University of Iowa Hospitals and Clinics

Department of Otolaryngology - Head and Neck Surgery

Esophageal Reflux Precautions

see also: Proton Pump Inhibitor Side Effects PPI Considerations; Esophageal Reflux Precautions; Singers Packet (Voice Clinic Handouts)

Lump In Throat (Throat Fullness, Globus Syndrome, Globus Sensation, Globus Hystericus, Globus Pharyngeus)

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 of the symptoms that people have from this include: cough, burning or soreness, hoarseness, throat clearing, excess mucous (which may cause symptoms of "post nasal drip"), bad taste and a sensation of a lump in the throat.

The following instructions are designed to:

• Reduce the volume in the stomach.

• Decrease pressure on the abdomen.

• Eliminate esophageal irritants.

• Neutralize stomach acid.

You should use as much of these suggestions as needed to get relief. If these measures do not help, or if your symptoms get worse, you should let your doctor know about it.

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

2. If you are overweight, you should lose weight.

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

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

5. Do not eat for 3 or 4 hours before retiring.

6. For night-time relief, sleep with the head of your bed elevated since 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 of the head of the bed. 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.

7. Clothing that fits tightly across the mid-section 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.

8. Prolonged periods of bending or stooping may aggravate reflux. This includes activities such as gardening and exercising requiring 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"

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. Potenial 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. ​