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Silent Reflux: Part 1

Welcome to the mysterious, evasive, often-undiagnosed, yet surprisingly common world of Laryngopharyngeal Reflux (LPR), where escaping stomach juices are a hidden cause of chronic cough and congestion, sore throat, stuffed nose, voice disorders, and lung ailments including pneumonia and asthma.

Part 1 this Month: What it is, How it Works & What to Eat

Part 2 Next Month: Herbs & Supplements

Escaping stomach juices are a hidden cause of chronic cough and congestion, sore throat, stuffed nose, voice disorders, and lung ailments including pneumonia and asthma.

By definition, “reflux” (both a noun and a verb) is when a fluid flows backwards through a tube or a channel vs. the direction is should be moving.  For example, plumbing in your house can reflux.  So can your digestive tract.

Most of us know about “normal” acid reflux – gastro-esophageal reflux disease, or GERD – where harsh acidic stomach juices rise up into the esophagus (the food pipe), and send a burning pain into your chest.  This is the one we call “heartburn.”

Most of us undergo dozens of reflux incidents a day.  A droplet here or there… We just don’t know it.   It’s only a problem after our defenses wear down.

Slightly less common, and much less well known is “silent reflux” – laryngopharyngeal reflux, or LPR – where stomach juices rise up through the esophagus, and then keep going.  These juices rise past the larynx (voice box) and enter the pharynx (common tube for food and air behind and below the mouth).  They can rise as high as the eustachian tubes, which connect the throat to the ears.  4 out of 5 LPR sufferers don’t report a burning sensation, or show damage to the esophagus. 

Meanwhile they may experience all sorts of “phantom symptoms” not intuitively connected to acid indigestion.

Symptoms of LPR may include:

  • chronic
    coughing and throat-clearing (especially following a meal, or upon waking)
  • nasal
    congestion and post-nasal drip
  • sore
    throat, hoarseness, and the feeling of something being stuck in the throat. 
  • sour
    and/or bitter taste in the mouth, and sometimes bad breath
  • vocal
    ailments including hoarseness and vocal fatigue
  • clogged
  • difficulty
  • frequent
  • lung
    ailments including worsening of asthma, and even pneumonia

Some of these symptoms appear or get worse only after meals.  Others get better or worse over days and weeks.  These are especially difficult to connect with digestion, unless you or your healthcare provider are looking.  Many healthcare providers don’t.  It’s not that they don’t know about LPR, in theory.  It’s just that LPR is rarely front-and-center in their minds.  They encounter a chronic cough, they look to the lungs; chronic nasal congestion, they think allergies.  Or you might get a diagnosis of asthma – which might be accurate, and treatable – but overlooks that LPR is making it worse. 

Some serious researchers estimate that a quarter or more of us have some kind of LPR – and don’t know it.  I’m not sure about that.  Most researchers put the prevalence around 5-10%, but higher among people already diagnosed with GERD.  Whatever the prevalence, it’s safe to say LPR is woefully underdiagnosed.  Some researchers suggest LPR is the #1 cause of chronic cough and chronic congestion in this country.

Is LPR Dangerous?

There’s a clear and strong link between GERD and a higher risk of esophageal cancer.  There isn’t a very clear link between LPR and cancers higher up in the throat.  Maybe a slight link…  It’s hard to say.  Maybe it’s that LPR really doesn’t do much damage.  Or maybe LPR is so poorly diagnosed, we haven’t made the connection yet.  Either way, stomach juices eating away at our sensitive tissues can’t be good

What Causes LPR?

Why do stomach juices escape out of the stomach in some people, but not others?  It’s not because anyone’s stomach acid is “too strong.”  Rather, it’s because the valve that holds in our stomach juices (called the lower esophageal sphincter, or LES) weakens.   

Foods that temporarily relax the LES include chocolate, mint, caffeine, and alcohol.  None of these are inherently unhealthy in moderation, but they can be problems if you’re susceptible.  

Increased pressure on the LES is also a factor.  We put increased pressure on the LES by increasing pressure in the stomach.  Tight clothing, especially around the waist, abdomen, and chest increase pressure.  Certain kinds of vigorous exercise increase pressure, especially after eating.  So can lying down within 3 hours of a meal.  Being overweight can definitely increase pressure in the stomach.  And perhaps the #1 culprit is large meals, especially very large meals.  We’ll talk about food choices in a bit. 

 Meanwhile, other factors lead to actual weakening of the LES over time.   Age, of course, plays a role.  But so does chronic increased pressure and stomach distension.  The valve can only take so much abuse.

Finally, both depression and Irritable Bowel Syndrome are strongly linked to LPR.  Although it’s not entirely clear how, why, or if there’s causality in either direction.

What to Eat for Reflux

Start with small meals, and if that means you eat five times a day instead of 3, so be it.  Normally eat a whole sandwich?  Eat half now, and save the other half for later.  You may not have to do this long-term, but it’s great in the beginning.

Avoid those foods that relax the LES mentioned above, and go easy on fatty and oily foods, which relax the LES and delay gastric emptying.   That includes both unhealthy fats like French fries, and healthy fats like sardines and almonds.  Carbonated beverages, which make you belch, often make things worse.  Some people find that onions, garlic, and gas-producing beans and veggies are a problem.  (Some don’t).  Fiber, too, is a mixed bag.  Most people do better with moderate amounts of gentle, soluble fiber – their reflux improves when whole grain breads replace white flour, etc., etc.  On the other hand, some people do worse with harsher “roughage” fiber like dry scratchy bran flakes cereal, raw cabbage and carrots.  Spicy foods are a mixed bag.  Avoid them if they bother you.  Don’t avoid if they don’t bother you. 

There’s some data out of Saudi Arabia which suggests coffee might actually be protective – arrayed against a million expert opinions which says it isn’t. 

Does all of this sound confusing?  Good.  It means you’re actually thinking about it.  Keep thinking.  Use trial and error to figure out what applies to you.  Also: chew your food.  Chew it well.

When to Eat for Reflux

 When you eat may be just as important as what you eat.  Generally, you don’t want to lie down for at least three hours after eating (maybe two hours if what you eat is really light, like fruit or a simple broth).  A good general rule is have dinner by 6:00, and no snacking afterwards.  Don’t eat before exercise, either. 

Your Bed and Your Chair

 Some people’s LPR is worse when they sleep.  When you lie down, gravity isn’t on your side!  Again, make sure to avoid meals (and even beverages) within 3 hours of bed.  Beyond that, try elevating the head of the bed (the entire mattress, not just your neck) 6-10 inches.  You can also try sleeping on your left side, which works better with your anatomy.

What about Acidic Foods?  Or, the Mystery of Tomatoes: Solved!

 People with reflux are often advised to avoid acidic (tart) foods like tomatoes, citrus, and raspberries, on the basis that acid is “bad.”  On one hand, that sort of makes sense.  On the other hand… the amount of acid in a tomato is a drop in the bucket compared to a healthy stomach.  So when you think about it, tomatoes really shouldn’t matter. 

 Except they do.  For a lot of people.  For a long time, I was puzzled by this.

Turns out, there’s a new theory which explains this, and it makes a lot of sense.  The idea is, acid isn’t even the culprit, but rather the protein-digesting enzyme pepsin.  The stomach produces both acid and pepsin, and both are washed up in reflux.  When acid washes up, you can wash it right back down with a glass of water.  However, when pepsin washes up, it sticks.  It gets lodged in the tissues of the throat, especially the larynx, and stays there for days.  It erodes delicate tissues and depletes natural defenses.  You don’t need to bathe in pepsin 24/7 to give yourself LPR.  You just need an occasional splash.

Now, here’s where the tomatoes come in.  Acid activates pepsin – and it stays activated until something alkaline comes along to turn it off.  Alkalinity deactivates pepsin – and it stays deactivated until something acidic comes along to turn it on again.  So back to our acidic tomato, even though it might not make a difference in the actual stomach, it sure makes a difference on its way down. 

If you’ve got pretty severe GERD or LPR (especially LPR), you’re going to want to avoid acidic foods for a while.  Many people who do, and who benefit from it, will find they can eventually reintroduce acidic foods without trouble – sometimes months down the road.  It takes a while to heal.

We’ll talk about alkaline water, herbal and nutrient interventions next month.

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