Gastro-Esophageal Reflux (GERD) & Laryngopharyngeal Reflux (LPR)

by Karen M. Sheffler, MS, CCC-SLP, BCS-S of SwallowStudy.com

Introduction:

Many people who have reflux come for evaluations by a Speech-Language Pathologist (SLP), who specializes in difficulty swallowing (dysphagia). Reflux can cause symptoms of dysphagia (see list later on in this article of symptoms specific to GERD versus LPR), but here are some common symptoms:

• • feelings of choking,
  • coughing during or after meals,
  • feelings of food getting stuck,
  • lump in the throat sensation (globus sensation),
  • burning and pain when swallowing, and
  • changes in voice quality like hoarseness.

I have heard people express fear of actually choking (asphyxiation – where the food blocks the airway). These sensations can trigger fears, and then the anxiety can increase the perceived dysphagia. This can severely affect your quality of life and enjoyment of eating. Some people start significantly limiting what they are eating, putting themselves at risk for weight loss. Please don’t let the issue spiral like that, and seek help in a timely fashion. 

When your medical team does an evaluation of your dysphagia, it is called making a differential diagnosis (meaning figuring out what you may have and what you do not have). Having an evaluation by an SLP can help you clarify at what level the problem is. During your swallow study, we may find that the food is NOT getting stuck up high in your throat at all, and there is no risk of actually choking on food.

People can really feel a strong sensation of a “lump in the throat” (or “globus” sensation) when they have reflux.  A thorough videofluoroscopic swallow study that scans down the esophagus with foods, liquids and a pill may also find that these items are actually hanging out in your food tube (esophagus) on the way to your stomach. This could be caused by reflux irritating the lining of the esophagus, causing inflammation, or it could be due to other issues. Based on your swallow study and your symptoms, we may suspect that you have reflux or other issues with the structure or movement (squeezing action to push things along) within your esophagus. Therefore, the SLP makes appropriate referrals to help the medical team clarify your difficulties.

Read on to learn more about reflux and what you can do about it. Most importantly, ask your doctor more about it. As always, do not follow recommendations on the internet without first discussing them with your medical team.

I was told I have reflux. What is it?

Reflux: a condition that causes material from your stomach (e.g., acidic and non-acidic stomach contents, food, and/or liquid) to abnormally return back up into your esophagus and possibly come as high up as your throat, voice box, airway, mouth and even your nose and sinuses.

Sometimes this happens right after a meal, but other times it could happen well after a meal, when you lie down, and/or overnight during sleep.

The stomach contents can irritate the lining of the esophagus, the throat (pharynx), the voice box (larynx), and even higher up. You may get a bitter taste into the mouth, have sinus issues, worsening asthma symptoms or other breathing problems. If the material comes up out of the esophagus into the lower part of the throat/pharynx, then it could fall into your airway. The refluxed material may cause irritation and inflammation of both your vocal cords and your lungs. This can cause an aspiration pneumonitis (inflammation of your lungs), and it can make your lungs more susceptible to getting pneumonia.

See more pictures and descriptions of reflux. 

However, not all reflux is the same. Everyone is different.

First, let’s label the reflux based on how far up it goes: 

• Gastro-Esophageal reflux (or GERD), which is when food, liquid and other stomach contents come up from the stomach to the food tube (esophagus) through a relaxed lower esophageal sphincter (LES – which should remain closed at rest). 

• Laryngopharyngeal reflux (or LPR), which is when the food, liquid and other stomach contents come ALL THE WAY UP to the throat (pharynx) and voice box (larynx). This has also been called Supraesophageal Reflux Disease (SERD) (Babaei, et al., 2015; Naftali, 2018).

Dr Jonathan Aviv, MD, FACS calls this “throatburn reflux.” See his article on DysphagiaCafe.com.

Factors that can cause reflux:

Because there are many factors that cause reflux, your treatment plan will be tailored to your specific condition. Please confirm your specific pattern with your medical team.

• Problems with the function of the esophagus and stomach, including impairments in the sphincter between the two. This sphincter is called the Lower Esophageal Sphincter (LES), and it is like a door that needs to stay closed on the stomach. The sphincter is closed up tight at rest. It should also close back up immediately after swallowed food, liquid, pills and saliva pass through into the stomach. If the LES abnormally relaxes and opens, it allows the stomach contents escape through this sphincter back into the esophagus.
• Problems with the Upper Esophageal Sphincter (UES), which is the final door that needs to remain closed at rest at the top of the esophagus to prevent the refluxed material from entering the lower throat and airway. If this abnormally opens and allows material to come back into your throat, the contents of your esophagus could fall into your airway or go up higher if you are laying down. 
• Hiatal hernia, which is where the stomach bulges up through the diaphragm muscle. This can cause food and liquid to get stuck, which can eventually reflux back up the esophagus and above. 
• Obesity can increase the pressure on the stomach, which may elevate your reflux risks.
• Certain genetic factors
• Medications can cause decreased stomach and esophageal emptying. They can also cause a relaxation of the lower esophageal sphincter. (Read more about medications and dysphagia – see the attached pdf with a section on the esophagus and reflux).
• Certain eating habits and lifestyle habits (see below).

Symptoms: 

There are many people who have GERD and LPR/SERD who are not aware of the symptoms, especially if you have had reflux for a long time. You may have been desensitized. The acid reflux can cause you not to feel it as it actually causes swelling and numbs your sensation over time (desensitization). We can think of this as “silent reflux.” Some people have LPR, but never felt “heartburn,” as the material can travel quickly through the esophagus to the throat. 

Common Symptoms of GERD:

• Heartburn (but not everyone will feel this, especially as you get older and desensitized)
• Acid regurgitations, which may leave a sour taste or bad breath in your mouth, especially in the morning.
• Indigestion or upset stomach
• Hiccups
• Difficulty swallowing, feeling foods getting stuck, and pain with swallowing, especially if left untreated.

Common Symptoms of LPR/SERD:

• Changes in the quality of the voice (e.g., hoarseness, vocal strain, or not reaching higher pitches when singing).
• Sensation of something sticking in the throat that does not clear with swallowing. Often described as a “ball” or “lump in the throat” (called a “globus sensation”).
• Thick and/or too much mucous in the throat
• Frequent throat clearing
• Recurrent sore throat and/or tongue pain
• Coughing during the day and night, with waking up at night coughing.
• Acid regurgitation, which will may leave a sour taste or bad breath in your mouth, especially in the morning.
• Difficulty swallowing

Why worry about reflux?

If left untreated, the symptoms and the seriousness could get worse. The lining of the esophagus can become inflamed, ulcerated, and the esophagus can become narrow or develop a stricture. It can lead to serious medical complications, including voice problems, pneumonia, and even esophageal cancer.

WHY is this happening?

To answer this, you will need further testing.

Your medical team should fully evaluate for the many factors that are causing your reflux in order to know why and how to best treat it.

This may include testing by:

• Otolaryngologists (aka, ENT for ear, nose and throat doctor)t: who can take an endoscopic view of your throat, voice box (larynx) and upper airway, and even the esophagus with a thin scope threaded through your nose. It is well tolerated and done in the doctor’s office and not under sedation. The Otolaryngologist may also suggest wearing a pH probe for 24 hours to record any acid and non-acid reflux events and how high up they come. To make the pH probe test more accurate in finding the higher up “throatburn” reflux, the doctor may be able to add impedance monitoring to measure the passage of material into the throat (Naftali, 2018).
• Gastroenterologist (aka, GI or stomach doctor): who can also perform endoscopy of the esophagus and stomach, but this is done under sedation. The GI doctor may recommend further radiology testing and/or esophageal motility testing. For example, the radiology exam called the Upper GI or Barium SwallowStudy.com, can better assess the lower esophageal sphincter (LES) and test for reflux of barium. Some GI doctors have High Resolution Impedance Manometry (HRM) to better evaluate the esophagus, especially the upper esophageal sphincter (UES) function. (The UES is at the top of the esophagus and is a sphincter that remains contracted/closed at rest). Babaei, et al. (2015) found that when they put liquid directly into the esophagus to simulate a reflux event, the people with LPR/SERD had abnormal reactions. Their upper esophageal sphincter relaxed (opened), rather than the normal response of contracting (closing) and swallowing in response to the sudden infusion of liquid into the esophagus.
• Speech-Language Pathologist (SLP) who specializes in voice can evaluate for LPR symptoms and help treat the voice related issues.
• Speech-Language Pathologist (SLP) who specializes in swallowing can watch you eat and drink during a videofluoroscopic swallow study (VFSS) or fiberoptic endoscopic evaluation of swallowing (FEES) in order to rule-out difficulty swallowing through the mouth and throat (oral and pharyngeal phases of the swallow).  (See also the blog: “How do I know I need a swallow study?“)  This is important as there are many reasons that people feel food getting “stuck” in the “throat” or “food tube.” The SLP can really help with the differential diagnosis process. The VFSS can evaluate the upper esophageal sphincter (UES), as well as scan the esophagus to see if food, liquid or pills are getting stuck in the esophagus and come back up into the throat and airway. The evaluation by the SLP can give you a peace of mind that you are not likely going to choke/asphyxiate, as the problem may be lower down. The SLP provides thorough education and can even show you the videos to make sure you understand your situation. Your goal is likely to enjoy eating and drinking without discomfort, risks and fear. The SLP can give you functional strategies immediately to help you meet that goal.

What can I do about this reflux?

• • 1. There are many reasons why your lower esophageal sphincter (LES) may not be doing its job. For example, the following should be avoided, as they cause the door or sphincter between the stomach and the esophagus to relax/open when it should be closed.
    • Smoking of cigarettes and marijuana (talk to your doctor about how to quit)
    • Alcohol
    • Caffeine in coffee, tea, chocolate, soda
    • Mint and menthol (e.g., peppermint and spearmint)
    • Fatty and fried foods
    • Onions
    2. Try to minimize or avoid the following foods/liquids that increase the acid and cause irritation:
    • Citrus foods
    • Tomato-based products
    • Processed foods, especially those with high fructose corn syrup, as this contains sulfuric acid (See Aviv’s article in DysphagiaCafe.com.)
    • Spicy foods
    • Garlic
    • Carbonated beverages
    • Acidic drinks like coffee, lemonade, orange juice
    3. Change lifestyle habits:
    • Avoid eating large meals (smaller, more frequent meals are easier to digest). Try eating slowly. When you overfill your stomach, it will be more likely to “overflow.”
    • Wait 2-3 hours after eating before lying down, which includes avoiding napping flat on the sofa after a big meal.
    • Avoid doing heavy physical activity or exercise right after a meal, especially if that includes bending over at the waist.
    • Keep yourself upright for at least 1 hour after eating a meal
    • Talk with your doctor about losing weight as needed, as excess weight increases the pressure on the stomach which could push stomach contents upwards.
    • Wear loose clothing around the waist
    • Elevate the head of your bed 6-12 inches with bricks or “bed risers” under the head of the bed. Otherwise, use a wedge pillow (reflux pillow) under your mattress. The goal is to elevate the head higher than the stomach, so that gravity will keep the stomach contents down where they belong. It is amazing the amount of pictures and info you can find by just searching “inclined sleep” on the internet.
    • NOTE: EXTRA PILLOWS UNDER YOUR HEAD ARE NOT SUFFICIENT. You will tend to fall down or be scrunched up at the waist by multiple pillows, and this could increase your refluxing.
    • Try laying on your left side, as this is the stomach-down side, and may use gravity to keep the stomach contents in place.
    • Stress can increase reflux. Talk with your doctor about a stress-reduction plan.
    4. Medications that could cause reflux:

As noted above, some medications can cause the lower esophageal sphincter to relax too much. If you have started a new medication and notice reflux symptoms, discuss this with your physician.  For example, many pain relievers like aspirin and ibuprofen can cause GERD.  This is also true of some drugs used to treat asthma, blood pressure, urinary tract disorders, glaucoma, and allergies.  Other drugs categories that can cause reflux are: sedatives, birth control pills, antidepressants, and iron pills.  Again, every person is different. It is critical that you consult your physician before beginning or discontinuing a medication.

Summary

The many prevention and treatment ideas above included: changing eating habits, avoiding certain substances, making lifestyle changes and avoiding medications that could cause reflux when possible. For many people making these changes is enough. However, sometimes treatment will also include a prescribed medication to treat your reflux. This article is not covering these medications in detail, as this needs to be a thorough discussion with your doctor. Talk with your doctor about the many types of Proton Pump Inhibitors (PPIs) and H2 Blockers, and anti-acids. Each one will have its specific risks/benefits and directions. In general:

• • • If your doctor prescribed medication one time a day, make sure to take it 30-60 minutes before breakfast.
    • If you doctor prescribed medication twice a day, make sure to take the morning dose 30-60 minutes before breakfast, and the evening dose either 30-60 minutes before dinner or 60 minutes before bedtime (or as prescribed by your doctor).
    • If you use anti-acids, like Tums, Rolaids, Maalox, for breakthrough reflux irritation during the day, review this and the quantity with your doctor. These are not for prevention. They are only for alleviating symptoms quickly when they occur.

Resources for more reading:

• Jamie Kauffman, MD, Jordan Stern, MD & master chef, Marc Michel Bauer: authors of: Dropping Acid: The Reflux Diet Cookbook & Cure
• Jonathan E. Aviv, MD, FACS: author of:

The Acid Watcher Diet: A 28-Day Reflux Prevention and Healing Program

Killing Me Softly From Inside: The Mysteries and Dangers of Acid Reflux And Its Connection to America’s Fastest Growing Cancer with A Diet That May Save Your Life   

Dr Aviv’s blog: www.acidwatcher.com

References:

Babaei, A., Venu, M., Naini, S.R., Gonzaga, J., Lang, I.M., Massey, B.T., Jadcherla, S. & Shaker, R. (2015). Impaired Upper Esophageal Sphincter Reflexes in Patients With Supraesophageal Reflux Disease. Gastroenterology, 149(6), 1381 – 1391. https://doi.org/10.1053/j.gastro.2015.07.007​

Naftali, T. (2018). Supraesophageal Reflux Disease (SERD). In: Bardan E., Shaker R. (eds) Gastrointestinal Motility Disorders. Springer, Cham. https://doi.org/10.1007/978-3-319-59352-4_14

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Clinicians: More on Patient Education and Patient Exercises

Do you love patient information handouts like this one?

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I have been working with MedBridge to help expand their SLP dysphagia platform, along with Yvette McCoy, MS, CCC-SLP, BCS-S and Rinki Varindani Desai, MS, CCC-SLP (www.RinkiSLP.com). (See guest blogging on SwallowStudy.com by clicking on their names.)  

This expanded SLP dysphagia platform will contain more patient handouts, like this one, as well patient exercises with instructional videos and step-by-step instructions. 

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