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Prevalence paper

This paper has been published on Academia.edu


Prevalence of Extra-Oesophageal Reflux symptoms amongst acid refluxers and perceived efficacy of regular medication and reflux reduction intervention.

Chris Robinson (Chairman of Barrett’s Wessex) June 2017

Abstract

A previous anecdotal survey of acid reflux patients (Aspiration of Upper Oesophageal Reflux – August 2014, Robinson C) had identified over 14 extra-oesophageal reflux symptoms evinced extensively amongst acid refluxers. Based on those findings, this study sought to confirm the prevalence of those symptoms and the efficacy of Acid Suppressant Medication and Anti-Reflux Surgery to manage them.

Conclusion. Two thirds of patients on ASM still suffered with symptoms of EOR whilst ARS reduced symptoms by 57%.

Recommendation: Patients predominantly exhibiting reflux symptoms should be considered for anti-reflux intervention rather than continued acid suppressant medication.

Methodology

Three parallel surveys were set up targetting different patient groups but using the same questions based on a rationalisation of the symptom list established by the 2014 study into 8 symptom groups concentrating on throat, chest, ears, eyes, nose and mouth manifestations.

Surveys were set up using Survey Monkey and targetted at different Facebook groups.

Analyses and results

Survey 1 targetted refluxers from the “Acid Reflux / GERD /LPR” Facebook support group who didn’t use daily pre-emptive medication but who may use occasional on-demand antacids as and when required. Over the collection period, 51 responses were garnered.

As will be seen in Table 1, throat symptoms were most commonly identified with 63% reporting hoarseness, sore throat, loss of voice, throat clearing as a symptom. The prevalence of the other symptom categories may be seen in table 1: 45% reporting globus, 43% post nasal drip, sinusitis of catarrh, 33% bad breath or taste in mouth, 31% dry or gritty eyes, 31% ear problems: waxing, glue ear, tinnitus or dizziness, 27% chest complaints, cough or asthma like symptoms and 22% dental problems.

Survey 2 targetted refluxers using daily medication from the “Barretts Esophagus Awareness” Facebook group. An initial question identified their usage of H2 blockers or Proton Pump Inhibitors at different doses. The maximum 100 responses were collected within 24 hours. Of those, 5 relied on H2 blockers, 13 on low dose PPI, 44 on high dose PPI (with 2 using H2 blockers to supplement) and 37 on high dose PPI (with 4 using H2 blockers to supplement).

(A medium dose was identified as 20mg omeprazole = 30mg lansoprazole = 40mg pantoprazole = 20mg rabeprazole = 20mg esomeprazole = 30mg dexlansoprazole with anything less regarded as low dose and anything more as high dose.)

As with survey 1, the most prevalent reported symptom was concerned with the throat: hoarseness, sore throat, loss of voice and throat clearing reported by 66% of relfuxers.

The prevalence of the other symptom categories may be seen in table 1: 50% report experiencing globus, 49% nasal problems, 48% ear problems, 46% cough, 44% oral, 42% eyes and 26% dental problems.

It is assumed those with the most prolific symptoms are the predominant users of ASMs. (It is strongly cautioned against jumping to any false conclusions that PPIs actually result in higher incidence of EOR symptoms.)

The dosage level seemed to make little difference. Those on H2 blockers averaged 3 symptoms from the list, on low dose PPI, 3.5 symptoms, medium dose 3.8 symptoms and high dose users 3.6 symptoms.

Survey 3 targetted recipients of anti-reflux intervention via “The Wrap (Nissen Fundoplication)” Facebook group. This used the same questions but required responses of pre and post intervention. 52 responses were amassed during the collection period.

The results are shown in table 2:

Pre intervention, 73% reported the throat issues and 58% globus with 50% reporting cough, 50% oral, 44% nasal, 35% aural, 33% eyes and 33% dental problems.

All but 2 repondees had received Nissen fundoplication, one had had Linx successfully and one had had Stretta unsuccessfully.

Post intervention, reported throat issues had been reduced to 35% oral problems 29%, globus 25%, cough 19% nasal problems 19%, eye problems 17%, ear problems 13% and dental erosion 10%.

A cumulative score of prevalence of symptoms reduced from 47% to 20% as a result of ARS.

Conclusions

In the management of symptoms of extra-oesophageal reflux, acid suppressant medication did not appear to be effective whereas reflux reduction surgery was.

For those exhibiting symptoms of extra-oesophageal reflux, reflux reduction should be considered in preference to acid reduction.

Table 1

Symptoms

Not taking regular medication

Taking regular medication

THROAT: Hoarseness, sore throat, loss of voice, throat clearing

63%


66%


CHEST: Chronic cough or asthma like symptoms

27%


46%


NOSE: Post nasal drip, Poor sense of smell, sinusitis, catarrhal symptoms

43%


49%


THROAT: Globus, feeling of lump in throat.

45%


50%


MOUTH: Tooth erosion

22%


26%


MOUTH: Bad breath or bad taste in mouth

33%


44%


EYES: Dry or gritty eyes

31%


42%


EARS: Waxing, Glue Ear, Tinnitus or dizziness

31%


48%



Table 2

Symptoms

Before intervention

After intervention

THROAT: Hoarseness, sore throat, loss of voice, throat clearing

73%


35%


CHEST: Chronic cough or asthma like symptoms

50%


19%


NOSE: Post nasal drip, Poor sense of smell, sinusitis, catarrhal symptoms

44%


19%


THROAT: Globus, feeling of lump in throat.

58%


25%


MOUTH: Tooth erosion

33%


10

%

MOUTH: Bad breath or bad taste in mouth

50%


29%


EYES: Dry or gritty eyes

33%


17%


EARS: Waxing, Glue Ear, Tinnitus or dizziness

35%


13

%



Addenda
A paper published in World Journal of Gastroenterology in May 2017 "Nissen fundoplication vs proton pump inhibitors for laryngopharyngeal reflux"  using reviews of 53 patients, also concluded:  "Laparoscopic Nissen Fundoplication achieves better improvement than PPIs for LPR."

• 92.6% of patients treated with LINX achieved the primary endpoint success criteria versus 8.6% of patients treated with twice a day omeprazole.
• Significant improvement in quality of life was achieved in 88.9% of patients treated with LINX versus 6.8% of patients treated with twice a day omeprazole.
• Normal levels of reflux were restored in 92% of patients treated with LINX compared to 36% of patients treated with twice a day omeprazole.

*This data was presented at Digestive Disease Week 2017 (DDW) in Chicago, IL, by Dr. Reginald Bell, SurgOne Foregut Institute, Englewood, CO.
PPI’s are intended for acid suppression, not reflux control. The CALIBER study is effectively showing that patients with troublesome regurgitation appear to significantly benefit from the reflux control provided by LINX over omeprazole which primarily affects gastric acidity”, commented Todd Berg CEO, Torax Medical.

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