Observational cohort study: Getting to the bottom of laryngopharyngeal reflux—It’s a motility disorder and not just about the acid

Abstract

Summary Background Laryngopharyngeal reflux (LPR) has been linked with irritable bowel syndrome (IBS). Functional colonic, upper gastrointestinal (GI) and LPR symptoms often coexist and all improve with osmotic laxative therapy. Reflux scintigraphy demonstrates direct contamination of the airway by refluxate. Aims Evaluate the clinical utility of reflux scintigraphy in managing LPR. Assess the effect of osmotic laxatives combined with acid suppression on both functional GI and LPR symptoms. Methods Forty consecutive patients referred over 6 months with functional colonic symptoms and significant LPR with a reflux symptom index (RSI)> 13 were followed prospectively. All patients underwent pre‐treatment reflux scintigraphy and gastroscopy with assessment of their reflux finding score (RFS). RSI and RFS were reassessed at ENT follow‐up at a median of 5 months. Functional GI symptoms and RSI were reassessed at a median of 17 months. Results Thirty‐nine of 40 (97.5%) demonstrated reflux into their oropharynx on reflux scintigraphy. The majority had minimal typical reflux symptoms (55%) and their LPR was refractory to acid suppression alone (62.5%). Short‐term combination therapy reduced both the RSI (22.6‐17.2, P < .01) and RFS (12.3‐7.7, P < .01). Longer term treatment reduced the RSI further (22.6‐9.2, P < .01) correlating strongly with improvement in functional GI symptoms. Conclusions LPR occurs frequently amongst IBS patients without typical reflux symptoms. Reflux scintigraphy is useful to both diagnose and optimise treatment of LPR. Reducing colonic distension with osmotic laxatives improves both functional GI and LPR symptoms.

Refractory Gastro-oesophageal Reflux Disease and Laryngopharyngeal Reflux - Use the Bottom up Approach

“…Impaired oesophageal motility on manometry and poor oesophageal bolus clearance on impedance are associated with increased lung contamination by isotope [38]. We found that up to 50% of patients with functional colonic symptoms have symptoms consistent with LPR affecting the nasal or laryngeal region and reflux scintigraphy has good sensitivity in diagnosing LPR with positive scans in 98% correlating nicely with their ear, nose, throat or lung disease in most cases [18]. Delayed gastric emptying of liquids was common and correlated with increased severity of LPR symptoms (Pearson Correlation Coefficient (PCC) 0.41, p=0.01).…”

“…In our prospective cohort study, forty subjects with both functional colonic and LPR symptoms consistently demonstrated excess colonic faecal loading on abdominal x-ray (AXR) (18) equivalent to IBS patients in Raahave's study [56]. Treatment of IBS symptoms predominantly with osmotic laxatives helped to improve or resolve refractory GORD symptoms in all cases (p<0.005) and significantly improved LPR symptoms (p<0.01).…”

“…Delayed gastric emptying of liquids was common and correlated with increased severity of LPR symptoms (Pearson Correlation Coefficient (PCC) 0.41, p=0.01). Although not quite reaching statistical significance (PCC 0.27, p=0.09), there was a trend for increased volume of scintigraphic reflux correlating with the degree of laryngeal inflammation and there was a strong positive correlation between improvement of laryngeal inflammation with treatment and volume of reflux (PCC 0.58, p<0.005) [18]. In addition, a group of controls with neither LPR symptoms nor evidence of GORD were shown to have physiological distal oesophageal reflux, but no airway reflux on scintigraphy as well as consistently normal gastric emptying times (in press).…”

“…Chronic cough related to LPR was also found to be an independent risk factor for both Barrett's oesophagus and oesophageal adenocarcinoma (OAC) [45,46]. LPR appears to be a functional disorder associated with impaired GI motility [18,47], not an aciddriven disorder. Barrett's patients, particularly those with complicated disease, are also known to have both increased bile reflux consistent with impaired upper GI motility [48,49] and ineffective oesophageal motility [50] making them more prone to LPR.…”

“…FH also has strong ties to FD [16] confirming the strong underlying functional component associated with refractory GORD. Not only is IBS a major risk factor for refractory GORD, but patients presenting with LPR or chronic cough are more likely to have IBS than typical GORD symptoms [17,18]. Slower gastric emptying, which occurs commonly in these patients, results in more proximal weakly acid reflux [19], which is a frequent finding in both refractory GORD [20] and LPR [21].…”