The Role of pH Monitoring in Extraesophageal Gastroesophageal Reflux Disease

The purpose of this review is to outline the recent developments in the field of extraesophageal reflux disease and provide clinically relevant recommendations.

The recommendations outlined in this review are based on expert opinion and on relevant publications from PubMed and EMbase. The Clinical Practice Updates Committee of the American Gastroenterological Association proposes the following recommendations:

Best Practice Advice 1: The role of a gastroenterologist in patients referred for evaluation of suspected extra esophageal symptom is to assess for gastroesophageal etiologies that could contribute to the presenting symptoms.

Best Practice Advice 2: Non-GI evaluations by ENT, pulmonary and/or allergy are essential and often should be performed initially in most patients as the cause of the extraesophageal symptom is commonly multifactorial or not esophageal in origin.

Best Practice Advice 3: Empiric therapy with aggressive acid suppression for 6-8 weeks with special focus on response of the extraesophageal symptoms can help in assessing association between reflux and extraesophageal symptoms.

Best Practice Advice 4: No single testing methodology exists to definitively identify reflux as the etiology for the suspected extra esophageal symptoms.

Best Practice Advice 5: Constellation of patient presentation, diagnostic test results and response to therapy should be employed in the determination of reflux as a possible etiology in extra esophageal symptoms.

Best Practice Advice 6: Testing may need to be off or on proton pump inhibitor (PPI) therapy depending on patients’ presenting demographics and symptoms in assessing the likelihood of abnormal gastroesophageal reflux.

A. On therapy testing may be considered in those with high probability of baseline reflux (those with previous esophagitis, Barrett’s esophagus or abnormal pH).

B. Off therapy testing may be considered in those with low probability of baseline reflux with the goal of identifying moderate to severe reflux at baseline.

Best Practice Advice 7: Lack of response to aggressive acid suppressive therapy combined with normal pH testing off therapy or impedance-pH testing on therapy significantly reduces the likelihood that reflux is a contributing etiology in presenting extraesophageal symptoms.

Best Practice Advice 8: Surgical fundoplication is discouraged in those with extra esophageal reflux symptoms unresponsive to aggressive PPI therapy.

Best Practice Advice 9: Fundoplication should only be considered in those with a mechanical defect (e.g., hiatal hernia), moderate to severe reflux at baseline off PPI therapy who have continued reflux despite PPI therapy and have failed more conservative non-GI treatments.

Current diagnostic tests for gastroesophageal reflux disease (GERD) do not consistently measure chronicity of reflux. Mucosal impedance (MI) is a minimally invasive measurement to assess esophageal conductivity changes due to GERD. We aimed to investigate MI pattern in patients with symptoms of extraesophageal reflux (EER) in a prospective longitudinal cohort study.

Patients with potential symptoms of EER undergoing esophagogastroduodenoscopy (EGD) with wireless pH monitoring were studied. Participants included those with erosive esophagitis (E+), normal EGD/abnormal pH (E−/pH+), and normal EGD/normal pH (E−/pH−). MI was measured from the site of injury in patients with E+, as well as at 2, 5, and 10 cm above the squamocolumnar junction (SCJ) in all participants.

Forty-one patients with symptoms of EER were studied. MI measurements at 2 cm above the SCJ were significantly (P = 0.04) different among the three groups, with MI lowest for E+ and greatest for E−/pH− patients. Although not statistically significant, there is a graded increase in median (interquartile range) MI axially along the esophagus at 5 cm (P = 0.20) and at 10 cm (P = 0.27) above the SCJ, with those with reflux (E+ and E−/pH+) having a lower MI than those without.

Patients with symptoms of EER and evidence of acid reflux have an MI lower than those without at 2 cm above the SCJ, with a trend at 5 cm and 10 cm as well. MI may be a tool to assess presence of GERD in patients presenting with EER symptoms.

Supraesophageal reflux of gastric contents can contribute to perennial nasopharyngitis, cough, and asthma. However, effective treatment strategies for supraesophageal reflux disease (SERD) remain inadequately defined.

The purpose of this study is to assess the prevalence and timing of SERD and to investigate the efficacy of head-of-bed elevation in its treatment.

A retrospective chart review of patients seen at Scripps Clinic Division of Allergy, Asthma and Immunology was performed who had undergone overnight nasopharyngeal pH monitoring with a commercially available nasopharyngeal pH-monitoring device, Dx-pH Measurement System from Restech, San Diego, Calif. Subjects with reflux were classified based on the position of reflux as either supine only, upright only, or both supine and upright. In a subset of subjects with supine-only reflux, pH monitoring was compared before and after elevating the head of bed 6 inches.

Adequate nasopharyngeal pH-monitoring data were obtained for 235 patients. Reflux was detected in 113 (48%) patients. The pattern of reflux observed was 62 (55%) supine only, 4 (4%) upright only, and 47 (42%) upright and supine. Sequential overnight nasopharyngeal pH monitoring before and after head-of-bed elevation was obtained in 13 individuals with supine-only reflux. Ten subjects demonstrated significant improvement, 8 of whom demonstrated complete resolution of supine reflux with 6 inches of head-of-bed elevation.

This study provides new evidence that SERD frequently occurs in the supine position and that 6 inches of head-of-bed elevation is effective in reducing supine SERD.

Reflux related cough, asthma and laryngitis are frequently encountered and are considered part of extraoesophageal syndromes. The diagnosis of extraoesophageal reflux is difficult due to the lack of gold standard diagnostic criteria. Esophagogastroduodenoscopy and esophageal pH monitoring are inadequate diagnostic tools for due to poor sensitivity and specificity. For this reason, empirical PPI therapy is recommended as an initial approach to diagnose and treat the potential underlying cause of these symptoms in patients without alarm symptoms. Diagnostic testing with esophageal pH and/or impedance monitoring and esophageal motility testing is usually reserved for those who continue to be symptomatic despite a trial of therapy with PPIs. Recent developments have increased our understanding of this difficult to treat group of patients but more research into reflux related extraoesophageal symptoms are needed to better diagnose and treat this group.