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Laryngopharyngeal reflux

Refluxate can sometimes reach beyond the upper oesophageal sphincter, resulting in damage to sensitive tissues including the larynx, pharynx and respiratory tract. This phenomenon is referred to as laryngopharyngeal reflux (LPR). Estimates show that approximately 25% of primary care patients in the UK present with symptoms related to LPR.

  • About the patient

    Joshua is a 41-year-old singer who has been undergoing a year-long investigation into his symptoms of hoarse voice and chronic dry cough. Recent test results have excluded a respiratory cause for these symptoms. He has also demonstrated a history of heartburn and indigestion.

  • Treatment goals

    When addressing Joshua’s treatment, you should aim to reduce his experience of symptoms and limit any refluxate-related damage to his pharynx and larynx. Results from Joshua’s investigations have excluded a respiratory-related cause for his symptoms. Along with this, Joshua has also demonstrated a history of heartburn, meaning LPR (i.e. a gastrointestinal [GI] cause for his symptoms) can now be addressed.

  • Challenges faced

    1. Not all symptoms are GI related

      Although extraoesophageal symptoms (i.e. symptoms of reflux that occur outside of the oesophagus, such as hoarse voice or cough) can be recorded in patients with reflux, not all patients presenting with these symptoms may have a GI-related cause. Before treating a patient for LPR, all other causes of these symptoms must be excluded.

    2. Acid is not the only contributor in LPR

      Most antireflux therapies, including proton pump inhibitors and H2-receptor antagonists, target the production of acid in the stomach, but do not prevent reflux of stomach contents. However, acid is not the only agent involved in LPR, with evidence indicating a role for pepsin and bile. This may limit the therapy options available for patients diagnosed with this condition.

  • Consultation advice

    As LPR differs from other upper GI conditions, not all reflux therapies will be appropriate for the management of Joshua’s symptoms.

    • Patient education and self-care

      Ensure Joshua understands the underlying principles of LPR, such as the various agents involved (e.g. bile and pepsin) and why not all therapies may be effective in managing his symptoms.

    • Prescribe alginate therapy

      Unlike other antireflux therapies, alginates form a raft in the stomach. This physical barrier prevents the retrograde flow of all stomach contents, including pepsin and bile, into the oesophagus and beyond. Joshua should be prescribed alginates indicated for use in LPR for a minimum of 12 weeks. He should be reminded to take the alginates regularly after meals and at bedtime for the specified minimum duration.

    • Lifestyle changes

      Changes in lifestyle can also help reduce Joshua’s symptoms. He should be advised on key techniques that can help to limit his experience of symptoms, including weight loss and reduction in alcohol intake.

    • Review of treatment

      After 12 weeks of treatment, you should arrange a review with Joshua to establish the efficacy of the alginate therapy. If this was ineffective, causes of his symptoms other than LPR should be explored.

  • Resources

This content hub is funded by RB. The view and opinions presented here represent those of the doctors and do not reflect those of RB.

Date of preparation: February 2019

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