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GERD
implicated in ear/nose/throat and pulmonary diseases
By Kathryn Blair
ORLANDO,
FL--Gastroesophageal reflux may play a role in ear/nose/throat
and pulmonary diseases, but it is tough to diagnose, Joel E. Richter,
MD, said at the annual meeting of the American College of Gastroenterology.
"Jamie Koufman, guru of acid-related ENT, said, 'Doing laryngology
without controlling for acid reflux is like fighting a fire with
water in one hose and gasoline in the other,'" said Dr. Richter,
Professor and Chairman, Department of Medicine, Temple University
School of Medicine, Philadelphia, PA.
Controlling for acid reflux is difficult, however, when the tests
for it are unreliable. Otolaryngologists look for laryngeal changes.
This is a subjective way of diagnosing GERD. There is poor agreement
on the severity of laryngeal findings (0.265), the likelihood of
gastroesophageal reflux as a cause of the symptoms (0.248), and
inter-rater reliability.(1)
"Don't bother with 24-hour pH monitoring to diagnose these
individuals," Dr. Richter said. A literature review of 12 published
studies showed that distal pharyngeal pH monitoring diagnosed GERD
in only 54 per cent of cases. The number and duration of pharyngeal
reflux events are similar in patients and controls.
Uncontrolled reports suggest that treating reflux laryngitis with
H2-receptor antagonists or proton pump inhibitors, or both, yields
a response in up to 92 per cent of patients.
However, as Professor David Sackett remarked, "Therapeutic
reports with controls tend to have no enthusiasm, and reports with
enthusiasm tend to have no controls." (2)
"We're finally getting placebo-controlled studies, and frankly
they're not encouraging," Dr. Richter said. Five placebo-controlled
studies of lansoprazole 30 mg BID or omeprazole 40 mg BID have been
reported. The two lansoprazole studies are conflicting. One omeprazole
study showed that mild hoarseness and throat clearing improved,
but ENT signs did not change. A study of pantoprazole for reflux-associated
laryngitis showed that the therapy may help relieve acute symptoms,
but that the advantage of long term treatment over placebo is overestimated.(3)
This study also showed that laryngitis improves despite persistent
reflux.
"Finally, we just completed a large multicentre study in which
100 subjects with signs and symptoms of reflux laryngitis received
esmoprazole 40 mg BID for 12 weeks and 50 patients received an identical
placebo," Dr. Richter told Gastroenterology Canada.
The study(4) was presented at Digestive Diseases Week this year.
"Whether or not you look at symptom resolution, whether or
not you look at symptom improvement, during this 12-week study duration,
patients on placebo did as well as patients on a big-gun PPI."
Pulmonary disease
While it is difficult to diagnose GERD-originating ENT complaints,
it is even more difficult to diagnose GERD as the cause of pulmonary
disease.
Symptoms linked to acid reflux and pulmonary disease include chronic
asthma, bronchitis, bronchiectasis, aspiration pneumonia, atelectasis,
hemoptysis, pulmonary fibrosis, apnea, and seizures related to hypoxia.
Asthma groups have done the most research into the link between
GERD and pulmonary disease because of the prevalence of asthma.
A Canadian study showed that 77 per cent of people with asthma have
heartburn.
Non-controlled studies have shown that medical and surgical therapies
may benefit people with GERD-related asthma. There are few controlled
trials and the results of those do not look promising.
What it means to clinical practice
It is up to physicians to do their own therapeutic trials, Dr. Richter
said. He, himself, puts patients he thinks have GERD-related disease
on a therapy. If they get better, he stops medication to see how
they do, thereby making a diagnosis. If they do not get better,
he does a pH test. (Only about one or two per cent of people have
abnormal acid reflux with aggressive testing.) A negative 24-hour
pH test indicates the patient does not have GERD and should be worked
up for something else.
Suggested
reading
1. Branski RC, Bhattacharyya N, Saphiro J. The reliability of the
assessment of endoscopic laryngeal findings associated with laryngopharyngeal
reflux disease. Laryngoscope 2002;112:1019-1024.
2. Sackett DL. Rules of evidence and clinical recommendations on
the use of antithrombotic agents. Chest 1989;95:2S-4S.
3. Eherer AJ, Habermann W, Hammer HF, et al. Effect of pantoprazole
on the cause of reflux-associated laryngitis: A placebo controlled
double-blind crossover study. Scand J Gastroenterol 2003;38(5):462-467.
4. Vaezi MF, Richter JE, Stasney R, et al. A randomised double-blind
placebo controlled study
of acid suppression for suspected laryngopharyngeal reflux. Gastroenterology
2004;126:A22.
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