BACKGROUND and AIM
According to the Lyon 2.0 consensus, patients with laryngopharyngeal reflux (LPR) symptoms should undergo upfront pathophysiologic tests to evaluate for conclusive evidence of reflux prior to medical management. The diagnosis of gastro-esophageal reflux disease (GERD) is confirmed in patients with an acid exposure time (AET) >6% on ambulatory reflux monitoring performed off therapy. So far, High-resolution manometry (HRM) had a secondary role in the diagnostic work-up for GERD. Recently, a novel score (Milan Score), generated from manometric evaluation of esophago-gastric junction (EGJ) morphology, ineffective esophageal motility (IEM), EGJ-contractile integral (EGJ-CI) and straight leg raise (SLR) response, has been demonstrated to predict abnormal AET, and could be a useful screening tool to determine the risk of GERD (Figure 1). The aim of this study was to evaluate the manometric characteristics of patients with LPR symptoms and to assess the effectiveness of the Milan Score in predicting GERD in these patients.

MATERIAL AND METHODS
We prospectively enrolled patients with suspected GERD who underwent HRM and MII-pH from nine referral centers. Among the study population, patients with isolated LPR symptoms (Reflux Symptom Index, RSI >13) were compared with patients reporting isolated typical GERD symptoms (GERD-Health Related Quality of Life, GERD-HRQL ≥10). In order to compute the Milan Score, manometric characteristics including EGJ morphology, IEM, EGJ-CI and SLR response were reviewed and compared. A Milan Score >137, corresponding to a 50% risk of AET>6% was considered positive. The effectiveness of the Milan Score in the identification of patients with pathologic GERD was assessed in the two patient groups.

RESULTS
Among 570 patients (median age 49 years, 49% females, median BMI 24 kg/m²) isolated LPR was found in 30 patients and isolated typical GERD symptoms in 154 patients. The other 356 patients presented either both symptom’s patterns or other symptoms. An AET>6% was found in 23% in the LPR group and in 43% in typical symptom group (p=0.034). Milan Score was higher with typical GERD symptoms compared to the LPR group (118.5 vs. 88.7, p=0.004), with higher scores for EGJ-CI (p=0.039) and SLR response (p=0.038) components. The likelihood of concordance of the Milan Score and AET on reflux monitoring was similar between the LPR and typical GERD symptoms groups (83.3% vs. 84.4%, p=0.532). When the Milan Score was <137, only 12.5% in the LPR group and 13.6% in typical symptoms group had a positive reflux monitoring study.

CONCLUSIONS
Patients with isolated LPR symptoms demonstrated a lower likelihood of EGJ disruption compared to those with typical symptoms. The Milan Score performed similarly well in the identification of GERD patients in both groups and could be used as screening upfront test in patients with LPR symptoms.

Figure 1

Anthony Hobson

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