Gastropharyngeal Reflux Research Articles

Gastro-pharyngeal reflux and total laryngectomy. Increasing knowledge about its management

PurposeInvestigate the incidence, the degree and the effect of gastro-pharyngeal reflux (GPR) in laryngectomised patients. Materials and methodsBehavioral and 24-hour pH- and impedance-monitoring data were prospectively analyzed for 25 laryngectomised patients with no previous history of GER in outpateints' setting. Reflux detected was characterized as either acid, weakly acidic or nonacid. Proximal reflux was found at 15cm above the LES. Results40% of patients presented a pathological number of reflux episodes in the upright position (p<0.0001); 9 of them presented a pathologic bolus exposure time. Bolus exposure at the proximal sphincter was one fourth-fold lower than 5cm above the LES (p=0.3593). There was a prevalence of acid reflux at both sphincters (p<0.0001); liquid reflux was prevalent at the LES (p=0.003) and mixed reflux at the UES (p=0.0001). Median REs was higher than time acid exposure (p=0.0013). ConclusionsPre- and post-surgical reflux investigation could identify preexisting reflux severity and screen potential high-risk cancer patients for postoperative complications. This might allow the early onset of acid suppressive therapy in presence of pathologic findings in high-complication risk cancer patients.

S117 – Gastropharyngeal Reflux and Eustachian Tube Dysfunction

Objectives Determine the response of gastropharyngeal reflux (GPR) in the pathogenesis of Eustachian tube dysfunction (ETD) in adults, using a therapeutic trial. Methods 18 adult outpatients with symptoms of ETD (associated or not to GPR symptoms) were randomized into two groups: The first group received nasal corticosteroids and Rabeprazole 20mg once daily for 6 weeks. The second group received nasal corticosteroids and placebo for 6 weeks. Symptoms’ severity was evaluated before and after treatment by a tympanometry and a self-administered questionnaire of 7 items focusing on the severity of ETD. Each of the items was scored on a numeric scale. The local ethics committee approval was obtained and patients signed an informed consent before their participation in the study that was conducted between November 2002 and May 2003. Results 8 patients were on Rabeprazole, 10 were on placebo. Patients in the 2 groups were comparable for all the variables except for the severity of symptoms. On enrollment, patients under Rabeprazole had more severe symptoms than those under placebo (SR = 12.4, SP = 7.15 with p = 0.035). At the end of the trial, the improvement of the symptom score under Rabeprazole was significantly higher than that of patients under placebo, using the Mann Whitney test (SR’ = 6.13, SP’ = 11.56 with p = 0.026). Conclusions By showing a significant improvement of ETD symptoms in patients under Rabeprazole compared to controls, this study suggests the response of GPR in the pathogenesis of ETD, but larger studies are needed.

Is obesity associated with gastropharyngeal reflux disease?

To examine the association between obesity and gastropharyngeal reflux disease (GPRD) as well as gastroesophageal reflux disease (GERD). We conducted a cross-sectional study of consecutive patients undergoing ambulatory 24-h dual-probe pH monitoring from July 2003 to December 2006. The association between body mass index (BMI) and parameters about gastroesophageal or gastropharyngeal reflux was examined in univariate and multivariate analyses. A total of 769 patients (307 men and 462 women; mean age 50.7 years) were finally enrolled. Most variables showing gastroesophageal reflux was higher in the obese patients than the patients with normal BMI. There was no difference in all the variables showing gastropharyngeal reflux according to the BMI. After adjustment for age, sex, alcohol intake and smoking, obese patients demonstrated an about 2-fold increase in risk of GERD compared with patients with normal BMI (OR, 1.9; 95 CI, 1.3-2.9), but overweight patients did not demonstrate increased risk of GERD (OR, 1.2; 95 CI, 0.8-1.7). Both obese patients and overweight patients did not demonstrated increased risk of GPRD compared with patients with normal BMI (OR, 1.1; 95 CI, 0.8-1.7; and OR, 0.9; 95 CI, 0.6-1.3, respectively). Obesity is not associated with GPRD reflux while it is associated with GERD.

Is ineffective esophageal motility associated with gastropharyngeal reflux disease?

To evaluate the association between ineffective esophageal motility (IEM) and gastropharyngeal reflux disease (GPRD) in patients who underwent ambulatory 24-h dual-probe pH monitoring for the evaluation of supraesophageal symptoms. A total of 632 patients who underwent endoscopy, esophageal manometry and ambulatory 24-h dual-pH monitoring due to supraesophageal symptoms (e.g. globus, hoarseness, or cough) were enrolled. Of them, we selected the patients who had normal esophageal motility and IEM. The endoscopy and ambulatory pH monitoring findings were compared between the two groups. A total of 264 patients with normal esophageal motility and 195 patients with the diagnosis of IEM were included in this study. There was no difference in the frequency of reflux esophagitis and hiatal hernia between the two groups. All the variables showing gastroesophageal reflux and gastropharyngeal reflux were not different between the two groups. The frequency of GERD and GPRD, as defined by ambulatory pH monitoring, was not different between the two groups. There was no association between IEM and GPRD as well as between IEM and GERD. IEM alone cannot be considered as a definitive marker for reflux disease.

Gastroesophageal Flap Valve Is Associated with Gastroesophageal and Gastropharyngeal Reflux

Background: The endoscopic grading of the gastroesophageal flap valve (GEFV) is suggested to be a good predictor of the reflux status. The aim of this study was to investigate the association of the GEFV and gastroesophageal and gastropharyngeal reflux. Methods: A total of 364 patients (151 men and 233 women; mean age 52.2 years) who underwent endoscopy, esophageal manometry, and ambulatory 24-hour dual probe pH monitoring were included. GEFV was graded I through IV using Hill's classification: the GEFV was largely classified into 2 groups: the normal GEFV group (grade I and II) and the abnormal GEFV group (grade III and IV). Findings of endoscopy, esophageal manometry, and ambulatory pH monitoring were compared among the groups. Results: Increased GEFV grade was significantly associated with an increased prevalence of both reflux esophagitis and Barrett's epithelium (p < 0.001). LES pressure was significantly lower in the abnormal GEFV group compared to the normal GEFV group (p < 0.001). All variables showing gastroesophageal reflux in the distal probe were significantly higher in the abnormal GEFV group compared to the normal GEFV group (p < 0.001). In addition, all variables, except the supine time of pH below 4, showing the gastropharyngeal reflux in the proximal probe were significantly higher in the abnormal GEFV group compared to the normal GEFV group (p < 0.001). The frequency of gastroesophageal reflux disease and gastropharyngeal reflux disease was significantly higher in the abnormal GEFV group compared to the normal GEFV group (p < 0.001). Conclusions: Endoscopic grading of the GEFV is easy and provides useful information about the status of gastroesophageal and gastrophryngeal reflux.

Endoscopic Grading of Atrophic Gastritis is Inversely Associated with Gastroesophageal Reflux and Gastropharyngeal Reflux

BackgroundReflux esophagitis is inversely associated with the presence of atrophic gastritis, and endoscopic grading of atrophic gastritis correlates with histological evaluation. The aim of this study was to investigate the association of the endoscopic grade of atrophic gastritis with gastroesophageal and gastropharyngeal reflux.MethodsA total of 627 patients, who underwent endoscopy and ambulatory 24-hour dual-probe pH monitoring, were included in this study. The grade of atrophic gastritis was endoscopically classified into 2 types with the atrophic pattern system: the closed-type (C-type) and the open-type (O-type). We compared the findings from endoscopy and ambulatory pH monitoring for these 2 types.ResultsThe O-type was significantly associated with a lower prevalence of reflux esophagitis (p=0.001). All variables showing gastroesophageal reflux in the distal probe were significantly lower in the O-type than in the C-type (p<0.05). Similarly for the proximal probe, all variables, except the supine time of pH<4, were significantly lower in the O-type than in the C-type (p<0.05). The frequency of gastroesophageal reflux disease and gastropharyngeal reflux disease was in significantly lower in the O-type than in the C-type (p<0.001, p=0.012, respectively).ConclusionsEndoscopic grading of atrophic gastritis is easy and is inversely associated with gastroesophageal and gastropharyngeal reflux.

Gastroesophageal flap valve is associated with gastroesophageal and gastropharyngeal reflux

The endoscopic grade of the gastroesophageal flap valve (GEFV) is suggested to be a good predictor of reflux status. The aim of this study was to investigate the association of the GEFV and gastroesophageal and gastropharyngeal reflux. A total of 364 patients (151 men and 233 women; mean age, 52.2 years) who underwent endoscopy, esophageal manometry, and ambulatory 24-h dual-probe pH monitoring were included. GEFV was graded I through IV using Hill's classification; then, GEFV was classified into two groups: a normal GEFV group (grades I and II) and an abnormal GEFV group (grades III and IV). Findings of endoscopy, esophageal manometry, and ambulatory pH monitoring were compared between the groups. Increased GEFV grade was significantly associated with an increased prevalence of both reflux esophagitis and Barrett's epithelium (P < 0.001). Lower esophageal sphincter pressure was significantly lower in the abnormal GEFV group than in the normal GEFV group (P < 0.001). All variables showing gastroesophageal reflux in the distal probe were significantly higher in the abnormal GEFV group than in the normal GEFV group (P < 0.001). In addition, all variables, except the supine time of pH < 4, showing gastropharyngeal reflux in the proximal probe were significantly higher in the abnormal GEFV group than in the normal GEFV group (P < 0.001). The frequency of gastroesophageal reflux disease and of gastropharyngeal reflux disease was significantly higher in the abnormal GEFV group than in the normal GEFV group (P < 0.001). Endoscopic grading of the GEFV is easy and provides useful information about the status of gastroesophageal and gastropharyngeal reflux.

C-FIBER BLOCKADE INFLUENCE NON-NUTRITIVE SWALLOWING IN NEWBORN LAMBS

PURPOSE: Non-nutritive swallowing (NNS) is especially important in the neonatal period for clearing secretions and gastro-pharyngeal reflux, and has been associated with neonatal apneas. One previous study has reported that systemic C-fiber blockade (CFB) inhibits induced swallowing in adult guinea pigs (Jin, Y et al, Am J Respir Crit Care Med. 1994). The aim of our present study was to investigate the effects of CFB on apnea and NNS frequency, and on the coordination between NNS and phases of the respiratory cycle in newborn lambs.

Artefacts in 24‐h pharyngeal and oesophageal pH monitoring: is simplification of pH data analysis feasible?

Background: Ambulatory 24‐h dual‐channel pharyngeal and oesophageal pH monitoring is the standard test for measuring gastro‐oesophageal and gastropharyngeal reflux. Artefacts caused by the intake of food may result in falsely positive gastropharyngeal reflux, which necessitates a manual review of 24‐h pH data. The purpose of the study was to investigate the influence of meals and whether leaving out meals affected the reliability of the test. Methods: Patients referred for otolaryngological complaints, suspected to have been caused by gastro‐oesophageal reflux, underwent 24‐h dual‐channel pH monitoring. The raw unprocessed pH data were corrected by visual inspection of the 24‐h tracings (corrected data), by leaving out meals or meals plus a 2‐h postprandrial period. Results: The raw pH data were substantially influenced by artefacts of food intake and pseudoreflux. Data obtained by leaving out meals agreed best with manually corrected data. Many of the falsely positive reflux episodes could be removed, thereby inducing a 9%–18% chance of undetected reflux. When examining the fraction of time supine, manually corrected data and data leaving out meals were fully concordant and detected 79% of patients with gastropharyngeal reflux. However, leaving out meals plus a 2‐h postprandrial period resulted in 21%–50% falsely negative tests. Conclusion: Leaving out the period of intake of meals and beverages from the raw pH data might be the second best test after the time‐consuming visual correction with a small chance of undetected gastropharyngeal reflux. For scientific purposes and when in doubt, it remains necessary to review the computer‐generated data manually to discover every gastropharyngeal reflux event.

Effect of cigarette smoking on gastropharyngeal and gastroesophageal reflux.

Gastropharyngeal reflux appears to be associated with various otolaryngological complaints. Cigarette smoking is known to affect adversely the defense mechanisms against reflux of acid gastric contents into the esophagus. To study the relationship between gastropharyngeal, as well as gastroesophageal, reflux and cigarette smoking, 15 subjects underwent 24-hour double-probe pH monitoring while smoking their daily amount of cigarettes. The percentage of time the pH was below 4 during the smoking period was significantly higher than the percentage of time the pH was below 4 during the nonsmoking period, proximal, at the level of the upper esophageal sphincter, as well as distal, above the lower esophageal sphincter. These findings demonstrate that smoking increases gastropharyngeal and gastroesophageal reflux. Smokers with complaints and disorders caused by reflux should therefore be advised to stop smoking in order to reduce reflux.

Gastropharyngeal and gastroesophageal reflux in globus and hoarseness.

The role of gastropharyngeal reflux in patients with globus pharyngeus and hoarseness remains unclear. To evaluate patients with complaints of globus, hoarseness, or globus and hoarseness combined for the presence of gastropharyngeal and gastroesophageal reflux. Prospective clinical cohort study of 3 groups of patients undergoing ambulatory 24-hour double-probe pH monitoring. In patients with pathologic gastroesophageal reflux, an upper gastrointestinal endoscopy was also performed. Tertiary care, outpatient clinic. Twenty-seven patients with globus alone, 20 patients with hoarseness alone, and 25 patients with globus and hoarseness combined. Patients with well-defined pathologic reflux (ie, gastroesophageal reflux with or without gastropharyngeal reflux) were present mainly in the group of patients with globus combined with hoarseness: 18 (72%) of 25 patients, compared with 7 (35%) of 20 patients with hoarseness alone and 8 (30%) of 27 with globus alone. Seven (10%) of all 72 patients had prolonged acid exposure at the laryngopharyngeal junction in the presence of a normal gastroesophageal pH registration. Abnormal findings in the esophagus were found at endoscopy in 17 (65%) of 26 patients with pathologic gastroesophageal reflux (with or without gastropharyngeal reflux). We found a high prevalence of pathologic reflux in patients with both globus and hoarseness. Based on these findings, we strongly advise upper gastrointestinal endoscopy for symptomatic otolaryngological patients with pathologic gastroesophageal reflux.

24-H Pharyngeal pH Monitoring in Healthy Volunteers: A Normative Study

Background: Gastropharyngeal reflux has been associated with disorders of the upper and lower airways. It may be shown by pharyngeal pH-metry, but reports on normality in healthy volunteers are scarce. No definite consensus has been reached considering the upper limit of normality (ULN). The aim of the present study was therefore to quantify the occurrence of pharyngeal acid exposure (pH < 4) in healthy volunteers and, further, to examine its relation to acid exposure of the oesophagus and oesophageal motility and its occurrence in relation to age, sex, and body position. Methods: Forty healthy volunteers underwent ambulatory 24-h pH-metry, using antimony electrodes positioned 2 cm above the upper oesophageal sphincter and 5 cm above the lower oesophageal sphincter on the basis of manometry. Technical artefacts were excluded before calculation of all results. Results: Gastropharyngeal reflux occurred in most healthy volunteers without any significant relation to age, sex, or body weight. Pharyngeal acid reflux occurred mainly in the upright position. The ULN for pharyngeal acid exposure time was assessed to 0.9% (0.2% after exclusion of mealtimes). The ULN for the number of acid events in the pharynx was 18 (6.1). The corresponding ULNs for the oesophagus were 7% and 84. Conclusion: Gastropharyngeal reflux may be effectively monitored by ambulatory pH-metry. The present study provides reference limits, a prerequisite for evaluating the pathophysiologic importance of the phenomenon.

Ex juvantibus approach for chronic posterior laryngitis: results of short-term pantoprazole therapy.

The aim of this study was to investigate whether patients with chronic posterior laryngitis and symptoms of gastro-pharyngeal reflux benefit from a six-week therapy with pantoprozole. Twenty-nine out-patients with voice disorders (case history of at least two months) and simultaneous symptoms of gastro-pharyngeal reflux were recruited for this study. At the entry to the study a symptom questionnaire and a video-laryngo/stroboscopy were completed. The symptom questionnaire and the video-laryngo/stroboscopy were repeated after the six weeks of therapy with pantoprazole 40 mg once a day and again six weeks and three months after this follow-up, during which time the patient was without therapy. Hoarseness, globus pharyngeus, sore throat, heartburn, and coughing were the symptoms which showed a significant (p < 0.05) recovery at the follow-ups (mean of hoarseness index: 7.28 to 0.92; mean of globus pharyngeus index: 3.14 to 0.58; mean of heartburn index: 2.86 to 0.5; mean of cough index: 1.72 to 0.25; mean of throat soreness index: 1.72 to 0.15). Laryngoscopy scores of the posterior laryngeal region, the glottic and the supraglottic region showed statistically significant improvement (p < 0.05) after the treatment with pantoprazole. The therapeutic effect exceeded the drug administration until the last follow-up (after three months). The medication was tolerated without side-effects in all patients. A primary (ex juvantibus) therapy with proton pump inhibitors seems to be a therapeutic option for patients with long-lasting chronic inflammation of the larynx not responding to common therapy. In this case a six-week course of treatment has been shown to be sufficient.

High incidence of gastropharyngeal and gastroesophageal reflux after total laryngectomy.

Gastroesophageal reflux (GER) appears to be related to laryngeal carcinoma. Little is known about GER and gastropharyngeal reflux (GPR) in the laryngectomized patient. Therefore, GER and GPR were studied in laryngectomized patients. In 11 patients, 24-hour double-probe pH monitoring was performed in an ambulant setting. An optic fiberscope was used for the accurate positioning of the proximal probe in the upper esophageal sphincter. In 9 of 11 patients pathologic GPR was found. Four of these 9 patients had reflux in upright and supine position, 5 patients had reflux only in upright position. A high incidence of GPR in laryngectomized patients was found. These results raise the question whether all laryngectomized patients should be investigated for reflux and in the presence of pathologic reflux findings should be treated with reflux prophylaxis.