Medical Management of LPR

  • Justin Field
  • Deena Midani
  • Yellowlees Douglas
  • Michael S. Smith


Laryngopharyngeal reflux (LPR) is a disorder that may cause a variety of symptoms, including dysphagia, chronic cough, postnasal drip, hoarseness, and fatigue. These symptoms stem from gastroesophageal reflux disease (GERD), which is far more widely studied and also offers multiple treatment modalities compared to the understudied LPR. These approaches prove particularly relevant for patients who have failed lifestyle modifications and include pharmacotherapy ranging from proton-pump inhibitors and histamine-2 receptor antagonists to GABAB agonists and neuromodulators. In addition, relatively new and minimally invasive endoscopic techniques for addressing LPR include transoral incisionless fundoplication, radiofrequency ablation of the lower esophageal sphincter, and anterior fundoplication, any of which may provide patients with relief from symptoms of LPR.


Laryngopharyngeal reflux Gastroesophageal reflux disease Proton-pump inhibitors Prokinetics Neuromodulators Endoscopic fundoplication 


  1. 1.
    Belafsky PC, Postma GN, Koufman JA. Validity and reliability of the reflux symptom index (RSI). J Voice. 2002;16(2):274–7.PubMedCrossRefPubMedCentralGoogle Scholar
  2. 2.
    Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2013;108:308–28.PubMedCrossRefPubMedCentralGoogle Scholar
  3. 3.
    Jacobson BC, Somers SC, Fuchs CS, et al. Body-mass index and symptoms of gastroesophageal reflux in women. N Engl J Med. 2006;354:2340–8.PubMedPubMedCentralCrossRefGoogle Scholar
  4. 4.
    Fraser-Moodie CA, Norton B, Gornall C, et al. Weight loss has an independent beneficial effect on symptoms of gastro-esophageal reflux in patients who are overweight. Scand J Gastroenterol. 1999;34:337–40.PubMedCrossRefPubMedCentralGoogle Scholar
  5. 5.
    Mathus-Vliegen LM, Tytgat GN. Twenty-four-hour pH measurements in morbid obesity: effects of massive overweight, weight loss and gastric distention. Eur J Gastroenterol Hepatol. 1996;8:635–40.PubMedPubMedCentralGoogle Scholar
  6. 6.
    Gagne DJ, Dovec E, Urbandt JE. Laparoscopic revision of vertical banded gastroplasty to roux-en-Y gastric bypass: outcomes of 105 patients. Surg Obes Relat Dis. 2011;7:493–9.PubMedCrossRefPubMedCentralGoogle Scholar
  7. 7.
    Stanciu C, Bennett JR. Effects of posture on gastro-oesophageal reflux. Digestion. 1977;15:104–9.PubMedCrossRefPubMedCentralGoogle Scholar
  8. 8.
    Duroux P, Bauerfield P, Emde C, et al. Early dinner reduces nocturnal gastric acidity. Gut. 1989;30:1063–7.PubMedPubMedCentralCrossRefGoogle Scholar
  9. 9.
    Hamilton JW, Boisen RJ, Yamamoto DT, et al. Sleeping on a wedge diminishes exposure of the esophagus to refluxed acid. Dig Dis Sci. 1988;33:518–22.PubMedCrossRefPubMedCentralGoogle Scholar
  10. 10.
    Pollmann H, Zillessen E, Pohl J, et al. Effect of elevated head position in bed in therapy of gastroesophageal reflux. Z Gastroenterol. 1996;43(suppl 2):93–9.Google Scholar
  11. 11.
    Sandhu DS, Fass R. Current trends in the management of gastroesophageal reflux disease. Gut Liver. 2017;12(1):7–16.PubMedCentralCrossRefPubMedGoogle Scholar
  12. 12.
    Gralnek IM, Dulai GS, Fennerty MB, et al. Esomeprazole versus other proton pump inhibitors in erosive esophagitis: a meta-analysis of randomized clinical trials. Clin Gastroenterol Hepatol. 2006;4:1452–8.PubMedCrossRefGoogle Scholar
  13. 13.
    Caro JJ, Salas M, et al. Healing and relapse rates in GERD treated with newer PPIs vs omeprazole, ranitidine, and placebo: evidence from RCTs. Clin Ther. 2001;23:998–1017.PubMedCrossRefGoogle Scholar
  14. 14.
    Sharma P, Shaheen NJ, Perez MC, et al. Clinical trials: healing of erosive oesophagitis with dexlansoprazole MR, a proton pump inhibitor with a novel dual delayed-release formulation—results from two randomized controlled studies. Aliment Pharmacol Ther. 2009;29(7):731–41.PubMedCrossRefGoogle Scholar
  15. 15.
    Gerson LB, Mitra S, Bleker WF, et al. Control of intra-oesophageal pH in patients with Barrett’s oesophagus on omeprazole-sodium bicarbonate therapy. Aliment Pharmacol Ther. 2012;35:803–9.PubMedCrossRefGoogle Scholar
  16. 16.
    Schindlbeck NE, Klauser AG, Berghammer G, et al. Three year follow up of patients with gastrooesophageal reflux disease. Gut. 1992;33:1016–9.PubMedPubMedCentralCrossRefGoogle Scholar
  17. 17.
    Vigneri S, Termini R, Leandro G, et al. A comparison of five maintenance therapies for reflux esophagitis. N Engl J Med. 1995;333:1106–10.PubMedCrossRefGoogle Scholar
  18. 18.
    El-Serag HB, Aguirre TV, Davis S, et al. Proton pump inhibitors are associated with reduced incidence of dysplasia in Barrett’s esophagus. Am J Gastroenterol. 2004;99:1877–83.PubMedCrossRefGoogle Scholar
  19. 19.
    Pace F, Tonini M, Pallotta S, et al. Systematic review: maintenance treatment of gastro-oesophageal reflux disease with proton pump inhibitors taken ‘on-demand’. Aliment Pharmacol Ther. 2007;26:195–204.PubMedCrossRefGoogle Scholar
  20. 20.
    Inadomi JM, Jamal R, Murata GH, et al. Step-down management of gastroesophageal reflux disease. Gastroenterology. 2001;121:1095–100.PubMedCrossRefPubMedCentralGoogle Scholar
  21. 21.
    Fackler WK, Ours TM, Vaezi MF, et al. Long-term effect of H2RA therapy on nocturnal gastric acid breakthrough. Gastroenterology. 2002;122:625–32.PubMedCrossRefGoogle Scholar
  22. 22.
    Lodato F, Azzaroli F, Turco L, et al. Adverse effects of proton pump inhibitors. Best Pract Res Clin Gastroenterol. 2010;24:193–201.PubMedCrossRefGoogle Scholar
  23. 23.
    Bavishi C, Dupont HL. Systematic review: the use of proton pump inhibitors and increased susceptibility to enteric infection. Aliment Pharmacol Ther. 2011;34:1269–81.PubMedCrossRefGoogle Scholar
  24. 24.
    Eom CS, Jeon CY, Lim JW, et al. Use of acid-suppressive drugs and risk of pneumonia: a systematic review and meta-analysis. CMAJ. 2011;183:310–9.PubMedPubMedCentralCrossRefGoogle Scholar
  25. 25.
    Sibbing D, Morath T, Stegherr J, et al. Impact of proton pump inhibitors on the antiplatelet effects of clopidogrel. Thromb Haemost. 2009;101:714–9.PubMedCrossRefGoogle Scholar
  26. 26.
    Furuta T, Iwaki T, Umemura K. Influences of different proton pump inhibitors on the anti-platelet function of clopidogrel in relation to CYP2C19 genotypes. Br J Clin Pharmacol. 2010;70:383–92.PubMedPubMedCentralCrossRefGoogle Scholar
  27. 27.
    Hermos JA, Young MM, Fonda JR, et al. Risk of community-acquired pneumonia in veteran patients to whom proton pump inhibitors were dispensed. Clin Infect Dis. 2012;54:33–42.PubMedCrossRefGoogle Scholar
  28. 28.
    Corley DA, Kubo A, Zhao W, et al. Proton pump inhibitors and histamine-2 receptor antagonists are associated with hip fractures among at-risk patients. Gastroenterol. 2010;139:93–101.CrossRefGoogle Scholar
  29. 29.
    Davidge Pitts CJ, Kearns AE. Update on medications with adverse skeletal effects. Mayo Clin Proc. 2011;86:338.PubMedPubMedCentralCrossRefGoogle Scholar
  30. 30.
    Yang Y-X. Chronic PPI therapy and calcium metabolism. Curr Gastroenterol Rep. 2012;14(6):473–9. Scholar
  31. 31.
    Giuliano C, Wilhelm SM, Kale-Pradhan PB. Are proton pump inhibitors associated with the development of community-acquired pneumonia? A meta-analysis. Expert Rev Clin Pharmacol. 2012;5:337–44.PubMedCrossRefPubMedCentralGoogle Scholar
  32. 32.
    Gomm W, von Holt TF, Broich K, et al. Association of proton pump inhibitors with risk of dementia: a pharmacoepidemiological claims data analysis. JAMA Neurol. 2016;73(4):410–6.PubMedCrossRefPubMedCentralGoogle Scholar
  33. 33.
    Fallahzadeh MK, Borhani Haghighi A, Namazi MR. Proton pump inhibitors: predisposers to Alzheimer disease? J Clin Pharm Ther. 2010;35(2):125–6.PubMedCrossRefPubMedCentralGoogle Scholar
  34. 34.
    Gray SL, et al. Proton pump inhibitor use and dementia risk: prospective population-based study. J Am Geriatr Soc. 2018;66:247.PubMedCrossRefPubMedCentralGoogle Scholar
  35. 35.
    Mainie I, et al. Acid and non-acid reflux in patients with persistent symptoms despite acid suppressive therapy: a multicentre study using combined ambulatory impedance-pH monitoring. Gut. 2006;55:1398–402.PubMedPubMedCentralCrossRefGoogle Scholar
  36. 36.
    Martinucci I, et al. Esophageal motility abnormalities in gastroesophageal reflux disease. World J Gastrointest Pharmacol Ther. 2014;5:86.PubMedPubMedCentralCrossRefGoogle Scholar
  37. 37.
    Dickman R, et al. Comparison of clinical characteristics of patients with gastroesophageal reflux disease who failed proton pump inhibitor therapy versus those who fully responded. J Neurogastroenterol Motil. 2011;17:387–94.PubMedPubMedCentralCrossRefGoogle Scholar
  38. 38.
    Kudara N, Chiba T, Orii S, Suzuki K. Gastric emptying of patients with persistent reflux symptoms and erosive esophagitis under PPI therapy [abstract] Neurogastroenterol Motil. 2004;16:654.Google Scholar
  39. 39.
    Ren LH, et al. Addition of prokinetics to PPI therapy in gastroesophageal reflux disease: a meta-analysis. World J Gastroenterol. 2014;20:2412–9.PubMedPubMedCentralCrossRefGoogle Scholar
  40. 40.
    Manzotti ME, et al. Prokinetic drug utility in the treatment of gastroesophageal reflux esophagitis: a systematic review of randomized controlled trials. Open Med. 2007;1:e171–80.PubMedPubMedCentralGoogle Scholar
  41. 41.
    Richter JE, et al. Omeprazole versus ranitidine or ranitidine/metoclopramide in poorly responsive symptomatic gastroesophageal reflux disease. Am J Gastroenterol. 1996;91:1766–72.PubMedGoogle Scholar
  42. 42.
    Tonini M, et al. Review article: clinical implications of enteric and central D2 receptor blockade by antidopaminergic gastrointestinal prokinetics. Aliment Pharmacol Ther. 2004;19:379–90.PubMedCrossRefGoogle Scholar
  43. 43.
    Mikami H, et al. Effects of metoclopramide on esophageal motor activity and esophagogastric junction compliance in healthy volunteers. J Neurogastroenterol Motil. 2016;22:112–7.PubMedPubMedCentralCrossRefGoogle Scholar
  44. 44.
    Grande L, et al. Lack of effect of metoclopramide and domperidone on esophageal peristalsis and esophageal acid clearance in reflux esophagitis – a randomized, double-blind study. Dig Dis Sci. 1992;37:583–8.PubMedCrossRefGoogle Scholar
  45. 45.
    DiPalma JA, Perucca PJ, Martin DF, Pierson WP, Meyer GW. Metoclopramide effect on esophageal peristalsis in normal human volunteers. Am J Gastroenterol. 1987;82:307–10.PubMedGoogle Scholar
  46. 46.
    Marakhouski KY, Karaseva GA, Ulasivich DN, Marakhouski YK. Omeprazole-domperidone fixed dose combination vs omeprazole monotherapy: a phase 4, open-label, comparative, parallel randomized controlled study in mild to moderate gastroesophageal reflux disease. Clin Med Insights Gastroenterol. 2017;10:1–8.Google Scholar
  47. 47.
    Foocharoen C, et al. Effectiveness of add-on therapy with domperidone vs alginic acid in proton pump inhibitor partial response gastro-oesophageal reflux disease in systemic sclerosis: randomized placebo-controlled trial. Rheumatology (Oxford). 2016; Scholar
  48. 48.
    Rao AS, Camilleri M. Review article: metoclopramide and tardive dyskinesia. Aliment Pharmacol Ther. 2010;31:11–9.PubMedCrossRefPubMedCentralGoogle Scholar
  49. 49.
    Doggrell SA, Hancox JC. Cardiac safety concerns for domperidone, an antiemetic and prokinetic, and galactogogue medicine. Expert Opin Drug Saf. 2014;13:131–8.PubMedCrossRefPubMedCentralGoogle Scholar
  50. 50.
    Leelakanok N, Holcombe A, Schweizer ML. Domperidone and risk of ventricular arrhythmia and cardiac death: a systematic review and meta-analysis. Clin Drug Investig. 2016;36:97–107.PubMedCrossRefGoogle Scholar
  51. 51.
    Sturm A, Holtmann G, Goebell H, Gerken G. Prokinetics in patients with gastroparesis: a systematic analysis. Digestion. 1999;60:422–7.PubMedCrossRefGoogle Scholar
  52. 52.
    Larson JM, Tavakkoli A, Drane WE, Toskes PP, Moshiree B. Advantages of azithromycin over erythromycin in improving the gastric emptying half-time in adult patients with gastroparesis. J Neurogastroenterol Motil. 2010;16(4):407.PubMedPubMedCentralCrossRefGoogle Scholar
  53. 53.
    Rubinstein E. Comparative safety of the different macrolides. Int J Antimicrob Agents. 2001;18(suppl 1):S71–6.PubMedCrossRefGoogle Scholar
  54. 54.
    Moshiree B, McDonald R, Hou W, Toskes PP. Comparison of the effect of azithromycin versus erythromycin on antroduodenal pressure profiles of patients with chronic functional gastrointestinal pain and gastroparesis. Dig Dis Sci. 2010;55:675–83.PubMedCrossRefGoogle Scholar
  55. 55.
    Hopkins S. Clinical toleration and safety of azithromycin. Am J Med. 1991;91:40S–5S.PubMedCrossRefGoogle Scholar
  56. 56.
    Zhang Q, Lehmann A, Rigda R, Dent J, Holloway RH. Control of transient lower oesophageal sphincter relaxations and reflux by the GABAB agonist baclofen in patients with gastro-oesophageal reflux disease. Gut. 2002;50:19–24.PubMedPubMedCentralCrossRefGoogle Scholar
  57. 57.
    Lidums I, Lehmann A, Checklin H, Dent J, Holloway RH. Control of transient lower esophageal sphincter relaxations and reflux by the GABA(B) agonist baclofen in normal subjects. Gastroenterology. 2000;118:7–13.PubMedCrossRefGoogle Scholar
  58. 58.
    Scarpellini E, et al. Effect of baclofen on the acid pocket at the gastroesophageal junction. Dis Esophagus. 2015;28:488–95.PubMedCrossRefGoogle Scholar
  59. 59.
    Li S, Shi S, Chen F, Lin J. The effects of baclofen for the treatment of gastroesophageal reflux disease: a meta-analysis of randomized controlled trials. Gastroenterol Res Pract. 2014;2014:307805.PubMedPubMedCentralGoogle Scholar
  60. 60.
    Koek GH, Sifrim D, Lerut T, Janssens J, Tack J. Effect of the GABAB agonist baclofen in patients with symptoms and duodeno-gastro-oesophageal reflux refractory to proton pump inhibitors. Gut. 2003;52:1397–402.PubMedPubMedCentralCrossRefGoogle Scholar
  61. 61.
    Cossentino MJ, et al. Randomised clinical trial: the effect of baclofen in patients with gastro-oesophageal reflux – a randomised prospective study. Aliment Pharmacol Ther. 2012;35:1036–44.PubMedPubMedCentralGoogle Scholar
  62. 62.
    Zhao F, Wang S, Liu L, Wang Y. Comparative effectiveness of histamine-2 receptor antagonists as short-term therapy for gastro-esophageal reflux disease: a network meta-analysis. Int J Clin Pharmacol Ther. 2016;54:761–70.PubMedCrossRefPubMedCentralGoogle Scholar
  63. 63.
    Sabesin SM. Safety issues relating to long-term treatment with histamine H2-receptor antagonists. Aliment Pharmacol Ther. 1993;7:35–40.PubMedCrossRefPubMedCentralGoogle Scholar
  64. 64.
    Piper DW. A comparative overview of the adverse effects of antiulcer drugs. Drug Saf. 1995;12:120–38.PubMedCrossRefPubMedCentralGoogle Scholar
  65. 65.
    Leonard J, Marshall JK, Moayyedi P. Systematic review of the risk of enteric infection in patients taking acid suppression. Am J Gastroenterol. 2007;102:2047–56.PubMedCrossRefPubMedCentralGoogle Scholar
  66. 66.
    Weigt J, Kandulski A, Busch F, Malfertheiner P. Nocturnal gastric acid breakthrough is not associated with night-time gastroesophageal reflux in GERD patients. Dig Dis. 2009;27:68–73.PubMedCrossRefGoogle Scholar
  67. 67.
    Rackoff A, Agrawal A, Hila A, et al. Histamine-2 receptor antagonists at night improve gastroesophageal reflux disease symptoms for patients on proton pump inhibitor therapy. Dis Esophagus. 2005;18:370–3.PubMedCrossRefGoogle Scholar
  68. 68.
    Mainie I, Tutuian R, Castell DO. Addition of a H2 receptor antagonist to PPI improves acid control and decreases nocturnal acid breakthrough. J Clin Gastroenterol. 2008;42:676–9.PubMedCrossRefGoogle Scholar
  69. 69.
    Kahrilas PJ, McColl K, Fox M, et al. The acid pocket: a target for treatment in reflux disease? Am J Gastroenterol. 2013;108:1058–64.PubMedCrossRefGoogle Scholar
  70. 70.
    Strugala V, Avis J, Jolliffe IG, Johnstone LM, Dettmar PW. The role of an alginate suspension on pepsin and bile acids–key aggressors in the gastric refluxate. Does this have implications for the treatment of gastro-oesophageal reflux disease? J Pharm Pharmacol. 2009;61:1021–8.PubMedCrossRefPubMedCentralGoogle Scholar
  71. 71.
    Kwiatek MA, Roman S, Fareeduddin A, Pandolfino JE, Kahrilas PJ. An alginate-antacid formulation (Gaviscon double action liquid) can eliminate or displace the postprandial ‘acid pocket’ in symptomatic GERD patients. Aliment Pharmacol Ther. 2011;34:59–66.PubMedPubMedCentralCrossRefGoogle Scholar
  72. 72.
    Rohof WO, Bennink RJ, Smout AJ, Thomas E, Boeckxstaens GE. An alginate-antacid formulation localizes to the acid pocket to reduce acid reflux in patients with gastroesophageal reflux disease. Clin Gastroenterol Hepatol. 2013;11:1585–91. (quiz e90).PubMedCrossRefPubMedCentralGoogle Scholar
  73. 73.
    Sweis R, Kaufman E, Anggiansah A, et al. Post-prandial reflux suppression by a raft-forming alginate (Gaviscon advance) compared to a simple antacid documented by magnetic resonance imaging and pH-impedance monitoring: mechanistic assessment in healthy volunteers and randomised, controlled, double-blind study in reflux patients. Aliment Pharmacol Ther. 2013;37:1093–102.PubMedCrossRefPubMedCentralGoogle Scholar
  74. 74.
    Weijenborg PW, de Schepper HS, Smout AJ, Bredenoord AJ. Effects of antidepressants in patients with functional esophageal disorders or gastroesophageal reflux disease: a systematic review. Clin Gastroenterol Hepatol. 2015;13(2):251–9.PubMedCrossRefPubMedCentralGoogle Scholar
  75. 75.
    Parkman HP. Pain Management for Gastroparesis. In: Gastroparesis: Humana Press, New York City; 2012. p. 289–302.Google Scholar
  76. 76.
    Stapleton J, Wo JM. Current treatment of nausea and vomiting associated with gastroparesis: antiemetics, prokinetics, tricyclics. Gastrointest Endosc Clin N Am. 2009;19(1):57–72.PubMedCrossRefPubMedCentralGoogle Scholar
  77. 77.
    Shi G, Tatum RP, Joehl RJ, Kahrilas PJ. Esophageal sensitivity and symptom perception in gastroesophageal reflux disease. Curr Gastroenterol Rep. 1999;1(3):214–9.PubMedCrossRefPubMedCentralGoogle Scholar
  78. 78.
    Kahrilas PJ. Diagnosis of symptomatic gastroesophageal reflux disease. Am J Gastroenterol. 2003;98(3s):S15.PubMedCrossRefPubMedCentralGoogle Scholar
  79. 79.
    Modlin IM, Kidd M, Lye KD. Historical perspectives on the treatment of gastroesophageal reflux disease. Gastrointest Endosc Clin N Am. 2003;13:19–55.PubMedCrossRefPubMedCentralGoogle Scholar
  80. 80.
    Trad KS, et al. Efficacy of transoral fundoplication for treatment of chronic gastroesophageal reflux disease incompletely controlled with high-dose proton-pump inhibitors therapy: a randomized, multicenter, open label, crossover study. BMC Gastroenterol. 2014;14:174.PubMedPubMedCentralCrossRefGoogle Scholar
  81. 81.
    Montgomery M, et al. Randomised clinical trial: transoral incisionless fundoplication vs. sham intervention to control chronic GERD. Aliment Pharmacol Ther. 2015;42:1261–70.PubMedCrossRefGoogle Scholar
  82. 82.
    Huang X, et al. Efficacy of transoral incisionless fundoplication (TIF) for the treatment of GERD: a systematic review with meta-analysis. Surg Endosc Other Interv Tech. 2017;31:1032–44.CrossRefGoogle Scholar
  83. 83.
    Bell RCW, et al. Univariate and multivariate analyses of preoperative factors influencing symptomatic outcomes of transoral fundoplication. Surg Endosc Other Interv Tech. 2014;28:2949–58.CrossRefGoogle Scholar
  84. 84.
    Wendling MR, Melvin WS, Perry KA. Impact of transoral incisionless fundoplication (TIF) on subjective and objective GERD indices: a systematic review of the published literature. Surg Endosc Other Interv Tech. 2013;27:3754–61.CrossRefGoogle Scholar
  85. 85.
    Triadafilopoulos G. Stretta: a valuable endoscopic treatment modality for gastroesophageal reflux disease. World J Gastroenterol. 2014;20:7730–8.PubMedPubMedCentralCrossRefGoogle Scholar
  86. 86.
    Triadafilopoulos G, et al. The Stretta procedure for the treatment of GERD: 6 and 12 month follow-up of the U.S. open label trial. Gastrointest Endosc. 2002; Scholar
  87. 87.
    Fass R, Cahn F, Scotti DJ, Gregory DA. Systematic review and meta-analysis of controlled and prospective cohort efficacy studies of endoscopic radiofrequency for treatment of gastroesophageal reflux disease. Surg Endosc. 2017;31:4865–82.PubMedCrossRefGoogle Scholar
  88. 88.
    Zacherl J, et al. Endoscopic anterior fundoplication with the medigus ultrasonic surgical endostapler (MUSE™) for gastroesophageal reflux disease: 6-month results from a multi-center prospective trial. Surg Endosc Other Interv Tech. 2015; Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Justin Field
    • 1
  • Deena Midani
    • 2
  • Yellowlees Douglas
    • 3
  • Michael S. Smith
    • 4
  1. 1.Division of Gastroenterology and Hepatology, Department of MedicineMount Sinai Beth Israel, Mount Sinai West and Mount Sinai St. Luke’s HospitalsNew YorkUSA
  2. 2.Gastroenterology, Cedars-Sinai Medical GroupLos AngelesUSA
  3. 3.Independent ResearcherBrooklynUSA
  4. 4.Division of Gastroenterology and Hepatology, Department of MedicineMount Sinai West and Mount Sinai St. Luke’s HospitalsNew YorkUSA

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