Question:
My 45 yr. old daughter has recently been diagnosed with LPR. and prescribed momeprazole 20 mg delayed released to be taken at bedtime. She has a swallow eval coming up. Symptoms are frequent throat clearing. Before eating she seems to have it the worse with some intensity, gasping and what seems to me like a muscle spasm event. The symptoms vary day to day. I have read the guide in your book and followed suggestions with diet etc. What else can be done? No previous digestive issues prior to this past 10 month period. Thank you so much.
Answer:
Acid from the stomach can go backwards up into the esophagus (the tube between the mouth and the stomach). When the acid goes into the esophagus, it often causes gastroesophageal reflux disease (GERD), which is commonly associated with the symptom of heartburn. However, the acid may also travel all the way into the throat, and this is called laryngopharyngeal reflux (LPR) and may be associated with a sore throat or irritated voice box (larynx). Typically, the sphincter, the muscle at the end of the esophagus, opens to let food into the stomach and closes to prevent food and stomach acid from going back up into the esophagus. In GERD and LPR, the sphincter does not function correctly, and food and acid back up into the esophagus.
All along the gastrointestinal tract from the mouth to the anus, the natural movement of food and waste is more likely to be impaired in people with Down syndrome (DS). Some of the complications of this include swallowing problems (dysphagia), GERD, and constipation. Like the higher frequency of these other conditions in people with DS, it is likely that LPR is more common in people with DS, too.
Symptoms
The symptoms of LPR may include:
- sore throat
- a persistent or chronic cough
- mucus in the back of the throat
- vocal hoarseness
- irritated voice box
- trouble swallowing
- sensation of gasping or gagging
- bitter taste in the mouth
Sometimes upon reaching the mouth, the stomach acid and/or food may then be aspirated into the airway and down into the lungs. This may cause more coughing, bronchospasm (wheezing), or lung inflammation (pneumonitis), or lung infection (pneumonia).
The symptoms are more commonly seen after eating or at night when lying down. However, some individuals will have a persistent sensation in their throat that is not directly related in time to eating. In addition, it is possible that some individuals will have an anticipatory fear of symptoms before eating. They have previously experienced discomfort after eating and anticipate that it will happen again when they are going to eat again.
Other conditions that can cause symptoms similar to those of GERD and LPR are:
- Narrowing of the esophagus. When a narrowing occurs, food and mucus (saliva) make it part way down the esophagus but then get “hung up” at the narrowing. This may then back up into the throat and cause similar symptoms. The symptoms often occur after the person eats (minutes to an hour or more).
- Achalasia is a condition that affects the motor (muscle) function of the esophagus. The food is not pushed through the esophagus because the muscles are not propelling it. In addition, the sphincter may not open correctly. Food gets “hung up” and can travel backwards up the esophagus. Achalasia appears to be more common in people with DS.
Treatment
Lifestyle changes
As described in our article on GERD, the initial recommendations for someone who is having symptoms suggestive of LPR or GERD often are:
- Eating smaller meals
- Not eating anything 3-4 hours before laying down or going to sleep
- Elevating the head of the bed with a riser or blocks
- Eating fewer fatty, spicy, and citrus foods
- Drinking less caffeine and fewer carbonated drinks like soda
- Avoiding medications that can make GERD or LPR worse, such as ibuprofen and other NSAIDs
- Not wearing clothing that is tight around the abdomen
- Losing weight
Over-the-counter medications
When lifestyle changes are not enough, there are several medications that a health care provider may recommend. Some medications are taken only as needed when a person gets symptoms and can be found over the counter. Examples of these are:
- Tums
- Rolaids
- Maalox
Prescription medications
Other medications are taken daily to prevent symptoms. There are two main classes:
- Proton pump inhibitors, including pantoprazole (Protonix), omeprazole (Prilosec), lansoprazole (Prevacid) and esomeprazole (Nexium)
- H2 receptor blockers, including famotidine (Pepcid), ranitidine (Zantac) and cimetidine (Tagamet)
Follow-up
When treatment is started, a doctor will follow up closely with a patient to make sure the symptoms are getting better. If symptoms do not get better, the person may need further testing. Testing may include:
- A video swallow study to assess swallowing. This study is typically done in the Radiology department with a radiologist and a speech therapist. The person is asked to eat and drink food and liquid mixed with barium and x-rays are taken and the speech therapist also assesses as the food and liquids are swallowed.
- An esophagram is an x-ray test in which the person swallows barium and the esophagus is x-rayed to assess function of the esophagus.
- An esophagogastroduodenoscopy (EGD) may be done to look through the scope at the esophagus and stomach (and first part of the small intestine). Strictures (narrowing), ulcers, inflammation of the stomach (gastritis), inflammation of the esophagus (esophagitis), or other abnormalities may be found.
- If more information is needed, an endoflip may be performed. This additional testing is done as part of an EGD and assesses the function of the esophagus.
- Additionally, manometry may be added to the EGD procedure. Manometry measures pressures inside the esophagus and can give more insight into the cause of the symptoms.
Surgery
If the symptoms persist, treatment beyond what is outlined above may be recommended based on the outcome of the additional testing.
If it is determined that the sphincter is not functioning, surgery may be considered. A Nissen Fundoplication is one surgery that may be recommended. More information on a Nissen Fundoplication is available from the Cleveland Clinic. In addition, there are published guidelines to review before considering surgery for GERD or LPR.
If achalasia is the cause, surgery is available for that as well. A procedure called Peroral endoscopic myotomy (POEM). More information on the POEM procedure is available from Johns Hopkins.