Conditions that may underly or aggravate Laryngopharyngeal Reflux

When I was first diagnosed with LPR, I saw it as its own condition. It was a disease like any other, with its own causes and its own symptoms. As I’ve read more and more about LPR, I’ve started to see it differently. It actually seems that most (if not all) cases of LPR are connected to other medical conditions. Usually, the underlying cause will also have something to do with digestion.

It may sound like stating the obvious, but Laryngopharyngeal Reflux is usually a result of poor digestion. The reason that any substance is coming back up the oesophagus and reaching the larynx, is that it hasn’t been digested efficiently. Of course poor digestion in itself can have many causes. You could think of LPR as the canary in the coal mine. It’s a sign that something’s not right somewhere in your digestive tract.

If you’re trying to recover from LPR, it’s important to think about what the underlying cause(s) might be. You may actually find that there are several. At the end of the day, any type of reflux is the sign of an unhappy system. If you’re suffering from LPR, you should probably think about these root causes rather than just treating the symptoms.

Medical Doctor's Desk - Diagnosing Related Conditions

The types of conditions that may underly LPR

Almost all the conditions that are connected with LPR are digestion-related. These are some of the ones that you may come across most often in your reading, but this may not be a complete list. It’s worth learning a little about each, to see if they sound like something worth investigating.

It should go without saying that you shouldn’t rely on symptoms or the internet to diagnose yourself. However, going to a doctor with a hypothesis can be a good idea. They can then help you determine definitively if one of these conditions is an underlying cause of your LPR.

Gut Dysbiosis

Gut dysbiosis is one of those terms that you may have heard a few time. It’s actually a bit vague. It basically means that somewhere in your gut, you have an infection or even just an imbalance. This can refer to the presence of bacteria, fungus or even parasites, but it doesn’t necessarily mean that you have a foreign invader in your body. It may just be that the very normal microbes are present in the wrong quantity or in the wrong place.

Here are some of the most common types of dysbiosis that you may find in your research about digestion issues and LPR…

Small Intestine Bacterial Overgrowth (SIBO)

The large intestine is where a huge amount of bacterial (and fungal) organisms live in your body. This is natural. In fact, it’s healthy, provided that they are the right type of bacteria in the right proportions. That’s why these days some doctors even prescribe introducing more bacteria in the form of probiotics.

The small intestine on the other hand is meant to be a pretty sterile environment. Sitting between your stomach and your large intestine, it’s actually where a lot of your digestion happens. For reasons that no one has conclusively explained, some people wind up with bacterial overgrowth in this part of the body, and that can cause serious digestion issues. Above all, SIBO seems to slow everything down, and cause particular issues for carbohydrate absorption. This is because the bacteria often associated with SIBO feed on carbs and release gases.

Entire blogs (let alone individual blog posts) have been written on the topic of SIBO. It’s a condition that’s not perfectly understood, but is getting a lot of attention these days. However, quite a few scientists and doctors believe that SIBO is the main underlying cause of all types of reflux.

Fungal overgrowth

SIBO is a problem of bacteria in the wrong numbers, in the wrong place, but fungal overgrowth can also cause issues. Our bodies naturally contain fungus, including a well known type called Candida. When you wind up with too much fungus, particularly in the wrong part of your digestive tract, this can also cause issues. You may hear this problem referred to as Candidiasis, Small Intestine Fungal Overgrowth (SIFO) or even just Candida.

While it may sound quite similar to SIBO, it does seem like the condition is quite different because fungal organisms behave differently to bacteria. Specifically, there seems to be some evidence that fungus responds more slowly to treatment. Having said that, it seems that SIBO is getting more attention as a potential root cause of reflux and LPR these days than fungal overgrowth.

Parasites

LPR can also be a symptom of a parasitic infection. With parasites, this could actually be the presence of an organism that isn’t supposed to be there at all. You can get parasites in lots of ways, including from food and water. If you have an undiagnosed parasitic infection, it can wreak havoc on your body and digestion, and LPR could just by a symptom of those issues.

Testing & treatment for gut dysbiosis

The good news is that there are treatments available for all types of dysbiosis. Most also have reasonably reliable tests that a medical practitioner can run. I would strongly recommend discussing these possibilities with your doctor. They can run tests and give you a conclusive answer, and then discuss treatment options with you. Usually there are both natural and pharmaceutical options available.

Gastroparesis

Whethere you have gut dysbiosis or not, another condition that could be causing or aggravating your LPR is gastroparesis. In simple terms, gastroparesis is a condition where your stomach empties too slowly. When food stays in your stomach too long, it can cause reflux, for obvious reasons.

There’s much less discussion about gastroparesis online in connection with LPR and GERD, but it is sometimes associated with reflux. Equally, any one of the other conditions mentioned in this article could aggravate gastroparesis. However, gastroparesis can also have neurological causes, such as damage to the vagus nerve.

Pancreatic issues and insufficient enzyme production

To digest your food properly, you need your pancreas (and to some extent your salivary glands) to produce enzymes. If this production is impaired, it can also cause digestion issues. That is at least one of the reasons that many LPR-sufferers turn to supplemental digestive enzymes.

Hypochloridia – low stomach acid

Similarly, to digest your food properly, you need to be producing sufficient stomach acid. Certain people suffer from a lack of sufficient stomach acid, and that of course can slow down your digestion. This is a potentially controversial suggestion as traditional medicine ascribes most reflux to an excess of acid rather than a lack thereof. However, the functional medicine community often favours the low stomach acid hypothesis, and actually recommends taking stomach acid supplements.

There are actually tests that a doctor can perform to measure your stomach acid levels. Hypochloridia tends to be more common among the elderly.

Bowel diseases

The waters start to get a little murkier as you move down the digestive tract in search of potential causes of LPR. However, it stands to reason that if your digestion is impaired at any stage, it can lead to symptoms elsewhere. Problems of the bowel (or large intestine) are numerous and common, but there are some scientists and doctors drawing a connection between some of these and all types of reflux.

Diseases of the bowel can include Crohns, Inflammatory Bowel Disease (IBD) and Diverticulitis. There are also other bowel diseases that could be at play, but the diagnosis that comes up most often in conjunction with LPR is IBS or Irritable Bowel Syndrome.

Irritable Bowel Syndrome (IBS)

IBS is a tricky topic, because it is a syndrome, rather than a disease. It’s a collection of symptoms that is offered as a diagnosis when other potential conditions are excluded as a possibility through testing. IBS can be debilitating, and is associated with constipation, diarrhoea or both. People who suffer from IBS, sometimes also suffer from some sort of reflux, including GERD or LPR.

It’s worth nothing that medical professionals have recently started linking IBS to SIBO, which in itself is considered a potential cause of LPR. If you have symptoms of both LPR and IBS, this could be worth considering as a potential explanation.

It’s all connected

Even just reading this article, you probably already get the sense that things are not clear cut. Many of these conditions are connected, and of course you can have more than one of these at the same time. Many people do! Trying to decipher which conditions your symptoms best match up with can be maddening. It also may be pointless. At the end of the day, all of these are signs of an unhealthy digestive system, and probably warrant dietary interventions and consultation with a doctor.

Seek help from a medical practitioner

The absolute best thing you can do is work with a doctor who can help you determine if any of the conditions mentioned here (or any others) are part of your problem. It’s much better to rely on conclusive testing than it is to rely on analysis of symptoms. Having said that, if you do need to work with symptoms, better to let someone with lots of experience interpret them than trying to do it yourself.

Many of the treatments prescribed by the conventional medical symptom focus more on symptoms than root causes, so you may want to consider seeing a functional medical practitioner, ideally one who can incorporate the best of traditional and alternative medicine in helping you work through your treatment plan.

The bottom line – think about the root cause

The bottom line here is that you should at least be thinking about the root cause of your LPR. In some cases, it may be an isolated condition, but it seems that for many, LPR may be the result of one or more related medical issues.

The types of interventions available for Laryngopharyngeal Reflux

If you scour the internet for long enough, you’ll find dozens of possible interventions and treatments for Laryngopharyngeal Reflux. There are many worth considering, and you’re likely to find a lot of different success stories based on a lot of different treatment types. Of course this also makes things pretty confusing. Where are you supposed to start?

Medication & Supplements

In this post, we’ll explore the types of interventions available by category, in the order in which it might make sense to try them – that is from least costly, difficult and invasive to the most extreme. When you decide what your treatment regimen is going to be, you may find it useful to think through these categories. How serious is your case? How urgent is resolution? Have you worked through simpler options before trying more extreme interventions? Hopefully this will serve as food for thought when you assess your treatment options.

Behavioural Interventions

Seated Meditation

Many people skip straight over this type of intervention and it may in fact be sufficient to treat your LPR if there’s no serious underlying condition involved. The reason that behavioural interventions may work for you, is that digestion is closely linked to your hormones and stress levels. If you’re unable to relax, you may not be able to digest, and that can lead to the symptoms of LPR. Most behavioural interventions involve either making food easier to digest or ensuring you’re relaxed enough for your body to digest naturally.

  • Chewing more thoroughly
  • Not drinking too much water with meals
  • Eating 3-4 hours before bed time and not lying down after eating
  • Taking deep breaths before eating
  • Stress management practices like meditation and deep breathing

Further reading:

Dietary Interventions

Bagels & Vegetables

Dietary interventions can also be a great place to start when trying to treat any kind of reflux including LPR. They are actually helpful in a number of scenarios:

  • Your LPR may be a reaction to a trigger food, an allergy or an intolerance
  • Your LPR may be the result of an underlying pathogen such as:
    • Parasities
    • Fungal overgrowth
    • Bacterial overgrowth

In both instances, some version of an elimination diet can be helpful. For food intolerances, allergies and triggers, an elimination diet can help you identify what those foods are that you should permanently eliminate. If on the other hand, you have an underlying pathogen, eliminating certain types of food can help to starve it. Having said that, elimination of some pathogens may require more aggressive treatments such as those described later in this artcile.

Types of elimination diet

It can be confusing to try to pick among the many types of elimination diet that are claimed to aid people who suffer with various types of reflux, but they broadly fall into the following families:

  • Low acid diet
  • Low fat diet
  • Gluten free diets
  • Dairy free diets
  • Low FODMAP diet
  • Specific Carbohydrate Diet
  • GAPs Diet
  • SIBO diets
  • Fast Tract Diet
  • Low Histamine Diet

Most dietary recommendations for treating LPR and reflux more broadly involve one or a combination of the above types of diet. Assessing the effectiveness of each of these types of diet for LPR is beyond the scope of this post, however the general principles are important:

  • Try to eliminate possible allergens or common food sensitivities
  • Try to reduce the types of foods that feed gut pathogens (mostly carbohydrates)
  • Reintroduce foods one at a time so you can clearly determine which may be aggravating your LPR

Natural Interventions

Herbal Vitamins

If diet and behavioural changes don’t help your LPR, some people like to consider natural or herbal interventions before they undertake pharmaceutical ones. Again, it’s difficult to share an assessment of each of these possible treatments, but all of these seem to have at least some support as possible treatments for all types of reflux and LPR specifically.

  • Demulcent herbs such as:
    • Deglycerized Licorice
    • Slippery Elm
    • Marshmallow Root
  • Manuka Honey
  • D-Limonene
  • L-Glutamine
  • Colostrum
  • Digestive Enzymes
  • Betaine HCL
  • Pepsin
  • Herbal antimocrobials including:
    • Oregano oil
    • Thyme oil
    • Sage oil
    • Berberine
    • Garlic
  • Combination herbal antimicrobial products such as:
    • Candibactin AR
    • Candibactin BR

Some of these treatments aim to soothe the symptoms of LPR. Others aim to eliminate pathogens that may be causing LPR. Finally, some of them simply aim to heal the gut and improve digestion.

Pharmaceutical Interventions

Prescription Medicine

Most people still turn to pharmaceuticals to help with all kinds of reflux. Pharmaceutical interventions can broadly be classified into over the counter (OTC) and prescription medications.

OTC LPR interventions

Over the counter options in most countries include:

  • Antacids such as:
    • Tums
    • Rennies
  • Raft-forming treatments with sodium alginate (usually also including antacids) such as Gaviscon Dual Action
  • H2 Blockers (in some countries these require a prescription)

Surgical Interventions

Female Doctor

For those who are really suffering with their LPR, the most serious intervention one can undertake is an operation. The most common operation for both GERD and LPR is the Nissen Fundoplication. This is quite an extreme option, that involves the stomach being surgically tied around the bottom of the oesophagus, effectively making the opening and lower oesophageal sphincter tighter. This is intended to physically stop any refluxate from travelling up the oesophagus.

Generally speaking, only those who have failed to experience any relief with any of the above types of treatments would consider getting a Nissen Fundoplication

Further reading

Which type of intervention is right for you?

Reading about all of these options may leave you wondering where to start. If your symptoms aren’t debilitating, then it might make most sense to work from the top of the list downwards, as it is organised from least to most costly and invasive. However, you should also take into consideration what’s available to you and what type of treatment sounds right for you. Of course, above all, you should consult with medical practitioner, particularly if your symptoms are severe or if you’re considering any of the more significant interventions.

The Trouble With Treatment & Timelines

I battled with LPR for almost a year before I really started to make inroads with the treatments I was trying. It was often discouraging, as I really struggled to understand what was working and what wasn’t. I kept abandoning treatments, and revisiting treatments, feeling unsure about what was helping. Sometimes a treatment that I thought was failing turned out to be helpful. Sometimes the opposite happened.

Looking back now, I realise that the problem wasn’t my treatments, but rather the timelines. In fact, it was the timelines that were making it difficult to understand what was happening. The internet is littered with ideas on how to treat LPR, as well as many other conditions. I think that part of the confusion comes from people not being certain what to attribute their healing to.

If you suffer from LPR, I think you can save a lot of time by thinking about the interplay between treatment and timelines. Here are some specific guidelines that might help you.

Hourglass being thrown

You need to give your treatment sufficient time to work

Whether they’re chemical, natural, herbal, behavioural or even controversial, the reality is that treating LPR takes time. I actually believe that it’s a particular sinister condition in the way that it shows no signs of abating, but in my experience, it also can disappear as quickly as it came. For some reason, LPR just didn’t seem to slowly fade away for me. It stuck around stubbornly, and then abruptly made an exit. I now realise, I may have given up on treatments in the past, just before they were about to really help.

LPR is multifactorial, and is associated with causes like motor neuron dysfunction, bacterial overgrowth and sensory neuropathy. It may be a combination of all those things. Regardless, any one of those potential root causes doesn’t resolve overnight. Almost all interventions aimed at addressing these root causes, will take weeks to work, and may not show any signs of help until that time has elapsed.

On the other side of things, many of the treatments themselves require consistent administration to achieve any lasting effect on the body. Even the classic PPI needs to build up in your system before it has its full effect. Behaviour and dietary changes also won’t lead to bodily changes before they’ve been repeated for quite some time.

Sadly, as an LPR sufferer you have no choice but to be patient, and give any treatment time to kick in before deciding if it’s working for you or not. I would say, it almost always needs at least a few weeks.

You need to isolate the treatment variable as much as possible

While you’re waiting for a treatment to work, it’s very tempting to try something else in parallel. Perhaps you’re on a PPI and you want to try changing your diet. Perhaps you’ve found one herbal supplement, but can’t see any good reason not to try another at the same time. I’ve been down that path, and I know it leads to utter confusion. I found that my symptoms seemed to be coming and going erratically (though the going may have been wishful thinking or just randomness), and I couldn’t pin down what was helping and what was hurting.

If you think about the fact that treatments can take weeks to work, and know anything at all about science, you’ll realise that this is a problem of isolating the variable. If you change too many things at once, you have no idea what is having what effect. That means that even if you start getting better, you might ascribe the improvement to the wrong treatment, and then backslide later. I certainly had that experience.

As frustrating as it is, I would really recommend that you try one treatment at a time if you’re suffering from LPR. It’s the only way you’ll be able to get any certainty about what will help you. You can try the scatter gun approach, and you may get better, but then you might find yourself right back where you started without any good explanation of why.

You need to stay the course

Of course all of what I’m describing is very psychologically difficult. LPR is a funny condition, in that it’s not life threatening. It can even sound a bit benign when you just describe it as a sore throat, but I think it exacts most of its punishment psychologically. Consistent discomfort is really taxing, but constant anxiety about what you can and can’t eat, or what you can and can’t do is even worse.

Nevertheless, I think in the long run, you’ll benefit from trying one treatment at a time, giving it a few weeks to work (or not) and taking careful note of its effects. That means when you finally find something that helps, you won’t miss the signs.

In my personal opinion, the right place to start is almost always diet, but that’s a subject for another post.

The Gastro Visit

I sidled up to the door reticently about 15 minutes before my appointment time. I was buzzed in by a receptionist wearing far too much makeup, probably intended to mask age as much as deep-seated misanthropy. The waiting room was innocuous at first glance, pastel-coloured with slightly frumpy and outdated furniture, piles of old magazines and a coffee table with a frosted glass top – standard waiting room issue.

As I took in my surroundings, the place started to make me feel a little uncomfortable. I noticed the other people sitting around displaying various degrees of unhappiness on their faces. Some of them looked groggy. Others looked like they were in pain. All seemed to show a slight bit of apprehension of whatever was coming next.

I approached the painted gate keeper behind the counter and I shared my name, appointment time and the name of the Gastroenterologist I was supposed to see. She had me wait while she searched for my entry on the computer. I took note of a wall clock behind her, proudly sponsored by a brand of PPIs. A quick scan around the desk area revealed several more big pharma freebies helping to grease the wheels of medical commerce.

“Please fill this out.”

She handed me a bright pink clipboard, which also had a brand of PPIs emblazoned on the clip. At least my expectations were being clearly set.

I completed my form and handed it back.

“Gastroscopy or colonoscopy?”

“Gastroscopy”, I quick responded, very eager to ensure that there wasn’t any confusion about which orifice was going to be inspected on this particular visit.

“The doctor is running a little late. The traffic into town from [POSH SUBURBIA] is bad in the morning”

Given that my appointment was for the earliest available slot (of 10:00), I was a little surprised that traffic was a big issue, but I resolved to sit down and wait patiently. I cracked open my laptop, did some work and tried hard not to think about what was coming next.

As the time passed, not thinking about having a metal tube shoved down my throat became increasingly difficult. The receptionist seemed surprised that I was enquiring about the Gastro’s whereabouts again and again. Clearly this was a man that people waited for.

When he finally arrived, the Gastro had the air of a school boy caught doing something naughty, despite his enormous gut and floppy grey hair. He mumbled something that sounded like it might border on an apology, and walked straight into his office. Ten additional minutes later, he opened the door and indicated he was ready to see his first patient, an hour after his first appointment time. I walked in.

The Gastro asked me a couple of questions but didn’t seem to be particularly concerned with the response. The words “foregone conclusion’ kept rattling around in my head. He started to explain how the gastroscopy would work, but then his mobile phone rang. “Sorry,” he said, not particularly apologetically. “I have to take this.”

I didn’t really take note of what he was saying while on the phone, but when he hung up a minute later, he offered a brief explanation: “My Banker”. “Who’s side are they on anyway?” he added, smiling at the quality of his own banter. He proceeded to explain that my throat would be numbed and that they would send a camera through a tube into my stomach to snap photos and take samples like the Mars Rover. I was ready to get it over with.

I lay down in the small room I was shepherded into, and a pleasant lady let me know that the stuff she was about to spray my throat with was a bit strong, but banana-flavoured, so it wasn’t so bad. While I didn’t taste bananas, I couldn’t feel my mouth anymore, so I was satisfied that it had done the job. She gave me a mild sedative, that made the room seem a bit more pleasant.

The Gastro came in, and after a quick bit of small talk, he shoved a black metal flexible pipe down my throat. I couldn’t feel any pain, or any contact really, but I could feel the force required to jam it through the resistance that my oesophagus was providing. The next thing I knew, my insides were up on a TV screen attached to the walls. It looked like any short video clip of the inside of a stomach – could have been anyone’s.

They quickly inserted and removed several smaller tubes through the main one that was in my throat, taking samples and such. I could feel my entire oesaphagus contracting violently as my gag reflex kicked in. Before long, the larger tube was being removed, and I was invited to lie there and recuperate for a bit. A few minutes later, I was guided back to the waiting room and offered tea and sugary biscuits. I remember being amused that this is what they offer people with digestive issues.

The Gastro called me into his rooms and delivered his diagnosis:

  • H. Pylori: Negative
  • Mild gastritis
  • Mild oesophagitis
  • Hiatal Hernia: Negative
  • Nothing else visibly wrong

He also offered his prescription:

  • Take a PPI (the one that paid for the clipboards)

“Should I make any dietary changes?” I asked. “Is it necessary to go on the PPI right away? Could there be any underlying causes?”.

“Just take the PPI and you’ll feel much better” he said. And with that I was encouraged to leave.

I remember feeling a fair bit of relief. At least there was visual confirmation that none of my darkest fears of what was brewing in my stomach were proving true. I never took that PPI though…

Dr. Ruscio’s 4 Tier Intervention Hierarchy for GERD

There are many medical websites and blogs out there these days. As someone who is suffering from LPR, or any kind of GERD, you’ve probably come across many of them. The challenge is that it’s very difficult to distinguish between genuine authorities, charlatans and everything in between.

One online authority who I’ve really come to respect recently is Dr. Ruscio. His podcast, blog post, videos and everything else seem very well thought out, balanced and clear. He takes an evidence-based approach, and he’s not hung up on either the natural/functional approach or the conventional medicine dogma. He seems happy to take the best of both, which is refreshing.

Dr. Ruscio recently released a podcast, in a collaboration with Dr. Ben Weitz, all about Gastroesphageal Reflux. This wasn’t specifically about laryngopharyngeal reflux, but I felt it really had a lot of very interesting ideas that would help LPR sufferers think about their treatments, as much as it would help those suffering from more mainstream types of GERD.

I would encourage you to watch or listen to the podcast in full, but I’ve tried to summarise some of the most interesting points and ideas in this blog post, as much for my own benefit as for any potential readers.

Dr. Ruscio uses 4-tier intervention hierarchy for GERD

One of the things I particularly appreciate about Dr. Ruscio is his structured thinking. In this instance, he describes a 4-tier hierarchy that he uses to approach treatment of patients with GERD.

Dr. Ruscio 4-tier Intervention Hierarchy GERD

My visualisation of the hierarchy Dr. Ruscio describes in the podcast

What’s great about the approach described is not only that it’s tiered and very clear; Dr. Ruscio also explicity talks about avoiding getting hung up with mechanisms. There’s a lot of overlap between symptoms and mechanisms of various related ailments, so he rather focuses on treatment options with his patients. Very practical!

Diet

Starting with diet, Dr. Ruscio explains that he likes to start with some sort of elimination diet. He feels that many instances of GERD have some sort of food allergy, intolerance or sensitivity at their root. The simple way to address this is to go through an elimination diet process. He recommends this over testing, particularly when cost is a factor.

In terms of type of dietary approach, he suggests using either a paleo or auto-immune paleo protocol, though he does say that more traditional elimination diets can also work. The point of this exercise is to eliminate the most likely potential culprits, such as:

  • Gluten
  • Dairy
  • Caffeine
  • Spicy foods
  • Alcohol
  • Nightshades
  • FODMAPs

The last one is potentially more difficult to address with a traditional elimination diet, but there are plenty of guidelines available on how to implement a low FODMAP diet out there, including Dr. Ruscio’s own guide.

Dr. Ruscio seems to think starting with a simpler elimination diet is based, and then if that is unsuccesful, trying a low FODMAP diet and even a low histamine diet, to try to narrow down the potential causes of GERD.

Dysbiosis

If elimination diets don’t expose any culprits in terms of food sensitivity, Dr. Ruscio then looks to the possibility of dysbiosis. He mentions two types that may be involved.

H Pylori

The link between H Pylori and ulcers has been known for some time, and H Pylori overgrowth can apparently also cause GERD. Dr. Ruscio recommends testing for H Pylori in more than one way to get a more certain diagnosis.

SIBO (Small Intestine Bacterial Overgrowth)

Echoing the ideas of many other functional medicine practitioners and GERD authorities, Dr. Ruscio also believes that SIBO can be one of the underlying causes of GERD. This is where the low FODMAP diet mentioned above can be particularly useful, as a low FODMAP diet limits the amount of fermentable carbohydrates in your diet. When you have SIBO, fermentable carbohydrates promote the release of gas by pathogens, which can force open the lower oesophageal sphincter.

Acid

The third tier in terms of intervention is addressing abnormal levels of acid. As discussed in the podcast, many functional medicine practitioners blame GERD on low stomach acid rather than high. Dr. Ruscio suggests that either one of them can be a problem.

Unsurprisingly, Dr. Ruscio’s recommendation here is to bring acid levels to normal levels. If acid is low, one should supplement with Betaine HCL. If acid is high, acid lowering medications may be appropriate.

On an interesting side note, Dr. Ruscio does take a moment to question the pervasive belief that GERD is driven by low stomach acid more often than not. He calls Dr. Jonathan Wright’s research into the area into some question, suggesting that the references he made to studies to support this hypothesis “don’t hold up”.

Natural interventions

The final tier in Dr. Ruscio’s intervention hierarchy is natural therapies for gastric healing. Here, he mentions quite a few potentially helpful substances:

  • Slippery elm
  • Melatonin
  • B Vitamins
  • Betaine
  • Prokinetics

He also mentions some specific products

  • Protexid
  • GI Guard
  • Motilpro
  • Iberogast

Other interesting food for thought from Dr. Ruscio

For any new sufferers of LPR or GERD, Dr. Ruscio’s 4-tier approach seems to make a lot of sense. There were also a few other ideas that jumped out, in listening to the podcast.

Maybe low stomach acid isn’t the problem

Already mentioned above, this is a particularly striking question to think about. Dr. Ruscio suggests that people may be too quick to attribute GERD to low stomach acid. He suggests that plenty of people actually are having issues because of the more conventionally accepted diagnosis of high stomach acid.

He mentions that if you’re young, have family members with a tendency towards GERD, having gnawing stomach pain or react badly to stomach acid supplements, your issue may be high rather than low stomach acid.

Motility is an important factor

Dr. Ruscio also mentions that reduced motility may play an important role in GERD. This is why he says that prokinetic compounds can help. This also is connected to the overlap between GERD, IBS & SIBO – an interesting topic that we will dive into in the future!

Don’t be afraid of short-term PPIs

I was quite surprised to hear Dr. Ruscio say that we shouldn’t be afraid of a short course of PPIs to help heal GERD-related conditions. He seemed to suggest that 4-8 weeks could be particularly useful for people suffering from ulcers. He goes on to explain that long term use may well be dangerous, but it seems that he thinks that PPIs have been unnecessarily demonised, and a short course may be beneficial for some people.

Keep an eye on Dr. Ruscio

I really believe that Dr. Ruscio is a great authority on the subject of all things digestive, particularly after listening to this podcast episode. His approach seems measured, well thought out and free from bias. I will certainly be keeping an eye on his podcast and blog going forward!

Listen to or watch the original podcast episode with Dr. Ruscio


How it all started for me

At the time of writing this, it’s been about a year since I started suffering from laryngopharyngeal reflux. Anniversaries are great times for reflection, and I’ve found myself thinking back to how this all started for me.

Early Warning Signs

There are a few distinct episodes that I remember very clearly – the ones that made me realise that something relatively serious was going on – but if I’m honest with myself, there were warning signs before that. In the year or two before I was diagnosed with laryngopharyngeal reflux, I had plenty of strange little niggles that, in retrospect, were signs of trouble brewing.

I remember a couple of occasions where I ate a small but fatty snack, and was completely unable to eat any dinner afterwards – as if I was completely full. I also recall a few occasions where the morning after a fatty dinner, I woke up with what I thought was a terrible hangover, despite not having consumed much alcohol. I started noticing that I was belching all the time, even when I hadn’t recently eaten. That last, particularly unpleasant symptom seemed to occur most often at the gym.

There were also some more acute warning signs that I didn’t connect with my digestion. For instance, I went to the doctor complaining of chest pains and was told it was a stress-induced oesophageal spasm. It seems pretty obvious now that this had to have some kind of gastrointestinal component, but at the time, I just took the suggestion that it was entirely stress induced at face value.

As unpleasant as it is to write about, I think the biggest warning sign was the fact that my stomach was never entirely happy. I didn’t have any serious symptoms. I never wound up sprinting for the toilet or going for days without a visit, but my digestion seemed to constantly be oscillating between a bit too slow, and a bit upset. I was anything but regular.

Despite all these signs that something in my gastrointestinal tract wasn’t quite right, I didn’t immediately make any connections with what ensued just about a year ago.

The Onset Of LPR

The first specific episode I remember was coming home from a relatively late dinner out that involved a bit of wine. My wife and I thought it would be fun to make fruit smoothies for a second dessert with our recently acquired Nutribullet. We blitzed some bananas and berries and gulped them down. Twenty minutes later, I felt incredibly bloated and was belching uncontrollably, to the point where I was even regurgitating a bit of my smoothie. I had just eaten dinner, and that’s what I ascribed it to, but I remember being quite worried that I could react this way to a bit of pureed fruit.

At a later date, I remember coming home from a big workout at the gym, and making coconut flour pancakes topped with macadamia nut butter, bacon and a little bit of Canadian maple syrup, one of our favourite (relatively) low carb indulgences. Within 30 minutes of eating, I was incredibly uncomfortable. This now familiar, but at the time very perturbing, feeling of a welling up in my throat started to come on. I had no idea what was happening to me, so I didn’t even know how to alleviate the symptoms. I just freaked out, which I’m sure didn’t make things any better.

Diagnosis

I think the final straw that convinced me to go to the doctor was after drinking what I thought was the healthiest possible breakfast smoothie. It was full of avocado, nuts, berries, a little bit of banana and some extra added fat in the form of coconut oil. My throat became so sore it felt like a stabbing pain. I remember feeling absolutely drained when it finally subsided, like I’d just been through a bout of torture.

That afternoon I took myself to the doctor. To his credit, he diagnosed me pretty quickly. That was the first time I heard the term laryngopharyngeal reflux. I walked out the door with the advice not to consume tomatoes, citrus, chocolate or coffee, as well as a prescription for Nexium, a common PPI.

I’m usually pretty careful about taking pharmaceuticals; I tend to do plenty of research before fulfilling a prescription, but I was so drained and desperate for help with this seemingly inexplicable issue, that I went straight to the pharmacy and took my first pill shortly thereafter. In retrospect, I wish I hadn’t, as the PPIs did anything but help, but that’s a story for another day…

Is fat good or bad for laryngopharyngeal reflux?

More and more people are turning to dietary and lifestyle changes to address all kind of digestion issues including GERD and LPR. With an increasing amount of evidence that there may be risks associated with pharmacological remedies, and also some indications that they might not be effective anyway, it’s no surprise that diet has come into the spotlight for sufferers of laryngopharyngeal reflux.

Some dietary recommendations for addressing LPR and GERD aren’t surprising, as they fall under the umbrella of generally sensible ways to address digestion issues. Avoiding processed foods and excessive alcohol for instance all seem like suggestions that are embraced both by conventional wisdom as well as the authorities in the space. However, one area that seems quite contentious is the appropriate level of fat consumption.

Brick of butter

Fat – a controversial macronutrient

Any discussion of fat consumption in the context of LPR needs to start with an acknowledgement of its divisive nature in health and wellness overall. For a good portion of the 20th century, fat, and particularly saturated fat, was viewed as a problematic type of food and was considered to be the cause of many different types of disease, most notably heart disease. This perspective was probably popularised because of the work of Ancel Keys, whose perspectives on saturated fat were ultimately adopted by the American Heart Association and became part of the generally accepted dietary recommendations the world over.

More recently, warnings of the dangers of fat intake have come under scrutiny and today, there are many advocates of a high fat diet, with some even recommendation a high intake of saturated fat. The Paleo movement, first popularised by Loren Cordain, most notably advocates the consumption of animal protein and fat.

Today, you’ll find many more advocates of high fat, low carbohydrate diets, though there are still those who suggest avoiding the consumption of saturated and animal fats specifically. While trying to point to a definitive answer on the general health effects of saturated and animal fats is beyond the scope of this article, suffice it to say that it’s not a cut and dry issue. However, it does seem that the link between saturated fat and disease is more tenuous than previously thought.

Fat and digestion

Fats are primarily digested in the small intestine and rely on a combination of the enzyme lipase and bile from the liver for successful digestion. While the mechanisms are complex, it’s worth noting that they are different to those mechanisms that help digest carbohydrates and proteins, which involve different enzymes, hydrochloric acid (stomach acid), and in the case of protein, pepsin.

It’s also important to note that fat digests more slowly than the other macronutrients, at least in part because it is found to slow the speed of gastric emptying (the speed at which food leaves your stomach).

Fat and reflux diet recommendations

One of the most common conventional dietary recommendations for any type of reflux (and particularly the traditional heartburn type) is to avoid fatty foods. Anyone who has suffered from reflux has heard this recommendation at some point. This recommendation has received some support from Jamie Koufman, one of the world’s most visible authorities on the topic of reflux. It’s worth mentioning that Dr. Koufman also played a role in identifying LPR as a distinct condition, though she seems to refer to it more often as ‘airway reflux’.

Dr. Koufman espouses the benefits of a “low fat, not no fat” diet for LPR. In this video, you can hear her briefly describe her recommended reflux detox, which is noticeably low on animal fat.

On the other side of the fence, you’ll find another reflux diet authority – Dr. Norman Robillard of the Digestive Health Institute. Dr. Robillard’s dietary recommendations are significantly different. He advocates a fairly high fat diet, as the best approach to reducing the symptoms of reflux and even LPR. He blames reflux on carbohydrate malabsorption and recommends reducing consumption of specific types of carbohydrates to address symptoms. When you try to reduce carbohydrates, it’s inevitable that the gap must be filled by something else, and his dietary recommendations seem to point to raising fat intake.

Dr. Robillard actually specifically questions the recommendation to reduce intake of fat in his book Fast Tract Digestion and on his website and blog:

Dr. Robillard doesn’t just question the idea that fat intake aggravates reflux, he even challenges the idea that fat intake slows gastric emptying. He ascribes the belief that fat is a culprit in reflux to the fact that many fatty foods are actually deep fried foods, battered in carbohydrates.

Fat – where does that leave us?

With some reflux authorities recommending high fat, and others recommending low fat, an LPR-sufferer is bound to be left feeling confused about what to do. A look through forums and facebook groups seems to suggest that some people benefit from both approaches, just as much as some people struggle from both.

Ultimately the effect of fat on LPR may be particular to the individual because of the underlying root causes of the reflux. For instance, if the underlying cause is Small Intestine Bacterial Overgrowth (SIBO) which is Dr. Robillard’s explanation for most cases of reflux, starving the bacteria of carbohydrates and eating a high fat diet may make sense. However, if someone has an enzyme deficiency or poorly functioning liver, making it difficult to digest fat, it seems plausible that reducing fat intake could help alleviate symptoms, as it might improve the speed and quality of digestion.

All of this points to the reality that dietary recommendations need to be personalised, and that different people will react differently to different foods, both in the context of overall health, and in the context of LPR. It may be prudent for long time sufferers of LPR to trial both approaches and see what works for them.

My own experience with fat consumption.

After reading the Fast Tract Diet book, I came to believe that carbohydrate malabsorption due to SIBO was the root cause of my problem with LPR. As a result, I decided to cut down on carbs significantly and up my fat intake. I’d read elsewhere that too much protein was potentially a problem, so high fat seemed to be the only way forward. I saw some improvement, but after some time, my symptoms seemed to worsen again.

I couldn’t figure out what was going on, but as I started to look at my food intake, I realised that I had continued to up my fat till it represented about 60% of my calories. I decided to try dialling back, and reduced the amount of fat I was consuming and sure enough, my symptoms improved again. For one reason or another, I didn’t seem to be able to digest all that fat, and I would feel it an hour or two after eating.

I don’t for a second think that my experience is necessarily representative, but I do think that I’ve concluded that very high fat doesn’t work well for me. That realisation, and the amount of time it took me to get there is one of the reasons I would encourage other LPR sufferers to experiment and draw their own conclusions, rather than simply following any one piece of advice they’ve found.

What is Laryngopharyngeal Reflux?

The term Laryngopharyngeal Reflux, and particularly its abbreviation – LPR – are becoming quite common. Thanks in part to the ubiquity of websites devoted to topics of health and medicine, what was an obscure diagnosis not so long ago, is now a condition that more of the general public is aware of. Having said that, an exact and agreed definition of LPR seems harder to come by, so in this post, we’ll explore what exactly LPR is (and a little bit of what it isn’t).

The most common definition of Laryngopharyngeal Reflux

At the time of writing this post, the Wikipedia article on Laryngopharyngeal Reflux states:

Laryngopharyngeal reflux (LPR), also extraesophageal reflux disease (EERD), refers to retrograde flow of gastric contents to the upper aero-digestive tract, which causes a variety of symptoms, such as cough, hoarseness, and wheezing, among others.

As the name implies, LPR is a type of reflux that affects the larynx and the pharynx which are both part of the throat, and play a role in respiration and speech. In other words, in the simplest terms, LPR is reflux that reaches the throat.

Anatomical picture of throat areas affected by Laryngopharyngeal Reflux

Anatomical drawing courtesy of Wikipedia

What is Reflux?

Now reflux in itself is a term worth digging into and is actually shorthand for the much more common and accepted medical diagnosis of Gastroesophageal Reflux Disease (GERD). GERD is typically associated with the symptom of heartburn and is also commonly called Acid Reflux. Some define Laryngopharyngeal Reflux as a sub-type of GERD, whereas others treat it as a separate condition.

According to Wikipedia:

Gastroesophageal reflux disease (GERD), also known as acid reflux, is a long-term condition where stomach contents come back up into the esophagus resulting in either symptoms or complications

Chris Kresser often refers to GERD as a disease of “acid in the wrong place at the wrong time” which is a nice way to summarise the problem. Reflux is essentially a case of stomach contents getting out of the stomach and into other parts of the body where they cause damage and discomfort.

Is LPR just a version of GERD?

On first glance, it may seem quite simple – LPR is just a version of GERD where stomach contents, and acid particularly, travel past the oesophagus all the way up into the throat and cause pain and discomfort. Unfortunately when you dig in to the topic, it quickly becomes clear that it’s much more complicated than that.

The first problem with this simplification of LPR is that many people who experience LPR, show no traditional symptoms of GERD. They feel throat discomfort and some of the associated symptoms, but none of the traditional heartburn. It may seem odd that stomach acid could travel up through the oesophagus to the throat and cause discomfort there without causing any on the way, and some medical professionals seem to believe that there is more at play than simply stomach acid reflux.

Other potential mechanisms to explain LPR

One potential explanation for the existence of LPR in the absence of traditional GERD symptoms is that the substance causing the symptoms is not stomach acid. One potential theory is that it is actually refluxed bile rather than acid that causes the symptoms of Laryngopharyngeal Reflux. This could potentially explain why sufferers don’t experience the chest pain typically associated with Acid Reflux.

Another potential theory about the cause of LPR is that it has to do with Pepsin, an enzyme that helps to digest protein in the stomach. Pepsin is activated by stomach acid, although it is not an acid itself, which may explain why LPR seems connected with Acid Reflux and yet distinct. The theory here is that Pepsin can get lodged in the throat and then can be activated by small amounts of acid, that aren’t sufficient to cause traditional heartburn, but will cause the Pepsin to damage the throat lining.

Is Laryngopharyngeal Reflux just a collection of symptoms?

With lots of different theories of what causes LPR and no consensus on which one(s) are the main driver(s), one might conclude that LPR is actually just a collection of symptoms that can’t be explained via other better understood mechanisms. These symptoms include:

  • Sore throat
  • Globus (a feeling of a lump in the throat)
  • Postnasal drip
  • Sinus congestion
  • Hoarseness
  • Cough
  • Loss of voice
  • Difficulty swallowing
  • Dyspesia (indigestion)
  • Trouble breathing
  • Accumulation of throat mucus

In short, LPR is characterised by symptoms of indigestion accompanied by symptoms associated with the throat and airways. It could well be that these are attributable to one or more of the causes mentioned above (acid, bile or pepsin) but it could be that there are other mechanisms at play that we’re not yet aware of.

Why does it matter?

This question of definition may not seem so important on first glance, until you realise that how one defines LPR bears a large impact on how one might go about treating it. For instance, if one defines LPR as just a particular type of GERD, one might be inclined to recommend typical GERD treatments to address it, but as we’ll explore in future posts, there’s plenty of evidence that some effective GERD treatments are much less effective for LPR.

Sadly, the jury still seems to be out on what exactly is going on in the bodies of sufferers of LPR, but thankfully more and more medical professionals are investigating this question, and hopefully clearer answers will come to light in the future.

I’ve Suffered From LPR For 6 Months

At the time of writing this post and launching this site, I’ve suffered from laryngopharyngeal reflux, commonly referred to as LPR, for just over six months. It’s been a humbling and frustrating experience, not least because I’ve always made a great effort to take care of my health. In fact, my LPR began around the same time that I became even more strict with a paleo-style diet, and took a break from alcohol entirely, all in the name of better health. I was pretty focused on regular and adequate sleep, stress management, exercise and everything else I could think of that was important. The fact that rather than feeling better, I developed this ailment was a bit of a blow.

The first few months, particularly before I really knew what was going on, were very challenging, on a psychological level as much (if not more) than on a physical level. I felt depressed, I was prone to intense mood swings, and I felt intense fear about the possibility that something more sinister was underlying my painful symptoms. What was particularly frustrating was the fact that nothing I tried seem to make me better. Some of what I tried actually seemed to be counterproductive, and I was completely overwhelmed by the myriad suggestions of diets, lifestyle changes, supplements and medications that I found online.

I really came to feel lost at sea when I realised how little help the conventional medical system could provide. I visited several doctors and a gastroenterologist and none of their recommendations seemed in my best interest, nor did they seem to come from a place of understanding of my problem. I’ll elaborate on my experience with the medical system in future posts, but suffice it to say, that I wound up feeling very alone with my issue.

Fast forward a few months and I’m happy to say I’m feeling much better, though I can’t say that I’m out of the woods yet. I’m happy to at least have a better understanding of what’s going on with my health and I feel much less anxious about the underlying causes of my LPR (another topic for future posts). I’ve learned to recognise the warning signs of my reflux symptoms, as well as a personal toolkit to address pain and discomfort when it arises. Perhaps most importantly, I feel like I’m on the mend and that at some point in the future, whenever that will be, I will be free of my laryngopharyngeal reflux, or at least have it under complete control.

Why am I launching a site about laryngopharyngeal reflux?

No doubt some people will find the idea of creating a website devoted to a very specific, non-life-threatening ailment a little odd. I admit that I ruminated over the idea for a long time before getting started, but I have a few reasons for wanting to create a site about LPR.

I want to share what I’ve learned about LPR

I’ve spent a lot of time reading about laryngopharyngeal reflux over the last few months. I think that’s probably true of a lot of people who suffer from this particular condition, but I feel compelled to document and share some of it in one place. I really think it may be useful to other sufferers, of which it seems there are many around the world. I think I may have been able to get to where I am now more quickly if I had been able to find more information earlier, particularly from a patient’s rather than a professional medical or encyclopaedic vantage point.

I want to find, gather and engage with a community of LPR-sufferers

Many people suffer with laryngopharyngeal reflux around the world – millions in fact. Depending on where they are located, they may or may not have access to good medical care for this fairly recently identified condition. I know that many people turn to the web for answers; you’ll find posts on this topic on general health and GERD-specific websites, as well as in the comments section of any LPR-related content. My impression is that the interactions are quite scattered though, and I really believe that people with LPR would benefit from a place on the internet where they can interact with others with this very specific set of symptoms.

I want to draw a distinction between LPR and GERD

There does seem to be an important link between gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux LPR, which I’ll explore in future posts, but LPR comes with its own symptoms, challenges and remedies. Too much of the content on the web about LPR is mixed in with content about GERD, and too often the recommendations are treated interchangeably. I don’t believe that’s appropriate or helpful based on my personal experience, so I want this to be a place where the focus is only on this very particular type of reflux. I think most LPR-sufferers will appreciate and benefit from the distinction.

I’m still on a journey to getting well

I’d love to be writing this having completely overcome this condition, but sadly that’s not the case. Part of my motivation for creating this site is create momentum in my own journey with LPR. I think that the endeavour will behove me to keep researching and focusing on solving this for myself. I also think building a community of people with the same problem will provide some psychological support.

I believe that working on this site will be positive for me regardless of what direction it takes or traction it gains. If it can also be helpful to other people, so much the better.