LPS vs LPRD: The San Diego Consensus Redefines LPR- AJG Feb.26

Introduction

“Laryngopharyngeal reflux (LPR)” has become a catch-all label for chronic throat and upper airway complaints—cough, throat clearing, hoarseness, phlegm, throat pain—often without objective evidence of reflux. This has led to overdiagnosis, prolonged proton-pump inhibitor (PPI) trials, unnecessary testing, and frequent frustration for both patients and clinicians.

The San Diego Consensus is a multidisciplinary effort (GI + ENT + speech-language pathology + psychology) that proposes a modern, objective, and practical care pathway.

The central paradigm shift

1) Rename the symptom state

Laryngopharyngeal Symptoms (LPS) = the symptom cluster (throat/upper airway symptoms) that may be reflux-related.

Laryngopharyngeal Reflux Disease (LPRD) = LPS plus objective evidence of reflux.

✅ Key message: LPS ≠ LPRD.

Most patients with LPS do not have proven reflux-driven disease.

What changes in daily practice?

2) Laryngoscopy is necessary, but it cannot diagnose LPRD

Laryngoscopy is valuable to:

evaluate nonreflux laryngeal pathology (including malignancy),

identify benign lesions and alternative ENT diagnoses.

But laryngoscopic signs are nonspecific and should not be used alone to diagnose “LPR.”

3) Split patients early: LPS with GERD symptoms vs isolated LPS

This is a major practical step because the algorithm diverges:

A) LPS + typical oesophageal reflux symptoms (heartburn/regurgitation)

Reasonable to start lifestyle measures + empiric acid suppression (often PPI twice daily for ~3 months) ± alginate.

If symptoms persist or management will escalate (long-term therapy or invasive reflux procedures): objective testing is required.

B) Isolated LPS (no typical GERD symptoms)

Do not default to empiric PPI-first management.

Prioritize:

ENT evaluation (laryngoscopy),

early consideration of behavioural/laryngeal hypersensitivity mechanisms, and

objective reflux testing if reflux is being considered as the driver.

4) Reflux monitoring is the reference standard for LPRD

For diagnosing reflux-driven disease, the consensus emphasises:

24-hour pH-impedance (best to characterise reflux episodes, nonacid/proximal events; helpful in isolated LPS when mechanism matters)

96-hour wireless pH (best for day-to-day variability and confirming/ excluding abnormal acid burden; particularly useful when considering escalation of reflux management)

These modalities are not mutually exclusive; they answer different questions.

Also:

Testing in “unproven GERD” should typically be done off acid suppression.

Oropharyngeal pH monitoring alone is not supported as a stand-alone diagnostic test due to poor specificity.

The “forgotten driver”: laryngeal hyperresponsiveness and hypervigilance

The consensus brings a clinician-friendly framing: many patients have symptoms driven or amplified by:

laryngeal hypersensitivity,

hyperresponsive behaviors (cough/throat clearing cycles),

symptom-specific anxiety and hypervigilance.

These respond to:

laryngeal recalibration therapy (voice-specialized SLP approaches),

neuromodulators (selected cases),

targeted behavioral therapies (e.g., CBT aimed at symptom-specific processes).

✅ Key message: Even when reflux exists, brain–larynx behavioral drivers can coexist and perpetuate symptoms.

Bottom-line takeaway:

The San Diego Consensus replaces “LPR as a diagnosis” with a more accurate framework: define LPS, confirm LPRD only with objective reflux evidence, avoid reflexive long-term PPI use in isolated throat symptoms, and explicitly treat laryngeal hyperresponsiveness/hypervigilance when present.

One-line GastroAGI takeaway

Most “LPR” isn’t reflux disease—diagnose LPRD with objective testing and treat the brain–larynx axis when needed.