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's Clark Rosen. I'm the uh co-director of the U CS F Voice and Swallowing Center, a chief of Laryngology within the Department of Vital Laryngology, head 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 E N T. Um And so I take care of people with voice problems, swallowing problems and uh breathing problems, uh all related to the larynx pyx 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 kind of 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 why 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 any place. 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 want to alert you that to that. Now, I'll, I'll alert it to you again when we get there. Um I wanted to um just 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 ologist 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 nonspecific. Uh The primary care physician says, you know, once you go see an oral ergo, you're having a throat problem, totally reasonable. Uh The E N T um sees a 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 PC P uh doing the, doing the due diligence reads, the E N T report or a letter back to um uh the uh the, the physician and uh sees that the reflux is in play and suggests that the patient goes to 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 G I and E N T world because of the increasing risk and increasing incidence of esophageal cancer. So the G I 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 ologist 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 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 that we can then we can navigate our way out of this uh problem. Uh First and foremost, gastroenterologists tend not to see E N T reflux related symptoms or E N T 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 will focus on stomach, stomach, stomach and often these patients, this has been very well studied and very well documented. Often patients have oology symptoms, mostly throat symptoms, but they have no heartburn at all. Um And so this is kind of why ologists have coined the term laryngo 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 of a certain uh uh uh component of what we, what I call G I nimby N B 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 because 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. Ologists um have had I would submit to uh a history in the past, not every single one but an, a little bit of a, a tendency overall 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 tests. So most patients don't really want that. And then the the biggest um uh confession I will have for you is that otologist cannot capital N O T look at the larynx and the PHN and definitively make a diagnosis of reflux even though we, we look at the larynx and Pharis 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 15, 20 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 19 fifties and sixties. 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 ologist 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, this was aided by the drug companies who wanted to sell more PriLOSEC and NexIUM and whatever it is. I mean, you know, you can't watch it, watch, watch a 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 common imbalance and, you know, some patients have reflux, some patients don't. And that's the crux of this lecture, um, or discussion. So, I've listed out the classic gird 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. L pr or L pr D, 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 three times, you know, three 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 GRD symptomology. We just get these throat symptoms and we have to figure it 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 want to 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 and or out. And so there's really no value if your primary focus is to make the diagnosis of reflex for a beri and swallow. Um Next is a uh esophagogastroduodenoscopy, what we call a G uh uh uh uh E G D, what this gastrologist do all day long. And, uh, it's a great, it's a great test or uh, methodology to evaluate a Barrett's. I had a hernia gastric ulcers, esophageal webs. It's not a good test for laryngo reflux disease period. Um, sometimes gastroenterologists say I scoped these people because, um, heartburn and reflux is a red flag syndrome for esophageal cancer. Ok. I'm all right with that. But it doesn't, a negative E G D does not tell you that your patient does not have reflux period. Um I'm gonna say that again because it's so darn important uh because patients come to me again and again, he goes, I had a scope so I can't have reflux because my gastroenterologist 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 the dual channel P H 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, a hospital based kind of setting. And uh usually a P A nurse practitioner uh or just nurse will pass this small little catheter through the nose down into the esophagus and then secure it. And then that probe has a whole sense of P H probes censors along the whole length of the uh of the uh of the tube, there's a bunch of different types, there's uh dual P H, there's multiple channels. But the whole concept is that it stays in there for about 24 hours and the patient and it measures P H through on 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 uh P H probe, what we call P H probe works. Uh uh a nice interesting version of, of a P H probe is called the bravo uh test. And this is done at the same time, it's an E G D and it's a wireless P H 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 it'll measure P H um And then, you know, it passes and goes away. So no wires um throughout, no, no, no tube throughout the nose. And so it's definitely an advantage from that perspective, but it only measures P H at one location. Um And so there's another diagnostic test uh for learning ringo reflux uh disease that we call an empiric trial. Um And I'm gonna go over in great detail empiric trial because I'm a big advocate of Imperial 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 P P I um uh twice a day, 30 to 60 minutes before a meal. Um And then I usually do that for at least two months, usually three months. Um There is a, a good uh body of evidence that shows that for laryngo reflux symptoms, it takes at least two months of, of acid suppression therapy to get significant and plateaued out symptom improvement. And so that's why, you know, a week or two of A P P I uh doesn't usually cut it to find out if the patient is gonna get bene 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 Empyra trial. Uh 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 because that'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 two months, time period. And so, um but um that's kind of uh the pros and cons of an, a periodic trial, a P H probe uh where impedance mo uh uh uh testing uh has the advantage of getting objective data. It'll tell you how many times, you know, the, the P H dropped uh where in the esophagus, the P H dropped. And how long was the P H at an aesthetic level? Um So you get a lot of really helpful information. The disadvantage is 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 a woman must reflex every 24 hours? So somebody could have a P H probe have a great day um And have no reflex symptomology at all and uh a negative P H 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 la visual reflux disease. We usually want to see it if the acid is truly coming all the way up the length of the esophagus E G D as I said, um is good to finding out other pathology but is not diagnostic for uh reflux disease either in a positive or negative way esophagram. Uh We don't need to discuss anymore. So what are our active issues when it comes to reflex? Uh A wide array of complaints that are um not pathetic 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 ca you know, causation is not the same as correlation. And so, is it truly related or is it, are they unrelated? And 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 empirical trial um which I can share with you if you want. Um There is also a lot of literature that shows that P P I S don't help patients with laryngo or reflux disease. And uh kind of an interesting factoid is that, you know, when, when the P P I 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 P P I S to laryngo 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 P P I versus placebo. And the reason that is is that none of these patients had a P had P H 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 P P I 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 B ID? 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 Q D to P, uh to B ID and even a little bit higher when you go to A PPP I B ID and H two blocker. Um, and so, um, think about that, if you're gonna do this as an empirical trial, I would say, go all in, at least do A B I DPP I, 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 P P I is going to control the symptoms and we'll talk about, about a positive empiric trio trial versus uh uh a negative trial. Um But if you suspect luring reflux disease, you put somebody on A P P I, 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 P P I S? We'll talk about that very shortly or at least put you at the lowest dose possible. So that's what I want to 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 farther away. Um And so we took patients who, um, had an empiric trial for Lario reflux disease came back and said I'm dramatically better. Thanks so much. And then, um we developed, we weaned them off P P I S 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 P P I without a recurrence of their symptomology. Um No surprise, the patients who had a high B M I um uh uh were not near as successful at weaning off P P I S. 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, 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 the overall, those are very, very important things. And as patients have become uh concerned about long term P P I use, they're now more motivated to do dietary changes, which is really, really, really good what are our alternatives to P P I s? Uh There, of course, there's H two blockers. Uh Zantac is off the market now. So um I use Pepsid. Um uh you can use an acids as well. You can use sloate. I haven't had a great result with sulphate and you know, an acids, you know, once in a while is OK. But if somebody's on a acids regularly, they probably need more uh intensive medical therapy. Nobody is actually ever studied if once a day P P I is less dangerous for P P I complications than B ID, nor even H two 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 P P I therapy and this is what I do for many of my patients who um have a positive impaired trial. They get better with P P I and then I'm weaning them off and they're still getting some symptoms is I put them on what I call Algate therapy. And Algate is a chemical that's found in seaweed. Um And when you take this chemical um and add it at, 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 contents going up into the esophagus. Um which is kind of what our presumed ideology is for Laga or Reflux Symptomology. There's three different um companies that make this, they're all over the counter. Um A as I mentioned in the beginning, I'll remind you um the company called Reflex Gourmet, uh which is um uh an, an excellent Algate option. I have a financial uh connection to uh the other uh two products. All of them, all three of these can be buy can be purchased at Amazon. Um uh And that's the easiest way to get them in my experience. Um There is a uh entity called Gaviscon Advance. Um that has an algate in it. You have to get the algae, the Gas Gun Advance that's sold in the UK. Um the Gaviscon against that's sold in America does not have Algate. So that's why you have to, you know, when you go to Amazon, you have to look specifically for gas gun against from the UK. And then you'll notice and verify that there's algate in it. The other agent is called the Soft Guardian. So that's an algate. I encourage people to do this. You can use it Q H S. Um You can use it pr N, 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 pro kinetics algate, 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 luring a 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 P P I S 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. This primary outcome measure is quite flawed. Um And then uh there's some other issues 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'd never seen them before and I said, tell me about your symptoms. Um What have you tried? What else happens? And so I kind of think it's a good 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 E N R war 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 peace with hoarseness, but no obvious lesion or neurologic abnormalities of the vocal folds, like voca 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 sno nasal allergic disease, uh psychological disease, uh subtle organic abnormalities of the vocal folds or a neurologic condition called spasmic dysphonia. So, again, when patients come back to me and they've got a voice problems and they didn't get better with reflux. So I always want to go back and read redouble my evaluation and my history and see if any of these um entities are at play and then I have 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 Q A to B ID, add A Q H S, uh H two 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 P H probe is a great test to kind of answer your questions. And I always tell people, you know, if we find out that your P H probe is stone cold normal, then we can move on and really up our sleeves and look for something else. Um uh And in contrast, if you do have a positive P H 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 Hyodo hernia that uh a hernia that no matter what they do from a diet perspective that until their high hernia is improved, they're still gonna have significant reflux so they may need high a hernia surgery. Um, so that's kind of a quick down and dirty, uh, review of what we call laryngo or reflux disease. I wanna thank you for your attention. I really, really look forward to answering any questions that you have.
