Department of Clinical and Molecular Medicine, NTNU, Norwegian University of Science and Technology, Prinsesse Kristinas gate 1, Trondheim, 7030, Norway.
Medicus Endoscopy, Trondheim, Norway.
BMC Gastroenterol. 2023 Sep 6;23(1):303. doi: 10.1186/s12876-023-02945-7.
The prevalence of gastroesophageal reflux disease (GERD) has had a marked increase in Western countries with a paralleling interest in extraesophageal (EE) manifestations of GERD, including laryngopharyngeal reflux (LPR). There are considerable differences in clinical practice between gastroenterologists, otolaryngologists and pulmonologists.
In this narrative review we address some of these controversies concerning EE manifestations of GERD and LPR.
It is disputed whether there is causal relationship between reflux and the numerous symptoms and conditions suggested to be EE manifestations of GERD. Similarly, the pathophysiology is uncertain and there are disagreements concerning diagnostic criteria. Consequently, it is challenging to provide evidence-based treatment recommendations. A significant number of patients are given a trial course with a proton pump inhibitor (PPI) for several months before symptoms are evaluated. In randomized controlled trials (RCTs) and meta-analyses of RCTs PPI treatment does not seem to be advantageous over placebo, and the evidence supporting that patients without verified GERD have any benefit of PPI treatment is negligible. There is a large increase in both over the counter and prescribed PPI use in several countries and a significant proportion of this use is without any symptomatic benefit for the patients. Whereas short-term treatment has few side effects, there is concern about side-effects after long-term use. Although empiric PPI treatment for suspected EE manifestations of GERD instead of prior esophageal 24-hour pH and impedance monitoring is included in several guidelines by various societies, this practice contributes to overtreatment with PPI.
We argue that the current knowledge suggests that diagnostic testing with pH and impedance monitoring rather than empiric PPI treatment should be chosen in a higher proportion of patients presenting with symptoms possibly attributable to EE reflux.
西方国家胃食管反流病（GERD）的患病率显著增加，同时对 GERD 的食管外（EE）表现，包括喉咽反流（LPR）也产生了浓厚的兴趣。胃肠病学家、耳鼻喉科医生和肺病学家之间的临床实践存在很大差异。
在本叙述性综述中，我们探讨了一些关于 GERD 和 LPR 的 EE 表现的争议。
反流与被认为是 GERD 的 EE 表现的众多症状和病症之间是否存在因果关系存在争议。同样，病理生理学也不确定，诊断标准也存在分歧。因此，提供基于证据的治疗建议具有挑战性。相当数量的患者在接受质子泵抑制剂（PPI）治疗数月后，症状才得到评估。在随机对照试验（RCT）和 RCT 的荟萃分析中，PPI 治疗似乎并不优于安慰剂，并且没有证据表明未经证实的 GERD 患者使用 PPI 治疗有任何获益。在许多国家，非处方和处方 PPI 的使用都有大幅增加，其中相当一部分的使用对患者没有任何症状改善。虽然短期治疗副作用较少，但长期使用的副作用令人担忧。尽管根据各种协会的指南，怀疑 EE 表现的 GERD 患者使用经验性 PPI 治疗而不是先前的食管 24 小时 pH 和阻抗监测，但这种做法导致了 PPI 的过度治疗。
我们认为，目前的知识表明，对于表现出可能归因于 EE 反流的症状的患者，应选择 pH 和阻抗监测的诊断性检测，而不是经验性的 PPI 治疗，以选择更高比例的患者。
