Updates in the field of non-esophageal gastroesophageal reflux disorder

ABSTRACT

Introduction: Gastroesophageal reflux disease (GERD) is one of the most prevalent conditions in Western Countries, normally presenting with heartburn and regurgitation. Extra-esophageal (EE) GERD manifestations, such as asthma, laryngitis, chronic cough and dental erosion, represent the most challenging aspects from diagnostic and therapeutic points of view because of their multifactorial pathogenesis and low response to proton pump inhibitors (PPIs). In fact, in the case of EE, other causes must by preventively excluded, but instrumental methods, such as upper gastrointestinal endoscopy and laryngoscopy, have low specificity and sensitivity as diagnostic tools. In the absence of alarm signs and symptoms, empirical therapy with a double-dose of PPIs is recommended as a first diagnostic approach. Subsequently, impedance-pH monitoring could help to define whether the symptoms are GERD-related.

Areas covered: This article reviews the current literature regarding established and proposed EE-GERD, reporting on all available options for its correct diagnosis and therapeutic management.

Expert opinion: MII-pH could help to identify a hidden GERD that causes EE. Unfortunately, standard MII-pH analysis results are often unable to define this association. New parameters such as the mean nocturnal baseline impedance and post-reflux swallow-induced peristaltic wave index may have an improved diagnostic yield, but prospective studies using impedance-pH are needed.

KEYWORDS:

• Extra-esophageal reflux syndrome
• Laryngopharyngeal reflux
• chronic cough
• GERD
• asthma
• dental erosion
• sinusitis
• pulmonary fibrosis
• otitis

Article highlights

• EE-GERD has a multifactorial pathogenesis and the part exclusively due to GER is certainly overestimated; other causes of EE symptoms must be excluded before suspecting GERD.

• Endoscopic signs of GERD by laryngoscopy are also present in healthy volunteers and are not specific to GERD diagnosis.

• Empirical double-dose PPI therapy is suggested by most guidelines, followed by a MII-pH study in patients who do not respond to PPIs.

• PPI therapy in EE-GERD usually has poor efficacy or no efficacy at all, especially in the absence of typical symptoms.

• Novel impedance parameters, including PSPW and MNBI, can enhance the usefulness of MII-pH in EE-GERD patients.

• When considering fundoplication, physicians must remember that only patients that respond to PPIs or those who have well-defined anatomical defects (e.g., hiatal hernia) are likely to show a good response to surgical treatment.

Declaration of interest

E. Savarino received lecture and Consultancy honoraria from Takeda, Janssen, MSD, Abbvie, Sofar, Malesci, Reckitt Benckiser, Medtronic. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.