Reflux Disease

Reflux is the escape of highly acid stomach contents upwards, through the junction between the stomach and the gullet, into the gullet and the throat.

Normally the muscles between the stomach and the gullet contract and close the passage, so the contents cannot come up. In some conditions they do.

When the acid reaches the gullet, it is called gastro-oesophageal reflux. When it reaches the throat, it is called laryngopharyngeal reflux.

Reflux affects about 20 per cent of the population. Even so, the diagnosis is sometimes missed, because patients do not take it seriously and doctors do not think of it first.

What makes reflux easier

• Loosening of the muscles that act as a one-way valve towards the stomach
• A hiatus hernia
• Anything that raises the pressure inside the abdomen, such as obesity and pregnancy
• Too much acid produced by the stomach
• Food passing more slowly from the stomach into the intestines
• Smoking and alcohol
• Eating very fatty food
• Sending too much food into the stomach at once
• Lying on your back

What it feels like

Some patients have no complaints at all. Others are very uncomfortable, depending on how strong the reflux is.

When the acid reaches only the gullet, it causes burning in the chest, indigestion, hiccups and sometimes a chest pain that feels like heart pain.

When the acid rises to the throat, it causes a tickle, a feeling of a foreign body or a lump in the throat, a long-standing cough and hoarseness.

The course of the disease

Gastro-oesophageal reflux disease is common. The typical complaints are a bitter and sour taste coming into the mouth from time to time, and burning in the gullet. A gastroenterologist should follow the patient.

The disease lasts a lifetime and usually comes and goes. Simple changes in how you live, together with medicines, usually control it.

In long-standing disease, the damage the acid causes at the lower end of the gullet should be examined and followed with endoscopy.

Do not stop your medicine, change its dose or switch to another one without talking to the doctor who follows you.

See a gastroenterologist at once if the character of your usual complaints changes, or if difficulty swallowing and weight loss appear. Reflux is typically not a malignant condition, though very rarely it prepares the ground for cancer of the gullet.

What the doctor sees

In laryngopharyngeal reflux the examination shows no very typical findings. The clearest is redness and irritation at the back part of the vocal cords. Apart from coarsening and swelling of the cords, there may be nothing else to see.

The most important thing in diagnosing reflux is what the patient says. Reflux is suspected from the complaints. Redness and irritation of the vocal cords, especially at the back, strengthens the diagnosis.

Tests that confirm it

• 24-hour acid (pH) measurement in the gullet. A device passed through the nose into the gullet measures acid at its upper and lower end.
• Endoscopy. An endoscope passed through the mouth looks for the damage the acid has caused in the gullet and the stomach.
• Barium swallow (oesophagography). The patient swallows a contrast medium and X-rays are taken. This shows structural abnormalities such as a hiatus hernia, and the backflow of stomach contents.
• Oesophageal manometry. Pressure measurements in the gullet.

The link with the voice

The ear, nose and throat symptom that laryngopharyngeal reflux causes most often is a change in the voice. When patients who come with hoarseness are investigated, repeated attacks of inflammation of the vocal cords are found.

Among patients with the functional voice disorders grouped as muscle tension dysphonia, which are thought to come from using the voice wrongly and too much, laryngopharyngeal reflux was found in 70 per cent.

Laryngopharyngeal reflux was found in 84 per cent of patients with cancer of the larynx.

Treatment

Treatment has three steps: measures, medicines and surgery.

Patients with reflux should

• Not lie on their back, or lie with the head higher than the stomach
• Not eat enough to fill the stomach
• Eat nothing in the 3 hours before bed, and avoid tea, coffee, alcohol, cola drinks and chocolate above all
• Stop smoking
• Not lie down straight after a meal
• Lose excess weight
• Not take medicines that raise stomach acid, aspirin and some painkillers above all
• Not wear trousers or skirts that are tight at the waist
• Not keep clearing the throat when it tickles, but drink water or swallow instead
• Cut down coffee, cola drinks, cocoa, mint, dill, parsley, alcohol and cigarettes, which are known to lower the pressure of the valve at the lower gullet