In this post we will cover the following topics:
As the name suggests there are some differences between silent reflux, acid reflux, and GERD. Namely, silent reflux does not typically cause heartburn. Symptoms commonly include:
- Hoarseness, inflammation of the throat and vocal chords
- Excessive throat clearing and coughing
- Mucus production and post nasal drip
As indicated in the Annals of Clinical Case Reports silent reflux has many synonyms including:
1. Extraesophageal Reflux
2. Supraesophageal Reflux
3. Gastropharyngeal Reflux
4. Atypical Reflux
5. Pharyngoesophageal Reflux
6. GERD Cough
7. Laryngopharyngeal Reflux (LPR)
That said, Silent reflux is most commonly referred to as LPR.
In addition to the more common symptoms listed above, the following complications can manifest in cases of extended silent reflux.
- Hoarseness / Pain When Speaking – A hoarse voice is often one of the first symptoms that LPR sufferers experience. This, as the larynx (voice box) is very close to the esophagus and consequently has higher exposure to potential reflux.
- Bad Breath / Bitter Taste In Back of Throat – Iron, bitter or sour taste in the mouth is due to stomach contents re fluxing into the airways and mouth.
- Stress – Stress, like anxiety are both side effects of social pressures and reflux medications.
- Burning / Dry throat – Throat pain is one of the earliest warning signs of reflux as the vocal chords and the larynx (throat) are the closest organs to the stomach.
- Excessive Belching – Copious burping goes hand in hand with silent reflux, as frequent exposure stomach gases is the cause of the vocal chord damage and burning sensations in the esophagus and mouth.
- Breathing disorders – Such as apnea, noisy breathing, pauses in breathing, or Choking Episodes (especially at night).
- Asthma-Like Symptoms – Asthma is a common initial misdiagnosis, this is because stomach contents aspirate into the airways, prompting an immune response that mimics asthma
- Ear infections – The ear, nose, and throat are all connected so inflammation, bacteria, and mucous responses can express through any of the three organs.
- Chronic Cough and Throat Clearing – Often times this can be a non-productive cough. LPR can irritate your mucus membranes which can also stimulate coughing and throat clearing. Quite often, silent reflux sufferers are mis-diagnosed as having another respiratory disease like asthma or sleep apnea.
- Globus Syndrome – This is that all too familiar sensation of something stuck in your throat. This is due to inflammation and swelling of your membranes.
- Difficulties swallowing (dysphagia) – Many LPR sufferers experience trouble swallowing due to throat inflammation.
- Post Nasal Drip – Post nasal drip and mucous production is your body’s natural response to protect sensitive tissues in your nasal cavity and esophagus (throat) from acid and acid vapors. This can result in excessive mucus in your throat and airways.
- Nausea or vomitting – This can be a side effect of throat stimulation or digestive issues, which ultimately may be the source of your reflux issues.
- Frequent Infections – As acid reflux is most often a symptom of poor digestive health and low stomach acidity. In a low acid environment, pathogens (such as bacteria and viruses) are able to thrive.
- Anxiety – Anxiety is often two fold 1. social stigmas from bad breath or hoarse / muted voice and 2. a side effect of vitamin B12 deficiency, a common side effect of long term acid reflux medication usage.
Take The Silent Reflux Quiz
Endless guidance and advice exists on the internet to help you eliminate your acid reflux, ranging from jaw exercise routines to diet plans. While some are helpful, most including prescription medications, focus on managing or reducing the discomfort caused by your symptoms. They do little-to-nothing to resolve reflux because they fail to address the actual root causes of the disease.
To put this in context, Americans spend more on their annual subscription to prescription acid reflux medications than they do on some video streaming services ($10 Billion on Proton Pump Inhibitors vs $2 Billion on Hulu Streaming Services). Yet, while the symptoms are somewhat alleviated, the disease remains. In fact, the disease tends to escalate in severity and frequency over time. This is because, at best, these medications only treat the symptom not the cause.
This is a topic that I am quite passionate about because I suffered with reflux for more than 15 years. Over that time I contributed to the $10 Billion as I estimate spending over $6,000 on prescriptions, over the counter medications, and antacids. Like you, I became increasingly dissatisfied with medical advice. However, with my hiatal hernia I was resigned to the fact that I would suffer the disease for life. Furthermore, my doctor essentially said my options were a lifetime prescription or throat cancer, as surgical technology still does not offer a long time solution.
However, for me everything changed when my symptoms suddenly took a turn for the worst. After eating a handful of candy at work I added several new and excruciating symptoms (persistent burning / sour mucus, post nasal drip, constant burning in the roof of my mouth and lips) that would plague me for the next 6 months, and that motivated me to understand address the root causes of my reflux and eliminate it for good.
The amazing thing is remedies such as the one described in this article are relatively simple, fast, and inexpensive. Sadly, however they are little known because the concepts are partially based on science that is only twenty years old, are somewhat counterintuitive, and contradict millennia of cultural understanding on this topic.
For thousands of years, a home remedy for indigestion involved chewing chalks and food grade charcoals. In modern day, these naturally occurring compounds (such as calcium carbonate) are the active ingredient in popular antacids such as Tums, Alka Seltzer and Pepto Bismol.
In addition to the long history in our culture around the concepts of acid suppression, the prevalence of acid blocking medications, the power of the pharmaceutical advertising machine, and the institutionalization of these medications easily crowd out more modern, targeted, and effective approaches to dealing with the disease.
If You Have Reflux, Here Is Why
There are two principle root causes for acid reflux. The first is a microbial imbalance in the digestive tract. The second is low acidity. In this section we will touch on both. Be sure to read to the end, however as we will also cover common risk factors that may have led to the onset of these root causes as well as the many strange side effects and symptoms of long term acid reflux that you may not have attributed to the disease.
Microbial Imbalance In the Digestive Tract
Have you ever had a feeling of butterflies in your stomach when you were doing something new, risky, or scary? That is because the gut and brain communicate with each other and are intricately connected. In fact, over the last twenty years a whole new field of medical science has emerged around this topic, called the gut-brain axis. Astonishingly, the gut which is often referred to as the second brain, has more than 500 million neurons. As you may know, the neuron is the fundamental unit of the brain and is responsible for interpreting sensory input and sending motor commands to the body.
What we have since learned is a third and equally important component of this connection called the microbiome. Your microbiome is the 5 pounds (2.3 kilos) of microorganisms and genes that live in your body and are essential to your survival. In fact, this expanded field of study which is now referred to the gut-brain-microbiome axis reveals that the number of cells in your microbiome outnumber the human cells in your body by a factor of 10-1. In fact, there are more than 100 trillion microorganisms including bacteria, fungi, viruses, and protozoa in a healthy human body.
We know the most about the 1000 species, and 7-9000 strains of bacteria because many of them can be cultured and studied in a laboratory environment. Much like the numerous examples we see in nature (Egyptian Plover removes rotting flesh from the open mouth of a Crocodile, Clownfish provides nutrients and the Sea Anemone provides protection) of co-operative organisms, they symbiotic bond with their host. Even more surprising, similar to the recently discovered co-operation and communication between trees via fungal networks, the gut, brain, and microbiome share three way communication.
We are only beginning to understand the depths of connection between this triumvirate. But, through study of mice and application in humans via Functional Medicine we know that a balanced microbiome is key to a healthy immune system, digestion, production and absorption of vitamins and nutrients, production of hormones such as dopamine (essential for brain and nervous system function), serotonin (mood and wellbeing), melatonin (sleep), adrenaline, and more.
Full coverage on this and other topics are beyond the scope of this article. That said, I have expanded on it in my recently released book ‘How I Cured My Silent Reflux | The Counterintuitive Path to Healing Acid Reflux, GERD, and Silent Reflux (LPR).’ Needless to say, I could easily start a series by authoring second title devoted to this topic.
The key thing you need to know is an imbalance the microbes that colonize your intestinal tract can be catastrophic to not only your digestion, but your mood, nervous system function, immune system, nutrition, brain health, and more. There are many risk factors that can lead to this imbalance, that we will explore later in the article. For now, we will explore a few of the more significant side effects of this this bacterial imbalance, also known as dysbiosis.
I start with indigestion because it is perhaps the earliest and most direct impact of dysbiosis. Your gut microbiome is considered ‘unbalanced’ when the proportion of beneficial microbes is outnumbered by their harmful counterparts. When in low numbers, these microbes are often harmless and can even be beneficial (more than 50% of people, in fact, have H Pylori). In fact, recent studies such as this one by Harvard Health indicate that H Pylori, often attributed for the development of Irritable Bowel Syndrome (IBS) may actually play an important role in regulating stomach acid.
That said, the wrong bacteria such as H Pylori or Clostridium Difficile (C. Diff.) can grow out of proportion in your stomach. For some of these bacteria, the process of decomposing food leads to fermentation and excess gas production which causes bloating (a common reflux symptom). Normally, this fermentation process should occur in the colon where it can be expressed through the anus. However, under the wrong conditions bacteria that normally colonize the colon are allowed to proliferate in the gut.
Additionally, as we have discussed, your body depends on the symbiotic relationship with your microbiome for digestion. When unbalanced, food contents sit on your stomach for extended periods, leading to indigestion (another common reflux symptom). As this occurs more often, this creates a cycle that supports further colonization of the offending bacteria, which in turn leads to higher frequency and severity of indigestion.
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Impaired Immune Function
Another important function of your microbiome is to improve immune function. Amazingly 70-80% of your immune cells are found in your gut. This might seem surprising at first, but think of it this way: We like to think the only portion of our body that is exposed to the outside world is our skin. But there is no dividing line between your skin, down through your mouth, throat, stomach, intestines, and colon; it’s all connected!
Additionally, your skin has an estimated surface area of 2 square meters which pales in comparison to the estimated 30 square meters of your digestive tract. By surface area, your digestive tract is WAY more exposed. Understanding this, the foods and drinks that you put into your body pose a more significant threat as compared to viruses and bacteria that are exposed to your skin.
One way your microbiome aids your body’s immune system is by helping to efficiently digest foods and prepare them for movement down the digestive tract. Foods that sit on the stomach too long or that are poorly digested can lead to inflammation, which can compromise the stomachs mucosal lining. In fact, when the body is unable to process a food it is tagged as an invader and attacked by the immune system, which triggers an inflammatory response. Inflammation allows the body to trap the offending agents so the immune system can consolidate an attack.
This inflammation is fine in isolated events, but the persistent presence of poorly digested foods leads to chronic inflation and long term damage of the single cell thick lining of the stomach. This occurs more often as bacteria are further out of balance as more and more foods cause and inflammatory (or triggering response using acid reflux terminology). Ultimately damage to the stomach lining (known as leaky gut) can allow for food particles, and harmful pathogens to enter the blood stream. This leads to inflammation in other parts of the body, such as the brain, which leads to brain fog, memory issues, anxiety, etc.. As you will see in the risk factors section, this can contribute to the downward spiral and ever escalating situation that characterizes acid reflux.
Lastly, I’ll cover malnutrition. As with any symbiotic relationship, neither party is altruistic! We humans get a needed boost to literally every body function, as proper digestion leads to the extraction of energy in the form of amino acids, simple sugars, fatty acids, etc. These ultimately form the building blocks that make us, us! The microbiota get the nutrients that fuel their incredibly short, yet productive lives.
Amazingly, a healthy gut, brain, and microbiome are in constant communication and coordination with regards to the production of building blocks for healing, immune function, proper cell function, development and conversion of hormones, etc. For instance, the human body alone is incapable of regulating estrogen levels, an essential hormone for women’s health. In fact, it is your microbiota that create the beta-glucuronidase that converts estrogen into its active forms.
As you can imagine, when these biota are imbalanced it can lead to a number of physical and neurological disorders. The brain, for instance is primarily composed of fat. Absent the abundance of critical building block our minds are quite literally limited. This can manifest due to malabsorption but also because certain bacteria are highly efficient at leeching certain nutrients for themselves.
Low Stomach Acid
Paradoxically, the other leading root cause of acid reflux is low stomach acid. You read that correctly, it is not high, but LOW stomach acid that often leads to acid reflux. There are many reasons for this. The first, and perhaps most obvious is the fact that reduced stomach acid impairs digestive efficiency which leads to indigestion. High stomach acid is required to efficiently dissolve your foods and prepare them for further digestion as it passes along the gastrointestinal tract.
Additionally, stomach acid is required as a signaling mechanism for the body to perform certain digestive and anti-reflux functions. In fact, the body is designed with five anti-reflux mechanisms that are controlled through the gut-brain-microbiome axis via the vagal nerve, which serves as a communication super highway. This nerve is the longest in the human body and a pillar of the autonomic nervous system. It alone conveys 80-90% of the body’s sensory information concerning the state of the body’s organs.
The first three anti-reflux / digestive mechanisms are the lower esophageal sphincter (LES), diaphragmatic sphincter and pyloric sphincter. Sphincters are a common design pattern in the body and exist as a ring shaped muscle that controls the passage of solids, liquids, and gases. Some are under voluntary control such as the anal sphincter (allows you to poop), the upper esophageal sphincter (allows you to swallow / burp), and the urethral sphincter (allows you to pee). In contrast, the LES, diaphragmatic and pyloric sphincters (pictured below) are signaled to open / close through your vagus nerve as a response to acidity.
The pyloric sphincter is responsible for emptying stomach contents into the lower intestines once sufficiently digested. If acidity is too low, signaling to the brain is weak or poorly timed, which leads to delayed digestion (indigestion) and bloating. The LES and diaphragmatic sphincters are responsible for keeping stomach contents out of the throat. If acidity is too low, these muscles do not contract with sufficient pressure and will allow stomach contents to flow backward into the throat.
The other two anti-reflux mechanisms are a bicarbonate (antacid solution) that is produced in your throat and saliva. This occurs automatically as well as a response to acid and levels of natural antacid can actually increase as much as 32 fold. This is the body’s last line of defense however and the low grade antacid are in sufficient to handle the high levels of stomach acidity that enter the throat and mouth due to poor sphincter function and indigestion.
Lastly, on the topic of low stomach acid I want to mention the fact that the stomach is designed as a highly acidic environment. In fact, as a measure of acidity from 1-14pH, with the highest levels expressed in low numbers, stomach acid is naturally in the range of 1-3 pH. This is slightly less potent than battery acid! Normally, the stomach, its mucosal lining, and your anti-reflux barriers are more than a match for this highly corrosive environment. It is necessary for digestion, to kill harmful pathogens in support of your immune system, and to support healthy balance of gut bacteria. For this reason, it is quite often that Small Intestinal Bacteria Overgrowth (SIBO) or Irritable Bowel Syndrome (IBS) often accompany low stomach acid.
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Many people who contact me come armed with a dozen or more things that they’ve tried in attempts to eliminate their reflux. The problem is very few of these supposed solutions can be correlated back to a root cause issue that they help resolve. Some do help to mitigate symptoms, but they do not offer healing. Sadly others like Gaviscon worsen symptoms because they reinforce the root causes by lowering acidity. Many are surprised by this as they were only aware of the highly advertised foam barrier that it purports. If I had a dollar for every time I heard the word Gaviscon from one of you I could easily cover the cost of maintaining this website!
Sadly, people are lulled into believing these medicines are helping them because they neutralize the uncomfortable / painful acids that escape into the throat. Consequently they decide to take them longer than the recommended 6-8 weeks, and because doctors do not have a better alternative they suggest buying over the counter or renew the prescriptions.
That said, I want to cover some of the more serious effects of long term acid reflux medication usage. It is well documented that long term use leads to several vitamin deficiencies, namely vitamin b12, magnesium, and calcium. Below is a list of the most common side effects. If have bolded several that I personally dealt with for years, not realizing they were associated with reflux. If you have experienced any of the below, you may be deficient in one or more of these vitamins.
- Weakness, tiredness, or lightheadedness
- Heart palpitations and shortness of breath
- Pale skin
- A smooth tongue
- Constipation, diarrhea, loss of appetite, or gas
- Nerve problems like numbness, muscle weakness, and problems walking
- Vision loss
- Mental problems like depression, memory loss, or behavioral changes
- Muscle Problems (aches, cramps, spasms, numbness, tingling in hands, arms, feet, legs and around the mouth)
- Extreme fatigue
- Nail and skin symptoms (itch, inflammation, psoriasis)
- Osteopenia and osteoporosis (low bone density)
- Painful PMS
- Dental problems
- Loss of appetite
Now, with your understanding of the root causes and long term side effects of reflux, I hope you are in a better position to judge the potential efficacy of the potential treatments that you try, before you spend time and money on them. As reflux is a multi-pronged issue, including digestion issues, microbial imbalance, malabsorption, and low acidity the solution needs to be one that addresses all of these issues. An effective approach should provide short term relief sufficient to enable a transition away from existing medications as well as a long term foundation for continued healing.
As such, I have summarized an approach that I used to successfully transition off of my acid reflux medications and ultimately to eliminate my reflux entirely.
Revise Phase I (2 weeks): Create a stable digestive environment to enable a smooth transition
- Continue taking reflux medications (if you are taking them)
- Eat plainly and avoid and identify trigger foods
- Add naturally fermented foods to your diet (for probiotics)
- Add high fiber foods to your diet (prebiotics) to rebalance your gut
- Take b12 and magnesium supplements (if you are deficient)
Restore Phase II (4-6 weeks): Supplement digestion & transition off reflux medications
- Take apple cider vinegar capsules (not liquid as it is corrosive) for prebiotics and to kill harmful pathogens
- Use digestive enzymes with meals to improve digestion
- Take betaine hydrochloride with pepsins with meals to restore acidity and sphincter function
- Stop taking reflux medications
Renew Phase III (2+ weeks): Reintroduce foods
- Slowly Reintroduce foods
- Avoid risk factors to avoid re-entering the reflux cycle
For a comprehensive / easy to follow plan, additional rationale, and the steps I took to resolve my reflux, get my #1 best-selling book ‘How I Cured My Silent Reflux | The Counterintuitive Path to Healing Acid Reflux, GERD, and Silent Reflux (LPR).’
Alternatively, if you’re a do it yourselfer, I have put together a quick three page checklist that covers the three phase plan. You can get that here:
Lastly, I want to briefly cover the three categories of risk factors that you should be aware of. This may help you correlate the onset of your symptoms to a lifestyle, disease, or medical event. This is important so that you are able to avoid falling back into the reflux cycle after you may have healed:
- Lifestyle Factors: Smoking, Alcohol, Caffeine, Pregnancy, Stress, Obesity, Eating Late, Over Eating, Poor Diet, Lack of Exercise
- Disease Factors: Hiatal Hernia, Peptic Ulcers, Connective Tissue Disorders
- Medical Factors: Surgery, Low Acidity, Medications (Asthma, Blood Pressure, Depression Medications, Sedatives, Antidepressants, Narcotics, Tranquilizers, …)
These are by no means an exhaustive list, and I go into more detail on these topics in my book, as well as ways each can affect the body’s ability to keep stomach contents contained, efficiently digest, and affect movement of food contents along the digestive tract.
For instance, I’m sure you know that exercise positively affects metabolism, but did you know It also directly effects digestive health and efficiency? This is achieved through a process called peristalsis, which moves food along the digestive tract through a series of involuntary yet coordinated muscle movements.
Also, the content of your diet has a direct effect on digestive health. The more narrow, processed, and high in sugar your food choices are, the more your digestive system is skewed to process these foods. This leads to harmful imbalances and side effects that negatively affect digestive efficiency.
In this article, we have covered silent reflux, its symptoms, and root causes as well as the treatment protocol that I applied to eliminate my reflux. I hope sincerely that this information will help you greatly on your personal journey to eliminate this terrible disease!
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