- Filed under: Reflux
Reflux is Hard to Swallow
Dr. Gregory N. Postma is a Professor and Vice Chairman of the Department of Otolaryngology-Head and Neck Surgery at the Medical College of Georgia at Augusta University and is the Director of the Center for Voice, Airway and Swallowing Disorders since 2005.
He completed his residency in Otolaryngology at the University of North Carolina at Chapel Hill in 1993. He completed a fellowship in laryngology and professional voice at Vanderbilt University and joined the faculty at Wake Forest in 1996.
He is a past President of the American BronchoEsophagological Society (ABEA), Dysphagia Research Society and Georgia Society of Otolaryngology Head & Neck Surgery.
He is the author or co-author of more than 130 peer-reviewed publications, edited 3 books, and has written 110 chapters and invited articles. He has given more than 700 presentations on a wide array of laryngologic topics. He has been selected as one of America’s Top Doctors, a reference that identifies the top 1 % of physicians in the nation, for the past 22 years was awarded the Isshiki Award for lifetime achievement in Laryngology in 2021 by the British Laryngological Association. In 2023 he became the first individual to be awarded the Chevalier Jackson award from the ABEA for the second time.
We all reflux.
Swallowing air is a normal part of speaking and breathing, and the stomach needs to vent gas. Transient lower esophageal sphincter relaxation (TLESR) is the primary mechanism by which the stomach performs this essential task. TLESRs are caused by distension of the stomach from both food and air. Half of TLESRs are gas only (a burp), and half bring with it acid reflux. Up to 50 TLESR reflux episodes per day can be considered normal.
It is when reflux causes troublesome symptoms and/or tissue injury to the aerodigestive tract that a person is said to suffer from gastroesophageal reflux disease or GERD. Consequences of reflux range from mild indigestion to esophageal cancer and death. One of the most concerning symptoms of GERD, and also most unknown to the general public, is dysphagia – difficulty swallowing. There are several mechanisms by which reflux can cause dysphagia.
One of the most concerning symptoms of GERD, and also most unknown to the general public, is dysphagia – difficulty swallowing.
Inflammation from GERD (esophagitis) causes both diminished sensitivity and reduced muscular contractility of the esophagus. Inflammation leads to the formation of scar tissue formation and strictures through a process called fibrosis. Scarring from GERD can result in ineffective esophageal motility (IEM), which results in prolonged transit time of food and liquid throughout the body of the esophagus, as well as the sensation of food getting stuck. The more severe the esophagitis and the longer that the esophagitis is present, the more severe the ineffective esophageal motility (IEM) and scar formation. A stricture is a reduction in the diameter of the esophageal opening caused by scar tissue. Esophageal strictures range from mild asymptomatic areas of narrowing found at the time of routine endoscopy, to near complete esophageal obstruction resulting in feeding tube dependency (bypassing the esophagus to deposit nutrition directly into the stomach).
If the esophagitis is long-standing, the mucosal lining of the esophagus may transform from one cell type to another. This cellular transformation (metaplasia) is called Barrett’s esophagus. Once Barrett’s occurs, the esophagus becomes less sensitive and heartburn may become less frequent or even go away entirely – it is not that the GERD has ceased, but that the individual can no longer feel it, making the resulting effect even more insidious. Therefore, difficulty swallowing may be the only symptom of reflux in patients with severe GERD; and, in fact, most reflux-induced esophageal cancer is not identified in patients with symptoms of chronic heartburn, but in persons who present with obstructive dysphagia (difficulty or inability to swallow). The most concerning history reported by a patient is, “I used to get heartburn, but it went away several years ago and now food is getting stuck.”
Another cause of swallowing difficulty in persons with reflux is hiatal hernia. Hernia not only increases the likelihood and severity of GERD through incompetence of the lower esophageal sphincter, but it can also cause impingement of food transit. When the stomach herniates into the chest, the diaphragm can obstruct food movement and cause a pseudo-stricture with difficulty swallowing.
The good news is that much of the dysphagia caused by reflux and hiatal hernia is treatable. Diaphragmatic impingement with hernia usually gets better with hernia repair. Swallowing difficulty caused by mild esophagitis without hernia can get better with behavioral modifications and alginate therapy alone. More severe forms of esophagitis and inflammatory strictures, usually associated with hiatal hernia, may require treatment with acid blockers (H2RA and/or PPI). We try and transition patients off acid blockers to alginates and behavioral strategies after esophageal healing if possible. That said, not all persons can be transitioned off of their acid blocking medication, and some persons do need to stay on these drugs for life.
The most concerning history reported by a patient is, “I used to get heartburn, but it went away several years ago and now food is getting stuck.”
Fibrotic strictures can be successfully treated with esophageal dilation. Obviously, it is better to successfully treat esophagitis before embarking on dilation as the inflammed esophagus does not heal well and re-stricturing is common. It is reflected in that old adage: An ounce of prevention is better than a pound of cure. However, if the esophagitis is longstanding and poorly controlled, reflux-induced esophageal scar and dysmotility may not get better with successful treatment, and the dysphagia may be permanent. It is for this reason that we treat and try and resolve even mild cases of esophagitis in young persons with GERD in order to prevent these issues later in life.
This is why, “It’s just a little heartburn,” is not a statement to be ignored.
GERD is one of the most common causes of swallowing difficulty. With adequate identification and management, however, it is readily treatable and even preventable.
This is why I am not being flippant when I say, reflux is hard to swallow.