ORLANDO, FLA. — Supraesophageal manifestations of reflux disease pose a treatment challenge, Reza Shaker, M.D., said at the annual meeting of the American College of Gastroenterology.
There is a misperception that when reflux is treated, other related disorders—such as laryngitis—will disappear as well, but that's not always the case, said Dr. Shaker, chief of gastroenterology and hepatology at the Medical College of Wisconsin, Milwaukee.
When faced with a patient who has lingering laryngitis, throat clearing, and other conditions presumed to be associated with gastroesophageal reflux disease, he recommends the following:
▸ Interview the patient carefully. A thorough history is imperative for ensuring the correct diagnosis. Most patients won't present with cut-and-dried signs and symptoms of GERD. More often, there is a little redness in the area of the supraesophageal structures. Studies show that the presence or absence of symptoms may not be as specific for diagnosis as previously thought.
▸ Evaluate the therapeutic options. Reevaluate the use and value of therapy; the treatment must be tailored to individual patient needs. Although some patients need simple acid suppressive therapy, others with mild disease could respond well to reflux precautionary measures, such as having an empty stomach at bedtime, he said. Others need a combination approach, and still others will require surgery.
Surgeons, however, are increasingly requiring that patients have shown a prior response to medical therapy, indicating that the diagnosis is correct.
In evaluating the effectiveness of the current therapy, check to see if acid has been adequately suppressed. The use of esophageal acid monitoring can be helpful. Also, ensure proper timing of medication dosing. “How many patients do we encounter who take their medicine at the wrong time in the morning and then drink a cup of coffee?” he asked.
Also, confirm that the dosage is adequate.
▸ Recommend the use of precautionary measures. A key difference between the esophageal and supraesophageal structures is that nonacidic and minimally acidic materials can cause injury to the supraesophageal structures. Having an empty stomach before bedtime is important.
Patients should be evaluated for delayed gastric emptying, which occurs in about 40% of GERD patients. This may not be important when dealing with complications of the esophagus in this age of proton pump inhibitors, but it can create a reservoir for acid and nonacid material that can be harmful to the supraesophageal area.
▸ Consider referral to an ear, nose, and throat specialist. Remember that reflux is not exclusive for aerodigestive tract disorder, and consider referring patients who fail to respond to therapy to an ENT physician for additional evaluation, he advised.