How can you naturally manage acid reflux symptoms. What lifestyle changes help reduce GERD discomfort. Which foods should be avoided to prevent heartburn. How does sleep position affect acid reflux. Why is weight management important for GERD control. What exercises can trigger acid reflux symptoms. How do carbonated beverages impact reflux.

Understanding Acid Reflux and GERD: Symptoms and Causes

Acid reflux occurs when stomach acid flows back into the esophagus, causing a range of uncomfortable symptoms. When these symptoms become chronic, it’s known as gastroesophageal reflux disease (GERD). Understanding the underlying causes and recognizing the symptoms is crucial for effective management.

Common Symptoms of Acid Reflux and GERD

• Heartburn (pain in the upper abdomen and chest)
• Regurgitation of stomach contents
• Chest pain
• Nausea
• Difficulty swallowing
• Chronic cough or hoarseness

These symptoms can significantly impact quality of life and may lead to more serious health complications if left untreated. Fortunately, there are several natural ways to manage and reduce acid reflux symptoms without relying on medication.

Dietary Modifications to Alleviate Acid Reflux

Making changes to your diet is often the first line of defense against acid reflux. By identifying and avoiding trigger foods, you can significantly reduce the frequency and severity of symptoms.

Foods to Avoid

Certain foods are more likely to trigger acid reflux symptoms in susceptible individuals. These include:

• Mint
• Fatty foods
• Spicy foods
• Tomatoes
• Onions and garlic
• Coffee and tea
• Chocolate
• Alcohol

Is eliminating these foods necessary for everyone with acid reflux? Not necessarily. Each person’s triggers may be different, so it’s important to pay attention to your body’s reactions and adjust your diet accordingly. You might consider keeping a food diary to identify patterns between what you eat and when symptoms occur.

Eating Habits That Help Reduce Reflux

How you eat can be just as important as what you eat when it comes to managing acid reflux. Consider adopting these habits:

1. Eat smaller, more frequent meals instead of large ones
2. Chew food thoroughly and eat slowly
3. Avoid lying down immediately after meals
4. Finish eating at least three hours before bedtime

By implementing these dietary changes, many people find significant relief from their acid reflux symptoms without the need for medication.

Lifestyle Adjustments for Better Acid Reflux Management

Beyond diet, several lifestyle modifications can help control acid reflux symptoms. These changes can have a profound impact on your overall digestive health and well-being.

Sleep Position and Timing

How you sleep can greatly affect the occurrence of nighttime reflux. Try these strategies:

• Elevate the head of your bed by 6-8 inches
• Use a wedge-shaped pillow to keep your upper body elevated
• Avoid sleeping on your right side, as this can increase reflux

Why does elevating your head help? Gravity helps keep stomach contents where they belong, reducing the likelihood of acid flowing back into the esophagus during sleep.

Exercise and Physical Activity

Regular exercise is beneficial for overall health, but certain activities can exacerbate acid reflux symptoms. To minimize discomfort:

• Avoid vigorous exercise for at least two hours after eating
• Choose low-impact activities that don’t involve bending or lying down
• Consider gentle post-meal walks to aid digestion

Can exercise actually help reduce acid reflux in the long term? Yes, maintaining a healthy weight through regular physical activity can decrease pressure on the lower esophageal sphincter, potentially reducing reflux episodes.

The Impact of Weight Management on Acid Reflux

Excess weight, particularly around the abdomen, can significantly contribute to acid reflux symptoms. Losing weight, if you’re overweight or obese, can be one of the most effective ways to alleviate GERD symptoms.

How Excess Weight Affects Reflux

Extra pounds increase pressure on the stomach and lower esophageal sphincter, making it easier for stomach contents to flow back into the esophagus. Even modest weight loss can lead to noticeable improvements in acid reflux symptoms.

Strategies for Healthy Weight Loss

• Focus on a balanced diet rich in fruits, vegetables, and lean proteins
• Practice portion control
• Incorporate regular physical activity into your routine
• Stay hydrated with water instead of sugary or carbonated beverages

By adopting these healthy habits, you’re not only addressing acid reflux but also improving your overall health and reducing the risk of other weight-related conditions.

Avoiding Carbonated Beverages and Their Effect on Acid Reflux

Carbonated drinks, including sodas and sparkling water, can exacerbate acid reflux symptoms. The bubbles in these beverages expand in the stomach, increasing pressure and promoting reflux.

Alternatives to Carbonated Drinks

Instead of carbonated beverages, opt for:

• Still water
• Herbal teas (avoiding mint and those containing caffeine)
• Non-citrus fruit infusions

Do all carbonated drinks have the same effect on reflux? While all carbonated beverages can potentially trigger symptoms, those containing caffeine or alcohol may be particularly problematic for some individuals.

The Role of Smoking Cessation in Acid Reflux Relief

Smoking is a known contributor to acid reflux and can worsen GERD symptoms. Nicotine relaxes the lower esophageal sphincter, allowing stomach contents to flow back more easily.

Benefits of Quitting Smoking for GERD

Quitting smoking can lead to:

• Improved function of the lower esophageal sphincter
• Reduced frequency and severity of reflux episodes
• Better overall digestive health

How quickly can you expect to see improvements in reflux symptoms after quitting smoking? While individual experiences vary, many people notice a reduction in symptoms within a few weeks of quitting.

Reviewing Medications and Their Impact on Acid Reflux

Certain medications can contribute to or exacerbate acid reflux symptoms. It’s important to review your current medications with your healthcare provider to identify any potential triggers.

Common Medications That May Affect Reflux

• Postmenopausal estrogen
• Tricyclic antidepressants
• Non-steroidal anti-inflammatory drugs (NSAIDs)
• Bisphosphonates

Can changing medications help reduce reflux symptoms? In some cases, switching to alternative medications or adjusting dosages can lead to significant improvements in acid reflux symptoms. Always consult with your healthcare provider before making any changes to your medication regimen.

Natural Remedies and Supplements for Acid Reflux Relief

While lifestyle changes are often the most effective approach to managing acid reflux, some natural remedies and supplements may provide additional relief.

Herbal and Natural Options

• Ginger: Known for its anti-inflammatory properties
• Licorice root: May increase mucus production in the digestive tract
• Aloe vera: Can help soothe the esophagus
• Apple cider vinegar: Some find it helpful, though scientific evidence is limited

Are these natural remedies effective for everyone? The effectiveness of natural remedies can vary greatly from person to person. It’s important to approach them with caution and consult with a healthcare provider before trying new supplements, especially if you have other health conditions or are taking medications.

Probiotics and Digestive Enzymes

Some studies suggest that probiotics and digestive enzymes may help improve overall digestive health and potentially reduce acid reflux symptoms. These supplements work by:

• Balancing gut bacteria
• Improving digestion and nutrient absorption
• Potentially reducing inflammation in the digestive tract

While more research is needed to fully understand their impact on GERD, many people find these supplements beneficial as part of a comprehensive approach to managing acid reflux.

Stress Management and Its Connection to Acid Reflux

Stress and anxiety can exacerbate acid reflux symptoms in many individuals. While stress doesn’t directly cause GERD, it can lead to behaviors that trigger or worsen symptoms, such as overeating, consuming alcohol, or smoking.

Stress-Reduction Techniques

Incorporating stress-management strategies into your daily routine can help alleviate acid reflux symptoms:

• Practice mindfulness meditation
• Engage in regular exercise
• Try deep breathing exercises
• Consider cognitive-behavioral therapy
• Prioritize adequate sleep

How does reducing stress help with acid reflux? Stress reduction can lower the production of stomach acid, improve digestion, and help maintain a healthy lifestyle that supports overall digestive health.

When to Seek Medical Attention for Acid Reflux

While many cases of acid reflux can be managed with lifestyle changes and natural remedies, it’s important to recognize when professional medical attention is necessary.

Warning Signs That Require Medical Evaluation

• Persistent symptoms despite lifestyle changes
• Difficulty swallowing or pain while swallowing
• Unexplained weight loss
• Chest pain or pressure (which could also indicate heart problems)
• Chronic cough or hoarseness that doesn’t improve

Should you continue self-management if symptoms persist? If you’ve tried lifestyle modifications and natural remedies without significant improvement, or if you experience any of the warning signs listed above, it’s crucial to consult with a healthcare provider. They can help rule out more serious conditions and provide appropriate treatment options.

Diagnostic Tests for GERD

To diagnose GERD and assess its severity, your doctor may recommend:

• Endoscopy: To visually examine the esophagus and stomach
• pH monitoring: To measure acid levels in the esophagus
• Esophageal manometry: To evaluate muscle function in the esophagus

These tests can help determine the best course of treatment and whether additional interventions are necessary beyond lifestyle changes and over-the-counter remedies.

Combining Strategies for Optimal Acid Reflux Management

Effectively managing acid reflux often requires a multifaceted approach. By combining various strategies, you can create a comprehensive plan tailored to your individual needs and triggers.

Creating a Personalized Management Plan

Consider incorporating the following elements into your acid reflux management strategy:

• Dietary modifications and trigger food avoidance
• Regular exercise and weight management
• Stress reduction techniques
• Sleep position adjustments
• Natural remedies or supplements (as advised by a healthcare provider)
• Medication review and adjustments (if applicable)

How can you determine which strategies work best for you? Keep a journal to track your symptoms, diet, and lifestyle factors. This can help you identify patterns and refine your approach over time.

The Importance of Consistency and Patience

Managing acid reflux is often a process of trial and error. It’s important to:

• Be consistent with your chosen strategies
• Give new approaches adequate time to show effects
• Stay in communication with your healthcare provider
• Be willing to adjust your plan as needed

Remember that significant improvements in acid reflux symptoms may take time. Patience and persistence are key to finding the right combination of strategies that work for you.

Emerging Research and Future Directions in Acid Reflux Management

As our understanding of acid reflux and GERD continues to evolve, new research is shedding light on potential treatment approaches and management strategies.

Promising Areas of Research

• Microbiome studies: Investigating the role of gut bacteria in GERD
• Genetic factors: Exploring genetic predispositions to acid reflux
• Novel surgical techniques: Developing less invasive procedures for severe cases
• Personalized medicine: Tailoring treatments based on individual factors

How might future research change acid reflux management? As we gain a deeper understanding of the underlying mechanisms of GERD, we may see more targeted and effective treatment options emerge, potentially reducing the need for long-term medication use.

The Role of Technology in GERD Management

Advancements in technology are also playing a role in acid reflux management:

• Wearable devices for pH monitoring
• Apps for tracking symptoms and identifying triggers
• Telemedicine options for remote consultations with specialists

These technological innovations may make it easier for individuals to monitor their symptoms, communicate with healthcare providers, and make informed decisions about their treatment plans.

By staying informed about the latest research and developments in acid reflux management, you can work with your healthcare provider to ensure you’re utilizing the most up-to-date and effective strategies for managing your symptoms. Remember that while natural remedies and lifestyle changes can be highly effective, severe or persistent symptoms should always be evaluated by a medical professional to rule out more serious conditions and determine the best course of action.

9 ways to relieve acid reflux without medication

If you are sounding a little hoarse and have a sore throat, you may be bracing for a cold or a bout of the flu. But if you’ve had these symptoms for a while, they might be caused not by a virus but by a valve — your lower esophageal sphincter.

That’s the muscle that controls the passage between the esophagus and stomach, and when it doesn’t close completely, stomach acid and food flow back into the esophagus. The medical term for this process is gastroesophageal reflux; the backward flow of acid is called acid reflux. Acid reflux can cause sore throats and hoarseness, and may literally leave a bad taste in your mouth.

What is GERD?

When acid reflux produces chronic symptoms, it is known as gastroesophageal reflux disorder, or GERD. Symptoms of GERD can include:

• heartburn — pain in the upper abdomen and chest — is the most common symptom of GERD
• regurgitation, or stomach contents coming back up through your esophagus and into your throat or mouth, which may cause you to taste food or stomach acid
• chest pain
• nausea
• problems swallowing or pain while swallowing
• symptoms of complications in the mouth, throat, or lungs, such as chronic cough or hoarseness.

Three conditions — poor clearance of food or acid from the esophagus, too much acid in the stomach, and delayed stomach emptying — contribute to acid reflux.

If not treated, GERD can lead to more serious health problems. In some cases, you might need medicines or surgery. However, many people can improve their symptoms of GERD through self-care and lifestyle changes.

How to get rid of acid reflux

If you’ve been having repeated episodes of heartburn — or any other symptoms of acid reflux — you might try the following:

1. Eat sparingly and slowly

When the stomach is very full, there can be more reflux into the esophagus. If it fits into your schedule, you may want to try what is sometimes called “grazing” — eating small meals more frequently rather than three large meals daily.

2. Avoid certain foods

People with acid reflux were once instructed to eliminate all but the blandest foods from their diets. But that’s no longer the case. We’ve evolved from the days when you couldn’t eat anything.

But there are still some foods that are more likely than others to trigger reflux, including:

• mint
• fatty foods
• spicy food
• tomatoes
• onions
• garlic
• coffee
• tea
• chocolate
• alcohol.

If you eat any of these foods regularly, you might try eliminating them to see if doing so controls your reflux, and then try adding them back one by one. The Foodicine Health website at www.foodicinehealth.org has diet tips for people with acid reflux and GERD, as well as for other gastrointestinal disorders.

3. Don’t drink carbonated beverages

They make you burp, which sends acid into the esophagus. Drink flat water instead of sparkling water.

4. Stay up after eating

When you’re standing, or even sitting, gravity alone helps keeps acid in the stomach, where it belongs. Finish eating three hours before you go to bed. This means no naps right after lunch, and no late suppers or midnight snacks.

5. Don’t move too fast

Avoid vigorous exercise for a couple of hours after eating. An after-dinner stroll is fine, but a more strenuous workout, especially if it involves bending over, can send acid into your esophagus.

6. Sleep on an incline

Ideally, your head should be six to eight inches higher than your feet. You can achieve this by using extra-tall bed risers on the legs supporting the head of your bed. If your sleeping partner objects to this change, try using a foam wedge support for your upper body. Don’t try to create a wedge by stacking pillows. They won’t provide the uniform support you need.

7. Lose weight if it’s advised

Increased weight spreads the muscular structure that supports the lower esophageal sphincter, decreasing the pressure that holds the sphincter closed. This leads to reflux and heartburn.

8.

If you smoke, quit

Nicotine may relax the lower esophageal sphincter.

9. Check your medications

Some — including postmenopausal estrogen, tricyclic antidepressants, and anti-inflammatory painkillers — can relax the sphincter, while others — particularly bisphosphonates like alendronate (Fosamax), ibandronate (Boniva), or risedronate (Actonel), which are taken to increase bone density — can irritate the esophagus.

14 Ways to Prevent Heartburn and Acid Reflux

You may be able to prevent or reduce acid reflux symptoms with a few lifestyle changes, including eating dinner earlier, adjusting your sleeping position, and avoiding certain acidic foods and drinks.

Most of us are all too familiar with the painful, burning sensation in the center of the chest that’s associated with heartburn.

In fact, between 18.1-27.8% of adults in the United States experience gastroesophageal reflux disease (GERD), a common condition that causes heartburn. GERD occurs when acid is pushed up from the stomach back into the esophagus, which leads to a heartburn sensation.

Although people often use medications to treat acid reflux and heartburn, many lifestyle modifications can also help you reduce symptoms and improve your quality of life.

Here are 14 natural ways to reduce your acid reflux and heartburn, all backed by scientific research.

Research shows that sleeping on your left side can help decrease acid reflux at night. According to one review, lying on your left side may decrease acid exposure in the esophagus by up to 71%.

Although the reason is not entirely clear, it could be explained by the anatomy of the esophagus. The esophagus enters the right side of the stomach, so sleeping on the left side keeps acid away from the lower esophageal sphincter.

The sphincter is normally responsible for keeping acid and your undigested food from coming back up to your throat, but different things can cause this to malfunction, such as your sleeping position, for example.

Summary

If you experience acid reflux at night, try sleeping on the left side of your body.

Some people experience acid reflux at night, which can affect sleep quality and make it more difficult to fall asleep.

One review of four studies found that elevating the head of the bed decreased acid reflux and improved symptoms like heartburn and regurgitation in people with GERD.

Summary

Elevating the head of your bed may reduce your reflux symptoms at night.

According to the International Foundation for Gastrointestinal Disorders (IFGD), if you experience acid reflux, you should try to eat dinner a few hours before going to bed.

Consider also having your big meal of the day at lunch so that your dinner can be lighter. Research shows that going to bed with undigested food, particularly if you’ve eaten a heavy meal, can worsen your symptoms at night.

Summary

Eating close to bedtime may worsen acid reflux symptoms at night.

4. Opt for cooked onions instead of raw

Raw onions are a common trigger for gastrointestinal symptoms like acid reflux and heartburn.

This is because raw onions are more difficult to digest and might irritate the lining of the esophagus, causing worsened heartburn. If you like to eat onions, consider eating them cooked.

Summary

Some people experience worsened heartburn and other reflux symptoms after eating raw onions.

5. Eat smaller, more frequent meals

The lower esophageal sphincter is a muscle that acts as a valve between the stomach and the esophagus. In people with acid reflux, this muscle is weakened or dysfunctional, causing acid to flow up into the esophagus.

Unsurprisingly, many reflux symptoms take place after a meal. Therefore, eating smaller, more frequent meals throughout the day may help reduce symptoms of acid reflux.

Summary

Acid reflux usually increases after meals, and larger meals seem to make it worse.

6. Maintain a moderate weight

However, if you have excess belly fat, the pressure in your abdomen may become so high that the lower esophageal sphincter gets pushed upward, away from the support of the diaphragm.

This condition, known as hiatal hernia, is considered the leading cause of GERD.

Furthermore, research shows that having excess belly fat may be associated with a higher chance of acid reflux and GERD. Obesity, in general, is associated with a greater chance of getting GERD due to greater pressure within the abdominal cavity.

If you’re interested in weight loss as a way to manage acid reflux, speak with your doctor first to determine if it’s right for you and, if so, how you can lose weight safely and sustainably.

Summary

Losing belly fat and maintaining a moderate weight might relieve some of your symptoms of GERD.

7. Follow a low carb diet

Research shows that eating a high carb diet can worsen acid reflux, and reducing your carb intake can help reduce the symptoms of GERD.

Some researchers suspect that undigested carbs may cause bacterial overgrowth and increased pressure inside the abdomen, which could contribute to acid reflex.

Having too many undigested carbs in your digestive system can often cause not only gas and bloating but also burping.

Summary

Some research suggests that poor carb digestion and bacterial overgrowth in the small intestine may result in acid reflux.

8. Limit your alcohol intake

Drinking alcohol may increase the severity of acid reflux and heartburn. Research has shown that higher alcohol intake could be linked to increased symptoms of acid reflux.

That’s because alcohol increases stomach acid, relaxes the lower esophageal sphincter, and impairs the ability of the esophagus to clear out acid.

Summary

Excessive alcohol intake can worsen acid reflux symptoms.

9. Don’t drink too much coffee

Research has found that coffee also temporarily may relax the lower esophageal sphincter, increasing the chance of acid reflux.

However, research findings are inconclusive, with older research not finding an association between coffee consumption and acid reflux symptoms

Summary

Evidence suggests that coffee may make acid reflux and heartburn worse.

10. Limit your intake of carbonated beverages

Research shows that regular consumption of carbonated or fizzy beverages, including soft drinks, club soda, and seltzer, could be linked to a higher chance of reflux.

This may be because the carbon dioxide that gives these drinks their bubbles can cause you to burp more, which can increase the acid coming out of your esophagus.

One study found that carbonated soft drinks, in particular, worsened certain acid reflux symptoms, including heartburn, fullness, and burping.

Summary

Drinking carbonated beverages temporarily increases the frequency of burping, which may promote acid reflux.

11. Don’t drink too much citrus juice

Many types of citrus juice, including orange juice and grapefruit juice, are considered common triggers for heartburn.

These ingredients are highly acidic and contain compounds like ascorbic acid, which could cause indigestion if you consume them in large amounts and may irritate the lining of your esophagus.

While citrus juice probably doesn’t cause acid reflux directly, it could make your heartburn worse temporarily.

Summary

Some people with acid reflux report that drinking citrus juice makes their symptoms worse.

12. Avoid mint, if needed

Peppermint and spearmint are common ingredients used to make herbal tea and add flavor to foods, candy, chewing gum, mouthwash, and toothpaste.

However, research shows that peppermint oil may decrease lower esophageal sphincter pressure, which may cause heartburn. Another study showed that menthol, a compound found in mint, could worsen reflux in people with GERD.

For this reason, it’s best to avoid mint if you feel that it makes your heartburn worse.

Summary

A few studies indicate that mint and some of the compounds it contains may aggravate heartburn and other reflux symptoms.

Fried foods and some other fatty foods may also be a trigger for GERD. Some research shows they may lead to heartburn. Examples include:

• fried foods
• potato chips
• pizza
• bacon
• sausage

High-fat foods like these may contribute to heartburn by causing bile salts to be released into your digestive tract, which may irritate your esophagus.

They also appear to stimulate the release of cholecystokinin (CCK), a hormone in your bloodstream that may relax the lower esophageal sphincter, allowing stomach contents back into the esophagus.

One study looked at what happened when people with GERD ate high fat foods. More than half of the participants who had reported food triggers said they experienced GERD symptoms after eating high fat, fried foods.

That said, you do need some fat to stay healthy. Learn more about healthy fats vs unhealthy fats.

Summary

Foods that are high in fat may trigger GERD symptoms, including heartburn, in some people.

Your saliva helps to neutralize the acid that comes up from your stomach to your esophagus. But smoking can reduce the amount of saliva in your mouth.

Smoking also lowers the pressure in the lower esophageal sphincter, which can cause coughing and acid reflux. Research shows that quitting smoking can reduce the severity of your acid reflux or GERD.

Learn more about smoking and acid reflux.

How do you get rid of acid reflux fast?

The quickest way to get relief from acid reflux might be to take an antacid like Tums. Learn more about treatments for GERD and acid reflux.

What can I drink to get rid of acid reflux?

Certain herbal teas, low fat or plant-based milk, non-citrus fruit juice, coconut water, and sometimes just regular water may help reduce your acid reflux symptoms. Learn what to drink for acid reflux.

Will acid reflux go away naturally?

If you have temporary heartburn related to something you are or a mild form of GERD, your acid reflux may go away on its own after a few hours. In more serious cases, you may need medication and lifestyle changes to manage your symptoms.

The bottom line

Heartburn is an uncomfortable issue that can be caused by a variety of different factors. If you notice that your symptoms are worse after you have certain foods or beverages, it’s reasonable to limit or avoid these things.

Although there are many medications and treatment options available to ease heartburn, making a few simple changes to your diet and lifestyle may also be beneficial.

Try some of the tips above to find what works for you to reduce heartburn and acid reflux.

Nasopharyngeal reflux. What do we know today?

Nasopharyngeal reflux (NPR) – high laryngopharyngeal reflux (LPR), which is a retrograde movement of stomach contents, including hydrochloric acid, enzymes (pepsin, trypsin) and even bile, into the larynx and pharynx, which leads to ENT symptoms organs [1]. LPR, in turn, is an extraesophageal manifestation of gastroesophageal reflux disease (GERD) [2].

Otorhinolaryngologists have to deal with a large number of pathological processes associated with GERD and LPR. Thus, out of 40,317 patients with GERD, 93% initially sought help from an otorhinolaryngologist [3]. Gastroesophageal reflux (GER) is the main cause of laryngeal pathology, which can result in a small amount of reflux and a small number of reflux episodes [4].

According to J. Koufman [1], even one episode of reflux above the upper esophageal sphincter should be considered pathological. More than 50% of patients with various symptoms of diseases of the larynx, such as chronic laryngitis, laryngomalacia, vocal cord nodules, functional disorders of the vocal apparatus, contact ulcers and granulomas, Reinicke’s edema, laryngostenosis, laryngeal carcinoma, chronic cough, mucus expectoration, laryngospasm, stridor, are caused by reflux [5]. In addition, the involvement of LPR in the development of laryngeal cancer has been confirmed [6].

It should be noted that the influence of GER is not limited only to the larynx and extends upward to the entire mucous membrane of the pharynx. Clinical manifestations of LPR are diverse. NFR plays an important role in the etiology of adenoid hypertrophy in children [6]. E.P. Karpova et al. [7] revealed a correlation between the course of chronic adenoiditis and the presence of pathological GER in a child.

It has been suggested that high gastric reflux contributes to pharyngeal tonsil hypertrophy in adults [8]. A relationship has been established between high reflux of gastric contents and symptoms of chronic rhinosinusitis (CRS) in children [9], CRS in adults [10]. There is a theory that GER is the cause of difficulty in nasal breathing without visible intranasal pathology in patients who constantly use vasoconstrictor sprays [11]. J. Napierkowski and R. Wong suggested a link between LPR and vasomotor rhinitis [5].

Chronic irritation of the mucous membranes of the nose can lead to the development of an inflammatory process and swelling of the tissues. As a result, the examination reveals: hyperemia of the mucous membranes, an abundance of mucous secretions, CRS, inflammation of the nasolacrimal canal, dacryostenosis, insufficiency of the Gasner valve [12]. NFR of gastric contents can also contribute to long-term nasopharyngitis [13].

In the study by V.E. Kokorina [14], the concomitant diagnosis of GERD was established in 58.7% of patients with pathology of the upper respiratory tract, poorly amenable to traditional conservative therapy, of which: 75.6% with pathology of the larynx, 46.2% with pathology of the pharynx, 12, 3% — with pathology of the nose and paranasal sinuses, 17.2% — with pathology of the middle ear and auditory tube [14].

Diagnosis of NFR is difficult. There are no reliable methods with high sensitivity and specificity for determining NFR as the cause of certain diseases. Previously, the “gold standard” test for detecting LPR was ambulatory daily pH monitoring using a transnasal double probe with simultaneous placement in the esophagus and pharynx [15].

Depending on the pH of the gastric juice, there are:

– acid reflux (pH <4) - stomach contents, consisting mainly of hydrochloric acid;

– weak acid reflux (pH 4-7) – mixed contents of the stomach;

– weakly alkaline reflux (pH <7) - stomach contents, consisting mainly of pepsin and bile acids from the duodenum [16].

In this case, pathological reflux was considered when the patient had pH <4.0 in the esophagus for 0.1% of the study time [17]. However, the laryngopharynx, oropharynx, and nasopharynx lack an effective desorbing movement of esophageal peristalsis, and this allows hydrochloric acid and pepsin to remain in place longer, causing further irritation. The epithelium of all parts of the pharynx is rather thin compared to the epithelium of the esophagus and is inherently poorly adapted to deal with caustic chemical damage from pepsin and acid [18]. Therefore, LPR symptoms require much less acid exposure than GERD symptoms (heartburn and belching). The upper limit of the norm for episodes of reflux from the stomach into the esophagus is considered to be 50 events per day, however, as many as 4 episodes of reflux of gastric contents into the laryngopharynx can cause symptoms of LPR.

Experimental topical application of acid to the larynx 3 times a week can lead to visible damage [19]. Therefore, GER penetrating above the upper esophageal sphincter should never be considered physiological, as even a single episode of hypopharyngeal pH <4 can cause characteristic symptoms and should be diagnosed as LPR.

Currently, 24-hour pharyngeal pH monitoring is not commonly used in clinical practice due to its low sensitivity (70–80%) and specificity [20]. One possible explanation for the low reliability of daily monitoring of pharyngeal pH is that most of the reflux events in it are caused by aerosol molecules that are not detected by pH catheters [21]. And the study of pH-metry cannot fix the presence of non-acidic or weakly acidic reflux, does not take into account the damaging effect of other components of the refluxate [22].

A systematic review of 11 studies using 24-hour dual-sensor pH monitoring in the esophagus and pharynx in patients with LPR compared with controls found no significant difference in the prevalence of pharyngeal reflux between the 2 groups, and only a small percent of patients with clinically diagnosed laryngitis had acid reflux in the pharynx [23].

Thus, the conventional pH recording system is unable to detect the presence of mild and alkaline pharyngeal reflux, and some patients may experience refractory symptoms on proton pump inhibitor (PPI) treatment due to non-acid or mild acid reflux that cannot be detected by dual probe monitoring alone pH of the esophagus and pharynx.

In patients with an incomplete response to acid suppression, the damaging effect is likely due to pepsin or bile, or both [24]. There are limited data and no consensus on the optimal methodology for pH testing in patients with extraesophageal symptoms.

The American Society of Gastroenterology guidelines recommend that patients with a low pre-test likelihood of GERD (atypical symptoms without heartburn or regurgitation) have a pH test if a PPI is negative. In a normal distal esophagus with no acid exposure, the presence of GERD is very unlikely, so PPI therapy may be stopped and diagnostic efforts should be focused on identifying an alternative etiology [25]. However, the American Society of Otorhinolaryngology does not recommend 24-hour esophageal and pharyngeal pH monitoring using 2 probes [26].

The poor sensitivity and reliability of 24-hour monitoring of esophageal and pharyngeal pH for detecting LPR has led to the hypothesis that non-acid reflux may cause symptoms to persist in patients after empiric PPI administration. This helped not only to detect liquid and gaseous refluxes, but also to distinguish between acidic, weakly acidic, and weakly alkaline reflux events in the esophagus [27].

It is now possible to accurately determine both the total amount of acid and non-acid reflux and the correlation between esophageal symptoms and various chemical types of reflux [28]. For this purpose, a pH monitoring system in the nasopharynx Restech Dx-pH Measurement System (Restech Corporation) was developed, which allows measuring changes in pH both in liquid and in aerosol droplets [29]. D. Scott and R. Simon conducted pH monitoring of the nasopharynx in 235 patients. Of these, NFR was detected in 113 (48%). The reflux pattern was observed in 62 (55%) patients only in the supine position, in 4 (4%) patients in the upright position, and in 47 (20%) patients both in the upright position and in the supine position [13].

Clearly, prospective studies are needed to better understand the clinical applications of oropharyngeal pH monitoring devices. Unfortunately, in Russia, the system for measuring pH in the oropharynx is not registered.

In 2017, a device was developed to measure the mucosal impedance of the esophageal epithelium. This minimally invasive device, which can be used through the working channel of an endoscope, provides measurement of impedance in the esophagus within seconds and is able to differentiate between GERD, non-erosive reflux disease, eosinophilic esophagitis, and the physiological state of healthy people based on the pattern of impedance in the esophagus. The results of a prospective longitudinal cohort study in 41 patients showed that in the presence of predominantly symptoms associated with extraesophageal reflux, esophageal impedance measurements were significantly lower compared with patients without signs of acid reflux [30]. However, impedancemetry data have not yet been evaluated on the laryngeal mucosa. Studies continue to be conducted using this technology to diagnose and predict response to LPR treatment [20].

Pepsin is the active form of pepsinogen, a peptidase enzyme secreted by the glandular cells of the stomach. Pepsin digests proteins by hydrolyzing peptide bonds. Exiting the stomach along with other stomach contents in GER, pepsin damages the mucous membranes of the structures it comes into contact with. By digesting intercellular junctions (gap junctions), pepsin impairs the epithelial barrier [31]. The presence of pepsin in LPR is determined in the pharynx [32].

Chronic irritation of the nasopharynx and surrounding structures by pepsin can lead to tissue inflammation, pharyngeal tonsil hypertrophy, or otitis media. Physical examination may reveal: hyperemia of the mucous membranes, the presence of mucus in the nasopharynx, nasopharyngitis, hypertrophy of the pharyngeal tonsil, swelling of the mouth of the auditory tubes, signs of inflammation in the middle ear.

H. Luo et al. [33] investigated the presence of pepsinogen in hypertrophied pharyngeal tonsils in healthy volunteers and patients with otitis media. Pepsinogen expression in the epithelium covering the pharynx of the pharyngeal tonsil was assessed by immunohistochemistry. There were higher concentrations of pepsinogen in the group of patients with exudative otitis media compared to the control group. In addition, the presence of pepsin was also confirmed in the middle ear fluid in the study group. J. Lieu et al. [34] conducted a similar study evaluating the presence of pepsin in fluid collected from the middle ear during paracentesis in children with chronic or recurrent exudative otitis media.

The presence of pepsin in the collected material was detected in approximately 70% of patients. A. Tasker et al. also studied the presence of pepsin in fluid collected from the middle ear during paracentesis in patients with exudative otitis media. Of the 65 patients in the group, pepsin was identified in the material collected from 59 (91%) [35]. G. Iannella et al. [12] described higher concentrations of pepsin in the tears of patients with LPR compared with the group of patients without reflux. Because pepsin plays a critical role in the pathophysiology of LPR, immunohistochemical analysis of tissue samples from the nasopharynx and larynx has been proposed to determine its presence in exposed tissues [36]. Two methods have been developed to identify pepsin in pharyngeal secretions [37]:

1) PEP-TEST, which requires the transfer of centrifuged secretions from the nasopharynx and oropharynx onto test strips. If pepsin is present in the secrets, it binds to the reagents and two lines appear on the test strip [38];

2) enzyme immunoassay (ELISA pepsin), which detects pepsin in the studied secrets using antibodies conjugated with the corresponding enzyme [37].

In a systematic review of publications from the PubMed (MEDLINE), Cochrain, EMBASE, SUM search, and Web of Science databases regarding pepsin as an LPR biomarker, 10 out of 12 studies found statistically significant differences in patients compared with healthy controls. The review authors concluded that the presence of pepsin in tissues and saliva could be a reliable marker in patients with LPR. The sensitivity of the method was 64%, the specificity was 68% [39].

T. Hoppo et al. [40] used a more accurate biomarker to identify LPR—the ratio of pepsin to the injury biomarker, the hypopharyngeal cell, Sep70 (pepsin/Sep70). Compared to healthy volunteers, the pepsin/Sep70 ratio was significantly lower in patients with LPR symptoms. The sensitivity of the method was 91%, but its specificity was low. In addition, the pepsin/Sep70 ratio test did not predict patient response to LPR treatment.

Information about the damaging effect of pepsin and its mechanism of action, in particular receptor-mediated penetration into epithelial cells, has made it possible to use pepsin inhibitors in the treatment of LPR. However, further studies are required to expand knowledge about the function of pepsin in LPR, which may confirm or refute the use of pepsin inhibitors [41].

A study has been published on the use of salivary pepsin measurements to monitor the effectiveness of surgical treatment of LPR [42]. However, salivary pepsin is currently of moderate value in the diagnosis of LPR, as questions remain regarding the optimal timing, best location, and thresholds for pepsin testing. Thus, further studies are also needed to identify the optimal technology for using pepsin in the diagnostic process of LPR [32].

So, given the presence of pepsin in the gastric contents, it is logical to assume that inflammation in the larynx, oropharynx, nasopharynx and nasal cavity may be the result of GER even at alkaline pH values ​​[44].

NFR and LPR, like other extraesophageal manifestations of reflux, are initially treated with a combination of proper diet and behavior modification. The role of pharmaceuticals is still controversial [45]. Although some patients respond to conservative behavioral and medical treatments, most require more aggressive and prolonged treatment (2 to 6 months) to achieve symptom regression. Surgery, such as laparoscopic fundoplication, is useful in selected cases where conservative treatment has failed in patients with lower esophageal sphincter insufficiency.

Russian national guidelines for the diagnosis and treatment of chronic laryngitis mention GERD as one of its causes and recommend consultation with a gastroenterologist [46]. However, a referral to a gastroenterologist does not always bring the desired result due to the absence of heartburn and belching as classic complaints of GERD, as well as the absence of changes in the esophageal mucosa visible during esophagogastroduodenoscopy. Further research is needed to develop algorithms for the diagnosis and treatment of NFR and LPR.

The authors declare no conflict of interest.

The authors declare no conflicts of interest.

Author contributions:

Research concept and design — I.A., S.K.

Collection and processing of material – I. A.

Statistical processing – I.A.

Writing the text – I.A.

Editing – S.K., I.Sh.

Credits

Angotoeva I.B. — https://orcid.org/0000-0002-6247-619X

Kosyakov S.Ya. — https://orcid.org/0000-0003-1016-3478

Shevkhuzheva I.B. — https://orcid.org/0000-0001-7008-3735

Corresponding author: Shevkhuzheva I.B. — e-mail: [email protected]

Treatment of acid reflux (GERD) in Krasnodar

• General
• Causes
• Symptoms
• When a doctor is needed
• Diagnosis and treatment

Gastroesophageal reflux disease (GERD) occurs when stomach acid often backs up into the tube that connects your mouth and stomach (esophagus). This release of acid (acid reflux) can irritate the lining of the esophagus.

Many of us experience this unpleasant state from time to time. GERD refers to mild acid reflux that occurs at least twice a week and moderate or severe acid reflux that occurs at least once a week.

Many people can manage the discomfort of GERD with a healthy lifestyle and over-the-counter medications. But some people with GERD may need stronger medications or surgery to relieve symptoms.

When you swallow, the round muscle band around the lower esophagus (lower esophageal sphincter) relaxes, allowing food and fluid to flow into the stomach. The sphincter then closes again.

If the sphincter relaxes or weakens abnormally, stomach acid can back up into your esophagus. This constant acid flush irritates the lining of the esophagus, often causing inflammation.

Risk factors.

• Overweight.
• A bulge of the upper abdomen up into the diaphragm (hernia of the esophagus).
• Connective tissue diseases such as scleroderma.
• Delayed gastric emptying.
• Pregnancy.

• Eating smoked meats.
• Large or late meal.
• Eating fatty or fried foods.
• Drinking certain drinks, such as alcohol or coffee.
• Taking certain medications, such as aspirin.

Complications of GERD.

• Narrowing of the esophagus (esophageal stricture) . Damage to the lower esophagus by stomach acid leads to the formation of scar tissue. Scar tissue narrows the digestive tract, which in turn leads to problems with swallowing.
• An open sore in the esophagus (esophageal ulcer). Stomach acid can thin the tissues of the esophagus, causing an open sore. An esophageal ulcer can bleed, cause pain, and make swallowing difficult.
• Eating fatty or fried foods.
• Use of certain drinks such as alcohol or coffee.
• Taking certain medications such as aspirin.

• A burning sensation in the chest (heartburn), usually after eating, which may get worse at night.
• Regurgitation (reverse flow) of food or acidic fluid.
• Sensation of a lump in the throat.
• Difficulties with swallowing.
• Chest pain.

• Chronic cough.
• Laryngitis.
• The appearance of asthmatic phenomena or worsening of the condition with existing asthma.
• Sleep disorders.

Get medical help right away if you have chest pain, especially if you also have shortness of breath or pain in your jaw or arm. These could be symptoms of a heart attack.

• Experiencing severe or frequent symptoms of acid reflux (GERD).
• Take over-the-counter heartburn medications more than twice a week.

Your doctor can diagnose acid reflux (GERD) based on a physical exam and your medical history.

To confirm (refute) the diagnosis of “acid reflux“ or check for complications, your doctor may recommend:

• Upper endoscopy. An endoscopist inserts a thin, flexible tube equipped with a light and a camera (endoscope) down the throat to examine the esophagus and stomach. Test results may be normal with reflux, but endoscopy may reveal inflammation of the esophagus (esophagitis) or other complications. An endoscopy may also be used to collect a tissue sample (biopsy) to check for complications such as Barrett’s esophagus.
• Ambulatory acid (pH) test . A monitor is placed in your esophagus to determine when and for how long stomach acid is spewing out there. The monitor connects to a small computer that you wear around your waist or on a shoulder strap. The monitor may be a thin, flexible tube (catheter) that is threaded through your nose into your esophagus, or a capsule that is placed in your esophagus during an endoscopy and that passes into your stool about two days later.
• Esophageal manometry . This test measures the rhythmic contractions of the muscles of the esophagus during swallowing. Esophageal manometry also measures the coordination and strength of the muscles in the esophagus.
• X-ray of the upper part of the digestive system. X-rays are taken after you drink the chalky liquid that coats and fills the inner lining of your digestive tract. This allows your doctor to see the silhouette of your esophagus, stomach, and upper intestine. You may also be asked to swallow a barium tablet, which can help diagnose narrowing of the esophagus,
  which may interfere with swallowing.

Your doctor will probably recommend that you try lifestyle changes and over-the-counter medicines first. If you don’t feel relief within a few weeks, your doctor may recommend prescription medications or surgery.

• Fundoplication . The surgeon wraps the top of the stomach around the lower esophageal sphincter to tighten the muscles and prevent reflux. A fundoplication is usually performed using a minimally invasive (laparoscopic) procedure. Wrapping the upper abdomen can be partial or complete.
• LINX Reflux Monitoring System . A ring of tiny magnetic beads is wrapped around the junction of the stomach and esophagus. The magnetic attraction between the balls is strong enough to keep the connection closed for acid reflux to occur, but weak enough to allow food to pass through. The Linx system can be implanted using minimally invasive surgery.

Lifestyle changes can help reduce acid reflux.

• Maintain a healthy weight . The extra pounds put pressure on the stomach, pushing it up and causing acid to reflux into the esophagus.
• Quit smoking . Smoking reduces the ability of the lower esophageal sphincter to function properly.
• Raise the head of your bed . If you regularly experience heartburn while sleeping, place footrests under the legs of your bed so that the headboard is raised 10-12 centimeters. If you can’t raise your bed, you can insert a spacer between your mattress and box spring to change your body positions. Raising your head with extra pillows is not effective..
• Do not go to bed immediately after eating .