When different doctors – PCPs, gastroenterologists and otolaryngologists – take different approaches to the common problem of acid reflux, patients often continue to suffer. In this talk packed with experience-based tips, otolaryngologist Clark A. Rosen, MD, explains the complexities of diagnosing reflux, the advantages and limits of commonly used tests, and how to work with patients on everything from a PPI trial to an effective natural supplement to dietary modifications.
Thank you so much. Uh, my name is Clark Rosen. I'm the, uh, co-director of the UCSF Voice and Swallowing Center, a chief of laryngology within the Department of Votolaryngology, head and neck Surgery, which is a whole bunch of fancy words and titles for saying that I'm an ear, nose, and throat doctor that specializes in the T of ENT, um, and so I take care of people with voice problems, swallowing problems. And, uh, breathing problems, uh, all related to the larynx, pharynx, and trachea. Um, and in that, um, uh, body of work or area, um, often we see patients with reflux. Um, uh, and I know that everybody in medicine other than our pathologist and our radiologist probably see people with reflux, and it's a really, really common issue. There's a lot of Misconceptions, there's a lot of, uh, of, of issues with respect to reflux. It's, uh, imperfect science in no uncertain terms. So, uh, a little bit ago, I put together this, uh, this talk to kind of, um, roll up our sleeves and, um, have a conversation about what we know about reflux, um, what we do well, uh, what we don't do well, and where kind of our our patients kinda get stuck, if you will. Um, and So I hope this is helpful. I definitely have plenty of time at the end to answer questions, and I love answering questions. One of the things I hate about Zoom is that I can't see your faces while I'm giving this talk. Um, but one of the things I love about Zoom is that, um, uh, I don't have to drive out and, and be anyplace, and so my ability to, to, to, to kind of, uh, communicate and connect with people is so much more, uh, amplified, so I really appreciate that. So, um, let me get started here and Uh, these are my disclosures. The bottom one is quite important, um, because I am a very minor, minor shareholder in a company, uh, that does have a reflux treatment, and I'll talk to you about that, but I wanna alert you that, to that now. I'll, I'll alert it to you again when we get there. Um, I want to, um, pause for a second and express gratitude for, um, all primary care. Physicians and providers, um, who do such important work, uh, to take care of patients, uh, on the front lines. And, uh, I really greatly appreciate, uh, all the work that you do, uh, taking care of patients. So, this is an overview of what I'd like to go through over the next 30 minutes or so. Um, the first is, uh, uh, kind of an engaging topic, what I call the reflux patient cycle. Of hell, uh, and I'll walk you through that. And then I'm gonna talk to you a little bit about how patients get trapped between otolaryngologists and gastroenterologists. Talk about some basics of reflux, and then talk about reflux, uh, testing, reflux diagnosis, and reflux, uh, uh, treatment options, and then we'll, as I said, have mentioned, have time for questions and answers. So, here's what I call the reflux patient cycle of hell. Patient develops some type of throat complaint. Uh, it could be hoarseness, could be thick mucus, could be globus, could be cough, could be dysphagia, you name it. Um, uh, very, very common and, um, you know, very, very non-specific. Uh, the primary care physician says, you know, once you go see an orolaryngologist, you're having a throat problem, totally reasonable. Uh, the ENT, um, sees the patient, uh, and makes the Diagnosis, and I put the diagnosis in quotes, as we'll talk about in a little bit of reflux and suggests a proton pump inhibitor. Um, uh, the PCP, uh, doing the, doing due diligence, reads the ENT report or letter back to, um, uh, the, uh, the, the physician and, uh, sees that the reflux is in play and suggests that the patient go see a gastroenterologist. Uh, the gastroenterologist scopes the patient because, you know, um, especially, um, you know, heartburn and other related complaints are kind of somewhat red flag symptoms for, uh, Barrett's and esophageal cancer, which is, you know, on everyone's mind, um, in the GI and ENT world because of the increasing risk, increasing incidence of esophageal cancer. So the GI scopes the patients, finds a normal esophagus, normal stomach, and says, you don't have reflux, stop that medication. And probably behind, under their breath, they're saying, uh, that olaryngologist has no idea what, uh, she or he are doing. Um, so then, the patient's caught in the middle and, um, is still symptomatic. And so this plays out, I see, I see almost a patient a week with this exact same scenario, um, again and again, and they'll never know what to do because they're kind of, uh, struggling. So, why does this happen? Um, and so I wanted to explore a little bit why this happens so we can understand the origin of the problem, so to speak, and then we can navigate our way out of this, uh, problem. Uh, first and foremost, gastroenterologists tend not to see ENT reflux-related symptoms. Or ENT reflux related patients. So they sometimes will doubt that this is even as an entity. They certainly never learned this in their training, um, even to this day, and they don't, definitely don't appreciate the magnitude of the problem. They focus on heartburn, heartburn, heartburn. They focus on stomach, stomach, stomach, and often these patients, this has been very well studied and very well documented. Often patients have Otolaryngology symptoms, mostly throat symptoms, but they have no heartburn at all. Um, and so this is kind of why otolaryngologists have coined the term laryngopharyngeal reflux. Sometimes you'll hear people talk about silent reflux. It's not a term I love to use, but it is one of the conundrums or one of our problems that why gastroenterologists don't understand what, um, some of these patients are going through. Um, there is a certain little bit, a certain, uh, uh, uh, component of what we, what I call GI NIMB. NIMB stands for not in my backyard. Uh, and so, they look at the esophagus, they look at the stomach and say, not my problem, see you later. Uh, and then they move on to their next patient cause they're busy and they have a lot of demands on their Schedule. Um, so that still leaves the patient stranded. And then on the flip side, just to be completely fair, otolaryngologists, um, have had, I would submit to you, uh, a history in the past, not every single one, but a, a little bit of a a tendency to overcall reflux. Um, it's not an easy diagnosis to make, as we're gonna discuss in just a minute. Um, it allows you to give a patient an immediate diagnosis and a pill which often patients want. Um, the detailed diagnosis or kind of a really rock solid diagnosis of reflux is, does typically involve an invasive test, so most patients don't really want that. And then, the, the biggest, um, uh, confession I will have for you is that otolaryngologists cannot, capital NOT, look at the larynx and the pharynx and definitively make a diagnosis of reflux. Even though we, we look at the larynx and pharynx all day long, it's one of the things we do. Really, really well, and it is an incredibly important part of our practice, uh, for, you know, infection, cancer, you name it, but to make a definitive diagnosis of reflux is not, uh, not, not in the cards, um, uh, just because, uh, it's a diff it's a more difficult diagnosis than just visual alone. So, I wanted to kind of back, take one step back and talk a little bit about kind of how new ideas get introduced into science. Um, and this concept of reflux related to the throat is a relatively new idea, say it's been around. 1520 years or so. And the way new ideas tend to get introduced into science, especially medicine, is that there's always a pioneer or a missionary type of person who goes around and says, I just discovered this, or I just found this, and then wants to tell the whole world. Um, and so then, um, after, you know, this missionary type of work, um, everybody gets on the bandwagon and then everybody in the world, you know, is thinking about this disease because it's brand new, just got discovered and so excited. And so there's a very big swing, uh, from, you know, not understanding the disease, i.e., nobody has reflux. If you don't have heartburn, you don't have reflux. That's the way, you know, uh, you know, it was in the 1950s and 1960s, that's the way gastroenterologists even today sometimes think. And then we had an explosion of concepts and ideas about reflux. We definitely had, uh, an otolaryngologist who was kind of quite the missionary, if you will, um, uh, um, uh, talking about this. And, um, and then Before you know it, everybody had reflux. And of course, you know, this, you know, uh this was aided by the drug companies who wanted to sell more Prilosec, uh, and Nexium and whatever it is. I mean, you know, you can't watch it, you watch, watch the NFL football game without seeing. At least in, in the past, you know, without seeing a, a proton pump inhibitor commercial. So, right now, I believe we're somewhere in the middle where we're trying to get a kind of a, a calm balance and, you know, some patients have reflux, some patients don't, and that's the crux of this lecture. Uh, or discussion. So, I've listed out the classic GERD, uh, symptomology that you learned about in medical school, heartburn, indigestion, sour taste, burning sensation, regurgitation type of thing. And then, the new paradigm, if you will, um, or a separate entity, which we call laryngopharyngeal reflux disease, LPR or LPRD, you know, Globus throat clearing, increased mucus, dysphagia, dysphonia, um, those types of symptoms. And so, uh, sometimes there's an overlap. It's great when there's an overlap when somebody tells me that, you know, that they're, you know, having all these throat symptoms, and by the way, they get heartburn 3 times, you know, 3 times a week, um, and that, you know, they admit to being really, really sensitive to tomato-based foods or spicy foods. That's great. I love it. Uh, but all too often we don't get that GERD symptomology. We just get these throat symptoms and we have to ferret out. Uh, what's the cause of these throat symptoms, and is it reflux or is it not? That's the big question. And so, uh, there's a variety of diagnostic tests that I wanna walk you through that have been developed, some good, some not so good for reflux. So I'm just gonna briefly go through this. Barium swallow is a horrible test to diagnose reflux in or out. And so there's really no value if your primary focus is to make the diagnosis of reflux for a barium swallow. Um, Next is uh uh esophagogastroduodenoscopy, what we call a GI uh uh uh EGD, what the gastroenterologists do all day long. And, uh, it's a great, it's a great test or if uh methodology to evaluate, uh, Barrett's, hiatal hernia, gastric ulcers, esophageal webs. It's not a good test for laryngopharyngeal reflux disease, period. Um, sometimes gastroenterologists say, I scope these people because, um, heartburn and reflux is a red flag syndrome for oesophageal cancer. OK, I'm all right with that. But it doesn't, a negative EGD does not tell you that your patient does not have reflux, period. Um, I'm gonna say that again cause it's so darn important, uh, cause patients Come to me again and again. He goes, I had a scope, so I can't have reflux cause my gastroentererologist said I don't have reflux. That's not absolutely true, unfortunately. Moving on to a little bit more sophisticated, uh, testing, a tad invasive, but more sophisticated for sure. This is called a dual-channel PH, um, um, uh, probe, um, plus or minus manometry. And, uh, pretty simple test. Um, the patient comes into a small little, uh, outpatient clinic or it can be done in an outpatient hospital, uh, hospital-based kind of setting. And, uh, usually a PA, nurse practitioner, uh, or just nurse will pass the small little catheter through the nose down into the esophagus and then secure it. And then that probe has a whole bunch of PH probes. Sensors along the whole length of the uh of the uh of the tube. There's a bunch of different types. There's uh dual pH. There's multiple channels, but the whole concept is that it stays in there for about 24 hours and the patient and it measures pH throughout the whole length of the, uh, probe. Um, and then patients will also tell you when they have symptoms and so you can correlate that. There's some nuances to the test which we can get into if somebody has questions, but That's generally how a, a pH probe, what we call a pH probe works. Uh, uh, a nice interesting version of, of a PH probe is called the Bravo, uh, test, and this is done at the same time as an EGD, and it's a wireless pH sensor that is typically placed at the lower esophageal sphincter, um, and it sends information for somewhere. 36, 48 hours to a little um um uh capturing device that usually the patient will hold on their belt buckle or something like that, and they'll measure pH um and then, you know, it passes and goes away. So, no wires um throughout, no, no, no tubes throughout the nose, and so it's definitely an advantage from that perspective, but it only measures pH at one location. Um, and so there's another diagnostic test, uh, for laryngopharyngeal reflux, uh, disease that we call an empiric trial. Um, and I'm gonna go over in great detail empiric trial cause I'm a big advocate of empiric trial and we'll talk about it more. Um, if you're gonna do an empiric trial, which I, I, I, I, I, I do all the time, you need to make sure that the dose is high enough. Um, and the treatment is long enough. So I typically, my empiric trial is usually uh 40 mg of Prilosec or some other full-dose PPI, um, uh, twice a day, 30 to 60 minutes before a meal. Um, and then I usually do that for at least 2 months, usually 3 months. Um, there is a a good uh body of evidence that shows that For laryngopharyngeal reflux symptoms, it takes at least 2 months of, of acid suppression therapy to get significant and plateaued out symptom improvement. And so that's why, you know, a week or 2 of a PPI uh doesn't usually cut it to find out if the patient's gonna get benefit from or not from acid suppression therapy. So let's do a little comparison, if you don't mind, of our reflux testing kind of pros and cons. Empiric trial, um, uh, it seems like we're doing a treatment, but it's actually a diagnostic trial. Um, and so it's kind of both diagnostic as well as therapeutic. Um, uh, lots of patients don't love the idea of taking a proton pump inhibitor cause it's been, had a lot of bad press. Uh, I have to tell the patients it's only for the first couple of months, you know, there's no major danger in 2 months' time period. And so, um, but, um, that's kind of, uh, the pros and cons of an empiric trial. A pH probe, uh, or impedance mon uh, uh, uh, testing, uh, has the advantage of getting objective data. It'll tell you how many times, you know, the, the pH dropped, uh, where in the esophagus the pH dropped, and how long was the pH at an aesthetic level. Um, so, you get a lot of really helpful information. The disadvantages, the discomfort. Uh, it's only a 24 hour window. I always joke that this is not a gold standard, it's a silver standard because no place in the 10 Commandments does it say that man or woman must reflux every 24 hours. So, somebody could have a pH probe, have a great day, um, and have no reflux symptomology at all, and uh have A negative pH probe and we just happen to miss them. So, it is a short testing window in no uncertain terms. Uh, the Bravo, which is the wireless device, um, obviously has the advantage of no catheter, a longer exam, uh, but it is only telling us about proximal disease. So that has some limitations, especially as it relates to laryngo. reflux disease, we usually want to see it if the acid is truly coming all the way up the length of the esophagus. EGD, as I said, um, is good to finding out other pathology, but is not diagnostic for, uh, reflux disease, uh, either in a positive or negative way. Esophagram, uh, we don't even need to discuss anymore. So what are active issues when it comes to reflux? Uh, a wide array of complaints that are, um, not pathognomonic in any way. Um, the history is often helpful, and that's why those symptomology, uh, are helpful. Um, but, um, uh, there is no really easy Well-done diagnostic test that's not super, super involved. And so that um leads us to, uh, a problem. And so, you know, sometimes patients will, will answer your questions uh positive with respect to, you know, dysphonia, dysphagia, or globus sensation. Uh, but they'll also say they have heartburn, but it doesn't mean, uh, you know, the cause, you know, causation is not the same as correlation. And so, is it truly related or is it, are they unrelated? That's kind of, uh, sometimes I have to kind of remind our medical students and our residents that You know, uh, uh, presence is not causation, and so, correlation is a different entity than, um, than this. So be careful along those lines. There's a couple, um, nice articles done on the role and the value of empiric trial, um, which I can share with you if you want. Um, there is also a lot of literature that shows that PPIs don't help patients with laryngopharyngeal reflux disease. And, uh, kind of an interesting factoid is that, you know, when, when the PPI's were all under, um, um, uh, not, you know, not, not, none of them were generic, the drug company spent a lot of time Trying to expand the indications for PPIs to laryngopharyngeal reflux disease, and so they did very complicated, nice, elegant, uh, randomized controlled clinical trials, and there's a handful of really well-done studies that show no difference in suspected reflux patients who had a PPI versus placebo. And the reason that is, is that none of these patients had a PP. Uh PH probe prior to entry. So many, many patients were injured in these studies, but they never actually had reflux disease. And if you start with a whole group of patients that don't have reflux disease, and then you give them PPI versus placebo, none of them are gonna get better because that's the wrong treatment. So, there is some, there is some kind of faulty literature out there. Uh, a couple of interest In studies, um, uh, people always, um, sometimes will ask me like, why do you treat, uh, BID? Why are you using such a big dose, and along those lines. And so there is a study that shows that, um, Um, empiric therapy increases the, the response rate to empiric therapy increases when you go from QA to uh to BID and even a little bit higher when you go to, uh, PPI, BID, and H2 blocker. Um, and so, um, think about that. If you're gonna do this as an empiric trial, I would say go all in, at least do a BID PPI, uh, for at least 2 to 3 months and then go from there. Um, and so, uh, what's our best practice? Uh, what are the next things? Um, you know, it's nice to know if a PPI is gonna control the symptoms, and we'll talk about, about a positive empiric trial versus, uh, uh, a negative trial. Um, but if you suspect laryngopharyngeal reflux disease, you put somebody on a PPI, they come back and they're like, oh my God, this is great. My cough has gone away. I'm swallowing so much better. My Voice is better, then you have a pretty good strong suspicion that it was uh reflux-related, and then your job is to say, OK, what can we do to get you off the PPIs? We'll talk about that very shortly, or at least put you at the lowest dose possible. So that's what I wanna talk about next. Uh, this is a study that, um, uh, I and my, um, uh, uh, colleagues did a handful of years ago, 2017. It's getting longer and Farther away. Um, and so we took patients who, um, had an empiric trial for laryngopharyngeal reflux disease, came back and said, I'm dramatically better, thanks so much. And then, um, we developed, we weaned them off PPIs over about a 10 to 14-day time period. We really, um, uh, doubled down on our behavior modification from a dietary behavioral perspective, and then we tracked them over time. Overall, 66% were able to be successfully weaned off PPI without a recurrence of their symptomology. Um, no surprise, the patients who had a high BMI, um, uh, uh, were not near as successful at weaning off PPIs. Uh, and so, this is an opportunity for me to remind everybody about the importance of what we call behavior modification. So fried foods, spicy foods, alcohol, coffee, mint, chocolate, late-night eating, all are huge, huge um activities that make reflux much, much worse. And, um, so I encourage you to have the conversation with patients about this. Um, more and more people are interested in low-acid diets. Alkaline water, those types of things that didn't exist 10 years ago, but overall, those are very, very important things. And as patients have become uh concerned about long-term PPI use, they're now more motivated to do dietary changes, which is really, really, really good. What are alternatives to PPIs? Uh, there, of course, there H2 blockers, uh, Zantac is off the market now, so, um, I use Pepcid. Um, uh, you can use antacids as well. You can use sulfate. I haven't had a great results with sulfate, and, you know, antacids, you know, once in a while is OK, but if somebody's on antacids regularly, they probably need more, uh, intensive medical therapy. Nobody has actually ever Studied if once a day PPI is less dangerous for PPI complications than BID nor even H2 blockers. So that's something we don't truly know. You could be, say it's intuitive and we should get the patients down to the lowest level of acid suppression therapy, which I think is reasonable and that's what I do too. Here is an interesting and um favorite alternative to PPI therapy. And this is what I do for many of my patients who um have a positive empiric trial, they get better with PPI and then I'm weaning them off and they're still getting some symptoms, is I put them on what I call alginate therapy. And alginate is a uh chemical that's found in seaweed. Um, and when you take this chemical, um, and add it, uh, you know, throw it into the, into the stomach after a meal, it combines with the gastric acid contents and forms a thick, um, uh, fibrous-like raft. On the air fluid interface in the stomach, and that creates a barrier from gastric uh contents going up into the esophagus, um, which is kind of what our presumed etiology is for laryngopharyngeal reflux symptomology. There's 3 different, um, companies that make this. They're all over the counter. Um, as I mentioned in the beginning, I'll remind you, um, the company called Reflux Gourmet, uh, which is, um, uh, an, an excellent alginate option. I have a financial, uh, connection to, uh, the other, uh, two products, uh, all of them, all three of these can be buy, can be purchased, uh, at Amazon, um, uh, and that's the easiest way to get them in my experience. Um, there's a, uh, entity called Gaviscon Advance, um, that has an alginate in it. You have to get the alginate, Gaviscon Advance that's sold in the UK. Um, the Gavisconganz that's sold in America does not have alginate. So, that's why you have to, you know, when you go to Amazon, you have to look specifically for Gavisconagans from the UK and then you'll notice and verify that there's alginate in it. The other agent is called esophageal guardian. So, that's an alginate. I encourage people to do this. You can use it QHS, um, you can use it PRN. You can use it, use it after every meal. Um, and, and I've had a lot of, a lot of clinical success with this. Um, this is just a, a review of a variety of alternatives to, uh, uh, proton pump inhibitor therapy. Um, we don't have Great data for any of these entities, um, to be completely, um, uh, honest, uh, between prokinetics, alginate, you know, meditation, things like that. Um, and so, this is still work that to be done. Uh, this is an article that sometimes patients like to talk about or physicians like to talk about, and then this is a, um, retrospective review. Of, uh, patients that were suspected laryngopharyngeal reflux. Again, none of them were proven they had reflux before they entered. Um, and, um, some were given alkaline water and a Mediterranean diet, and others were put on PPIs, and they had no difference in their outcome. Um, so, uh, this study is intriguing and reminds us the importance of behavior modification. Um, but, um, it, it also has a lot of limitations. Its primary outcome measure is quite flawed, um, and then, uh, there's some other issues, uh, about this, but I do want to bring that out to you, and it's a reminder that diet is so, so important. Um, so, what happens if the patient doesn't get better? Um, this is when I think it's important for us to have an open mind. Um, and so I usually will, you know, talk to the patient again like I've never seen them before, and I said, tell me about your symptoms. Um, what have you tried? What else happens? And so, I kinda think it's a good To go back to step one, listen to them again, explore different avenues, and so it's also important to have a differential diagnosis. So this is, uh, uh, uh, you know, an, an ENT more related slide, but I'll go over it briefly. This is, you know, a differential diagnosis that our residents should be able to come up to for Patients with hoarseness, but no obvious lesion or neurologic abnormalities of the vocal folds like vocal fold paralysis, vocal fold cysts, and things like that. Reflux, uh, there's a disease called muscle tension dysphonia, which is an inappropriate amount of muscle use in the muscles of the neck and the larynx, uh, synonasal allergic disease. Uh, psychological disease, uh, subtle organic abnormalities of the vocal folds, or a neurologic condition called spasmodic dysphonia. So again, when patients come back to me and they've got, uh, voice problems and they didn't get better with reflux, I always wanna go back and redouble my evaluation and my history and see if any of these, um, entities are at play, and then I've missed the boat, um, um, uh, by thinking too much about reflux. So, um, again, this is kind of my Treatment failure, paradigm. Uh, maybe it was the wrong diagnose diag wrong diagnosis, so that's when, what we just talked about. Maybe it was the wrong medication, um, and so maybe I need to increase it, maybe the compliance was poor, um, you know, go from QA to BID, add a QHS, uh, H2 blocker. Those are all different options that you can do as next steps. Um, and then, um, a wrong use of medication. So I talked about patient compliance. Did they really take it? Did they Take it the right time of day. Um, and so, uh, those are kind of my troubleshooting, uh, thought processes when I see patients back who aren't doing, uh, well. And then in the end, uh, if you're really still struggling with like what's going on, does this patient have reflux or not, a PH probe is a great test to kind of answer your questions. And I always tell people, you know, if we find out that your pH probe is stone cold normal, then we can move on and really Pull up our sleeves and look for something else. Um, uh, and in contrast, if you do have a positive pH probe, then we just need to figure out why, you know, what dosing and what compliance and what type of schema we need to do to get you, uh, under control. Sometimes patients have such bad hiatal hernia that, uh, a hiatal hernia that no matter what they do from a diet perspective, that until their hiatal hernia is improved, they're still gonna have significant reflux, so they may need hiatal hernia surgery. Um, so, that's kind of a quick down and dirty, uh, review of what we call laryngopharyngeal reflux disease. I wanna thank you for your attention. I really, really look forward to answering any questions, uh, that you have.
