Pharyngeal pH measurements in patients with respiratory symptoms before and during proton pump inhibitor therapy

doi:10.1016/S0002-9610(01)00597-9

The American Journal of Surgery

Volume 181, Issue 5, May 2001, Pages 466-470

https://doi.org/10.1016/S0002-9610(01)00597-9 Get rights and content

Abstract

Background: Pharyngeal pH monitoring is a diagnostic tool used to identify Gastroesophageal reflux disease (GERD) as an etiology of respiratory symptoms. We performed pharyngeal pH monitoring on 14 patients with respiratory symptoms thought to be induced by GERD.

Methods: Symptoms and pH monitoring (esophageal and pharyngeal) were assessed prior to and 3 months after the initiation of double-dose proton pump inhibitor therapy.

Results: Symptoms included cough, hoarseness, and throat clearing. Ten patients had at least one episode of pharyngeal reflux (PR+) and 4 patients had no pharyngeal reflux (PR−). Pharyngeal reflux episodes in PR+ patients decreased from 3.5 to 0.9 (P <0.05) per day with 8 of 10 (80%) patients having elimination or reduction of such episodes. Eight of 9 PR+ patients (89%) with suppressed pharyngeal reflux on medical therapy had resolution of respiratory symptoms. Three of 4 PR− patients (75%) had persistent symptoms on medical therapy.

Conclusions: Proton pump inhibitor therapy improves clinical symptoms and decreases pharyngeal reflux episodes in patients with respiratory symptoms related to GERD. Direct measurement of pharyngeal pH is helpful in the identification of patients likely to respond to antireflux therapy.

Section snippets

Methods

Esophageal function (including pharyngeal pH) was assessed in 14 consecutive patients with respiratory symptoms thought to be related to gastroesophageal reflux. The patients underwent symptom evaluation, pharyngeal pH monitoring, and in some cases laryngoscopy prior to starting (or restarting) medical therapy. After 3 months of medical therapy, using a double dose of proton pump inhibitor, the patients returned for repeat evaluation while continuing to take the medications.

Symptoms

Table 1 describes the most common symptoms reported by these patients. Upon entry into this study, 6 patients were thought to have pulmonary aspiration of refluxed material and the other 8 were thought to have primary laryngeal manifestations of gastroesophageal-pharyngeal reflux. As shown, 3 months of double-dose proton pump inhibitor therapy caused a significant reduction of these symptoms in the majority of the patients.

Pharyngeal and esophageal pH testing

Ten of 14 patients (71%) had pharyngeal reflux documented on the initial

Comments

Although gastroesophageal reflux has long been suspected of causing respiratory symptoms, the ability to link the two has been hampered by lack of an objective way to demonstrate reflux into the airway. Respiratory symptoms respond to medical or operative treatment in only 70% to 80% of patients, which is less than the 85% to 95% response rate of the more classic symptoms of GERD, including heartburn and regurgitation [6], [11], [12], [13], [14]. One explanation for this finding is that

Conclusions

Pharyngeal pH monitoring showed abnormal pharyngeal reflux in 70% of patients with respiratory symptoms. Eighty-nine percent of these patients had a favorable symptomatic response to medical therapy. In these patients, as symptoms decreased, pharyngeal reflux either disappeared or was significantly decreased. In 1 patient with pharyngeal reflux before treatment, whose symptoms continued while on treatment, pharyngeal monitoring showed persistence of pharyngeal reflux. This study provides

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The aim of this study is to identify factors that can predict hiatal hernia recurrence (HHR) in patients after anti-reflux surgery with hiatal hernia (HH) repair.
A single-institution, prospectively collected database was reviewed (January 2002–October 2015) with inclusion criteria of GERD and laparoscopic anti-reflux (AR) surgery with HH repair. Demographics, esophageal symptom scores, and pre- and post-upper gastrointestinal imaging (UGI) were collected. Mesh usage, HH type (sliding, paraesophageal (HH) or type IV), and size were evaluated, and patients who had HHR versus those who did not (NHHR) were compared. Statistical analysis was performed using IBM SPSS v.23.0.0, with α = 0.05.
Three hundred twenty-two patients met inclusion criteria. Mean age was 56.9 ± 14.8 years (60.9% female), and mean follow-up was 19.9 ± 23.8 months. 88.2% underwent total fundoplication and 11.8% underwent partial fundoplication. HHR rate was 15.5%. HHR patients had larger HH than the NHHR group. There was no significant difference between groups for age, gender, BMI, race, and mesh usage. Only 3 patients (10.3%) with HHR reported mild-to-moderate heartburn, regurgitation, and solid or liquid dysphagia at 12-month follow-up. Overall reoperation rate was 1% in this population.
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A citation list search of the remaining 24 studies identified four additional studies for potential inclusion (28 in total). A placebo control group was not included in 10 of these, and they were excluded.23–32 Another study was excluded because it did not specify the definition of GERD used.33
Epidemiologic and physiologic studies suggest an association between gastroesophageal reflux disease (GERD) and chronic cough. However, the benefit of antireflux therapy for chronic cough remains unclear, with most relevant trials reporting negative findings. This systematic review aimed to reevaluate the response of chronic cough to antireflux therapy in trials that allowed us to distinguish patients with or without objective evidence of GERD.
PubMed and Embase systematic searches identified clinical trials reporting cough response to antireflux therapy. Datasets were derived from trials that used pH-metry to characterize patients with chronic cough.
Nine randomized controlled trials of varied design that treated patients with acid suppression were identified (eight used proton pump inhibitors [PPIs], one used ranitidine). Datasets from two crossover studies showed that PPIs significantly improved cough relative to placebo, albeit only in the arm receiving placebo first. Therapeutic gain in seven datasets was greater in patients with pathologic esophageal acid exposure (range, 12.5%-35.8%) than in those without (range, 0.0%-8.6%), with no overlap between groups.
A therapeutic benefit for acid-suppressive therapy in patients with chronic cough cannot be dismissed. However, evidence suggests that rigorous patient selection is necessary to identify patient populations likely to be responsive, using physiologically timed cough events during reflux testing, minimal patient exclusion because of presumptive alternative diagnoses, and appropriate power to detect a modest therapeutic gain. Only then can we hope to resolve this vexing clinical management problem.
Typical GERD symptoms and esophageal pH monitoring are not enough to diagnose pharyngeal reflux
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Abnormal pharyngeal reflux of acid (PR) (as measured by pH monitoring) is associated with microaspiration, and is a good predictor of airway symptom response to medical and surgical anti-reflux therapy. However, in clinical practice the link between airway disease and Gastroesophageal reflux disease (GERD) is still based on the presence of typical symptoms (e.g., heartburn) and/or standard esophageal function testing (manometry and 24-pH monitoring). PR is rarely measured directly. We undertook this study to determine if typical symptoms and standard testing could reliably predict the presence of PR.
The study group consisted of 518 patients with suspected reflux induced airway disease evaluated from December 1998 through January 2002. Each patient completed a standardized symptom questionnaire, underwent esophageal manometry, and 24-h esophageal and pharyngeal pH monitoring. Patients were classified having abnormal pharyngeal reflux (PR+) if they had >1 episode of PR detected during pH monitoring.
One hundred eighty-one patients were PR+ and 337 were PR−. The most common symptoms, namely cough (PR +73%, PR− 68%), hoarseness (PR +64%, PR− 66%), and dyspnea (PR +59%, PR− 59%) were present with similar incidence in PR+ and PR− patients. The incidence of heartburn was 54% in the PR+ and 52% in the PR− patients. Logistic regression analysis revealed that abnormal esophageal acid exposure was a predictor of PR+ (P < 0.001). Neither the presence of heartburn or specific respiratory symptoms, the pressure of the lower esophageal sphincter (LES) or upper esophageal sphincter (UES), or amplitude of esophageal contractions predicted PR+. There was substantial variability in esophageal length (UES to LES), thus the placement of the distal pH probe from the LES varied considerably (median = 13 cm, 2–20 cm). Using established normal values of acid exposure at multiple levels of the esophagus, 24% of PR+ patients had normal amounts of esophageal acid exposure.
Typical GERD symptoms, such as heartburn, and typical symptoms of aspiration such as hoarseness, cough, or dyspnea are not enough to positively identify PR. While patients with abnormal esophageal acid exposure are three times more likely than those with normal values to have PR, abnormal esophageal acid exposure alone does not identify all patients with PR. Therefore, relying on symptoms and standard diagnostic testing may fail to identify patients with extraesophageal reflux. Pharyngeal pH monitoring should be considered for patients with suspected reflux-induced airway disease.
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Although there are no controlled clinical trials assessing the diagnostic utility of 24-hour esophageal pH testing in GER-induced asthma, the American Gastroenterological Association recommends pH testing in patients suspected to have reflux-triggered asthma.54 Studies using proximal esophageal and pharyngeal pH measurements are ongoing and have shown some promise.41 However, the data do not clearly support an advantage to adding proximal esophageal pH testing to distal esophageal pH testing in this clinical setting.49
The association between gastroesophageal reflux disease (GERD) and extraesophageal disease is often referred to as extraesophageal reflux (EER). This article reviews EER, discussing epidemiology, pathogenesis, diagnosis, and treatment with a focus on the most studied and convincing EER disorders—asthma, cough, and laryngitis. Although EER comprises a heterogeneous group of disorders, some general characterizations can be made, as follows. First, although GERD's association with extraesophageal diseases is well-established, definitive evidence of causation has been more elusive, rendering epidemiological data scarce. Secondly, regarding the pathogenesis of EER, 2 basic models have been proposed: direct injury to extraesophageal tissue by acid and pepsin exposure or injury mediated through an esophageal reflex mechanism. Third, because heartburn and regurgitation are often absent in patients with EER, GERD may not be suspected. Even when GERD is suspected, the diagnosis may be difficult to confirm. Although endoscopy and barium esophagram remain important tools for detecting esophageal complications, they may fail to establish the presence of GERD. Even when GERD is diagnosed by endoscopy or barium esophagram, causation between GERD and extraesophageal symptoms cannot be determined. Esophageal pH is the most sensitive tool for detecting GERD, and it plays an important role in EER. However, even pH testing cannot establish GERD's causative relationship to extraesophageal symptoms. In this regard, effective treatment of GERD resulting in significant improvement or remission of the extraesophageal symptoms provides the best evidence for GERD's pathogenic role. Finally, EER generally requires more prolonged and aggressive antisecretory therapy than typical GERD requires.
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In a follow-up study, 10 patients with documented pharyngeal reflux and symptoms including hoarseness, cough, and throat clearing, were treated with double-dose proton pump inhibitor (PPI) therapy for 3 months, and then restudied. Of the 9 patients in whom pharyngeal acid reflux was suppressed on PPI therapy, 8 had resolution of respiratory symptoms.13 Three of the 4 patients who did not have positive pharyngeal reflux at baseline had persistent respiratory symptoms after being treated with PPI therapy for 3 months.
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Laryngoscopy and pharyngeal pH are complementary in the diagnosis of gastroesophageal-laryngeal reflux
2002, Journal of Gastrointestinal Surgery
Pharyngeal pH monitoring and laryngoscopy are routinely used to diagnose gastroesophageal-laryngeal reflux as a cause of respiratory symptoms. Although their use seems intuitive, their ultimate diagnostic value is yet to be defined. We studied 10 asymptomatic (control) subjects and 76 patients with respiratory symptoms. Both patients and control subjects were given a symptom questionnaire. Each underwent direct laryngoscopy using the reflux finding score (RFS) to grade laryngeal injury, esophageal manometry, and 24-hour esophagopharyngeal pH monitoring. The patients were then classified as RFS+, if the score was greater than 7, and pharyngeal reflux (PR)+, if they had more than one episode of PR detected during pH monitoring. The most common symptoms reported by patients were hoarseness (87%), cough (53%), and heartburn (50%). Control subjects had a significantly lower RFS (2.1 vs. 9.6, P < 0.01) and fewer episodes of PR (0.2 vs. 3.4, P < 0.01), than patients. None of the control subjects had more than one episode of PR during a 24-hour period. Fifty patients (66%) were RFS+ and 26 (34%) were RFS−. Thirty-two patients (42%) were PR+ and 44 (58%) were PR−. Fifteen patients had a normal RFS and no PR (group I = RFS−/PR−). Forty patients had discordance between the laryngoscopic findings and the pH monitoring (group II = RFS−/PR+ or RFS+/PR−). Twenty-one patients had both an abnormal RFS and PR (group III = RFS+/PR+). Patients in group III had significantly higher heartburn scores and distal esophageal acid exposure. Eighty-three percent of patients in group III but only 44% in group I improved their respiratory symptoms as a result of antireflux therapy. An abnormal PR or RFS differentiates patients with laryngeal symptoms from control subjects. Agreement between PR and RFS helps establish or refute the diagnosis of gastroesophageal reflux as a cause of laryngeal symptoms. Patients who are RFS+ and PR− may have laryngeal injury from another source, whereas patients who are RFS− and PR+ may not have acid entering the larynx, despite the presence of PR. Patients who are RFS+ and PR+ have more severe gastroesophageal reflux disease and their reflux causes laryngeal damage. Laryngoscopy and pharyngeal pH monitoring should be considered complementary studies in establishing the diagnosis of laryngeal injury induced by gastroesophageal reflux. ( J Gastrointest Surg 2002;6:189–194.)

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Pharyngeal pH measurements in patients with respiratory symptoms before and during proton pump inhibitor therapy

Abstract

Section snippets

Methods

Symptoms

Pharyngeal and esophageal pH testing

Comments

Conclusions

Am J Surg

Gastroenterology

J Voice

Otolaryngol Head Neck Surg

J Gastrointest Surg

Gastroenterology

Am J Surg

J Allergy Clin Immunol

Am J Surg

Gastroenterology