November 7, 2006 Features

Gastroesophageal Reflux Disease

Serious Illness Potential Often Misunderstood

More than 60 million Americans suffer from heartburn, the most common symptom of gastroesophageal reflux disease (GERD) (Castell, 2003). Other symptoms may include dysphagia with a globus sensation (a feeling that there is a lump in one's throat) in the pharynx or burning in the esophagus while swallowing. Others experience nighttime choking episodes, or may have black, tar-like stools. The voice may become dysphonic. Asthmatic reactions may appear. These symptoms all reflect inflammatory reactions in the epithelium (skin lining) of the esophagus, pharynx, vocal folds, and sinuses, as well as the trachea, bronchi, and lungs.

The serious illness potential of GERD is widely misunderstood by the public. Individuals often delay essential medical intervention, largely because GERD affects so many people; in many cases, it is treatable and well-controlled with over-the-counter medications. Barrett's Esophagus is found in 5%-10% of people who have frequent heartburn symptoms (Rosen, 2003). In Barrett's Esophagus, the esophagus is coming into regular contact with gastric acids, creating a lining more like that of the intestinal lining, which causes damage to the lining of the esophagus and sets up a pre-cancerous environment.

People who experience heartburn symptoms at least once per week have the potential of developing Barrett's Esophagus. Of those, 5%-10% go on to develop esophageal cancer, a very deadly form of cancer (Rosen, 2003). Inflammatory reactions are caused by acid injury of the lining cells of the pharynx and the airways. The esophagus, while tolerant of the acidity, is not nearly as tolerant as the stomach lining. This results in heartburn, which is experienced as anterior chest discomfort. Atypical asthma reactions, causing persistent cough, rhinitis, and dysphonia are caused by the flushing of gastric acid onto the tender epithelium of the vocal folds and airways including the lungs, causing swelling and narrowing of the passages. This causes redness on the arytenoid cartilages and swelling of the vocal folds. Also prevalent is aspiration of gastric acids into the lungs. Shortness of breath is common in these cases, as is inspiratory stridor.

Inspiratory stridor is defined as audible inspiration secondary to a narrowed segment of the
respiratory tract, either found in the trachea or in the larynx. In severe cases the patient may have laryngospasms that close the glottis, creating the need for emergent tracheotomy. Inspiratory stridor can be functional, as in paradoxical vocal dysfunction, or related to cardiac or neurological deficits as well as trauma, neoplasms (tumors), infectious conditions, or
congenital anomalies.

If the gastric fluid is non-acidic, one may experience the same dysphonia and breathing discomfort without concomitant heartburn. This is called laryngopharyngeal reflux, or LPR, which is a variant of GERD. LPR is common in performing artists. Due to the nature of their work, they are making consistent use of the diaphragm and the intercostals in athletic fashion, which causes a lot of stomach contraction. This sets up a reflux environment.

Others who have a higher propensity toward GERD would be those who drink a great deal of
caffeinated or alcoholic beverages. Smokers and recipients of secondary smoke as well as those who are overweight and who eat to full satiation or who eat spicy foods regularly are at risk. Those with sedentary lifestyles, and who eat and then lie down, are greatly susceptible. Though common, GERD and LPR need to be taken extremely seriously. Without lifestyle changes and medication, it can quickly become a deadly situation.

Assessment

Patients often initially see their primary care physicians. Based on clinical symptoms and exam, the physician refers the patient to radiology for a barium esophagram, or upper GI series. This is to assess for primary reflux causation such as diverticulosis, hiatal hernia, cricopharyngeal dysfunction, or prominent osteophyte, for example. If a primary diagnosis is found, it is then treated on the basis of the core issue, whether that means medical follow-up or surgical intervention.

Some patients are referred to an otolaryngologist when symptoms persist. S/he will examine the nasal sinus region, the vocal folds, and possibly swallow function using FEES (fiberoptic endoscopic examination of swallowing). Patients at this point complain of symptoms of heartburn, dysphonia that is more prevalent in the morning, dysphagia with a globus sensation, or sinusitis and post-nasal drip. The patient is assessed for nasal airway obstruction, swallowing function in conjunction with the speech-language pathologist, and vocal fold pathology using nasendoscopy. Medication may be prescribed, such as a proton pump inhibitor, which prevents the release of acid in the stomach and in the intestine (such as Aciphex, Nexium, Protonix, Prilosec, or Prevacid) or an H2 blocker, which reduces the amount of hydrochloric acid produced (such as Zantac or Efferdose). If breathing is short and labored, particularly on exhalation, the patient is referred to pulmonology for possible
inflammatory asthma.

If these measures fail to help the patient, then a referral to gastroenterology is made. The gastroenterologist will conduct many studies. Esophagus motility testing evaluates peristalsis. If there are stenotic (narrowed) regions, then dilatation or myotomy (cutting of the cricopharyngeous muscle in the upper esophageal sphincter) may be done. Esophageal function testing (EFT) includes the swallow challenge test and the combined multichannel intraluminal impedance test (MII), which determine the proximal extent of the refluxate based on impedance characteristics. The findings are then associated with individual symptoms, such heartburn, chest pain, regurgitation, cough, and nausea, along with manometry and its findings. Also commonly used is GER monitoring, which consists of ambulatory reflux monitoring with combined MII + pH study. Some physicians routinely use a double pH probe technique, with one probe placed at the UES (upper esophageal sphincter) and one placed in the distal esophagus. Some physicians are now using a triple probe technique, with an additional probe also placed at the LES (lower esophageal sphincter). The patient is monitored for a 24-hour period, and all the gastric washes are recorded in terms of location, frequency, and acidity.

The complete array of studies in this way explains why some patients have persistent symptoms despite adequate acid suppression and good vocal and breathing bio-mechanics. Using the Dual Modality Reflux Test, with ambulatory MII + pH, both acid and non-acid reflux is measured. The advantage of the MII is that one can view and characterize bolus movement independent of radiation. Specifically, it measures acid and non-acid reflux as they correlate to symptoms. They look at the height of possible migration, bolus clearance time, and acid clearance time (pH). Potential MII-pH applications then are used to diagnose patients with persistent Sx while on PPiRx to evaluate atypical GERD, and to evaluate postprandial GERD.

Pediatric Issues

Somatic complaints in adults for which GERD is automatically considered and treated also should be considered in pediatric populations. GERD is an important inflammatory cofactor in laryngomalacia (low-pitched or squeaky intermittent inspiratory sound in infants), chronic rhinitis, sinusitis, and otitis, and can complicate problematic choanal stenosis (abnormal narrowing of the choana, the passageway from the back of the nose to the throat). This occurs in children under 2 years of age. More than 10 episodes of pharyngeal reflux per 24 hours is pathologic, even in infants less than 1 year of age (Halstead, 2003). GERD is an important inflammatory cofactor in subglottic stenosis, recurrent croup, apnea, and chronic cough, and may play a causative role. GERD may persist for many years in premature children.

To evaluate the pediatric airway, the physician uses a standard fiberoptic laryngoscope with a video camera attachment and notebooks to catalogue the tapes. The etiology of laryngomalacia shows elongated arytenoids with short aryepiglottic folds. It is 80% clinically significant for GERD and 14% with associated upper airway anomalies (Halstead, 2003). Laryngomalacia is specifically evaluated with fiberoptic laryngoscopy with video recording, a barium swallow and airway study, and a double pH probe, as well as direct laryngoscopy and bronchoscopy as indicated.

To evaluate for true vocal cord dyskinesia, the
physician uses fiberoptic laryngoscopy with video recording, but the patient also needs a complete neurological work-up, double pH probe, brain MRI, and a laryngeal EMG. If the patient has true vocal cord dyskinesia, it ultimately would be due to benign delay in neurologic maturation, but also would have significant findings of GERD, as well as Sandifer's Syndrome, diffuse brain atrophy, and increased intracranial pressure syndromes (hydrocephalus and meningomyelocele).

Looking at GERD in pediatric patients with upper airway disorders, laryngoscopic results are as follows: with recurrent croup, erythema (skin breakdown) of arytenoids and true vocal cord (TVC) edema; with chronic cough, erythema and edema of TVC's and posterior glottis; with chronic rhinitis/sinusitis/otitis, posterior glottic edema and thickened tracheal mucosa; and with recurrent choanal stenosis, posterior glottic edema and thickened tracheal mucosa (Halstead, 2003).

Treatment

Treatment options for primary non-cancerous GERD and LPR include medication and lifestyle changes. If the patient also presents with dysphonia, a referral is made to the speech-language pathologist, who then plays a key role in monitoring the patient's hoarseness, aligning vocal bio-mechanics, and instructing the patient on behavioral reflux precautions. The SLP takes a detailed case history of diet, including types of food eaten, portions, and the time lapse between eating and reclining or engaging in rigorous activity.

Equally important is knowing the patient's current medications, and whether they are taken properly (including time of day and whether or not medications need to be taken with food). The patient is guided to follow strict behavioral reflux precautions, including:

  • Eat light meals at least three hours prior to a performance, intense vocal activity, reclining or sleeping
  • Avoid ingestion of alcohol, caffeinated beverages, decaf coffee, carbonated beverages, and citrus juices
  • Eliminate fatty, fried, spicy, and acidic foods from the diet
  • Avoid acidic medications such as aspirin and vitamin C
  • Take medications as directed
  • Elevate the head of the bed by at least six inches
  • Take antacids when acute symptoms appear
  • Avoid chemically filled environments
  • Avoid mints, chocolates, or nuts
  • Eat slowly

Standard voice therapy then is utilized to align proper vocal bio-mechanics. If this is accomplished with no change in dysphonic features, the SLP can assume that further medical investigation is warranted. Judicious referral to proper medical personnel is imperative, due to the potentially quick progression of the disease.

Refer to a gastroenterologist if the current medical coverage does not appear to be alleviating gastric symptoms. Follow up with the otolaryngologist if dysphonia worsens. Schedule a modified barium swallow study if swallow function worsens beyond a globus sensation. Refer to cardiology if the patient's symptoms reflect nocturnal apneic dyspnea and/or significant and consistent inspiratory stridor at rest. Follow up with pulmonology if stridorous inhalation and exhalation appears or persists along with chronic cough.

Physicians consider various medication regimes in cases of primary GERD. For ongoing use, three types of medications include proton pump inhibitors, such as Prilosec 2-4mg/kg/day and the usual dose rate is 5-10mg po BID; or the H2 blockers QHS (once at bedtime), such as Zantac 6mg/kg QHS, syrup 15mg/1ml, or 150mg Efferdose tablets or granules (Rosen & Murry, 2003). The other treatment may include prokinetic agents, which are still
considered controversial at this time.

For severe reflux in both children and adults, surgical treatment of fundoplication connects the LES with the stomach and improves the sphinteric function, and there is endoscopic repair and laryngotracheoplasty for endoscopic management of stenosis.

For patients who have had an esophagogastroendoscopy (EGD)-an examination of the entire upper gastrointestinal (GI) tract using an endoscope-and who have been found to have displasia of the esophagus, the esophagus may be scraped of abnormal cells, or pre-cancerous cells. At other times they will be given a strict medication regimen that may include a combination of H2 blockers and proton pump inhibitors. Then they will be closely monitored for signs of healing or further erosion. If a tumor is found a biopsy must be taken. If the tumor is cancerous and is determined to be the primary cancerous site with no metastatic secondary sites, the tumor is removed surgically.

GERD and LPR are common among Americans as well as people from other countries whose lifestyles and food choices affect the health of the digestive tract. This common disease can be managed and treated if behavioral and other management strategies are used to alleviate symptoms. All too often, however, people tend to ignore symptoms, or believe that medication will allow them to continue leading sedentary lifestyles, eating foods that encourage reflux, or snacking before going to bed. They often do not realize that their esophagus has possibly begun a journey of erosive esophagitis.

In holistic medicine, the triad relationship between breathing, swallowing/digestion, and the nasal sinus region is well understood. GERD is both a primary diagnosis that affects all three regions and secondary regions as well, and is also causative or symptomatic of more serious diseases, such as Barrett's Esophagus, or esophageal cancer, for example. When any symptoms point back to GERD or LPR, it is wise to be examined thoroughly, and to strictly follow the recommendations for follow-up.

Ellen N. Friedman, is a speech-language pathologist in private practice in Ohio. She also is a consultant and public speaker, and her work focuses on voice and GERD-related anomalies. Contact her at elrachel345@aol.com or on the Web at www.ellennfriedman.com.

cite as: Friedman, E. N. (2006, November 07). Gastroesophageal Reflux Disease : Serious Illness Potential Often Misunderstood. The ASHA Leader.

Focus on Divisions

Special interest divisions that cover research, diagnosis, and treatment related to GERD are Division 13, Swallowing and Swallowing Disorders, and Division 3, Voice. These divisions offer their affiliates the opportunity to earn ASHA CEUs through self-study of their peer-reviewed publications, Perspectives. Affiliates also have access to exclusive Web content, including a Web forum for affiliates-only. For more information on these divisions and affiliate benefits and to view sample articles from Perspectives, go to Division 13's Web page.

References

Castell, D. (2003, April). Investigating the patient with acid and non-acid reflux. Paper presented at the meeting, "Medicine in the Performing Arts," Charleston, SC.

Halstead, Lucinda. (2003, April). Pediatric voice disorders. Paper presented at the
meeting, "Medicine in the Performing Arts," Charleston, SC.

Rosen, C. (2003, April). Gastroesophageal reflux and its influence on adult voice disorders. Paper presented at the meeting, "Medicine in the Performing Arts," Charleston, SC.

Rosen, C., & Murry, T. (2003). Acute management of the performing voice. Voice Disorders and Phonosurgery II, 33(4), 751-757.

Satalof, R. (2005). The professional voice. (3rd ed.). San Diego: Plural Publishing, Inc.



  

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