Supraesophageal Manifestations Research Articles

Impaired Upper Esophageal Sphincter Reflexes in Patients With Supraesophageal Reflux Disease

Normal responses of the upper esophageal sphincter (UES) and esophageal body to liquid reflux events prevent esophagopharyngeal reflux and its complications, however, abnormal responses have not been characterized. We investigated whether patients with supraesophageal reflux disease (SERD) have impaired UES and esophageal body responses to simulated reflux events. We performed a prospective study of 25 patients with SERD (age, 19-82 y; 13 women) and complaints of regurgitation and supraesophageal manifestations of reflux. We also included 10 patients with gastroesophageal reflux disease (GERD; age, 32-60 y; 7 women) without troublesome regurgitation and supraesophageal symptoms and 24 healthy asymptomatic individuals (controls: age, 19-49 y; 13 women). UES and esophageal body pressure responses, along with luminal distribution of infusate during esophageal rapid and slow infusion of air or liquid, were monitored by concurrent high-resolution manometry and intraluminal impedance. A significantly smaller proportion of patients with SERD had UES contractile reflexes in response to slow esophageal infusion of acid than controls or patients with GERD. Only patients with SERD had abnormal UES relaxation responses to rapid distension with saline. Diminished esophageal peristaltic contractions resulted in esophageal stasis in patients with GERD or SERD. Patients with SERD and complaints of regurgitation have impaired UES and esophageal responses to simulated liquid reflux events. These patterns could predispose them to esophagopharyngeal reflux.

Prevention of esophagopharyngeal reflux by augmenting the upper esophageal sphincter pressure barrier

Incompetence of the upper esophageal sphincter (UES) is fundamental to the occurrence of esophagopharyngeal reflux (EPR), and development of supraesophageal manifestations of reflux disease (SERD). However, therapeutic approaches to SERD have not been directed to strengthening of the UES barrier function. Our aims were to demonstrate that EPR events can be experimentally induced in SERD patients and not in healthy controls, and ascertain if these events can be prevented by application of a modest external cricoid pressure. Individual case control study. We studied 14 SERD patients (57 ± 13 years, 8 females) and 12 healthy controls (26 ± 3 years, 7 females) by concurrent intraesophageal slow infusion and pharyngoscopic and manometric technique without and with the application of a sustained predetermined cricoid pressure to induce, detect, and prevent EPR, respectively. Slow esophageal infusion (1 mL/s) of 60 mL of HCl resulted in a total of 16 objectively confirmed EPR events in none patients and none in healthy controls. All patients developed subjective sensation of regurgitation. Sustained cricoid pressure resulted in a significant UES pressure augmentation in all participants. During application of sustained cricoid pressure, slow intraesophageal infusion resulted in only one EPR event (P < .01). Slow esophageal liquid infusion unmasks UES incompetence evidenced as the occurrence of EPR. Application of 20 to 30 mm Hg cricoid pressure significantly increases the UES intraluminal pressure and prevents pharyngeal reflux induced by esophageal slow liquid infusion. These techniques can be useful in diagnosis and management of UES incompetence in patients suffering from supraesophageal manifestations of reflux disease.

Translation and cultural adaptation of the Reflux Finding Score into brazilian portuguese

The supraesophageal manifestations of Gastroesophageal Reflux Disease commonly known as Laryngopharyngeal Reflux (LPR) are highly prevalent. The diagnosis of LPR is challenging and mostly based on suggestive symptoms and signs of inflammation at the larynx and pharynx. In order to decrease the subjectivity of clinical assessment, a score based on endolaryngeal videolaryngoscopic findings, the Reflux Finding Score (RFS), was proposed by Belafasky et al. This score has proven to be highly sensitive and reproducible in the English language. ObjectiveTranslate and culturally adapt the RFS into Brazilian Portuguese and test its reliability. MethodFollowing international guidelines, translation and back translation of the RFS was made by 2 independent professional translators who were native English speakers. The translated version of the RFS was then applied to the videolaryngoscopic images of 24 patients by 3 examiners twice with a 24-hour minimum interval between scoring sessions, and tested for intraobserver reliability. ResultsThe translation and cultural adaptation were carried out satisfactorily. Examiners applied the instrument, after brief technichal training, without difficulties. Intraobserver test re-test reliability and reproducibility were high. ConclusionThe Portuguese version of the RFS presents semantic similarity to the English version, and with reliability.

Frequency and clinical implications of supraesophageal and dyspeptic symptoms in gastroesophageal reflux disease

We studied the frequency of supraesophageal and dyspeptic symptoms and their impact on the quality of life (QoL) and treatment response in patients with gastroesophageal reflux disease (GERD). Multicenter, prospective, observational study of patients who consulted a gastroenterologist because of typical GERD symptoms. Upper digestive symptoms were assessed using direct interviews. The Short Form-12 and the Quality of Life in Reflux and Dyspepsia questionnaires were used to measure QoL. Patients were treated with proton pump inhibitors (PPIs). A total of 301 patients (58% men; mean age, 45 years) were included. Baseline symptoms were heartburn (99% of cases; nocturnal heartburn 78%), regurgitation (86%), both heartburn and regurgitation (85%), dyspeptic symptoms (91%; epigastric pain syndrome 20%, postprandial distress syndrome 4%, both 75%), and supraesophageal symptoms (58%). In 56% of cases of heartburn, 35% of regurgitation, and 34% of nocturnal heartburn, symptoms were severe or very severe. One in six patients had dysphagia. Supraesophageal and/or dyspeptic symptoms were associated with worse scores on the Short Form-12 and Quality of Life in Reflux and Dyspepsia instruments. After treatment, heartburn and regurgitation disappeared in 93 and 87% of the patients, respectively. The percentage of patients responding to PPI treatment was significantly higher (P<0.05) in those with heartburn than those without heartburn (96 vs. 86%) and in those with regurgitation than without regurgitation (95 vs. 83%), whereas no differences were observed in those with and without supraesophageal or dyspeptic symptoms. Patients with typical GERD symptoms (heartburn and/or regurgitation) very frequently have dyspeptic and supraesophageal manifestations, which are related to a worse QoL but unrelated to PPI response.

W1072 A Pilot Study Evaluating the Role of Combined Impedance-pH Monitoring in the Evaluation of Asian Patients With Suspected Supra-Esophageal Manifestations of Gastro-Esophageal Reflux Disease (GERD): Establishing the Presence of Acid and Non-Acid Reflux (NAR)

W1072 A Pilot Study Evaluating the Role of Combined Impedance-pH Monitoring in the Evaluation of Asian Patients With Suspected Supra-Esophageal Manifestations of Gastro-Esophageal Reflux Disease (GERD): Establishing the Presence of Acid and Non-Acid Reflux (NAR)

Diagnostic value of the dual channel esophageal pH-metry in supraesophageal manifestations of gastroesophageal reflux disease

Aim: To compare the value of 24-h dual channel pH-metry in the diagnosis of GERD associated respiratory complications with symptom analysis, endoscopy, esophageal manometry and distal pH-monitoring. Patients, methods: 117 patients (pts) with GERD (43 pts with asthma, 44 pts with chronic hoarseness and 30 pts without supraesophageal manifestation) were submitted to detailed symptom analysis, upper gastrointestinal endoscopy, esophageal manometry and 24-h dual channel esophageal pH-monitoring. Results: Silent GERD was observed more frequently among asthma pts (21%) and pts with hoarseness (18%) than in pts without respiratory symptoms (3%). The endoscopic score based on Los Angeles classification (NERD=0, LA-A=1, LA-B=2, LA-C=3, LA-D=4) was not significantly different between the 3 pts groups (0.6±0.14 in asthma, 0.7±0.17 in hoarseness and 0.6±0.17 in pts without supraesophageal manifestations). No differences were observed in the results of LES manometry between pts with or without respiratory complaints (LES pressure: 15.3±1.49, 12.0±0.98 and 14.5±2.18 Hgmm). 5cm above LES the pH parameters were less pathological in pts with supraesophageal manifestations as compared with respiratory symptom free pts (DeMeester score: 14.5±1.98, 12.4±1.37 vs. 22.2±5.16, p<0.05; fraction time below pH 4: 3.5±0.61% and 2.7±0.40% vs. 9.9±2.25%, p<0.05). In contrast to the distal esophageal parameters, pH-monitoring 20cm above LES showed significantly pronounced reflux activity in pts with airway symptoms as compared with pts without supraesophageal manifestations (fraction time below pH 4: 0.7±0.18%, 0.5±0.14% vs. 0.3±0.08%, p<0.05). Conclusions: Symptom analysis, endoscopy, manometry and conventional distal pH-metry were not able to separate the GERD pts with airway complications from respiratory symptom free GERD subjects, only proximal pH-monitoring was able to select GERD pts with supraesophageal manifestations. Our results evidence the diagnostic value of routine dual channel pH-monitoring in the diagnosis of GERD induced respiratory complications.

Prevalência de queixas supra-esofágicas em pacientes com doenças do refluxo erosiva e não-erosiva

Respiratory, ear-nose and throat complaints, chest pain and dysphagia can be a part of clinical manifestations of gastroesophageal reflux disease. The first two are named supraesophageal manifestations of gastroesophageal reflux disease. Controversy about the prevalence of these clinical manifestations in patients with non-erosive and erosive gastroesophageal reflux disease exists. Evaluate the prevalence of supraesophageal manifestations in patients with erosive and non-erosive gastroesophageal reflux disease. Files from patients submitted to upper endoscopy, esophageal manometry and pH monitoring for the investigation of gastroesophageal reflux disease (heartburn as the chief complaint) were reviewed and respiratory and ear, nose and throat symptoms were recorded. Patients with erosive disease (grades I to III according to Savary-Miller classification) and with non-erosive disease (normal endoscopy with abnormal pH monitoring were selected. Statistical analysis included the chi-square test. Two hundred and eighty patients fulfilled the inclusion criteria being 162 with erosive disease (70% with grade I esophagitis) and 118 with non-erosive disease. Overall, 88 patients had ear, nose and throat symptoms (31%), the more frequent were hoarseness and clearing and 42, respiratory manifestations (15%), being cough the more prevalent. In the ear, nose and throat symptoms group, 45 were erosive disease (28%) and 43 non-erosive disease (36.4%). As for the respiratory symptom group, 21 patients (13%) were erosive disease and 21 (18%) were non-erosive disease. There was no difference in the prevalence of supraesophageal manifestations between patients with gastroesophageal erosive and non-erosive reflux disease.

Supraesophageal Reflux: Validation of a Symptom Questionnaire

To develop and validate a questionnaire for supraesophageal manifestations of reflux (SER) that will facilitate its study in clinical and research settings. The Supraesophageal Reflux Questionnaire (SERQ) and previously validated Reflux Symptom Index (RSI) were subjected to multiple types of validity testing, including content validity, concurrent validity, reproducibility, and predictive validity. The concurrent validity and reproducibility of both instruments was good to excellent for most items tested. The predictive validity of the SERQ was superior to the RSI when it included the covariates of history of sinusitis, use of over-the-counter antacid medications, age, gender, and body mass index. The SERQ will serve as both a useful clinical and research tool by offering not only SER symptom information, like the RSI, but also information about the patient's medical history and medication usage that will facilitate use of the SERQ in research protocols. B-2b.

Pharyngoesophageal pH monitoring

Pharyngeal acid reflux events may be significant in the pathogenesis of various supraesophageal manifestations of gastroesophageal reflux disease. Intragroup variation and an extensive overlap among subject groups and normal controls make proximal esophageal 24-hour pH monitoring studies unreliable for the diagnosis of pharyngeal reflux. However, the clinical value of pharyngeal pH monitoring still remains uncertain. A 24-hour pharyngeal pH monitoring study has shown that at least some pharyngeal reflux events occur in most healthy subjects, mainly in the upright position. Based on these data, values for the upper limits of normal for total pharyngeal acid exposure time and pharyngeal acid events have been determined. This study provides clinicians with reference values for physiologic pharyngeal reflux, but the parameters of abnormal pharyngeal reflux events are still unknown. More research is needed before this practice can become part of the routine evaluation of patients with pharyngeal, laryngeal, respiratory, or ear, nose, and throat symptoms or disorders.

Medical treatment of supraesophageal complications of gastroesophageal reflux disease

A growing number of bronchopulmonary, laryngopharyngeal, and oral cavity disorders are suspected of being caused by gastroesophageal refluxate traveling from the esophageal body. Although diagnostic methods have not been developed to positively identify the etiology of these conditions as being related to refluxate, many patients with these supraesophageal manifestations of gastroesophageal reflux disease (SeGERD) respond to empiric antireflux therapy with proton pump inhibitors (PPIs). When used in an appropriate dose (twice daily) and for an appropriate duration (12 weeks or longer), PPIs can be effective in relieving SeGERD symptoms. Economic issues and outcome studies are needed to help further define the role of PPIs in SeGERD.

An overview of reflux-associated disorders in infants: apnea, laryngospasm, and aspiration

Problematic airway responses in infants are common. Reflux-induced apnea affects nearly 1% of infants and involves airway closure or laryngospasm. Recurrent or chronic stridor, caused by dynamic or structural airway abnormalities, occurs in up to 1 in 100 babies. It can be difficult to distinguish microaspiration, which may represent inadequate airway protection mechanisms, from reflexive responses to esophageal refluxate, which may represent overeffective airway protection mechanisms. The diagnosis of gastroesophageal reflux (GER) in babies can be facilitated by a careful history in conjunction with esophageal pH probe monitoring, laryngoscopic evaluation, bronchoalveolar lavage, or nuclear medicine scintigraphy. Conservative lifestyle measures for treating supraesophageal manifestations of infantile GER include prone positioning and thickened feedings. Prokinetic and acid-suppressing therapies are widely used, but their efficacy is incompletely established, and none is currently approved by the US Food and Drug Administration for this purpose. Fundoplication is not indicated if nonsurgical management can prevent serious problems during the child’s maturation phase when many of these manifestations spontaneously resolve. Much remains to be learned about the developmental aspects of these supraesophageal manifestations of GER. This information not only will provide a greater understanding of developmental pathophysiology, but also will improve the clinical care of large numbers of infants.

Strategies for diagnosis and short and long term treatment: respondent overview

Research protocols investigating the value and cost of endoscopy in patients with GERD being screened for Barrett's esophagus should be a priority given the clinical and economic importance of this issue. Similarly, the cost-effectiveness of surveillance of this lesion is also important. The optimal PPI test strategy should be determined, as well as the appropriate therapeutic strategy that follows. This will need to be determined in each of the clinical presentations of GERD, both typical and atypical. Finally, we have almost no information regarding appropriate diagnostic and therapeutic strategies of supraesophageal manifestations of GERD. Given the enormous health care burden of asthma alone in this country, this is obviously an area requiring a high priority for research efforts.

The frequency and spectrum of esophageal dysmotility disorders in supraesophageal manifestations of GERD

The frequency and spectrum of esophageal dysmotility disorders in supraesophageal manifestations of GERD

Management of supraesophageal complications of gastroesophageal reflux disease in infants and children

Therapy of supraesophageal manifestations of gastroesophageal reflux disease (GERD) in infants and children nearly always includes “lifestyle modifications” (conservative or nonpharmacologic therapy). Depending on the severity of the GERD manifestation, pharmacotherapy is often added. Although data to support the practice are not abundant, it is rational to begin with prokinetic pharmacotherapy and to add acid suppression if pathologic effects of acid contact with the esophagus or airway are suspected. Pathologic effects of acid produce most forms of supraesophageal GERD; the exception is infantile regurgitation, the most common example of supraesophageal GERD, which is often unaccompanied by either esophagitis or evidence of acid entry into the airway. Currently, fundoplication is rarely required for pediatric GERD, but the supraesophageal complications of GERD are more common indications for this surgery than the esophageal complications in children. Other management options for supraesophageal symptoms in children include delivery of nutrients by tube feeding slowly and continuously into the stomach or, better, small intestine. Short-term or trial tube feeding uses a transnasal tube, for example, for nasojejunal feeding; longer-term tube feeding is simplified by a gastrostomy, which can be placed relatively noninvasively using endoscopy or fluoroscopy.