GERD and LPR

What is GERD?

Gastroesophageal reflux, often referred to as GERD, occurs when acid from the stomach backs up into the esophagus. Normally, food travels from the mouth, down through the esophagus and into the stomach. A ring of muscle or “valve” at the bottom of the esophagus, the lower esophageal sphincter (LES), contracts to keep the acidic contents of the stomach from “refluxing” or coming back up into the esophagus. In those who have GERD, the LES does not close properly, allowing acid to move up into the esophagus. When stomach acid touches the sensitive tissue lining the esophagus and throat, it causes a reaction similar to squirting lemon juice in your eye. This is why GERD is often characterized by the burning sensation known as heartburn. Almost all individuals have experienced reflux (GER), but the disease (GERD) occurs when reflux happens on a frequent basis over a long period of time.

What is LPR?

During gastroesophageal reflux, the acidic stomach contents may reflux all the way up into the back of the throat. This happens if the upper esophageal sphincter or valve (a ring of muscle at the top of the esophagus) relaxes too much. This is known as laryngopharyngeal reflux (LPR), which can affect anyone. Adults with LPR often complain of a foreign body sensation in their throat that is called globus. This can feel like phlegm, a “lump in the throat”, a “frog in the throat,” and leads to frequent throat clearing or cough. The acid spills over onto the voice box and causes the vocal cords to swell which leads to hoarseness or a change in voice. LPR is frequently called “silent reflux” because heartburn is often absent.

What are the symptoms of GERD and LPR?

The symptoms of GERD may include heartburn, acid regurgitation, nausea, hoarseness in the morning, or trouble swallowing. Some people have GERD without heartburn. Instead, they experience pain in the chest that can be severe enough to mimic the pain of a heart attack. GERD can also cause a dry cough and bad breath. LPR may feel as if they have food stuck in their throat, a bitter taste in the mouth on waking, voice changes, throat clearing.

If you experience any of the following symptoms on a regular basis (twice a week or more) then you may have GERD or LPR. For proper diagnosis and treatment, you should be evaluated by your primary care doctor for GERD or an otolaryngologist for LPR.

Who gets GERD or LPR?

Women, men, infants, and children can all have GERD. This disorder may result from physical causes or lifestyle factors. Physical causes can include a malfunctioning or abnormal lower esophageal sphincter muscle (LES), hiatal hernia, abnormal esophageal contractions, and slow emptying of the stomach. Lifestyle factors include diet (chocolate, citrus, fatty foods, spices), destructive habits (overeating, alcohol and tobacco abuse) and even pregnancy. Young children experience GERD and LPR due to the developmental immaturity of both the upper and lower esophageal sphincters. Unfortunately, GERD and LPR are often overlooked in infants and children leading to vomiting, coughing, airway/respiratory problems. Most infants grow out of GERD or LPR by the end of their first year.

What role does an ear, nose, and throat specialist have in treating GERD and LPR?
A gastroenterologist, a specialist in treating gastrointestinal orders, will often provide initial treatment for GERD since it is the lower sphincter that is faulty. But an ENT doctor often provides the diagnosis and treatment of LPR since these symptoms can overlap with several other ENT disorders (throat cancer, vocal nodules, airway stenosis, or even sinus infections. ENT doctors have the tools (scopes) and training to fully evaluate these problems. For these reasons, your primary care physician or pediatrician will often refer suspected LPR to an ENT doctor for a complete evaluation.

Diagnosing and Treating GERD and LPR

In adults, GERD can be diagnosed or evaluated by a physical examination and the patient’s response to a trial of treatment with medication. Other tests that may be needed include an endoscopic examination (a long tube with a camera inserted into the nose, throat, windpipe, or esophagus), biopsy, x-ray, examination of the throat and larynx, 24 hour pH probe, esophageal motility testing (manometry), emptying studies of the stomach, and esophageal acid perfusion (Bernstein test).

LPR can be diagnosed by an ENT doctor by history and examination which often entails looking at the throat with a scope. This takes less than 5 minutes and is performed while awake. Numbing solution is sprayed into the nose and a small flexible scope is placed through the nose to see the voicebox. LPR causes distinct changes in the voicebox. This can also help to rule out other disorders such as vocal nodules or throat cancers.

Most people with GERD or LPR respond favorably to a combination of lifestyle changes and medication. Surgery is rarely recommended. Medications that could be prescribed include antacids, histamine antagonists, proton pump inhibitors, pro-motility drugs, and foam barrier medications. Some of these products are now available over-the-counter and do not require a prescription.

Children and adults who fail medical treatment or have anatomical abnormalities may require surgical intervention. Such treatment includes Nissen fundoplication, a procedure where a part of the stomach is wrapped around the lower esophagus to tighten the LES.

Adult lifestyle changes to prevent GERD and LPR:

  • Avoid eating and drinking within 2-3 hours prior to bedtime
  • Avoid alcohol, caffeine, chocolate, and peppermint
  • Slowly eat small meals
  • Limit problem foods (fatty, spicy)
  • Limit tomato and citrus
  • Lose weight
  • Quit smoking