The notion of “silent reflux” implies the fact that the disorder does not necessarily trigger the occurrence of symptoms. For this reason, it is difficult to diagnose.
Not only does the patient show little to no signs, but it can take a long time for the acid to damage the esophagus before one can notice that something is wrong.
How Does the Silent Acid Reflux Take Place?
The burning sensation we feel every now and then is totally normal when it happens once a month. Repeated exposure of the esophagus and the superior throat area to the acid can lead to severe medical conditions. Population-based studies[1] conducted by the U.S. experts show an increase of up to 4% per year ever since 1976 in the number of patients with either LPR or GERD. Moreover, silent acid reflux was proven to be an active factor[2] in the onset of esophageal cancer.
Frequently, people tend to either mistake one for the other or make no difference between the two whatsoever. Here is the thing with LPR: whereas it can attack the esophagus multiple times before affecting it, it takes much less time for it to wreak havoc on the larynx.
No wonder the silent acid reflux is related to a plethora of laryngeal diseases such as vocal nodules, granulomas or laryngeal cancer.
Esophagus and Larynx, the Main Affected Areas
The esophagus has certain anatomical-functional features that differentiate it from the body’s other organs. It is a muscular tube having a length of 22-26 centimeters, with a superior orifice that is closed by the lower pharynx constrictor and a lower orifice, the sphincter, which separates it from the stomach. The esophagus’ lining is covered by a well-vascularized stratified epithelium. Generally seen as a resistant structure, it can easily be attacked by caustic, alkaline or acidic substances. Damage to the lining due to prolonged contact with stagnant foods leads to scarring. The lesions can provoke acute inflammation and subsequent emergence of conditions like chronic, purulent or mycotic esophagitis.
The larynx is a cavitary organ located in the anterior part of the neck. In the upper portion, it communicates with the pharynx while in the lower one is connected to the trachea and esophagus. It consists of nine cartilages, three unpaired and six paired. They are connected by ligaments, membranes, and muscles that allow the larynx to open or close either one of its extremities. In normal conditions, the three elements act as a valve which prevents the passage of substances from one organ to another if they prove to be harmful to the respective body area.
For the most part, the processes taking place inside the organism follow strict rules. The food is chewed, swallowed, and then digested. From a functional point of view, the gastric mucosa produces, on the one hand, the mucus that forms a protective coating on its surface. On the other hand, it secretes a particularly acidic gastric juice capable of digesting the ingested food. The liquid is combined with albuminoid substances, pepsin, labferment, and lipase.
Stomach disorders are quite numerous, being caused by infections, food poisoning, overeating or injuries of the nearby organs. Gastrointestinal issues also cause serious damage to the body, especially to those organs placed in the upper body. When there is an excess of gastric juice, the valve connecting the stomach and the esophagus opens, allowing the passage of the fluid. Usually, the side effects are diminished due to numerous factors such as the lower and upper esophageal sphincters, saliva or gravity.[3]
However, it appears that in the case of LPR and GERD, the leakage of stomach content is eased by the falling of these barriers. The esophagus with its strong lining is the more resistant portion. Recent data[4] shows that it is capable of producing bicarbonate with which it can neutralize acid following an episode of gastric reflux. On the contrary, the larynx does not exhibit the same properties. In one study[5] conducted on pig laryngeal mucosa, specialists have shown that the cells were prone to damage, although only at a pH 4.0 which contained pepsin.
We fully feel the consequences of a copious meal on the esophagus in the form of gastric acid that leads to the infamous heartburn. But this is not the case with the larynx. Given that the gastric juice rarely reaches the superior digestive tract, we would be inclined to think that the larynx cannot be affected. Even when this happens, we do not worry too much because there are no visible effects telling us that something is wrong. Still, this is what doctors warn us about.
The lack of symptomatology allows things to unfold without us knowing to what extent. This is the danger behind LPR, and the reason why it is called silent acid reflux. Unfortunately, most people suffering from it are either misdiagnosed or cannot receive a clear answer due to an absence of classical GERD signs. Moreover, the majority of possible patients do not know what medical specialist to consult in order to get a clear diagnosis. An otolaryngologist, involved in the treatment of the throat and sinuses, is probably the best option when it comes to LPR.
Who Is Prone to Suffering from Silent Acid Reflux?
Generally speaking, every person who does not care about the food they eat or live a chaotic lifestyle, has a higher risk of suffering from LPR at some point. There are however certain groups slightly more sensitive. They include:
- People with diets high in processed sugars and saturated fats
- Individuals who smoke and drink alcohol in excess
- People who have deformed or malfunctioning esophagus sphincters; also, those with slower digestion
- Overweight persons
- Pregnant women
Data reports that one in five children suffers from LPR. This might happen because their sphincter muscles are still developing, thus weaker than an adult’s. Childhood-related obesity[6] is another causative factor. Kids with Chronic Otitis Media seem to be a target group[7].
Causes of Laryngopharyngeal Reflux
Whereas half of the LPR patients also suffer from GERD, the two conditions are relatively different in symptomatology. A disturbance in the protective mechanisms of action or the amount of acid produced is involved in the acid reflux pathology.
Malfunctioning Sphincters
A weak lower esophageal sphincter (LES) has been noticed in most patients, but experts tend to believe that a dysfunctional sphincter system in all its totality (upper and lower) is the underlying cause.
LES is a circular muscle segment which connects the esophagus and stomach. Its role is to relax and open up the moment food arrives at the stomach’s entrance; it also functions as a protective barrier against gastric acid. Research concludes[8] that nitric oxide is responsible for inducing the opening-closing movement. Impaired nitric oxide action leads to achalasia, which occurs when the sphincter’s motor function is inhibited. Additionally, dysfunctions at this level can trigger GERD which brings about the heartburn sensation.
The thing with the lower esophageal sphincter is that the more it is used, the weaker it gets. When this happens, it is much easier for the stomach acid to penetrate into the upper areas. From here to affecting the larynx is but a step.
One study[9] suggests that high-intensity exercises coupled with drinking water might reduce LOS symptoms in healthy individuals who show signs of GERD.
With regard to the upper esophageal sphincter (UES), its function is to prevent air from entering the esophagus during breathing and impede the gastric acid to reach for the larynx or even pharynx. In LPR patients, repeated attack of the gastric acid on the muscular tissue leads to looseness. Because the elements of the respiratory system are much more sensitive than those of other bodily functions, they could be severely harmed by an acid quantity that would cause no damage to the esophagus.
The Gastric Acid
Direct exposure of the larynx to the acidic contents of the stomach showed injuries at a cellular level and was deemed as the number one cause of LPR. Research points towards two other factors, namely pepsin and bile acid, that have an equally disastrous effect. The human stomach acid has a pH with values between 1.5 and 2, which makes it a good ally in the digestion process.
Scientists have stated that in spite of its effectiveness in this domain, an acidic pH is generally harmful[10] to the body, constituting a favorable onset for disease development. The larynx and pharynx, on the other hand, are neutral, with a pH value around 7. Evidence suggests that it takes no more than a couple of exposures for the damage to occur in such an alkaline environment. There are voices who claim that the acid is rather ineffective unless paired with pepsin[11], the enzyme which breaks down proteins. Pieces of information link the bile acid with a higher incidence of LPR. In one project conducted on rodents, taurocholic and chenodeoxycholic acids, both derivatives of the bile ones, caused laryngeal inflammation[12] in pH 1.5 to 7.4.
Pepsin
In the silent acid reflux pathology, pepsin seems to be the one to blame for the lack of symptoms. Data indicates that whereas gastric acid alone might travel all the way to the larynx, it loses its power and cannot do much harm when it is up there. However, when pepsin was found in its composition, experts have observed[13] how the enzyme had the capability to remain stable at a pH of 7.4, which is little over the larynx’s natural pH. Moreover, there is evidence showing that pepsin can decrease the organ’s alkaline properties, and can be reactivated at any time, provided it remains in a pH lower than eight (a value at which it becomes inactive).
In one study[14], pepsin was found in the intracellular tissue of nineteen patients diagnosed with LPR. One trial[15] pinpointed the connection between pepsin activity and inhibition of protective proteins such as carbonic anhydrase or E-cadherin.
Symptoms of Silent Acid Reflux
To detect the symptoms of a disease that is popular precisely because of the lack of signs has proven to be a challenge for specialists over the years. Laryngopharyngeal reflux is sometimes mistaken for GERD about which much more information is known in regards to its cause or manifestation. One study[16] made the distinction between the two showing that whereas common symptomatology was a fact, the number of patients exhibiting signs of both conditions was rather insignificant. Diagnosis based solely on certain marks can lead to unclear results. In a 2010 project[17], specialists have noticed how GERD and silent acid reflux can mimic the symptoms of asthma, hence the misdiagnosis.
We have listed below the main LPR signs which a person suffering from the condition could easily notice:
- Excessive throat clearing
- Hoarseness
- Chronic cough
- Globus pharyngeus ( also known as the “lump in the throat” sensation)
- Difficulty in swallowing
- Shortness of breath
- Snoring
- Bad breath
- Excessive belching
- Airways with excessive mucus
- Regurgitation
- Change in voice
- Nausea
- Sleep apnea
- Tooth decay
- A higher risk of infection
Belafsky et al have created a questionnaire with nine questions. The minimum score was 0, and the maximum was 45. Surveys involving possible LPR patients indicated that the set of questions was reliable in that it could identify both the symptoms and those suffering from laryngopharyngeal reflux.
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Silent Acid Reflux Diagnosis
In most cases, the process is aggravated by the fact that the reflux does not attack a single area of the body. Unlike GERD whose primary target is the esophagus, LPR appears to damage the tissues of the esophagus, larynx, and pharynx. If not treated in time, the acid may also target sinus involvement. For this reason, people try all sorts of things, from going to a gastroenterologist to an otolaryngologist and even a pulmonologist. Lacking a distinct medical specialty, LPR might be even more dangerous. Not knowing who to consult first, the suffering one could prolong and even aggravate his state. Additional evidence suggests the existence of two mechanisms of action:
- When the acid escapes the stomach, goes upward and returns after reaching for the esophagus’ superior area (in this case the larynx’s neutral pH might be involved)
- When the reflux takes place repeatedly, and there is long-drawn contact with the mucosa (in most LPR cases)
When it comes to diagnosis, there are currently some effective methods that specialists are actively using.
Laryngoscopy
Recent technological advancement has made possible the recognition of inflamed areas within the pharynx. An improvement in video technology led to the identification of erythema and edema in the affected posterior areas, and their association with LPR. The swollen membrane in LPR patients led to the subsequent discovery of granulomas and contact ulcers. Additionally, a connection between silent acid reflux and cancer has been made, but data remains inconclusive for the moment.
Direct laryngoscopy is a method often employed in checking the airways. Nonetheless, there are times when the procedure fails. Moreover, there have been mixed opinions in regards to the veracity of a final diagnosis given that most doctors are subjective in accordance with their medical specialty. For this reason, Belafsky et al have created another type of questionnaire, for specialists this time. It consisted of the identifying of 8 main elements that are to be found in LPR patients. The factors varied from the more common excess mucus in the larynx to granuloma and subglottic edema.
In spite of a potentially high rate of success, laryngoscopy might not be the most effective method. In a study, a high incidence of LPR-specific symptoms was also seen in healthy individuals. Misdiagnosis can imply the recommendation of inappropriate or unnecessary medical treatments in persons with no health issue.
In spite of certain benefits, laryngoscopy could become a source of failure unless coupled with additional investigation.
pH Monitoring
Diagnosis of LPR is often time obtained via symptomatology description. There is controversy around this method, but in the absence of better tests experts often resort to the simplest and best known way. In the last decade the pH level measurement for LPR suspected patient has seen a higher number of studies.
Research asserts that silent gastric acid occurs when the pH level in the larynx and nearby organs decreases to 4. Both gastric acid and pepsin are capable of affecting them in such an acidic environment. In one project, one hundred and seventy patients were divided into two groups and given either a proton pump inhibitor treatment (PPI) or treatment based on a 24-hour oropharyngeal pH monitoring. The latter showed improved lifestyle and better response to medication.
Analysis of sixteen studies conducted on a 12-year period showed a difference in symptoms between healthy individuals and those suffering from LPR. On the other hand, examination of another eleven studies pointed toward a lack of differentiation in signs.
The results of a 24-hour probe consisting of laryngeal cell exposure to acid remain inconclusive. LPR diagnosis based on pH monitoring is not fully reliable at the present moment. Addition of multichannel intraluminal impedance therapy could improve diagnostic accuracy.
Medical Condition Associated with LPR
Physiological testing, as well as control studies, have correlated silent acid reflux with a plethora of diseases. Management of LPR might lead to symptom alleviation and improved living standards.
Role in the Onset of Cancer
Laryngeal cancer is a common form of carcinoma, often diagnosed in men between 40 and 70 years of age. While there is a great deal of controversy around its pathology, smoking, alcohol and virus infection have been deemed as main causes. LPR is a significant risk factor in laryngeal cancer. Association with carcinoma in the larynx was proven by some studies. The earliest one dates back to 1960 when two scientists have shown that constant interaction with reflux acid causes malignant structures.
Evidence suggests that most patients with silent acid reflux suffering from laryngeal cancer are neither avid smokers nor alcoholics. A study on twenty-nine cases indicated squamous cell carcinoma in all individuals, with the glottis and supraglottis as affected areas. In the same project, the cancer group was tested alongside with a control group consisting of three hundred healthy persons who showed signs of LPR. All subjects were monitored for 24 hours, during which time their pH was measured. Laryngopharyngeal endoscopy was performed on the models. Results pinpointed that the control group showed a lower predisposition to the effect of gastric acid, and decreased prevalence of developing laryngeal cancer.
In another clinical trial, forty adults with either dysplasia, T1 or T2 carcinomas underwent a 24-hour pH monitoring. Findings suggested an 85% incidence of LPR symptoms and a lack of heartburn in most subjects. Most people have felt the distinctive signs when placed in an upwards position.
Involvement of pepsin and laryngopharyngeal reflux as determinant factors for cancer in the larynx was confirmed by data made public in 2013 by the American Cancer Society. Around 12.000 cases were estimated at that time. Pieces of information mention that chronic inflammation in the larynx’s’ area leads in time to DNA damage and cancer cell proliferation. Moreover, due to its nearness to the esophagus, it appears that spreading might be just a matter of time.
Invasion of the surrounding tissues is eased by a lack of protection mechanisms in the case of the larynx such as bicarbonate production. Regarding pepsin, the organ reacts to it by increasing the number of proinflammatory cytokines which are associated with cancer cell proliferation and disease progression. Reflux events occur more often in patients with vocal cord leukoplakia and early glottic cancer.
Silent Acid Reflux and High Blood Pressure
Heartburn and reflux can be very distressing and impede one from living life to the fullest unless treated. However, reflux alone seems to do so much more damage in that it can constantly attack the inner organs without the affected one having any idea of what is going on.
Reports show a possible link between LPR and blood pressure. Whereas the two affect different body parts and act in a distinct manner, they are triggered by the same element: stress. Poor digestion as well as higher blood pressure have been deemed as results of exposure to stressful circumstances. Research implies that treating one might end up with helping the other as well. In one study, experts have assumed that frequent contact of gastric acid with the superior areas of the stomach leads to cardiovascular disease. Starting from this hypothesis, they tested eighty-six hypertension patients to see if manifestation of LPR symptoms was visible in any of them. About 14% of them saw synchronicity in the symptomatology of the two medical conditions. Administration of antiacid medication brought about an improvement in the general state.
According to another report, thirteen healthy male volunteers were tested to see the effect of anti-hypertensive drugs on esophageal contraction. Researchers believe that impaired esophageal function allows the gastric acid to be refluxed up through the esophagus and reach for the larynx, pharynx and even the oral cavity. Analysis of the subjects suggested that administration of a beta-blocker improved esophageal muscle action.
LPR Might Cause Back Pain
More recently, LPR has been named as a potential, although minimal, cause for back pain. Things do not necessarily go the other way round, with back trouble not being a common symptom of silent acid reflux. Most people with LPR have no problems whatsoever with that body area. Nevertheless, pieces of information imply that the reflux can induce a state of unhealthiness and ill-being in some individuals. This does not happen as the result of damage produced to the muscle tissue. Better said, it is the esophagus inflammation that which determines the painful sensation. That is why in the cases where these two conditions coincide, people confess feeling pain in the upper back.
Discomfort in the space between the shoulders might be caused by the standing position as well. The majority of people who have trouble with acid reflux sit in a vertical posture for extended time periods. This could be an element of distress.
Sensitivity of the Throat
The throat is easily one of the most affected areas of the body when it comes to the action of gastric acid. Being in direct connection with the esophagus, damage to this level is easily understandable. Advances in LPR diagnosis and mechanism of action link the impairment of the two esophageal sphincters to throat sensitivity. This causes numerous other complications such as difficulty in swallowing, a sour taste in the mouth or the feeling that something is stuck in the esophagus. The burning sensation usually felt in the chest can reach for the larynx as well. This could impede the eating process or make it disturbing.
Dry Mouth and Dental Erosion
In terms of dental erosion, the process is a long one and can last for several years before affecting the teeth in a visible manner. Tooth decay is mainly coupled with sugary drinks. A secondary factor is the gastric acid that sometimes reaches the oral cavity and induces enamel erosion. The acid’s corrosiveness is potent enough for it to attack the protective coating.
In one study, 112 children were placed in two groups, namely LPR patients and healthy individuals. Both groups went evaluation via GERD questionnaire, endoscopy and pH measuring. The conclusions were the following:
- 53 out of the 54 patients with acid reflux symptoms had dental erosion
- Only 11 out of the 58 healthy kids had teeth problems
- pH monitoring worked better than laryngoscopy
Another research conducted by specialists from the University of Oslo stated that individuals aged 18 and older with tooth decay have higher chances of being diagnosed with LPR. A decreased saliva production and the feeling of having a dry mouth are often times associated with LPR. Smoking, which contributes to the gastric reflux as well, can aggravate the issue. Damage to the salivary glands can also be related to chemotherapy.
LPR and General Nausea
Gastric acid might influence induction of nausea-related symptoms such as vomiting, dizziness or physical weakness. A common element in LPR patients is regurgitation. When this happens, a feeling that something remained stuck in the throat might occur. In some situations, the feeling can lead to vomiting. Certain foods such as the greasy ones, red sauces, chocolate or alcohol could trigger the sensation. People with bulimia could suffer from LPR as they follow a binge eating-purging pattern which increases the quantity of acid present in the esophagus and oral cavity.
Acid Reflux in Pregnancy
Morning sickness affects most of the soon-to-be mothers. The concept, also known as “nausea gravidarum” or “nausea/vomiting of pregnancy” is a set of symptoms that many pregnant women deem as something normal, and which tends to vanish as soon as the person in question enters the 12th week of pregnancy. When a woman is pregnant, the amount of progesterone found in her body registers a rise, as to offer the baby an environment safe for him to grow in. High levels of this hormone are meant to make the uterus’ muscles more relaxed as to provide the child with more space for him to grow in. Unfortunately, progesterone works in more ways than just one, and can even relax the stomach and intestines, as these organs are found in the uterus’ proximity. As a result, there is an increased release of gastric acids which in turn influences the gastroesophageal reflux and make the pregnant one want to vomit. As in the case of progesterone, during pregnancy, the woman will see an increase in estrogen quantity as well. There is information according to which the hormone levels are up to one hundred times higher in pregnant women than in those who are not. Research projects show that this specific hormone stimulates the production of nitric oxide which in turn relaxes the stomach muscles and increase the chances of gastroesophageal reflux.
Some studies indicate that women who are more prone to breaking down in stressful situations will usually experience nausea and a feeling of sickness that does not occur only in the morning, but can be felt at any point throughout the day.
Negative Impact on Irritable Bowel Syndrome
Statistics show that the regular individual carries 5 to 20 pounds of waste material in his colon. This aspect is worrisome given that harmful toxins thrive in these conditions. Numerous factors such as stress, poor diet, low water intake or drug addiction contribute to the overall damage.
Sadly, the symptoms of a toxic colon are often overlooked or mistaken for those of other diseases. Acid reflux plays an active part in the irritable bowel syndrome, thus affecting the colon and its well-functioning. 1476 patients with gastrointestinal dysfunction took part in a project whose purpose was to show overlapping of IBS and acid reflux symptoms. The results met the study’s purpose, with 63,3% of the IBS subjects exhibiting signs of gastric acid reflux. A weakening of the colon muscle’s function in LPR patients can cause either constipation or diarrhea. Muscular tissue movement can be worsened if the condition remains untreated. There is evidence according to which the gastrointestinal tract’s lower part is more easily affected by the acid’s presence in the upper tract when there are other factors such as stress or bacterial infection involved. LPR is associated with indigestion and bloating as well.
Silent Acid Reflux and Coughing
Irritated airways can cause coughing due to a difficulty in swallowing or a sensation that something blocks the throat.
According to a study made public by the University of North Carolina School of Medicine, acid reflux is responsible for about 25% of all cases of chronic cough. Moreover, higher coughing incidence is a fact in LPR patients. Most of them experience reflux of non-acidic content which means sour taste or heartburn might be absent. An inflamed larynx can also cause hoarseness and impede talking. Further organ lesion could cause granulomas that are very much alike to laryngeal carcinoma. Importance of coughing as a sign of LPR cannot be minimized.
LPR Might Cause Shortness of Breath
An even more dangerous facet of gastroesophageal reflux is its property to penetrate inside the lungs. Shortness of breath, also known as dyspnea, occurs when the airways become swollen due to the acid’s effect. Affected people can experience severe respiratory complications. LPR might endanger their lives to an ever greater extent as the acid acts especially during the night when people are lying down. Bronchospasm and aspiration during one’s sleep could be life-threatening.
The reflux involves the chest area as well. Non-cardiac pain due to esophagus inflammation was noticed in subjects with both LPR and GERD. A burning sensation is a common complaint among patients.
Specialists believe that silent acid reflux could mimic asthma symptoms. Data suggests that LPR is a common condition in asthma patients. The exact connection between the two remains unclear, but it seems that they trigger each other. From one point of view, acid reflux affects the airways whose dysfunctions are associated with higher asthma prevalence. From another one, asthma patients are more likely to suffer from acid reflux as stated in a study of the American Lung Association Asthma Clinical Research Centers.
Can Reflux Acid Cause Heart Palpitations?
Whereas there is not enough data on the subject, the existing one does not necessarily link silent acid reflux to heart palpitations. Factors such as caffeine, nicotine or stress have been more extensively studied in regards to this sensation. Still, LPR might play a role in regards to this condition in that it causes chest pain which people could easily mistake for heart issues. Additionally, reflux acid is a stress factor so it might be involved in the process, albeit to an insignificant extent.
Connection to Headache
Evaluation of forty three thousand individuals showed that people suffering from LPR or GERD were more likely to suffer from headaches. Moreover, the majority of those involved in the study have noticed a worsening of migraines when heartburn occurred. In 2011, Reuters Health made public a study in which cases of children with abdominal pain have been investigated. Whereas an exact cause was hardly determined, specialists concluded that the physical discomfort was likely caused by abnormal cell activity at the brain level. Irregular pathway modulation might have led to changes both in the brain and gastrointestinal tract. Lately, the latter was given a suggestive name- “the second brain“. It was revealed that most of the cells in the intestinal tract lining are capable of transmitting information to the brain and trigger neuronal activity.
Postural Orthostatic Tachycardia Syndrome, or simply POTS, is an autonomic disturbance characterized by too little blood circulating towards the heart when one is moving from a lying to a standing position. Common symptoms include headaches, heart palpitations, and digestive issues. In spite of little evidence on the subject, POTS could be another underlying factor for silent acid reflux. By affecting the nervous system, it could induce stress which is yet another factor involved in LPR.
Allergic Reactions Could Be Mistaken For LPR
Silent acid reflux mimics symptoms of various other diseases, and that is why it is so hard to diagnose. It can also have common signs with different allergies. The most common is that with eosinophilic esophagitis (EOE). Usually determined by pollen inhalation, EOE irritates the lining of the esophagus. People with this kind of allergy suffer from chronic coughing or experience an irritated throat sensation. Heartburn, although not that regular, can occur.
Some people complain that food allergies, besides that they can affect the stomach and trigger LPR, might also cause an itching sensation in the abdominal area.
Silent Acid Reflux and Weight Loss
A smaller number of kilograms is not necessarily related to damaging gastric acid activity. It is true that LPR can affect the digestion process, and lead to either constipation or diarrhea. In addition, the acid reflux could be a hindrance to daily nutrition in the sense that one can no longer eat and drink whatever he or she wants. Regarded from this point of view, weight fluctuation might be a fact in LPR patients, but not as a result of the gastric acid action in the body. Rather, it is the dietary changes such as excluding fats, sweets and alcohol from the usual lifestyle those that make the difference.
On the other hand, pieces of information show connection between LPR and obesity. 1659 patients with acid reflux symptoms were selected for a study. After a 24-hour esophageal pH monitoring it was reported that the higher the body mass index in subjects, the more aggressive the acid’s activity. Dysfunction at the lower esophageal sphincter level was also noticed.
Can Silent Acid Reflux Kill You?
If left untreated for a long period of time, LPR could cause irreparable damage to the body. However, no deaths were reported with gastric acid action as main cause. Most likely, they occurred due to esophagus or larynx cancer. Despite these issues, living with LPR might prove to be a real challenge. Another aspect which has gained more attention lately is LPR’s role in Barrett’s esophagus disease occurrence. The medical condition implies abnormal changes at the level of the cells lining the esophagus, increasing the risk of esophageal adenocarcinoma. Whereas there are small or rather inexistent chances that one will die from silent acid reflux alone, the day-to-day difficulties might make life less enjoyable.
Silent Reflux in Newborns
Newborns do not have a good digestive system when they come into the world. Although its functions are already well established, the digestive tract becomes stronger with the passing of time. Exposure to new foods develops it, allowing the baby to benefit from optimal health. Many newborns spit up soon after they are fed. This is a common thing, and usually happens when they eat faster or more than their stomachs allow them to. They tend to stop regurgitating around twelve months of age. Nonetheless, parents should worry in situations where:
- Spitting is frequent
- They show visible pain signs such as uncontrollable crying or arched back
- They cough or try clearing their throats rather often
- The babies vomit, have fever or diarrhea
- They do not gain weight (food refusal)
A small percentage of babies can suffer from silent acid reflux. They are more prone to its negative effect due to weaker protective mechanisms. Diagnosis in newborns is equally challenging as LPR symptoms overlap with those of food allergies. Complications such as anemia, breathing issues or even pneumonia can occur.
Triggering Foods for Silent Acid Reflux
Dysfunctions in the esophagus sphincter and a possible genetic predisposition are studied as main LPR causes. Leaving the two aside, there is considerable evidence which links consumption of certain foods with laryngopharyngeal reflux. A chaotic lifestyle with late night snacks, high-fat foods, sugary drinks, alcohol or nicotine increases the risk of suffering from silent acid reflux.
Here is a list of foods and substances to avoid:
- Alcohol
- Tobacco
- Soft drinks
- Citrus fruits (lemon, orange, grapefruit, limes)
- Tomatoes
- Onion and garlic
- Spices
- Foods high in saturated fats
- Dairy products
- Chocolate
- Sweets
- Fried foods (potato chips, chicken wings)
- Tea (due to caffeine content)
If one cannot completely abstain from any of them, then he or she should try to eat them only rarely.
Other Factors
Silent Acid Reflux can be provoked or worsened by the following:
- Tight-fitting clothing which puts pressure on the abdominal area. Stomach squeezing can in turn lead to its acidic content backing up the esophagus
- Badly-timed physical exercise, usually within two hours after a copious meal when digestion is in full process
- Laying down after eating, a main cause of acid reflux during the night time but that can be just as harming during the day
- Weight gain that puts extra pressure on the entire body but which tends to gather in the belly area
How Long Does LPR Last?
There is no information available on how long the silent acid reflux lasts. The time period is connected to and influenced by various factors such as:
- Genetics
- Inner organ dysfunction
- How early or late the diagnosis was established
- Diet and lifestyle
- Effectiveness of the treatment
- Other existing medical conditions
Generally, it takes a few months until the affected one starts noticing specific signs. A diagnostic can be offered sooner or later, depending on the used technology. Also, another time interval is required for the patient to adapt to the treatment and see how well he responds to it.
Some newborns as well are prone to feeling the consequences of gastric acid action. Medication is used only in serious cases. Most babies grow out of LPR by eight months.
How To Treat LPR?
At present, silent acid reflux treatment consists of dietary restrictions and lifestyle changes such as quitting smoking and alcohol, losing weight or avoiding the habit of eating until late at night. All these are most of the times coupled with medical treatment. Still, the drugs used depend on the patient’s physical condition, and how affected the upper part of the digestive tract is. Some people with LPR exhibit minor symptoms such as throat clearing, whereas others are suspected of laryngeal cancer.
PPIs
Clinical evidence suggests that the use of antacids is the safest and most effective medication for LPR known to this date. It was demonstrated that proton pump inhibitor administration (PPI) provides relief from heartburn and a plethora of other LPR symptoms. Pharmacological data have shown that a twice a day PPIs administration for a period of at least three months had therapeutic value in many of the cases. Treatment could be prolonged depending on the severity of the situation.
However, in the recent years there has been increasing controversy around the proton inhibitors. In spite of evident short-term effect, the long-term complications might be of higher importance. PPIs are a class of antiacids with role in inhibiting certain enzymes in the gastric acid. While their effectiveness cannot be doubted, new opinions have come to the surface in regards to side effects. It seems that after extended exposure, the body starts reacting to PPIs the way it would to inflammatory agents. In the stomach area it increases the number of chemical messengers responsible for acid production. In addition, skipping just one day of treatment might end up with LPR symptom resurfacing.
As a rule, PPIs work better when coupled with an H2- blocker. A three-month therapy should suffice for the patient to see an improvement in the general state. If this is not the case, new investigations are necessary.
Recommended medication includes:
- PPIs: rabeprazole, esomeprazole, lansoprazole, omeprazole and dexlansoprazole
- H2 blockers: Pepcid, Tagamet, ranitidine
- Gastroprokinetic agents such as Bethanechol or Domperidone (complications at the heart and large intestine levels might occur)
Drug use in newborns and children with reflux acid happens only in severe cases. Pregnant women could use Tums or Maalox if they deal with LPR. Nonetheless, as these two groups are more sensitive to the side effects of medical treatments, it is compulsory to consult a doctor beforehand. Self-medication could prove to be fatal.
Surgery as Option
Laparoscopic fundoplication is a well-known and debated surgical treatment for people with GERD. Success rate in the case of LPR patients, although small, is a fact. Researchers suggest that the surgery might be helpful in individuals with both laryngeal and GERD symptoms. Those with silent acid reflux alone may have lesser opportunities to be treated in this way. The surgery is labeled as inappropriate and possibly ineffective in people with resistance to PPIs. One study showed little to no difference between a group reluctant to PPIs action and one that went on with the usual therapy.
What Foods Help With Gastric Reflux?
Experts think that a well-rounded diet consisting mainly of fruits and vegetables is a great help in preventing and even treating LPR. The property of these food groups to be alkaline helps the body deal better with the acid in the stomach and can inhibit the reflux process. People with LPR should eat more of the following:
- Fruits: avocado, banana, mango, berries, pears, pineapple, plums, watermelon
- Most vegetables except for tomatoes, garlic and onion
- Meat: turkey, lean ground beef, skinless chicken breast
- Seafood: shrimp, lobster
- Dairy: low fat milk, plant-based milk (soy, rice, almond), soy cheese, plain yogurt
- Egg whites
- Licorice
- Baked vegetables
- Chewing gum
Gastric acidity can easily be controlled if we include these foods in the daily diet. Certain tea that doesn’t naturally contain caffeine-like compounds can reduce the acidity of the stomach. The most popular ones are the fennel, star anise, coriander, ginger or chamomile ones.
Changes in Posture Can Help LPR Patients
Gastric acid affects the upper area of the intestinal tract no matter how someone is sitting. The symptoms appear anyway and are disturbing, whether they do it to a greater or lesser extent. However, when the body is laid horizontally, LPR manifests quicker. Changes in posture, especially during the night time when we tend to sit in the same position for hours might be more than welcome. Also, the larynx and esophagus remain without one of their protection mechanisms as there is less activity in the salivary glands. Randomized projects have shown that when the head is placed a few inches above the chest level there is decreased esophageal acid exposure. Moreover, reflux periods became more and more rare as time passed.
The Power of Probiotics
Probiotics are bacteria naturally occurring in the human body, with the biggest number being in the gut. They are also found in yogurt, pickled vegetables or soy cheese. A multitude of probiotic supplements can be found in drug stores. Two of its most important roles are attacking harmful bacteria and healing the affected area. In people with silent acid reflux they might provide relief from IBS and improve digestion which are some of LPR’s underlying causes. While there is not enough evidence on the subject, the existing one suggests they may prevent stomach ulcers from forming and impede bad bacteria growth.
Conclusion
Silent Acid Reflux is a serious medical condition which, when left untreated, can harm the body in unimaginable ways. Whereas similar in symptomatology with GERD, LPR is a disorder of its own. Enough pieces of information on its manner of action are provided to the general public. Management through lifestyle and dietary changes, medication or surgery has been a success in many cases. Evolution of antiacid therapy and pH monitoring might play key roles in treating LPR in the near future. New diagnostic methods, as well as additional research, are more than welcome in a field of medicine that requires so much more attention due to an involvement of vital organs in the disease’s development.
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