Silent Reflux (LERD or LPR) – Causes, How to Diagnose It Properly, and How to Find Relief!

My Personal Struggle with Silent Reflux

I remember the day when I first became chronically ill like it was yesterday. I was at my grandmother-in-law’s house eating a delicious catfish dinner. Afterwards, my stomach felt like it was on fire for the first time in my life and ached severely. I tried to lie down, but after an hour, the pain was so overwhelming that I could barely move. I went to the emergency room, and they could not find anything wrong with me. They told me I was perfectly healthy. I did not know at the time but I was developing LPR.

Over the next month, I developed OCD, had significant anxiety, LPR symptoms, gastritis, stomach pain, and my resting heart rate increased thirty beats per minute. During this stressful period, I thought that I was going to die, or at the very least, I was concerned that I might be slipping into madness. For the first time in my life, my health was rapidly deteriorating. I visited several doctors, and their tests showed nothing significant except for an elevated heart rate. The only treatment my doctors offered me was a drug test in the hospital to see if I was a user. Once I passed the drug test, all they wanted to do was admit me into the hospital, and monitor my condition. My primary doctor planned to prescribe a series of prescription medicines, including some powerful heart and anti-anxiety medications to calm me down because he thought anxiety had caused all my problems. My grandfather told me to stop the ACE inhibitor and to wait a few days to see if I would improve. He said that any medicine, at any given time, might cause side effects in anyone. The next day, I discontinued my ACE inhibitor, checked my resting heart rate, and it relieved me to find that it had returned to normal.

Unfortunately, the damage had been done. The ACE inhibitor left me with horrible side effects, and I almost fell into an adrenal crisis. It took me over a year to recover from the severe adrenal fatigue that I had developed. For years I was left with silent reflux as my main symptom and it took me forever to discover that was my issue through many diagnostic tests. I started supplementing with zinc carnosine and magnesium and it became manageable, yet I still had flare-ups, and it was always there just lessened. I thought I would forever be afflicted with silent reflux, because I believe the primary cause was the abdominal surgeries I had as an adolescent and the scar tissue associated with them. I was wrong, however, in the back of my mind I believed I was suffering from H. pylori dysbiosis but mostly every test I had ever taken was negative. The final test I had taken showed I had antibodies to a toxin H. pylori produces CagA+. I received these positive test results in my seventh year of suffering from silent reflux, and I researched as much as I could about H. pylori and started a protocol. Through my research I determined that I contracted H. pylori around the time of the catfish dinner and the ACE inhibitor had suppressed my immune system so that it could flourish. I finally achieved silent reflux remission in six months on protocols to reduce H. pylori dysbiosis and improve my microbiome. I am lucky since silent reflux has so many different proposed causes not everyone can achieve remission. I know what it is to suffer the hell that is silent reflux, you are not alone, and hopefully, I can help anyone that is suffering from it overcome this terrible condition.

Silent Reflux (LERD or LPR) an Often Misdiagnosed Disease

Laryngopharyngeal reflux disease is a more recently known, less understood “cousin” of GERD (gastroesophageal reflux disease). LPR (larygopharyngeal reflux disease) differs from GERD in that people with LPR have their symptoms above the esophagus. Most people who suffer from LPR do not have traditional heartburn, pain in the throat, chest, or any symptoms of GERD. LPR sufferers usually have their symptoms during the day, whether they eat or not, and symptoms usually occur when sitting. GERD sufferers typically have their symptoms in the evening, after they eat, and when they are lying down. Most LPR symptoms are instead felt when you arise out of bed in the morning and throughout the day. It is also harder for LPR to be diagnosed correctly because the symptoms are so universal for most people. LPR can disguise itself as breathing, oral cavity, ear, or sinus issues. Finally, some people can have symptoms of GERD and LPR in which they have LERD, laryngopharyngeal esophageal reflux disease.1 2 3 4

The various symptoms of LPR include:5 6 7 8

  • Periods of dry mouth
  • Periods of backwash and increased saliva production
  • Sour, sweet, or metallic taste inside your mouth
  • Feeling of having backwash
  • Burning mouth feeling (may become burning mouth syndrome)
  • Halitosis (bad breath)
  • Salivary stones
  • Enlarged tongue
  • Geographic tongue
  • Periodontal disease
  • Adenoiditis
  • Tonsillitis
  • Tonsil stones
  • Post-nasal drip
  • Loss of sense of smell
  • Sinusitis
  • Chronic sinus infections
  • Nasal polyps
  • Tears that feel like they burn
  • Inflammation of the eyes
  • Watery eyes
  • Dry eyes
  • Chronic ear infections
  • Hearing problems
  • Tinnitus
  • Ear fullness
  • Ears pop while swallowing (eustachian tube inflammation)
  • Hearing self-generated sounds like breathing (patulous eustachian tubes)
  • Coughing
  • Consistent throat clearing
  • Pharyngitis
  • Dysphagia (difficulty swallowing)
  • Severe throat swelling and possible closing
  • Sore throat
  • Visceral hypersensitivity
  • Lump in the throat feeling (globus pharyngitis)
  • Hoarseness
  • Laryngitis
  • Laryngospasm
  • Tachycardia, arrhythmia, or spiked blood pressure during episodes of reflux
  • Roemheld syndrome
  • Asthma
  • Perceived breathlessness
  • Aspiration pneumonia
  • Pulmonary fibrosis
  • Esophageal spasms
  • Frequent belching
  • Dyspepsia
  • Upper gut bloating
  • Mental disorders including anxiety, panic attacks, and depression occurring from gastrointestinal issues
  • Malaise
  • Unlike GERD, the esophagus usually appears somewhat normal in people with LPR. Mild irritation in the esophagus might be seen in people with silent reflux. The esophagus seems somewhat normal because the acid and pepsin that are refluxed are quickly swallowed downward. Reflux does not become trapped between the two sphincters (LES and UES), as it does in people suffering from GERD. Less inflammation within the esophagus generally occurs in people suffering from LPR. However, more inflammation for people suffering from LPR occurs in the upper airway, UES (upper esophageal sphincter), larynx, throat, oral cavity, sinus cavities, and eustachian tubes because of a lack of antireflux cellular mechanisms in these areas of the body offering less protection from reflux to these tissues. For some, their reflux is aerosolized, and the irritating gas inflames and deposits an enzyme called pepsin onto their tissues. Finally, embedded pepsin, when activated by either acidic reflux, acidic aerosolization, or ingestion of acidic food, triggers inflammation and causes cellular damage by breaking down tissue over time.9 10 11 12

    Pepsin is the primary enzyme produced by our stomach to digest protein. Pepsin is one of three main proteases (enzymes that metabolize protein) our body produces for digestion. Pepsin is the most efficient protease in breaking down peptide bonds between hydrophobic and aromatic amino acids including tryptophan, phenylalanine, and tyrosine. Pepsinogen is released by the chief cells in the stomach wall and activates becoming pepsin when it mixes with acidic gastric juice. Pepsin helps break down protein into polypeptides for proper metabolism. Pepsin later becomes inactivated, by turning back into pepsinogen when it is mixed with alkaline bicarbonate and bile released from the pancreas and gallbladder or liver into the duodenum. Neutralization of pepsin and acidic stomach chyme that enters the duodenum prevents inflammation, injury, and break down of tissues in the rest of the digestive system that cannot handle a low pH.13

    The inactivation of pepsin by sodium bicarbonate does occur in the throat (it can in the esophagus in moderation because of carbonic anhydrase). The baseline pH of the throat is rather neutral. However, anytime you swallow anything with a low pH like vinegar, pepsin’s enzyme activity is reactivated and it begins to break down your tissue causing inflammation. I recommend gargling and rinsing with alkaline water after meals, throughout the day, and before bed to inactivate pepsin. In addition, limiting acidic foods like citrus fruits or vinegar and eating a diet containing more alkaline foods can also help relieve silent reflux symptoms by lessening the chance of reactivating pepsin in the oral cavity, throat, and esophagus.14

    An endoscopy may also be performed to get an idea of esophageal damage and the general function of your LES, UES, stomach, and duodenum. During an endoscopy, a flexible wire with a camera positioned at the end of the wire is swallowed. The camera takes pictures down the esophagus and into the stomach and duodenum. Traditional endoscopies are known to have issues associated with the procedure including potential injury or death from sedation, increased risk of aspiration, and slightly increased risk of infections from improperly sterilized (autoclaved) instruments. I recommend you talk to your doctor about performing the safer; transnasal esophagoscopy procedure, that does not require sedation to view the health of your throat and esophagus.15 16 17

    One of the best assessments utilized in the diagnosing of LPR is an esophageal pH monitoring test. A flexible catheter with a pH monitor at the end is placed through the nose down into the esophagus for at least 24 hours. A 48-hour dual sensor pH catheter monitoring test (one pharyngeal probe and one esophageal probe) that can measure both acid and nonacid reflux events is instrumental in establishing a LPR diagnosis. In addition, ask if your provider also offers Bilitec monitoring at the same time to determine if you are also suffering from bile reflux.18

    Finally, there is a noninvasive test for LPR known as the Peptest. The Peptest tests saliva, sputum, aspirate, and gastric juice for pepsin. If your saliva tests positive for elevated pepsin, it is probably the cause of your silent reflux. You can order the Peptest yourself; you do not need a doctor to order the test.

    In most people with LPR, the upper and lower esophageal sphincters are not functioning properly. The UES, known as the upper esophageal sphincter, closes off the throat from the esophagus. In most people with GERD, the LES, known as the lower esophageal sphincter, is the only sphincter that is not functioning properly. The non-functioning LES causes stomach chyme to become stuck in-between the stomach and the UES creating the sensation known as heartburn. The UES is the sphincter at the top of the esophagus that opens and closes when you swallow to protect the throat, oral cavity, nasal cavities, and eustachian tubes from aspiration.19 20 21 22

    The main problem with LERD is conventional medicine does not have an effective treatment for it. There is no proven diagnostic cause of LERD. Proton pump inhibitors are prescribed with little effectiveness. “Data from controlled treatment trials convincingly show that PPI therapy is no more effective than placebo in producing symptom relief in patients suspected of laryngo-pharyngeal reflux disease. Furthermore, neither symptoms, nor laryngoscopic findings or abnormal findings on pH monitoring will predict response to PPI therapy. A reliable diagnostic test for LPR or one that might predict response to a PPI does not exist.” Reflux surgery may bring relief for a time, but it does not correct any of the following underlying issues and in time LPR returns.

    Hypotheses of the many possible causes of LPR:

  • SIBO (small intestine bacterial overgrowth)
  • Upper gut dysbiosis causing an elevated stomach pH
  • Dysbiosis of the nasal cavities, oral cavity, throat, or esophagus
  • Magnesium deficiency
  • Zinc deficiency
  • Improper endogenous collagen production (lack of vitamin C ingestion and copper metabolism issues) and inadequate sphincter tone
  • Inefficient production of endogenous vitamin D
  • Chronic stress (causing HPTAG [hypothalamus, pituitary, thyroid, adrenal, gonadal] axis issues and an under active parasympathetic nervous system)
  • Adrenal fatigue
  • Hypothyroidism
  • Overactive sympathetic nervous system (compromised vagus nerve function)
  • Nerve damage or inflammation to both the LES and UES (might occur after an acute viral throat infection)
  • Chronic viral reactivation (Herpesviridae, mainly Varicella zoster)
  • Mercury amalgams
  • Oral cavitations (mostly caused by root canals) and nerve damage/dysbiosis
  • General Advice for LPR:

    • Ask a physical therapist about using shaker neck exercises to strengthen your throat muscles and improve upper esophageal sphincter tone.23 24
    • Drink only room temperature water during meals, and do not overeat. Eat three meals daily and try not to snack if possible to help maintain proper motility.
    • Chew your food well while eating especially if what you are eating contains carbohydrates (to mix well with what little salivary amylase we produce). The more you masticate your food, the less your digestive system has to work.
    • Drink two ounces of natural, alkaline water (Evamor, Icelandic Spring, and Mountain Valley Spring Water are good brands) two hours after a meal to deactivate pepsin in the oral cavity, throat, and esophagus. Swish well and gargle with the alkaline water before swallowing. In addition, drink two ounces of natural alkaline water before bed.25
    • Wash the nasal passages out with saline at least once a day. In addition, use saline drops in the nose daily and blow your nose afterward. The saline is to deactivate excess pepsin that might be in your nose from the reflux caused by the LPR. Do not use a neti pot unless needed because it can reduce the amount of mucus that makes up the beneficial mucus barrier within the sinuses.
    • Sleep on your left side at night to prevent reflux. Sleeping on our left side or back prevents lack of LES tone and helps with maintaining proper anatomical position. If you cannot tolerate sleeping on your left side, sleep on your right side, do not sleep on your stomach, it increases gastrointestinal pressure. Some people notice relief from sleeping on a wedge pillow or elevating the front of their bed. Finally, practice good sleep hygiene. Melatonin production is important for proper digestive health and LES function.
    • Reduce intake of acidic foods that can trigger silent reflux. I would try to limit what I ingest with a pH lower than 5.5. I recommend following the Dropping Acid diet as well.
    • If you are suffering from bile reflux, combined with pepsin reflux, reduce your ingestion of foods high in omega 9, known as oleic acid. Avocados, avocado oil, olives, and olive oil are example of foods that contains elevated amounts of oleic acid.
    • Increased endogenous production of vitamin D seems to help most people with silent reflux. I cannot stress the importance of this advice enough; it has made the most significant difference in my life and those I have coached that made the lifestyle changes. If you live in an area where it is hard to get sun or UV-B, the use of a UV-B producing tanning bed or supplementation might be needed. Get your 25-hydroxy and 1-25 hydroxy levels checked to see if your vitamin D levels are in range.
    • Maintain proper amounts of omega-3 fatty acids in your diet. Ingest leaner fish like cod, flounder, and salmon.
    • Practice Buteyko breathing techniques when possible. Do not practice breathing exercises if you are very bloated and have a lot of gas. For some, breathing exercises can increase bloating and gas, possibly from swallowing more air.
    • Relieve constipation and maintain proper motility.
    • The following link is a list of medications that may cause the symptoms or make silent reflux worse.
    • If you suffer from chronic cough then I would recommend avoiding spicy food. Capsaicin ingestion activates your TRPV1 receptors throughout the digestive tract which among other actions elicit a cough reflex.26
    • The use of Pulsed electromagnetic therapy from a trained chiropractor or naturopathic doctor over time may help improve LES and UES tone and relieve reflux.27
    • The use of low-level laser therapy (LLLT) from a trained chiropractor or naturopathic doctor may reduce esophageal inflammation and pain and help relieve silent reflux symptoms.28 29
    • Improve your oral hygiene.

    Silent Reflux (LPR) Protocol

    • Zinc carnosine – One to two capsules with each meal.
    • Magnesium glycinate – 200 mg per fifty pounds of body weight, taken at bedtime. Glycine has been shown to help increase LES strength.

    Coat and Repair Your Esophagus and Throat

    • Supplement with collagen daily.
    • Recipe to help coat and relieve your throat – In one cup of hot filtered water, mix in 1/2 teaspoon of slippery elm powder and 1/8 teaspoon of DGL powder, consume after each meal. Swish well, mixing with saliva before swallowing. Consider adding one tsp. of manuka honey to the drink to help coat your throat and reduce possible bacterial overgrowth in the upper gut.
    • Eat organic grass-fed beef liver once weekly for a good source of retinol and ceruloplasmin-bound copper.
    • Consider using D-limonene to help coat and protect the esophagus and larynx. For some people, it helps immensely, for others it may not be easily tolerated.
    • Consider using liposomal colostrum to help invigorate your immune system and reduce inflammation.

    Tackle Outstanding Medical Problems That may Cause LPR:

    1. http://www.webmd.com/heartburn-gerd/guide/laryngopharyngeal-reflux-silent-reflux
    2. http://www.doctoroz.com/article/silent-reflux-epidemic
    3. http://www.voiceinstituteofnewyork.com/
    4. Beers, Mark. The Merck Manual, Merck Research Laboratories, 2006.
    5. http://www.webmd.com/heartburn-gerd/guide/laryngopharyngeal-reflux-silent-reflux
    6. http://www.doctoroz.com/article/silent-reflux-epidemic
    7. http://www.voiceinstituteofnewyork.com/
    8. Beers, Mark. The Merck Manual, Merck Research Laboratories, 2006.
    9. http://www.webmd.com/heartburn-gerd/guide/laryngopharyngeal-reflux-silent-reflux
    10. http://www.doctoroz.com/article/silent-reflux-epidemic
    11. http://www.voiceinstituteofnewyork.com/
    12. Beers, Mark. The Merck Manual, Merck Research Laboratories, 2006.
    13. Patton, Kevin, Thibodeau, Gary, Douglas, Matthew. Essentials of Anatomy and Physiology, Mosby, March 16, 2011.
    14. http://www.voiceinstituteofnewyork.com/
    15. http://transnasalesophagoscopy.com/
    16. http://www.ncbi.nlm.nih.gov/pubmed/22425272
    17. http://transnasalesophagoscopy.com/wp-content/uploads/2011/03/TNE-White-paper-20081.pdf
    18. http://www.gwdocs.com/assets/form/ent-ear-nose-throat-center/Laryngopharyngeal%20Reflux%20%28LPR%29.pdf
    19. https://www.refluxgate.com/ultimate-guide-to-lpr-causes-and-treatment
    20. http://www.doctoroz.com/article/silent-reflux-epidemic
    21. http://www.voiceinstituteofnewyork.com/
    22. Beers, Mark. The Merck Manual, Merck Research Laboratories, 2006.
    23. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2895999/
    24. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2593402/
    25. http://evamor.com/static/pdf/koufman_1242.pdf
    26. https://www.sciencedirect.com/science/article/pii/S1094553910001458
    27. https://www.youtube.com/watch?v=ULfsQnWk3Gc
    28. https://www.ncbi.nlm.nih.gov/pubmed/23613090
    29. https://www.ncbi.nlm.nih.gov/pubmed/25916131