Refractory Gastro-oesophageal Reflux Disease and Laryngopharyngeal Reflux - Use the Bottom up Approach

The pathophysiology of typical gastro-oesophageal reflux disease (GORD) symptoms and reflux oesophagitis is associated with excess acid reflux, but both refractory GORD and laryngopharyngeal reflux (LPR) have strong links with functional gut disorders [1-3]. Oesophageal pH impedance monitoring, our accepted gold standard for diagnosing GORD, has significant shortcomings when assessing proximal oesophageal and in particular pharyngeal reflux [4]. In addition, identifying potential contamination of other parts of the respiratory tract such as lungs or sinuses is not possible. The association between irritable bowel syndrome (IBS) and both refractory GORD and LPR suggests a common pathogenesis. IBS subjects are known to have increased sensitivity to colonic distension causing pain and increased contractility [5], but colonic distension has also been found to affect upper gut motility [6-9] and increase reflux events in physiological studies [10]. Treating GORD and LPR symptoms refractory to proton pump inhibitor (PPI) therapy remains challenging, but the effect of downstream colonic distension or occult constipation on treating GORD and LPR to date has been largely ignored. Hence in our study, we hypothesised that reducing colonic distension mainly with simple osmotic laxative therapy would not only improve colonic symptoms but also LPR, refractory GORD and functional upper gut symptoms.