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Laryngopharyngeal Reflux: Symptoms, Signs, and Presence of Pepsin in Saliva - A Reliable Diagnostic Triad

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Introduction Twenty-four-hour multichannel intraluminal impedance with double probe pH monitoring (MII-pH), though considered the most sensitive tool for the diagnosis of gastroesophageal reflux disease (GERD), is invasive, time consuming, not widely available, and unable to detect non-acid reflux. In contrast, the presence of pepsin in the saliva would act as a marker for reflux, considering that pepsin is only produced in the stomach. Objective To evaluate the predictive value of salivary pepsin in diagnosing laryngopharyngeal reflux (LPR) as suggested by the results of reflux symptom index (RSI > 13), reflux finding score (RFS > 7), and positive response to treatment with a 4-week course of proton-pump inhibitors. Methods This prospective study was done at a tertiary care hospital on 120 adult patients attending ENT OPD with clinical diagnosis of LPR. The presence of pepsin in their pharyngeal secretions and saliva using a lateral flow device, the Peptest, was compared with RSI, RFS, and with the response to medical treatment using the Chi-squared test. Results Salivary pepsin was found to be positive in 68% of the patients, with 87.5% of them showing positive response to treatment. Chi-squared analysis showed a significant association between positive salivary pepsin and RFS > 7, RSI >13, a combination of RFS > 7 and RSI > 13 as well as with response to treatment (p < 0.0001). Conclusion When considered along with the clinical indicators of RFS and RSI of more than 7 and 13, respectively, and/or with a response to treatment, a positive salivary pepsin test indicates statistically significant chance of presence of LPR.
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Laryngopharyngeal Reux: Symptoms, Signs,
and Presence of Pepsin in Saliva - A Reliable
Diagnostic Triad
Shilpa Divakaran1Sivaa Rajendran2Roshan Marie Thomas3Jaise Jacob2Mary Kurien2
1Department of ENT, NMC Specialty Hospital, Muscat, Oman
2Department of Biochemistry, Pondicherry Institute of Medical
Sciences, Kalapet, Puducherry, India
3Department of ENT, City Hospital , Kochi, Kerala, India
Int Arch Otorhinolaryngol
Address for correspondence Shilpa Divakaran, MS ENT, MRCS Edin
(ENT), Specialty Doctor, Department of ENT, Sandwell and West
Birmingham NHS trust, Dudley Road, Birmingham, United Kingdom
(e-mail: dr.d.shilpa@gmail.com).
Introduction
Gastroesophageal reux disease (GERD) is dened as the
retrograde ow of gastric contents into the esophagus or
above. Laryngopharyngeal reux (LPR) is the condition aris-
ing from the retrograde ow of gastric contents into the
larynx/pharynx, thus causing tissue damage that results in a
wide array of clinical symptoms and signs. Though LPR and
GERD are an extension of similar diseases, they differ con-
siderably in the pathophysiology, clinical presentation, diag-
nosis, and treatment. Gastroesophageal reux disease is said
to occur due to dysfunction of the lower esophageal sphinc-
ter whereas in LPR, the up per esophageal sphincter is at fault.
The main symptom of GERD is heartburn due to esophagitis.
In LPR, only 25% of the patients have esophagitis, and around
40% complain of heartburn.1
Keywords
reux ndings score
reux symptoms
index
saliva
pepsin
laryngopharyngeal
reux
Abstract Introduction Twenty-four-hour multichannel intraluminal impedance with double
probe pH monitoring (MII-pH), though considered the most sensitive tool for the
diagnosis of gastroesophageal reux disease (GERD), is invasive, time consuming, not
widely available, and unable to detect non-acid reux. In contrast, the presence of
pepsin in the saliva would act as a marker for reux, considering that pepsin is only
produced in the stomach.
Objective To evaluate the predictive value of salivary pepsin in diagnosing laryng-
opharyngeal reux (LPR) as suggested by the results of reux symptom index
(RSI >13), reux nding score (RFS >7), and positive response to treatment with a
4-week course of proton-pump inhibitors.
Methods This prospective study was done at a tertiary care hospital on 120 adult patients
attending ENT OPD with clinicaldiagnosis of LPR. The presence of pepsin in theirpharyngeal
secretions and saliva using a lateral ow device, the Peptest, was compared with RSI, RFS,
and with the response to medical treatment using the Chi-squared test.
Results Salivary pepsin was found to be positive in 68% of the patients, with 87.5% of
them showing positive response to treatment. Chi-squared analysis showed a signi-
cant association between positive salivary pepsin and RFS >7, RSI >13, a combination
of RFS >7andRSI>13 as well as with response to treatment (p<0.0001).
Conclusion When considered along with the clinical indicators of RFS and RSI of more
than 7 and 13, respectively, and/or with a response to treatment, a positive salivary
pepsin test indicates statistically signicant chance of presence of LPR.
received
October 27, 2019
accepted
March 4, 2020
DOI https://doi.org/
10.1055/s-0040-1709987.
ISSN 1809-9777.
Copyright © by Thieme Revinter
Publicações Ltda, Rio de Janeiro, Brazil
THIEME
Original Research
Published online: 2020-06-30
The major symptoms of LPR are globus sensation, throat
irritation, dysphagia, frequent throat clearing, drynessof throat,
chronic cough, hoarseness of voice, and voice fatigue. These
symptoms are long-term and cause intermittent concern to the
patient. If severe, there can be vocal fold/subglottic edema
andendolaryngeal mucus/granuloma formation.2It has been
shown that mixed as well as non-acid reux contribute to most
of the symptoms of LPR as compared with purely acid reux, in
the case of GERD.3Pepsin is an enzyme in gastric juice that has
been implicated in thepathogenesisof LPR as it can damage the
laryngeal mucosa, even at mild acidic or alkaline pH.46
The diagnosis of LPR based on symptoms and laryngeal
ndings alone has poor sensitivity and specicity as most of
the abnormal ndings are also seen in around 86% of healthy
individuals.7The mainstay of the diagnosis of LPR at present is
a combination of symptoms, beroptic endoscopic ndings,
and 24-hour multichannel intraluminal impedance (MII) com-
bined with double-probe pH monitoring (MII-pH). Multichan-
nel intraluminal impedance-pH monitoring is now considered
the most sensitive tool for the diagnosis and characterization
of GERD and its laryngopharyngeal symptoms. It detects both
acid and non-acid gastric reux and assesses the proximal
extent and nature of reuxate. However, MII-pH monitoring is
invasive, time consuming and not available in many centers,
with additional patient intolerability.811 Moreover, non-acid
reux cannot be detected by pH monitoring alone. Recent
insight intothe pathophysiology of LPRwith the help of MII-pH
studies has demonstrated non-acid and mixed reux to be
more common than acid reux.3Pepsin plays a major role in
the pathogenesis of LPR. Pepsin can damage the laryngeal and
pharyngeal mucosa at both acidic and alkaline pH, as it shows
some activity even at pH 8.12 Johnston et al did a prospective
translational study in established porcine in vitro model to
examine the effect of active/inactive pepsin on laryngeal CAIII
and Sep70 protein levels. They reported detectable levels of
pepsin in laryngeal epithelia after a reux event.12 Normally,
pepsin in this site would be enzymatically inactive, as the
mean pH of the laryngopharynx is 6.8. Signicantly, pepsin
would be reactivated by a subsequent decrease in pH, such as
would occur during an acidic reux event or possibly after
uptake into intracellular compartments of lower pH. Since
pepsin is produced only in the stomach, its presence in the
saliva would act as a marker for reux.13 Pepsin, thus, has the
potential to overcome the invasive,time-consuming,and ex-
pensive MII-pH studies, as it can be easily detected in the
pharyngeal secretions and saliva using a lateral ow device
such a Peptest.
There is a paucity of reports from the Indian subcontinent
on this easily available, relatively less expensive, less time-
consuming and non-invasive test utilizing salivary pepsin in
the diagnosis of LPR. Hence, this study was undertaken.
Materials and Methods
This prospective study was performed at a tertiary carehospital
following institutional research and ethical committee approval
(No. RC/16/142). The objective of the present study was to
evaluate the diagnostic value of pepsin in saliva in the diagnosis
of LPR. Written informed consent was obtained from all
patients. All adult patients attending the ear, nose and throat
outpatient department with a history of change in voice/
burning sensation in the substernal or epigastric region/regur-
gitation/dysphagia/throat pain/cough/foreign body sensation
in throat/frequent throat clearing for more than 4 weeks with
clinical diagnosis of LPR were selected for the study. They were
then asked to complete a questionnaire with various possible
symptoms suggestive of LPR for calculating reux symptom
index (RSI). The RSI is a 9-point questionnaire, each rated on a
Likert scale from 0 to 5,considering a score >13 suggestive of
LPR.8All patients then underwent exible nasopharyngolar-
yngoscopy for assessing reux ndings score (RFS), which is an
8-component assessment tool for quantifying thevseverity of
laryngeal inammation. An RFS score >7issuggestiveofLPR.
9
Those with previous laryngeal surgery, neoplasm of the phar-
ynx and larynx, chronic granulomatous lesion of the larynx/
pharynx, and use of proton pump inhibitors in the previous
month were excluded.
Saliva samples were collected 1 hour after meals. Patients
were instructed to cough up saliva from the back of their throat
and spit into 30-ml standard tubes containing 0.5mL of
0.01 mol/L citric acid at pH 2.5 to preserve the action of any
pepsin present. The samples were refrigerated at 4°C. Immu-
noserologic pepsin analysis was performed within a week of
collecting the sample, using a Peptest lateral ow device (LFD)
(RD Biomed Ltd, Hull,UK) by one of the coinvestigatorswho was
blinded to the clinical data. The collection tubes were centri-
fuged at 4,000 rpm for 5 minutes. EightyμL of the supernatant
were drawn up using standardmicropipettes and transferred to
a clear screwtop microtube containing 240 μL of migration
buffer solution. This tube was mixed with a vortex mixer for
10 seconds. Using a dual bulb pipette, 80 μL of this sample was
placed in the well of the lateral ow device (LFD). The control
line appeared within a few minutes and the test line appeared
within 5 to 15 minutes if the result was positive.
All patients were given proton pump inhibitor (PPI eso-
meprazole 40 mg twice a day) and prokinetic (domperidone
10 mg twice a day) for 4 weeks and the response to treatment
was assessed with RSI reduction by 50%. The patients were
divided into 3 groups for analysis and response to treatment
groupA (with RFS >7); Group B (RFS >7 and RSI >13); Group C
(RFS >7, RSI >13,and positive responseto treatment) (Fig. 1)
Results
A total of 120 patients were recruited for the study, of which
there were 53 men and 67 women. The age range was from 21
to 68, with the average agebeing 40 years. The average age was
39 in those with positive salivary pepsin and 43 in those with a
negative test. The most common symptoms were throat
irritation (58.3%), globus sensation (46%), dry cough (24%),
and regurgitation (15%). The mean RSI was 14.86 overall, 16.61
in the pepsin-positive, and 12.14 in the pepsin-negative
patients. The mean RFS was 8.53 overall, 9.01 in the pepsin-
positive, and 7.89 in the pepsin-negative patients. The general
characteristic of both groups (pepsin-positive and negative)
are shown in Table 1.
International Archives of Otorhinolaryngology
Laryngopharyngeal Reflux: Symptoms, Signs and Presence of Pepsin in Saliva Divakaran et al.
Of the 120 participants who enrolled in the study, 97
(80.8%) had RFS >7, and 72 (60%) had RSI >13. On combining
these two parameters, there were a total of 68 (56.7%) partic-
ipants who had both RFS >7andRSI>13, whereas only 19
(15.8%) had both RFS and RSI below this cut off. Salivary pepsin
was found to be positive in 82 of the 120 subjects (68.1%).
Seventy-two ofthe patientsshowed a positive response to the
treatment, of which 63 had a positive Peptest, whereas 48
participants showed no response to the treatment,29 of whom
tested negative for pepsin (Tables 2 &3).
The chi-squared analysis showed a signicant association
between positive salivary pepsin and RFS >7 as well as with
RSI >13. Similarly, positive associations were observed for
positive pepsin and a combination of RFS >7andRSI>13
alone as well as with response to treatment (Table 4).
Discussion
Laryngopharyngeal reux has become a highly prevalent
condition, causing considerable concern both for the patient
and the otolaryngologist.10 It presents a diagnostic challenge
owing to atypical presentation and lack of readily available
sensitive diagnostic tests. Mo re often than not, the treatment
is started empirically with PPIs. In a common clinical setting,
LPR is diagnosed based on symptoms and laryngoscopic
ndings. Reux symptom score (RSI) is a commonly used
Fig. 1 Flowchart showing study procedures.
Table 1 Comparison of general characteristics of pepsin-
positive and pepsin-negative groups
Characteristic Pepsin (þ)Pepsin(-)
Age 39 43
Men 29 (55%) 24 (45%)
Women 44 (66%) 23 (34%)
Mean RSI 16.61 12.14
Mean RFS 9.01 7.89
Mean RSI after
treatment
10.34 9.53
Response to
treatment
54 (45%) 19 (16%)
Most common
item in RSI
Globus
sensation
(54%)
Globus
sensation
(38%)
Excess throat
mucus (23%)
Dry cough
(18%)
Most common
sign in RFS
Arytenoid
congestion
(67%)
Arytenoid
congestion
(47%)
Thick
endolaryngeal
mucus (34%)
Vocal cord
erythema
(26%)
Abbreviations: RFS, reux ndingscore;RSI,reux symptom index.
International Archives of Otorhinolaryngology
Laryngopharyngeal Reflux: Symptoms, Signs and Presence of Pepsin in Saliva Divakaran et al.
tool, which helps in keeping a record of symptoms for
reassessment after treatment. An RSI score >13 is highly
suggestive of LPR.9In our study, the me an RSI score was 14.86
(overall), which showed improvement with treatment in 60%
of patients (Table 1).
Several studies have been conducted evaluating pepsin as
a marker for LPR, all of them showing considerable variation
in the sensitivity and specicity of Peptest. A cross-sectional
study conducted by Ocak e al,14 in which a two-channeled
24-hour esophageal p H monitoring catheter was placed i n 20
patients with a suspicion of LPR, and each patient gave one
sample of sputum for the immunoserologic pepsin detection
test. This test was noted to have a sensitivity of 30% and a
specicity of 100%, with a positive predictive value of 100%.
The low sensitivity was attributed to single sample collec-
tion. In addition, this study also noted the proximal probe of
the pepsin positive patients having an apparent acidic pH as
compared with the pepsin-negative group (pH: 3.26 versus
Table 2 Distribution of different groups based on salivary
pepsin
Group Pepsin þPepsin -
RFS >77423
RFS <7815
RSI >13 68 4
RSI <13 14 34
RFS >7&RSI>13 65 3
RFS <7&RSI<13 5 14
Positive Response to treatment 63 9
No Response to treatment 19 29
RFS >7&RSI>13 & positive
response to treatment
56 1
Abbreviations: RFS, reux ndingscore;RSI,reux symptom index.
Table 3 Latent class distribution
Group RFS >7RSI>13 RESPONSE þPEPSIN þFREQ CUMULATIVE FREQ
1þ  15 15
2þ  116
3 þ 218
4  þ 523
5þþ  225
6þ þ 530
7þ  þ 535
8þ þ 035
9þ  þ 035
10  þ þ 035
11 þþ þ 136
12 þþ  945
13 þ þ þ 449
14 þ þ þ 352
15 þþ þ þ 56 108
16   12 120
Abbreviations: FREQ, frequency; RFS, reux ndingscore;RSI,reux symptom index.
Table 4 Chi-squared analysis between positive pepsin and the various clinical parameters
RFS >7
N(%)
RSI >13
N(%)
RFS >7&RSI>13
N(%)
RFS >7&RSI>13 &
positive response to
treatment
N(%)
YES NO YES NO YES NO YES NO
PEPSIN þ74 (76.3) 8(34.7) 68(94.4) 14(29.2) 65 (95.6) 5(26.3) 56 (98.2) 5(29.4)
PEPSIN - 23 (23.7) 15 (65.3) 4(5.6) 34(70.8) 3 (4.4) 14(73.7) 1 (1.8) 12(70.6)
TOTAL 97 23 72 48 68 19 57 17
Chi-squared statistic (pValue) 14.8
(<0.00019)
56.7
(<0.0001)
45.3
(<0.0001)
42.8
(<0.0001)
Abbreviations: RFS, reux ndingscore;RSI,reux symptom index.
International Archives of Otorhinolaryngology
Laryngopharyngeal Reflux: Symptoms, Signs and Presence of Pepsin in Saliva Divakaran et al.
pH: 6). They thus suggest that a positive pepsin test in a
patient clinically suspected to have LPR can be a cost-effec-
tive, accurate, and alternative diagnostic method.12 Another
study by Alexander et al15 suggests that salivary pepsin has a
sensitivity of 78% and specicity of 53% for predicting an RFS
>7. Wang et al16 conducted a meta-analysis to assess the
diagnostic value of pepsin in saliva for LPR. The pooled
sensitivity and specicity were 64% and 68%, respectively.
They concluded that salivary pepsin has moderate value in
diagnosing LPR and requires further studies to optimize the
method of detection of pepsin. The reason for such varied
results across various studies could be differences in sample
size, number of salivary samples collected, timing of sample
collection, method of pepsin detection and criteria for diag-
nosis of LPR. As there is a wide range of concentration of
salivary pepsin observed in an individual over a period of
24 hours, samples collected soon after reux event are more
likely to be positive.16 In our study, 82 patients (68.1%) were
positive for salivary pepsin. Similar results were observed in
a study by Ianella et al to assess the correlation between
obstructive sleep apne a (OSA) and LPR, where salivar y pepsin
was used to conrm the diagnosis of clinically suspected LPR
based on positive RSI & RFS. 66.6% of the patients with
clinical LPR tested positive for salivary pepsin.17
There are a few studies comparing treatment response to
salivary pepsin, but none have studied the correlation be-
tween pepsin and combined RSI, RFS, and a positive response
to treatment. A study by Wang et al noted signicant
association between strongly positive salivary pepsin and a
good treatment response.18 Another study by Alexander et al
showed signicant correlation between RFS scores and posi-
tive Peptest, but no correlation between RSI and a positive
Pepstest.15 Sereg-Bahar et al studied pepsin and bile acids in
the saliva of patients with LPR and reported a signicant
correlation between the RSI and RFS scores and the level of
total pepsin and bile acids in the saliva.19 There was a
signicant association between a positive Peptest and
RSI >13 and RFS >7, individually, as well as on combining
RSI and RFS together. The association was signicant even
when combining RFS, RSI and response to treatment (p<
0.05), in our study (Table 4), making our study the rst to
compare associations between these parameters together.
This prospective study indicates that salivary pepsin test
is indeed a very useful test in the diagnosis of LPR, especially
in a set up in which MII-pH is not available. A positive pepsin
test in combination with RSI, RFS and trial of response to
treatment revealed signicant association.
Conclusion
In the clinical presentation of a constellation of symptoms
and signs in LPR, RSI)and RFS)are to be considered. The
present prospective study of immunoserologic pepsin anal-
ysis in the saliva of patients revealed that a positive salivary
pepsin test along with RSI >7, RFS >13, and positive
response to treatment with PPIs indicates statistically signif-
icant chance of presence of LPR. Hence, salivary pepsin test, a
relatively inexpensive, less time-consuming and patient
friendly non-invasive test is being suggested as part of
armamentarium in the diagnosis of LPR.
Limitations
The diagnosis of LPR could not be conr med with MII-pH due
to non-availability of the equipment.
Only a single sample of saliva was tested. The number of
positives may have been more if there were multiple sam-
ples. However, multiple samples could not be obtained due to
limited funds. There was a lack of control group.
Funding
The present study was possible with internal funding
provided by the research committee of the Pondicherry
Institute of Medical Sciences, Puducherry, India.
Conict of Interests
The authors have no conict of interests to declare.
References
1Koufman JA. The otolar yngologic manifestations of gastroesoph-
ageal reux disease (GERD): a clinical investigation of 225
patients using ambulatory 24-hour pH monitoring and an exper-
imental investigation of the role of acid and pepsin in the
development of laryngeal injury. Laryngoscope 1991;101(4 Pt
2, Suppl 53):178
2Koufman JA, Aviv JE, Casiano RR, Shaw GY. Laryngopharyngeal
reux: position statement of the committee on speech, voice, and
swallowing disorders of the American Academy of Otolaryngolo-
gy-Head and Neck Surgery. Otolary ngolHea d NeckS urg 2002;127
(01):3235
3Lee JS, Jung AR, Park JM, Park MJ, Lee YC, Eun YG. Comparison of
Characteristics According to Reux Type in Patients With Lar-
yngopharyngeal Reux. Clin Exp Otorhinolaryngol 2018;11(02):
141145
4Bulmer DM, Ali MS, Brownlee IA, Dettmar PW, Pearson JP.
Laryngeal mucosa: its susceptibility to damage by acid and
pepsin. Laryngoscope 2010;120(04):777782
5Jiang A, Liang M, Su Z, et al. Immunohistochemical detection of
pepsin in laryngeal mucosa for diagnosing laryngopharyngeal
reux. Laryngoscope 2011;121(07):14261430
6Hicks DM, Ours TM, Abelson TI, Vaezi MF, Richter JE. The preva-
lence of hypopharynx ndings associated with gastroesophageal
reux in normal volunteers. J Voice 2002;16(04):564579
7Hila A, Agrawal A, Castell DO. Combined multichannel intra-
luminal impedance and pH esophageal testing compared to pH
alone for diagnosing both acid and weakly acidic gastroesopha-
geal reux. Clin Gastroenterol Hepatol 2007;5(02):172177
8Belafsky PC, Postm a GN, Koufman JA. Validity and reliabilit y of the
reux symptom index (RSI). J Voice 2002;16(02):274277
9Belafsky PC, Post ma GN, Koufman JA. T he validity and reliabilit y of
the reux nding score (RFS). Laryngoscope 2001;111(08):
13131317
10 Altman KW, Stephens RM, Lyttle CS, Weiss KB. Changing impact of
gastroesophageal reux in medical and otolaryngology practice.
Laryngoscope 2005;115(07):11451153
11 Knight J, Lively MO, Johnston N, Dettmar PW, Koufman JA.
Sensitive pepsin immunoassay for detection of laryngopharyng-
eal reux. Laryngoscope 2005;115(08):14731478
12 Johnston N, Dettmar PW, Bishwokarma B, Lively MO, Koufman JA.
Activity/stability of human pepsin: implications for reux attrib-
uted laryngeal disease. Laryngoscope 2007;117(06):10361039
International Archives of Otorhinolaryngology
Laryngopharyngeal Reflux: Symptoms, Signs and Presence of Pepsin in Saliva Divakaran et al.
13 Bardhan KD, Strugala V, Dettmar PW. Reuxrevisited:advancing the
role of pepsin. Int J Otolaryngol 2012;2012:646901. Doi: 10.1155/
2012/646901
14 Ocak E, Kubat G, Yorulmaz İ. Immunosero logic pepsin detection in
the saliva as a non-invasive rapid diagnostic test for laryngophar-
yngeal reux. Balkan Med J 2015;32(01):4650
15 Spyridoulias A, Lillie S, Vyas A, Fowler SJ. Detecting laryngophar-
yngealreux in patients with upper airways symptoms: Symptoms,
signs or salivary pepsin? Respir Med 2015;109(08):963969
16 Wang J, Zhao Y, Ren J, Xu Y. Pepsin in saliva as a diagnostic
biomarker in laryngophar yngeal reux: a meta-analysis. Eur Arch
Otorhinolaryngol 2018;275(03):671678
17 Iannella G, Vicini C, Polimeni A, et al. Laryngopharyngeal
Reux Diagnosis in Obstructive Sleep Apnea Patients Using
the Pepsin Salivary Test. Int J Environ Res Public Health 2019;
16(11):2056
18 Wang CP, Wang CC, Lien HC, et al. Saliva Pepsin Detection and
Proton Pump Inhibitor Response in S uspected Laryngopharyngeal
Reux. Laryngoscope 2019;129(03):709714
19 Sereg-Bahar M, Jerin A, Jansa R, Stabuc B, Hocevar-Boltezar I,
Sereg-Bahar M. Pepsin and bile acids in saliva in patients with
laryngopharyngeal reux - a prospective comparat ive study. Clin
Otolaryngol 2015;40(03):234239
International Archives of Otorhinolaryngology
Laryngopharyngeal Reflux: Symptoms, Signs and Presence of Pepsin in Saliva Divakaran et al.
... Almost all previous studies used the scale method or pepsin concentration alone to evaluate its diagnostic value, or to explore the correlation [7]. A prospective study of immunoserologic pepsin analysis in the saliva of patients revealed that a positive salivary pepsin test along with RSI > 7, RFS > 13 and positive response to treatment with PPIs indicates statistically significant chance of presence of LPR [31]. The results of Weitzendorfer's trial also showed that the pepsin test with the highest level in each patient had a significant correlation with the RFS score, could also allow a combined multiparameter approach of the Peptest (RDBiomed), RSI score and RFS score to diagnose LPR [18]. ...
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Full-text available
Objective To explore the diagnostic efficacy of pepsin concentration in saliva for laryngopharyngeal reflux (LPR) disease. Methods In this study, we recruited 40 participants with abnormal sensation of throat into the study who visited our hospital from March 2020 to December 2020. The 24 h multichannel intraluminal impedance and pH monitoring (24 h MII-pH), reflux symptom index (RSI) and reflux finding score (RFS), pepsin concentration in saliva were collected. The Cohen’s kappa test and receiver-operating characteristic (ROC) curves were performed to determine and compare the sensitivity and specificity of five diagnostic methods: RSI; RFS, pepsin concentration, RSI + RFS, RSI + RFS + pepsin concentration. Results The area under the curve (AUC) of RSI, RFS, pepsin concentration, RSI + RFS, RSI + RFS + pepsin concentration were 0.767, 0.733, 0.870, 0.750,0.867, respectively. That is, the pepsin concentration has maximum AUC (the cutoff point is 219.47 (ng/mL); the sensitivity and 1-specificity is 0.300, 0.933, respectively.). The positive predictive value was 90.3% (28/31), and the negative predictive value was 77.8% (7/9). The Cohen’s kappa coefficients of the five diagnostic subgroups were: RSI 0.486 (95% CI 0.207–0.764, P = 0.001); RFS 0.333 (95% CI 0.021–0.644, P = 0.032); RSI + RFS: 0.517 (95% CI 0.205–0.829, P = 0.001); pepsin concentration: 0.699 (95% CI 0.379–0.931, P = 0.001); RSI + RFS + pepsin concentration: 0.500 (95% CI 0.181–0.819, P < 0.001). Conclusion The pepsin concentration has the maximum AUC area and highest consistency with the 24 h MII-pH. Therefore, it has certain value in the screening and diagnosis of diseases related to LPR disease.
... The major symptoms of LPR are hoarseness of voice, globus sensation, throat irritation, dysphagia, frequent throat clearing, dryness of throat, chronic cough, and voice fatigue. 2 However, many people with LPR have other reasons for their symptoms such as glottic insufficiency, 3 allergy, 4 and so on. ...
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Objective To study the value of multitime point salivary pepsin testing (MTPSPT) for the diagnosis of laryngopharyngeal reflux (LPR). Study Design Prospective noncontrolled. Methods For patients who met the enrollment criteria, the reflux symptom index (RSI) and reflux finding score (RFS) were calculated and salivary pepsin testing was performed. The pepsin test was performed every hour from 7:00 a.m. to 6:00 p.m. by collecting fresh saliva samples. A single positive test result was needed for the diagnosis of LPR. The consistency in the diagnosis of LPR between the two methods was compared with the weighted Cohen's kappa statistic. Results A total of 204 patients were included. The kappa value between the two methods was 0.566 (p = .00). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of MTPSPT were 76.43%, 85.94%, 92.24%, and 62.5%, respectively. We also compared a single pepsin measure at 7 a.m. with the screening results based on the RSI and RFS, and found a much lower kappa agreement value (0.223, p = .00). The sensitivity, specificity, PPV, NPV, and false-negative rate of pepsin testing at 7 a.m. (fasting) were 37.86%, 92.18%, 91.38%, 40.41%, and 58.57%, respectively. Conclusion The use of the result of a single salivary pepsin test in the morning yields a relatively higher rate of missed diagnosis of LPR, and multitime point testing through a day increased the accuracy and sensitivity of detection of LPR twofold compared to a single morning fasting sample. Level of Evidence 3
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Objective: This study aims to explore the effects of laryngopharyngeal reflux disease (LPRD) and proton pump inhibitor (PPI) treatment on Eustachian tube function in patients with obstructive sleep apnea (OSA). Methods: The Eustachian tube score-7 (ETS-7) was observed before and after PPI treatment in the control group, OSA only group, and OSA + LPRD group. Results: Age, sex, smoking history, and drinking history showed no differences among 3 groups (P > .05). The body mass index (BMI) in the control group was lower than that in other groups (P < .017). Before PPI treatment, the abnormality rate of ETS-7 in the OSA + LPRD group statistically differed from that in the control group and the OSA only group (P < .017). After PPI treatment, the abnormality rate of ETS-7 in the OSA + LPRD group exhibited no significant differences compared with that in the control group and the OSA only group (P > .017), and it declined remarkably compared with that before PPI treatment (75% vs 35%, χ2 = 13.334, P = .001). Moreover, the multivariate analysis revealed that only LPRD had an independent correlation with the abnormality of ETS-7 (OR = 1.245, 95% CI: 1.759-6.861, P = .000). Conclusion: In view of its high incidence in OSA patients, LPRD may be a considerable factor for the high incidence of abnormality rate of ETS-7 in OSA patients, and PPI therapy is of significant value in improving Eustachian tube function in OSA patients with LPRD.
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Background: To investigate the presence of laryngopharyngeal reflux in patients with obstructive sleep apnea (OSA) employing the salivary pepsin concentration method. To compare the results of pepsin concentration with the severity of the pathology. Methods: Seventy-five OSA patients (44 males, 31 females) were enrolled in the study. For each patient, the AHI (apnea-hypopnea index) and the BMI (body mass index) were initially evaluated. All the patients enrolled were assessed using the reflux symptom index (RSI) and the reflux finding score (RFS) in order to perform a clinical diagnosis of laryngopharyngeal reflux. In all patients a salivary sample was taken to estimate the presence of pepsin and its concentration. Results: The incidence of LPR (laryngopharyngeal reflux) in OSA patients, evaluated using the salivary pepsin concentration test (PEP-test), was found to be 32% of cases. Linear regression testing did not show any correlation between AHI and pepsin concentration in salivary samples (p = 0.1). Conclusion: A high number of patients with OSA seem to show positivity for salivary pepsin, correlated to an LPR. There does not appear to be a correlation between the severity of apnea and the grade of salivary pepsin reflux. On the other hand, direct correlation between BMI and the value of pepsin in salivary specimens was observed.
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Objectives/Hypothesis To evaluate the prediction value of saliva pepsin detection for an 8‐week proton pump inhibitor (PPI) response in patients with a Reflux Symptoms Index (RSI) score ≥13, which indicates possible laryngopharyngeal reflux. Study Design Prospective individual single‐cohort study. Methods Patients were recruited who had experienced chronic laryngopharyngeal symptoms (RSI score ≥13) for more than 3 months after excluding other etiologies. The patients received PPI (40 mg of esomeprazole once daily) treatment for 8 weeks. Prior to treatment, the patients submitted saliva/sputum samples that were collected during the time symptoms were observed. The samples were taken for pepsin detection, and performed using the commercially available Peptest lateral flow device. The association of the Peptest results and PPI response were statistically analyzed with the χ² test. Results Seventy‐four patients completed the study, and upon completion of PPI treatment, the mean RSI score was significantly reduced from 19.22 ± 5.18 to 8.99 ± 5.69. Forty‐four (59.5%) patients exhibited a good response as defined by an RSI score reduction ≥50%. The results of the Peptest were semiquantitatively graded as 0, 1, 2, 3 (negative, weak positive, moderate positive and strong positive, respectively) based upon the visual intensity of the test sample line as compared to the control line. Twenty‐four patients (32.4%) exhibited grade 3 strong positive results. The Peptest strong positive results (P < .05) were significantly associated with a good PPI response, with the positive predictive value being 79.2%. Conclusions Analysis of strong positive results for pepsin detection in saliva/sputum samples may be a useful, noninvasive method for predicting better PPI response in patients with suspected reflux induced chronic laryngopharyngeal symptoms. Level of Evidence 2 Laryngoscope, 2018
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Objective: Pepsin in saliva has been proposed as a biomarker for the diagnosis of laryngopharyngeal reflux (LPR), but the results remain controversial. We assessed the diagnostic value of pepsin in saliva for LPR. Methods: PubMed, Embase, and Web of Science were searched for studies in English that evaluated the utility of pepsin in saliva in the diagnosis of LPR, published up to 15 March 2017. We used Stata 12.0 to summarize the diagnostic indexes for the meta-analysis. Results: Eleven eligible studies met the inclusion criteria. After the meta-analysis of included studies, the pooled sensitivity and specificity were 64% [95% confidence interval (CI) 43-80%] and 68% (95% CI 55-78%), respectively; the positive (PLR) and negative (NLR) likelihood ratios were 2.0 (95% CI 1.4-2.9) and 0.54 (95% CI 0.33-0.87), respectively; the diagnostic odds ratio (DOR) was 4 (95% CI 2-8); and the area under the curve (AUC) was 0.71 (95% CI 0.67-0.75). Conclusion: Pepsin in saliva has moderate value in the diagnosis of LPR. The cutoff value used could affect the diagnostic value. Therefore, further investigations are required to find the optimal method to detect salivary pepsin in diagnosing LPR.
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Objectives: To analyze laryngopharyngeal reflux (LPR) as an acidic, nonacidic, or mixed type according to 24-hour multichannel intraluminal impedance (MII) pH monitoring and the clinical characteristics of each type. Methods: Ninety patients were prospectively enrolled in this study. All patients underwent 24-hour MII pH monitoring as a diagnostic tool. Eighty-three patients were diagnosed with LPR. The patients were classified into three groups according to the pH of the hypopharyngeal probe: the acid reflux group, nonacid reflux group, and mixed reflux group. Subjective symptoms and objective findings were evaluated based on patients' responses to the Short Form 12 Survey (SF-12), LPR health-related quality of life (LPR-HRQOL), reflux symptom index, and reflux finding score. Results: The Results of each group were compared. As a result, 34 patients were classified into the nonacid reflux group and 49 into the mixed reflux group. There were no patients classified as having acid reflux alone. There was no significant difference between the two groups when comparing the reflux symptom index, reflux finding score, LPR-HRQOL, or the mental component score of the SF-12. However, the physical component score of the SF-12 was higher in the nonacid reflux group (P=0.018). The DeMeester composite score (P=0.015) and total number of LPR events (P=0.001) were lower in the nonacid reflux group than in the mixed reflux group. Conclusion: In Conclusion, no LPR patient had only acid reflux. The nonacid reflux LPR patients showed similar clinical characteristics and findings compared to the mixed reflux group, but exhibited significantly fewer LPR episodes.
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Background: The most common tool for the diagno- sis of laryngopharyngeal reflux (LPR) is still 24-hours esophageal pH monitoring; there is lack of non-inva- sive, less expensive and accurate diagnostic tools for this frequent disease. Aims: To evaluate the accuracy of immunoserologic pepsin detection in the saliva for the diagnosis of LPR. Study Design: Cross-sectional study. Methods: A two channeled 24-hour esophageal pH monitoring catheter was placed in patients with a sus- picion of LPR. During the 24-hour period, each patient gave one sample of sputum for the immunoserologic pepsin detection test. Pathologic gastroesophageal re- flux (GER) findings, LPR findings, pH score in the proximal and distal probes when the sputum sample was given were recorded. The sensitivity, specificity, positive and negative predictive values of the pepsin detection test were analyzed and compared to pH mon- itoring scores. Results: The study group consisted of 20 patients who met the criteria. A positive pepsin detection test was elicited from 6 patients. The sensitivity and specificity of the pepsin detection test was 33% and 100%, respec- tively. A positive predictive value of 100% was record- ed. When the pH results of the pepsin positive patients (PPP) and the rest of the study group in the proximal probe at the sample time were compared, the PPP had an apparent acidic pH value compared to the pepsin negative patients (pH: 3.26 for the PPP, pH: 6.81 for the pepsin negative patients). Conclusion: Pepsin detection in the saliva is a recent method and becoming increasingly popular. Because of the benefits and ease of application, a positive salivary pepsin test in a patient suspected of having LPR can be a cost effective, accurate and alternative diagnostic method. Increasing the daily number of sputum sam- ples may increase the sensitivity of the test.
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Gastroesophageal reflux disease is mediated principally by acid. Today, we recognise reflux reaches beyond the esophagus, where pepsin, not acid, causes damage. Extraesophageal reflux occurs both as liquid and probably aerosol, the latter with a further reach. Pepsin is stable up to pH 7 and regains activity after reacidification. The enzyme adheres to laryngeal cells, depletes its defences, and causes further damage internally after its endocytosis. Extraesophageal reflux can today be detected by recognising pharyngeal acidification using a miniaturised pH probe and by the identification of pepsin in saliva and in exhaled breath condensate by a rapid, sensitive, and specific immunoassay. Proton pump inhibitors do not help the majority with extraesophageal reflux but specifically formulated alginates, which sieve pepsin, give benefit. These new insights may lead to the development of novel drugs that dramatically reduce pepsinogen secretion, block the effects of adherent pepsin, and give corresponding clinical benefit. “For now we see through a glass, darkly.” —First epistle, Chapter 13, Corinthians
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Objective Laryngopharyngeal reflux (LPR) and biliary duodenogastric reflux can cause damage to the laryngeal mucosa and voice disorders. The aim of this study was to find out whether levels of pepsin and bile acids in the saliva can serve as diagnostic markers of LPR.SettingA prospective comparative study.ParticipantsTwenty-eight patients with LPR proven via high-resolution manometry and combined multichannel intraluminal impedance and 24-hour pH monitoring and 48 healthy controls without symptoms of LPR were included in the study.Main outcome measuresIn the patients with LPR symptoms, oesophagogastroscopy with oesophageal biopsy was performed. The levels of total pepsin, active pepsin, bile acids and the pH of the saliva were determined in all participants and compared between the groups. Reflux symptom index (RSI) and reflux finding score (RFS) were also obtained and compared. The groups differed significantly in RSI (p=0.00), RFS (p=0.00), the levels of bile acids (p=0.005) and total pepsin in saliva (p=0.023). The levels of total pepsin and bile acids were about three times higher in the patients with LPR than in the healthy controls. There was a significant correlation between the RSI and RFS score and the level of total pepsin and bile acids in the saliva. Histopathological examination of the oesophageal biopsy taken 5cm above the lower oesophageal sphincter confirmed reflux in almost 93% of patients with symptoms.Conclusions The study results show that the levels of total pepsin and bile acids in saliva are significantly higher in patients with LPR than in the controls, thus suggesting this as a useful tool in the diagnosis of LPR and particularly biliary LPR.This article is protected by copyright. All rights reserved.
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Exposure of pig laryngeal mucosa to pepsin and acid will have a differential damaging effect depending on the anatomical site, mirroring the effects seen in the human larynx in laryngopharyngeal reflux (LPR). This study aims to quantitate damage caused to laryngeal tissue by acid alone, and acid and pepsin, and also to determine if the extent of this damage depends on the tissue site. Prospective translational research study. An excised porcine laryngeal damage model in a small Ussing chamber was used to measure the effect of pepsin and acid on five sites (ventricles, vocal folds, posterior commissure, supraglottic, and subglottic mucosa). The tissue samples were incubated on the lumenal side for 1 hour with pH 2 and 4 HCl, pH 2 plus 1 mg/mL pepsin, and pH 4 plus 1 mg/mL pepsin. Damage was assessed by changes in absorbance of the bathing solution at optical density (OD) 260 nm and OD 280 nm and by measurement of released DNA compared to tissues bathed in pH 7.4 buffer. Damage was also assessed histologically. Based on histology, all the tissues were resistant to pH 4.0 except the subglottic mucosa. Only the posterior commissure was not damaged by pH 2.0 plus pepsin. Similar patterns were observed with absorbance changes and DNA release. The subglottic mucosa was the most susceptible to damage and the posterior commissure the least. Laryngeal tissues are essentially resistant to damage at pH 4.0, but are damaged when pepsin is present. This suggests that in LPR, pH 4.0 or above refluxate would only be damaging if it contains pepsin. Laryngoscope, 2010
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To investigate whether the pepsin immunohistochemical (IHC) staining of the laryngeal mucosa epithelia is an available test for diagnosing laryngopharyngeal reflux (LPR) in clinic. Prospective case series. Biopsy specimens from interarytenoid mucosa of LPR patients (seven acid LPR and eight nonacid LPR) and 21 sex- and age-matched normal controls were obtained for pepsin IHC staining. The diagnosis of LPR was based on 24-hour combined multichannel intraluminal esophageal impedance pH monitoring. The results of IHC staining were semiquantitatively analyzed and scored as negative (-), weakly positive (+), moderately positive (++), and strongly positive (+++). Six of seven acid LPR (85.7%) and six of eight nonacid LPR (75%) mucosa samples were moderate to strongly positive for intracellular pepsin. By contrast, only three of 21 normal controls (14.3%) were moderately positive. The difference in intracellular pepsin between LPR and the normal laryngeal mucosa was statistically significant (P < .01). No significant difference in intracellular pepsin was observed between the acid and nonacid LPR mucosal samples (P = .453). Using weak positivity (+) as a cutpoint, the presence of intracellular pepsin in the laryngeal mucosa had a sensitivity of 100% and a specificity of 47.6% in detecting LPR (P < .05). However, using the moderate positivity (++) as the cutpoint, the pepsin had a slightly decreased sensitivity of 80% but a sharply increased specificity of 85.7% (P < .05) in the detection of LPR. Pepsin IHC staining of the laryngeal mucosa appears to be a sensitive and specific test for diagnosing LPR in a clinical application.