Not all instances of gastro-esophageal reflux disease involve classical heart-burning sensations, regurgitation. Silent reflux is a type of gastric reflux with no symptoms or atypical symptoms. The unique characteristic of silent reflux in comparison to other forms of acid reflux is that it can affect the larynx or throat and in worst cases the respiratory system. There are no heartburns experienced, and patients usually do not recognise the symptoms because they are misleaded that they are suffering from something else.
What is silent reflux
1. If there is upward movement of the stomach’s contents that reaches the esophagus it is called Gastroesophageal Reflux disease (GERD). If it reaches the larynx and pharynx, then the condition is referred to as Laryngopharyngeal Reflux (LPR).
2. A reflux with atypical or no classical symptoms of GERD is called silent reflux.
3, The mucous membrane of the throat is much more fragile compared to the esophagus; hence, even mild reflux is disruptive and painful.
Symptoms
1. Clearing the throat constantly
2. Hoarseness of voice
3. Feeling like something is stuck in the throat
4. Night coughing and breathlessness
5. Difficulty swallowing
6. Sleep disturbances
7. Excess secretions in the throat
These problems usually increase in the early hours of morning as most reflux occurs during sleep.
Causes
Dysfunction of the Lower Esophageal Sphincter (LES) that normally prevents the movement of food backwards to the esophagus, is the main cause for GERD.
Other factors that worsen GERD:
1. Eating spicy/acidic foods
2. High consumption of caffeine products
3. Smoking
4. Drinking alcohol
5. Obesity and a sedentary life
6. Late-night eating and over-eating
7. Stress, that may impair the functioning of the digestive tract
8. Even people who do not have the above risk factors can suffer from LPR.
Why LPR is often misdiagnosed
The symptoms of other diseases such as allergies, sinusitis, and upper respiratory tract infections often overlap, so LPR can commonly be mistaken for these illnesses. Usually, it takes multiple ENT consultations and failed treatments before an accurate diagnosis can be reached.
Prevention
1. Avoiding food 2-3 hours before going to bed
2. Elevating the head while sleeping, lying on your left side
3. Limiting the consumption of foods like: citrus fruits, coffee, chocolate, and fries
4. Maintaining a good BMI — regular exercise and diet
5. Remaining hydrated will protect the throat mucosa
Apart from reducing reflux occurrences, these steps can help the damaged throat tissue heal.
Treatment and management
1. LPR management involves endoscopy to asses the luminal status of the upper gastrointestinal tract.
2, Dietary and lifestyle changes.
3. Medications like PPIs (Proton Pump Inhibitors) and H2 inhibitors to help minimise acid production.
4. In case of voice strain and hoarseness, voice therapy can be offered.
The main factor ensuring success is the patient’s ability to change his/her lifestyle.
Fundoplication, a surgery to correct the defective lower esophageal sphinchter is the definitive treatment for patient not responding to medical management.
Why early intervention matters
1. When undetected, it could result in the development of inflammatory conditions affecting the throat like laryngitis, vocal cord polyps, etc., causing the individual to have difficulty talking
2. Some patients will develop respiratory issues due to micro-aspirations, that may cause idiopathic pulmonary fibrosis
3. Unchecked persistent inflammation can result in cancer
This atypical and misleading presentation can be very distressing to patients, especially those who depend on their voice on a daily basis, like teachers and singers. The repeated hospital visits and delayed diagnosis takes a toll on the patient’s health, time, and money. Early diagnosis and timely intervention cures the patient, preventing the perils of cancer and respiratory complications.
(The writer, Dr Pravindhira SN, is a consultant - Surgical Gastroenterology & Hepato-Pancreato-Biliary Surgery, SRM Global Hospitals, Chennai)