Multichannel intraluminal impedance in the evaluation of patients with persistent globus on proton pump inhibitor therapy

Is there Really a Lump in My Throat? The Incidence and Implication of Vocal fold Abnormalities in Patients Presenting with Globus

OBJECTIVE

To identify the prevalence of vocal fold abnormalities in patients with a primary complaint of globus sensation. Secondly, to determine the relationship between globus, vocal fold abnormality, and patient-reported quality of life questionnaire score.

STUDY DESIGN

Retrospective chart review.

METHODS

A retrospective chart review was performed to identify all new patients evaluated at a tertiary academic care laryngology practice between January 2018 and December 2018 presenting with a chief complaint of globus. Variables of interest include age, gender, laryngeal symptoms, self-reported quality-of-life questionnaire results, and laryngostroboscopy findings. Questionnaires selected for this investigation include the reflux symptom index (RSI), eating assessment tool-10 (EAT-10), and voice handicap index-10 (VHI-10).

RESULTS

Two hundred twenty-eight subjects with an average age of 54 ±17 years, were categorized based on one of three laryngostroboscopic findings: absence of vocal fold abnormality, vocal fold paresis/paralysis (motion abnormality), or a vocal fold mass lesion. Fifty percent of patients reporting globus had a normal laryngeal exam, and 50% had a mass lesion or motion abnormality. Twenty five percent had vocal fold motion abnormality (paresis, paralysis, or supraglottic squeeze); 19% had a mass lesion; and 3% had both a lesion and motion abnormality. The average self-reported survey scores were compared among the three groups. Patients with dysphonia had a significantly higher VHI-10 (P = 0.00), and a significantly higher RSI (P = 0.00) than those without dysphonia. Those patients with dysphagia had significantly higher EAT-10 (P = 0.00) and RSI (P = 0.02) scores than those who did not have dysphagia. Patients with vocal fold motion abnormality had significantly higher VHI-10 than those with normal vocal fold mobility (P = 0.02) CONCLUSIONS: Identifying the etiology of globus presents a significant challenge to laryngologists. Data presented here suggest that vocal fold abnormalities may contribute to the sensation of globus and should therefore be considered in the differential when managing these patients.

Proximal reflux frequency not correlated with atypical gastroesophageal reflux disease (GERD) symptoms

Though most known for heartburn and regurgitation, gastroesophageal reflux disease (GERD) is attributed to countless atypical, extra-esophageal (EE) manifestations like cough and throat clearing. While GERD has been studied extensively, the relationship between reflux character and symptom manifestation remains poorly understood. The aim of this study was to examine proximal reflux frequency and its relationship with typical or atypical symptoms. 540 (75.1% female, 24.9% male) pH-impedance monitoring studies from the last 3-years were divided by symptom indication and retrospectively reviewed for proximal reflux frequency, total acid exposure time, mean nocturnal baseline impedance, and total reflux episodes in both abnormal and normal, and borderline studies. Baseline characteristics were also collected. Both total reflux events and mean proximal reflux frequency were found to differ significantly between those with typical versus atypical symptoms. Total reflux events [median (IQR)] were 43.5 (24.0-74.0) in typical patients and 35.0 (20.0-57.0) in atypical patients (P-value 0.0369). Proximal reflux frequency [median (IQR)] was 12.0 (4.0-19.0) typical and 7.0 (3.0-17.0) atypical (P-value 0.0348). Results for exclusively abnormal studies also favored typical patients but not significantly. Baseline characteristics and use of gastric acid control did not differ significantly. Proximal reflux frequency was observed to increase among those with typical GERD symptoms. Total acid reflux events were also significantly higher on average with typical patients. Our findings that proximal reflux frequency is reduced in patients with atypical symptoms compared with patients with typical symptoms suggest that proximal reflux exposure may play a significant role in the symptom presentation of typical classic heartburn and regurgitation symptoms. The differential diagnosis for atypical EE symptoms is vast and can be multifactorial. Our results indicate proximal reflux events may contribute to atypical EE symptoms less than previously reported.

ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) continues to be among the most common diseases seen by gastroenterologists, surgeons, and primary care physicians. Our understanding of the varied presentations of GERD, enhancements in diagnostic testing, and approach to patient management have evolved. During this time, scrutiny of proton pump inhibitors (PPIs) has increased considerably. Although PPIs remain the medical treatment of choice for GERD, multiple publications have raised questions about adverse events, raising doubts about the safety of long-term use and increasing concern about overprescribing of PPIs. New data regarding the potential for surgical and endoscopic interventions have emerged. In this new document, we provide updated, evidence-based recommendations and practical guidance for the evaluation and management of GERD, including pharmacologic, lifestyle, surgical, and endoscopic management. The Grading of Recommendations, Assessment, Development, and Evaluation system was used to evaluate the evidence and the strength of recommendations. Key concepts and suggestions that as of this writing do not have sufficient evidence to grade are also provided.

Modified Reflux Scintigraphy Detects Pulmonary Microaspiration in Severe Gastro-Esophageal and Laryngopharyngeal Reflux Disease

INTRODUCTION

Previously described methodologies for detecting laryngopharyngeal reflux (LPR) have limitations. Symptoms alone are non-diagnostic, and pH-impedance studies have poor sensitivity. Pulmonary micro-aspiration is under-recognised in LPR and gastro-esophageal reflux disease (GERD). The present study aimed to describe the results of a modified technique for scintigraphic reflux studies in two groups with severe reflux: those with typical reflux symptoms and those with laryngopharyngeal manifestations of reflux.

METHODS

A prospective database of severely symptomatic, treatment-resistant reflux patients was grouped based upon predominant symptom profile of typical GERD or LPR. All patients underwent reflux scintigraphy. Results were obtained for early scintigraphic reflux contamination of the pharynx and proximal esophagus, and delayed contamination of the pharynx and lungs after 2 h.

RESULTS

187 patients were studied (82 GERD, 105 LPR). The LPR patients were predominantly female (70.5% vs. 56.1%; p = 0.042) and older than the GERD group (median age 60 years vs. 55.5 years; p = 0.002). Early scintigraphic reflux was seen at the pharynx in 89.2% (GERD 87.7%, LPR 90.4%; p = 0.133), and at the proximal esophagus in 89.7% (GERD 88.9%, LPR 90.4%; p = 0.147). Delayed contamination of the pharynx was seen in 95.2% (GERD 93.9%, LPR 96.2%; p = 0.468). Delayed pulmonary aspiration was seen in 46% (GERD 36.6%, LPR 53.3%; p = 0.023).

CONCLUSION

Reflux scintigraphy demonstrated a high rate of reflux-related pulmonary aspiration. Contamination of the proximal esophagus and pharynx was observed frequently in both groups of severe disease. The likelihood of pulmonary aspiration and potential pulmonary disease needs to be entertained in severe GERD and LPR.

A new diagnostic paradigm for laryngopharyngeal reflux disease: correlation of impedance-pH monitoring and digital reflux scintigraphy results

PURPOSE

No gold-standard investigation exists for laryngopharyngeal reflux (LPR). Multichannel intraluminal impedance (MII)-pH testing has uncertain utility in LPR. Meanwhile, reflux scintigraphy allows immediate and delayed visualisation of tracer reflux in the esophagus, pharynx, and lungs. The present study aimed to correlate MII-pH and scintigraphic reflux results in patients with primary LPR.

METHODS

Consecutive patients with LPR underwent MII-pH and scintigraphic reflux studies. Abnormal values for MII-pH results were defined from existing literature. MII-pH and scintigraphic data were correlated.

RESULTS

105 patients with LPR [31 males (29.5%), median age 60 years (range 20-87)] were studied. Immediate scintigraphic reflux was seen in the pharynx in 94 (90.4%), and in the proximal esophagus in 94 (90.4%). Delayed scintigraphic contamination of the pharynx was seen in 101 patients (96.2%) and in the lungs of 56 patients (53.3%). For MII-pH, abnormally frequent reflux was seen in the distal esophagus in 12.4%, proximal esophagus in 25.7%, and in the pharynx in 82.9%. Patients with poor scintigraphic clearance had higher Demeester scores (p = 0.043), more proximal reflux episodes (p = 0.046), more distal acid reflux episodes (p = 0.023), and more prolonged bolus clearance times (p = 0.002).

CONCLUSION

Reflux scintigraphy has a high yield in LPR patients. Scintigraphic time-activity curves correlated with validated MII-pH results. A high rate of pulmonary microaspiration was found in LPR patients. This study demonstrated a high level of pharyngeal contamination by scintigraphy and MII-pH, which supports the use of digital reflux scintigraphy in diagnosing LPR.

Does the Reflux Symptom Index Predict Increased Pharyngeal Events on HEMII-pH Testing and Correlate with General Quality of Life?

OBJECTIVES

To determine the ability of the reflux symptom index (RSI) to predict objective impedance and pH-probe testing, and to examine the relationship between disease-specific and general health status in patients diagnosed with laryngopharyngeal reflux (LPR).

METHODS

Adults presenting to a tertiary care academic center with a primary voice complaint completed the RSI and the Patient-Reported Outcomes Measurement Information System 10-item global health instrument (PROMIS). An RSI score ≥13 was considered abnormal. Objective testing for LPR was performed using hypopharyngeal-esophageal multichannel intraluminal impedance catheter with dual pH (HEMII-pH) testing; a positive test was defined as more than one pharyngeal impedance events over 24 hours. Spearman rho analyses were applied, and the sensitivity and specificity of the RSI to detect HEMII-pH findings were determined.

RESULTS

One hundred four patients underwent HEMII-pH testing. Mean scores were 16.7 (95%CI 15.1-18.3) for RSI. Sixty-three (60.6%) patients were diagnosed with LPR by HEMII-pH testing. RSI scores were moderately correlated with PROMIS physical (Spearman rho 0.43, P < 0.0001), social (Spearman rho 0.33, P < 0.0001) and mental health (Spearman rho 0.33, P < 0.0001) scores. The RSI has a sensitivity and specificity of 66.7% and 31.7%, respectively, for detecting pharyngeal events on HEMII-pH testing.

CONCLUSIONS

There is moderate sensitivity and lack of specificity of the RSI for detecting increased pharyngeal reflux events. Reflux-specific and general health status instruments are correlated. Further investigation could assess the diagnostic ability of RSI compared proximal reflux events on HEMII-pH, as well as whether health status instruments can be used to detect clinically meaningful change in the LPR population.

Duodenogastroesophageal reflux and its effect on extraesophageal tissues: A review

We conducted a literature review to identify elements of duodenogastroesophageal reflux (DGER)—namely pancreatic fluids, hydrochloric acid, pepsin, and bile—as to the effects each has when refluxed to the extraesophageal structures. Further, we wished to acquaint clinicians with the possibilities that, in addition to hydrochloric acid, the other components of DGER are likewise contributing to disease in the extraesophageal areas. Our review included studies that have indicated reflux of the above mentioned components of DGER to the pharynx, larynx, tracheobronchial tree, oral cavity, nasopharynx, nose and sinuses, eustachian tube, and middle ear. Findings demonstrate that injury to the upper aerodigestive tract can occur from a variety of substances secreted from the stomach and duodenum. Treatment for DGER is nonspecific. We conclude that patients with an incomplete response to acid suppression may have significant involvement of pepsin, bile, or both. Future studies are needed to clarify the importance of these elements and to suggest more precise treatments.

Comparison of esophageal motility in gastroesophageal reflux disease with and without globus sensation

BACKGROUNDS AND AIMS

This study aimed to compare the esophageal motility between gastroesophageal reflux disease (GERD) patients with typical symptoms but without globus sensation and GERD patients only with globus symptoms.

METHODS

A total of 57 consecutive GERD patients diagnosed by endoscopy or by 24-hour pH monitoring between May 2013 and September 2015 were included retrospectively into the study. The patients were grouped based on the presence or absence of globus. Thirty patients presented with typical reflux symptoms but without globus were assigned to the typical GERD group and 27 patients only with globus symptom were assigned to the globus GERD group. All patients underwent esophageal high resolution manometry (HRM) and the differences in esophageal motility between the two groups were analyzed.

RESULTS

The globus GERD group showed a significantly greater lower esophageal sphincter (LES) length, LES basal pressure and upper esophageal sphincter (UES) residual pressure than that of the typical GERD group (3.47 ± 0.76 vs. 2.65 ± 0.62 cm, 21.71 ± 9.68 vs. 16.04 ± 8.49 mmHg, 7.30 ± 4.42 vs. 4.12 ± 2.92 mmHg, all p < 0.05). There was no significant difference between the two groups in terms of the distal wave amplitude, mean wave duration, distal contractile integral (DCI), contractile front velocity (CFV), distal latency (DL), integrated relaxation pressure (IRP) and UES basal pressure. The incidence of esophageal dysmotility in the globus GERD group (33.3%) was higher than in the typical GERD group (23.3%). There was no significant difference in esophageal acid exposure of the non-erosive gastroesophageal reflux disease (NERD) patients between the two groups.

CONCLUSIONS

Globus GERD patients have a higher UES residual pressure, longer LES length, higher LES basal pressure and greater esophageal dysmotility than typical GERD patients. HRM is useful in evaluating esophageal motility of GERD patients.

Extraesophageal Symptoms and Diseases Attributed to GERD: Where is the Pendulum Swinging Now?

The purpose of this review is to outline the recent developments in the field of extraesophageal reflux disease and provide clinically relevant recommendations. The recommendations outlined in this review are based on expert opinion and on relevant publications from PubMed and EMbase. The Clinical Practice Updates Committee of the American Gastroenterological Association proposes the following recommendations: Best Practice Advice 1: The role of a gastroenterologist in patients referred for evaluation of suspected extra esophageal symptom is to assess for gastroesophageal etiologies that could contribute to the presenting symptoms. Best Practice Advice 2: Non-GI evaluations by ENT, pulmonary and/or allergy are essential and often should be performed initially in most patients as the cause of the extraesophageal symptom is commonly multifactorial or not esophageal in origin. Best Practice Advice 3: Empiric therapy with aggressive acid suppression for 6-8 weeks with special focus on response of the extraesophageal symptoms can help in assessing association between reflux and extraesophageal symptoms. Best Practice Advice 4: No single testing methodology exists to definitively identify reflux as the etiology for the suspected extra esophageal symptoms. Best Practice Advice 5: Constellation of patient presentation, diagnostic test results and response to therapy should be employed in the determination of reflux as a possible etiology in extra esophageal symptoms. Best Practice Advice 6: Testing may need to be off or on proton pump inhibitor (PPI) therapy depending on patients' presenting demographics and symptoms in assessing the likelihood of abnormal gastroesophageal reflux. A. On therapy testing may be considered in those with high probability of baseline reflux (those with previous esophagitis, Barrett's esophagus or abnormal pH). B. Off therapy testing may be considered in those with low probability of baseline reflux with the goal of identifying moderate to severe reflux at baseline. Best Practice Advice 7: Lack of response to aggressive acid suppressive therapy combined with normal pH testing off therapy or impedance-pH testing on therapy significantly reduces the likelihood that reflux is a contributing etiology in presenting extraesophageal symptoms. Best Practice Advice 8: Surgical fundoplication is discouraged in those with extra esophageal reflux symptoms unresponsive to aggressive PPI therapy. Best Practice Advice 9: Fundoplication should only be considered in those with a mechanical defect (e.g., hiatal hernia), moderate to severe reflux at baseline off PPI therapy who have continued reflux despite PPI therapy and have failed more conservative non-GI treatments.

Pharyngeal manifestations of gastroesophageal reflux disease

This article discusses the extraesophageal manifestations of gastroesophageal reflux disease, focusing primarily on the gamut of pharyngeal abnormalities that can be detected on barium swallows. Abnormalities of pharyngeal swallowing caused by gastroesophageal reflux are illustrated. We particularly emphasize how pharyngoesophageal relationships can guide the radiologist for performing tailored barium swallows to optimally evaluate pharyngeal abnormalities in patients with underlying gastroesophageal reflux disease.

Facts and Fantasies on Extraesophageal Reflux: A Gastroenterologist Perspective

Gastroesophageal reflux disease encompasses a wide spectrum of disorders related to the reflux of gastric contents into the esophagus. Extraesophageal reflux (EER) may be suspected in patients with unexplained chronic cough, pharyngolaryngeal symptoms, and asthma. For physicians, suspected EER is challenging as there is currently no tool that can reliably make a definitive diagnosis. Endoscopic signs are not specific, pharyngeal and proximal reflux monitoring are not reliable, and if distal pH or pH-impedance monitoring can identify patients with abnormal reflux, they cannot predict the response to therapy. Controlled randomized trials have failed to reliably demonstrate any benefit of high-dose proton-pump inhibitors over placebo in patients with laryngeal symptoms, chronic cough, and asthma. Overall, the role of gastroesophageal reflux has been largely overestimated in patients with suspected EER. Especially when proton-pump inhibitors failed to improve symptoms, other diagnosis should be considered, such as functional laryngeal disorders which are probably much more prevalent in these patients than pathologic gastroesophageal reflux.

The importance of combined 24-hour multichannel intraluminal impedance-pH monitoring in the evaluation of children with suspected laryngopharyngeal reflux

OBJECTIVE

The aim of this study was to investigate the diagnostic usefulness of combined multichannel intraluminal impedance-pH (MII-pH) monitoring in children with suspected laryngopharyngeal reflux (LPR).

DESIGN, SETTING AND PARTICIPANTS

A prospective study including children in whom, due to LPR suggestive symptoms, MII-pH monitoring was performed at tertiary medical centre from February 2012 to July 2015.

INTERVENTIONS

All included children underwent same diagnostic protocol which included examination by single pulmonologist and ENT specialist and underwent 24-hour MII-pH monitoring.

MAIN OUTCOMES

Primary outcome was to determine MII-pH characteristics of the children in whom LPR was suspected based on symptoms and ENT examination.

RESULTS

One hundred and four patients (mean age 8.9 years; range 0.4-17.9 years; male/female 57/47) participated in the study. In children with signs and symptoms suggestive of LPR, MII-pH monitoring found the median incidence of proximal gastro-oesophageal reflux (GER) of 15 (range 0-129), proximal acidic GER of 6.5 (range 0-66) and weakly acidic GER of 5 (range 0-102). There were significant positive correlations between the number of GER (proximal total, acidic and weakly acid) with Reflux Finding Score, Reflux Symptom Index and presence of eosinophils in nasal swabs. The only endoscopy ENT finding which significantly correlated with total proximal GER, acid proximal GER and weakly acidic proximal GER was arytenoid hyperaemia.

CONCLUSION

Both acid and non-acid reflux seem to have a significant role in the pathogenesis of LPR.

Management of refractory typical GERD symptoms

The management of patients with refractory GERD (rGERD) is a major clinical challenge for gastroenterologists. In up to 30% of patients with typical GERD symptoms (heartburn and/or regurgitation), acid-suppressive therapy does not provide clinical benefit. In this Review, we discuss the current management algorithm for GERD and the features and management of patients who do not respond to treatment (such as those individuals with an incorrect diagnosis of GERD, inadequate PPI intake, persisting acid reflux and persisting weakly acidic reflux). Symptom response to existing surgical techniques, novel antireflux procedures, and the value of add-on medical therapies (including prokinetics and reflux inhibitors) for rGERD symptoms are discussed. Pharmaceutical agents targeting oesophageal sensitivity, a condition that can contribute to symptom generation in rGERD, are also discussed. Finally, on the basis of available published data and our expert opinion, we present an outline of a current, usable algorithm for management of patients with rGERD that considers the timing and diagnostic use of pH-impedance monitoring on or off PPI, additional diagnostic tests, the clinical use of baclofen and the use of add-on neuromodulators (tricyclic agents and selective serotonin reuptake inhibitors).

The complexity of globus: a multidisciplinary perspective

Globus is a topic of interest for many specialties including otorhinolaryngology, gastroenterology and psychiatry/psychosomatic medicine, but, although many hypotheses have been suggested, key questions about its aetiology remain. This Review provides an overview of the extensive literature concerning this topic and discusses the quality of the evidence to date. Globus has been associated with oropharyngeal structural lesions, upper oesophageal sphincter disorders, oesophageal disorders, GERD, psychosocial factors and psychiatric comorbidity. However, findings are often contradictory and the literature remains highly inconclusive. Indeed, with the exception of patients with structural-based globus, the Rome III criteria for functional globus only apply to a subgroup of patients with idiopathic globus. In clinical reality, there exists a group of patients who present with idiopathic (nonstructural) globus, but nevertheless have dysphagia, odynophagia or GERD-exclusion criteria for globus diagnosis according to Rome III. The symptomatology of patients with globus might be broader than previously thought. It is therefore crucial to approach globus not from one single perspective, but from a multifactorial point of view, with focus on the coexistence and/or interactions of different mechanisms in globus pathogenesis. This approach could be translated to clinical practice by adopting a multidisciplinary method to patients presenting with globus.

Upper esophageal sphincter dysfunction: diverticula-globus pharyngeus

The following discussion of upper esophageal sphincter dysfunction includes commentaries on the role of the cricopharyngeus muscle in reflux disease; the etiology and treatment of Zenker diverticulum; the use of videofluoroscopy in patients with dysphagia, suspicion of aspiration, or globus; the role of pH-impedance monitoring in globus evaluation; and treatment for reflux-associated globus.

High-resolution Manometry and Globus: Comparison of Globus, Gastroesophageal Reflux Disease and Normal Controls Using High-resolution Manometry

Background/Aims

Globus is a foreign body sense in the throat without dysphagia, odynophagia, esophageal motility disorders, or gastroesophageal reflux. The etiology is unclear. Previous studies suggested that increased upper esophageal sphincter pressure, gastroesophageal reflux and hypertonicity of esophageal body were possible etiologies. This study was to quantify the upper esophageal sphincter (UES) pressure, contractile front velocity (CFV), proximal contractile integral (PCI), distal contractile integral (DCI) and transition zone (TZ) in patient with globus gastroesophageal reflux disease (GERD) without globus, and normal controls to suggest the correlation of specific high-resolution manometry (HRM) findings and globus.

Methods

Fifty-seven globus patients, 24 GERD patients and 7 normal controls were studied with HRM since 2009. We reviewed the reports, and selected 5 swallowing plots suitable for analysis in each report, analyzed each individual plot with ManoView. The 5 parameters from each plot in 57 globus patients were compared with that of 24 GERD patients and 7 normal controls.

Results

There was no significant difference in the UES pressure, CFV, PCI and DCI. TZ (using 30 mmHg isobaric contour) in globus showed significant difference compared with normal controls and GERD patients. The median values of TZ were 4.26 cm (interquartile range [IQR], 2.30-5.85) in globus patients, 5.91 cm (IQR, 3.97-7.62) in GERD patients and 2.26 cm (IQR, 1.22-2.92) in normal controls (P = 0.001).

Conclusions

HRM analysis suggested that UES pressure, CFV, PCI and DCI were not associated with globus. Instead increased length of TZ may be correlated with globus. Further study comparing HRM results in globus patients within larger population needs to confirm their correlation.

High-resolution Manometry and Globus: Comparison of Globus, Gastroesophageal Reflux Disease and Normal Controls Using High-resolution Manometry

BACKGROUND/AIMS

Globus is a foreign body sense in the throat without dysphagia, odynophagia, esophageal motility disorders, or gastroesophageal reflux. The etiology is unclear. Previous studies suggested that increased upper esophageal sphincter pressure, gastroesophageal reflux and hypertonicity of esophageal body were possible etiologies. This study was to quantify the upper esophageal sphincter (UES) pressure, contractile front velocity (CFV), proximal contractile integral (PCI), distal contractile integral (DCI) and transition zone (TZ) in patient with globus gastroesophageal reflux disease (GERD) without globus, and normal controls to suggest the correlation of specific high-resolution manometry (HRM) findings and globus.

METHODS

Fifty-seven globus patients, 24 GERD patients and 7 normal controls were studied with HRM since 2009. We reviewed the reports, and selected 5 swallowing plots suitable for analysis in each report, analyzed each individual plot with ManoView. The 5 parameters from each plot in 57 globus patients were compared with that of 24 GERD patients and 7 normal controls.

RESULTS

There was no significant difference in the UES pressure, CFV, PCI and DCI. TZ (using 30 mmHg isobaric contour) in globus showed significant difference compared with normal controls and GERD patients. The median values of TZ were 4.26 cm (interquartile range [IQR], 2.30-5.85) in globus patients, 5.91 cm (IQR, 3.97-7.62) in GERD patients and 2.26 cm (IQR, 1.22-2.92) in normal controls (P = 0.001).

CONCLUSIONS

HRM analysis suggested that UES pressure, CFV, PCI and DCI were not associated with globus. Instead increased length of TZ may be correlated with globus. Further study comparing HRM results in globus patients within larger population needs to confirm their correlation.

Management of globus pharyngeus

Globus pharyngeus is a common ENT condition. This paper reviews the current evidence on globus and gives a rational guide to the management of patients with globus. The aetiology of globus is still unclear though most ENT surgeons believe that reflux whether acidic or not plays a significant role. Though proton pump inhibitors are used extensively in practice, there is little evidence to support their efficacy. Most patients with globus can be discharged after simple office investigations. The role of pepsin-induced laryngeal injury is an exciting concept that needs further study. Given the benign nature of globus pharyngeus, in most cases, reassurance rather than treatment or extensive investigation with rigid oesophagoscopy or contrast swallows is all that is needed. We need more research into the aetiology of globus.

Role of Acid and weakly acidic reflux in gastroesophageal reflux disease off proton pump inhibitor therapy

BACKGROUND/AIMS

Available data about reflux patterns and symptom determinants in the gastroesophageal reflux disease (GERD) subtypes off proton pump inhibitor (PPI) therapy are lacking. We aimed to evaluate reflux patterns and determinants of symptom perception in patients with GERD off PPI therapy by impedance-pH monitoring.

METHODS

We retrospectively reviewed the impedance-pH data in patients diagnosed as GERD based on results of impedance-pH monitoring, endoscopy and/or typical symptoms. The characteristics of acid and weakly acidic reflux were evaluated. Symptomatic and asymptomatic reflux were compared according to GERD subtypes and individual symptoms.

RESULTS

Forty-two patients (22 males, mean age 46 years) were diagnosed as GERD (17 erosive reflux disease, 9 pH(+) non-erosive reflux disease [NERD], 9 hypersensitive esophagus and 7 symptomatic NERD). A total of 1,725 reflux episodes were detected (855 acid [50%], 857 weakly acidic [50%] and 13 weakly alkaline reflux [< 1%]). Acid reflux was more frequently symptomatic and bolus clearance was longer compared with weakly acidic reflux. In terms of globus, weakly acidic reflux was more symptomatic. Symptomatic reflux was more frequently acid and mixed reflux; these associations were more pronounced in erosive reflux disease and symptomatic NERD. The perception of regurgitation was related to acid reflux, while that of globus was more related to weakly acidic reflux.

CONCLUSIONS

In patients not taking PPI, acid reflux was more frequently symptomatic and had longer bolus clearance. Symptomatic reflux was more frequently acid and mixed type; however, weakly acidic reflux was associated more with globus. These data suggest a role for impedance-pH data in the evaluation of globus.

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.

Reflux episode reaching the proximal esophagus are associated with chronic cough

Background/Aims

Gastroesophageal reflux (GER) has been implicated in the pathogenesis of chronic cough. The aims of this study were to evaluate the diagnostic usefulness of multichannel intraluminal impedance combined with pH monitoring (MII/pH monitoring) in patients with suspected symptoms of gastroesophageal reflux disease (GERD) and to assess the correlation between GER symptoms and reflux nature.

Methods

Seventy patients with suspected symptoms of GERD (such as heartburn, acid regurgitation, non-cardiac chest pain, globus and chronic cough) were enrolled. All patients were asked to discontinue medications that would influence esophageal motor function and gastric acid secretion at least one week ago. All subjects underwent MII/pH monitoring.

Results

Forty-five patients (64.3%) were diagnosed with GERD. Among these patients, eleven patients (15.7%) had pathologic acid reflux by pH data and thirty-four patients (48.6%) had pathologic bolus exposure by impedance. Subjects with chronic cough had a higher DeMeester score (p=0.009), percentage of acid exposure time (p=0.007), acid bolus exposure % time (p=0.027), distal acid reflux episodes (p=0.015) and proximal acid reflux episodes (p=0.030) than subjects without chronic cough.

Conclusions

The results of this study showed that the impedance monitoring enhanced diagnostic sensitivity than pH-monitoring alone by 48.6%. In addition, reflux episodes at the distal and proximal esophagus were noted to be important factors associated with chronic cough.

How much pharyngeal exposure is "normal"? Normative data for laryngopharyngeal reflux events using hypopharyngeal multichannel intraluminal impedance (HMII)

BACKGROUND

Laryngopharyngeal reflux (LPR) can cause atypical symptoms, asthma, and pulmonary fibrosis. The aim of this study was to establish the normative data for LPR using hypopharyngeal multichannel intraluminal impedance-pH (HMII).

METHODS

Asymptomatic subjects underwent endoscopy followed by 24-h HMII using a specialized impedance catheter configured to detect LPR before and after a 2-week course of proton pump inhibitors (PPI). Subjects were excluded if they had esophageal pathology or a positive DeMeester score. A cohort of 24 LPR patients who had a complete response to treatment was used for comparison with the normative data.

RESULTS

Forty subjects were enrolled. Thirty-four subjects completed one, and 25 completed both HMII testing periods off and on PPI. There was no difference in the total number of reflux events between off and on PPI [22 (8-32) and 24 (10-28), respectively, p = 0.89]. The 95th percentiles of LPR off and on PPI were 0 and 1, respectively. All patients with treatment responsive LPR had pre-treatment HMII values of LPR greater than the 95th percentile.

CONCLUSION

LPR events are rare in an asymptomatic population. One or more LPR events should be considered abnormal in patients with LPR symptoms regardless of whether there is a positive DeMeester score.

Is impedance pH monitoring superior to the conventional 24-h pH meter in the evaluation of patients with laryngorespiratory symptoms suspected to be due to gastroesophageal reflux disease?

OBJECTIVE

Cough and laryngo-pharyngeal symptoms (LPS) are associated with gastroesophageal reflux disease (GERD). The role of acid reflux (AR) and non-acid reflux (NAR) in atypical GERD pathogenesis is controversial. The aims of the study were to determine the prevalence of high esophageal acid exposure time (AET) in patients presenting with cough or LPS and determine the incremental yield of multichannel intraluminal impedance-pH (MII-pH) monitoring.

METHODS

We undertook a prospective study of patients with cough or LPS referred for GERD evaluation between January 2009 and May 2011. All patients underwent esophageal manometry, gastroscopy and MII-pH. Patients' characteristics, gastroscopy findings, distal esophageal AET, bolus exposure (BE) time and numbers of AR and NAR episodes in the proximal and distal esophagus were studied.

RESULTS

Overall 50 patients (22 male, mean age 47.5 ± 14.2 years) were evaluated for unexplained chronic cough (n = 23, 46.0%), and LPS symptoms including globus (n = 10, 20.0%), sore throat (n = 12, 24.0%) and hoarse voice (n = 5, 10.0%). A normal gastroscopy, Los Angeles grade A and B esophagitis occurred in 44 (88.0%), 5 (10.0%) and 1 (2.0%) patient, respectively. Seven (14.0%) recorded elevated AET (chronic cough, 4; sore throat, 2; and hoarse voice, 1). Nine patients recorded abnormal impedance characteristics (raised BE time and/or increased reflux numbers) despite a normal AET leading to an incremental diagnostic yield of 18%.

CONCLUSION

An isolated high AET is uncommon in patients with cough or LPS. Combined MII-pH improves the diagnostic yield in patients with atypical GERD manifestations.

[Diagnosis of gastroesophageal reflux disease: a systematic review]

The prevalence of gastoesophageal reflux disease (GERD) has been rapidly increased in Korea during last 20 years. However, there has been no systematic review regarding this disease. The aim of this article was to provide a review of available diagnostic modalities for GERD. This review includes proton pump inhibitor (PPI) test, endoscopy, ambulatory pH monitoring, impedance pH monitoring, and esophageal manometry in order to provide a basis for the currently applicable recommendations in the diagnosis of GERD in Korea. With weekly heartburn or acid regurgitation, the prevalence of GERD has been reported as 3.4% to 7.9%, indicating an increase of GERD in Korea. As the prevalence of Barrett's esophagus has been reported to be low, the screening endoscopy for Barrett's esophagus is not recommended. Several recent meta-analyses re-evaluated the value of the PPI test in patients with typical GERD symptoms and non-cardiac chest pain. That is, the PPI test has been proven to be a sensitive tool for diagnosing GERD in patients with non-cardiac chest pain and in some preliminary trials regarding extraesophageal manifestations of GERD. Ambulatory pH monitoring of the esophagus helps to confirm gastroesophageal reflux in patients with persistent symptoms (both typical and atypical) in the absence of esophageal mucosal damage, especially when a trial of acid suppression has failed. Impedance pH test is useful in refractory reflux patients with primary complaints of typical GERD symptoms, but this value has not been proved in patients with non-cardiac chest pain or extraesophageal symptoms. This systematic review is targeted to establish the strategy of GERD diagnosis, which is essential for the current clinical practice.

Do patients with globus sensation respond to hypnotically assisted relaxation therapy? A case series report

Globus sensation is a bothersome and difficult symptom to treat. The aims of this study were to evaluate the acceptability and utility of hypnotically-assisted relaxation (HAR) in decreasing the perception of globus sensation and the effect of HAR on interdeglutitive upper esophageal sphincter (UES) pressure. Sixteen subjects with persistent globus sensation unresponsive to therapy for reflux disease and with normal esophageal/laryngeal imaging studies were invited to participate in a 7-session clinical protocol. Before and after HAR, subjects completed standard questionnaires including the esophageal symptoms questionnaire. High-resolution manometric assessment of respiratory augmentation and average resting UES pressure were assessed before and after HAR. Ten of the 16 subjects agreed to participate in the protocol. All participants were women with median age 51.5 (range 30-72 years). The participants found HAR acceptable and completed the entire 7-session trial. Globus symptom severity varied widely pre-treatment (median=52.5, range 16-72), and 9 of 10 subjects reported a reduction in globus symptomatology following treatment (median=14.0, range 3-19; P=.007). Only 1 subject exhibited abnormal respiratory augmentation of UES pressure (>27 mm Hg) prior to treatment and was normal following treatment (9.9 mm Hg). Resting UES pressure was normal in all subjects (<118 mm Hg). Group respiratory augmentation and average resting UES pressure were unaffected by HAR (P=.48, .89). This case series suggests that HAR can provide a substantial improvement in globus sensation irrespective of cause. UES function was unaffected. We suggest that HAR therapy is an acceptable and useful intervention for patients with globus sensation.

Combined Dual Channel Impedance/pH-metry in Patients With Suspected Laryngopharyngeal Reflux

BACKGROUND/AIMS

Laryngopharyngeal symptoms of gastroesophageal reflux disease (GERD) such as globus sensation, hoarseness and chronic cough are becoming increasingly recognized. This study was aimed to investigate the diagnostic usefulness of combined dual channel multichannel intraluminal impedance (MII)/pH-metry in 'off-proton pump inhibitor (PPI)' patients with suspected laryngopharyngeal reflux.

METHODS

Ninety-eight patients with laryngopharyngeal symptoms of GERD were included. All patients were 'off-PPI' state for at least 2 weeks prior to the study, and underwent endoscopy and dual channel combined MII/pH-metry.

RESULTS

The mean age of the patients was 49.8 +/- 10.9 years and there were 44 males (44.9%). Fifty-three patients (54.1%) showed pathologic gastroesophageal reflux (GER). Combined dual channel MII/pH-metry achieved highest diagnostic yield of 49.0% and diagnostic yield of single channel combined MII/pH-metry was 37.8%. Addition of MII to standard pH-metry increased twofold of the diagnostic yield for detecting GER. Among 37 patients (37.8%) who had pathologic GER being detected by MII/pH-metry, 19 patients (19.4%) had nonacid GER (nonacid GER group) while 18 patients (18.4%) had acid GER (acid GER group). Pathologic GER group, as classified by MII/pH-metry showed more frequent globus sensation than nonpathologic GER group. Acid GER group had more proximal reflux than nonacid GER group, especially in the upright position.

CONCLUSIONS

In this study, combined dual channel MII/pH-metry showed the highest diagnostic yield for detecting GER. This technique can be performed primarily to accurately diagnose laryngopharyngeal reflux disease and exclude other causes of laryngopharyngeal symptoms.

Management of laryngopharyngeal reflux: an unmet medical need

Laryngopharyngeal reflux (LPR) is defined by the association of laryngeal symptoms with laryngeal inflammation at laryngoscopy. However, these symptoms are difficult to characterize and the laryngoscopic signs lack specificity. Moreover, to date, the diagnosis of LPR can rely neither on esophageal investigations (endoscopy, pH/impedance monitoring) nor on response to high dose proton pump inhibitors because of a high placebo effect. Therefore, there is a need for the development of new tools which may help to better identify the subgroup of patients with laryngeal symptoms related to supra-esophageal reflux.

Globus jugularis and dysphagia in patients with hiatus hernia

The aim of the article was to study if there is any relationship between globus sensation in the jugular fossa (GJ), intermittent esophageal dysphagia (IED), and the presence of a hiatus hernia, and if GJ can be relieved after hiatus hernia repair. 167 patients with a hiatus hernia (Group A) and 61 other patients with hiatus hernia and gastroesophageal reflux disease who were surgically treated with Nissen fundoplication (Group B), filled in a symptom questionnaire on GJ and IED. GJ was found in 66% and IED in 68% of patients in group A. In group B, 49% had GJ and 64% IED before surgery. At surgical follow-up 16% (P < 0.005) and 43% (P < 0.05) had GJ and IED, respectively. The combination of GJ and IED was found in 28% of IED patients before operation and in 31% at surgical follow-up. The high frequency of GJ in patients with hiatus hernia and the significant relief of GJ after hiatus hernia repair imply that GJ most likely is a referred sensation from the esophagus. IED and GJ are two parallel phenomena in patients with hiatus hernia, but do not seem to have any causal relationship.

Utility of non-endoscopic investigations in the practical management of oesophageal disorders

The current available methods for diagnosis of GORD are symptom questionnaires, catheter and wireless pH-metry, impedance-pH monitoring and Bilitec(@). Osophageal pH monitoring allows both quantitative analysis of acid reflux and assessment of reflux-symptom association. Impedance-pH monitoring detects all types of reflux (acid and non-acid) and allows assessment of proximal extent of reflux, a relevant parameter for understanding symptoms perception and extraoesophageal symptoms. Bilitec provides a quantitative assessment of duodeno-gastro-oesophageal reflux. Oesophageal motor abnormalities have been associated with GORD symptoms as well as chest pain and dysphagia. High-resolution manometry contributed to re-classify oesphageal motor disorders. However, barium swallows are still essential for evaluation of oesophageal anatomy and combined oesophageal manometry-impedance can assess oesophageal motility and bolus transit simultaneously in a non-radiological way. Still in experimental phase, high-frequency ultrasound allows monitoring of the oesophageal wall thickness and exaggerated longitudinal muscle contraction that might be associated to chest pain and dysphagia. This chapter provides a critical evaluation of the clinical application of these techniques.

Gastroesophageal reflux disease and idiopathic pulmonary fibrosis

Gastroesophageal reflux disease occurs with a higher prevalence in patients with idiopathic pulmonary fibrosis than in matched controls. Silent reflux occurs in about a third of patients with significant gastroesophageal reflux disease; thus, objective measurements are required to evaluate gastroesophageal reflux disease in patients with advanced lung diseases. We provide here a detailed description of acid and non-acid reflux and the diagnostic evaluation for pulmonologists and lung transplant surgeons suspecting reflux as a contributing factor in advanced lung diseases. We review the evidence for gastroesophageal reflux disease causing idiopathic pulmonary fibrosis and other select pulmonary diseases and the potential role of antireflux surgery in the management of advanced lung disease and transplant patients.

The diagnosis and management of globus pharyngeus: our perspective from the United Kingdom

PURPOSE OF REVIEW

To review recent literature on diagnostic and treatment options for globus pharyngeus.

RECENT FINDINGS

There are no controlled studies looking at the use of proton pump inhibitors specifically for globus. The small volume of level I evidence has failed to demonstrate superiority of proton pump inhibitors over placebo for treatment of laryngopharyngeal reflux symptoms (including globus). A recent pilot nonplacebo-controlled study has shown promising results for treating laryngopharyngeal reflux symptoms with liquid alginate suspension. The role of cognitive-behavioural therapy may hold hope for patients with refractory symptoms. A small randomized trial showed promising results for treating globus with speech therapy, but larger trials are required. There is no evidence for the use of antidepressants or anxiolytics.

SUMMARY

After many decades of interest, the most popular organic theory that 'a lump in the throat' is reflux related is still challenged by lack of strong evidence for empiric antacid treatment of this symptom. Globus pharyngeus is a clinical diagnosis and not a diagnosis of exclusion and overinvestigating these patients is unnecessary. Complete history and otolaryngological examination, fibreoptic laryngoscopy or transnasal oesophagoscopy with reassurance and monitoring of symptom progress with validated symptom questionnaires appear to remain the mainstay of management.

The diagnosis and management of globus: a perspective from Japan

PURPOSE OF REVIEW

The etiology of globus is multifactorial and its management is controversial. Recent findings in the etiology and diagnosis of globus are discussed, and a subjective opinion on its management is presented.

RECENT FINDINGS

Although there is considerable debate concerning the role of gastroesophageal reflux disease (GERD) in patients with globus, the globus symptom score has been shown to be significantly higher in patients with GERD than in those without GERD. This definite association between GERD and globus leads to the practical division of patients with globus into two groups: the GERD/laryngopharyngeal reflux (LPR)-induced and non-GERD/LPR groups. When the presence of GERD or LPR or both is established in patients with globus, management of this condition should be considered. Owing to limitations in the technology for the detection of GERD/LPR, precise discrimination between the two groups is still difficult. For practical purposes, empirical approaches for targeting GERD in patients with globus appear to be justified. A 24 h pH-metry/multichannel intraluminal impedance test may increase the detection of reflux events in patients with globus.

SUMMARY

A practical approach for dividing patients with globus into GERD/LPR-induced and non-GERD/LPR groups is introduced.

The diagnosis and management of globus: a perspective from the United Kingdom

PURPOSE OF REVIEW

Globus pharyngeus is a common disorder that accounts for approximately 4% of new ear, nose and throat referrals. The presenting symptoms are a cause of anxiety for patients and clinicians alike. There is a great deal of controversy surrounding the diagnosis and treatment of this disorder. This article discusses current trends in the management of this condition.

RECENT FINDINGS

Globus symptoms are associated with proximal reflux. Globus symptoms in patients with laryngopharyngeal reflux treated with proton pump inhibitor resolve more slowly than classic reflux symptoms in patients with gastroesophageal reflux. Thyroid surgery may help improve globus symptoms in patients with goiter. Short-tem results suggest that speech therapy is effective in relieving symptoms of globus.

SUMMARY

The cause of globus symptoms remains an enigma. The diagnosis of this symptom complex is essentially clinical. There is a limited role for investigations in patients with atypical symptoms. Treatment remains controversial and includes reassurance, speech therapy and proton pump inhibitors in patients with laryngopharyngeal reflux.

Hyperdynamic upper esophageal sphincter pressure: a manometric observation in patients reporting globus sensation

OBJECTIVES

Although globus sensation is a common symptom, its pathogenesis is poorly defined. The aim of this study was to quantify the timing and magnitude of respiratory variation in upper esophageal sphincter (UES) pressure with high-resolution manometry (HRM) in patients with globus sensation, normal controls, and gastroesophageal reflux disease (GERD) patients without globus sensation.

METHODS

HRM recordings spanning from the hypopharynx to the stomach were analyzed in 131 consecutive globus patients with normal (64) and abnormal (67) distal esophageal motility. Resting UES pressure was analyzed up to 5 min before 10 5-ml water swallows. Change in UES pressure, its average magnitude between inspiration and expiration, and nadir UES relaxation pressure in globus patients were compared with those in 68 controls and 46 GERD patients without globus.

RESULTS

UES pressure typically increased during inspiration in both controls and patients. Respiration-related change in resting UES pressure was significantly amplified in globus patients (37.3 mm Hg) compared with controls (10.6 mm Hg) and GERD patients (13.0 mm Hg) (P<0.0001). A respiratory change in UES pressure>27 mm Hg was found in >60% of globus patients and <15% of controls and GERD patients without globus. This hyperdynamic UES was not associated with other abnormalities of esophageal motor function.

CONCLUSIONS

Hyperdynamic respiratory UES pressure changes were prevalent in patients reporting globus sensation irrespective of their deglutitive UES and distal esophageal motility. Although the etiology of this hyperdynamic UES is unclear, it does appear to be a frequent manometric observation in this patient group and may provide a new focus for further studies into pathogenesis and therapy.

Globus: are we any nearer to understanding it?

Globus is a common functional symptom without a clearly accepted etiology. Upper esophageal sphincter (UES) hypertension and gastroesophageal reflux have been proposed but not confirmed. Kwiatek et al. report a detailed study in globus patients using high-resolution manometry (HRM). The study showed greater respiratory augmentation of UES pressure compared with control groups among two-thirds of globus patients. Further prospective studies are needed to confirm these findings and to establish whether they are of etiologic significance.

Gastroesophageal reflux monitoring: pH (catheter and capsule) and impedance

Diagnostic testing for GERD has evolved to include multi esophageal sites (distal, proximal and hypopharyngeal monitoring), wireless pH, and oropharyngeal devices. The versatility of the devices has increased our ability to better understand the role of acid reflux in various disorders involving reflux of acid. Wireless pH monitoring improves patient comfort and allows monitoring for gastroesophageal reflux events over several days. Ambulatory MII-pH monitoring is another exciting diagnostic tool, which is capable of detecting more than one type of reflux and achieves higher sensitivity and specificity to detect GERD than endoscopy or pH-metry. It is useful in patients with either typical or atypical reflux symptoms who are refractory to proton pump inhibitor (PPI) therapy. In this setting, MII-pH can be performed on PPI therapy to assess the efficacy of PPIs and the role of nonacid or acid reflux in persistent symptoms.

Ambulatory monitoring of GERD: current technology

Various techniques have been devised to diagnose, characterize, and classify gastroesophageal reflux (GER). Stationary techniques, such as fluoroscopy and scintigraphy, provide interesting anatomic and functional information related to GER but are not sensitive enough and are usually performed in nonphysiologic conditions. Ambulatory techniques for GER monitoring have been developed and used since 1974. The current available techniques include catheter and wireless pH-metry, Bilitec, and impedance-pH monitoring. Prolonged wireless pH monitoring can be useful to evaluate patients off and on proton pump inhibitor (PPI) treatment. Impedance-pH monitoring is being used increasingly in patients who have persistent symptoms on PPI therapy because it can establish an association between symptoms and weakly acidic or nonacid reflux. Bilitec is performed in patients suspected to have increased duodenogastroesophageal reflux (DGER). This article discusses the technical details, clinical indications, and applications of these diagnostic techniques.

High-resolution manometry and impedance-pH/manometry: valuable tools in clinical and investigational esophagology

Both high-resolution manometry (HRM) and impedance-pH/manometry monitoring have established themselves as research tools and both are now emerging in the clinical arena. Solid-state HRM capable of simultaneously monitoring the entire pressure profile from the pharynx to the stomach along with pressure topography plotting represents an evolution in esophageal manometry. Two strengths of HRM with pressure topography plots compared with conventional manometric recordings are (1) accurately delineating and tracking the movement of functionally defined contractile elements of the esophagus and its sphincters, and (2) easily distinguishing between luminal pressurization attributable to spastic contractions and that resultant from a trapped bolus in a dysfunctional esophagus. Making these distinctions objectifies the identification of achalasia, distal esophageal spasm, functional obstruction, and subtypes thereof. Ambulatory intraluminal impedance pH monitoring has opened our eyes to the trafficking of much more than acid reflux through the esophageal lumen. It is clear that acid reflux as identified by a conventional pH electrode represents only a subset of reflux events with many more reflux episodes being composed of less acidic and gaseous mixtures. This has prompted many investigations into the genesis of refractory reflux symptoms. However, with both technologies, the challenge has been to make sense of the vastly expanded datasets. At the very least, HRM is a major technological tweak on conventional manometry, and impedance pH monitoring yields information above and beyond that gained from conventional pH monitoring studies. Ultimately, however, both technologies will be strengthened as outcome studies evaluating their utilization become available.

Response rate and predictors of response in a short-term empirical trial of high-dose rabeprazole in patients with globus

BACKGROUND

Although the aetiology of globus (the sensation of a lump in the throat) remains unclear, gastro-oesophageal reflux disease is associated with globus. A short-term trial with a high-dose proton pump inhibitor has been shown to be a sensitive tool for diagnosing gastro-oesophageal reflux disease.

AIM

To see whether patients with globus symptom responded to short-term high-dose rabeprazole trial and assess predictors of symptom response.

METHODS

Sixty-four patients with globus symptom were analysed. Patients received rabeprazole 20 mg b.d. for 14 days. Patients completed a daily diary assessing the severity and frequency of globus.

RESULTS

Forty-one patients (64%) were diagnosed clinically with gastro-oesophageal reflux disease. Based on the pH testing and endoscopy, the prevalence of gastro-oesophageal reflux disease was 22% (14 of 64). The globus symptom score was significantly higher in patients with gastro-oesophageal reflux disease compared with patients without gastro-oesophageal reflux disease (P = 0.004). Two patients (3%) had complete resolution and 22 (34%) had more than a 50% improvement in the globus symptom score. Endoscopic findings (P = 0.714), pathological acid exposure on pH testing (P = 0.741) or baseline gastro-oesophageal reflux disease symptoms (P = 0.606) were not associated with improvement of globus symptom.

CONCLUSION

While gastro-oesophageal reflux disease may be an aggravating factor in patients with globus, it does not appear to be the sole cause of globus symptom.

Impedance-pH monitoring: new standard for measuring gastro-oesophageal reflux

Impedance monitoring is a new technique that can be used to detect the flow of fluids and gas through hollow viscera. With impedance monitoring gastro-oesophageal reflux can be detected independent of its acidity by differences in electrical impedance between the mucosal surface, fluids and gas that surround the catheter. Clinically, it is used in combination with oesophageal pH monitoring, and the combination of impedance-pH monitoring allows recognition of both acidic and weakly acidic reflux episodes. Studies have shown that impedance-pH monitoring is useful in the evaluation of patients with proton pump inhibitor-resistant typical reflux symptoms, as it provides a higher yield in detecting reflux as the cause of a patient's symptoms compared to pH monitoring alone. It is therefore likely that impedance-pH monitoring will largely replace pH monitoring in the next 5 years and it will become the standard for reflux detection.

Esophageal impedance-pH monitoring

Classical techniques like endoscopy and esophageal pH-metry are routinely used to study patients with symptoms related to gastroesophageal reflux disease (GERD). Although these techniques have been useful over the years both for diagnosis and therapeutic guidance, there are still many patients with typical or atypical GERD symptoms with normal endoscopy and pH-metry that do not respond adequately to antisecretory therapy. Ambulatory esophageal impedance-pH monitoring is a new technique that can be used to evaluate all types of gastroesophageal reflux, achieving higher rates of sensitivity and specificity than standard techniques. This review describes esophageal impedance-pH monitoring, summarizing the current literature on validation studies and clinical application.