Gastroesophageal Reflux Disease (GERD) - Laryngopharyngeal Reflux (LPR) - Extraesophageal Reflux Disease

Gastroesophageal and Laryngopharyngeal Reflux

Gastroesophageal Reflux Disease (GERD)

Gastroesophageal Reflux Disease (GERD)

Gastroesophageal reflux disease (GERD), stomach reflux disease or acid reflux disease is the leakage of stomach acid into the esophagus, upward from the stomach, and the resulting mucosal damage in the esophagus (esophagus).

Laryngopharyngeal Reflux (LPR) or Extraesophageal Reflux Disease

Laryngopharyngeal Reflux (LPR) or Extraesophageal Reflux Disease

Acid reflux disease is called laryngopharyngeal reflux (LPR) or "extraesophageal reflux disease" (EERD), causing signs and symptoms related to the larynx and respiration by escaping further up the stomach contents. Unlike gastroesophageal reflux disease, the heartburn is rarely seen and is sometimes referred to as "Silent Reflux".

This condition, which is often confused with chronic pharyngeal or thyroid diseases, can cause annoying and dry cough in the throat despite the use of long-term throat gargles or lozenges. Laryngopharyngeal reflux is more likely to occur in patients with a stressful work environment, irregular diet, laxity in the lower end of the esophagus, overweight than normal or with a larger than normal waist circumference, and sleep apnea.

Laryngopharyngeal Reflux (LPR)
Laryngopharyngeal Reflux (LPR)
posterior commissure hypertrophy 
interarytenoid thickening, pachydermia

In the above photograph, the inner part of the throat of the patient, who has a feeling of tearing and tingling when swallowing, is seen. The edematous mucosal area is seen in the "interarytenoid region", which means the arytenoid cartilages (posterior commissure hypertrophy, interarytenoid thickening), located just in front of the entrance part of the esophagus, behind the vocal cords. Being more white than normal is called "pachydermia" and is a sign of chronic gortal reflux. Patients describe this edematous area as "I can't remove solid sputum in my throat" or "I have a piece of bread and it doesn't come out of my throat."

You can see more details about Laryngopharyngeal Reflux (LPR) at >> Laryngopharyngeal Reflux (LPR)

Symptoms and Signs of Gastroesophageal Reflux Disease

Common Symptoms and Findings in Adult Patients:
  • A burning sensation in the chest or heartburn
  • Stomach contents coming into the mouth (Regurgitation)
  • Painful swallowing

More Rare Symptoms and Findings in Adult Patients:

  • Sore throat (odynophagia)
  • Increased saliva secretion
  • Nausea
  • Chest pain
In gastroesophageal reflux disease, acidic stomach contents that chronically escape into the esophagus cause damage to the esophagus. Injuries to the esophagus:
  • Reflux esophagitis - After damage to the esophageal epithelium near the junction of the stomach and esophagus, ulcers and necrosis may be seen.
  • Esophageal (esophagus) strictures - permanent narrowing of the esophagus due to chronic damage due to reflux
  • Barrett's esophagus - Changes in epithelial cells in the lower esophagus and intestinal metaplasia (transformation of the bowel into squamous cell epithelium)
  • Esophageal adenocarcinoma (a rare type of esophageal cancer that usually arises at the lower end of the esophagus)
The following symptoms and diseases can also be seen with Gastroesophageal reflux disease (controversy continues regarding the relationship of these diseases and symptoms with reflux, presented below):
  • Chronic cough
  • Laryngitis (hoarseness, throat clearing)
  • Asthma
  • Erosion of tooth enamel
  • Tooth sensitivity
  • Sinusitis
  • Pharyngitis
  • Globus pharyngeal and globus hystericus (choking in the throat, foreign body sensation)
  • Recurrent ear infections
  • idiopathic pulmonary fibrosis
  • Larynx cancer

Gastroesophageal Reflux Symptoms and Findings in Children

It is difficult to diagnose reflux in infant and child patients. GERD in children can cause other breathing problems such as recurrent vomiting, sputum production, coughing, and wheezing. Crying, bad breath odor, refusal to suck and belching can also be seen.

Diagnosis of Gastroesophageal Reflux Disease

For the diagnosis of GERD, pH monitoring, barium swallow X-rays, esophageal manometry and esophagogastroduodenoscopy are used. Currently, the gold standard in the diagnosis of GERD is pH monitoring. Besides being the most objective method to diagnose the disease; It is also used to monitor responses to medical or surgical treatment.

Clinically, improvement in symptoms after treatment with short-term proton pump inhibitors also supports the diagnosis of GERD.

Otolaryngologists can see the larynx area with the help of angled endoscopes from inside the mouth. During this examination, the area between the beginning of the esophagus and the larynx can also be examined. Edema and redness in the mucosa in the area at the posterior junction of the vocal cords (interarytenoid region) (edema in the interarytenoid region) is a symptom of reflux laryngitis. In chronic reflux laryngitis, epithelial hyperplasia occurs in this area and edema increases. This finding is called "Pacidermia".

Causes of Gastroesophageal Reflux Disease

Causes of Gastroesophageal Reflux Disease
The following reasons can cause reflux disease to occur:

- Obstructive Sleep Apnea Syndrome: during sleep breathing stops and excessive contraction of abdominal muscles puts pressure on the stomach and it becomes easier for acid to escape into the esophagus.
- Stressful lifestyle: acid production increases in the stomach due to stress hormones.
- Relaxation of the sphincter, which acts as a barrier between the esophagus and stomach (as in hiatal hernia)
Obesity: increased body mass index is associated with more severe GERD. With the increase in weight, the increase in fat around the waist may increase the pressure on the stomach.
- Zollinger-Ellison Syndrome: There is an increase in stomach acid due to the increased gastrin production.
Hypercalcemia: may cause increased gastrin production and increased acid secretion
- Esophageal Dysmotility: Movement disorders occur in the esophagus in diseases such as scleroderma and systemic sclerosis. Problems may arise in the transport of food to the stomach.
- Using drugs such as cortisone that can increase the production of stomach acid

Precautions for Gastroesophageal Reflux Disease

The following measures can prevent the occurrence of reflux disease or reduce symptoms.

- Measures related to sleeping position: Lying with a pillow under the back with the head and body together at least 30 degrees above the esophagus to be higher than the stomach level; Lying on the left side can also cause the stomach to descend lower than the esophagus level.
- Precautions regarding feeding time and amount: Eating large amounts of food and eating at least 2 hours before going to sleep should be avoided. Eating a small amount of food can reduce the amount of stomach acid secreted, and an empty stomach before bedtime will reduce the escape of ayst from the stomach to the esophagus.
- Dietary precautions: The consumption of acidic fruits, acidic fruit juices or other acidic beverages, fatty foods, coffee, tea, onion, mint, chocolate, alcohol, fermented drinks (beer and red wine) should be avoided. Consumption of these foods, especially before going to bed, can easily lead to reflux, as the stomach acid will be increased to make the body horizontal.
- Measures related to weight loss: Since reducing the body fat ratio will reduce the pressure on the stomach and the sphincter at the lower end of the esophagus, weight loss is very important in preventing reflux.
- Precautions regarding dressing style: It is important to avoid wearing tight clothes that tighten the abdomen and stomach area. Wearing this type of clothing, especially during sleep, can easily cause reflux due to being in a horizontal position (stomach and esophagus in line).
- Cessation of smoking: There are sources that smoking facilitates reflux. In particular, the effects of the lower end sphincter on decreased muscle tone and increased acid secretion in the stomach have been reported.

Treatment of Gastroesophageal Reflux Disease

Medical Treatment

Despite the implementation of the above-mentioned measures, medical treatment is primarily applied to patients whose complaints do not improve. Drugs that can be used in medical treatment of reflux:

- Proton pump inhibitors (PPI): It is the most effective drug group that reduces acid secretion in the stomach.
H2 receptor blockers: They reduce the acid secretion in the stomach.
- Alginic acid: It covers the mucous and decreases the mucosa damage by increasing the acidic pH.
- Prokinetics: They accelerate gastric emptying.
Sucralfat: They prevent the occurrence of damage in the esophagus.
Baclofen: They increase the low end sphincter tone at the junction of the esophagus with the stomach and may reduce acid leakage from the stomach to the esophagus.
- Antibiotics: Antibiotic treatment may be given to patients who have undergone gastric endoscopy and are suspected of having a role in the disease, where a Gram-negative bacterium called Helicobacter pylori (or Campylobacter pyloridis) is detected in the stomach.

Surgical treatment

Standard surgical procedure is "Nissen Funding Surgery". It is applied in the presence of hiatal hernia that does not respond to medical treatment or causes insufficiency in the lower esophageal sphincter. It is generally applied by laparoscopic method.

Nowadays, drugs are preferred instead of nerve cutting surgery that gives stimulus to stomach acid secretion called "High Selective Vagotomy", which was applied in the past when there was not such a wide variety of drugs.

Reflux Treatment During Pregnancy

Lifestyle and dietary changes have limited effect on reflux treatment during pregnancy. Reflux occurs due to the baby, which puts pressure on the stomach in the abdomen and increases in size. In this period, antiseptic drugs can be used.

Reflux Treatment in Babies

H 2 receptor blockers such as ranitidine can also be used in addition to feeding the baby with his head up, frequent and low feeding.

Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon - ENT Doctor in Istanbul

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