GASTROENTEROLOGY ARTICLE OF THE WEEK
November 20, 2003
Vaezi MF, Hicks DM, Abelson TI, Richter JE. Laryngeal signs and symptoms and gastroesophageal reflux disease (GERD): A critical assessment of cause and effect association. Clin Gastroenterol Hepatol 2003;1:333-344.
1. The important injurious agents to the larynx in gastric refluxate are
a. food contents
b. conjugated bile acids in an alkaline environment
c. pepsin in an acidic environment
d. conjugated bile acids in an acidic environment
e. pepsin in either an acidic or alkaline environment
2. Laryngoscopic findings that are believed to more specifically correlate with GERD-associated laryngeal damage includes
a. laryngeal erythema
b. laryngeal pseudosulcus [whatever this may be…]
c. reflux finding score >7 [how to calculate the score is a secret]
d. damage to the posterior pharyngeal wall, the true/false vocal folds, the arythenoid medial wall
3. pH studies in the evaluation of suspected GERD-related laryngeal injury
a. is the most accurate test to diagnose this condition
b. locating one of the pH probes in the hypopharynx greatly increases the sensitivity and specificity of the test
c. are usually not needed in the initial (pre-treatment) evaluation of these patients
d. pH probe results are reproducible when the test is repeated in different days
e. hypopharyngeal acid reflux may occur in normal individuals
d. Only 54% of patients with abnormal laryngoscopic findings will have abnormal
esophageal acid exposure irrespective of the pH probe location
4. Use of PPI’s to treat ENT signs and symptoms
a. Should be used once a day, taken in the evening
b. Current literature suggests empiric therapy should be bid, for at least 4 months
c. For non-responders, adding an H2RA at bedtime may increase efficacy
d. After 4 months of bid therapy, about 50%-70% of patients will have symptom response
e. Laryngoscopic findings may take longer than 4 months to resolve, even in patients with improved symptoms
True or False
5. Only intermittent or small amounts of injurious refluxate are needed to cause laryngeal damage
6. Fundoplication should be recommended for those patients with suspected GERD-related ENT complications who do not respond to aggressive PPI therapy for 4 months.
7. Over 80% of patients with laryngoscopic signs suggesting GERD respond to aggressive acid suppression.
8. Globus sensation is a sign of anxiety and is never caused by reflux
9. Close to 90% of normal subjects with no complaints related to GERD will have at least one abnormal laryngoscopic finding that could be attributed to GERD-related injury
10. The approach to a patient with laryngeal signs suspected to be related to GERD should include
a. baseline endoscopy in all patients
b. baseline 24h pH study off therapy in most patients
c. empiric trial of once a day PPI in the evening for 6 months
d. empiric trial of twice a day PPI for 4 months
e. pH study on therapy for non-responders
f. addition of H2RA in the evening for non-responders
g. positioning of the pH probe in the hypopharynx is crucial
h. results of proximal probe acid exposure score are used to define the presence of ENT complications of GERD
