Medical therapy of supraesophageal gastroesophageal reflux disease

Symptomatic response to GERDOFF® in patients with gastro-esophageal reflux disease and poor response to alginates: an exploratory, post-market, open-label study

BACKGROUND/AIMS

A novel medical device based on hyaluronic acid, chondroitin sulphate plus aluminum hydroxide (GERDOFF®, melt-in-mouth tablets) showed efficacy in reducing GER-related symptoms. This exploratory, open-label study evaluated symptomatic effects of a 14-day treatment with GERDOFF® in GERD patients.

MATERIALS AND METHODS

GERD Impact Scale (GIS) questionnaire was filled at baseline visit, after 7 and 14 days of treatment; patients' Global Satisfaction was evaluated at the final visit. Primary endpoint was the reduction of heartburn episodes per week; secondary endpoints were GERD-related symptoms, patients' satisfaction, and safety.

RESULTS

Forty patients were included, 22 were on stable therapy with proton pump inhibitor (PPI). Compared to baseline, the days with heartburn episodes and the GIS score progressively decreased during the first (p<0.0001) and the second week of treatment (p<0.0001). Heartburn episodes per week (p<0.0001) and the GIS score (p<0.0001) decreased in the first and the last 7 days of 14-day treatment and did not differ between patients on and off PPI. The treatment was safe and well-tolerated, and it was rated as very good (46.2%) or good (43.6%) on the satisfaction questionnaire.

CONCLUSION

GERDOFF® could effectively treat GER symptoms in patients not responding to PPI or alginate-based formulation. ISRCTN_15143752.

The Use of Inhaled N-Acetylcysteine for Laryngopharyngeal Reflux Disease: A Randomized Controlled Trial

OBJECTIVES

Proton pump inhibitors (PPIs) are the mainstay of the medical treatment for laryngopharyngeal reflux disease (LPRD). However, extraesophageal symptoms of LPRD, such as globus, are often refractory to PPI treatment. Many kinds of adjunctive medications have been attempted to address those refractory cases. We aimed to study whether inhaled N-acetylcysteine (NAC), a mucolytic agent, has additive effects for the treatment of LPRD when used in conjunction with PPIs.

METHODS

Patients with reflux symptom index (RSI) greater than 13 and reflux finding scores (RFS) greater than 7 were prospectively enrolled and were randomly assigned to control or study group. Patients were treated with oral rabeprazole in the control group and with oral rabeprazole and inhaled NAC in the study group. Patients were followed once a month for 2 months with questionnaires and stroboscopic examination. At every follow-up, RSI and RFS were checked. The extent of improvements of RSI and RFS were evaluated and compared between two groups.

RESULTS

With treatment, the mean RSI changed from 21.0 to 7.6 (P < 0.001) in control group and from 19.7 to 4.5 (P < 0.001) in study group. The mean RFS also changed from 12.9 to 7.1 (P < 0.001) in control group and from 13.5 to 6.9 (P < 0.001) in study group. For both RSI and RFS, the extents of improvement were not significantly different between two groups. In patients whose RSI improved less than nine at the first follow-up (poor early responders), RSI became significantly lower in the study group (4.6 ± 2.0) than in the control group (9.5 ± 4.6) at second follow-up (P = 0.019). In good early responders, however, RSI was not significantly different between the two groups in the second follow-up.

CONCLUSIONS

In this study, there were no significant differences in the overall outcome between patients treated with inhaled NAC and PPI and those with PPI alone. Interestingly, some additional therapeutic effect of NAC appeared late for the patients with poor early response. Further studies are required to investigate the underlying mechanism for this.

Dietary modification for laryngopharyngeal reflux: systematic review

OBJECTIVE

This study aimed to determine the relationship between laryngopharyngeal reflux and dietary modification.

METHODS

A systematic review was conducted. The data sources for the study were PubMed, Embase, Cochrane Library and Web of Science. Articles were independently extracted by two authors according to inclusion and exclusion criteria. The outcome focus was laryngopharyngeal reflux improvement through diet or dietary behaviour.

RESULTS

Of the 372 studies identified, 7 met our inclusion criteria. In these seven studies, laryngopharyngeal reflux symptoms improved following dietary modifications. However, the studies did not present the independent effect of each dietary factor on laryngopharyngeal reflux. Moreover, only one of the seven studies had a randomised controlled study design.

CONCLUSION

The reference studies of dietary modification for laryngopharyngeal reflux patients are not sufficient to provide recommendations.

Treatment of laryngopharyngeal reflux using a sleep positioning device: A prospective cohort study

OBJECTIVE

Laryngopharyngeal reflux (LPR) symptoms are often resistant to management and cause significant quality of life impairment to patients with this disease. This study assesses the utility of a sleep-positioning device (SPD) in treating LPR.

DESIGN

Single center prospective cohort study.

SETTING

Tertiary medical center PARTICIPANTS: 27 adult patients with diagnosed laryngopharyngeal reflux.

INTERVENTION

An SPD consisting of a two-component wedge-shaped base pillow and a lateral positioning body pillow (Medcline, Amenity Health Inc.) was given to patients with a diagnosis of LPR. Subjects slept using the device for at least 6h per night for 28 consecutive nights.

MAIN OUTCOMES

Primary outcomes were Nocturnal Gastroesophageal Reflux Symptom Severity and Impact Questionnaire (N-GSSIQ) and the Reflux Symptoms Index (RSI) survey instrument. Each was collected at baseline, after 14, and after 28days of SPD use.

RESULTS

27 patients (19 female and 8 male; age 57.1±12.8, BMI 29.0±8.1) were recruited. At baseline mean N-GSSIQ was 50.1±22.4 and mean RSI of 29.6±7.7. Repeated measure analysis showed that subjects' total N-GSSIQ scores decreased by an average of 19.1 (p=0.0004) points by two weeks and 26.5 points by 4weeks (p<0.0001). RSI decreased an average of 5.3 points by 2weeks (p=0.0425) and an average of 14.0 points by 4weeks (p<0.0001).

CONCLUSIONS

In patients with LPR, SPD treatment significantly improves self-reported symptoms of nocturnal reflux as well as symptoms specific to LPR. These results support the therapeutic efficacy of a SPD for patients with LPR.

Assessment of treatment response in patients with laryngopharyngeal reflux

To evaluate treatment response in patients with laryngopharyngeal reflux (LPR). A prospective study of 100 patients with voice disorders was conducted. Patients were evaluated using reflux symptom index (RSI) and reflux finding score (RFS) by 70° rigid laryngoscope. Patients with RFS score of 7 or more were diagnosed of having LPR and were started with anti-reflux therapy for a period of 6 months. Patients were assessed at regular intervals using RSI and RFS. The prevalence of LPR in patients with voice disorders was found to be 25%. The mean RSI score improved gradually and significantly over a period of 6 months from 11.84 at presentation to 2.04 after 6 months of treatment (p value <0.001). The mean value of RFS improved from 7.92 at entry to 1.52 after 6 months of treatment (p value <0.001). However, it was found that the improvement was not significant at end of first month of treatment, and improvement in RSI and RFS scores was found only after 2 months of treatment. RSI and RFS improve significantly after treatment for 6 months with PPI like Omeprazole. But the improvement starts from the 2nd month from the onset of treatment. Treatment of LPR for at least 6 months may be indicated to attain a full resolution of physical findings.

Efficacy of acid suppression therapy in gastroesophageal reflux disease-related chronic laryngitis

BACKGROUND

This research aims to assess the response to acid suppression therapy in gastroesophageal reflux disease (GERD)-related chronic laryngitis (CL).

METHODS

Data were extracted from Web of Knowledge, Embase, and PubMed for English language article published up to March 2016. Pooled overall response rate (ORR) rates were evaluated to determine acid suppression treatment efficacy. Random effects model was used with standard approaches to sensitivity analysis, quality assessment, heterogeneity, and exploration of publication bias.

RESULTS

Pooled data from 21 reports (N = 2864, antireflux medicine: 2741; antireflux surgery: 123, study duration 4-108 week) were analyzed. With the random-effect model, the ORR was 66% (95% confidence interval [CI] 54%-78%). The ORRs were 80% for antireflux surgery (95% CI 67%-93%, 3 studies, 123 patients), whereas 64% for antireflux medicine (95% CI 50%-77%, 18 studies, 2741 patients), and the ORR was 70% (95% CI 55%-85%, 15 reports, 2731 patients) for >8 weeks' therapy duration, whereas 57% (95% CI 48%-65%, 6 reports, 133 patients) for ≤8 weeks' duration of therapy.

CONCLUSIONS

Acid suppression seems to be an effective therapy for GERD-related CL. There was an increase in effect among patients with surgery therapeutic method and longer therapy duration.

WITHDRAWN: Acid reflux treatment for hoarseness

Review withdrawn from Issue 4, 2015 as it is out of date.

The editorial group responsible for this previously published document have withdrawn it from publication.

Pathophysiology and treatment of patients with globus sensation--from the viewpoint of esophageal motility dysfunction

"Globus sensation" is often described as the sensation of a lump in the throat associated with dry swallowing or the need for dry swallowing, which disappears completely during eating or drinking and for which no organic cause can be established. Due to the uncertain etiology of "globus sensation", it remains difficult to establish standard treatment strategies for affected patients. Lately most attention has been focused on gastroesophageal reflux disease and several reports have indicated that there is a close relationship between esophageal acid reflux and globus sensation. Nowadays, empirical therapy with a high dose of a proton pump inhibitor (PPI) is considered to be indicated for patients with globus sensation, after excluding organic diseases such as pharyngeal cancer, Zenker's diverticulum, or thyroid enlargement. If patients are nonresponsive to PPI therapy, evaluation of esophageal motility should be done. In our recent study, 47.9% had abnormal esophageal motility, with the most common esophageal motility abnormality being an ineffective esophageal motility in PPI-resistant patients with globus sensation. This suggests that prokinetics alone or adding prokinetics to PPI should be the treatment to be considered, although few studies have investigated the efficacy of prokinetics in the treatment of patients with globus sensation. If patients without any esophageal motility dysfunctions are nonresponsive to PPI therapy, either cognitive-behavioral therapy, anti-depressants, or gabapentin could be helpful, although further well-designed, randomized controlled large-scale studies will be necessary to determine the effectiveness of each treatment strategy on patients with globus sensation.

Therapeutic strategies for laryngeal manifestations of gastroesophageal reflux disease

Gastroesophageal reflux disease is increasingly associated with ear, nose, and throat symptoms, including laryngitis. Many patients are unaware of the gastroesophageal etiology of their symptoms. A variety of criteria are used to diagnose this condition, including laryngoscopy, esophagogastroduodenoscopy, and the use of ambulatory pH and impedance monitoring. However, no test serves as the gold standard for the diagnosis given their lack of sensitivity and specificity for reflux disease. Numerous trials have assessed the role of proton pump inhibitor therapy in patients with laryngopharyngeal reflux and most have revealed no benefit to acid suppression over placebo. Despite many uncertainties there has been some progress regarding the role of acid-suppressive therapy as well as other agents in this unique group of patients. In this review we explore therapeutic options and their rationale for patients with laryngeal signs and symptoms.

Globus pharyngeus: a review of its etiology, diagnosis and treatment

Globus is a persistent or intermittent non-painful sensation of a lump or foreign body in the throat. It is a commonly encountered clinical condition that is usually long-lasting, difficult to treat, and has a tendency to recur. Furthermore, due to the uncertain etiology of globus, it remains difficult to establish standard investigation and treatment strategies for affected patients. As a first step for managing globus, careful history taking and nasolaryngoscopy are essential. Given the benign nature of the condition and the recent notion that gastroesophageal reflux disease is a major cause of globus, empirical therapy with a high dose of proton pump inhibitors is reasonable for patients with typical globus. If patients are nonresponsive to this therapy, definitive assessments such as endoscopy, multichannel intraluminal impedance/pH monitoring, and manometry should be considered. Speech and language therapy, anti-depressants, and cognitive-behavioral therapy can be helpful in patients whose symptoms persist despite negative investigations.

Addition of a H2 receptor antagonist to PPI improves acid control and decreases nocturnal acid breakthrough

BACKGROUND

The addition of a bedtime H2 receptor antagonist (H2RA) to proton pump inhibitor (PPI) b.i.d. to inhibit nocturnal acid breakthrough (NAB) is controversial. H2RA tolerance has been documented suggesting limitations in its long-term effect.

AIM

To compare the intragastric pH and NAB occurring with twice daily PPI with or without the addition of a H2RA.

METHOD

Multichannel intraluminal impedance-pH studies in 100 patients were reviewed. Fifty-eight patients (female 41; mean age, 54 y; range, 17 to 85) were studied on twice daily PPI. Forty-two patients (female 36; mean age, 53 y; range 20 to 85) were studied on a PPI b.i.d.+H2RA for at least 1 month at bedtime. The percentage time of intragastric pH<4 (upright, recumbent, and total) and NAB were compared between the groups.

RESULTS

In the patients with PPI b.i.d. 64% had NAB, compared with only 17% of patients on PPI b.i.d. and H2RA q.h.s. (P<0.001). The percent time intragastric pH<4 for patients on PPI b.i.d. was significantly higher (P<0.01) compared with patients on PPI b.i.d.+H2RA q.h.s. during upright (29.1+/-3.0 vs. 18.3+/-2.9), recumbent (33.5+/-3.4 vs. 12.5+/-3.1), and entire period (31.5+/-2.8 vs. 18.0+/-3.0).

CONCLUSIONS

The addition of a bedtime H2RA reduces the percentage time of the intragastric pH<4 and also NAB. H2RA should be considered as adjunct therapy in whom greater suppression of gastric acid control is considered desirable.

Gastroesophageal reflux in infants and children

Gastroesophageal reflux disease (GERD) is the most common esophageal disorder and the most frequent reason why infants are referred to the pediatric gastroenterologist, affecting as much as 30% of the pediatric population. Presenting features of GERD in infants and children are quite variable and follow patterns of gastrointestinal and extra-esophageal manifestations that vary between individual patients and may change according to age. Patients may be minimally symptomatic, or may exhibit severe esophagitis, bleeding, nutritional failure, or severe respiratory problems. GERD is also complex for the diagnostic techniques required to assess its repercussions or explain its origin. Although different abnormalities in motility variables, such as lower eso-phageal sphincter (LES) function, esophageal peristalsis and gastric motor activity can contribute to the development of GERD, the degree of esophageal acid exposure represents the key factor in its pathogenesis. Esophageal pH monitoring, based on both the detection of acid reflux episodes and the measurement of their frequency and duration, has been regarded as the most sensitive and specific diagnostic tool for diagnosing reflux disease. The aim of this paper is to give a concise review for the clinicians encountering this specific disease in infants and children.

Review article: The laryngological manifestations of reflux disease; why the scepticism?

BACKGROUND

Despite increasing clinical and experimental evidence of its existence, otolaryngological manifestations of reflux disease remain controversial, concerning diagnosis as well as treatment.

AIM

Proper understanding of laryngopharyngeal reflux disease (LPRD).

METHOD

Review of literature.

RESULTS

Scepticism concerning LPRD is based upon differences between gastro-oesophageal reflux disease and LPRD; lack of specificity and sensitivity of diagnostic tests to confirm LPRD; non-specificity of laryngological symptoms, which are difficult to distinguish from other causes of upper respiratory tract inflammation; non-specificity of laryngological signs in laryngoscopy, with high intra- and inter-observer variability in evaluation; diagnosis of LPRD is essentially only based on a combination of diagnostic signs and symptoms, which cannot be attributed to other pathology; slow, or sometimes lack of, response of LPRD symptoms to proton pump inhibitor (PPI) medication and lack of evidence concerning efficacy of PPIs in placebo-controlled trials.

CONCLUSIONS

LPRD remains a diagnosis by exclusion and resolution of symptoms following 4-month trial of 40 mg PPI twice daily is, for all practical purposes, considered proof of the initial diagnosis. However, non-response does not exclude LPRD as PPIs have no influence on noxious non-acid components of the refluxate.

Reflux Laryngitis: A Feasible Indication for Laparoscopic Antireflux Surgery?

Laparoscopic fundoplication is a routine surgical approach in the treatment of moderate or severe gastro-esophageal reflux disease. However, there are still contradictions regarding supraesophageal symptoms as an indication for surgery. The aim of this study was to determine the subjective symptomatic outcome and objective laryngeal findings after antireflux surgery in patients with pH monitoring proven reflux laryngitis. Between 1998 and 2002, 40 patients with reflux laryngitis underwent laparoscopic Nissen fundoplication. Patients were referred to surgery and followed-up by a specialist in otorhinolaryngology. Subjective symptoms were collected by a structured questionnaire at a median follow-up of 42 months. The objective laryngeal findings improved from the preoperative situation; at 12 months after surgery, the otorhinolaryngeal status was improved in 92.3% (n=24) of the patients. However, only 38.5% (n=10) of these patients evaluated an improvement in their voice quality. Of all, 62.5% (n=25) of the patients reported no or only mild cough or voice hoarseness symptoms postoperatively, 22.5% (n=9) had moderate symptoms, and 15.0% (n=6) suffered from difficult supraesophageal symptoms. Ninety-five percent of the patients regarded the result of their surgery excellent, good, or satisfactory. Of all, 82.5% (n=33) of the patients would still choose surgery, 7.5% (n=3) would abstain from surgery, and 10% (n=4) of the patients were hesitant about their choice. For patients suffering from supraesophageal symptoms of gastro-esophageal reflux disease with objective evidence of pharyngeal acid exposure, laparoscopic Nissen fundoplication provides a good and alternative adding to current treatment.

Defining the relationship between gastroesophageal reflux and cough: probabilities, possibilities and limitations

The common co-existence of cough and gastroesophageal reflux disease (GORD) is well established. However, ascertaining cause and effect is more difficult for many reasons that include occurrence by chance of two common symptoms, the changing definition of GORD, equipment limitations and the lack of randomised controlled trials. Given these difficulties, it is not surprising that there is disparity of opinion between respiratory and gastroenterology society guidelines on the link between GORD and chronic cough. This commentary explores of these issues.

Diagnosis and management of laryngopharyngeal reflux disease

PURPOSE OF REVIEW

Laryngopharyngeal reflux remains a controversial subject for both diagnosis as well as treatment. Nevertheless, there is increasing clinical and experimental evidence to suggest that it is associated with many nonspecific otolaryngological symptoms.

RECENT FINDINGS

Twenty-four hour dual probe pH tests fail to prove or exclude laryngopharyngeal reflux because of insufficient specificity and sensitivity. Therefore, the diagnosis is usually based on a combination of diagnostic signs and symptoms, which cannot be explained by pathology other than laryngopharyngeal reflux. Many signs of laryngopharyngeal reflux, however, are also found in individuals without symptoms. Treatment should consist of high-dose proton-pump inhibitor medication twice daily.

SUMMARY

Laryngopharyngeal reflux disease is a diagnosis by exclusion, and resolution of symptoms following a 4-month trial of high-dose proton pump inhibitor twice daily is, for all practical purposes, considered proof of the initial diagnosis. Nonresponse does not exclude the diagnosis of laryngopharyngeal reflux disease, however, since proton-pump inhibitors will only reduce the acid component of the refluxate.

Acid reflux treatment for hoarseness

BACKGROUND

Acid reflux is a common problem, and is thought to occur in 4% to 10% of patients presenting to ENT clinics. A recent study of reflux and voice disorders suggests that up to 55% of patients with hoarseness (dysphonia) have laryngopharyngeal reflux. Anti-reflux therapy is often used empirically in treating patients with hoarseness, where no other cause has been identified by examination.

OBJECTIVES

The aim of the review was to assess the effectiveness of anti-reflux therapy for patients with hoarseness, in the absence of other identifiable causes, whether or not a definitive diagnosis of laryngopharyngeal and gastro-oesophageal reflux has been made. This was assessed by evaluation of prospective randomised controlled studies that were identified by a systematic review of the literature. Both medical and surgical treatments were evaluated.

SEARCH STRATEGY

The Cochrane ENT Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library Issue 3, 2005), MEDLINE (1966 to 2005), EMBASE (1974 to 2005) and conference proceedings were searched with prespecified terms. The date of the last search was September 2005.

SELECTION CRITERIA

Randomised controlled trials recruiting patients with hoarseness in the absence of other identifiable causes, such as malignancy, cord palsy or nodules, whether or not a definitive diagnosis of laryngopharyngeal and gastro-oesophageal reflux has been made.

DATA COLLECTION AND ANALYSIS

Three reviewers examined the search results and identified studies before deciding which would be included in the review.

MAIN RESULTS

302 potential studies were identified by the search strategy. No trials were identified which met our inclusion criteria. Six randomised controlled trials were identified in which some, but not all patients presented with hoarseness, and were treated with proton pump inhibition. As we could not determine with certainty whether all these patients had hoarseness among the other laryngeal symptoms, these were excluded. However, these studies suggest a significant placebo response, which is comparable to the benefit derived from anti-reflux therapy in some studies. As no trials met our criteria, we are unable to reach any firm conclusions regarding the effectiveness of anti-reflux treatment for hoarseness.

AUTHORS' CONCLUSIONS

There is a need for high quality randomised controlled trials to evaluate the effectiveness of anti-reflux therapy for patients with hoarseness which may be due to laryngopharyngeal and gastro-oesophageal reflux.

Histamine-2 receptor antagonists at night improve gastroesophageal reflux disease symptoms for patients on proton pump inhibitor therapy

While night-time symptoms of gastroesophageal reflux disease (GERD) are common, considerable controversy exists regarding the use of histamine-2 receptor antagonists (H2Ras) for night-time reflux control. Some studies have suggested possible tolerance to H2RA while others have suggested that long-term efficacy of gastric acid control can be maintained with night-time H2RA use. The aim of this study was to identify if GERD patients have sustained symptom improvement with long-term use of night-time H2RA. Records of 56 consecutive GERD patients on twice daily proton pump inhibitor (PPI) and night-time H2RA therapy were reviewed. During a phone interview patients were asked a 5-item questionnaire, which included overall assessment of symptoms, night-time symptoms, sleep disturbance, duration and frequency of therapy. Of the 56 patients, 39 (31 women, mean age 56) completed the questionnaire (15 were not reached and 2 did not recall enough information). All respondents had taken night-time H2RA for at least 1 month (28/39 patients with > 6 months duration) with 33/39 patients taking H2RAs every night. The addition of H2RA led to an improvement in overall symptoms in 28/39 (72%) patients, improvement in night-time reflux symptoms in 25/34 (74%) patients and improvement of GERD-associated sleep disturbance in 18/27 (67%) patients. Five (13%) patients had stopped the H2RA on their own, stating that its efficacy waned after 1 month. Our results suggest that the majority of patients report persistent improvement in GERD symptoms from night-time H2RA use and that possible clinically important tolerance to H2RAs occurs in a small number of patients. Further prospective, placebo-controlled studies may help confirm that there is a role for night-time H2RAs in GERD symptom control.

Efficacy of laparoscopic fundoplication in controlling pulmonary symptoms associated with gastroesophageal reflux disease

BACKGROUND

Gastroesophageal reflux disease (GERD)-induced pulmonary symptoms (PS) can be difficult to control. The effectiveness of laparoscopic fundoplication (LF) in controlling PS among patients with medically recalcitrant GERD is poorly documented. We evaluated our results in controlling important PS in patients with GERD undergoing LF.

METHODS

Seventy-four patients (28 men, 46 women) were identified with clinically important PS from a prospective cohort of 155 patients undergoing elective LF for recalcitrant GERD. Median age was 52.5 years (range, 29-84 years). Sixty-seven (91%) patients were taking proton pump inhibitors at the time of operation. Quality of life by using the SF36 physical (PCS) and mental (MCS) component summary scores (normal, 50) and heartburn severity by using the health-related quality of life (HRQOL) (best score, 0; worst score, 45) were measured.

RESULTS

All 74 patients with PS survived operation, and minor morbidity occurred in 5 (7%) patients. Median hospital stay was 2 days (range, 1-6 days), and return to normal activity was seen at 2.2 weeks (range, 1-8 weeks). Median follow-up was 12 months. PS were improved significantly (P < .01) for hoarseness (62% to 17.6%), bronchospasm (60% to 9.5%), and aspiration (22% to 1.4%). Before LF, 11 (14.9%) patients required bronchodilators or oral steroids. Postoperatively such therapy was required in only 3 (4.2%) patients (P = .019), with no patient requiring oral steroids. Patients with poorer control of their GERD on the basis of high HRQOL scores had significantly more PS after operation.

CONCLUSIONS

A significant number of patients with medically recalcitrant GERD (46% from our prospective database) have important PS. LF can improve PS, decrease requirement for pulmonary medications, as well as improve typical reflux symptoms and quality of life.

A review of the atypical manifestations of gastroesophageal reflux disease

Manifestations of atypical gastroesophageal reflux disease (GORD) are varied, and the presentation of atypical symptoms may occur in the absence of typical symptoms. The most sensitive and specific investigation for GORD is pH monitoring, and its application in atypical disease is utilized throughout this paper as a basis for correlating disease and pathogenesis. The less well-known areas of laryngeal manifestations, particularly chronic hoarseness and globus, are discussed in addition to recent work on orodental manifestations. Well-known areas of cardiac and respiratory manifestations, which include chronic cough and asthma, are also reviewed. Evidence from clinical trials indicates that aggressive anti-reflux therapy in patients with atypical symptoms can be effective. Where appropriate, medical therapy may involve long-term proton pump inhibitor, although further research outlining the roles of other therapies such as surgery is awaited.

Management of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is a chronic condition requiring long-term treatment. Simple lifestyle modifications are the first methods employed by patients and, because of their low cost and simplicity, should be continued even when more potent therapies are initiated. Potent acid-suppressive therapy is currently the most important and successful medical therapy. Whereas healing of the esophageal mucosa is achieved with a single dose of any proton pump inhibitor (PPI) in more than 80% of cases, symptoms are more difficult to control. Patients with persistent symptoms on therapy should be tested (preferably with combined multichannel intraluminal impedance and pH) for association of symptoms with acid, nonacid, or no GER. Long-term follow-up studies indicate that PPIs are efficacious, tolerable, and safe medication. So far, promotility agents have shown limited efficacy, and their side-effect profile outweighs their benefits. Antireflux surgery in carefully selected patients (ie, young, typical GERD symptoms, abnormal pH study, and good response to PPI) is as effective as PPI therapy and should be offered to these patients as an alternative to medication. Still, patients should be informed about the risks of antireflux surgery (ie, risk of postoperative dysphagia; decreased ability to belch, possibly leading to bloating; increased flatulence). Endoscopic antireflux procedures are recommended only in selected patients and given the relative short experience with these techniques, patients treated with endoscopic procedures should be enrolled in a rigorous follow-up program.

Managing gastroesophageal reflux disease

A common condition, gastroesophageal reflux disease (GERD) involves the reflux of gastric contents into the esophagus. GERD may contribute to asthma, noncardiac chest pain, and other problems. This article presents trends in GERD management, including pathophysiology, diagnosis, and treatment. The authors also explore lifestyle modifications, pharmacologic therapy, and gastroenterology referral.

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.

Evaluation of omeprazole in the treatment of reflux laryngitis: a prospective, placebo-controlled, randomized, double-blind study

OBJECTIVES

Proton-pump inhibitors are often recommended in the treatment of laryngitis secondary to gastric reflux. Despite prospective treatment studies reporting high efficacy, only one previous report has been placebo-controlled and blinded. The objective of this study was to determine the efficacy of omeprazole in treating proven reflux laryngitis.

STUDY DESIGN

Prospective, placebo-controlled, randomized, double-blind clinical trial.

METHODS

Fifty-three patients with one or more reflux laryngitis symptoms were recruited to undergo 24-hour dual-channel pH probe testing. Thirty patients with more than four episodes of laryngopharyngeal reflux were enrolled. By random assignment, 15 patients received 40 mg omeprazole twice a day and the other 15 received placebo for a period of 2 months. Symptoms (hoarseness, throat pain, lump in throat sensation, throat clearing, cough, excessive phlegm, dysphagia, odynophagia, and heartburn) and endoscopic laryngeal signs (erythema, edema, and mucus accumulation) were recorded initially, at 1 month, and 2 months.

RESULTS

In general, most symptom scores improved over time for both the omeprazole and placebo groups. Hoarseness, when patients begin with low hoarseness symptom scores, and throat clearing improved significantly more in patients on omeprazole than in those on placebo during the 2-month study. Throat pain, lump in throat sensation, excessive phlegm, difficulty swallowing, pain with swallowing, and heartburn showed improvement in both treatment arms, signifying the possibility of a placebo effect. Endoscopic laryngeal signs did not change significantly over the course of the study for either treatment group.

CONCLUSIONS

A placebo effect appears to exist in the treatment of reflux laryngitis. However, hoarseness, when initially scored low, and throat clearing resulting from reflux laryngitis are effectively treated by omeprazole.

Bedtime H2 blockers improve nocturnal gastric acid control in GERD patients on proton pump inhibitors

AIM

Proton pump inhibitors taken twice daily before meals (proton pump inhibitor b.d. AC) effectively controls daytime gastric pH; however, nocturnal gastric acid breakthrough (NAB) occurs in more than 75% of patients. Adding an H2-blocker at bedtime decreases NAB in normal subjects. The efficacy of this regimen has not been evaluated in GERD patients. The aim of this study was to assess the effects of proton pump inhibitor b.d., both with and without bedtime H2-blocker on intragastric pH and the occurrence of NAB in GERD patients.

METHODS

Prolonged ambulatory pH studies in GERD patients were reviewed. Group A: 60 patients (mean age 53 years, male 30) taking either omeprazole 20 mg or lansoprazole 30 mg b.d. Group B: 45 patients (mean age 49 years, male 23) on proton pump inhibitor b.d. (omeprazole 20 mg or lansoprazole 30 mg) plus an H2-blocker at bedtime (ranitidine 300 mg, famotidine 40 mg or nizatidine 300 mg). Eleven patients were evaluated during treatment with both regimens (group C). The percentage time of nocturnal and daytime intragastric pH > 4 and per cent of patients with gastric NAB were analysed. In the patients with NAB, its duration and associated oesophageal acid exposure also were analysed.

RESULTS

Median percentage time intragastric pH > 4 overnight was 51% in group A, compared to 96% in group B (P < 0.0001). Median percentage daytime pH > 4 was 73% in group A and 79.8% in group B (P=0.14). Median percentage time intragastric pH >p 4 overnight increased from 54.6% without H2RA to 96.5% after adding bedtime H2RA (P=0.0013) in group C patients. NAB occurred in 82% patients in group A and 40% in group B (P < 0.0001). The mean duration of oesophageal acid exposure during NAB was significantly shorter in group B (18 +/- 6 min) than in group A (42 +/- 9 min, P=0.04).

SUMMARY

Adding a bedtime H2-blocker to the treatment enhanced nocturnal gastric pH control and decreased NAB compared to the proton pump inhibitor b.d. regimen. A bedtime H2-blocker also decreased oesophageal acid exposure during NAB.

CONCLUSION

Adding a bedtime H2-blocker to a proton pump inhibitor b.d. regimen should be considered in patients who require continued nocturnal gastric acid control whilst taking proton pump inhibitor b.d.