Chen Yen-Yang, Wang Chen-Chi, Chuang Chun-Yi, Tsou Yung-An, Peng Yen-Chun, Chang Chi-Sen, Lien Han-Chung
Division of Gastroenterology, Taichung Veterans General Hospital, Taichung 402, Taiwan.
Department of Otolaryngology, Taichung Veterans General Hospital, Taichung 402, Taiwan.
World J Gastroenterol. 2024 Dec 28;30(48):5162-5173. doi: 10.3748/wjg.v30.i48.5162.
Diagnosing laryngopharyngeal reflux (LPR) is challenging due to overlapping symptoms. While proton pump inhibitors (PPIs) are commonly prescribed, reliable predictors of their responsiveness are unclear. Reflux monitoring technologies like dual potential of hydrogen (pH) sensors and multichannel intraluminal impedance-pH (MII-pH) could improve diagnosis. Research suggests that a composite pH parameter, defined by ≥ 2 pharyngeal acid reflux (PAR) episodes and/or excessive esophageal acid reflux (EAR), predicts PPI efficacy. The criteria for PAR episodes, a pharyngeal pH drop of ≥ 2 units to < 5 within 30 seconds during esophageal acidification, showed strong interobserver reliability. We hypothesized that PAR episodes alone might also predict PPI responsiveness.
To investigate whether PAR episodes alone predict a positive response to PPI therapy.
Patients suspected of having LPR were prospectively recruited from otolaryngologic clinics in three Taiwanese tertiary centers. They underwent a 24-hour esophagopharyngeal pH test using either 3-pH-sensor or hypopharyngeal MII-pH catheters while off medication, followed by a 12-week esomeprazole course (40 mg twice daily). Participants were categorized into four groups based on pH results: PAR alone, EAR alone, both pH (+), and both pH (-). The primary outcome was a ≥ 50% reduction in primary laryngeal symptoms, with observers blinded to group assignments.
A total of 522 patients (mean age 52.3 ± 12.8 years, 54% male) were recruited. Of these, 190 (mean age 51.5 ± 12.4 years, 61% male) completed the treatment, and 89 (47%) responded to PPI therapy. Response rates were highest in the PAR alone group (73%, = 11), followed by EAR alone (59%, = 68), both pH (+) (56%, = 18), and both pH (-) (33%, = 93). Multivariate analysis adjusting for age, sex, body mass index, and endoscopic esophagitis showed that participants with PAR alone, EAR alone, and both pH (+) were 7.4-fold ( = 0.008), 4.2-fold ( = 0.0002), and 3.4-fold ( = 0.03) more likely to respond to PPI therapy, respectively, compared to the both pH (-) group. Secondary analyses using the definition of ≥ 1 PAR episode were less robust.
In the absence of proven hypopharyngeal predictors, this post-hoc analysis found that baseline ≥ 2 PAR episodes alone are linked to PPI responsiveness, suggesting the importance of hypopharyngeal reflux monitoring.
由于症状重叠，诊断喉咽反流（LPR）具有挑战性。虽然质子泵抑制剂（PPI）是常用药物，但尚不清楚其反应性的可靠预测指标。诸如双极氢离子（pH）传感器和多通道腔内阻抗-pH（MII-pH）等反流监测技术可能会改善诊断。研究表明，由≥2次咽酸性反流（PAR）发作和/或过度食管酸性反流（EAR）定义的复合pH参数可预测PPI疗效。PAR发作的标准为食管酸化期间30秒内咽部pH值下降≥2个单位至<5，观察者间可靠性强。我们假设单独的PAR发作也可能预测PPI反应性。
研究单独的PAR发作是否能预测对PPI治疗的阳性反应。
从台湾三个三级中心的耳鼻喉科诊所前瞻性招募疑似LPR的患者。他们在停药期间使用3-pH传感器或下咽MII-pH导管进行24小时食管咽部pH测试，随后进行为期12周的埃索美拉唑疗程（每日两次，每次40毫克）。根据pH结果将参与者分为四组：仅PAR、仅EAR、两者pH均为阳性（+）和两者pH均为阴性（-）。主要结局是主要喉部症状减少≥50%，观察者对分组情况不知情。
共招募了522例患者（平均年龄52.3±12.8岁，54%为男性）。其中，190例（平均年龄51.5±12.4岁，61%为男性）完成了治疗，89例（47%）对PPI治疗有反应。仅PAR组的反应率最高（73%，n = 11），其次是仅EAR组（59%，n = 68）、两者pH均为阳性（+）组（56%，n = 18）和两者pH均为阴性（-）组（33%，n = 93）。对年龄、性别、体重指数和内镜下食管炎进行校正的多变量分析显示，与两者pH均为阴性（-）组相比，仅PAR组、仅EAR组和两者pH均为阳性（+）组对PPI治疗有反应的可能性分别高7.4倍（P = 0.008）、4.2倍（P = 0.0002）和3.4倍（P = 0.03）。使用≥1次PAR发作定义的二次分析结果不太可靠。
在缺乏已证实的下咽预测指标的情况下，这项事后分析发现基线时单独≥2次PAR发作与PPI反应性相关，提示下咽反流监测的重要性。
