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Gastro-oesophageal reflux disease: Surgery is an alternative, which is also better and cheaper
- David Mahon, Michael Rhodes (17 January 2006)
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Posture in gastro-oesophageal Reflux Disease.
- norman K Gibbon (19 January 2006)
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Laryngopharyngeal Reflux: a disease with "typical" symptoms
- Peter D Karkos, Spiros P Potamianos (28 January 2006)
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David Mahon, SpR General Surgery North Hampshire Hospitals NHS Trust, Basingstoke, RG24 9NA, Michael Rhodes
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Gastro-oesophageal reflux disease, being very common (and increasingly so), is a huge problem and prescribing of proton pump inhibitors is a large burden on the NHS. Whilst Fox and Forgacs [1] did mention surgical management towards the end of their article, we disagree with the implication that antireflux surgery is limited to those patients in whom medical management is either ineffective or poorly tolerated - for those patients who do not want to remain dependant on daily medication it may simply be an alternative therapy, a lifestyle choice. Also not mentioned was the fact that there has recently been a randomised controlled trial of laparoscopic Nissen fundoplication versus PPI therapy [2] - carried out in the UK. This gave results favouring surgical fundoplication. It was accompanied by an economic analysis [3], which shows that surgical management, in the long term, is in fact the more cost effective solution. This is an important consideration in today’s NHS. [1] Fox M. Forgacs I. Gastro-oesophageal reflux disease. BMJ. 332:88- 93, 2006. [2] Mahon D. Rhodes M. Decadt B. Hindmarsh A. Lowndes R. Beckingham I. Koo B. Newcombe RG. Randomized clinical trial of laparoscopic Nissen fundoplication compared with proton-pump inhibitors for treatment of chronic gastro-oesophageal reflux. British Journal of Surgery. 92(6):695- 9, 2005 Jun. [3] Cookson R. Flood C. Koo B. Mahon D. Rhodes M. Short-term cost effectiveness and long-term cost analysis comparing laparoscopic Nissen fundoplication with proton-pump inhibitor maintenance for gastro- oesophageal reflux disease. British Journal of Surgery. 92(6):700-6, 2005 Jun. Competing interests: Research has been funded by: Janssen Pharmaceuticals Ethicon Endosurgery |
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norman K Gibbon, Consultant Urologist (Rtd). 30,Barton Heys Rd., Formby, Liverpool, L37 2EY.
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I was surprised to find in this paper no mention of the effects of posture on GORD.Admittedly, controlled trials are not possible in this respect but surely some weight must be given to the experience of many patients and doctors. In my own case,I can report on over seventy years of coming to terms with peptic ulceration and over thirty years of trying to cope with severe reflux.Gross adverse reactions to the modern acid-suppressants as well as clarithromycin have forced me to rely on a postural approach which is very effective when combined with a simple ant-acid mixture taken after meals and at bedtime. Sufferers should be advised to avoid bending down especially after meals.Again, they should be encouraged to sleep in a semi-upright position.This is achieved ideally by the use of an adjustable mattress but such beds are very expensive and they are not transportable. A back-rest is easily improvised but a 'Donkey' is required behind the knees to prevent the patient from sliding down the bed. Traditionally, a bolster has been used for this purpose. To prevent it rolling down the bed it has to be wrapped in a draw-sheet the ends of which are tucked under the mattress on each side. This works well but may be too awkward to take on holiday. What is needed nowadays is a portable, inflatable plastic bolster . If it were to be coated with or wrapped in a material with a suede finish the friction generated would stop it from sliding. I have improvised cushions of this type with success but some manufacturing problems have to be overcome. Competing interests: None declared |
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Peter D Karkos, Specialist Registrar in Otolaryngology Arrowe Park Hospital,Wirral,UK, Spiros P Potamianos
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We read with interest the well-written review by Fox and Forgacs.1 In our opinion the "Atypical part of GORD" is about time to be considered a different entity than GORD; over last few years the spectrum of those atypical otorhinolaryngological and respiratory symptoms are more or less deallt directly by laryngologists. In primary care, general practitioners are becoming more aware of these difficult throat symptoms and start referring then directly to laryngologists or begin antireflux treatment, mainly with aggressive and prolonged doses of proton pump inhibitors.2 Laryngopharyngeal reflux (LPR) is thought to be the movement of gastric contents into the laryngopharyngeal area. Many Ear Nose and Throat “mystery” symptoms such as globus pharyngeus, constant throat clearing, chronic cough, idiopathic hoarseness, catarrh and choking episodes are thought, by some, to be reflux-related. It is well recognised that reflux can present with throat symptoms but it is the lack of an ideal diagnostic test that have transformed LPR into such a controversial “disease” with believers and non -believers. Laryngologists over the world, with pioneers the North Carolina group3, have been trying for years to define LPR and to diagnose it with a non invasive and reproducible test. LPR is not a new entity and gastroenterologists would treat their “atypical” GORD patients with aggressive and prolonged doses of proton pump inhibitors. The controversy surrounding the existence of this mystery disease is not overated. Symptoms such as catarrh, idiopathic hoarseness, globus, chronic cough and choking episodes-that are thought to be related to reflux- are not well understood and may or may not respond to antireflux treatment. All the above symptoms may equally respond to other empiric treatment modalities. For example, catarrh may also respond to nasal steroid spays, hoarseness and globus may respond to speech therapy and voice hygiene advice or lifestyle modification advice etc. To make things worse, laryngoscopic “signs” of reflux are often non-specific and a picture of a red and “angry” larynx is not interpreted in the same way by laryngologists. The lack of diagnostic tests with a good sensitivity and specificity creates even more controversy. Prolonged dual probe pH-metry is not ideal and despite its popular use (not in the UK) has false negative results. Recent research in pepsin may give answers to many questions regarding LPR.4 The combination of pepsin measurements in the sputum, perhaps with pH-metry and/or impedance techniques will get us closer in diagnosing LPR as accurately as it is feasibly possible for a disease which still remains to be accurately defined. Throughout the UK, it is common knowledge, although anecdotal, that otolaryngologists have different attitudes towards managing patients with suspected atypical reflux. There are those who choose to ignore this entity completely and others who are willing to “embrace” it as one of the many-in ENT-mystery diseases. Nevertheless, “empiric”treatment means treatment “based on experience” and, therefore, by definition, lacks evidence. The systemic review of the literature confirms that there is lack of level I evidence for empiric treatment of LPR with PPIs.5 If we-as otolaryngologists- are to promote awareness of LPR both in the community as well as in our own specialty, we should refrain from referring to hoarseness, globus, throat clearing and chronic cough as “atypical manifestations of Gastroesophageal reflux”. They are in fact the typical symptoms of Laryngopharyngeal reflux. References 1 Fox M, Forgacs I. Gastro-oesophageal reflux disease BMJ 2006; 332: 88-93 2 Karkos PD, Thomas L, Temple RH, Issing WJ. Awareness of general practitioners towards treatment of laryngopharyngeal reflux: a british survey. Otolaryngol Head Neck Surg 2005; 133: 505-508. 3 Koufman JA. The otolaryngologic manifestations of gastroesophageal reflux disease (GERD): A clinical investigation of 225 patients using ambulatory 24-hour pH monitoring and an experimental investigation of the role of acid and pepsin in the development of laryngeal injury, Laryngoscope 1991; 101(Suppl 53): 1-78. 4 Knight J, Lively MO, Johnston N, Dettmar PW, Koufman JA. Sensitive pepsin immunoassay for detection of laryngopharyngeal reflux. Laryngoscope 2005; 115: 1473-1478. 5 Karkos PD, Wilson JA. Empiric Treatment of Laryngopharyngeal reflux with proton pump inhibitors: a systematic review. Laryngoscope 2006; 116: 144-148 Competing interests: None declared |
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