Testing to no avail? the diagnostic and treatment conundrum in patients with extraesophageal manifestations of gastroesophageal reflux disease

© Annals of Laparoscopic and Endoscopic Surgery. All rights reserved. Ann Laparosc Endosc Surg 2017;2:143 ales.amegroups.com Extraesophageal reflux (EER), which includes cough, asthma, and laryngopharyngeal reflux (LPR), is an important and prevalent disease state with a large economic burden of up to fifty billion dollars, largely due to the pharmaceutical costs of empiric treatment (1). Patients with presumed EER are often treated with empiric acid suppressive therapy (AST), but if symptoms remain refractory, they are then referred for further testing. Despite advent of ambulatory reflux monitoring and impedance testing, diagnostic testing in this population have poor test characteristics with suboptimal sensitivity and specificity (2,3). Esophagogastroduodenoscopy (EGD) is specific for GERD, but lacks sensitivity (less than 30%) due to lack of overt esophagitis in some patients with GERD. Ambulatory pH testing and intraluminal impedance are gold standard for diagnostics, but are also limited due to a limited period of testing, which is often challenged by patient comfort and compliance with intranasal catheter (4). The presence of dilated intracellular spaces (DIS) has been suggested as a marker of chronicity in patients with GERD both with esophagitis and non-erosive GERD, but there remains uncertainty on optimal biopsy, need for costly EGD, and the use of transmission electron microscopy limiting the applicability of this test (5). Mucosal impedance (MI) uses indirect measurements of mucosal conductivity and studies have shown lower intraluminal impedance in patients with GERD compared to controls (6). Finally, in highly selected patients, surgery can be performed for treatment of EER, where symptom relief after surgery can confirm a diagnosis of EER though conclusions are limited by lack of high quality randomized control studies as recently published by this group (7). In this article in the Annals of Surgery, Sidhwa et al. performed a review of 271 articles with 128 meeting their study criteria to ask three important questions: (I) how are extraesophageal manifestations of reflux diagnosed? (II) What is the effect of medical therapy? and (II) what is the effect of surgical therapy? (8). In evaluating the triumvirate of cough, asthma, and LPR, the authors found that there is lack of diagnostic criterion for all three diseases. Patients with suspected EER associated symptoms initially undergo a PPI-trial ranging from 8 to 16 weeks with improvement in symptoms indicating GERD as the underlying etiology. In patients that are unresponsive to PPI trial, further testing including multichannel intraluminal impedance with pH (MII-pH) might be helpful in determining if reflux might be a contributing factor in this difficult group of patients. Authors also suggest that symptom association probability (SAP) determined by the association of reflux events defined by MII-pH and self-reported cough might be helpful with a specificity of 82% in one study (9). However, clinical utility of SAP is very limited. We would suggest the readers Editorial