Mr. potato hea 2007-11-25 09:56:00
I think I learned something new about my condition. I keep reading
about GERD and wonder why that doesn’t match what I’m feeling. But
today I read about LPR–Laryngopharyngeal Reflux.
Typical LPR presents with almost the exact symptoms that I’m feeling,
GERD does not.
LPR is different than gastroesophageal reflux disease (GERD). Patients
with GERD are usually seen by a gastroenterologist. They typically
suffer from heartburn and many persons with GERD have esophagitis.
Although some persons with LPR do suffer from heartburn or esophagitis
(12%), most persons with LPR do not.
Then there’s Esophagopharyngeal reflux (EPR) which is a consideration
if treatments for GERD and LPR don’t work.
I’ve only felt these symptoms for about three months now. These
articles indicate that any LPR, GERD or EPR drug therapy can take much
longer than that. But still, I’m trying to find a connection between
the hiatus hernia and my seemingly LPR symptoms and have been
unsuccesful–Howard, I know, I know… but I’m stubborn. I’m still
trying to find out what causes GERD or LPR? Age? (i’m 42),
family?–I’m confused by this because I’ve never had it before. Either
way, PPI are the treatment for GERD and LPR and I’m on Aciphex now. The
only thing though is that my dr has me take it once a day–20mg. The
articles I’ve read indicate that patients should take PPIs twice a day.
Anyway, thought I’d share. If anyone has any comments on these
different conditions, by all means, I’d love to read them.
Howard mccolli 2007-11-25 09:56:30
LPR is a subset of GERD, but otherwise you’re correct. In fact only about
40% of patients with GERD have “heartburn”. The rest have extraesophageal
manifestations (like LPR), or no symptoms at all.
A hiatus hernia MIGHT contibute to displacement of the LES into the chest
which MIGHT result in lower resting pressures, which MIGHT result in
increased reflux. Low LES resting pressure is one cause of reflux – the
other is transient inappropriate LES relaxation and that has nothing to do
with hiatus hernia. The relationship between your hiatus hernia and your
GERD, therefore, is that your hiatus hernia MIGHT be contributing to your
reflux. We don’t know how large your hiatus hernia is. Small ones are not
usually much of a factor.
“I’ve never had it before”……I hear that all the time – people tend to
think that their bodies will stay the same and somehow bypass the aging
process, which is increasingly accelerated by wear and abuse. People are
well, right up until the day they get sick. Welcome to middle age 🙂 In
your struggle to understand, be aware that your hiatus hernia might have NO
relationship to your GERD. You may just have a weak and/or malfunctioning
You have GERD because you were born with that tendency. It definitely does
run in families.
Different PPIs have different pharmacokinetics, so the doses and the dosing
schedule isn’t the same for all 5 of them. Use of Aciphex twice a day might
be indicated in someone with esophagitis, but we don’t know that about you
since you have only had an upper GI contrast xray. The standard dose of
Aciphex is 20 mg once a day.
Note again that use of PPI’s does not cure anything, it stops acid reflux.
It doesn’t stop alkaline (“non-acid”) reflux, which is just as damaging to
the lower esophagus (IOW does not stop Barrett’s metaplasia), nor does it
always stop LPR. If PPI’s do stop LPR, it can take as long as 6 months to
have that effect. You problem is a malfunctioning lower esophageal
sphincter. There is no medication to fix that, so all your doing (maybe)
with the PPI’s is trying to control the symptoms. We’ll see….I wish you
the best of luck in that.
Mr. potato hea 2007-11-25 09:56:33
thanks Howard, you’ve been a wealth of information on this.
What is LES resting pressure? Is the the amount of acid reflux pressure
when body is at rest?
What is transient LES relaxation? Related to resting pressure?
My doctor told me it was small but I don’t know what constitutes as
small. I’ll have to go back and ask her for more detailed information.
She told me the results of the esophagram over a phone call.
Ok, so what do you suppose happens in our GI that has anything to do
with aging? Does the ELS weaken as we get older? I’m not discounting
the fact that most people in my family have some sort of GERD type
I’m trying to understand the anatomy of the LES and a hiatus hernia.
I’m assuming that part of the stomach is protruding through the LES? Is
that right? So if I may have had a hiatus hernia for years, why does
it now allow so much acid to reflux?
I’m going to keep bugging my doctor about maybe getting scoped to
ensure that we are not “visually” missing anything. At least now I can
ask the tell the doctor that I want to focus on my LPR type symptoms.
Thanks again, Howard.
Howard mccolli 2007-11-25 09:56:35
The lower esophageal sphincter is a ring of muscle situated between the
stomach and esophagus. Its function is to maintain a continuous state of
contraction (muscle “tone”) so that it will continuously “pinch off” the
esophagus from the stomach. That muscle tone is the LES “resting pressure”,
and that pressure has to be high enough to exceed the pressure differential
between the esophagus and stomach. When you swallow, the swallowing reflex
will cause that LES to relax enough to let the food through into the
stomach. That’s the only time the LES is supposed to relax, otherwise it’s
supposed to continually have a resting pressure of somewhere between 15-30
The LES is not a “flap” valve that provides one-way passage, it’s a circular
“ring”, and esophageal coordination as part of the swallowing reflex is
critical to its appropriate function. You may have been having years of
asymptomatic reflux that didn’t cause any symptoms, but still damaged that
coordination of the esophagus (“submucosal fibrosis”).
The hole in the diagphragm where the esophagus goes through from the abdomen
to the chest is called the “esophageal hiatus” or “diaphragmatic hiatus”.
Normally the LES would be located about there. Normally, you would have
about -6 mmHg pressure in your chest cavity (where the esophagus is), and
you would have about +6 mmHg pressure in the abdominal cavity (these are
averages). That means that under resting conditions, there would be about a
12 mmHg gradient of pressure continually trying to pull acid into the
esophagus. If the LES has a resting contraction pressure of less than that,
acid can flow freely into the esophagus. Note that pressure in the abdominal
cavity can significantly exceed 6 mmHg when you strain, bend over, or even
with a full stomach. If the LES is too weak relative to that pressure
differential, stomach contents can flow into the esophagus. That is GERD. It
can flow so far up the esophagus that it can get into the posterior pharynx
and cause cough, laryngitis etc – that is LPR. Transient inappropriate LES
relaxation can happen when that LES just transiently relaxes and loses its
muscle tone. It’s not supposed to do that so that event is “inappropriate”.
Various things can trigger that, such as alcohol, nicotine, caffiene and
some foods. Tomato-based foods can do that in many people. That’s why many
foods like that can exacerbate reflux. (“Italian food causing heartburn” is
Many things can cause the LES resting pressure to be too low to keep stomach
contents from getting into the esophagus. Age can weaken that muscle, or it
loses some of its tone, just as various other muscles in your body have less
muscle tone now than when you were 18. Additionally, a hiatus hernia
displaces the LES upward into the chest so that it no longer gets any
additional support from the diaphragmatic hiatal muscle sling (“crura”) and
other attaching structures.
The workup for GERD is quite straightforward. It includes an EGD first,
because erosive esophagitis needs to be ruled out, as does Barrett’s
esophagus. If neither of those things are present on EGD, it’s appropriate
to treat the symptoms of GERD with medication and lifestyle changes. At the
point where that treatment no longer controls the symptoms to the patient’s
satisfaction, then additional testing needs to be done – ambulatory pH
testing to determine the extent and circumstances of reflux, and esophageal
manometry to measure the LES pressure/performance, and esophageal strength
and coordination. Upper GI xrays have little or no place in the diagnostic
workup – and EGD provides far more useful information.
You are focused on your particular symptoms. You are presuming that they are
LPR, but if so, your problem is not LPR, it’s GERD. It’s your GERD that
needs to be worked up, not your LPR. You can empirically try PPIs to treat
your symptoms – that’s not a wrong approach, but if you are refluxing
stomach contents into your posterior pharynx, you will continue to do so
even on PPI’s, but that refluxate will no longer contain acid (which is
blocked by the PPI). Therefore, medical treatment may have no effect on your
symptoms (it might, or might not depending of the extent and nature of your
particular refluxate – we don’t know this about you because you haven’t had
any diagnostic studies yet). Be aware that it can take months for
extraesophageal manifestations of GERD to relent.
Blocks to book 2007-11-25 09:56:39
Please forgive selective trimming and for jumping into this thread. Now
that I read about the physical description of the LES and its function and
relation to the diaphragm, etc. my concern is if the stress produced by
weight lifting and/or having a full stomach from a big meal could
conceivably compromise and damage a stretta repair of the LES. My fitness
activities are necessary for the maintenance of my bone health as well as my
over-all well being and, at this time, they are a non-negotiable item. I’d
ask the surgeon at my Stretta workup next month, but, in the past, I’ve had
surgeons who wanted to do a pelvic repair surgery exhibit over-confidence
about the sturdiness of a repair whereas physicians who are not the
potential surgeon have given me an entirely different story. -Blocks
Howard mccolli 2007-11-25 09:56:41
If you have GERD, you shouldn’t ever be eating a big meal. That increases
the pressure gradient across the LES, *and* it contributes to transient
inappropriate LES relaxation.
That said, the best answer I can give you is *maybe*. Repeated straining
against the LES, especially vomiting, can compromise any type of LES repair.
This is likely more true of a Nissen than a Stretta, but even that is
generally of less concern once the patient is beyond the immediate post-op
period (about 6 – 8 weeks).
Mr. potato hea 2007-11-25 09:56:44
Howard, this is the sort of information that I’m looking for. As long
as I know that it can potentially take months to heal then I can
realistically make better use of my time with the doctor and ask better
informed questions rather than whine and worry myself into more
abdominal problems–which is part of what’s been happening.
I’ve been in general good health most of my life although a little on
the heavy side. Maybe it’s starting to take its toll–that and my
family’s history with indigestion–especially on my mother’s and
grandfather’s (her father) side. I still remember my grandfather
taking Alka-seltzers and complained about doctors’ incompetence to fix
him. But four years ago, he died at 92 of natural causes.
Ok, LPR is potentially a secondary condition as a result of the primary
condition which may be GERD. As stated before, I will ask the doctor
about an EGD in the next month or so if I don’t see any changes in my
My goal was to completely get off all my meds as I feel like there is
an alternate and natural solution for almost everything. That may or
may not be realistic but most older people in my family have resolved
have resolved their symptoms using natural solutions and therapies. But
again, we’re all different despite heritage and that may not apply to
Anyway, thanks again for the information on the anatomy and prognosis
of GERD related conditions.
Foggydoggy 2007-12-02 08:24:13
Occasional lurker here.
My naturopath got me off the Nexium and I’ve been off since early May 06
after about 7 yrs on PPI’s. I had reflux induced asthma and for me those
drugs were lifesavers. Once I got on these meds I was able to stop all my
GERD was never a definitive diagnosis. My endoscopy showed nothing, motility
test showed delayed emptying and the acid probe test showed nothing but when
I got onto Axid all my symptoms disappeared. Unfortunately,the drug effects
wore off over time and had to switch around until I used Nexium which
continued to work for years.
I started seeing a naturopath Oct/05 and she was very disturbed at the
Nexium and told me that in 80 % of the cases she sees the symptoms are not
true reflux but actually caused by LOW acid levels. She said that the
symptoms of high & low acid are the same and automatically people are
treated with PPI’s.She said that low acid levels causes relaxation of the
LES and returning the levels back to normal will tighten the LES. So I
started taking Betaine HCL (hydrochloric acid) with my meals to increase
acid level and improve digestion. Over the months I took these capsules just
to before the point of feeling heartburn ( 2 caps) and at the same time very
slowly & gradually cut out my Nexium. It took 5-6 months but I finally got
off of the Nexium with no heartburn symptoms. I still have to watch my diet,
elevate head of bed and avoid large meals but I’m off the meds and with
adequate acid levels my digestion is improved.
Mary 2007-12-02 08:24:16
I’m experimenting with going off prescription medication as well, under
the direction of a naturopath. I was diagnosed with Barrett’s Esophagus
(no dysplasia) last year when I went to see the doctor for a persistent
stomach ache, which I was sure was an ulcer – a high, round hot spot.
(I suppose that’s heartburn; not sure.) Now, a year later, I can
clearly tell that chocolate makes it worse, and probably coffee, wine,
Altoids and high fat foods, all of which I avoid now. The bed wedge
appears to help, too, and I wonder if the slope of our water bed hasn’t
contributed to this over the years. I’m trying to figure out how long
to give this stomach to heal. I appreciate the time folks take to share
their own experiences here, as well as the doctor’s advice, which is
generous of him.
Foggydoggy 2007-12-02 08:24:22
If you have Barrett’s I would say you definitely have GERD because only the
esophageal exposure to stomach acids would have caused those tissue changes.
With the Barretts I would be cautious in going off the meds, you really have
to be monitored carefully. In my case the GERD was not definite, in fact,
one GI doc felt it was more irritable bowel spread throughout the digestive
tract. And I’ve noticed during this Omega 3 induced heartburn flare my
irritable bowel is also in a tizzy.
Does the bed wedge you have bother your back? I have one and it was too
uncomfortable to use so I put grocery bags full of old newspapers under our
mattress to elevate it. Not ideal but I can’t put the head of our bed on
blocks.We have one of those Scandinavian style beds that the mattress fits
into a platform frame and there’s no feet to elevate. My hubby’s also
developed some mild reflux so we’re going to change only the bed itself.
There’s lots of beds out there now with “feet” and can be put on blocks.