Why Is Laryngopharyngeal Reflux (LPR) So Hard To Treat?
Cough, chronic throat clearing, post nasal drip, a lump in the throat, and hoarseness may be caused by a form of gastroesophageal reflux called Laryngopharyngeal Reflux (LPR). The larynx is the area of the throat where the vocal cords are located. Not only is the larynx very sensitive to very small amounts of acid, it is injured by other stomach contents such as pepsin and other enzymes.
Laryngopharyngeal Reflux causes damage not only due to acid, but also due to bile and enzymes. These enzymes continue to reside in the throat beyond the time of the reflux event. A reflux event is when stomach contents come up the esophagus into the chest or even all the way up to the throat, sinuses or lungs. When there is a lot of acid coming up it causes heartburn. Long exposures of acid in the esophagus cause serious damage to the esophagus called erosive esophagitis. Short exposures or modest amounts of acid do not tend to cause esophagitis or severe heartburn. Most people with LPR (Laryngopharyngeal Reflux) do not complain of significant heartburn.
We Are Often Frustrated By The Inability Of Medications To Control Laryngopharyngeal Reflux (LPR)
Erosive esophagitis is successfully treated with standard doses of Proton Pump Inhibitor (PPI) medications that block acid very effectively. With avoidance of large meals, lying down within 3 hours of eating, and daily use of one of several Proton Pump Inhibitors, symptoms improve in as little as a day, and the damage of erosive esophagitis resolves in 95% by 8 weeks. If nothing is done about the underlying causes of erosive esophagitis, long term maintenance is often needed, as relapse rates are quite high.
We are not nearly as successful with Laryngopharyngeal Reflux. Some studies of Laryngopharyngeal Reflux suggest that PPI are little better than placebo in well performed studies. Other studies show some success in resolving symptoms with acid suppression, but often more intense control of acid with twice daily dosing (double the usual dose) for a long duration, such as three months) is required to be effective. The U.S. F.D.A. has not approved twice daily dosing of any PPI and has not approved the treatment of Laryngopharyngeal Reflux with any drug due to failure to conclusively prove benefit in large well controlled studies.
Patients with Laryngopharyngeal Reflux (LPR) have a normal appearing esophagus 85% of the time on endoscopy without serious damage as erosions or Barrett’s esophagus. Therefore, gastroenterologists who do not specialize in GERD and LPR fail to recognize the disease as the testing appears to be normal. patients, likewise, are frustrated by the lack of immediate response to treatment. Esophageal acid tests often show degrees of acid exposure to be normal overall, with reflux episodes being most often upright, short in duration, and without nighttime reflux. So why is it so much harder to treat than it it is to treat people who have more heartburn symptoms and more damage to the esophagus or esophagitis?
In fact, even when acid is controlled by PPI medication, reflux of stomach contents to the throat and airway may continue. The stomach juices contain digestive enzymes and bile without there being significant acid exposure. Although typically enzymes such as pepsin need acid with a pH below 4 to activate these enzymes, pepsin from the stomach can be activated in the throat by mild acids in ingested food and beverages, such as soda or citrus juices, and tomato sauces. The stomach typically has a very low pH due to hydrochloric acid with a pH of 1 to 2. Unlike the esophagus, it takes very little to damage the vocal cords, airway, sinuses, and lungs. And it takes a lot longer to recover from the damage.
Acid blocking medications may need to be given at high doses, and for long periods before effective results can be achieved. Avoidance of ingested acidic foods is critical. Often treatment is still ineffective, or side effects may limit therapy. These side effects may include abdominal pain, diarrhea, constipation, gas and bloating, or headaches. Alternatively, fundoplication surgery can prevent both acid and non-acid reflux.
The Reflux Care of New York provides a unique difference in approach from other gastroenterology, ENT, or surgical practices that treat reflux. Dr. David Gutman has the expertise and focus to offer both medical, dietary, and surgical experience. He has the resources to collaborate in a multidisciplinary fashion, and tailor the diagnostic and treatment to the individual, rather than try to treat all patients in the same fashion. He is among the first gastroenterologists in the New York Metropolitan area to perform reflux surgery endoscopically. As the leading expert on Laryngopharyngeal Reflux, Gastroesophageal Reflux, and World Trade Center Syndrome presenting with reflux, he has the tools, know-how, and technologic expertise to deal with frustrating and complex evaluation and treatment of this important disease.
Photo By: Vince Alongi