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Since the Joan Rivers tragedy last summer, followed by President Obama’s sore throat and then Charlie Sheen’s hoarseness, acid reflux, traditionally thought of as a disease presenting as heartburn, is finally being recognized as a condition that can present not only with gastric type complaints, but also with throat symptoms.

Acid reflux occurs when acid in the stomach reverses flow and suddenly travels back up towards the esophagus and anatomically related structures including the lungs, vocal folds, mouth, sinuses and middle ear spaces. Since the esophagus lies between the spine and the trachea, connecting the head and neck to the stomach, it is uniquely positioned to be the vortex of problems related to caustic acid injury.

Here are 5 surprising facts you need to know about acid reflux disease:

  1. Acid reflux is one of the most common diseases in the world

Acid reflux disease affects about 30% of the Western world and in the United States alone it is estimated that 60 million Americans have acid reflux disease (1, 2). Unlike the acid reflux commercials of yore where an individual with a pot belly and male-pattern baldness is sitting on the edge of a bed complaining that he “ate the whole thing”, today’s acid reflux does not respect body type, age, gender or creed.

  1. Throat symptoms are potential ALARM symptoms

The traditional type of acid reflux disease is characterized by the symptoms of heartburn and regurgitation. However there is another type of acid reflux called “throatburn reflux” or LaryngoPharyngeal Reflux (LPR) where the primary complaints are throat-related such as a lump-like sensation in the throat severe enough to cause difficulty swallowing, or dysphagia (3). Other common symptoms are chronic cough, defined as more than 8 weeks of cough, hoarseness, frequent throat clearing, and sore throat. Because acid coming up from the stomach can swell and numb the adjacent esophageal tissues often those with throatburn reflux have no heartburn complaints, only throat complaints (4, 5). Therefore when you have persistent throatburn reflux symptoms it may mean that acid reflux has been going on unchecked for quite a long time, so you should have your esophagus examined (6, 7).

  1. Untreated acid reflux disease can lead to complications

Untreated, or insufficiently treated, acid reflux disease can lead to severe inflammation in the esophagus, lungs, vocal folds and throat which can cause esophageal ulcers, areas of esophageal narrowing called strictures, pneumonia, breathing problems and vocal fold polyps. In some cases, when acid reflux is ignored, or inadequately addressed, it can lead to esophageal cancer, the fastest growing cancer in America and Europe since the mid 1970’s (8).

  1. Events in the 1970’s led us to an acid reflux epidemic. How did we get here?

Legislative changes and food industry changes.

Legislative changes

In the mid 1970’s America’s Food and Drug Administration (FDA) introduced a law called Title 21 which mandated that any food in a can or a bottle needs to be acidified to act as preservative to prevent food poisoning (9). The unintended consequence was that food items we all thought exceedingly safe, are now actually harmful. For example, take a whole banana. The pH, or relative acidity, of a banana is near neutral, however, baby banana food, in a bottle, is about 100 hundred times more acidic than a whole banana (10).

Food Industry changes

The explosion of processed foods since the mid to late 1970’s has also contributed to the acid reflux epidemic (11). For example, SUGAR, went from more expensive cane and beet sugar to less expensive corn-based sugar, specifically high fructose corn syrup (HFCS). What’s the problem with HFCS? First of all, it has sulfuric acid in it, which is an extremely acidic substance (12). In addition, the chemicals used in the processing of the HFCS have the physiological effect of loosening the lower esophageal sphincter which is the muscle that separates the stomach from its adjacent organ, the esophagus, which then allows caustic stomach contents to rise unchecked into the esophagus and throat (13, 14).

Photo credit: Mustafa Sayed / Foter / CC BY
Photo credit: Mustafa Sayed / Foter / CC BY

Another example is SOFT DRINKS, specifically carbonated, sugary sodas. In 1975 soft drinks surpassed coffee as America’s favorite beverage, and we never looked back (15, 16). Soft drinks are the most acidic substances we consume, similar to our car’s battery acid (17).

  1. Diagnosing acid reflux disease can be done WITHOUT using sedation

There are two ways to examine the esophagus endoscopically when someone is suspected of having acid reflux disease, a traditional method called EsophagoGastroDuodenoscopy (EGD) and another method called TransNasal Esophagoscopy (TNE). With EGD a camera the size of a garden hose is placed via the mouth and then slid into the throat to then examine the esophagus, stomach and duodenum, which is the first part of the small intestine. Because the powerful gag reflux is located at the bottom portion of the tongue in the back of the mouth, sedation is required to suppress or dampen the gag reflex. Because of the extra monitoring that is required during a sedation procedure, EGD is generally performed in an endoscopy center or in a hospital. With TNE, first reported in the 1990’s, an ultrathin soft, pliable camera, the size of a strand of spaghetti, is placed via the nose to get to the throat and then to the esophagus and top portion of the stomach. Traversing the nose allows the examiner to go behind the location of the gag reflex so no sedation is necessary, only a little numbing medication is necessary and that is misted into the nose (18, 19). As a result TNE is performed with the patient wide awake, in a doctor’s office.

Most consumers are not aware that sedation during EGD has a small, but finite, risk of “cardiopulmonary unplanned events”, specifically, heart attack, stroke or respiratory arrest, of roughly 0.5% (20-25). At 10 million upper endoscopies performed per year in the USA, we are talking about 50,000 people annually who suffer these complications. While far fewer die as a result of these adverse events, it is nevertheless a large number of near catastrophic events involving a large amount of morbidity.

The decision of whether or not to have a sedation or unsedated examination of the esophagus should be discussed with your doctor. The key point is to always ask your doctor about alternatives when a sedation procedure is brought up.

Conclusion

In summary, because of events from several years ago, acid reflux disease is ubiquitous, and throat symptoms can often herald significant disease without any heartburn complaints. So pay attention to seemingly innocuous throat symptoms and have the esophagus examined, which now may include office-based techniques that do not require sedation and its attendant risks.

Links of Interest

Dr. Jonathan E. Aviv MD is the author of: Killing Me Softly From Inside: The Mysteries and Dangers of Acid Reflux And Its Connection to America’s Fastest Growing Cancer with A Diet That May Save Your Life

He writes a blog called AcidWatcher.com

References

  1. El-Serag HB, Sweet S, Winchester CC, et. al. (2014). Update on the epidemiology of gastro-oesophageal reflux disease: a systematic review. Gut; 63(6): 871-880.
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4046948/
  2. Dent J, El-Serag HB, Wallander MA, et. al. (2005). Epidemiology of gastro-oesophageal reflux disease: a systematic review. Gut; 54: 710-717.
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1774487/
  3. Koufman, J., Aviv, J., Casiano, R., et. al. (2002). Laryngopharyngeal reflux: Position statement of the Committee on Speech, Voice, and Swallowing Disorders of the American Academy of Otolaryngology-Head and Neck Surgery. Otolaryngology Head and Neck Surgery; 127: 32-35.
    http://www.researchgate.net/publication/11224445_Laryngopharyngeal_reflux_Position_statement_of_the_committee_on_speech_voice_and_swallowing_disorders_of_the_American_Academy_of_Otolaryngology-Head_and_Neck_Surgery
  4. Korkmaz M, Tarhan E, Unal H, Selcuk H, Yilmaz U, Ozluoglu L. Esophageal mucosal sensitivity: possible links with clinical presentations in patients with erosive esophagitis and laryngopharyngeal reflux. Dig Dis Sci. 2007;52(2):451–456.
    http://www.ncbi.nlm.nih.gov/pubmed/17219066
  5. Niemantsverdriet EC, Timmer R, Breumelhof R, et. al. (1997). The roles of excessive gastrooesophageal reflux, disordered oesophageal motility and decreased mucosal sensitivity in the pathogenesis of Barrett’s oesophagus. Eur J Gastroenterol Hepatol; 9(5): 515–519.
    http://www.ncbi.nlm.nih.gov/pubmed/9187887
  6. Nason, K., Wichienkuer, P., Awais, O., et. al. (2011). Gastroesophageal reflux disease symptom severity, proton pump inhibitor use, and esophageal carcinogenesis. Archives of Surgery, 146(7): 851–8. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4086744/
  7. Reavis, K., Morris, C., Gopal, D., Hunter, J., et. al. (2004). Laryngopharyngeal reflux symptoms better predict the presence of esophageal adenocarcinoma than typical gastroesophageal reflux symptoms. Annals of Surgery, 239: 849–858. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1356293/
  8. Pohl, H., Welch, H. (2005). The role of over-diagnosis and reclassification in the marked increase of esopha­geal adenocarcinoma incidence. JNCI; 97(2): 142-146.
    http://jnci.oxfordjournals.org/content/97/2/142
  9. U.S. Food and Drug Administration. (2010). Draft Guidance for Industry: Acidified Foods. Food and Drug Administration.
    Retrieved from:
    http://www.fda.gov/food/guidanceregulation/ucm222618.htm
  10.  Aviv, JE. (2014). pH Basics and the pH of Commonly Consumed Foods in Killing Me Softly From Inside. The Mysteries and Dangers of Acid Reflux and Its Connection to America’s Fastest Growing Cancer with a Diet that May Save Your Life. North Charleston, SC. Create Space Independent Publishing Platform, pp. 70-78.
    http://www.amazon.com/Killing-Softly-From-Inside-Connection/dp/1494761971
  11. Moss, M. (2013). Salt Sugar Fat: How the Food Giants Hooked Us. New York, NY: Random House.
    http://www.amazon.com/Salt-Sugar-Fat-Giants-Hooked/dp/0812982193
  12. Lyden, E. (October 6, 2012). High Fructose Corn Syrup: A Food to Completely Avoid to Stay Healthy. Policy.Mic.
    Retrieved from:
    http://mic.com/articles/15310/high-fructose-corn-syrup-a-food-to-completely-avoid-to-stay-healthy
  13. Lacy, BE, Carter J, Weiss JE, Crowell, MD. (2011). The effects of intraduodenal nutrient infusion on serum CCK, LES pressure, and gastroesophageal reflux. Neurogastroenterology & Motility; 23: 631–638.
    http://www.ncbi.nlm.nih.gov/pubmed/21435103
  14. Stanhope, KL, Schwarz, JM, Keim, NL, et. al. (2009). Consuming fructose-sweetened, not glucose-sweetened, beverages increases visceral adiposity and lipids and decreases insulin sensitivity in overweight/obese humans. Journal of Clinical Investigation;119(5):1322–1334.
    http://www.jci.org/articles/view/37385
  15. Carpenter, M. (2014). Introduction: A Bitter White Powder in Caffeinated: How our daily habit helps, hurts and hooks us. New York, NY. Hudson Street Press. p. xvi.
    http://www.amazon.com/Caffeinated-Daily-Habit-Helps-Hurts/dp/1594631387
  16. Carpenter, M. (April 22, 2014). Why Do Americans Drink Half as Much Coffee Today as They Did 60 Years Ago? In the Tank. A blog from the New America Foundation.
    Retrieved from:
    http://inthetank.newamerica.net/blog/2014/04/why-do-americans-drink-half-much-coffee-today-they-did-60-years-ago
  17. Chin, TW, Loeb, M, Fong, IW.(1995). Effects of an acidic beverage (Coca-Cola) on absorption of ketoconazole. Antimicrobial Agents and Chemotherapeutics. 39; 1671-1675.
    http://aac.asm.org/content/39/8/1671.long
  18. Aviv, J., Takoudes, T., Ma, G., Close, L. (2001). Office-based esophagoscopy: A preliminary report. Otolaryngology – Head and Neck Surgery, 125. 170-5.
    http://www.ncbi.nlm.nih.gov/pubmed/11555750
  19. Aviv, J. (2006). Transnasal esophagoscopy: State of the art. Otolaryngology – Head and Neck Surgery, 135. 616-619.
    http://www.entandallergy.com/userfiles/files/magazine/tne_state_of_art_oto_hns_2006.pdf
  20. Cohen, L., DeLegge, M., Aisenberg, J., Brill, J., Inadomi, J., Kochman, M., & Piorkowski, J. (2007). AGA Institute Review of Endoscopic Sedation. Gastroenterology, 133. 675-701.
    http://www.gastrojournal.org/article/S0016-5085(07)01115-8/abstract?referrer=http%3A%2F%2Fwww.ncbi.nlm.nih.gov%2Fpubmed%2F17681185
  21. McQuaid, K. & Laine, L. (2008). A systematic review and meta-analysis of randomized, controlled trials of moderate sedation for routine endoscopic procedures. Gastrointestinal Endoscopy, 67(6). 910- 923.
    http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0026357/
  22. Petrini, J. & Egan, J. (2004). Risk management regarding sedation/analgesia. Gastrointestinal Endoscopic Clinicians of North America, 14. 401–414.
    http://www.ncbi.nlm.nih.gov/pubmed/18440381
  23. Enestvedt, BK, Eisen, GM, Holub, J, Lieberman, DA. (2013). Is the American Society of Anesthesiologists classification useful in risk stratification for endoscopic procedures? Gastrointestinal Endoscopy; 77: 464-71.
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3816502/
  24. Al-Awabdy, B, Wilcox, CM. (2013). Use of anesthesia on the rise in gastrointestinal endoscopy. World J Gastrointestinal Endoscopy 5(1): 1–5.
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3547114/
  25. Liu H, Waxman DA, Main R, Mattke S. (2012). Utilization of anesthesia services during outpatient endoscopies and colonoscopies and associated spending in 2003-2009. JAMA. 307(11):1178-84.
    http://jama.jamanetwork.com/article.aspx?articleid=1105089

 

6 COMMENTS

  1. Thank you for providing references for follow up to your article. Some of the information was new for me. I am hoping some of them will be specific to pediatrics and appropriate to share with pediatricians.

  2. Due to nerve damage because of a brain tumor I have swallowing problems and reflux problems. Please email me any new info and/or articles. Thank you. Nancy

  3. Thank you for the reference and links! I think I now have a clearer understanding of what seems to be a heart burn problem. Now I have better information to discuss with my personal doctor and perhaps get an appropriate referral and treatment. 🙂

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