LPR

Checking on a number of different on-line forums and facebook pages each day, I noticed many common questions concerning symptoms which I had also previously experienced (see the Barrett's and Refluxer pages), so I ran a patient survey and obtained these results.

A copy of this paper may be downloaded at the bottom of the page.

2014 August

Aspiration of Upper Oesophageal Reflux

Chris Robinson

Chairman of Barrett's Wessex

Background and Aims

Acid reflux has been the focus of many studies of reflux at the Lower Oesophageal Sphincter (GORD) readily identified by symptoms such as heartburn which may lead to the pre-cancerous lesion, Barrett's oesophagus. Normal treatment is usually delivered via Acid Suppressant Medication (PPIs or H2RAs) to reduce acidity and damage to the oesophagus.

Although other reflux symptoms, e.g. chronic cough, have been recognised, they have frequently been attributed to LOS reflux and attempts to medicate with ASMs have been largely ineffective.

This study proposes reflux via the Upper Oesophageal Sphincter (cricopharyngeus), also commonly referred to as LaryngoPharyngeal Reflux (LPR), requires better understanding.

Methods

A simple Anecdotal Patient survey was established. Using commonly reported symptoms reported via on-line forums and facebook groups, a simple questionnaire was developed using Survey Monkey.

Limitations: Only 100 responses were allowed without excessive expenditure.

Structure and design: One simple question listed 13 commonly reported symptoms and requested respondents to indicate which they experienced. An extra box allowed for further symptoms to be listed. Respondents could only undertake the survey once.

The questionnaire was advertised on the following On-line forums: Barrett's Oesophagus Campaign forum, MD Junction GERD forum, MD Junction Barrett's Esophagus forum, Health Central Acid Reflux forum, and Facebook groups: Barrett's Wessex, Barrett's Esophagus Awareness, Raising Awareness – Cancer of the Oesophagus, LINX surgery for GERD. The 100 responses limit of the questionnaire was exceeded within 2 days.

Results

From the list of symptoms presented,

70% reported experiencing Hoarseness, 64% constant throat clearing, 58% post nasal drip, 58% chronic cough, 53% sinusitis, 53% bad taste in mouth, 50% Globus (lump in throat), 42% Asthma-like symptoms (shortness of breath), 41% tooth decay or sharp edges to teeth, 35% Catarrhal symptoms (blocked nose), 35% Loss of voice, 35% dry or gritty eyes, 30% nocturnal ear waxing (particularly right ear {reflux being more common when lying on the right side})

In other responses, the following indicators were highly indicated: Bad breath, Tinnitus, Hyposmia (poor sense of smell), Sore throat.

Retrospectively, whilst most of the respondents were assumed to have been taking ASMs due to their presence on the specified forums, this was not established within the questionnaire.

Conclusions

Although GOR is commonly recognised, extra-oesophageal reflux via the UOS requires further attention. GORD medication may not be efficacious for LPR. Reflux reduction surgery may be more appropriate.

References

Shaheen NJ, Crockett SD, Bright SD, Madanick RD, Buckmire R, Couch M, Galanko JA, Sharpless G, Morgan DR, Spacek MB, Heidt-Davis P, Henke D Randomised clinical trial: high-dose acid suppression for chronic cough - a double-blind, placebo-controlled study. Alimentary Pharmacology & Therapeutics. 2011 Jan

CONCLUSION: In subjects with chronic cough and rare or no heartburn, high-dose proton pump inhibitor does not improve cough-related quality of life or symptoms.http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2036.2010.04511.x/full

Naik RD, Vaezi MF. Extra-esophageal manifestations of GERD: who responds to GERD therapy?

Current Gastroenterology Reports. 2013 Apr.

PPI-unresponsive patients usually have causes other than GERD for their extra-esophageal signs and symptoms and continued PPI therapy in this group is not recommended. http://www.ncbi.nlm.nih.gov/pubmed/23435747

Hom C1, Vaezi MF. Extra-esophageal manifestations of gastroesophageal reflux disease: diagnosis and treatment. Drugs. 2013 Aug.

unresponsive patients usually have causes other than GERD for their extra-esophageal symptoms and continued PPI therapy in this group is not recommended. http://www.ncbi.nlm.nih.gov/pubmed/23881666

Ates F1, Vaezi MF. Approach to the patient with presumed extraoesophageal GERD. Best Practice and Research: Clinical Gastroenterol. 2013 Jun

more research into reflux related extraoesophageal symptoms are needed to better diagnose and treat this group. http://www.ncbi.nlm.nih.gov/pubmed/23998979

Harding SM1, Allen JE, Blumin JH, Warner EA, Pellegrini CA, Chan WW. Respiratory manifestations of gastroesophageal reflux disease. Annals of New York Academy of Science. 2013 Oct

search for a marker for microaspiration and reflux-induced airway disease http://www.ncbi.nlm.nih.gov/pubmed/24117633

Lee JS1, Lee YC1, Kim SW2, Kwon KH3, Eun YG4. Changes in the quality of life of patients with laryngopharyngeal reflux after treatment. Journal of Voice. 2014 Jul

PPI treatment for 3 months could improve the QOL of patients diagnosed with LPR. http://www.ncbi.nlm.nih.gov/pubmed/24598356

Zerbib F1, Sifrim D2, Tutuian R3, Attwood S4, Lundell L5. Modern medical and surgical management of difficult-to-treat GORD. United European Gastroenterology Journal. 2013 Feb

Approximately 30-40% of patients taking proton pump inhibitors (PPIs) for presumed gastro-oesophageal reflux (GOR) symptoms do not achieve adequate symptom control, especially when … extra-oesophageal symptoms are concerned http://www.ncbi.nlm.nih.gov/pubmed/24917938

Saritas Yuksel E1, Vaezi MF. Extraesophageal manifestations of gastroesophageal reflux disease: cough, asthma, laryngitis, chest pain. Swiss Medical Weekly. 2012 Mar

Poor response to PPI therapy may be an important indicator for non-GER causes for patients' symptoms and should initiate a search for other potential causes. http://www.ncbi.nlm.nih.gov/pubmed/22442097

Wong IW, Rees G, Greiff L, Myers JC, Jamieson GG, Wormald PJ Gastroesophageal reflux disease and chronic sinusitis: In search of an esophageal-nasal reflex. American Journal of Rhinol Allergy. 2010 Jul-Aug

These results support the possibility that a neural reflex exists between the esophagus and the paranasal sinuses via the vagus nerve. http://www.ingentaconnect.com/content/ocean/ajra/2010/00000024/00000004/art00004

Further

The use of the following anti-reflux techniques have been reviewed: Fundoplication (Nissen, Toupet, Collis, Belsey), Transoral Incisionless Fundoplication (Endostim, StomaphyX, EsophyX, EndoCinch, MUSE), LINX, Stretta, Angelchik, Enteryx, Plicator, Gatekeeper

This paper (from Aetna insurance) evaluated some of them:

Clinical Policy Bulletin: Gastroesophageal Reflux Disease (GERD): Treatment Devices http://www.aetna.com/cpb/medical/data/200_299/0213.html