Pepsin Detection in Patients with Laryngopharyngeal Reflux Before and After Fundoplication

Eelco B Wassenaar, MD PhD, Nikki Johnston, PhD, Albert L Merati, MD, Martin Montenovo, MD, Rebecca P Petersen, MD MSc, Roger P Tatum, MD, Carlos A Pellegrini, MD, Brant K Oelschlager, MD. Department of Surgery, University of Washington, Seattle WA

Background:
Laryngopharyngeal reflux (LPR) is an extreme manifestation of gastroesophageal reflux disease that can lead to substantial airway damage. No single diagnostic test can accurately determine its presence. We hypothesized that the presence of pepsin (which originates in the stomach) in the epithelium of the larynx and potentially in sputum may provide the diagnostic accuracy that is needed to guide therapy.

Methods:
Ten patients with clinical LPR, undergoing fundoplication were enrolled in this pilot study. Pre-operative laryngoscopy, laryngeal epithelial biopsy and/or sputum analysis, 24-hr pH monitoring, and a standardized questionnaire about symptoms were completed. The same testing was performed 6 months post-fundoplication. Pepsin content was measured by Western blot analysis.

Results:
The primary presenting LPR symptom was hoarseness in 7, cough in 2 and globus in 1 patient. Pepsin was detected in 8 of the 10 patients pre-operatively. There was correlation between biopsy and sputum (+/+ or -/-) in 4 of 5 patients who had both analyzed pre-operatively. Nine patients were available for follow-up. Post-operative pH monitoring improved in all patients and normalized in 5 of 8 patients studied. Eight of 9 patients had improvement of their primary LPR symptom (6 good and 2 mild). Only one patient (who had negative pre-operative pepsin) reported no response to treatment of her primary LPR symptom. Post-operatively pepsin was detected in only 1 patient, though it was substantially decreased compared with the pre-operative value.

Conclusion:
Our study shows that pepsin is found consistently in the laryngeal epithelial biopsy and sputum of patients with pH-proven GERD and symptoms of LPR. In such patients, a fundoplication results in the clearance of pepsin from the upper airway and corresponds to clinical improvement. Detection of pepsin may have value in the diagnostic armamentarium of LPR. A larger clinical trial is needed to further delineate its predictive value.


Session: SS04
Program Number: S016

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