Jen Carter is a speech pathologist who has been treating adults with dysphagia for more than 25 years. She is a Board-Certified Specialist in Swallowing and treats patients at her clinic the Carter Swallowing Center in Denver, Colorado.
Reflux and difficulty swallowing
Almost every patient I see for swallowing therapy has a history of “reflux”. The term reflux means “backflow” and describes the cause of the symptom of heartburn. But there is more to reflux than just heartburn.
Gastroesophageal reflux disease (GERD) is when reflux from the stomach leaks backward to the esophagus (food tube from the lower throat to the stomach). Laryngopharyngeal reflux (LPR) is when the stomach contents reflux into the esophagus and then progress further into the larynx (voice box) and pharynx (food tube in the upper throat). While GERD and LPR are very similar in nature, the symptoms of these 2 conditions are actually quite different depending on where the reflux goes.
GERD: GERD is one of the most common medical conditions in the Western hemisphere, which has a lot to do with the diet and lifestyle of this culture. It is estimated that 44% of people experience some sort of esophageal reflux on a regular basis. The hallmark of GERD is heartburn, and if you’ve watch TV lately no doubt you’ve seen that there are numerous medications on the market for the treatment of heartburn and GERD. The diagnosis of GERD is made by a gastroenterologist who can determine which type of medication would be most appropriate for treating a particular patient’s symptoms.
LPR: When the acidic stomach contents reflux to the throat, significant damage can be done to the throat which includes the voice box (larynx), airway (trachea), and food tube (pharynx). The symptoms of LPR include hoarseness, excessive throat clearing or coughing, copious amounts of mucous, a feeling of a lump in the throat, and difficulty swallowing. LPR is often called “silent” reflux because the symptoms of this condition rarely include the heartburn that most people think of when they hear the term reflux. The reason that patients with LPR do not generally suffer from heartburn is that the reflux spends little time in the esophagus and actually does most of its damage in the throat. As a speech pathologist, I see many, many patients with the diagnosis of LPR and almost all of them are not aware that they have “reflux”. While the diagnosis of GERD is typically made by a gastroenterologist, a diagnosis of LPR is usually made by an otolaryngologist (ear, nose and throat doctor). ENTs and speech pathologists work together to manage LPR with patients who have the symptoms of hoarseness, throat clearing, and difficulty swallowing.
The Voice and Swallowing Clinic at UC Davis has developed a validated a 9-item Reflux Symptom Index (RSI) to assess the severity of LPR symptoms. A RSI score greater than 10 may indicate significant reflux.
Medical treatment for GERD and LPR: Even though the symptoms of these 2 conditions can be quite different, the treatments, which aim to reduce the backflow of stomach contents, are similar.
Some medications decrease the amount of acid produced in the stomach (proton pump inhibitors or PPIs) and some medications lower the amount of acid released in the stomach (H2 blockers). A gastroenterologist can determine which type of medication would be most appropriate for reducing the backflow of stomach acid for each particular patient.
Behavior treatment for GERD and LPR: When talking with my swallowing therapy patients that have been diagnosed with GERD and LPR, I emphasize that lifestyle changes related to reflux play a role equally important to medications in effective treatment of these conditions. Behavioral changes that I suggest as part of swallowing therapy include the following:
- Minimize caffeine, alcohol, and peppermint. These items relax the sphincter between the stomach and the esophagus which may allow more backflow of the stomach contents into the esophagus.
- Lose weight loss, if overweight
- Avoid foods that may incite more acid production or have a higher acid content: citrus, tomato, vinegar, high fat foods, olives and olive oil, nuts, dairy, and coffee
- Elevate the head of the bed 6-8 inches. The elevation needs to be a gradual angle rather than bending at the waist with extra pillows which can pinch the stomach and make the problem worse. There are bed frames can be purchased online that can create this gradual angle of elevation, or a less expensive option is to elevate the head of the bed 2-6 inches on both sides with wood blocks or bricks.
- Avoid eating 3-4 hours prior to lying down or sleeping.
- Avoid wearing abdominally restrictive clothing such as tight pants
- Eat smaller meals
More next time on “why are patients with LPR and GERD seeing a swallowing therapist?”….