Got Acid? GERD and Its Less Common Presentations

Have you ever had a feeling of burning pain in your chest or throat after having a delicious meal? How about having a sour or bitter taste up into your throat or mouth? If you have, you are not alone. These are the typical symptoms of acid reflux, a normal condition when experienced occasionally. Acid reflux may seem like a nuisance, but it can lead to harmful outcomes.

Gastro-esophageal Reflux Disease (GERD) is one of the most common digestive disorders in the Western world, affecting around 20 to 30 percent of the population. Despite its prevalence, diagnosing GERD can be challenging because some patients manifest atypical or extraesophageal symptoms instead of the typical heartburn.

This post aims to explain the condition and raise awareness of its role as a potential contributor of asthma, chronic cough, laryngitis, chronic sore throat, and noncardiac chest pain.

What is Acid Reflux?

Acid reflux is a common condition that occurs when your stomach acid flows back up into the esophagus (food pipe). It happens when your lower esophageal sphincter (LES) doesn’t close or opens too often after the food has passed through it. This reflux of acid can cause a symptom known as heartburn, which is like a burning sensation in the lower chest area. 

What Causes Acid Reflux?

A lot of people experience acid reflux symptoms from time to time. In fact, almost everyone will experience heartburn at some point in their life, especially after having a large meal. Several risk factors could trigger this condition including:

  • Being overweight or obese
  • Eating certain foods — such as tomatoes, chocolate, citrus, onions, and fatty or spicy foods
  • Drinking certain beverages — such as coffee, alcohol, and carbonated drinks
  • Smoking (active or passive)
  • Eating large meals and lying down right after
  • Eating snacks close to bedtime
  • Pregnancy
  • Taking certain medications — such as aspirin, ibuprofen, and blood pressure medications.

In cases of GERD, one of the most common causes is a stomach abnormality called hiatal hernia. Normally, your LES and diaphragm help keep the acid in your stomach. But if you have a hiatal hernia, your diaphragm leaves a hole that allows part of your stomach to move up into your chest, resulting in acid reflux.

Here is a Food that would cause of acid reflux.
Photo by Alena Shekhovtcova on Pexels.com

What are the Symptoms of Acid Reflux?

Acid reflux features two typical symptoms that are usually present in GERD patients but not always:

Heartburn: a burning sensation or discomfort that is felt from the lower part of your chest that moves up to your throat.

Regurgitation: an unpleasant sour or bitter-tasting liquid that moves up to your throat and mouth.

GERD patients may also manifest other symptoms including:

  • Chest pain;
  • Difficulty swallowing;
  • A sensation of a lump in your throat;
  • Chronic cough;
  • Laryngitis;
  • Asthma;
  • Nausea and vomiting;
  • Hoarseness; and
  • Chronic sore throat.

Types of Acid Reflux

There are 2 types of acid reflux. When gastric acid repeatedly moves up from the stomach into the esophagus alone, it is known as gastroesophageal reflux disease or GERD. However, if acid travels all the way up to your throat (pharynx) and voice box (larynx), it causes laryngopharyngeal reflux or LPR.

GERD

If you experience acid reflux more than twice a week, you have GERD. It is a common condition that affects the patients’ daily living and is part of the economic concern. About 4.6 million Americans with signs of GERD undergo outpatient checkups and consultation costing up to $10 billion value in medications.  It may be difficult to treat and can worsen over time if it remains untreated. Some of the patients do not seek medical attention, and instead, prefer taking over-the-counter medicines. Although acid causes the symptoms in reflux, treating it doesn’t always address the problem.

GERD are categorized into three types namely:

  1. Non-erosive Reflux Disease (NERD)

The most common phenotype with the usual reflux symptoms but no visible esophagus wound.

  1. Erosive Esophagitis (EE)

This type shows significant swelling, irritation, and esophageal damage. Erosive esophagitis manifests a struggle when swallowing. 

  1. Barrett’s Esophagus (BS)

A condition when the flat pink lining of the esophagus is excessively irritated due to frequent acid reflux, causing it to become inflamed and damaged. This may lead to esophageal cancer when not given serious attention (interval scopes) and medication.

Laryngopharyngeal Reflux (LPR)

Acid can move up the esophagus and into the throat and voice box causing LPR. It is sometimes called silent reflux because it may not have the classic symptoms of GERD (heartburn & regurgitation), making its diagnosis challenging. LPR is common to people who eat certain foods, are overweight, and who wear tight clothes. 

The symptoms of LPR:

  • Sore throat
  • A feeling of a lump in the throat
  • Hoarseness
  • The need to frequently clear your throat
  • The feeling of mucus stuck in the throat
  • Trouble swallowing
  • Trouble breathing
  • Swollen larynx
  • Persistent cough

The Diagnosis

LPR can be diagnosed by examining the throat and the back of the voice box for any swelling or irritation. This can be done with direct viewing with a nasal endoscopy, a swallowing study, or an esophageal pH test

Treatment

A lifestyle change is a must if you want to get treated. If it becomes a serious risk, however, esophageal surgery may be recommended. Here are the following tips for treatment:

  • Observe a low acid and fat diet;
  • Avoid spicy foods;
  • Eat a small amount of food frequently;
  • Avoid caffeine, tobacco, and alcohol; 
  • Avoid eating 2 hours before sleep;
  • Sleep with a slightly elevated head to prevent stomach acids from coming up to your throat;
  • Avoid repeatedly clearing your throat;
  • Lose weight;
  • Reduce stress; and
  • Take over-the-counter antacids. 

Take note that when LPR is not managed well, it may complicate and lead to:

  • Chronic sore throat
  • Chronic cough
  • Swollen vocal folds
  • Vocal fold ulcers
  • Formation of mass in the throat
  • Worsening asthma and bronchitis
  • Cancer of the voice box.

4 Stages of Acid Reflux

Acid reflux has four different stages that vary from one another, depending on the intensity of the reflux. Let’s discuss them one by one.

Stage 1: Mild Acid Reflux

In this stage, your lower esophagus begins to swell. Generally, when you are diagnosed with GERD, you are under mild acid reflux. Typical symptoms include heartburn, regurgitation, a feeling of a lump in the back of the throat, and chest pain. 

The treatment at this stage involves your diet plan as all you have to do is avoid the foods and drinks that will trigger the reflux. Do not drink coffee and alcoholic beverages and avoid fatty and spicy foods. You may need to take antacids and refrain from eating 3 hours before going to bed. If the reflux is still present, you may slightly elevate your head using an additional pillow to promote better sleep.

Stage 2: Moderate Acid Reflux

If the symptoms in stage 1 happen multiple times in a week, then you may already have moderate acid reflux. You will experience more irritation and swelling in the esophagus area at this stage. If not treated, this may affect your daily living. 

Over-the-counter medicine cannot mitigate the reflux. Prescription medications like histamine receptor 2 blockers or proton pump inhibitors may be necessary.

Stage 3: Severe Acid Reflux

Around 15% of people with acid reflux are under this stage where prescription medications are needed to alleviate extreme symptoms. Your esophagus at this time is probably extremely swollen and eroded. At this stage, symptoms may include a cough that doesn’t get better, sore throat, and hoarseness of voice. 

Proper medication is needed to control the reflux because diet and lifestyle changes alone may not be enough. You also need a specialist to help you with the right treatment and avoid further severe complications. 

Stage 4: Esophageal Cancer

When stage 3 is left untreated, it may develop into a precancerous condition also known as Barrett’s esophagus. If acid reflux remains, Barrett’s esophagus will eventually lead to esophageal cancer. Approximately 10% of patients with acid reflux reach this stage.

You need a GERD specialist to help you with your treatment. A series of examinations and laboratory tests may be needed to determine the severity of your condition. You might also need to go through cancer treatments or surgical procedures. 

Acid Reflux and Its Atypical Presentations

The problem with chronic acid reflux is that sometimes it can masquerade as other diseases. Over the years as the prolonged presence of acid continues to irritate and damage your esophagus, it can bring about an entire set of symptoms other than simple heartburn. For some patients, heartburn was never reported, and thus, the significance of acid reflux with the onset of chronic cough, hoarseness, and asthma-like symptoms was often overlooked. 

But now, experts and physicians alike are starting to recognize that it is a good clinical practice to evaluate the possible presence of reflux in patients with these so-called “atypical presentations”. They also believe that treating the underlying reflux can have a significant effect on the improvement of symptoms in these patients. 

Here are some of the atypical or extraesophageal symptoms that are closely linked with acid reflux:

Respiratory Symptoms

Studies show that 50% to 80% of asthma patients also have GERD and around 75% of them have abnormal 24-hour pH levels. It is difficult to establish a causal relationship between asthma and GERD because both of them induce each others’ conditions. In patients who have both conditions, only 30% of them have GERD that is caused by asthma. Asthma attacks can cause increased acid reflux due to pressure changes inside the chest and abdomen. Additionally, bronchodilators that are used in the treatment of asthma may also worsen reflux. 

Asthma symptoms that worsen after eating large meals, drinking alcohol, or lying in the supine position, as well as adult-onset asthma, may be associated with GERD. However, even testing with 24-hour pH monitoring and upper endoscopy may not be enough to establish the cause and effect relationship between the two conditions.  

Up to 75 percent of patients with GERD-related chronic cough have no identifiable gastrointestinal symptoms. Moreover, 94 percent of chronic coughs are caused by either asthma, postnasal drip, GERD, or all of them combined.  GERD can also be a risk factor for aspiration and pneumonia.

Nasopharyngeal Symptoms

Acid reflux is the cause of 25 to 50 percent of globus sensation in patients presenting with ENT symptoms. Reflux is also responsible for 10 percent of hoarseness and around 60 percent of both chronic laryngitis and refractory sore throat. However, patients with these symptoms may still have normal 24-hour pH monitoring and upper endoscopy results. 

Generally, reflux laryngitis is diagnosed based on the following laryngoscopic findings:

  • Laryngeal erythema and edema;
  • Posterior pharyngeal cobblestoning;
  • Contact ulcers;
  • Granulomas; and
  • Interarytenoid changes.

Unfortunately, these signs are nonspecific for GERD. A recent study found that 86% of healthy individuals who did not even have acid reflux or laryngeal symptoms manifested at least one of these signs. Many of these signs may be caused by laryngeal irritation that is not related to reflux like alcohol use, smoking, viral illness, or environmental allergens. Thus, the presence of these signs is insignificant and may only lead to the misdiagnosis of GERD. This may explain why half of the patients with laryngeal signs do not respond well to antisecretory therapy. Acid reduction treatment has a more favorable response in GERD patients with posterior laryngitis, medial erythema of vocal cords, ulcers, and granulomas. 

Noncardiac Chest Pain

Aside from the typical heartburn, some GERD patients also manifest chest pain similar to angina or heart pain. However, all patients with chest pain should be thoroughly evaluated for potential coronary diseases first before considering a GERD-related cause. On the other hand, if your doctor has ruled out your chest pain as coming from the heart, then it might be coming from your esophagus. Around 20 to 30 percent of patients classified as having noncardiac chest pain can be attributed to GERD. Additionally, abnormal acid exposure can be seen in up to 50 percent of patients with noncardiac chest pain.

acid reflux can contribute to chest pain sensation or "heartburn"
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Acid Reflux and Its Esophageal Complications

Chronic acid reflux that is left untreated for many years can cause severe damage to the esophagus that leads to several complications such as:

  • Esophageal stricture. When the esophagus is continually exposed to stomach acid, it causes damages that can lead to the formation of scar tissue. This scar tissue causes narrowing of food pathways that makes swallowing difficult. 
  • Esophageal ulcer. Stomach acid can cause the formation of open sores (ulcers) as tissue in the esophagus wears away. An esophageal ulcer causes several discomforts such as pain, bleeding, and difficulty swallowing. 
  • Esophageal web and rings. This is a condition where the tissue in the esophagus forms a structure called  “web” or “rings” that blocks or narrows the food pathway. Similar to the first two complications, the most common symptom is dysphagia or difficulty swallowing. While the cause of esophageal webs is relatively unknown, some pieces of evidence can link GERD to its development. 

Acid Reflux and Its Treatment

For many patients, lifestyle changes together with over-the-counter medications are enough to control acid reflux symptoms. While antacids can help neutralize the acid in the stomach, they may also cause diarrhea or constipation, especially when abused. The best antacids to use to help counteract gastrointestinal side effects are those that contain both magnesium hydroxide and aluminum hydroxide. 

Sometimes, however, antacids alone won’t work and your doctor may try other medications that need a prescription such as:

  • Foaming agents — which cover stomach contents with foam to prevent reflux.
  • H2 blockers — bind to histamine type 2 receptors and blocks acid production.
  • Proton Pump Inhibitors (PPI) — bind to proton pumps in the stomach to reduce the amount of acid production.
  • Prokinetics — reduce acid reflux by strengthening the LES and helping empty the stomach contents faster.  

If lifestyle changes and medical treatment aren’t enough and the acid reflux continues to interfere with your quality of life, your doctor could recommend surgery as a last resort. 

Final thoughts

For the most part, acid reflux can be controlled and managed with changes in lifestyle and occasional medical treatment as prescribed by your doctor. Losing weight, avoiding alcohol, quitting smoking, and modifying eating habits are some of the few sacrifices you need to make to mitigate reflux. In spite of that, the challenge remains in detecting and diagnosing acid reflux as it can easily be mistaken for other diseases. Some patients don’t even seek consultation and are self-medicating, which could make matters worse. 

At the end of the day, the best way to deal with acid reflux is to be thoroughly evaluated by a qualified physician as soon as you experience reflux symptoms (including the atypical symptoms) more than twice a week. 

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