GOALS: To identify clinical features associated with geographic residency in patients with eosinophilic esophagitis (EoE).

BACKGROUND: Prior studies on the geographic distribution of eosinophilic esophagitis (EoE) have focused on disease prevalence. Geographic and environmental factors may impact the clinical characteristics and phenotypes of EoE, although data remain limited.

STUDY: This was a cross-sectional study of consecutive patients residing in Massachusetts with newly diagnosed EoE (≥15 eosinophils/hpf). Patients' residency settings were classified as urban or nonurban based on the 2020 US Census and residential zip codes. Clinical, endoscopic, and histologic variables were recorded. EoE patients in urban versus nonurban settings were compared using the student t test or the Fisher exact test for univariate analyses. Multivariable logistic regression was performed to identify the independent association between urban residency and comorbid atopic conditions, the inflammatory endotype, and the fibrostenotic endotype.

RESULTS: Six hundred eighty-three EoE patients were included, with 136 (20.0%) urban and 547 (80%) nonurban residents. Urban patients had higher rates of atopy (63.2% vs. 51.8%, P =0.02), severe food/environmental allergies (17.7% vs. 8.3%, P =0.002), and inflammatory findings endoscopic (43.4% vs. 27.8%, P =0.0006). On multivariable analysis, atopy (OR=1.57, CI: 1.02-2.40, P =0.04), severe food/environmental allergies (OR=1.99, CI: 1.09-3.63, P =0.02), and inflammatory findings (OR=1.90, CI: 1.22-2.94, P =0.004) remained independently associated with urban residency.

CONCLUSIONS: Urban residency is independently associated with severe food/environmental allergies and inflammatory endoscopic findings at EoE diagnosis, suggesting increased allergic phenotype and active inflammation at presentation. Allergen exposure, particularly indoors, and social determinants may be contributory factors. Environmental considerations, such as geographic residency, may impact EoE disease presentation, activity, and outcome.

BACKGROUND: Since gastroesophageal reflux disease (GERD) manifests typical and atypical symptoms of varying frequency and severity, the dominant symptom needs identification and quantification.

GOALS: We aimed to compare 5-point Likert scales assessing symptom burden to validated GERD questionnaires and outcomes following GERD management.

STUDY: We retrospectively analyzed pooled data from patients undergoing pH-impedance testing for reflux symptoms from 2 centers. Preprocedure questionnaires assessed symptom severity and frequency on 5-point Likert scales (0=not severe, infrequent; 4=extremely severe, multiple daily episodes); the product for the highest scoring symptom constituted the dominant symptom intensity (DSI). DSI was compared against validated instruments [global symptom severity (GSS), GERD questionnaire (GERDQ) and reflux symptom index (RSI)], and pH-impedance parameters per Lyon Consensus 2.0. DSI change after GERD management was compared against GSS and satisfaction with therapy.

RESULTS: Among 808 patients (mean age: 53.8±1.44 y, 65.2% female). DSI significantly correlated with GSS ( R =0.682), GERDQ ( R =0.414), RSI ( R =0.577), acid exposure time (AET) ( R =0.175), total reflux episodes ( R =0.194) and mean nocturnal baseline impedance ( R =-0.157) ( P <0.0001 for each comparison). On ROC analyses, DSI (AUROC=0.60) was noninferior to GSS, GERDQ, and RSI in predicting pathologic AET and total reflux episodes, and conclusive GERD. Percentage DSI improvement after antireflux treatment significantly correlated with GSS change ( R =0.632, P <0.0001) and treatment satisfaction ( R =0.513, P <0.0001) and was an independent predictor of GSS change (β=0.302, P <0.0001), and satisfaction with therapy (β=0.833, P =0.011) on multivariable regression.

CONCLUSIONS: DSI correlates with validated reflux questionnaires and discriminates abnormal from normal reflux burden. DSI change reflects reflux treatment outcome and satisfaction.

BACKGROUND: The San Diego Consensus for Laryngopharyngeal Symptoms (LPS) and Laryngopharyngeal Reflux Disease (LRPD) describes a broad-based multidisciplinary management paradigm that focuses on mechanisms underlying symptoms to improve treatment outcomes.

PURPOSE: This review expands on the San Diego Consensus framework to discuss multidisciplinary management of LPS and LPRD. LPS manifest as persistent or disproportionate symptoms despite minimal or inconsistent evidence of reflux exposure. Emerging evidence suggests that hyperresponsiveness, hypervigilance, and symptom-specific anxiety are more strongly associated with LPS than objective reflux metrics and may contribute to symptom persistence through heightened attention to perceived irritation and protective behavioral responses. Repeated peripheral sensory input may further contribute to central sensitization and lower perceptive thresholds. While these behavioral and neurophysiological processes may be partially improved by reducing reflux exposure, behavioral therapies that address the multidimensional nature of LPS may provide additional benefit. Laryngeal Recalibration Therapy addresses LPS by retraining maladaptive laryngeal behaviors, enhancing vagal tone via heart rate variability biofeedback, and cognitive reframing to reduce symptom amplification. Meta-therapy, a clinical dialogue approach used in speech-language pathology to facilitate behavioral change, alongside psychological interventions such as mindfulness meditation, cognitive-behavioral therapy, and gut-directed hypnotherapy, may further target cognitive-affective processes that shape perception. Behavioral interventions can be combined with neuromodulators, particularly delta ligands such as gabapentin in patients with chronic cough, and tricyclic antidepressants or selective serotonin reuptake inhibitors in select cases. Effective management relies on multidisciplinary collaboration, integration of reflux-directed and behavioral therapies, and patient-centered education that supports adaptive symptom interpretation.

BACKGROUND: Esophageal symptoms are common among elderly patients, although evidence on age-related esophageal dysfunction remains inconsistent. Esophageal contraction reserve measured by response to multiple rapid swallows (MRS) on high-resolution manometry (HRM) provides additional insights beyond conventional HRM metrics. We aimed to evaluate the impact of age on esophageal contraction reserve among symptomatic adults.

METHODS: Adults with esophageal symptoms undergoing HRM and pH-impedance monitoring off acid suppression were included. Patients with prior foregut surgery or major peristaltic disorder were excluded. MRS response was assessed by the ratio of post-MRS distal contractile integral (DCI) to mean DCI from single water swallows, with a ratio > 1 defining a positive response (MRS+).

RESULTS: Among 619 patients (mean 56.5 years, 59.1% female), 372 patients (60.1%) exhibited intact contraction reserve. MRS+ patients were younger (54.3 ± 15.7 vs. 59.8 ± 12.5 years, p < 0.0001) and MRS+ prevalence declined with advancing age groups (< 35 years: 78.8%; 35-50 years: 65.4%; 50-65 years: 59.6%; > 65 years: 51.7%, p-trend = 0.0008). On multivariable logistic regression, age negatively predicted MRS+ (OR: 0.97, CI: 0.96-0.99, p = 0.0004), after adjusting for potential confounders. In separate models constructed with categorized age groups, age > 65 years independently correlated with less MRS+ compared to all younger groups: Age < 35 (OR: 0.23, CI: 0.10-0.53, p = 0.0005), age 35-50 (OR: 0.58, 95% CI: 0.31-0.98, p = 0.045), and age 50-65 (OR: 0.55, 95% CI: 0.33-0.90, p = 0.017).

CONCLUSION: Esophageal contraction reserve measured by MRS during HRM declines with advancing age. Age-related loss of contractile adaptability may contribute to esophageal dysfunction and unexplained symptoms in older adults. Provocative testing with MRS on HRM provides value in evaluating symptomatic elderly patients.

BACKGROUND: The San Diego Consensus for Laryngopharyngeal Symptoms (LPS) and Laryngopharyngeal Reflux Disease (LRPD) offers a modern interdisciplinary paradigm that focuses on symptoms and aligns evaluation with underlying mechanisms of disease.

PURPOSE: This review uses the San Diego Consensus as the framework to discuss who should be tested for reflux, timing and selection of diagnostic testing, and practical diagnostic algorithms in patients with LPS and LPRD. Patient reported outcome measures are useful to characterize LPS, quantify symptom burden and monitor response, but are not specific for a diagnosis of LPRD. Patients presenting with both LPS and typical esophageal symptoms have higher pretest probability of LPRD, and time limited empiric acid suppressive agents and alginates may be appropriate. In contrast, upfront objective testing is recommended in isolated LPS prior to long-term acid suppressive therapy. Laryngoscopy or stroboscopy can identify alternative etiologies of LPS. Esophagoscopy can demonstrate conclusive reflux evidence, but diagnostic yield is low. pH-impedance monitoring, especially with hypopharyngeal sensors, assesses reflux mechanisms when investigating LPS, and can provide numbers of reflux episodes irrespective of acidity as well as proximal extent of these episodes. High-resolution manometry does not provide a diagnosis of LPRD but serves to rule out motility disorders that mimic LPS. Prolonged wireless pH monitoring may be appropriate when typical esophageal reflux symptoms coexist. The evaluation of LPS requires a paradigm shift away from reflexive attribution to reflux and toward a structured diagnostic approach that systematically considers alternative etiologies of LPS.

BACKGROUND: Throat and airway symptoms are common, but only a small proportion are reflux-related. The term "laryngopharyngeal reflux" has variable definitions in the literature and has been used to describe symptomatic patients with or without objective reflux, often leading to prolonged/unnecessary treatment trials.

PURPOSE: The San Diego consensus introduced the term laryngopharyngeal symptoms (LPS) to describe upper aerodigestive symptoms with potential relationship to reflux physiology, including cough, regurgitation, throat pain, throat clearing, excess phlegm, and hoarseness/voice change. This review describes presentation, health care burden and risk stratification of throat and airway symptoms in light of the San Diego consensus definitions and clinical approach. Laryngopharyngeal reflux disease (LPRD) requires objective evidence of pathologic reflux in addition to LPS. Importantly, LPS alone do not predict LPRD. While various validated patient-reported outcome instruments are available, only some are LPS/LPRD-specific, and all lack specificity for making a diagnosis of LPRD. These instruments may have value in tracking symptoms over time and post-treatment. Concurrent typical reflux symptoms may prompt empiric anti-reflux medication trials as initial therapy. Risk stratification scores have been developed for the purpose of directing upfront therapy for high-risk patients and investigation for intermediate/low-risk patients, but their clinical use needs further validation. Objective diagnosis of LPRD provides confidence in escalation of reflux interventions. Life-threatening long-term sequelae are infrequent in LPS/LPRD, although impact on quality of life and healthcare burden can be profound.

BACKGROUND: Symptoms and reflux burden in gastroesophageal reflux disease (GERD) may vary between populations.

AIMS: To evaluate relationships between symptom profiles and objective reflux burden in patients in two world regions, Asia and the United States.

METHODS: This was a cross-sectional study of patients undergoing pH-impedance monitoring from one Asian and two US centres. Validated patient-reported symptom instruments were prospectively collected. Symptom characteristics were compared against objective reflux burden (acid exposure time, AET; total reflux episodes, TRE; mean nocturnal baseline impedance, MNBI) from pH-impedance monitoring between the two populations.

RESULTS: Of 1099 patients, 162 were in Asia (age 47.4 ± 1.1 years, 36.4% female, body mass index, BMI 24.2 ± 0.4 kg/m2) and 937 in the United States (53.1 ± 1.3 years, 67.7% female, BMI 30.1 ± 0.3 kg/m2). Regurgitation dominated in Asia (59.9% vs. 50.3% heartburn in the United States), with higher TRE (55.4 ± 2.4 vs. 46.4 ± 1.2, p < 0.001). Despite this, reflux burden was lower in Asia (mean AET 2.19% ± 0.4% vs. 3.53% ± 0.2%; pathologic AET 11.1% vs. 20.5%; MNBI 2472 ± 62 Ω vs. 1745 ± 81 Ω; conclusive GERD per Lyon 2.0: 13% vs. 25.7%) (all p < 0.001), with higher symptom burden (GERDQ 8.97 ± 0.2 vs. 8.44 ± 0.1, p < 0.05; global symptom severity, GSS: 65.1 ± 1.8 vs. 48.1 ± 1.1, p = 0.001). Changing the AET threshold to 4% increased diagnostic yield by 21% among Asians (p = 0.035 vs. US). On multivariable linear regression, Asian patients (β = 19.3, p < 0.0001), higher AET (β = 1.02, p = 0.0004), higher reflux episodes (β = 0.11, p = 0.0029), lower BMI (β = -0.37, p = 0.0046) and female sex (β = 8.14, p = 0.0007) were independent predictors for higher GSS.

CONCLUSIONS: Compared to US patients, GERD profiles in Asian patients associate with higher symptom reporting despite lower objective reflux burden.