Johan Poelmans

Extraoesophageal manifestations of gastro-oesophageal reflux

A variety of pulmonary and ear, nose, and throat (ENT) symptoms and disorders are considered to be extraoesophageal manifestations of gastro-oesophageal reflux disease (GORD). These extraoesophageal manifestations include asthma, chronic cough, laryngeal disorders, and various ENT symptoms. Recent studies have established that GORD underlies or contributes to chronic sinusitis, chronic otitis media, paroxysmal laryngospasm, excessive throat phlegm, and postnasal drip. Traditionally, management of extraoesophageal GORD manifestations relies on prolonged empiric therapy with high doses of proton pump inhibitors (PPI), followed by pH monitoring under PPI in refractory cases. Recent studies found no benefit of empiric long term high dose PPI therapy. The diagnostic yield of endoscopy in extraoesophageal GORD manifestations seems higher than previously appreciated while pH monitoring under PPI therapy has a low yield. Based on these new findings, a new management algorithm can be proposed that uses short term empiric PPI therapy and GORD investigations off PPI. Well designed controlled studies evaluating the proposed management algorithms and treatment approaches in this area are urgently needed.

Prospective study on the incidence of chronic ear complaints related to gastroesophageal reflux and on the outcome of antireflux therapy.

Over a 2-year period (1997 to 1999), 5 consecutive adult patients with chronic refractory secretory otitis media (CSOM) and 16 with a chronic refractory feeling of pressure in the ear(s) (CRFP) thought to be related to concomitant eustachian tube dysfunction were prospectively studied for coexisting gastroesophageal reflux (GER). All patients underwent an extensive standardized otorhinolaryngological examination, ambulatory 24-hour dual-probe esophageal pH monitoring with a distal pH probe 5 cm and a proximal probe 20 cm above the lower esophageal sphincter, and upper gastrointestinal endoscopy. Most of them also underwent esophageal manometry. All patients with CSOM and 12 of the 16 patients with CRFP had evidence of GER. Only 5 patients experienced heartburn or regurgitation. All patients responded very well to antireflux therapy with omeprazole 20 mg twice per day (40 mg twice per day in 2 patients) accompanied by conservative antireflux measures, ie, complete cessation of their middle ear complaints. This study demonstrates the role of GER in the pathogenesis of refractory CSOM and CRFP and the effectiveness of sustained antireflux therapy.

The Yield of Upper Gastrointestinal Endoscopy in Patients with Suspected Reflux-Related Chronic Ear, Nose, and Throat Symptoms

OBJECTIVES:It is well established that various ENT disorders and symptoms may be a manifestation of gastroesophageal reflux disease (GERD). Erosive esophagitis is considered a rare finding in ENT patients and therefore upper gastrointestinal (GI) endoscopy is not recommended in the diagnostic work-up. However, large prospective studies underscoring this policy are lacking. The aim of the present study was to investigate the prevalence and severity of esophagitis in patients with suspected GERD-related chronic ENT symptoms.METHODS:Endoscopy was performed in 405 ENT patients with suspected GERD and 545 typical GERD patients. The presence of erosive esophagitis, Barretts esophagus, hiatal hernia, peptic ulcer, and Helicobacter pylori infection on biopsies was determined and compared with the results of a symptom questionnaire.RESULTS:The prevalence of erosive esophagitis (52.3%vs 38.4%; p < 0.05), mainly grade 1 (31.9%vs 22.7%; p < 0.05), and of peptic ulcer (8.4%vs 4.3%; p < 0.05) was significantly higher in patients with GERD-related ENT symptoms compared to typical GERD. Barretts mucosa occurred in, respectively, 4.9% and 4.5% of the patients (NS). Esophagitis prevalence was highest in patients with predominant cough and lowest in globus pharyngeus and throat symptoms. The presence of esophagitis was associated with significantly higher rates of symptom relief during the first 8 wk of proton pump inhibitor (PPI) therapy.CONCLUSIONS:Patients with suspected GERD-related ENT symptoms have a high prevalence of esophagitis and this is associated with better response to antisecretory therapy.

Characteristics and clinical relevance of proximal esophageal pH monitoring

OBJECTIVE:It is well established that various ENT disorders and symptoms may be a manifestation of gastroesophageal reflux disease (GERD). Measuring proximal esophageal acid exposure might be useful in the evaluation of patients with suspected reflux-related ENT manifestations, but the limited available data are conflicting. The aim of the present study was to study the determinants of proximal esophageal acid exposure (PR) and to evaluate the clinical usefulness of ambulatory proximal pH monitoring.METHODS:Twenty healthy controls and 346 patients with suspected reflux disease underwent typical and atypical GERD symptom assessment, endoscopy, esophageal manometry and ambulatory combined dual esophageal pH, and Bilitec duodeno-gastro-esophageal reflux exposure (DGER) monitoring. The presence of pathological PR and its relation to symptom pattern and distal esophageal acid exposure (DR) and DGER exposure were analyzed.RESULTS:Fifty-seven patients (16%) had pathological PR. Demographic characteristics, symptom pattern, and manometric findings did not differ in patients with normal or pathological PR. Patients with pathological PR had significantly higher DR and DGER. The multivariate analysis identified only pathological DR as an independent risk factor for the presence of pathological PR (odds ratio 4.515, 95% CI 2.48–8.23, p < 0.0001). Only 20 patients (6%) had pathological proximal reflux without pathological distal acid reflux.CONCLUSION:The findings of the present article do not support routine proximal esophageal pH monitoring as a clinical tool: PR does not differentiate patients with typical or atypical GERD manifestations and depends mainly on DR.

Chronic middle ear disease and gastroesophageal reflux disease : A causal relation?

Objective To describe one patient with a puzzling therapy-resistant unilateral chronic otitis media, analyze his diagnosis, and describe three similar patients with the same symptoms and signs, i.e., a chronic ear problem together with gastroesophageal reflux disease (GERD). Study Design Thorough analysis of one patient with a chronic ear problem and GERD, both of which responded favorably after antireflux therapy consisting of omeprazole and conservative antireflux measures (raising the head of the bed by 20 to 25 cm, avoiding meals and drinks 3 hours before retiring, and other dietary and lifestyle modifications), and a search for more patients with similar coexisting conditions. Setting Tertiary referral center. Methods Patients with chronic ear problems and GERD were thoroughly analyzed by the otorhinolaryngologist and the gastroenterologist. The latter used endoscopy and Savary-Millers classification of esophagitis, a 24-hour ambulatory dual esophageal pH monitoring, and esophageal manometry. Results Four patients were identified who had a chronic ear problem and simultaneous GERD. It is reasoned that the GERD leads to nasopharyngitis and this to a chronic ear problem. All the patients responded favorably to anti-GERD therapy. Conclusions GERD may manifest itself as an extraesophageal manifestation, such as nasopharyngitis, leading to ear disease. Therapy-resistant chronic middle ear disease may be caused by GERD.

Determinants of Long-Term Outcome of Patients with Reflux-Related Ear, Nose, and Throat Symptoms

Gastroesophageal reflux disease (GERD) is present in up to 75% of patients with chronic refractory ear, nose, and throat (ENT) symptoms, and proton pump inhibitor (PPI) therapy induces symptom relief in the majority of these patients. It has been suggested that endoscopic findings and quantification of esophageal acid exposure may help to predict the long-term outcome of medical therapy, but prospective studies that confirm this hypothesis are lacking. The aim of the present study was to investigate the relationship of endoscopic findings and quantification of reflux with long-term outcome in patients with reflux-related ENT symptoms. One hundred six consecutive patients with chronic refractory unexplained ENT symptoms underwent upper GI endoscopy, 24-hr dual-channel esophageal pH and Bilitec (n = 35) monitoring, and esophageal manometry. Subsequently, all were treated with omeprazole, 20 mg b.i.d., and patients were followed at 2-week intervals until symptom relief. Four weeks later, omeprazole therapy was gradually decreased and the lowest effective omeprazole maintenance dose, if any, was determined. Eighty-one patients (49 men; mean age, 50) experienced a clear or excellent therapeutic response after, on average, 4 weeks of omeprazole, 20 mg b.i.d. In 36 patients (44%; group A), PPI treatment could be stopped completely, 27 patients (33%; group B) required a maintenance dose of omeprazole, 20 mg/day, and 18 patients (22%; group C) required maintenance with omeprazole, 40 mg/day. The prevalence of reflux esophagitis was significantly lower in group A patients, who also had significantly lower distal esophageal acid exposure, proximal esophageal acid exposure, and esophageal duodenogastroesophageal reflux exposure compared to groups B and C. Multivariate analysis identified the presence of esophagitis and pathological distal esophageal acid exposure as risk factors for the need of maintenance therapy. In patients with reflux-related ENT symptoms, initial findings on upper GI endoscopy and 24-hr pH-metry help to predict the need for maintenance therapy.

Paroxysmal laryngospasm: a typical but underrecognized supraesophageal manifestation of gastroesophageal reflux?

Thirty-five consecutive adult patients with paroxysmal laryngospasm (LS) and with unimpaired vocal fold mobility were prospectively studied for coexisting gastroesophageal reflux disease (GERD). Nineteen patients reported frequent (>3 episodes a week) LS episodes (FLS patients) and 16 patients reported occasional LS episodes (OLS patients). All patients underwent an extensive otorhinolaryngological (ORL) examination, upper gastrointestinal (GI) endoscopy, ambulatory 24-hr dual-channel esophageal pH monitoring, and esophageal manometry. In addition, a subset of LS patients also underwent ambulatory duodenogastroesophageal reflux (DGER) monitoring. Patients with daily LS used the symptom marker during pH monitoring indicating separate LS episodes. All FLS patients and 14 OLS patients (87%) had a diagnosis of GERD. Only 10 patients (29%) experienced heartburn and/or regurgitation. Compared to OLS patients, FLS patients generally had more severe GERD as indicated by a higher prevalence of a hiatus hernia, higher distal and proximal esophageal acid exposure times, and higher values of DGER. In six FLS patients, 21 LS episodes (91%) occurred simultaneously with acid reflux, indicating a causal association between LS and GER. On antireflux therapy consisting of omeprazole, 20 mg bid, or lansoprazole, 30 mg oid, and lifestyle measures, LS ceased completely in all patients within 6 weeks. The present study not only demonstrates the role of GER in the pathogenesis of LS and the effectiveness of antireflux therapy, but also suggests that LS in adult patients with unimpaired vocal fold mobility might be considered a typical, although most frequently unrecognized, supraesophageal manifestation of GER.

The Role of (Duodeno)gastroesophagopharyngeal Reflux in Unexplained Excessive Throat Phlegm

Gastroesophageal reflux (GER), through the occurrence of gastroesophagopharyngeal reflux (GEPR), is an established cause of several otorhinolaryngological (ORL) manifestations. It has been suggested that unexplained excessive throat phlegm might also be a manifestation of GER, but formal evidence is lacking. The aim of the present study was to investigate the prevalence of GER as well as duodenogastroesophageal reflux (DGER) in consecutive patients with chronic complaints of excessive throat phlegm. Fifty-nine consecutive patients with chronic unexplained excessive throat phlegm, transparent in 33 patients (TTP) and yellow in 26 patients (YTP), underwent gastrointestinal endoscopy, 24-hr dual esophageal pH monitoring, and fiberoptic DGER monitoring. Proximal esophageal DGER monitoring was performed in seven YTP patients and analysis of bile acids in throat phlegm was performed on 16 samples. The effect of high-dose acid suppressive therapy was evaluated at 2-week intervals. Endoscopy and pH monitoring established a diagnosis of pathological GER in 75% of the patients. Pathological DGER was present in 56% of the patients and this was associated with YTP. Proximal DGER exposure was high in all investigated subjects and chemical analysis revealed a median bile acid concentration of 0.184 μM in nine YTP samples and no detectable bile acids in seven TTP samples. After a median of 4 weeks of acid suppressive therapy, most patients improved and 61% became asymptomatic. YTP patients were more likely to require maintenance acid suppressive therapy than TTP patients. Unexplained excessive throat phlegm is a sign suggestive of GER and GEPR, and unexplained yellow throat phlegm a sign suggestive of duodenogastroesophagopharyngeal reflux (DGEPR).

Episodic Laryngospasm: A manifestation of gastroesophageal reflux disease

Aims: To show whether the eradication of HP with H2 receptor antagonists and antibiotics is jus t as effective as the treatment with Omeprazole and antibiotics. Methods: The study population consisted of 70 patie nts who were confirmed as having HP infection and also acute duodenal ulcers . These patients were treated over a 7 day period at random with 250 mg Clarithromycine, 400 mg Metronidazole and additionally with either 300 mg Nizatidine or 20 mg Omeprazole b.d.. 5 weeks after cessation of the antibiotic therap y the healing of the ulcers and eradication of the HP infect ion was evaluated. Results: The healing and eradication rate showed 97% in both groups. Conclusion: The H2 receptor antagonist Nizatidine is exactly comparable with Omeprazole when used within the eradication schemes . The same results can be shown for other H2 receptor antagonists. 5910