Esophageal Reflux Episodes and Endoscopic Findings in Laryngopharyngeal Reflux Patients with Persistent Symptoms despite Acid Suppression Therapy

Background & Aim: Although micro-aspiration of gastric contents particularly acid reflux may be responsible for laryngopharyngeal reflux (LPR), some patients fail to respond to antisecretory therapy. The aims of this prospective study were to elucidate evidence of gastric reflux and its correlation with esophageal injury in nonresponder patients. Methods: Forty-seven consecutive patients, who had signs and symptoms of chronic laryngitis and were refractory to at least 3-months empirical therapy with proton pump inhibitors, were enrolled. After cessation of acid-suppression medication for 2 weeks, all participants underwent upper gastrointestinal magnified narrow band endoscopy with esophageal biopsies followed by monitoring of gastroesophageal reflux episodes using multichannel intraluminal impedance (MII) 24-hour pH testing. Results: Patients had a mean age of 48 ± 10 years; 81% were female; and mean body mass index was 22.3 ± 3.1 kg/m 2 . At screening visit, 70% of patients reported symptoms of globus pharyngeus, 60% noted clearing throat, 60% had regurgitation, 53% reported heartburn and 40% developed hoarseness. Mean reflux symptom index (RSI) scores was 13 ± 7.9. Based on the MII-pH results, 409 liquid containing reflux events were recorded in 45 patients and 1,615 gas reflux events were detected in 28 patients. Among the cohorts with liquid reflux events, 11 patients (23%) were considered to have classic acid-reflux disease, 8 had “weakly acid” reflux episodes and 2 had “weakly alkaline” reflux episodes. Patients with classic acid-reflux disease were more often male (45% vs 11%, p = 0.02) and active alcoholic drinkers (27% vs 3%, p = 0.04) when compared to those without classic acidreflux disease. Clinical characteristics including age, body mass index, history of smoking, laryngeal and gastroesophageal symptoms, the RSI scores, and duration of antisecretory therapy were similar between two groups. With white light endoscopy, erosive esophagitis were identified in only 2 patients documented to have classic acid-reflux disease on MII-pH testing. Subsequently, the magnified narrow-band imaging system was used to enhance visualization of esophageal mucosa. Non-erosive esophagitis was detected and confirmed by histology in 5 patients with classic acid-reflux disease, 3 patients with “weakly acid” reflux, 1 patient with “weakly alkaline” reflux, and 6 patients with gas reflux. Conclusions: This study suggested that retrograde flow of gastric contents might be a cause of chronic laryngitic symptoms in some patients who do not respond to empirical antisecretory therapy. MII-pH monitoring and magnifying endoscopy might be helpful in further refinement of LPR treatment.