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Esophageal Reflux Precautions

last modified on: Fri, 11/10/2023 - 11:48

see also: Handout: Esophageal Reflux Precautions; Proton Pump Inhibitor Side Effects PPI Considerations; Lump In Throat (Throat Fullness, Globus Syndrome, Globus Sensation, Globus Hystericus, Globus Pharyngeus)

INTRODUCTION

In some people, irritating acid stomach juices may leak out of the stomach and into the esophagus and throat. This causes irritation and muscle spasm in the throat. Some symptoms that people experience with this problem include coughing, burning or soreness, hoarseness, throat clearing, excess mucous (which may cause symptoms of "post nasal drip"), bad taste in the mouth, and a sensation of a lump in the throat.
The following instructions are designed to:

  1. Reduce the volume in the stomach

  2. Decrease pressure on the abdomen

  3. Minimize esophageal irritants

  4. Neutralize stomach acid

SUGGESTIONS

You should use as many of these suggestions as needed to get relief. If these measures do not help, or if your symptoms get worse, you should inform your doctor.

  • Take an antacid in liquid form (Gelusil, Maalox, or others of your choice) 20 to 30 minutes after meals and at bedtime.

  • If you are overweight, you should lose weight.

  • Diet restrictions help control symptoms. A bland diet divided into multiple small feedings is recommended. You should avoid highly seasoned food that is either very hot or very cold. Care should be taken to chew food properly.

  • Alcohol, tobacco, and coffee are irritants to the esophagus and should be avoided. Alcohol and coffee also stimulate stomach secretions.

  • Do not eat for 3 to 4 hours before retiring.

  • For nighttime relief, sleep with the head of your bed elevated; symptoms are more likely to occur if you lie flat. The best way to achieve elevation is to place cinder blocks, wood, or bricks under the legs at the head of the bed. Commercially available bed risers are sold by some medical supply stores. The desired elevation ranges from 4 to 11 inches, with 8 inches a customary average. If this is not practical, sleep on 2 or 3 pillows. Sometimes sleeping on the right side prevents distressing attacks.

  • Clothing that fits tightly across the midsection of the body should be avoided. Women should not wear a girdle. Men may benefit from use of suspenders rather than a belt. Use of "abdominal supporting belts" should be avoided.

  • Prolonged periods of bending or stooping may aggravate reflux. This includes activities such as gardening and exercise that require lifting or bending.

Updated (12-2017) perspective comes from a recent well-publicized study "the alkaline water- Mediterranean diet study":

A prospective study comparing outcomes of two different treatments for LPR (laryngopharyngeal reflux) for patients with that diagnosis (Zalvan 2017)

All patients were treated with "Standard reflux precautions" which included prohibition of use of coffee, tea, chocolate, soda, greasy fired fatty and spicy foods and alcohol.

a. One group: Standard reflux precautions and a PPI inhibitor termed PS (85 patients)

b. Other group: Standard reflux precautions and use of alkaline water (replacing all other beverages) and a Mediterranean-style diet termed AMS (99 patients); alkaline water was suggested as an effective adjuvant due to expected inactivation of pepsin and neutralizing and acid environment (Koufman 2012)

The reflux symptom index (RSI) was determined before implementing treatment and 6 weeks after treatment was begun. 

The percent reduction in the RSI was significantly greater for the AMS group (39.8% reduction) than the PS group (27.2%).

Conclusion: "our data demonstrate that treatment with PPI therapy is not significantly more effective than a wholly dietary approach" in treating laryngopharyngeal reflux. They also identify that proton pump inhibitors "play an important role in cases of refractory LPRD, complicated disease, and poor diet control". The investigators discussion includes a detailed analysis of the shortcomings of the study identifying that "Randomized clinical trials are necessary to corroborate the results of this study". They "recommend that a patient with suspected LPR at least attempt a dietary approach prior to any pharmacological intervention".

An editorial follows the work above (Kavitt 2017) and is appropriately titled (with extension) "Will 'an apple a day' (ie, plant-based dietary modifications and/or alkaline water) keep the LPR and PPI away, as well as have the potential to reduce health care costs?" The editorial reiterates the shortcomings offered by Zalvan et al in their discussion and concludes with the comment: "We can look forward to future studies to build on the findings of Zalvan and colleagues to help answer this question".

A more recent review of complementary and alternative medicine (CAM) for LPR by Huestis et al (Huestis 2020) identified 20 relevant articles addressing alginate, diet modification, prokinetics, respiratory retraining, voice therapy rikkunshito (RKT), hypnotherapy and sleep positioning - leading to these authors recommendation that "anti-reflux diet is recommended for all patients" and that "there is some low-quality evidence to support alkaline water". For those with "vocal symptoms there is evidence that supports voice therapy". Overall they identified in their review "mixed evidence with a high degree of bias and heterogeneity between studies".  

A prospective randomized controlled study of the impact of alginate suspension on LPR (laryngo-pharyngeal reflux) by Tseng et al (2018) compared placebo to 8 weeks of treatment with Alginos Oral Suspension (TTY Biopharm Co.Ltd.,Taipei, Taiwan) = sodium alginate 1,000 mg three times daily). Efficacy was assessed with RSI (Reflux Symptom Index), RFS  (Reflux Finding Score) and MII-pH monitoring (Mulichannel Intraluminal Impedance-pH monitoring) 8 weeks after treatment. These investigators identified a pronounced placebo effect - that may actually reflect improvement seen in both groups possibly due to counseling from nursing given about lifestyle modification. This lifestyle modification applied to both placebo and drug-treated groups has been found in other studies to be associated with significant improvement (Steward 2004). These lifestyle modifications are:

  • Avoidance of oral intake within 2 hours of bedtime

  • Lying down with blocks placed under bedposts to raise the head of bed by 6 inches

  • Reduction in caffeine consumption 

REFERENCES

Zalvan CH, Hu S, Greenberg B, and Geliebter J: A Comparison of Alkaline Water and Mediterranean Diet vs Proton Pump Inhibition for Treatment of Laryngopharyngeal Reflux  JAMA Otolaryngol Head Neck Surg. 2017;143(10):1023-1029

Koufman JA, Johnston N. Potential benefits of pH 8.8 alkaline drinking water as an adjunct in the treatment of reflux disease. Ann Otol Rhinol Laryngo. 2012;121(7):431-434

Kavitt RT: Dietary Modifications in the Treatment of Laryngopharyngeal Reflux-Will "an Apple a Day" Keep the Laryngopharyngeal Reflux Away?   JAMA Otolaryngol Head Neck Surg. 2017 Oct 1;143(10):1030-1031. ​

Koufman J.A.: Low-acid diet for recalcitrant laryngopharyngeal reflux: therapeutic benefits and their implications. Ann Otol Rhinol Laryngol 2011; 120: pp. 281-287

Yang J, Dehom S, Sanders S, Murry T, Krishna P, Crawley BK.: Treating laryngopharyngeal reflux: Evaluation of an anti-reflux program with comparison to medications. Am J Otolaryngol. 2018 Jan - Feb;39(1):50-55. doi: 10.1016/j.amjoto.2017.10.014. Epub 2017 Oct 31.

Steward DL, Wilson KM, Kelly DH et al Proton pump inhibitor therapy for chronic laryngo-pharyngitis: a randomized placebo-control trial. Otolaryngol Head and Neck Surg 2004;131:342-350

Tseng W-H, Tseng P-H, Wu J-F, et al: Double-Blind, Placebo-Controlled Study With Alginate Suspension for Laryngopharyngeal Reflux Disease. Laryngoscope, 128:2252-2260, 2018

Huestis MJ, Keefe KR, Kahn CI, Tracy LF, Levi JR. Alternatives to Acid Suppression Treatment for Laryngopharyngeal Reflux. Ann Otol Rhinol Laryngol. 2020 Oct;129(10):1030-1039. doi: 10.1177/0003489420922870. Epub 2020 May 25. PMID: 32449369.