What is Silent Reflux?

“Reflux is not just indigestion and heartburn,” proclaims physician Jamie Koufman in her best-selling book, Dropping Acid: The Reflux Diet Cookbook & Cure.

Koufman coined the term “silent reflux” to describe symptoms like hoarseness, chronic cough, difficulty swallowing, and other throat ailments caused by reflux, even among people who don’t have heartburn.

However, nearly everything about silent reflux, or LPR (laryngopharyngeal reflux), is controversial. For example:


Does reflux cause throat symptoms? “We can use pH monitoring, which uses a probe to measure how high up the esophagus the acid is going,” says Lauren Gerson, a gastroenterologist at the California Pacific Medical Center in San Francisco. But pH monitoring picks up reflux in many people without symptoms.

“Even if I find that someone has reflux into their throat, it’s difficult to prove 100 percent that it’s causing the LPR symptoms,” notes Gerson.

Do PPIs help? If silent reflux causes symptoms like hoarseness, drugs that curb reflux should help, such as proton pump inhibitors (PPIs) which work by turning off the pumps in the stomach that make acid. But when Vanderbilt University’s Michael Vaezi gave 145 people with LPR symptoms a PPI (Nexium) or a placebo for 16 weeks, LPR symptoms disappeared in about 15 percent of both groups, suggesting that reflux didn’t cause their symptoms.

Still, it’s worth trying PPIs to see if they work. “Reduce that acid,” says Vaezi.

Do acid-free diets help? “There’s this belief among ear, nose, and throat doctors that somehow pepsin is the trigger that’s causing the damage and symptoms in the throat,” says Vaezi.

Pepsin is an enzyme that mixes with stomach acid to break down the protein in foods. Because acid activates pepsin, Dropping Acid urges patients to avoid acidic foods like citrus, hot sauce, and carbonated soda.

“I think it’s a bit shortsighted to blame pepsin because you’re not selectively refluxing pepsin. You reflux what’s in your stomach,” notes Vaezi.

“The evidence to support dietary measures in patients with LPR is even weaker than for GERD,” adds Gerson.

If you find that certain foods trigger hoarseness, avoid them, says Vaezi. “But the idea of suggesting that everyone should ‘drop acid’ is a bit extreme.”

Sources: Otolaryngol. Head Neck Surg. 121: 725, 1999; Laryngoscope 116: 254, 2006.


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