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
- 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?
- 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.”
- 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.
- 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.
