Showing posts with label reflux. Show all posts
Showing posts with label reflux. Show all posts
Sunday, 15 June 2014
, a medication to treat acid 
as ex-prescriptions now OTC.Saturday, 3 May 2014
In one of the more unusual studies I have seen, researchers deliberately infused 60 cc of hydrochloric acid into the esophagus of 14 patients who suffered from LPR as well as 12 healthy controls. 9 patients exhibited confirmed LPR (laryngopharyngeal reflux) events, but none in the control group. With moderate sustained cricoid pressure (20-30 mmHg), only one patient had a confirmed LPR event.
Theoretically, why would cricoid pressure work?
The cricoid cartilage is located immediately below the voice box. It is a circular cartilage that is right at the level where the throat connects to the esophagus. By putting pressure on the cricoid cartilage, the top part of the esophagus is manually compressed shut which theoretically would prevent reflux from regurgitating up into the throat.
It is based on this theory that anesthesiologists often perform cricoid pressure to prevent aspiration during intubation for surgery, especially if a patient is suspected of drinking/eating something prior to surgery.
The problem with cricoid pressure is that in order for this to work, it needs to happen continuously which may make it unrealistic and impractical for patients who suffer from LPR. Continuously means 24/7/365. Not just when symptoms are present (because it's too late than).
Reference:
Prevention of esophagopharyngeal reflux by augmenting the upper esophageal sphincter pressure barrier. Laryngoscope. 2014 Apr 29. doi: 10.1002/lary.24735.
Saturday, 12 April 2014
Here is a video demonstrating how esophagoscopy can be performed in the office without any sedation. The esophagus is the tube that connects the mouth to the stomach. The exam, called trans-nasal esophagoscopy (TNE), can be performed in any patient as long as the nose is large enough to accommodate the endoscope and lack a severe gag reflex. A very thin disposable sheath (like a condom) is used to protect endoscope and maintain sterility between patient use.
Monday, 24 March 2014
This retrospective study found that although 67.4% had symptom normalization, 32.6% of patients showed no subjective or objective treatment response. For all patients whose symptoms did not normalize, pH scores also did not normalize. For individuals whose symptoms normalized but whose pH scores did not normalize, there was a significant decrease in upright pH score.
Based on these findings, one should NOT assume that lack of response to reflux medications indicative of reflux being an incorrect diagnosis. Further study with a pH or impedance monitoring should be performed in non-responders to help figure out what is going on.
Reference:
Effects of Proton Pump Inhibitor Therapy for Laryngopharyngeal Reflux on Posttreatment Symptoms and Hypopharyngeal pH. Otolaryngol Head Neck Surg. 2014 Mar 19. [Epub ahead of print]
Tuesday, 4 February 2014
Common to all incisionless devices is the fact that the procedure is performed using an endoscope introduced through the mouth threaded down into the stomach. At this point, the technique used by the devices to tighten the valve separating the esophagus and stomach varies.
With Stretta (first on the market), radiofrequency energy is used to induce scarring of the valve causing it to constrict.
With Esophyx (next to market), a 270 degree 2-3cm fundoplication is performed by manipulating the esophago-gastric tissue in a rotating twisting manner and anchoring in place using 12 or more full-thickness polypropylene fasteners.
With SRS, the stomach is folded up against the esophagus and anchored in place using a few staplers. Watch the video below to see how this system works.
The technique that is best for a given patient will vary based on surgeon's comfort and experience with the device as well as unique patient variables. As such, no technique is perfect or applicable to everybody. Also, only time will tell if this or any other incisonless technique provides long-term reflux relief with minimal risk and side effects.
Ask your GI or general surgery specialist on what option is best for you.
Wednesday, 22 January 2014
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| Image from Wikipedia |
The National Enquirer, which is not know for stellar journalism, goes on to report that she has been pushing her voice hard in order to succeed as a singer like her more famous father Elvis.
In spite of what the story implies, although singing can lead to vocal cord damage (i.e., nodules)... singing in and of itself does not cause or lead to increased risk of cancer.
However, uncontrolled reflux which can cause throat and vocal cord damage CAN lead to throat cancer. In one report, reflux can increase the risk of throat cancer by 78% (this risk is separate from esophageal cancer).
Source:
WORLD EXCLUSIVE: LISA MARIE THROAT CANCER NIGHTMARE. National Enquirer 1/20/14.
Friday, 30 August 2013
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| Image by Steven Fruitsmakk from Wikipedia |
BUT, it is also a foregone conclusion that reflux increases the risk of esophageal and throat cancer too. So, why would there be an increased incidence of esophageal cancer when reflux is being better "controlled" now more than ever with medical acid suppression?
The answer might be bile... the substance made in the liver and secreted into the small intestine via the gallbladder. Bile is what helps the body digest dietary fat.
But when bile not uncommonly refluxes into the esophagus... bad things may happen, especially when acid production has been suppressed by reflux medications.
Disclaimer... The following is hypothetical and unproven.
Bile, if it happens to be in the esophagus or throat, is more destructive to the mucosal lining when acid is suppressed.
Bile salts/acids have fairly complicated acid-base properties, but an over-simplified explanation for the purpose of this blog is as follows.
Bile in a chemically unconjugated state has a pKa of 7. When such bile is in an acid environment (pH less than 6), it is insoluble and relatively harmless. However, when unconjugated bile enters a relatively alkaline environment (pH greater than 6), it becomes water soluble and "active" in its ability to damage mucosal linings.
As such, when acid suppression is induced by medications like zantac and prilosec, yes... the acid is suppressed but by the very fact that it raises the stomach and distal esophageal pH to a relative alkaline state, any bile that may be present now becomes activated and causes potentially just as much damage as acid.
And that's why over a prolonged period of time repeated bile exposure in a relative alkaline environment may explain why esophageal cancer incidence seems to be increasing as the use of acid reflux medications has increased.
Proof?
Regardless of the "how," does taking reflux medications actually increase risk of cancer???
In one study (2011), patients taking proton pump inhibitors were 61.3% to 81.5% more likely to develop esophageal pre-cancerous lesions or frank cancer (adenocarcinoma).
In another study published in the summer of 2013, it was found that patients with reflux were found to have a 78% increased risk of developing throat cancer. What researchers also found was that taking antacids for reflux (but NOT proton pump inhibitors or H2 blockers) seemed to protect against the development of throat cancer by 41% in patients with frequent heartburn.
To reiterate, antacids reduced risk of throat cancer... but NOT proton pump inhibitors like prilosec and H2 blockers like zantac.
Why? Because antacids work transiently to neutralize acid, but not suppress acid production whereas proton pump inhibitors and H2 blockers actually suppress acid production for a prolonged period of time.
The transient nature of acid neutralizers like TUMS allow for acid to still be produced thereby theoretically preventing bile from becoming soluble and damaging.
Prediction
So which is worse for you? Acid reflux or bile reflux? I'm not sure... but personally, I predict that once additional studies are performed that may ultimately strengthen the relationship between bile reflux and mucosal injury that may lead to cancer formation, reflux medications may go out-of-favor along with a class-action lawsuit. That's a big if... I might end up being completely wrong.
Of course, that may be the reason why drug companies specify that such reflux medications should not be used longer than 2 months and prescribing information stress "short-term" treatment rather than long-term.
More Confusion
We can also throw more mud into this messy predicament... Pepsin, which is a stomach enzyme that breaks down proteins, can also damage esophageal and laryngeal mucosa. However, it is most active in an acidic environment. Once pH levels rise above 6.5, pepsin becomes inactivated. At pH 8.0, it becomes irreversibly inactivated.
As such, acid and pepsin cause damage in an acidic environment. Taking reflux medications to eliminate the acid creates an alkaline environment.
However, an alkaline environment than activates bile which can also cause damage.
Treatment
So what to do?
Ideally, given this no-win situation, the best way to treat reflux would be to keep bile where it is supposed to be (in the small intestine) and acid/pepsin in the stomach where it is supposed to be.
As such, I suspect that even more emphasis will be placed on lifestyle/dietary changes for reflux control. Medication-wise, use of antacids and barrier-type medications like alginate will become the main way of treating reflux long-term while medications that suppress acid will be prescribed only for short-term treatment spans.
Surgical management of reflux will become much more accepted and popular for patients who suffer from bad reflux to try and restore proper anatomical compartmentalization of bile, acid, and pepsin. Surgical management will include LINX, TIF, Nissen, etc. (more info)
At the very least, certainly caution should be present when placing a patient on long-term acid suppression with medications like prilosec and zantac, especially when such medications are already known to cause a whole host of other problems including bone fractures, clostridium difficile infections, and malabsorption of vitamins and minerals. (more info)
Special thanks to Dr. Kevin Gillian who assisted in writing this blog.
References:
Bile Acid. Wikipedia
Gastroesophageal reflux disease symptom severity, proton pump inhibitor use, and esophageal carcinogenesis. Arch Surg. 2011 Jul;146(7):851-8. doi: 10.1001/archsurg.2011.174.
Gastric Reflux Is an Independent Risk Factor for Laryngopharyngeal Carcinoma. Cancer Epidemiology Biomarkers & Prevention. Published Online First May 23, 2013; doi: 10.1158/1055-9965.EPI-13-0183
The otolaryngologic manifestations of gastroesophageal reflux disease (GERD): a clinical investigation of 225 patients using ambulatory 24-hour pH monitoring and an experimental investigation of the role of acid and pepsin in the development of laryngeal injury. Laryngoscope. 1991 Apr;101(4 Pt 2 Suppl 53):1-78.
Bile reflux gastritis and Barrett's oesophagus: further evidence of a role for duodenogastro-oesophageal reflux? Gut 2001 Sep;49(3):359-63.
Acid and bile reflux in erosive reflux disease, non-erosive reflux disease and Barrett's esophagus. Hepatogastroenterology. 55 (82-83), 442-7.
The role of bile acids in the neoplastic progression of Barrett's esophagus - a short representative overview. Z Gastroenterol. 50 (9), 1028-34.
Tuesday, 16 July 2013
And we are one of the very few offices in the United States that offer this spit test. Even major laboratory companies like Labcorp and Quest do not offer this test yet.
How does such a test work?
It basically looks for a stomach protein called pepsin.
Given reflux is when stomach contents moves up towards the mouth and pepsin is a protein ONLY produced in the stomach... pepsin should NOT be found in the throat/mouth.
As such, the test can state yes or no whether LPR is present or not.
The steps to the test are as follows:
How good is the test?
Depending on the study, sensitivity ranges in the 80-100% (can actually detect reflux if truly present) and specificity is around 85% (truly no reflux if test is negative).
One test company is RDbiomed (in Europe) using their Peptest kit.
This test is currently not FDA approved yet and as such, is a test that is NOT covered by insurance at this time. Due to a special arrangement our office has with RDBiomed, the Peptest kit can be obtained in our office at a discounted price of $125 (compared to normal price of $175). Price includes the kit, test supplies, and courier shipping service.
Please note that this testing is ONLY offered to current patients of ours.
However, if you are not a current patient of ours, you can order this test yourself online as an individual without a visit to our office. It is recommended you take the standard 3 sample peptest. Click here for more information.
References:
Sensitive pepsin immunoassay for detection of laryngopharyngeal reflux. Laryngoscope. 2005 Aug;115(8):1473-8.
Rapid salivary pepsin test: Blinded assessment of test performance in gastroesophageal reflux disease. Laryngoscope. 2012 Jun;122(6):1312-6. doi: 10.1002/lary.23252. Epub 2012 Mar 23.
Thursday, 11 July 2013
Although the effectiveness of such drugs are clear in adults suffering from acid reflux, it is less so in children. As is true with so much of medicine, there's no clear answer to the question of what the best reflux med is for infants and children. According to one review of literature, the answer is decidedly mixed and variable depending on what outcome was looked at (subjective symptom improvement or objective test findings).
In fact, symptom improvement (or lack of) did not always correlate with objective test findings (24 hour testing, barium swallow, EGD, etc) of reflux improvement and vice-versa. The most common finding was reduction in reflux based on tests, but no significant improvement in symptoms. Such findings does bring into question whether the diagnosis of reflux was even accurate.
In any case, when looking at SYMPTOMS in infants (less than 12 years of age) use of proton pump inhibitors was decidedly not favorable (one study in support and 4 against). In children (over 1 year of age), proton pump inhibitors were found to be equally effective to alginates and ranitidine.
When looking at OBJECTIVE test findings, proton pump inhibitors were found to be equally effective in both infants and children compared with placebo, alginates, or ranitidine. For reducing histologic aberrations, proton pump inhibitors showed no difference compared with ranitidine or alginates.
Conclusion
If GERD symptom control is the main goal, proton pump inhibitors should not be used in infants. In older children, these medications are helpful but potentially no better than alginates and zantac which have better side effect profiles. As is true with most studies, more study is needed.
Reference:
Efficacy of proton-pump inhibitors in children with gastroesophageal reflux disease: a systematic review. Pediatrics. 2011 May;127(5):925-35. doi: 10.1542/peds.2010-2719. Epub 2011 Apr 4.
Sunday, 7 July 2013
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| Image by WJ Pilsak from Wikipedia |
With pepsin triggered symptoms, treatment to resolve can become exceedingly frustrating given standard treatment with zantac
, prilosec
, and other "reflux" medications do not work as well. Furthermore, human pepsin remains stable at pH 7.4 and can be repetitively reactivated by acid from any source (ie, orange juice).BUT... keep in mind that test tube results in this research may not necessarily translate to actual improvement in humans. However, drinking a small amount of alkaline water
a few times a day (just enough to coat the throat) can't hurt.Keep in mind that most tap and bottled waters (typically pH 6.7 to 7.4) would not be expected to affect pepsin stability.
I should also mention that drinking alkaline water
will not do much to help acid reflux as the alkaline water will only briefly neutralize any acid and is ineffective for long-duration acid suppression. For those suffering from acid reflux, stick with the traditional reflux medications which work extremely well.Reference:
Potential benefits of pH 8.8 alkaline drinking water as an adjunct in the treatment of reflux disease. Ann Otol Rhinol Laryngol. 2012 Jul;121(7):431-4.
Wednesday, 29 May 2013
In this dental situation where novacaine got injected leading to a temporary induced neuropathy... a similar phenomenon can also occur in the throat region due to neuropathy most commonly triggered by a virus or throat-level reflux (LPR). This condition is called laryngeal sensory neuropathy (LSN).
And because the neuropathy occurs in the throat region... a sensation of swollen or lump feeling in the throat (globus) may occur just like the sensation in the face/jaw after getting numbed up for a dental procedure.
Similarly, a mucus phlegmy throat sensation may also occur just like a drooling sensation of the face/jaw after being injected with novacaine.
Such a swollen throat or phlegmy throat sensation can also be temporarily induced in normal patients when the throat gets numbed up with lidocaine or other anesthetic for a surgical procedure.
How is this condition treated?
First and foremost, other non-neurologic etiologies must first be ruled out with medications and extensive testing. Also, triggers that may have led to this neuropathy must be thoroughly addressed as well. Such testing may include allergy testing, specific food avoidance, 24 hour multichannel pH impedance, manometry, etc, etc.
SELSAP is a promising test to evaluate for laryngeal sensory neuropathy.
Once laryngeal sensory neuropathy is confirmed, medications like amitriptyline, neurontin, and tramadol can be tried.
For more information, click here for globus and here for phlegmy throat.
Unfortunately, with any Zenker's treatment including ESD, there is a small percentage (~10%) that the Zenker's diverticulum recurs typically within one year of treatment (average 8.5 months).
Why might that be?
There are some known (and unknown) issues that may lead to recurrence including:
• Incomplete division of the cricopharyngeus muscle: If the pouch is small, the cricopharyngeus muscle may not be completely divided using the ESD method. It is a shortcoming inherent to the method itself and not a lapse on the surgeon's part. The only way to completely address the muscle when the pouch is small (less than 1 .5cm) is via external approach or use of a laser with its associated increased risk of complications.
• Unaddressed or persistent laryngopharyngeal reflux: Proton pump inhibitor medications are ALWAYS prescribed before and after surgery... even if heartburn symptoms are absent. However, even with such medications, there may be a certain sub-population that suffer from persistent throat-level reflux that may trigger the Zenker's diverticulum to reform. This factor is probably the single most important reason why recurrence may occur within months.
• Loose staples: After surgery is performed, all loose staples are removed to minimize recurrence from this factor.
• Idiopathic scarring of the common wall: Some unindentified inflammatory process leads to restenosis of the common wall.
• Unknown: Whatever factor lead to the Zenker's formation in the first place may cause it to happen again. Indeed, we actually don't precisely know what causes the Zenker's pouch to occur in the first place.
As such, if recurrence occurs years after treatment, it usually will suggest an incomplete cricopharyngeus muscle division. Repeat ESD can be performed with good results.
If recurrence occurs within one year of treatment, I typically will consider the possibility of persistent throat-level reflux (laryngopharyngeal reflux) that was not or incompletely addressed with reflux medications. Before performing ESD again after a recurrence, I will obtain a few studies to determine how significant throat-level reflux may be present.
That typically entails getting a 24 hour multi-channel pH and impedance testing with manometry. The most important result from this study is the frequency of proximal esophageal reflux events and as such, any other type of reflux study that does not include proximal esophageal or hypopharyngeal sensors would be considered inadequate. Ideally, it should be as close to zero as possible. If proximal esophageal reflux events are present, this needs to be thoroughly eliminated prior to revision Zenker's surgery... otherwise, the Zenker's pouch may yet again recur.
Manometry is performed to ensure the cricopharyngeus muscle (if present) is adequately "loose".
Of course, the barium swallow needs to be repeated as well.
Friday, 24 May 2013
The study group also did not heavily smoke, drink, or have HPV (other independent risk factors for throat cancer).
Individuals with frequent heartburn were found to have a 78% increased risk of developing throat cancer. What researchers also found was that taking antacids for reflux (but not proton pump inhibitors or H2 blockers) seemed to protect against the development of throat cancer by 41% in patients with frequent heartburn.
The explanation for how reflux can cause throat cancer is similar to how it can also cause esophageal cancer. With repetitive mucosal injury by gastric juices to the delicate lining of the throat, there is a cycle of healing and injury that may eventually trigger cancer development. Patients with reflux that reaches the throat level have a condition called LPR or laryngopharyngeal reflux. Although symptoms may be similar to the more common GERD, it is not unusual for patients to experience only throat symptoms without the heartburn. Such atypical symptoms include:
• Chronic cough
• Phlegmy throat
• Chronic throat clearing
• Vocal cord dysfunction
• Globus pharyngeus
It is also notable that it takes far less reflux episodes in the throat region compared to the esophagus in order to trigger mucosal damage... it takes fewer than THREE episodes per WEEK! [link]
In any case, more research is needed to determine at what point cancer risk increases in individuals with LPR, what type of reflux (acid?, non-acid?, pepsin?, bile?) triggers cancer concern, to what degree of reflux prevention is required to protect against cancer development.
Also more needs to be done to figure out why antacids help reduce cancer risk, but not other types of reflux medications.
References:
Gastric Reflux Is an Independent Risk Factor for Laryngopharyngeal Carcinoma. Cancer Epidemiology Biomarkers & Prevention. Published Online First May 23, 2013; doi: 10.1158/1055-9965.EPI-13-0183
The otolaryngologic manifestations of gastroesophageal reflux disease (GERD): a clinical investigation of 225 patients using ambulatory 24-hour pH monitoring and an experimental investigation of the role of acid and pepsin in the development of laryngeal injury. Laryngoscope. 1991 Apr;101(4 Pt 2 Suppl 53):1-78.
Wednesday, 8 May 2013
Of course, perception is not always supported by research...
"Milk and dairy product intake was not associated with an increase in upper or lower respiratory tract symptoms of congestion or nasal secretion weight. [...] We conclude that no statistically significant overall association can be detected between milk and dairy product intake and symptoms of mucus production in healthy adults, either asymptomatic or symptomatic, with rhinovirus infection." [link]However, other research support the possibility that dairy products might increase mucus production only if the milk contains beta-CM-7 protein (not all milk contains this protein). [link]
I have a different hypothesis for why milk may cause the perception of increased mucus production. I should preface that I have no research study to quote to prove this hypothesis. Might be a good research project for a medical student???
In any case, milk contains a protein called casein. When the milk is not refrigerated, it causes bacteria to metabolize lactose within the milk leading to lactic acid production as a byproduct. When acidity is present, the casein congregate in a process called curdling. That's the "chunks of milk" seen in milk gone bad.
Now, bacteria certainly will not be playing a role in lactic acid production after fresh milk is consumed, BUT, there IS acid present in the stomach which can initiate curdling.
Now what if a patient suffers from acid reflux... and what if some of the reflux episodes reach the throat level?
So, hypothetically speaking, if somebody who suffers from acid reflux drinks a lot of milk, two things might hypothetically happen (or drinks orange juice followed by milk):
1) Milk temperature goes up from body heat (which assists in curdling)
2) Acid present from the reflux will initiate curdling
If acid is present in the mouth and throat from reflux or secondary source (like recently drunk orange juice), curdling to some degree may occur from milk residue mixing with acid residue present leading to perception of mucus production.
Now does this actually happen???
I don't know and I hope some researcher looks into this hypothesis further!
However, in the end, if dairy avoidance helps with a phlegmy throat, than it can't hurt to avoid it! I should also point out that egg and wheat does cause a similar phlegmy problem in some patients.
Reference:
Relationship between milk intake and mucus production in adult volunteers challenged with rhinovirus-2. Am Rev Respir Dis. 1990 Feb;141(2):352-6.
Does milk increase mucus production? Med Hypotheses. 2010 Apr;74(4):732-4. doi: 10.1016/j.mehy.2009.10.044. Epub 2009 Nov 25.
Saturday, 13 April 2013
Any parent who has lived with a toddler or preschooler knows the pain of hearing a child’s endless cough, daytime, nighttime, all the time... It seems as if the cough never clears up in a day or two, or after a cold, but may last for weeks. Even if it does clear up, it always seems to return without much warning, and can be more stubborn than your 4 year old about eating vegetables! If you are wondering why cough medications can't stop your child's cough, or for that matter, why inhalers for "asthma", another 10 days of antibiotics, and/or allergy medications are all not working, then continue reading. Have you dragged your child all over town to see yet another specialist to find out why they just keep coughing?
Here is what I explain to all families who come to see me about cough. Cough is an involuntary reflex, or protective mechanism the body has to get unwanted particles or irritants out of our airway. So if dust got into our windpipe, or a droplet of liquid goes into the airway accidentally while your child was drinking and trying to talk at the same time, or the phlegm that he/she gets with a viral illness... all of these things can make our children cough. While most children are thankfully not intermittently or continuously inhaling dust, or running around drinking with their head tilted while talking at the same time, the one frustrating thing about young children is the fact that they get 7-10 viral upper respiratory track illnesses, or colds every year. Each one of these “colds” last 7-10 days, and so pretty quickly, you can have a child with cold symptoms for a third of the year!
So... without further ado... the top 3 reasons why the cough is still hanging on...
NUMBER 3: Post-viral neurogenic cough or habitual throat-clearing. Whatever the reason was, your child started out having a bad cold and coughed due to being sick. Even after the fever and acute illness goes away after 7-10 days, their throat and voice box somehow stays irritated and they continue to cough. At some point, your child may not even realize that he/she is "coughing". Often these are children who are throat-clearing and not really coughing (more often in short annoying bursts, as often as every few minutes). If you no longer hear them "coughing" during sleep, but only when they are awake, then this is likely what your child has. These children often show no other signs of illness or discomfort. It's a difficult diagnosis to make and usually after all other reasons have been rules out. I often offer strategies to families to help break these habits such as creating a game (older than 3 or 4 years of age can do this) whereby a kitchen timer is used to help suppress the urge to "cough" starting from 30 seconds and working up to 5 minute intervals. School aged children who do not appear ill but have a “dry” throat clearing do very well with this exercise. Another option is when they get into a coughing fit, to distract them with chewing gum, having them count backwards from 20, hopefully distracting them from this habit.
NUMBER 2: Chronic Rhinosinusitis (CRS). Your child may have developed true chronic rhinosinusitis which means inflammation from thickening of the lining inside their sinus cavities and their sinus "plumbing" is clogged up. Chronic sinus inflammation is NOT a bacterial infection so antibiotics will not make it go away completely, even if it seems to decrease the cough temporarily. This usually occurs in children older than 4, especially if they have underlying test proven allergies to common aero-allergens like trees, pollen, grass, dust-mites, and other environmental allergens. Sometimes this is bad luck and develops after your child has experienced a terrible viral illness, such that the mucous membranes inside the nasal passages were so swollen that the natural drainage points that lead each sinus cavity into the nasal passage are blocked, which then leads to the inflammation inside the sinus. Since there is a built-in mechanism called the "sinopulmonary reflex", children who have inflamed sinus mucous membrane lining will likely continue to cough until the nasal passage and sinus mucous membranes are no longer swollen and healthy again. The only way to truly know if your child has CRS is for him/her to get a CT scan, a special imaging of their sinus cavities which can involve some radiation exposure. These children tend to complain of a stuffy nose all the time along with the cough, and can't blow anything out of their nose even if they try. Mothers always tell me that their child is stuffy and can’t breathe well, leading to snoring, fatigue, sometimes headaches.
NUMBER 1: The Milk and Cookie Disease (MCD). Your child is coughing because day after day, night after night, their larynx (voicebox) is bombarded with stomach content backwash (gastroesophageal reflux and laryngopharyngeal reflux) coming up to and irritating the voicebox. The voicebox which enables humans to talk is also designed to "cough" as a way to keep unwanted materials from entering our airway. If it did not protect itself by coughing, then we would aspirate and possibly get pneumonia. Find out how your child can live and eat in "A Healthier Wei
" and fight the Milk and Cookie Disease, by minimizing dairy and sugar in the evenings and then his/her voicebox can rest and not be in "fighting" mode all the time. I have met thousands of children who have chronic cough not because they are sick, but because they were eating a diet or drinking beverages containing too much dairy and sugar, as well as possibly greasy foods and processed foods. All these items increase likelihood of reflux or backwash and assault on the larynx. If the voicebox is always on “alert” and ready to “fight” and protect the body, then it really can’t relax and rest. I believe that when this happens chronically from MCD, and let’s not forget those 7-10 colds and how they also lead to an irritated overreactive cough, then together, this child has no chance and probably will cough, A LOT! By making changes in diet and dietary habits in children, we can decrease the chance of stomach backwash coming up to irritate the voicebox and cause cough, then hopefully your child only coughs when it is truly because of a cold. Don’t take my word for it, try “A Healthier Wei”. You will likely notice at least much less coughing, and coughing ending much sooner after a cold. I also ask parents to stop dairy/milk for up to 1 week during the time their child is sick. This is when digestion is not at its best, and things get sour and gross in the stomach increasing chance for reflux and more cough. by Julie Wei, MD, FAAP
Sunday, 24 February 2013
"Dear Dr. Chang,
I have been taking a [insert reflux medication] for [insert number] weeks and I see no improvement in my [insert symptom]. What should I do?"
The reflux medication typically mentioned include nexium, dexilant, prilosec, prevacid, protonix, or some other proton pump inhibitor.
The most common symptoms typically mentioned include:
• Globus
• Cough
What Should You Do?
Well, assuming you never have taken a reflux medication in the past, proton pump inhibitors work extremely well in suppressing acid; even at low dosages.
As such, if you indeed have been taking a proton pump inhibitor for at least 3 weeks and see no improvement in symptoms, one must consider the possibility that acid reflux may not be the problem.
I rarely if ever just increase the dosage of a reflux medication in somebody who previously was never on one. Increasing the medication dosage MIGHT be considered only if somebody has already been on reflux medication for some time baseline.
So if acid reflux is not the problem, what may be causing above-mentioned symptoms?
There could be an anatomic problem...
• Cricopharyngeal spasms/hypertrophy
• Esophageal dysmotility
• Esophageal web or stricture
etc
Essentially, there's something wrong with your swallowing tube such that things back up into the throat causing symptoms. Think of it like a clogged sink... the pipe (esophagus) has a physical issue that causes water to backup into the sink (throat).
Workup to evaluate these possibilities include trans-nasal endoscopy, EGD, barium swallow, and/or manometry.
It could still be a reflux problem...
Just maybe, it's NOT acid reflux however, but mucus or non-acid reflux. Standard reflux medications do not work for non-acid reflux. The best way to evaluate this possibility is to undergo a 24 hour multichannel pH and impedance testing. Of note, BRAVO or pH monitoring alone is NOT good enough. Impedance must be measured as well as having sensors near the throat level.
In the meantime, one could also try avoiding eating anything that contains dairy, egg, and wheat (flour). These foods are considered highly mucogenic (most people can relate to the fact that when drinking too much milk, the mouth and throat can get phlegmy).
Is it allergy?
Post-nasal drainage can sometimes lead to throat symptoms. If you do have some sino-nasal allergies, try taking a steroid nasal spray and an anti-histamine nasal spray. Oral medications typically do not work as well.
There's also a condition known a eosinophilic esophagitis that can cause throat symptoms. The only way to diagnose this condition is an upper endoscopy (EGD) with biopsies of the esophageal lining.
Summary
Now this article just scratches the surface in FULLY addressing an individual patient's throat symptoms. After all, not everybody is exactly the same. For a more in-depth evaluation and individualized treatment of YOUR throat issues, please make an appointment with your ENT.
Here are some related articles that may be helpful:
Chief among the reflux medications are the proton pump inhibitors that include medications like prilosec, nexium, protonix, prevacid, dexilant, etc.
When such medications are taken by a patient, especially one who does not normally take proton pump inhibitors, effective acid suppression occurs. It works EXTREMELY well; even at low doses.
However, such medications should not be taken any longer than necessary and should be prescribed along with lifestyle changes to minimize persistence and/or recurrence.
Why?
In some ways, a patient suffering from reflux may become "addicted" to the reflux medication for continued symptom relief.
In other words, the reflux medication can induce the stomach to produce even more acid leading to the need for continued medical therapy... or increase dosages for continued symptom relief. Stopping the medication can cause even worse reflux... which leads the patient to resume the medication.
This "addiction"can occur in as little as 8 weeks in up to 40% of normal, healthy individuals. [link]
What happens?
The way proton pump inhibitors work is by blocking protein channels known as proton pumps in stomach cells (B) from producing acid (C).
The stomach cells realizing their proton pumps are being blocked, start revving up production of even MORE proton pump channels to fix its acid shortage which would in turn increase acid production and potentially lead to symptoms.
Sounds like a vicious cycle... because it is.
Although this "addiction" which is really an acid rebound phenomenon, is typically associated with proton pump inhibitors, it can also happen with H2-blockers (zantac, pepcid, etc), though not as severe.
Should you experience acid rebound after stopping a reflux medication, the unusually vigorous acid production and associated symptoms (the "withdrawal") go away if you can stand to wait it out. Since it takes time for the stomach to re-adjust, this wait can be significant:
• After stopping an H2-blocker, rebound symptoms usually start within two days and usually subside within 10 days.
• After stopping a proton pump inhibitor, rebound symptoms usually start after a week and continue for up to two months.
One can also slowly "taper" down the dosage of reflux medication and address any acid symptoms with an antacid.
Now, in certain circumstances, it is imperative that reflux medications be taken for months if not longer because the benefits outweigh the risks (gastric ulcer, Barrett's esophagus, vocal cord granuloma, etc). There is a specific reason for long-term treatment.
But if treatment is solely due to symptom relief alone, such medications should not be used daily indefinitely.
Talk to your doctor if you have concerns.
References:
Proton-pump inhibitor therapy induces acid-related symptoms in healthy volunteers after withdrawal of therapy. Gastroenterology. 2009;137:80-87. Epub 2009 Apr 10.
Rebound hypersecretion after omeprazole and its relation to on-treatment acid suppression and Helicobacter pylori status. Gastroenterology. 1999;116:239-247.
Systematic review: rebound acid hypersecretion after therapy with proton pump inhibitors. Aliment Pharmacol Ther. 2007;25:39-46.
Results of an intervention in an academic Internal Medicine Clinic to continue, step-down, or discontinue proton pump inhibitor therapy related to a Tennessee Medicaid formulary change. J Manag Care Pharm. 2009;15:344-350.
Safety of the long-term use of proton pump inhibitors. World J Gastroenterol. 2010;16:2323-2330.
Sunday, 17 February 2013
When surgery is performed on the vocal cords, there are some very specific after-care that is required to allow for optimal healing. In order to understand the "why" such post-operative care is required, one must first understand how the vocal cords normally work. If you already know, just skip down to the bottom.
The vocal cords are arranged in the shape of a "V". When breathing, the vocal cords are open to allow air to pass through and down into the windpipe. When talking, the vocal cords come together and vibrate. Click here to watch a video.
When surgery is performed on the vocal cords, one is actually cutting into the actual organ that allows one to talk and make other noises.
As such, the care required after vocal cord surgery requires the elimination of any activity that may lead to damage to the surgery site and allow proper and safe healing.
I should mention that the following instructions are our opinion. Other laryngologists may have different after-care instructions.
Strict Voice Rest!
This means absolutely no talking and whispering. Such activities cause the vocal cords to come together and "bang" against the surgery site. I even instruct patients to avoid even mouthing words as it causes the brain to "think" you are talking even if you are not. Essentially, the lips should always remain closed except when eating/drinking.
The analogy would be if you have surgery done on the heel of your foot, you should not walk or put any weight on the heel, otherwise risk improper healing.
Strict voice rest typically lasts for 1-2 weeks after surgery.
No Coughing or Throat-Clearing
Just as with talking, coughing and throat-clearing also causes the vocal cords to come together and should be avoided if at all possible. Narcotic strength cough-suppressants (ie, hycodan) are often prescribed to help suppress the urge to cough.
Take Reflux Medications
Reflux medications should be taken both before and after surgery to prevent any possibility of acid damage to the surgery site. Such medications should be taken EVEN IF you do not have any symptoms of acid reflux. I typically recommend patients to start such medications one week before surgery and to continue for as long as 3 months after surgery.
Voice Therapy
Voice therapy is recommended before surgery so that patients will understand what and how they are supposed to talk once cleared to do so after surgery. It's much easier to answer questions and practice proper talking technique before surgery rather than after surgery when you are on strict voice rest!
The rationale for voice therapy is to prevent continued phono-trauma to a freshly healing surgery site on the vocal cord. Often, if improper talking technique persists after surgery, the surgery site becomes damaged again or heals with abnormal scar tissue leading to the possibility of needing surgery again.
Voice therapy minimizes the likelihood of needing repeat vocal cord surgery in the future!
Restricted Voice Rest
Once the period of strict voice rest ends, the patient is slowly allowed to talk under voice therapy guidance. From this point forward over the next 4-6 months, the patient is under restricted voice rest.
Restricted voice rest is a fairly broad phrase, but essentially means to:
• NEVER abuse the voice (ie, yelling, screaming, loud talking, etc)
• Talk only when you must (ie, no social talking)
This period of restricted voice rest is important because it allows time for the new vocal cord tissue that has developed to not only heal, but also strengthen. Abusing the voice may tear the freshly healed surgery site which must be avoided at all costs!
The vocal cords are arranged in the shape of a "V". When breathing, the vocal cords are open to allow air to pass through and down into the windpipe. When talking, the vocal cords come together and vibrate. Click here to watch a video.
When surgery is performed on the vocal cords, one is actually cutting into the actual organ that allows one to talk and make other noises.
As such, the care required after vocal cord surgery requires the elimination of any activity that may lead to damage to the surgery site and allow proper and safe healing.
I should mention that the following instructions are our opinion. Other laryngologists may have different after-care instructions.
Strict Voice Rest!
This means absolutely no talking and whispering. Such activities cause the vocal cords to come together and "bang" against the surgery site. I even instruct patients to avoid even mouthing words as it causes the brain to "think" you are talking even if you are not. Essentially, the lips should always remain closed except when eating/drinking.
The analogy would be if you have surgery done on the heel of your foot, you should not walk or put any weight on the heel, otherwise risk improper healing.
Strict voice rest typically lasts for 1-2 weeks after surgery.
No Coughing or Throat-Clearing
Just as with talking, coughing and throat-clearing also causes the vocal cords to come together and should be avoided if at all possible. Narcotic strength cough-suppressants (ie, hycodan) are often prescribed to help suppress the urge to cough.
Take Reflux Medications
Reflux medications should be taken both before and after surgery to prevent any possibility of acid damage to the surgery site. Such medications should be taken EVEN IF you do not have any symptoms of acid reflux. I typically recommend patients to start such medications one week before surgery and to continue for as long as 3 months after surgery.
Voice Therapy
Voice therapy is recommended before surgery so that patients will understand what and how they are supposed to talk once cleared to do so after surgery. It's much easier to answer questions and practice proper talking technique before surgery rather than after surgery when you are on strict voice rest!
The rationale for voice therapy is to prevent continued phono-trauma to a freshly healing surgery site on the vocal cord. Often, if improper talking technique persists after surgery, the surgery site becomes damaged again or heals with abnormal scar tissue leading to the possibility of needing surgery again.
Voice therapy minimizes the likelihood of needing repeat vocal cord surgery in the future!
Restricted Voice Rest
Once the period of strict voice rest ends, the patient is slowly allowed to talk under voice therapy guidance. From this point forward over the next 4-6 months, the patient is under restricted voice rest.
Restricted voice rest is a fairly broad phrase, but essentially means to:
• NEVER abuse the voice (ie, yelling, screaming, loud talking, etc)
• Talk only when you must (ie, no social talking)
This period of restricted voice rest is important because it allows time for the new vocal cord tissue that has developed to not only heal, but also strengthen. Abusing the voice may tear the freshly healed surgery site which must be avoided at all costs!
Wednesday, 16 January 2013
Introduction
Over time, I have received a number of emails from patients regarding the best type of Gaviscon Advance they should purchase for relief of NON-acidic laryngopharyngeal reflux (LPR). The blunt answer is to get the Gaviscon Advance Suspension/Liquid made by Reckitt Benckiser which contains at least 500mg of sodium alginate in 5ml dose (1 tsp) or 1 gram in 10cc dose (2 tsps). This formula of Gaviscon Advance cannot be purchased in the United States, but instead overseas via online pharmacies located in the United Kingdom (link). Occasionally, Amazon.com
does stock it.The Gaviscon (without the "advance") sold in the United States is manufactured and distributed by GlaxoSmithKline (GSK) and not Reckitt Benckiser. The US brand of Gaviscon by GSK contains less of the key ingredient sodium alginate which helps with NON-acidic reflux. Alginate is a natural product derived from seaweed. The alginate reacts with the acid in the stomach to produce a "raft" barrier that acts as a physical block to reflux. It is the only non-surgical treatment that can physically prevent reflux disease regardless of whether it is acidic or not. Alginates work rapidly, are long lasting, inexpensive, and have no known side-effects.
Sodium Alginate
But because Gaviscon Advance is so hard to obtain in the United States, one of my patients suggested why not take just the sodium alginate and forget about the gaviscon? After all, it's the sodium alginate that's the key ingredient that is thought to help.
Great idea!
Even better is the fact that sodium alginate is easier to find and obtain.
If possible, I would stick to roughly the same amount of sodium alginate that would be ingested if Gaviscon Advance itself was taken:
500mg to 1000mg of sodium alginate after every meal and at bedtime.
Here's one product I found on Amazon.com
.DISCLAIMER!!! Please be aware that I can NOT vouch for overall effectiveness given these "supplements" have NOT been scientifically tested for clinical effectiveness nor is regulated by the FDA even though the same active ingredient sodium alginate is present. Use at your own risk!!!
References:
An evaluation of the antireflux properties of sodium alginate by means of combined multichannel intraluminal impedance and pH-metry. Aliment Pharmacol Ther. 2005 Jan 1;21(1):29-34
The value of a liquid alginate suspension (Gaviscon Advance) in the management of laryngopharyngeal reflux. Eur Arch Otorhinolaryngol. 2009 Feb;266(2):243-51. Epub 2008 May 28.
The role of an alginate suspension on pepsin and bile acids - key aggressors in the gastric refluxate. Does this have implications for the treatment of gastro-oesophageal reflux disease? J Pharm Pharmacol. 2009 Aug;61(8):1021-8.
Sunday, 6 January 2013
• Antacids
• H2 Blockers
• Proton pump inhibitors
• Barriers
• Combinations
What is also explained are the limitations of such medications when it comes to disorders like non-acid reflux.
Check it out here!
Some example reflux medications that can be purchased over-the-counter:
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