Contemporary approach to the etiology, diagnosis and therapy of laryngopharyngeal reflux – literature review

Autori:

Ana Đanić Hadžibegović, Ratko Prstačić, Juraj Slipac, Ika Gugić Radojković, Davorin Đanić

Sažetak
Pregledom recentne literature prikazali smo nove spoznaje u patofiziologiji, simptomatologiji, dijagnostičkim i terapijskim metodama zbrinjavanja bolesnika s laringofaringealnim refluksom (LPR-om). Iako se broj istraživanja LPR-a značajno povećao posljednjih nekoliko godina, i dalje ne postoje zlatni standardi niti standardizirani protokoli dijagnosticiranja i liječenja LPR-a te je neophodan interdisciplinarni pristup u rješavanju ove problematike. Upitnici za samoprocjenu težine simptoma i skale kliničkih znakova trebali bi uključivati i simptome i znakove gastroezofagealne refluksne bolesti i respiratornog sustava, a objektivna dijagnostika trebala bi se temeljiti na lako dostupnom i jednostavnom testu određivanja razine koncentracije pepsina u slini. Nejasne slučajeve treba uputiti na daljnju dijagnostičku obradu: višekanalnu impendaciju s pH-metrijom, koja omogućuje određivanje tipa refluksa (kiselinski, mješoviti i nekiselinski) te provođenje personalizirane terapije. Prema najnovijim spoznajama kod blagih oblika bolesti primjena bihevioralnih mjera bila bi metoda izbora liječenja. Kod umjerenih i teških oblika lijek izbora ili kombinacija lijekova ovisi o tipu refluksa. Medikamentnu terapiju treba provoditi minimalno osam tjedana, a optimalno tri mjeseca, nakon čega slijede kontrolni pregledi i revizija simptoma i kliničkih nalaza te u slučaju značajnog poboljšanja smanjivanje medikamentne terapije, a u slučaju blagog poboljšanja pojačanje doze i produljenje terapije dodatna tri mjeseca. U slučajevima bez promjene ili eventualnog pogoršanja bolesnike treba uputiti na dodatnu gastroenterološku obradu i eventualno kirurško liječenje. Preporučuje se strogo pridržavanje bihevioralnih mjera, dok se dugotrajna primjena inhibitora protonske pumpe ne preporučuje s obzirom na dokazane brojne nuspojave lijeka.
Summary

We performed a review of recent literature in order to present new insights in pathophysiology, symptomatology, diagnostics and therapy of laryngopharyngeal reflux (LPR). Although the number of LPR studies has increased significantly over the past few years, there are still no gold standards or standardized protocols for diagnosing and treating LPR, and an interdisciplinary approach is necessary. Questionnaires for symptom severity self-assessment and clinical signs should include both symptoms and signs of gastroesophageal reflux disease and respiratory system, and primary objective diagnostic tool should be a simple determination of
the most reliable biomarker pepsin, from easily obtainable fluid, such as saliva. Unclear cases should be referred for further assessment with multichannel impedance and pH monitoring. It allows the determination of the type of reflux (acidic, mixed and non-acidic) and implementation of personalized therapy. According to the latest findings, behavioural therapy would be the method of choice in the treatment of mild forms of the LPR. In moderate and severe forms, the combination of drugs depends on the reflux type. Drug therapy should be carried out for a minimum of eight weeks, optimally three months, followed by follow-up examination and revision of symptoms and clinical findings. Significant improvement allows drug therapy reduction, while cases with slight improvement demand dosage increase and another three months of treatment. In cases without change or possible deterioration, patients should undergo additional gastroenterological work-up and potential surgical treatment. Strict adherence to behavioural measures is proposed, while long-term prescription of proton pump inhibitors is not recommended given the proven number of adverse drug reactions.

Volumen: 7-8, 2021

Liječ Vjesn 2021;143:294–304

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