PPI-Refractory GERD, Dysphagia and Aspiration After Head and Neck Cancer Treatment

28 Sep 2023 02:00 04:00
Milwaukee
Nikki Johnston Host

Patient Profile & Clinical History

  • Patient: 59-year-old man

  • Previous Cancer History: Right tonsillar fossa squamous cell carcinoma, status post chemo/radiation completed in 2012, currently NED.

  • Current Presentation: Progressive dysphagia with an esophageal stricture, now status post dilation.

  • Past Medical History: Obstructive sleep apnea and chronic kidney disease.

  • Clinical Symptoms: Dysphagia, reflux, and aspiration significant enough to require hospitalization and antibiotics.

Diagnostic Evaluation

  • Reflux Management: Reflux is refractory to PPI therapy.

  • pH Impedance Study: Normal acid exposure.

  • Symptom Correlation: The patient has a heterogeneous group of symptoms, including cough, that seemed to be linked to acid reflux episodes more than weakly acid or non-acid episodes.

Clinical Questions

  • Is the oropharyngeal function the cause of the aspiration?

  • Is it reflux?

  • Non-acid reflux now on PPI?

Gastroesophageal Reflux Disease

Gastroesophageal reflux disease significantly impacts patient quality of life and is a major risk factor for the development of Barrett’s esophagus and esophageal adenocarcinoma. PPIs are the standard-of-care for GERD and are among the most prescribed drugs in the world. While PPIs are highly effective for resolving erosive lesions due to GERD, they provide insufficient symptom relief in 20–40% of patients with esophagitis and perform even poorer in patients with non-erosive reflux disease.

Panel for Discussion

Nikki Johnston (Medical College of Wisconsin, Milwaukee, WI) | Simon Blaine-Sauer (Medical College of Wisconsin) | David Richards (MD Anderson, TX) | Sumeet Mittal (Norton Thoracic Institute, Phoenix, AZ)

Topics for Discussion

  1. PPI-refractory GERD: Evaluation and management from a gastroenterology perspective.

  2. Surgical perspective: Role of surgical evaluation and treatment in patients with persistent reflux symptoms despite PPI therapy.

  3. Research perspective: Current understanding and emerging approaches for PPI-refractory GERD.

  4. Aspiration and reflux: Differentiating oropharyngeal dysfunction, acid reflux, weakly acid reflux, and non-acid reflux as potential causes of aspiration and respiratory symptoms.