Endoscopic argon plasma coagulation ablation of cervical inlet patch improves proton-pump inhibitor-refractory laryngopharyngeal symptoms

Abstract

Cervical inlet patch (CIP) is an islet of heterotopic gastric mucosa found at upper esophagus with the incidence ranging between 0.1% and 10% in conventional diagnostic esophagogastroduodenoscopy. CIP has been associated with common troublesome laryngopharyngeal symptoms, such as globus sensation, hoarseness, odynophagia, and dysphagia. Medical treatment for symptomatic CIP usually begins with strong acid suppressive agents, such as proton-pump inhibitors (PPIs), but the response remains unsatisfactory. Endoscopic therapy with argon plasm coagulation (APC) has been increasing shown to be effective in alleviating the laryngopharyngeal symptoms in patients with CIP in a few Western studies.^{1, 2} Long-term effect up to 27 months of follow-up has also been reported.³ However, no relevant study regarding the application of APC in CIP patients has been conducted in Taiwan and other Asian countries. We would like to present a CIP patient with PPI-refractory laryngopharyngeal symptoms, who was successfully treated with endoscopic APC ablation. This case shed light on the possible application of APC for Taiwanese patients with symptomatic CIP.

A 52-year-old female patient presented with persistent symptoms of burning and lumpy sensation in the throat for over 6 months. Initial treatment with standard dose of PPI for 8 weeks showed only minimal improvement, and the symptoms worsened upon PPI discontinuation. Esophagogastroduodenoscopy (EGD) revealed an area of salmon-colored mucosa, approximately 0.8 cm in size, located in the inlet of the upper esophagus (Figure 1A). Endoscopic biopsy demonstrated the presence of mature gastric body mucosa in the lamina propria of esophagus that confirmed the diagnosis of CIP (Figure 1B). After shared decision-making with the patient, endoscopic APC was applied (60 W, 2 L/min) to ablate the CIP completely in two sessions (Figure 1C). No adverse event, such as odynophagia or bleeding, developed after ablation. A follow-up EGD 2 months later revealed neither residual CIP nor complications, such as stricture or ulcers (Figure 1D).

The visual analog scores (from 0 to 10; the higher the score, the more severe the symptoms) for symptoms of dry throat, burning throat, globus sensation, and hoarseness before APC were 8, 10, 8, 6 (without PPI therapy), 7, 5, 5, 7 (with PPI therapy), and the scores improved significantly, that is, 2, 1, 1, 1 after ablation^{3, 4} (Figure 1D). Throughout the 1-year follow-up after the procedure, the patient did not experience any recurrence of laryngopharyngeal reflux symptoms and was free from PPI therapy, evidenced by 1, 0, 0, 1 in dry throat, burning throat, globus sensation, and hoarseness.

Our case demonstrated that APC ablation may be a promising treatment with a durable effect for CIP patients with PPI-refractory laryngopharyngeal symptoms in Taiwanese population. Future prospective randomized studies with a larger sample size are needed to confirm the efficacy and safety APC on symptomatic CIP patients.

This study was funded by Ping Tung Christian Hospital under the PS113005 program.

The authors declare no conflicts of interest.

Written informed consent was obtained from the patient.