At-A-Glance
- Reflux follows a downward spiral, as damage from reflux creates more reflux. Inflammation and swelling of the lower esophageal sphincter (LES) reduce its ability to function, leading to more reflux.
- As reflux persists, the esophagus becomes inflamed, impairing its motility and ability to clear itself, which worsens the condition.
- The upper esophageal sphincter (UES) is the last barrier (antireflux defense) to be affected, but if the LES isn’t functioning correctly and esophageal motility is compromised, the UES can become inflamed, stiff, and ineffective.
- If the condition becomes severe, a comprehensive approach involving lifestyle, dietary, and medical interventions is necessary to break the cycle, as small fixes aren’t enough.
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Acid reflux isn’t just a minor inconvenience—it’s a persistent condition that can lead to further health complications if left unaddressed. Since reflux creates damage, which leads to more reflux, the key to breaking free from this downward spiral is understanding how this process occurs and taking intentional steps to interrupt the cycle.
Understanding the Reflux Cycle
Reflux causes inflammation, and inflammation, in turn, exacerbates reflux. This vicious cycle begins at the lower esophageal sphincter (LES), the valve that separates the stomach and esophagus.
When this valve becomes inflamed and swollen, it loses its ability to function effectively. Consequently, the more reflux occurs, the less competent the LES becomes, perpetuating further episodes of reflux and further damage.
The Role of Pepsin in Acid Reflux
Pepsin, a digestive enzyme produced in the stomach, plays a significant role in the damage caused by acid reflux. While its primary function is to break down proteins, pepsin becomes problematic when reflux brings it into contact with the sensitive tissues of the esophagus or throat.
Pepsin is activated by acid, meaning that when reflux occurs, the acidic environment can trigger pepsin to cause even more tissue damage. This creates a compounding effect, intensifying inflammation and irritation.
How Acid Reflux Affects the Esophagus
Reflux doesn’t just stop at damaging the LES. It also causes inflammation in the esophagus, which can impair its natural ability to clear itself, a condition known as dysmotility.
As esophageal motility weakens, refluxed stomach contents linger longer, causing further irritation and swelling. Eventually, the upper esophageal sphincter (UES), typically the last line of defense, can also become inflamed, stiff, and ineffective.
Acid Reflux and Breathing Problems
While acid reflux often begins as an esophageal problem, it can progress to affect other areas, including the throat and respiratory system. This is known as respiratory reflux (or silent reflux) and occurs when refluxed stomach contents travel beyond the esophagus, often reaching the throat, voice box, or airways.
Shortness of breath (SOB) has become the second leading symptom of respiratory reflux, behind postnasal drip. Commonly, reflux-caused SOB is confused/misdiagnosed with asthma. The latter has attacks where getting air out of the lungs during expiration is the issue, whereaswith reflux, it is trouble with inspiration/inhalation. Also, refluxers often complain that it is uncomfortable or difficult to take a full breath.
This progression is more likely when the LES and UES are compromised, but respiratory reflux can sometimes occur even when esophageal inflammation is minimal.
In most cases, respiratory reflux presents as chronic cough, hoarseness, or breathing difficulties without significant esophageal symptoms. The tissues in the throat and airways are highly sensitive to even small amounts of refluxed material. Unlike the esophageal lining, which has some degree of protection against stomach acid, the lining of the larynx lacks comparable defenses, making it more susceptible to injury from reflux.
Notably, endoscopic examinations may fail to reveal obvious inflammation in such cases, making it appear as though the esophagus is unaffected. However, subtle dysfunction in the LES or esophageal motility often plays a key role in allowing this type of reflux to occur.
Diagnostic Tools for Acid Reflux
Accurate diagnosis of reflux involves a combination of tools and observations:
- Barium Swallow Esophagram: While modern diagnostic tools like endoscopies are valuable, the old-fashioned barium swallow esophagram remains an excellent way to evaluate reflux. This test involves swallowing a chalky substance while video imaging captures the functional integrity of the upper and lower esophageal sphincters, as well as esophageal motility. Performing the test in both upright and supine positions provides critical insights into how reflux behaves under different conditions.
- Throat Examination: The throat can provide valuable clues about the severity of reflux. For instance, examining the voice box often reveals inflammation that extends to the back of the throat, a hallmark of respiratory reflux. Using tools like the Reflux Symptom Index can help quantify the severity of symptoms and guide treatment strategies.
Combining these diagnostic methods can give a more comprehensive picture of the reflux system breakdown. I must offer a word of caution to people with respiratory reflux. In my experience, gastroenterologists’ esophageal reflux testing methods, e.g., impedance and Bravo, are inaccurate and useless for diagnosing this condition. Furthermore, GIs are also ill-equipped to treat it.
A 4-Week Healing Protocol for Acid Reflux
When reflux becomes chronic, to the point that symptoms occur almost with every meal and even after meals as well, along with symptoms such as nocturnal respiratory reflux, a detoxification program is essential. The goal is to stop reflux long enough for the esophageal valves and tissues to heal. The dietary guidelines are based on the reflux detox program. Below is a four-week healing protocol:
- Avoid eating or drinking within 3-5 hours of bedtime. This practice minimizes reflux episodes during sleep, giving the LES time to recover.
- Eliminate carbonated beverages and alcohol. Alcohol weakens the LES, while carbonated drinks increase stomach pressure and activate pepsin, exacerbating tissue damage.
- Adopt a low-fat, low-acid diet. Low-acid foods prevent pepsin activation, while low-fat meals reduce stomach pressure and maintain LES integrity. Examples include oatmeal, bananas, and lean proteins.
- Sleep on an incline. Elevating the head of the bed helps prevent stomach contents from reaching the esophagus while lying down. A wedge pillow or adjustable bed can make this adjustment easier.
- Use medications strategically. Famotidine 20 mg before breakfast and dinner, and 40 mg before bed) reduce stomach acid when taken before meals and at bedtime. Alginate-based products, such as Gaviscon or RefluxRaft, create a protective barrier to shield the esophagus from refluxed material.
- Identify and avoid trigger foods. Common culprits include chocolate, onions, peppers, garlic, and spicy dishes. See this post for more detailed information.
Why Small Fixes Aren’t Enough
While dietary supplements like DGL or ginger can provide some relief, they are insufficient once the LES and esophageal motility are significantly compromised. At this stage, more comprehensive measures, like those outlined above, are necessary to halt the downward spiral.
Conclusion
Reflux is a self-perpetuating condition where inflammation feeds dysfunction, and dysfunction feeds inflammation. Without intervention, the cycle can lead to significant discomfort and health risks. However, by addressing the root causes with a comprehensive approach, it is possible to interrupt this cycle. The journey to healing starts with a clear understanding of how reflux operates and a commitment to the necessary changes.
For more information about diagnosis and treatment of acid reflux, see two companion books on Amazon: Dr. Koufman’s Acid Reflux Diet and Dropping Acid: The Reflux Diet Cookbook & Cure. If you would like to receive personalized guidance and strategies for lasting relief, consider scheduling an online consultation.