Patients often present with symptoms that are not classic for reflux such as chronic cough, worsening asthma, sore throat, or globus.
In the upper GI section of the postgraduate course program, Rena Yadlapati, MD, and C. Prakash Gyawali, MD, MRCP, educated us about optimal strategies for diagnosis and treatment of this difficult group of patients. Dr. Gyawali reminded us of risk stratification of patients into those with high or low likelihood of reflux as contributing etiology for patients with suspected extraesophageal reflux. Dr. Yadlapti reviewed the utility of the HASBEER score in stratifying patients into these two risk categories. Patients with known reflux at baseline and/or if they have classic symptoms of reflux in addition to extraesophageal symptoms may be at higher likelihood of having abnormal esophageal acid exposure than those without classic heartburn and/or regurgitation. The low-risk group may then benefit from diagnostic testing off PPI therapy (either impedance/pH monitoring or wireless pH testing), whereas those in the high-risk group for reflux may undergo impedance pH testing on PPI therapy to ensure control of reflux while on therapy.
Dr. Yadlapati also updated the audience about lack of robust data to suggest clinical utility for oropharyngeal pH test or salivary pepsin assay testing. It was generally agreed on that the majority of patients who do not respond to aggressive acid suppressive therapy likely do not have reflux related extraesophageal symptoms and alternative etiologies may be at play.
Finally, both investigators outlined the importance of neuromodulation in those whose symptoms may be due to “irritable larynx.” They emphasized the role of tricyclics as well as gabapentin as off label uses for patients who have normal reflux testing and continue to have chronic cough or globus sensation.
Michael F. Vaezi, MD, PhD, MSc, is an associate chief and a clinical director of the division of gastroenterology, hepatology, and nutrition and director of the Clinical Research and Center for Esophageal Disorders at Vanderbilt University, Nashville, Tenn. He reports consulting for Phathom, Ironwood, Diversatek, Isothrive, and Medtronic. These remarks were made during one of the AGA Postgraduate Course sessions held at DDW 2021.