Silent Reflux

What is Silent Reflux?

The term reflux means "back flow" of stomach contents or acid back into the esophagus. Normally, two valves (called sphincter muscles) at the top and bottom of the esophagus prevent this backflow. In some people, for a variety of reasons, these valves allow backflow to reach all the way up into the throat (per) and voice box (larynx).

Many people with silent reflux or LPR do not experience heartburn, hence the term "silent." This is because the material that is refluxed does not usually stay in the esophagus for very long and does not have enough time to irritate the esophagus and cause heartburn. While a person may not experience heartburn, there may still be injury and irritation to the sensitive tissues of the throat and voice box. Even small amounts of refluxed acid present for short periods of time can irritate the throat and voice box tissues causing a variety of symptoms.

LPR is usually experienced during the daytime but can also occur at night. LPR can also occur even if a person hasn't eaten. LPR can be aggravated by certain foods, certain patterns of eating, as well as stress.

You may experience some or all of the following symptoms if you have LPR:

hoarseness (chronic or intermittent)
trouble swallowing
too much throat mucus or nose and throat drainage
a "lump" sensation in the throat
chronic cough or throat clearing
heartburn

If you have any of these symptoms and, especially if you smoke, you should ask your doctor about LPR. The specialist who most often treats people with LPR is the Otolaryngologist (Ear, Nose and Throat Physician)

How is LPR evaluated?

If your doctor thinks you could have LPR, he or she will probably perform a throat exam first and look at the voice box and the lower throat. If this area looks swollen and/or red, you may have LPR. At that point, your doctor may order some additional tests or recommend specific, treatment.

The most common tests for LPR are 24 hour pH monitoring and a barium swallow. A barium swallow involves swallowing a chalky white substance while an x-ray is taken of your throat, esophagus and stomach. This shows how you swallow as well as any other abnormality in the throat or esophagus. A 24-hour pH test is a special test that involves wearing a small, flexible tube through your nose and into your esophagus overnight. The tube, called a "ph probe", is connected to a small computer (worn around the waist), that measures the acid in your esophagus and throat. This test is often very helpful in determining the amount and frequency of acid reflux events and is sometimes used to determine how effective the medications are at stopping acid.

How is LPR treated?

Sometimes, changes in diet and lifestyle that are known to aggravate reflux symptoms are recommended. In most cases, however, dietary and lifestyle changes are not enough and must be combined with medications to control reflux. In severe cases, surgery may even be recommended to prevent reflux.

There are various medications used to treat reflux. Acid neutralizers such as Mylanta, Maalox, and turns are designed to neutralize the stomach acid to some degree and are thought to be minimally effective in controlling the problem long-term. H2 blockers such as Zantac, Axid and Pepcid, which can be bought over the counter or prescribed by your doctor, are considered more effective than neutralizers as they work to limit the production of stomach acid. Finally, proton pump inhibitors such as Nexium, Prevacid, Prilosec, Protonix and Aciphex are considered the most effective class of medicines for reflux and also work to limit the production of stomach acid. A combination of these medicines may be prescirbed to best control your symptoms.

Dietary restrictions and lifestyle changes to reduce refux and control symptoms:

Avoid caffeine in coffee, tea, or soda
Quit smoking (Smoking makes you reflux. After every cigarette you may have some LPR)
Avoid alcoholic beverages, particularly in the evening.
Aim to eat a low-fat diet, limit your intake of red meat; avoid butter, fried foods, chocolate, cheese, eggs
Avoid peppermints or lozenges which may increase the production of stomach acid and irritate the stomach
Avoid Aspirin, Motrin, Ibuprofen which may aggravate the stomach lining
Do not lie down just after eating. In fact, do not eat within 2-3 hours of bedtime
If you are overweight, weight loss is recommended
Avoid wearing clothes that fit tightly across the mid-section of the body such as tight belts or girdles
You may try elevating the head of your bed by 4-6 inches with cinder blocks or books
Do not skip meals. Eating at least 3 or 4-6 smaller meals per day will stop the buildup of stomach acid on an empty stomach

How long is treatment needed?

The answer to this question is different for everyone and is often a matter of patient preference. It often takes a number of months for injury to the throat and voice box to heal once acid has been suppressed. In many cases, increasing the dosage or frequency of the medication for an extended period of time may be necessary for a person to get relief: Many people with LPR require treatment indefnitely to control symptoms. Some people require treatment intermittently. That is, a person may recover completely for months or years and not require medications, then they may have a relapse and recurrence of symptoms.

In severe cases, aggressive, prolonged treatment of the reflux with medications and routine monitoring of the throat is recommended. Further testing to determine whether a patient needs "anti-reflux" surgery (called fundoplication) may also be necessary to restore a new and better stomach valve.

Other problems related to reflux:

LPR can cause such problems as choking episodes, breathing problems (such as asthma and bronchitis), and very uncommonly, cancer of the esophagus, lung, throat or voice box (note: for cancer to develop, the LPR must be very severe and go untreated for many years)

Taking your Reflux Medications:

Most commonly, proton pump inhibitors (e.g., Prilosec, Prevacid) are prescribed for reflux. The role of this drug is to limit the production of stomach acid before it starts. For the drug to be most effective, it is important to take the medication 1/2 hour to 1 hour BEFORE eating a meal. If you are prescribed once a day dosing, take the medication 1/2-1 hour BEFORE breakfast or first meal of the day. If you are prescribed twice a day dosing, take the second dose 1/2 to 1 hour BEFORE your supper meal. If you take the medicine after you eat, you've already produced some stomach acid. Also, if you take the pill but do not eat, the medicine will not be as effective.

Compliance and consistency with taking your medications are extremely important. If you frequently skip dosages or take the medication sporadically, you are not likely to improve. Remember, only small amounts of acid experienced intermittently may be enough to continue irritation and inflammation of the throat and voice box.