Acid reflux is the most prevalent and misunderstood disease of our time. It is so pervasive that it is almost invisible. For patients and doctors alike, reflux is a confusing and difficult problem.
This chapter provides background and context for this book, and it is intentionally abbreviated. If you are interested in the science and research, please read Dropping Acid: The Reflux Diet Cookbook & Cure,1 particularly the front matter and the chapter “Reflux Science You Can Digest.”
The word reflux literally means “backflow.” It is the backflow of the gastric (stomach) contents into both the esophagus—the swallowing tube that goes from the throat to the stomach—and the throat. Reflux into the esophagus is called gastroesophageal reflux. If it damages the esophagus or causes symptoms, then it is called gastroesophageal reflux disease, or GERD. Esophageal reflux is a simpler term, and throughout this book it will be used in place of GERD.
When gastric reflux escapes from the esophagus upward into the throat and respiratory tract, it is usually called laryngopharyngeal reflux, or LPR, and sometimes airway reflux or silent reflux. All of these medical terms are mine, but in this book I am introducing a new term, respiratory reflux, which is both descriptive and intuitive, and will be used instead of LPR.
Respiratory reflux includes reflux into the nose, sinuses, throat, voice box, trachea, bronchial tubes, and lungs. Respiratory reflux causes, or complicates, almost all respiratory diseases, including many that are still not recognized as reflux-related. In fact, respiratory reflux is a main cause of sinus disease, sleep apnea, and cancer of the esophagus, throat, and lungs. Respiratory reflux affects millions of people who do not have digestive symptoms, so they and their doctors are unaware of the problem.
In my experience, the three most common misdiagnoses in America are allergies, sinus disease, and asthma, with as many as three-quarters of the cases actually being caused by respiratory reflux.
You do not have to have heartburn to have reflux. In fact, respiratory reflux symptoms—postnasal drip, chronic throat clearing and cough, sore throat, hoarseness, lump-in-the-throat sensation, difficulty swallowing—are far more common than heartburn, the primary symptom of esophageal reflux. This misconception among patients and physicians—that heartburn is acid reflux—has had colossal negative health consequences.
I recently examined data from my reflux patients using the Reflux Symptom Index (the quiz provided on page 3). Here were the symptoms, in decreasing order of frequency:
Not only was heartburn only the sixth-most common symptom, heartburn was the chief complaint or primary symptom of only seven percent of the patients. Furthermore, almost half said that they had never had heartburn! Look at these results from the one-question poll on the www.refluxcookbookblog.com website:
1. Post-nasal drip | 15% |
2. Chronic throat-clearing | 14% |
3. Lump-in-the-throat sensation | 14% |
4. Hoarseness | 12% |
5. Sore throat | 11% |
6. Heartburn | 10% |
7. Chronic cough | 9% |
8. Difficulty swallowing | 8% |
9. Choking episodes | 7% |
With over 55,000 respondents, the results confirm that reflux is not just about heartburn. The data also suggest that most people have multiple symptoms of respiratory reflux. Indeed, most respiratory reflux patients have an average of six of the above symptoms. That is an important clinical observation: many symptoms suggest respiratory reflux and not another diagnosis.
If the above findings represent the population at large, and there is no reason to think otherwise, poorly recognized respiratory reflux is a much bigger and more important problem than esophageal reflux. Symptoms like postnasal drip, too much throat mucus, and chronic throat clearing are the tip of a massive respiratory reflux iceberg that affects almost 20 percent of the population, or over 60 million people.8
Would it surprise you to know that respiratory reflux can cause any respiratory symptom or disease? It can even cause life-threatening lung diseases, not just common problems like postnasal drip. Listed on the next page are many of the symptoms and conditions that are reflux-related.
|
Symptoms | Conditions |
Heartburn | Esophagitis |
Regurgitation | Dental and gum disease |
Chest pain | Esophageal spasm |
Shortness of breath | Esophageal stricture |
Choking episodes | Esophageal cancer |
Hoarseness | Reflux laryngitis |
Vocal fatigue | Laryngeal and vocal cord cancer |
Voice breaks | Endotracheal intubation injury |
Chronic throat clearing | Contact ulcers and granulomas |
Excessive throat mucus | Subglottic stenosis |
Postnasal drip | Arytenoid fixation |
Chronic cough | Paroxysmal laryngospasm |
Dysphagia | Globus pharyngeus |
Difficulty swallowing | Throat cancer |
Difficulty breathing | Vocal cord dysfunction |
Wheezing | Paradoxical vocal cord movement |
Globus | Vocal cord nodules and polyps |
Food getting stuck in throat | Lung cancer |
Lump-in-the-throat sensation | Recurrent leukoplakia |
Intermittent airway obstruction | Polypoid degeneration |
Chronic airway obstruction | Laryngomalacia |
Abdominal bloating | COPD (chronic obstructive |
Nasal congestion | Pulmonary disease) |
Noisy breathing | Croup |
Stridor | Sudden infant death syndrome |
Nausea | Sinusitis and allergic symptoms |
Snoring | Asthma |
Sleep apnea | |
Chronic bronchitis | |
Aspiration pneumonia | |
Idiopathic pulmonary fibrosis | |
Community-acquired pneumonia | |
Pneumonia (or recurrent pneumonia) |
† Note: In this table the two columns, “Symptoms” and “Conditions,” are independent of each other; a symptom on the same line as a condition (and vice versa) does not imply correlation.
Although I cannot discuss all of these conditions in this chapter, I will comment on the most important ones: postnasal drip, allergies, sinus disease, asthma, bronchitis, chronic cough, and chronic obstructive pulmonary disease (COPD). I will also briefly discuss the relationship between reflux and aerodigestive tract cancers, cancers of the mouth, larynx (vocal cords), esophagus, and lungs.
Nocturnal reflux is the worst kind of reflux pattern because damaging acids and digestive enzymes can remain in contact with the tissues for many hours.
The nighttime refluxer may only have daytime symptoms, and those are the symptoms that get all the attention. Therefore, one of the great problems with respiratory reflux is that it may go undetected.
Because reflux causes tissue inflammation, changes may be seen on the lining membranes of any or all the parts of the respiratory system and esophagus. The inflamed lining membranes typically increase mucus production. If nighttime reflux enters the nose, nasal congestion and postnasal drip during the day can easily develop and be mistaken for allergies. Believe it or not, nasal congestion is a quite common reflux symptom.
If the lining membranes around the sinus openings swell, sinus symptoms or even actual sinusitis may result. Nevertheless, the underlying cause is reflux. So, reflux-caused symptoms are commonly misdiagnosed as allergies and sinusitis. Among my most frustrated patients are those who previously had ineffective or unnecessary nose and sinus surgery—often multiple surgeries. When their reflux is corrected, their “sinus” symptoms subside.
More about mucus. Under normal conditions, we produce approximately one quart of mucus a day, mostly in the nose. Inflammatory disease of the nose and throat is absolutely characteristic of respiratory reflux; indeed, inflammation results in increased mucus production. It is as if the sick tissue tries to protect itself by manufacturing more mucus, because mucus provides a partial tissue barrier against reflux.
When examining patients, I can often diagnose nocturnal reflux because on examination the patient will demonstrate upper and lower throat findings—so-called cobblestoning and tiger-striping—that suggest that the refluxate was pooling in certain places in the nose and throat during the night. Those findings are usually associated with an increase in mucus. In fact, thick white mucus on the vocal cords is considered a finding of reflux laryngitis. Such findings, although not well recognized by most physicians, help me accurately diagnose the nighttime refluxer.
Allergies look different than reflux. When examining the nose of the allergic patient, the nasal membranes are swollen and purple and the discharge is thin, watery, and clear. Further, refluxers usually have other throat symptoms whereas patients with allergies do not. It is fairly easy to differentiate reflux from allergies in patients with nasal congestion and postnasal drip.
Postnasal drip, chronic throat clearing, excess mucus, sticky throat, lump-in-the-throat sensation, and hoarseness are the most common symptoms of respiratory reflux.
Breathing problems represent the other significant group of reflux misdiagnoses, the most common being asthma and bronchitis. “Asthma” affects eight percent of Americans (one out of 12) and 17 percent of poor, nonwhite children. We spend in excess of $56 billion a year to treat it. In my book The Chronic Cough Enigma,32 I report that as many as 80 percent of people with asthma are misdiagnosed. Indeed, if that number of “asthma” patients actually has respiratory reflux, then we might save $45 billion a year through accurate diagnosis.
The first question to ask anyone with “asthma”—and amazingly, most physicians don’t know this—is: When you have trouble breathing during an attack, do you have more difficulty getting air IN or OUT? Trouble during inhalation is due to respiratory reflux, never asthma. Trouble during exhalation is asthma.29,32
How does this work? The difference between breathing IN and OUT is explained by the anatomy and physiology of the airway. With reflux, airway obstruction occurs at the level of the larynx. The upper part of the larynx contains acid receptors, which act like electrical switches. When triggered by exposure to acid, these receptors close the vocal chords, resulting in trouble breathing IN.12,13,15,29,32 This type of airway obstruction is similar to that seen in children with croup, who may make loud, crowing sounds when breathing IN.
The mechanism of airway obstruction in asthma is completely different. People with asthma have trouble getting air OUT, because breathing tubes within the lungs inside the chest cavity become narrowed. Then, during exhalation, the full lungs exert additional pressure on the already partially collapsed bronchial tubes, resulting in further compression and narrowing. Trying to exhale through such narrowed bronchial tubes leads to prolonged expiration. Noisy breathing during expiration in true asthma is usually called wheezing.
A problem breathing IN is never asthma. Indeed, people with wrongfully diagnosed asthma don’t respond particularly well to asthma treatment, but they do get well when their reflux is controlled. Asthma sufferers and their doctors should know about this.
The next most common respiratory misdiagnoses are chronic cough, bronchitis, and chronic obstructive pulmonary disease (COPD), particularly in nonsmokers.32 Such patients are usually nocturnal refluxers. Most, but not all, productive (“wet”) coughs are due to reflux; although some are actually due to infections or other pulmonary (lung) diseases.
I ask all of my patients to cough out loud to determine if the cough is wet or dry. One can appreciate this by the sound, and most patients know the difference if asked. Generally speaking, a wet cough implies that the reflux goes into the trachea or possibly the lungs at night. For such patients, the cough is usually most productive after the patient arises in the morning.
Anyone with chronic bronchitis or even intermittent bronchitis who is a nonsmoker should be evaluated for respiratory reflux.
People who have pneumonia may very well have reflux aspiration events at night. There appears to be a strong correlation between the findings of nocturnal reflux with massive swelling of the back of the larynx (especially tiger-striping) and wet cough in my respiratory reflux patients. A wet cough by itself is not diagnostic, but the first thing I look for with successful reflux treatment in my patients with respiratory reflux is that the cough is no longer wet.
The final conditions that I wish to discuss here are cancers of the mouth, throat, esophagus, and lungs, all of which may be caused by reflux. My practice is replete with lifelong nonsmokers with tongue, throat, and lung cancer whose reflux was never diagnosed or treated. An item as simple as the Reflux Symptom Index (page 3) might be able to identify respiratory refluxers who are at risk of developing cancer, or if they have had cancer, help to reduce treatment complications and the risk of recurrences.
Twenty-five years ago, I stood at a national meeting and said, “It is my belief that you can get cancer—and I mean all of the aerodigestive cancers, larynx, lung, and esophagus—without smoking, but not without reflux.” In the intervening years, I have not changed my mind. Indeed, my clinical experience has confirmed that opinion.
If you have allergies and treatment hasn’t helped, think respiratory reflux. If you have sinus disease and surgery hasn’t helped, think respiratory reflux. If you have asthma or lung disease (of any type) and the cause is unexplained and/or the treatment ineffective, think respiratory reflux. If you are a nonsmoker or long-time ex-smoker with mouth, throat, or lung cancer, think respiratory reflux. Finally, if you have esophageal cancer (or precancer—i.e., Barrett’s esophagus), think (inadequately treated) reflux.
Reflux need not become chronic, and fortunately for most people, it is correctable. It is useful to understand the pattern and progression of disease that must be altered to allow a person’s antireflux defenses to repair the damage and normalize aerodigestive physiology.
Reflux disease is a vicious downward spiral, descending until it seems chronic. Reflux causes reflux, which causes more reflux. Here’s the typical scenario: reflux starts for whatever reason—overeating, drinking too much, a late-night binge, the flu—and up come acid and digestive enzymes that inflame healthy tissues.
Unfortunately, the stomach valve itself, the lower esophageal sphincter (LES), which is the most important physiologic barrier preventing stomach contents from escaping into the esophagus, gets swollen and inflamed. With continuing reflux, over time LES function becomes increasingly compromised. Thus, the barrier that is supposed to prevent reflux is damaged, which leads to worsening reflux.
The more one refluxes, the worse esophageal function becomes, until the esophagus is just like a wide-open pipe. Finally, the upper esophageal sphincter (UES), the valve in the lower throat, gives out, so that when the refluxer lies down, everything in the stomach washes into the tunnel-like esophagus and then all the way up into the throat and respiratory tract.
At this stage, esophageal and respiratory reflux occur all night, every night. People with this severity of disease will sometimes wake at night coughing and gasping for air like a fish out of water. This is serious reflux and puts the lungs at risk for aspiration.
But many people with nocturnal reflux sleep right through it, and this explains “silent reflux.” People who reflux at night wake in the morning with respiratory symptoms, not digestive symptoms. Indeed, silent reflux has come to mean acid reflux that occurs without heartburn or indigestion.
To defeat reflux, it takes an all-out effort, with diet and lifestyle changes as the essential therapeutic elements. Just as there is a vicious reflux-causes-reflux cycle progressing downward, cleaning up the problem usually results in an upward spiral toward normalcy.
Yes, normal function of the esophagus and UES can be restored, and diseased respiratory and esophageal tissue can be healed. For more about the cycle of reflux disease, see Chapter 5, “Stages of Reflux and Recovery” (page 29).
Reflux-related respiratory disease, such as misdiagnosed allergies, sinus disease, and asthma can be cured with effective reflux treatment. Even Barrett’s esophagus30–33 can be cured with effective dietary and lifestyle antireflux treatment.32 For more about that, see Beyond Barrett’s in “The Longevity Diet” chapter (page 82).
The Internet is a double-edged sword. It is a great source of both information and misinformation. When it comes to reflux, the Internet is remarkably full of nonsense. In this section, I will address five particularly egregious fallacies.
If I take reflux medicine, I can eat whatever I want. Most people, including doctors, mistakenly assume that the primary treatment for reflux disease is acid-suppressive medication. Television advertisements strongly suggest that treatment of heartburn is the goal of antireflux treatment, and that if you take a purple pill, you can eat whatever you want. Unfortunately, nothing could be further from the truth. The goal of antireflux treatment should be to stop reflux and the progression of reflux-caused disease.
The strongest acid-suppressive medications are the proton pump inhibitors (PPIs). These are aggressively marketed, but they should be taken under a doctor’s supervision. The belief that PPIs control reflux was turned on its head by a national Danish study of 10,000 patients that concluded that long-term use of PPIs was associated with an increased risk of esophageal cancer.34 A recent study also found an association between PPIs (though not H2-antagonists) and heart attacks.35
When the Danish report came out I was not surprised because the vast majority of my reflux patients come to me already on PPIs, and I knew that PPIs do not control reflux. The esophagus is a very quiet organ, and other than heartburn, it does not complain much. So, symptom relief is not the goal of therapy. The progression of reflux disease in patients taking PPIs goes on unabated. Alleviating just some symptoms is like sweeping dirt under the rug; eventually it will catch up with you.
While the use of acid-suppressive medications is warranted in some patients with reflux, successful treatment and eradication of disease depends more on lifestyle and dietary modifications than on pills.8 There is even a role for antireflux surgery in highly selected patients, but even laparoscopic fundoplication or other surgeries are doomed to failure without some dietary restraint. The topics of antireflux medication and antireflux surgery are covered in greater detail on pages 41 and 45, respectively.
This book is a call to action to the medical community to recognize that the most prevalent diseases in America are related to unhealthy diet and lifestyle and that they cannot be cured by pills and procedures.
Some people don’t have enough stomach acid. There is a common misperception that some people don’t produce enough stomach acid. This is not true. Since 1983, I have been performing reflux testing using a specialized ambulatory acid-sensing device that permits 24-hour pH monitoring. In that time, I have pH tested approximately 15,000 patients, and while there may have been a few people without stomach acid, I cannot recall the last time I came across one.
The exceptions are people who have had certain types of stomach surgery and those with a disease called pernicious anemia. Pernicious anemia is an autoimmune disease in which the lining of the stomach is affected, leaving the person with achlorhydria (no stomach acid). The idea that acid suppression with PPIs might cause pernicious anemia is also false. Pernicious anemia is associated with vitamin B12 deficiency, but antireflux treatment doesn’t cause it.
There is another belief that if you take acid-suppressive medications you won’t have enough acid to digest your food or to absorb calcium. This is also untrue. PPIs work by inhibiting the cells in the stomach that are responsible for manufacturing stomach acid; but figuratively, if you took handfuls of PPIs every day, you would produce half a ton instead of a ton of acid a day. No acid-suppressive medicine suppresses all of your acid.
Some people have nonacid (bile) reflux. There is no credible evidence that people have nonacid reflux, with the exception of patients who have had their stomachs removed. The suggestion by GI doctors that reflux above pH 4.0 was “nonacid” reflux is not true. Any reflux, even that above pH 4, can damage the respiratory system. The cell biology that was performed in my laboratory over a decade ago showed that acid at pH 5 was damaging to the larynx and vocal cords.16,22,23,26,27
I am developing a spit-in-a-cup test for the detection of pepsin (the main stomach enzyme) in the saliva.23–25 Since pepsin only comes from the stomach, if someone has pepsin in their saliva, they have respiratory reflux. Pepsin in the mouth is pepsin in the airway.
Some acidic foods become alkaline in the body, and some alkaline foods become acidic in the body. This is false. Acid is acid, and alkaline is alkaline. When someone consumes excessive amounts of acid, for example, the excess acid is secreted in the urine, making it more acidic.
Testing one’s urine or saliva for acidity is not worthwhile because it has no clinical relevance. It is also important to emphasize that most lists of pH values of foods and beverages on the Internet are confusing and inaccurate. I recommend using pH paper to test common foods that are regularly consumed. For some additional pH food lists, see Dropping Acid: The Reflux Diet Cookbook & Cure1 and www.refluxcookbookblog.com.
Apple cider vinegar (or lemon juice) is good for reflux. One commonly recommended home remedy for heartburn is apple cider vinegar or lemon juice. Perhaps this is based upon the idea that some people don’t have enough acid, but for those with respiratory reflux or esophageal reflux, consuming apple cider vinegar or lemon juice is a bad idea.
The entire thrust of this book is that an alkaline diet is important to protect against reflux disease. The scientific evidence and rationale for an alkaline diet is discussed in the next section. In any case, there is not a shred of evidence in the scientific or medical literature that apple cider vinegar is of therapeutic benefit in treating reflux. However, there are reports suggesting that it makes reflux worse.
The best first step you can take to feel better and improve your reflux and your long-term health is to stop consuming acids in any form.
The term acid reflux is actually a misnomer because it is the main stomach enzyme, pepsin, which causes tissue inflammation and damage.1,8,16,22–28,36 Pepsin is also the likely cause of aerodigestive tract cancers.1,9,22,37,38
The confusion comes from the fact that pepsin requires acid for its activation. So, instead of calling it peptic reflux, I think it is important to explain the cell biology of reflux, or how reflux causes tissue inflammation and how damage occurs.
Until Dropping Acid: The Reflux Diet Cookbook & Cure, no one had investigated the adverse effects of the acid in the foods and beverages we consume. Everyone worries about equalizing the stomach’s natural acid, yet we continue to pour down ever more acidified foods and drinks. Pepsin can only cause problems when acid is around to activate it.1,9,16,22 Then it gets busy breaking down proteins into smaller, more easily digestible particles.
Any foods that are high in acid activate pepsin and, if there is no protein around that needs digesting, the pepsin will gnaw on whatever is handy—such as the linings of your throat and esophagus. The old adage “You are what you eat” might in this case be rephrased, “Be careful what you eat, because what you eat could be eating you.” Once a pepsin molecule is bound to your throat, for example, any dietary source of acid can reactivate it, such as soft drinks, fruit juice, vinegar, or strawberries.
One of the most potent missteps of the FDA resulted in acidification of almost everything packaged in a bottle or can. When they made the pH less than 4.6 rule,1 they never anticipated the consequences.
Stomach acid is pH 2–4, and today almost every beverage in a bottle or can (except still water) is as acidic as stomach acid; because of this, reflux disease has soared.
I am frequently asked why so many young people have reflux. In 2010, the American Beverage Association reported that the average 12-to-29-year-old American had consumed between 100 and 160 gallons of soda. That amounts to almost a half a gallon per person per day and helps explain why we are currently seeing reflux in 37 percent of young people.8 For this group, it can be relatively easy to correct the reflux problem—drink water, do not eat late, and avoid junk food and alcohol.