Silent reflux and Peptest
We are often approached by patients with distressing upper airway or other laryngeal symptoms that can have a devastating effect on quality of life, are difficult to diagnose and consequently difficult for the patient, and doctor, to find an effective treatment.
Many of these patients have used Peptest and gained reassurance and a new course of action from a positive diagnosis for the presence of pepsin in their samples. However, some patients are also consistently negative for pepsin which points to a potential other cause for their symptoms.
A negative Peptest in such cases is often a more important discovery in the eyes of the physician and may indicate that an alternative diagnosis needs to be sought.
So why do we sometimes get a negative result for pepsin in suspected silent reflux patients?
The answer is complex and the first thing to note is that no diagnostic is 100% accurate, so for any single test there is a small chance that a false negative result is received. However, particularly if multiple diagnostic procedures or multiple Peptest results point away from reflux, it is important to realise that other causes for these symptoms do exist.
I recently came across the reflux guidelines issued by the University of Michigan and I thought they might help to answer some of these questions. The excerpt reproduced below is specifically aimed at what they refer to as atypical signs of GERD or LPR. (The full text can be found here http://www.med.umich.edu/1info/fhp/practiceguides/gerd/gerd.12.pdf )
Extract from GERD practice guidelines:
Reflux may manifest atypically as pulmonary (asthma, chronic cough), ENT (laryngitis, hoarseness, sore throat, globus, throat clearing) or cardiac
(chest pain) symptoms, often without symptoms of heartburn and regurgitation. Mechanisms for this include direct contact and microaspiration of small amounts of noxious gastric contents into the larynx and upper bronchial tree (triggering local irritation, and cough), and acid stimulation of vagal afferent neurons in the distal esophagus (causing non-cardiac chest pain and vagally-mediated bronchospasm/asthma). Laryngeal neuropathy has been implicated recently as a cause for laryngitis symptoms and cough.
Pulmonary.
Asthma and GERD are common conditions that often coexist with 50-80% of asthmatics having GERD and up to 75% having abnormal pH testing. However, only 30% of patients who have both GERD and asthma will have GERD as the cause for their asthma. The causal relationship between asthma and GERD is difficult to establish because either condition can induce the other (GERD causing asthma as above, and asthma causing increased reflux by creating negative intrathoracic pressure and overcoming LES barrier). Furthermore, medications used for asthma, such as bronchodilators, are associated with increased reflux symptomatology. Historical clues to GERD-related asthma may include asthma symptoms that worsen with big meals, alcohol, and supine position, or adult-onset and medically refractory asthma. Diagnostic testing with pH probe and EGD have limited utility in establishing causality in this population.
Ear, nose, and throat.
In patients presenting with ENT symptoms, 10% of hoarseness, up to 60% of chronic laryngitis and refractory sore throat, and 25-50% of globus sensation may be due to reflux. EGD and pH testing are frequently normal in this population. Reflux laryngitis is usually diagnosed based on the laryngoscopic findings of laryngeal erythema and edema, posterior pharyngeal coblestoning, contact ulcers, granulomas, and interarytenoid changes. However, a recent study found these signs to be nonspecific for GERD, noting at least 1 sign in 91 of 105 (87%) healthy people without reflux or laryngeal complaints. Many of these signs may be due to other laryngeal irritants such as alcohol, smoking, postnasal drip, viral illness, voice overuse, or environmental allergens, suggesting their use may contribute to over-diagnosis of GERD. This also may explain why many patients (up to 40-50%) with laryngeal signs don’t respond to aggressive acid therapy. Posterior laryngitis, medial erythema of false/true vocal cords and contact changes (ulcers and granulomas) are more common in GERD patients and predict a better response to acid reduction.
Although we may not agree entirely with the breakdown of cause of symptoms presented here the key message is that getting an accurate diagnosis for the cause of symptoms is vital for the management and treatment of the condition. Peptest is a highly accurate predictor of reflux in all types of patients and a positive Peptest tells a patient and their doctor that they need to manage their reflux in order to help with their symptoms. A negative Peptest on the other hand is a key indicator that other factors could be involved in causing the symptoms and is equally as important to the physician in the ongoing treatment of the patient.
The key factors to getting an accurate diagnosis using Peptest are:
- Always collect samples when you are symptomatic.
- Always clear the throat with a cough to ensure that saliva from the throat and mouth are mixed prior to collection
- Always collect samples before undertaking a lifestyle changes or new medication etc. so that you can be sure reflux is the cause. (It is possible that symptoms will persist for a period of time after the actual reflux has improved or stopped due to the treatment).
- Always follow the instructions provided carefully and note anything that might affect your reflux.
For further information please contact us or visit our website www.peptest.co.uk
Hello,
I am thinking of ordering the test but my dr put me on anti anxiety meds xanax and lexapro due to the stress of reflux, rx probiotic, and sucralfate, zantac, pepsid and gaviscon advance. Are any of these meds needing to be stopped before I can do the peptest?
Hello Shelly, thank you for your question. The only medication you need to stop using from the list you provided is the Gaviscon Advance. We ask that you do not use this 48 hours prior to providing your samples.
Thank you.
ok thank you Jeanine!
My son, 6 years old, has suffered from terrible “vomit in his mouth” reflux for years. He has a very hoarse, raspy voice that sometimes even gets “caught” while he’s talking and will cause a reflux into his mouth. We have tried every medication for Acid Reflux, none of which had a successful result. We have done an UpperGI x-ray with the barium drink and an Endoscopy, as well, at Children’s Hospital Los Angeles. We’ve seen a number of different GI doctors and no one can help us. I came across this test and I hope we’ll be able to take it from the US?? I want to know for sure whether his condition is acid-based or whether it is biological or caused by something else. Please let me know if I can order this test and send it back from the US? Or is there somewhere in the US I can order and send back the tubes?
The symptoms that you describe that your son is experiencing is airway reflux /Laryngopharyngeal reflux (LPR). This type of reflux is not caused by acid and PPIs / acid suppression medication will not help as the symptoms are caused by weak acid/ non-acid reflux and pepsin will be the main aggressive factor. Our reflux diagnostic Peptest, which is completely non-invasive and all that is needed is a saliva sample, will detect pepsin and tell us if airway reflux is indeed responsible for your son’s symptoms. You can order from the US – your collection kit and full instructions will be sent direct to your address via FedEx. Once you have collected your samples just call FedEx and they will collect your samples directly from your address and return to our laboratory for analysis. All FedEx courier costs are included in the price.
I usually have low-grade symptoms every day (predominantly hoarse/swollen throat, throat clearing, post-nasal drip, occasional shortness of breath) rather than a very obvious flare-up of symptoms.
When should I take the saliva samples for the most accurate results?
Hello Richard,
Thank you for your question.
We would recommend you use the continuous symptoms collection method:
Sample 1 – should be taken immediately on rising from overnight sleep and before eating or brushing teeth. Ensure you are in an upright position when producing sample.
Sample 2 – should be taken one hour following your lunch time meal.
Sample 3 – Should be taken one hour following your evening meal.
You will receive information sheets explaining the sample collection procedure in more detail along with your collection tubes in your Peptest kit, which has been sent out to you.
If you have any further questions please do not hesitate to ask.
Many thanks.
Hi,
I’m a psychologist in Lincoln, MA and I’m wondering if you, Jeanine Fisher, are also the well known therapist of the same name in the Boston area? I’ve been diagnosed with LPR with sore throat as the major symptom. Mass Eye and Ear put me on PPi’s and Zantac but I’m wanting more info. I’m arranging a Restech ph monitor with one ENT and want to do a TNE at B.I.hospital to see if there is any Barrett’s. I’ve come to realize how very fragmented both diagnosis and treatment is of this condition.
PS I’ve also ordered a Peptest !
Hello Norm,
We are actually based in the UK so our Jeanine is not the same one you are thinking about.
Thank you for your Peptest order. We sent your Peptest kit to you yesterday and it will be with you very shortly.
After we have received and tested your samples we will email you your results so you can share them with your Doctor. These results will show whether or not you were refluxing at the times your samples were collected.
If you have any further questions please do not hesitate to contact us.
Many thanks.
Hi, I have just ordered the peptest, but I am in Australia. Will you be able to test for results?
Hi Sandy,
Thank you for your question and your order.
Yes we will be able to test your samples. You will receive your Peptest kit via FedEx in 3 working days. Once you have collected all of your samples you just have to follow the return instructions included in the kit. Then when we have received your samples back in the UK we will test them and send out your results report via email.
If you have any further questions please do not hesitate to contact us.
Many thanks.
Hi,
If peptest is positive, what kind of treatment will be the best to treat it ( for example) ? If I understand it will be not a PPI..?
Thank you very much
Hi Celia,
Thank you for your question.
Peptest detects the presence and amount of Pepsin in the samples provided. This is used to create a results report which we ask you to share with your Doctor along with a letter explaining to them what Peptest is and suggested actions to be taken depending on the amount of Pepsin detected.
Suggested actions for positive results include dietary and lifestyle changes and use of Gaviscon advance for a 6 – 8 week period.
However any treatment decisions should ultimately be made by your Doctor.
Many thanks.
HiJeanine
Thank you for your answer. I am going to take the Peptest to be sure about it. However, I like to know if I have to stop my diet as well (because I follow the Dr Aviv’s diet but still no improvement). I don’t know if this diet could alternate the result of Peptest..?
Thank so much for your return
Celia
Hi Celia,
Thank you for your question.
You can continue your diet whilst collecting your samples.
Please carefully read the Peptest sample collection information, which will be included in your Peptest Kit, before collecting your samples.
Many thanks.
PS : I’ve seen that PPI is allowed but I’m in DOUBLE DOSE of Nexium.. I’d just known if it’s still ok to do a peptest with this?
Thank you for your answer about my 2 questions.
Celia
Hi Celia,
Thank you for your question.
You can continue taking Nexium as this will not affect the test.
Many thanks.
Hello,
Do I have to do the peptest rapidly after to have receive it or ? For exemple can I wait one month before collect the sample ?
Thank you again Jeanne !
Hi Celia,
Thank you for your question.
You do not need to collect your sample as soon as your Peptest kit arrives. You can wait for a month or longer, if you wish, before collecting.
On the Peptest label of the collection tube is the expiry date of the citric acid inside, which has a shelf life of 2 years.
Please remember that whenever you decide to start collecting your samples you need to collect and return all three samples within 3 days of collecting your first sample.
Many thanks.