A Different Kind of Acid Reflux

| Posted On Feb 05, 2021 | By:

Acid Reflux in a woman's throatMost of us have experienced heartburn at one time or another. Maybe you ate too much at a holiday gathering, or chowed down a chili cheese dog at a ball game, or had some other “dietary indiscretion” and before you knew it, the classic burning feeling in the chest began. Heartburn is caused when the acid in your stomach, there to break down the food you ate, refluxes (flows in the wrong direction) and enters your esophagus which connects your throat to your stomach. If this happens frequently, you can develop gastroesophageal reflux disease (GERD), or chronic acid reflux.

Sometimes, refluxing acid travels all the way up the esophagus and makes contact with the tissues in your upper esophagus or throat, injuring those tissues. When this happens, it is called laryngopharyngeal reflux, LPR for short. Unlike the lower part of your esophagus, the tissues of the throat are not designed to tolerate acid at all. Think about it like this: if lemon juice is squeezed onto the skin of your hand, it’s just going to feel wet. But if lemon juice is squeezed into your eye, you’re going to feel it! It’s the same difference between the tissues in your esophagus and those in your throat.

Your system can tolerate many (50 or more) episodes of acid refluxing in the lower esophagus, but it only takes a few episodes – two or three in a 24-hour period – of acid making its way to your throat to hurt it. This is why as many as 80% of people that have LPR never have the classic indigestion and heartburn symptoms of typical acid reflux; our bodies generally handle the refluxing acid in the esophagus but cannot handle it in the throat.

Symptoms

The most common symptoms of LPR are:

LPR is one of the top three diagnoses we see in the ear, nose, and throat (ENT) specialty, and estimates of how many people have LPR range from 10-15%. Because similar symptoms can be caused by many common ailments – allergies, infection, a virus – and because people often do not experience typical acid reflux symptoms, LPR can go undetected for years.

Factors that may Increase Your Risk for LPR

The risk factors of LPR overlap with those of traditional acid reflux or GERD:

Diagnosis

An ENT doctor can sometimes diagnose LPR based on your symptoms alone and prescribe a treatment regimen. Given the treatment focuses on your digestive system and not your throat, if the medicines work, it’s fairly easy to confirm the diagnosis of LPR.

The second diagnostic path may involve a physical exam in the form of a laryngoscopy. Your ENT doctor will insert a very small fiber optic tube into your nose and down your throat to look for redness and irritation which are cardinal signs of LPR.

Another test called an esophageal pH test can be done by placing and leaving a tube in the esophagus for 24 hours to measure how much acid comes up. Additionally, measuring the level of pepsin (a digestive enzyme that comes from the stomach and activates the acid in your stomach) in your saliva can indicate that acid has likely entered the throat and caused tissue damage.

Treatment

Treatment involves both medications and lifestyle changes. The primary medicines used are those that you would also take for GERD as they suppress acid production in the stomach. It’s not that you necessarily have too much acid, you just have acid that moves in the wrong direction. Nevertheless, it’s relatively easy to suppress the amount of acid so it more likely remains where it should.

There are two classes of drugs that suppress acid. The first drug class is H2, or histamine, blockers, with brand names Pepcid and Tagamet and generic drug names famotidine and cimetidine. Then there is a newer class of drugs called proton pump inhibitors, or PPIs. PPI generic drug names all end with -zole – omeprazole, lansoprazole, rabeprazole, pantoprazole, esomeprazole and so forth – and have the brand names Prilosec, Prevacid, Aciphex, Protonix, and Nexium. While H2 blockers shut off most of the acid production, PPIs can shut off acid secretion completely.

Because the throat tissues are more vulnerable and need time to heal, we typically prescribe PPIs to be used twice a day for 6-8 weeks, and then taper down to either a once a-day PPI or a PPI in the morning and then an H2 blocker at bedtime. We like to move off PPIs and onto H2 blockers if we can. While PPIs are safe drugs, compared to H2 blockers they have some potential side effects, primarily around calcium and magnesium metabolism and a higher risk of osteoporosis. In total, the medication phase for LPR can last anywhere from a few weeks to three or four months, and then we control your LPR with lifestyle modifications.

In extreme cases, there are some surgical interventions and also endoscopic procedures we do. But very, very few people should require surgical procedures for LPR, as the vast majority can be controlled with medications and lifestyle.

Lifestyle Changes to Manage LPR

This is the list of foods and drinks you should try to avoid altogether or consume judiciously, as they either increase acid production or relax the upper and lower sphincter muscles, allowing acid to more easily reflux:

Additionally, there are other lifestyle changes you can try that can make a big difference:

I know that lifestyle changes are probably the hardest thing to do for most people. For example, if you’ve had an additional cup of coffee every afternoon for the last 20 years, and I say – “You know, one cup of coffee in the morning and that’s it!” – you’re going to struggle with that. I also know that the list above contains many favorite foods! The good news is that not every food is a trigger for every person – what might bother one person might not bother the next. So I tell my patients to try and identify the foods that bother them the most and work to remove those.

Also, speak with your doctor about whether taking an extra, occasional dose of medication is right and safe for you if you know you’ll be in situations that might disrupt your careful routine. For example, say you’re going to a wine and cheese get together with your friends at 6:00pm. You typically take your Pepcid at 11:00pm before you go to sleep. Most people can handle taking an extra dose of an H2 blocker from time to time, so take an extra Pepcid at 5:30pm in this example.

Bottom line:  while LPR is a condition that you may remain susceptible to, it can be managed well with common-sense lifestyle changes you can control and advice and guidance from your clinician on how best to use medications that are safe and effective.

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About Dr. Ralph Iannuzzi

Dr. Ralph Iannuzzi is an otolaryngologist (ear, nose, and throat or ENT physician) at Atrius Health. Dr. Iannuzzi received his medical degree from the University of Massachusetts Medical School and completed his surgical internship at St. Elizabeth’s Medical Center and ENT residency at the Massachusetts Eye and Ear Infirmary. Since joining Atrius Health in 2008, Dr. Iannuzzi has served as chief of the Atrius Health ENT department, Chief of Cosmetics, Chief of Allergy and Associate Chair for Specialties. He has served on the Board of Trustees for the organization. He is an assistant professor at Harvard Medical School, Senior Surgeon at Mass Eye and Ear and was previously an assistant professor at the University of Massachusetts Medical School.

Comments

  1. Great article! Thank you.

    Comment by Bob Baga on February 17, 2021 at 10:24 am
  2. Thank you for this. I was diagnosed with asthma and GERD for years.

    The GERD was accurate but the asthma was not. I ended up being hospitalized and had emergency surgery for ISS. Idiopathic Subglottic Stenosis.

    This is another thing you should make patients aware of. I had never heard of it. It also goes hand in hand with GERD as it can aggravate the GERD when you are closing.

    I am now being closely following at MASS EYE & EAR.

    Comment by Carmel T Kerrigan on February 17, 2021 at 10:29 am
  3. Dr. Iannuzzi, I found your article to be very clear and informative. Thanks for writing it. I am a patient of Dr. Paskal in the Medford office and almost certainly have LPR (related to my Zanker’s diverticulum, which I believe that you diagnosed and referred me to Dr. Emerick for surgery several years ago.)

    Comment by Richard Adler on February 17, 2021 at 10:41 am
  4. Very well written post. I enjoyed reading it.
    Jeanne Says Hi.

    Comment by Gregory A Smith on February 17, 2021 at 10:41 am
  5. Very nice article – clear and informative. Thanks for writing it.

    Comment by Richard Adler on February 17, 2021 at 10:42 am
  6. Very helpful since I currently take Pepcid for my acid reflex.

    Comment by Robert K Ganong on February 17, 2021 at 11:38 am
  7. It was good reading this text. It’s typically what I had experience. I am doing much better since I have been taking the famotidine twice a day.
    Thanks

    Comment by Marie Rose Maguie Moreau on February 17, 2021 at 11:54 am
  8. Thank you! This is the first time I have ever seen my symptoms identified specifically as LPR. Your article helped me to understand exactly what’s going on with me and confirms that the treatment plan I am on is generally the right course. I will now be better able to follow up with my PCP going forward.

    Comment by David Brown on February 17, 2021 at 12:05 pm
  9. Dr. Iannuzzi,
    Thank you for sharing this information in such a way that it easily understandable; rooted in common sense; and based on manageable techniques for intervention. Your column is written with empathy and compassion for the readers you address.
    Sincerely,
    Janice D’Avignon

    Comment by Janice D'Avignon on February 17, 2021 at 12:09 pm
  10. Thank you so much for this wonderful information because I have the same symptoms for quite long time and taking almost similar medication mentioned above and was diagnosed with reflux and lately with LPR by an ENT .

    Comment by Abdulrazaq Hasan on February 17, 2021 at 1:23 pm
  11. Hello, great post! How severe can these symptoms get for people? I have been eating a ketogenic diet for the last couple of years, on and off, but mostly on. So, every food that’s on the “avoid” list has been a staple in my diet.

    I constantly feel like I have thick mucous and difficulty swallowing. I am actually being treated with PPIs (Prilosec) by my PCP and have gone through all of the blood and heart tests to rule out something more severe. I have cut back on caffeine and am already practicing intermittent fasting but am still feeling symptoms.

    Anyway, great article! I was extremely surprised to hear LPR/Silent Reflux was a thing that existed!

    Comment by Christopher on February 17, 2021 at 7:31 pm
  12. This was very helpful! I clicked on it because my sister has this condition and now, reading it, I think I do, too! Appreciate the information.

    Comment by Ione Bissonnette on February 17, 2021 at 10:24 pm
  13. It’s funny that you put this up this month. Im76 now and lately I have experienced this in my throat. Its not all the time .Its when I skip a meal or just have a small snack . If I have some milk it takes it away and I’m good to go . I just have to put something in my stomach that will fill me up a little. I have noticed this now as you said as we get older things change in our systems. I’m understanding this feeling now and as of now I don’t think I have to use anything that you said to use. I drink a lot of milk every week with my meals , If it gets worse Ill see a doctor and we can go from there.
    Thank you

    Comment by D.c.surette on February 18, 2021 at 2:16 am
  14. Thank you. I appreciate this clear and thorough article on this topic. It addresses my questions and concerns and provides guidance on how to handle acid reflux.

    Comment by Wendy Schwartz on February 18, 2021 at 6:43 pm

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