Scott Simpson, MD, on Reflux Scintigraphy in Laryngopharyngeal Reflux

Research shows that reflux scintigraphy with single photon-emission computed tomography is more sensitive in confirming the diagnosis of suspected LPR. The tool may also provide useful data on esophageal clearance and gastric emptying, which aids in the optimization of treatment in patients with LPR.

In a new study, Scott Simpson, MD, from the Section of Gastroenterology at Sydney Adventist Hospital in Australia, and colleagues sought to evaluate the clinical utility of reflux scintigraphy in the management of LPR, as well as assess the effect of osmotic laxatives—combined with acid suppression—on functional gastrointestinal (GI) tract symptoms and LPR symptoms.

Results showed that reflux scintigraphy can be useful in the diagnosis of LPR and aid in treatment optimization in patients with LPR. Additionally, reducing colonic distension via osmotic laxatives improves both functional GI and LPR symptoms.

Gastroenterology Consultant caught up with Dr Simpson about the research.

Gastroenterology Consultant: What prompted you to conduct the study?

Scott Simpson: Cough and LPR symptoms are more prevalent in patients with functional colonic and upper GI tract symptoms compared with patients with gastroesophageal reflux disease (GERD). LPR is a distinct clinical disorder from GERD, and most patients have tiny volumes of weakly acid clinically silent reflux. Patients with LPR often do not have typical GERD symptoms. We hypothesized that reflux scintigraphy would be clinically useful in both diagnosing and managing LPR‐related ear, nose, and throat (ENT) conditions. Treatment of functional colonic symptoms with osmotic laxatives often improves both colonic and LPR symptoms. We also hypothesized that using acid suppression in combination with osmotic laxatives to reduce colonic distension and improve GI motility would be more effective for both the treatment of patients with LPR and reducing functional upper gut and colonic symptoms.

GASTRO CON: What are the clinical implications of the study?

SS: Reflux scintigraphy was found to be clinically useful in both the diagnosis of LPR and managing LPR symptoms; the areas of contamination with reflux correlated nicely with ENT symptoms. There was excellent correlation between improvement in functional colonic, upper GI tract, refractory GERD, and LPR symptoms, suggesting that these conditions share a common pathophysiology. Reflux scintigraphy with the correct protocol should be the first-line screening tool to investigate LPR symptoms in this patient population. Patients who present with functional GI, refractory reflux, and LPR symptoms require routine assessment of how full their colon is with a plain abdominal x-ray. Previous GI tract physiological studies confirm that colonic distension causes colonic pain and altered motility, increases reflux events, and suppresses upper GI tract motility. Our study suggests that regardless of stool frequency or transit time, colonic distension may need to be reduced by treatment to improve symptoms. Osmotic laxatives with or without stimulant laxatives or prucalopride, if titrated correctly, usually result in more efficient colonic emptying with reduced colonic distension without increasing stool frequency, and in most cases, improve functional GI tract, refractory reflux, and LPR symptoms.

GASTRO CON: How do you think the use of reflux scintigraphy can optimize care and treatment for patients with LPR?

SS: To interpret LPR symptoms, reflux scintigraphy is cheaper, noninvasive, well-tolerated, more readily available, and easier to interpret compared with esophageal impedance pH monitoring. The tool confirms the diagnosis of LPR, as well as identifies areas of contamination which may explain another ENT or lung pathology and provides useful data to aid in the medical management of LPR such as gastric emptying. More invasive esophageal studies could potentially be limited more to patients specifically being considered for anti-reflux surgery.

GASTRO CON: What are the next steps of your research?

SS: We want to examine the effect of colonic decompression with bowel prep on LPR events using reflux scintigraphy. We also want to perform concurrent reflux scintigraphy and esophageal impedance pH monitoring to assess what impedance events occur at the time of scintigraphy reflux events. Further, we want to investigate the possibility of randomized controlled trials to compare PPI therapy or other standard therapy with whole gut motility therapy for patients with LPR with both laryngeal and chronic rhinosinusitis symptoms.

Reference:

Simpson SB, Qian KY, Sacks R, Novakovic D, Simpson R, Van der Wall H. Observational cohort study: getting to the bottom of laryngopharyngeal reflux—it’s a motility disorder and not just about the acid. GastroHep. 2019;1(5):223-235. doi:10.1002/ygh2.361.