Ever notice that brackish acid taste in the back of your throat, shooting upwards from your stomach? Or a burning sensation in your mid-chest or the area just below your sternum (the “epigastrium”)? Or waking up in the mornings with a hoarse voice, when you very well know you weren’t screaming in your sleep or partying and hollering the night before? Or you feel a sense of something not quite right in our throat, of a lump, a mass that you can’t clear up? Well, you might have GERD.
Gastroesophageal reflux disease (GERD) occurs when stomach acid travels upwards into the esophagus (the tube connecting the throat (pharynx) to the stomach), and sometimes way up into the throat. Of course, this is not normal since everything that travels down into the stomach ought to stay in the stomach. Classic symptoms of GERD include heartburn and/or a sensation of stomach acid coming up towards the throat, sometimes causing a sour taste. Not everyone has these classic symptoms though. GERD can often manifest as an irritation in the larynx (voice box) and the part of the throat near and around the larynx; this is called laryngopharyngeal reflux (LPR). Symptoms of LPR may present as a foreign body sensation in the throat (globus pharyngeus), hoarseness upon waking up, a chronic dry cough, persistent sore throat, or frequent throat clearing. The effects of LPR can be seen as a swelling, ulcer or redness of the larynx when examined (often using a fiberoptic scope).
Normally swallowed food and liquids (including beer and foreign objects you’re not suppose to ingest) travels down into the throat, behind the larynx, into the esophagus and from there into the stomach. Substances are pulled down partly by gravity (which is the reason you oughtn’t eat lying down or standing on your head—you may aspirate through the voice box and into your lungs) but mostly by waves of contraction called peristalsis. Once into the stomach, there is a constricting gateway or valve you might say, that tightens and closes the opening between the esophagus as it empties into the stomach. This is called the lower esophageal sphincter (LES) and prevents whatever is in the stomach to pass back upwards into the esophagus.
The stomach secretes enzymes to digest food and drink but also produces a lot of hydrochloric acid (HCl for you chemistry-minded folk). This acid helps break down substances, much in the way you’ve seen HCl eat away stuff in the chem lab. Only too much acid can harm the mucosal lining of the stomach and rest of the digestive tract (the cause of ulcers) even though the stomach is made of some pretty resilient material.
If the peristalsis is affected or the LES is weakened, partially digested food and acid can travel upwards from the stomach and into the esophagus. This is the cause of the “heartburn” and/or acidic sensation one may feel during a GERD bout. The acid can inflame the esophageal mucosa. If acid travels farther up, the larynx and pharynx become irritated and inflamed, creating hoarseness (often after sleeping, when lying flat, increasing risk of acid rising into the esophagus and throat), throat irritation or soreness, throat clearing, even a sensation of thick phlegm. Inflammation to these areas along with the upper esophageal sphincter (UES) can give rise to that lump-in-the-throat sensation known as globus pharyngeus. And inflammation anywhere along the esophagus can cause dysphagia, where food or liquids actually lodge or stick on the way down, or odynophagia, pain with swallowing.
Persistent acid irritation can also cause changes to the cells lining the esophagus, called metaplasia, where cells change from one type to another, which in this case increases the risk the cells becoming cancerous. This change is called Barrett’s Esophagus, a condition closely followed by gastroenterologists (GI doctors).
Known factors that increase stomach acid, weaken the LES and exacerbates reflux are: 1) alcoholic beverages; 2) caffeine; 3) chocolate; 4) spicy and fatty foods; 5) stress. All of these should be eliminated or reduced.
TREATMENT
RECOMMENDATIONS:
1. Avoid the foods above. Reduce stress levels. Avoid smoking or chewing tobacco.
2. Elevate the head of the bed so that it is
slanted 20-30 degrees. Simply lying on
a pillow under the head will only flex the neck. Instead place the pillows so your back is
also angled upwards without flexing your neck; then both the esophagus and
stomach are lower than the throat. If
you have an adjustable bed, elevate it to a 20-30 degree angle. Another method is to place wood blocks or a
couple of books under the legs of the headboard to achieve the same effect.
3. Limit the intake of food or liquids prior to
bedtime will decrease the chance of stomach acid washing back up into the
esophagus and into the throat. Thus,
don’t eat or drink two to three hours before going to bed.
4 Tums or antacids before going to bed can be
helpful. Your doctor may also recommend
an over-the-counter medication (OTC)such as omeprazole (Prilosec) OTC. If so, take one per day before meals for at
least 30 days. If a stronger medication
is needed, a prescription will be provided.
5. If there is an ulceration or a lesion that
does not heal, then a direct laryngoscopy and biopsy under anesthesia in the
operating room may be indicated to rule out other causes.
6. If this problem continues and the measures
mentioned above are not helpful, then it may be necessary to refer you to a
gastroenterologist for further evaluation and treatment, including an upper
endoscopy to check the entire esophagus and stomach. In other words, the GI doc
is able to view areas where the ENT doc is unable to do so with the typical
office nasopharyngoscope.
7. Other treatments include medications that
enhance peristalsis and reduce upward migration of acid. Some of these have been taken off the market
due to severe side-effects, and we usually leave such treatment to the
discretion of the GI doc.
8. The last resort is surgery to strengthen the LES, via a procedure called a Nissen fundoplication, where the upper part of the stomach (which contains layers of muscle) is wrapped around the LES. Nowadays, this is done laparoscopically with small incisions.
I provide much of these treatment recommendations as a written handout to patients (found in ENT Information Guide, a free downloadable booklet)
Additional, related topics: globus pharyngeus, phlegm, throat and esophageal foreign bodies, nasopharyngoscope
©Randall S. Fong, M.D. www.randallfong.com
For more topics on medicine, health and the weirdness of life in general, check out the rest of the blog site at randallfong.blogspot.com
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