Supra‐oesophageal manifestations of gastro‐oesophageal reflux disease

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Abstract
Supra-oesophageal manifestations of gastro-oesophageal reflux disease (GERD) are common and often under-appreciated, in part due to the absence of classic symptoms of heartburn and regurgitation. Patients with supra-oesophageal manifestations of GERD may report symptoms involving the pulmonary, otolaryngologic or pharyngeal systems. Endoscopy is often negative and therefore of limited diagnostic value in these patients, and while laryngoscopy and 24 h dual-channel intra-oesophageal pH-metry may have greater yields they are costly, invasive and time-consuming. Therefore, a trial of proton pump inhibitor therapy is now widely considered a first-line diagnostic test in those with suspected GERD-induced supra-oesophageal symptoms. The dose as well as duration of the proton pump inhibitor trial is dependent upon a patient's presenting symptoms. For example, GERD-related non-cardiac chest pain may be relieved with a short-term (e.g. 1 week) treatment with standard doses of a proton pump inhibitor. The use of high-dose twice daily proton pump inhibitor therapy for an extended period (e.g. 2-3 months) may be required before any discernible improvement in pulmonary symptoms or pharyngo-laryngitis is noted. Patients who do not experience symptom improvement following a proton pump inhibitor trial may require further diagnostic evaluations including 24 h oesophageal pH studies, while on acid anti-secretory therapy, to establish the absence of persistent acid reflux. The role of anti-reflux surgical or endoscopic interventions in those with supra-oesophageal manifestations of GERD remains to be established.