In Laryngopharyngeal Reflux
Pepsin is one of the primary causes of mucosal damage during laryngopharyngeal reflux. Pepsin remains in the larynx (pH 6.8) following a gastric reflux event. While enzymatically inactive in this environment, pepsin would remain stable and could be reactivated upon subsequent acid reflux events. Exposure of laryngeal mucosa to enzymatically active pepsin, but not irreversibly inactivated pepsin or acid, results in reduced expression of protective proteins and thereby increases laryngeal susceptibility to damage.
Pepsin may also cause mucosal damage during weakly acidic or non-acid gastric reflux. Weak or non-acid reflux is correlated with reflux symptoms and mucosal injury. Under non-acid conditions (neutral pH), pepsin is internalized by cells of the upper airways such as the larynx and hypopharynx by a process known as receptor-mediated endocytosis. The receptor by which pepsin is endocytosed is currently unknown. Upon cellular uptake, pepsin is stored in intracellular vesicles of low pH at which its enzymatic activity would be restored. Pepsin is retained within the cell for up to 24 hours. Such exposure to pepsin at neutral pH and endoyctosis of pepsin causes changes in gene expression associated with inflammation, which underlies signs and symptoms of reflux, and tumor progression. This and other research implicates pepsin in carcinogenesis attributed to gastric reflux.
Pepsin in airway specimens is considered to be a sensitive and specific marker for laryngopharyngeal reflux. Research to develop new pepsin-targeted therapeutic and diagnostic tools for gastric reflux is ongoing.
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