Extraesophageal reflux disease

return to: Proton Pump Inhibitor Side Effects PPI Considerations

see also: Swallowing Disorders Management Protocols; Management of Swallowing Disorders;

Speech Pathologists; Reflux Symptom Index (RSI)

1. PRESENTATION
   1. Definitions
      1. GER:  Gastroesophageal reflux
      2. GERD:  Gastroesophageal reflux disease:  “Defined as a condition which develops when the reflux of stomach contents causes troublesome symptoms and/or complications.”  20% of Americans experience symptoms weekly and 44% monthly. Symptoms include heartburn and regurgitation.  Can lead to reflux esophagitis, reflux stricture, Barrett’s esophagus or adenocarcinoma.  Most common cause is defective lower esophageal sphincter.
      3. EER:  Extraesophageal reflux:  Reflux up into hypopharynx, nasopharynx, oropharynx, larynx or trachea.  
      4. EERD:  Extraesophageal reflux disease:  Non gastrointestinal manifestations of reflux.
         1. Asthma:  There is a clear association between EERD and asthma.  However, current literature as to weather EERD has a causative role in asthma is controversial.
         2. Chronic cough:  EERD is the cause of 10-40% of cases of chronic cough.
         3. Laryngitis:  EERD is known to be a common cause of laryngitis.
   2. History:
      1. Symptoms: 
         1. Hoarseness
         2. Cough
         3. Chronic throat clearing
         4. Chronic sore throat
         5. Change in voice
         6. Dysphagia
         7. Globus sensation
         8. Postnasal drip
         9. Strange taste in mouth
         10. Note: only 40% have heartburn
      2. Reflux Symptom Index (RSI)
         1. A nine-item outcome tool to diagnose laryngopharyngeal reflux. 
         2. An RSI > 13 is abnormal
         3. Reflux Symptom Index (RSI)
2. WORK UP 
   1. Flexible fiberoptic laryngoscopy:  Classically see edema and erythema involving the posterior third of the larynx. 
   2. Empiric therapy:  Most reliable diagnostic test to confirm EERD is documented resolution of symptoms with antireflux treatment.
   3. pH testing:  Recommended as next step for those who fail empiric therapy for EERD.  Most reliable test in diagnosis of GERD with sensitivity and specificity of 92%.  Must stop acid-suppressing medications at least 3 days in advance.  
   4. Intraluminal impedance testing:  Assesses nonacid reflux. 
   5. Endoscopy and barium esophagram. The incidence of esophagitis is lower than in patients with GERD and thus the yield of these examinations in confirming the diagnosis is low.  Endoscopy has value in detection of complications of GERD.
3. TREATMENT
   1. Lifestyle modifications
      1. Esophageal Reflux Precautions
   2. Medical treatment
      1. Standard dose of PPI BID or double dose of PPI at bedtime  for 2-3 months. 
      2. If treatment is effective, can titrate dose down, or try H2 receptor blocker. 
      3. If treatment is unsuccessful consider pH probe.
   3. Antireflux surgery.  Fundoplication.  For those intolerant to reflux medications or resistant to PPI.
4. SUGGESTED READING
   1. Belafsky PC, Postma GN, Koufman JA.  Validity and reliabiltiy of the reflux symptom index (RSI).  Journal of Voice 2002, 16(2):274-277
   2. Napierkowski J, Wong RK. Extraesophageal manifestations of GERD. Am J Med Sci. 2003 Nov;326(5):285-99.
   3. Khan AM, Hashmi SR, Elahi F, Tariq M, Ingrams DR.  Laryngopharyngeal reflux: A literature review. Surgeon. 2006 Aug;4(4):221-5.
   4. Frye JW, Vaezi MF.  Extraesophageal GERD. Gastroenterol Clin North Am. 2008 Dec;37(4):845-58, ix.