechanisms responsible for ongoing symptoms? Because PPIs have been so effective in relieving GERD symptoms, the basic mechanism that enables gastroesophageal reflux has been mostly ignored. I am referring here to the presence of both anatomic factors, such as the presence of a hiatus hernia, and physiologic factors, specifically the function of the lower esophageal sphincter (LES). It is possible that non-acid gastric contents that access the esophagus through a faulty LES may cause symptoms. Another possibility may be that GERD-like symptoms are independent of gastroesophageal reflux, and are merely interpreted as GERD. A new clinical tool may help both investigation and management. With multichannel impedance manometry (MIM), an impedance catheter is passed transnasally into the esophagus. It detects the presence of gas and fluid in the esophagus, and the direction of travel (i.e., towards the stomach with a swallow, towards the mouth with gastroesophageal reflux). With MIM and pH monitoring, reflux episodes can be counted and separated into acidic and non-acidic events. If further combined with a patient symptoms diary, a clinician can determine the relationship of GERD-like symptoms to reflux events. Using MIM, researchers have shown that patients with GERD who are treated with PPIs do not have fewer reflux events, but the refluxate composition changes from primarily acidic to primarily non-acidic.5 Baclofen, which decreases LES relaxation frequency, decreases reflux events and symptom burden.6 Unfortunately, due to its side-effect profile, baclofen will likely not be widely used for refractory GERD symptoms. However, there may be other medications that improve LES function and have similar effects. It is also possible that surgical interventions may be useful for patients with refractory GERD symptoms who have ongoing non-acidic reflux.7 Hopefully, the development of MIM will foster further research into the pathophysiology of refractory GERD, allowing pharmaceutical developers to better identify potential therapeutic targets, and giving clinicians the tools necessary to pluck the juiciest fruit right from the highest reaches of the trees. Meanwhile, pharmacists should strive to identify patients with symptoms refractory to PPI therapy, who may be candidates for a PPI reduction or discontinuation. ■

Whistler Summary: “The Slow Rate of Rapid Progress”

Gastroesophageal Reflux Disease Presenting as Dystonia

Outcomes of surgical fundoplication in children