1st Corollary – Conflicting elements are held together by function & purpose

•   •   •

2nd Axiom – Decompensation is preceded by often ignored warning signs

2nd Corollary – During early destabilization, imbalance is assessable

•   •   •

3rd Axiom – Last straw principle: When threshold is exceeded, collapse occurs

3rd Corollary – Recovery requires stabilization and repair of all essential elements

There is pepsin in Barrett's (IHC shown)

Identify – Treat – Drop the Acid

Acid reflux is epidemic today, and it is the cause esophageal cancer, which has become the fastest growing cancer in the United States. It has increased 850% since the 1970s!

Reflux affects 125 million Americans 22% with typical esophageal reflux, the symptoms of which are heartburn and indigestion, and another 18% with airway reflux, the symptoms of which are hoarseness, post-nasal drip, chronic cough, asthma, sinusitis, lump-in-the-throat sensation, and difficulty swallowing. Sometimes airway reflux is called “silent reflux” or “LPR” (laryngopharyngeal reflux).

Remember, our goal here is not just early detection of cancer, but rather cancer prevention. For this, there are three key steps for people with reflux symptoms: (1) esophageal screening to indentify those at risk for developing esophageal cancer (EC); (2) effective medical treatment; and (3) long-term, antireflux dietary (and lifestyle) modification, which means truly healthy eating—with the addition of a couple of supplementary esophageal superfoods. And yes, healthy eating appears to be the single most important factor in EC prevention.

STEP I: Esophageal Screening for People with Any/All Reflux Symptoms

It is important to note that people with airway reflux, even without any heartburn, are at equal risk to develop esophageal cancer and its precursor, Barrett’s esophagus. Indeed, today about 8% of people with reflux have Barrett’s. That converts to over ten (10) million people. All of these people need early screening examinations of the esophagus by transnasal esophagoscopy (TNE). TNE is quick, well-tolerated by people, and requires no sedation. It is done in the doctor’s office, and right after this kind of endoscopy, people can return to normal activity. And yes, it is as effective as sedated endoscopy (EGD) to diagnose trouble in the esophagus (www.TransnasalEsophagoscopy.com).

There may come a time when all adults should have routine TNE esophageal screening, but in the meanwhile, at present we recommend that all people with esophageal and airway reflux symptoms undergo TNE examinations. Then, people who are found to have Barrett’s esophagus (EC pre-cancer), pre-Barrett’s (an irregular Z-line), and esophagitis are all at risk for the development of EC; and therefore need to be on antireflux medication and learn about esophageal health. What does esophageal health mean? It’s a low-acid, low-fat, pH-balanced diet.

When we do a TNE, we may or may not perform a brush biopsy to get preliminary histologic information. If there is any question about the findings, the diagnosis, or the biopsy on TNE, we send the patient to a gastroenterologist for EGD with Seattle Protocol biopsy and potential ablation if in fact there is dysplasia, especially high-grade dysplasia.  (See also, Save Money: Throw Out the Baby.)

STEP II: Effective Medical Treatment

For people who have airway reflux, we almost always recommend twice-daily (before breakfast and before the evening meal) PPIs (proton pump inhibitors), such as Prilosec, Protonix, and Nexium, as well as an H2-antaonist, such as Zantac, before bedtime. Sometimes this regimen is called “maximum” medical treatment. Meanwhile, we recommend this dosing for any patient with Barrett’s esophagus or an irregular Z-line (pre-Barrett’s).

The visual in the ads on television that show little acid pumps (in the stomach) giving up at the sight of a purple pill simply isn’t so. None of the acid-suppressive medications, regardless of dose, actually turns the acid off. At best, it cuts the acid in half. That is why we recommend the higher dose for really “at risk” people, at least at the beginning of the treatment program. The idea is to try and produce around the clock acid suppression. Most of the drugs that claim that once-daily is enough actually work well for about sixteen hours. What about the other eight?  By the way, “beginning of the treatment program” usually means 6-12 months or until the tissue heals.

STEP III: Healthy Low-Acid Low-Fat Eating

It may come as a surprise to you, but what you eat may be eating you. Here’s the scoop. When you reflux, acid and pepsin (the powerful digestive enzyme of the stomach) comes up. When the pepsin attaches itself to your tissues (in your throat, esophagus, lung, etc.), then it’s off to the races. Pepsin is the cause of tissue damage. The clincher is that pepsin requires acid to activate it. In other words, without acid, pepsin can’t wreak its havoc.

In the last few years, we have discovered that acid in the foods and beverages that we consume causes most of the trouble. The single greatest risk factor for the development of reflux disease is the consumption of soft drinks. According to the American Beverage Association, in 2010 the average 12-29-year-old consumed 160 gallons of soft drinks; that is almost one-half gallon per day; and all are very acidic. BTW, I recently diagnosed Barrett’s in two 28-year-old heavy soda-drinkers. Barrett’s used to be a problem only seen in middle-aged people.

Does diet make a real difference? We are now seeing reversal (cure) of biopsy-proven Barrett’s esophagus in some of our patients. What does it take? (1) maximum antireflux treatment (all the meds); (2) a strict low-acid, low-fat, pH-balanced diet; (3) alkaline water (Evamor is the very best and is recommended); and (4) Manuka honey twice a day (after breakfast and before bed).

Our book is Dropping Acid: The Reflux Diet Cookbook & Cure. Our reflux diet is the healthiest, most sustainable diet in the world. It is like an extension of the healthy-heart diet that emphasizes the additional element of low-acid. This, we believe, is the key to esophageal health.

Next: The Four Phases of Dr. Koufman’s Low-Acid Barrett’s Diet

Barrett's esophagus as seen by transnasal esophagoscopy (TNE)

Esophageal screening by Transnasal Esophagoscopy (TNE) will provide better healthcare for Americans at a much lower cost.

The Reuter’s article, Special Report: Cancer screening feeds overdiagnosis debate, by Frederik Joelving (April 20, 2012) contains erroneous premises and incorrect information so that its conclusions are all wrong. It appears that Joelving would like to throw the baby out with the bath water! Here are the facts:

• Acid reflux is epidemic, and reflux-caused esophageal cancer—having increased 850% since the 1970s—is now the fastest growing cancer in America … by far.
• Acidity in the American diet is the cause of the reflux epidemic, and proper dietary treatment for reflux is highly effective. Reflux disease can be reversed!
• People with airway (“silent”) reflux—with hoarseness, chronic cough, and breathing difficulties (including asthma)—are more likely to have esophageal cancer and precancer (Barrett’s esophagus) than people with typical acid reflux with heartburn and indigestion.
• People with both esophageal and airway reflux should have esophageal screening examinations by TNE.

  Reflux and Reflux-Related Esophageal Cancer is Epidemic

  The prevalence of acid reflux disease has increased dramatically in our lifetimes.^1-6 Analysis of 17 prevalence studies showed that the rate of growth of reflux disease has been 4% per year since 1976.² In the last decade alone in ENT (ear, nose and throat) practice, office visits for reflux increased 500%.³

  In 2010, we estimated the prevalence of reflux (GERD and LPR) in America by interviewing 656 people waiting to purchase discount theater tickets (at TKTS) in Times Square in New York City.^1,5 The data revealed that an astonishing 40% (262/656) of the study group had reflux disease with 22% (144/656) classic esophageal reflux (aka GERD, gastroesophageal reflux disease) and another 18% (118/656) with silent (airway) reflux (aka LPR, laryngopharyngeal reflux).⁶ The most striking and unanticipated result was that 37% of the 21-30 year-old age group had reflux.⁵ In the past, reflux was primarily a disease of overweight, middle-aged people. But now we are finding that many of our reflux patients are neither old nor obese.⁷

  An even more ominous trend is that the prevalence of esophageal cancer in the United States has increased 850% since 1975.^1,4 During this same time period its mortality (deadliness) has increased seven-fold.⁵ In addition, the prevalence of esophageal precancer (Barrett’s esophagus) is also increasing, and it is just as high in people with hoarseness, sore throat, and chronic cough as it is in people with heartburn and indigestion.⁸

  In addition, today, asthma is very often overdiagnosed and misdiagnosed. The author (JK) recently reported a series of patients with a chief complaint of chronic cough for 10 years and found that reflux was mistaken for asthma by physicians 80% of the time.⁹ (If you have “asthma,” and if during breathing attacks you have more trouble getting air “in” rather than “out” (wheezing), you don’t have asthma; you have reactive airways disease because of reflux.)

  Dietary Acid May Be the Missing Link

  Coincident with the reflux epidemic, the American diet has changed dramatically.^1,10 Since the 1960s, there have been four parallel unhealthy dietary trends: (1) increased saturated fat, (2) increased high-fructose corn syrup, (3) increased exposure to organic pollutants (e.g., DDT, PCBs, dioxins), and (4) increased acidity.¹⁰ The last of these trends—increased dietary acid—may hold the key to understanding the contemporary reflux epidemic and the dramatic increases in Barrett’s esophagus and esophageal cancer.

  In 1973, following an outbreak of food poisoning (botulism), Congress enacted Title 21, mandating that the Food and Drug Administration (FDA) assure the safety of processed food crossing state lines by establishing “Good Manufacturing Practices.”^1,10-12 How was this accomplished? Through acidification of bottled and canned foods, intended to prevent bacterial growth and prolong shelf life. Today, almost all food that is bottled or canned is pH <4.^11-13

  Today, in the office, I saw a woman from Seattle whom I had first seen a year ago. She had originally come to see me because she knew that I would help her find the best diet for her Barrett’s esophagus with the idea that it might be reversed. (She had been previously diagnosed, biopsy-proven Barrett’s, by a gastroenterologist shortly before coming to see me.)  I knew that pepsin was produced in Barrett’s, and I knew that a low-acid diet was likely to be beneficial. So today, my patient showed me a recent endoscopy/biopsy report from her gastroenterologist: Now a year later, her Barrett’s was gone. How? Low-acid, low-fat, pH-balanced eating with Manuka honey (t.i.d.) and alkaline water. FLASH: Barrett’s esophagus reversed by healthy diet!  In other words, this patient chose lifestyle and dietary modifications over ablation — she had no procedures for her Barrett’s — with the best possible result.

  Connect the dots. While it may sound like a conspiracy theory; it is true. Dietary acid appears to be the primary factor in the prevalence, mechanisms, manifestations (including cancer), and outcomes of reflux disease. Until now, it appears that fundamental nutritional questions related to how food has been preserved for the last two generations may have been overlooked.^1,10,13 In the meanwhile, the proof of the pudding is that people with reflux disease, including some with Barrett’s esophagus, significantly benefit from a low-acid diet. Contrary to popular belief, reflux disease is reversible.^1,10

  Who Should Be Screened for Esophageal Cancer?
  

  Last month alone, I found Barrett’s esophagus in two refluxers in their 20s. Reflux used to be a disease of people in middle age. Not any more. Now, we are seeing advanced disease in young people, and in thin people, too. It’s no longer a disease of just the obese. In fact people with airway reflux tend not to be overweight. But here is a statistic for you: In 2010, the average 12-29-year-old American consumed 160 gallons of acidified soft drinks, almost a half-gallon per person per day (American Beverage Association data).

  I recently reported that a staggering 63% of patients with chronic cough had significant esophageal pathology, including 47% with esophagitis and 8% with Barrett’s.⁹ The problem with reversible-by-healthy-diet reflux disease is that it needs to be properly diagnosed to be properly treated.^1,9,10

  Today, 40% of Americans have reflux (22% with esophageal reflux another 18% with airway reflux). If any disease needs screening it is reflux. The introduction of transnasal esophagoscopy (TNE) a decade ago provided an important advance in the care of patients with reflux, dysphagia (swallowing problems), and esophageal pathology.¹⁴ The TNE endoscope offers brilliant illumination, excellent image quality, and the capability to obtain biopsies. TNE is inexpensive, well-tolerated by the vast majority of patients, though it is performed in a comfortable, seated, awake patient who can walk out the door as soon as the procedure is complete.

  The esophageal examination test that is expensive and wasteful is EGD (esophagogastroduodenoscopy) under aesthesia, and not TNE, but some medical specialists have a huge financial stake in maintaining the status quo of EGD. Last year in the U.S., 10 million sedated EGDs were performed at a “facility fees” cost of $10 billion (and that doesn’t include physician fees or biopsies).

  TNE is one of the most important and cost-effective advances in the diagnosis and prevention of serious disease in the past decade. Who should have it? The 100 million Americans with reflux. It is foolish to lump TNE with any other screening tests that have low yield and high cost. Save the baby!

  References

  1. Koufman JA. Low-Acid Diet for Recalcitrant Laryngopharyngeal Reflux: Therapeutic Benefits and Their Implications. Ann Otol Rhinol Laryngol 120:281-87, 2011.

  2. El-Serag HB. Time trends of gastroesophageal reflux disease: A systematic review. Clin Gastroenterol Hepatol 2007;5:17-26.

  3. Altman KW, Stephens RM, Lyttle CS, et al. Changing impact of gastroesophageal reflux in medical and otolaryngology practice. Laryngoscope 2005;115:1145-53.

  4. Pohl H, Welch HG. The role of overdiagnosis and reclassification in the marked increase of esophageal adenocarcinoma incidence. J Natl Cancer Inst 2005;97:142-6.

  5. Conio M, Blanchi S, Lapertosa G, et al. Long-term endoscopic surveillance of patients with Barrett’s esophagus. Incidence of dysplasia and adenocarcinoma: A prospective study. Am J Gastroenterol 2003;98:1931-9.

  6. Koufman JA, VanHorn G. The Prevalence of Reflux in America—The Times Square Study. (Unreported data), 2010 (manuscript in prepartion).

  7. Halum SL, Postma GN, Johnston C, Belafsky PC, Koufman JA. Patients with isolated laryngopharyngeal reflux are not obese. Laryngoscope 2005;115:1042-5.

  8. Reavis KM, Morris CD, Gopal DV, Hunter JG, Jobe BA. Laryngopharyngeal reflux symptoms better predict the presence of esophageal adenocarcinoma than typical gastroesophageal reflux symptoms. Ann Surg 2004;239:849-56.

  9. Koufman J. Diagnosis and management of non-pulmonary chronic cough. Presented at the annual meeting of the American Broncho-Esophagological Association, April 19, 2012, San Diego, CA (submitted to the Annals of Otology, Rhinology & Laryngology).

  10. Koufman JA, Stern JC, Bauer MM. Dropping Acid: The Reflux Diet Cookbook & Cure. Reflux Cookbooks LLC (Brio Books), Minneapolis MN, 2010.

  11. “Acidified Foods.” Code of Federal Regulations—Title 21—Food and Drugs Chapter I, Department of Health and Human Services Subchapter B—Food for Human Consumption Part 114. United States Food and Drug Administration. Arlington, VA, Washington Business Information, 2010.

  12. “Generally Recognized as Safe Food Additives: FDA Database of Selected GRAS Substances.”  United States Food and Drug Administration. National Technical Information Service, Springfield, VA, 2009.

  13. “Food Safety: FDA Should Strengthen Its Oversight of Food Ingredients Determined to Be Generally Recognized as Safe (GRAS).”  GAO-10-246: United States Government Accountability Office, February 3, 2010.

  14. Amin MR, Postma GN, Setzen M, Koufman JA. Transnasal esophagoscopy: A position statement from the American Broncho-Esophagological Association. Otolaryngol Head Neck Surg 2008;138:411-3.

Thursday, March 7, 2012. I’ve experienced something unique this year, both my personal experience and in my medical practice, in my patients. I’ve been calling it the “never ending virus” for two month already. Here is my personal case history:

In mid-December I felt that I was coming down with an upper respiratory infection (URI), with excessive sneezing, a runny nose, and fatigue. Just before Christmas, about a week after the onset of the first symptoms, I developed a terrible dry cough. Five days after that when I arrived in Florida for a golf holiday, I found myself sick in bed with what seemed like the flu, but without fever, and a terrible cough. The malaise was so severe I got out of bed only to go to the bathroom, drink water, eat cereal, or soup. On the third day in bed, I developed right maxillary sinusitis (with fullness and pain in my face and teeth). With effort I made it to the drug store to pick up an antibiotic, and thankfully, the sinusitis resolved within a few days. After four days in bed, and oh yes, drinking Nyquil like it was water, on the last day of my holiday vacation, I got up feeling weak and dizzy, and looking the mirror it looked like I’d lost a significant amount of muscle mass.

The next week (back at work), I was exhausted. The following week the cough got worse again, and it was keeping me from sleeping. The fatigue was difficult and I saw my doctor, who on chest auscultation (examination) thought that I might have pneumonia. So, he put me on Levaquin, a strong antibiotic. My lungs cleared quickly, but I went straight downhill having had a serious side-effect of the Levaquin, one that involved all my muscles and joints. I even got fluid in my knee. Moving and walking was difficult, but I continued to work. I was concerned about the Levaquin complication because I did not know how long it would take for my joints to get better. (Now six weeks later, my joints are fine except for my left knee that remains rather stiff.)

At the end of January I was feeling pretty good except for my joints, when all of a sudden, it began all over again. I developed the same URI with sneezing, copious rhinorrhea (runny nose), and cough.  I thought that one developed immunity from a virus after a URI; nevertheless, I felt that I was starting my fourth recrudescence. It took about ten days for it to subside, and this time no complications. By mid-February I was back to my normal self with good energy. But again one day, I again began coughing with sneezing and runny nose all over again. This came and went in two days. Meanwhile, through the month of February I was using an allergy nasal spray thinking it might be allergies, but it is not allergy, this strange affliction.

To set my illness in perspective: M 29-year-old daughter had this URI with severe cough for six weeks, not unusual for a viral URI. My sister has had a similar on and off again respiratory infection for a three months now; and recently, David Letterman (with apparent nasal congestion) announced, “I’ve had a cold for five months now.”

Now come my patients. Today, I saw a 25-year-old man with symptoms of an on-again-off-again URI for a month. On examination, his entire nose and throat looked like a severe respiratory URI with mucus of varying viscosity everywhere. The watery stuff was dripping down from above, like a waterfall, and there was thick, white, almost Elmer’s-glue-like mucus on the pharynx, and the entire larynx (voice box) was swollen with watery edema. And there was  and mucus everywhere. That is the pattern of an acute upper respiratory infection, but young people don’t get sick for 4-6 weeks. Another strange thing, I have some singers coming in with no real symptoms except for mild hoarseness who appear to have findings of a rip-roaring URI; see below.

Findings: thick and thin mucus, diffuse inflammation (redness and granularity of all the nose/throat tissue)

Furthermore, many of my patients shared my experience of getting well, only to have full blown recrudescences (this terrific word means “breaking out anew”). Different people’s manifestations of this NEVER-ENDING VIRUS tend to remain constant for each individual, meaning that the on-again-off-again-on-again pattern is usually with the same symptom complex in each person. (I was the only person I know who developed typical URI symptoms, then sinusitis, then pneumonia.) Most people with this URI either do or don’t develop cough.

I’ve spoken to colleagues in internal medicine and expressed concern about “the never-ending virus,” but I have not gotten any answers. Here is why I am concerned. Usually after a URI one has immunity; you don’t get the same virus back again just after it’s over. That just doesn’t happen in my experience, but that is what is happening this year. It’s almost as though the virus in our community this year does not confer immunity against itself. Of  concern is the question of why?  Why doesn’t the immune system banish this virus by producing antibodies after the infection? Instead, it comes back again and again like a bad penny. I am posting this because I am interested in other people’s experience, particularly people who work in the fields of infectious disease and immunology.

In conclusion, the URI virus in our community this year does not follow a recognized pattern; the usual post-URI immunity seems to be lacking. Of course the big question is might this NEVER-ENDING VIRUS be different? Could it possibly be altering the immune system in some pernicious way? Would that not explain its bizarre recurring pattern?

Final note: Yesterday I was sneezing and coughing again, and now I must say I’ve had this NEVER-ENDING VIRUS for a full two months. HELP!

The Never-Ending Virus is “SILENT” in Some Patients

Today, a patient with laryngopharyngeal (airway) reflux came in saying that her reflux symptoms (chronic throat clearing, a sensation of a lump in the throat, sore throat and hoarseness) were much worse. When I examined her I found the same evidence of an acute URI that I described above; however, she didn’t think that she was sick. (The photos from her exam are shown below.) This is a “silent: URI? The whole thing here is very odd!

Click on the picture to see it in greater detail: the mucus is like glue!

Have you ever wondered why there are so many different (medical) terms for acid reflux?  There are so many terms because different  medical specialist groups use different terms that they invented to describe their viewpoints.  The table below shows the most common ones.

Most Common Medical Terms for Acid Reflux
Gastroesophageal reflux disease (GERD)
Laryngopharyngeal reflux (LPR)
Gastro-oesophageal reflux disease
Extraesophageal reflux disease
Supraesophageal reflux disease
Esophago-pharyngeal reflux
Gastropharyngeal reflux
Atypical reflux disease
Esophageal erosions
Barrett’s esophagus
Reflux esophagitis
Reflux laryngitis
Silent reflux
Esophageal reflux
Airway reflux

Reflux is like the elephant in the famous tale of the three blind men and the elephant: The first blind man, feeling the leg of the elephant, exclaims, “I can see it clearly; the elephant is like a tree.” The second blind man holds the trunk and says, “No, the elephant is like a very large snake.” The third blind man grasps an ear. “Aha, you are both wrong,” he says. “The elephant is rather like a giant leaf.” Each of the blind men embraces a part of the truth, but none understands its entirety.

In the case of reflux, the three blind men are represented by three medical specialties, each one focusing on a different part of the aerodigestive tract: (1) The otolaryngologist (ENT physician) specializes in the ears, nose, and throat; (2) the gastroenterologist (GI physician) specializes in the esophagus (the swallowing tube that connects the throat with the stomach); and (3) the pulmonologist (PUL physician) specializes in the lungs. Many other medical specialties encounter patients with reflux as well, including internists, family practitioners, pediatricians, and critical care specialists.

GIs are unfamiliar with the signs and symptoms of airway reflux, but they insist on using diagnostic tests designed for esophageal reflux to evaluate airway reflux, because that’s what they know and understand.

Many gastroenterologists make their livings performing sedated endoscopies, mainly  esophagoscopy (aka EGD, esophagogastroduodenoscopy) and colonoscopy. This involves intravenous sedation, recovery, and it is sometimes associated with serious (even life-threatening) complications.

Sedated EGD is overkill for screening the esophagus for pathology such as Barrett’s in patients with acid reflux. We recommend transnasal esophagoscopy instead. Transnasal esophagoscopy (TNE) can be done in the doctor’s office without sedation, with comfort, and without complications.  Is TNE new? Not really. At the Voice Institute of New York, we have been performing TNE routinely for more than a decade. Gastroenterologists, however, have been reluctant, or at least slow, to embrace this technology. Why?

Last year, there were 10,000,000 sedated endoscopies done in the United States by approximately 10,000 gastroenterologists (GIs). If every GI did endoscopy (which they don’t), then each would have performed 1,000 last year,  that is, 20 per week or 4 per day.

The “facility fees” alone for sedated endoscopy were $10,000,000,000, that’s right, $10 billion!  The average facility fee for endoscopy last year was $1,000. And that’s just the fee that the endoscopy facility received; this does not include the doctors’ professional fees. Do the math; if the GI doctor owned her/his endoscopy facility, and many are owned by groups of GIs, the take “facility fee” take-home would be $1,000,000, that is $1,000 per X 1,000 procedures). GI doctors appear to have a significant conflict of interest in favor of sedated EGD procedures.

When GIs perform sedated EGDs, usually they do not examine the throat. Indeed, the endoscope is usually passed blindly, that is, without viewing the path into the esophagus. This is one of the reasons that GIs do not recognize airway reflux. By the way, it is time to stop using all those different terms for acid reflux. It now makes sense just to use two: ESOPHAGEAL REFLUX and AIRWAY REFLUX.

Patients with Airway Reflux DO NOT Usually Have Esophageal Reflux

We have published articles examining how ineffective GI diagnostics were in patients with airway reflux. We found that 80% of patients with airway reflux did not have esophageal findings of reflux. This is because the airway is 500 times more susceptible to damage from reflux than the esophagus. The latter organ is robust by comparison so that the acid/etc. can pass through the esophagus quickly and then do damage to structures in the airway. In addition, we found that the positive predictive value of esophageal (only) reflux (pH) monitoring in patients with airway reflux was 49%.  Would you get a test that got it right less than half of the time?  And impedance testing isn’t much better.

GIs also do not understand the importance and impact of diet in people with airway reflux. A month ago, I had a patient come see me from Oregon. She had airway reflux, and I started her on the Reflux Induction Diet and antireflux medication. A few days ago she returned dramatically improved. “Your reflux diet makes all the difference in the world,” she reported; then she added, “I went back to my GI and told him what happened, and you know what he said?  ‘I have reflux too, but I don’t want to change my diet; I love burgers and fries and all … so I take pills and they help’.”  After that interaction the patient confided that she wouldn’t be seeing that GI doctor ever again.

Almost One in Five Americans Have Airway Reflux

In the Time Square Study, we found that 22% of Americans had esophageal reflux and 18% had airway reflux. Not surprisingly, many of the people with airway reflux had “silent reflux,” meaning that they suffered acid reflux without heartburn or indigestion. These numbers are a wake-up call. It is time to recognize that airway reflux is common, important, and still under-diagnosed and under-treated. What are the symptoms?

Symptoms of Airway Reflux
Hoarseness
Chronic cough
Choking episodes
Difficulty swallowing
Lump-in-the-throat sensation
Food and/or pills getting stuck
Too much throat mucus
Chronic throat clearing
Shortness of breath
Post-nasal drip
Sore throat
Sinusitis
Asthma

“Asthma” is a very interesting presenting symptom in my clinic. True asthma is characterized by wheezing, trouble getting air out. About 8% of people with airway reflux have reactive airway disease, including laryngospasm, paradoxical vocal fold movement, and pseudo-asthma. With reflux, patients have difficulty getting air in (not out), and they almost always know the difference.

“When you have an ‘asthma’ attack, do you have more trouble getting the air in or out,” I ask, and 90% my patients respond “IN” without hesitation. Most people with adult-onset asthma actually have reflux-related reactive airways disease, and  when the reflux is effectively treated, the “asthma” usually disappears. The same is true of chronic cough symptoms; most are due to reflux.

At present, ENT (ear, nose, and throat) doctors are the ones to see for people with airway reflux, not gastroenterologists. Here is a slight but important paradox: Endoscopy (esophagoscopy, TNE) is not how you diagnose airway reflux. That takes a throat examinations and sometimes special (pH) testing. If one has reflux, however, a screening endoscopy should be performed to rule-out significant esophageal disease. We now know that people with airway and esophageal reflux have a similar incidence of esophageal cancer and pre-cancer. Silent reflux causes just as much cancer and the non-silent type.

Meanwhile, what is missing? What is needed?  In a way, the biggest problem with airway reflux is that most physicians, even those who recognize its symptoms, don’t have a way to confirm the diagnosis. At the Voice Institute of New York, we do special airway reflux testing, and we are now working on two new diagnostics for airway reflux; see www.KoufmanReflux.com. The first is a spit-in-a-cup screening test (similar to a pregnancy test) that detects pepsin, the principle enzyme of the stomach. Pepsin is only made in the stomach so that if a person has detectable pepsin in their spit, they have acid reflux (either airway or esophageal reflux). In preliminary testing, the spit test for pepsin is approximately 90% accurate.  This is terrific for a screening test. We hope that we can have the test, known as Koufman Reflux Test Strips (YouTube video) on the market by the summer of 2012. It will help physicians and their patients by making the right diagnosis.

Also under development by Koufman Diagnostics, is a definitive,  turn-key, airway reflux pH testing system that may be employed by any physician regardless of medical specialty (e.g., pulmonology, gastroenterology, otolaryngology, family practice) to make a definitive diagnosis of airway (and/or esophageal) reflux. The system uses ambulatory pH-monitoring technology with foolproof probe-placement and a software that makes interpretation foolproof.  This test is also coming this year.

If you think you have airway reflux, see an ENT doctor, or come see me here at The Voice Institute of New York.  Also, the book,  Dropping Acid: The Reflux Diet Cookbook & Cure, may help.

]]> http://www.jamiekoufman.com/2012/02/02/why-most-gastroenterologists-just-don%e2%80%99t-understand-airway-reflux-at-all/feed/ 1 http://www.jamiekoufman.com/2011/11/30/the-silent-reflux-epidemic/ http://www.jamiekoufman.com/2011/11/30/the-silent-reflux-epidemic/#comments Thu, 01 Dec 2011 04:02:34 +0000 Jamie A. Koufman, M.D., F.A.C.S. http://www.jamiekoufman.com/?p=529

It’s pernicious!

And you probably have it, because 125 million people do. Half don’t even know they have it, and their doctors don’t know it either. Millions of Americans have undiagnosed and untreated acid reflux, sometimes for years or even life-long. How could this be? Because too-specialized medical specialists can’t see the reflux forest for the trees; because many millions have “silent reflux”; and because the role of one particular food additive, ACID. Indeed, acid in food has been overlooked as a cause of massively widespread and uncontrolled airway reflux. The latter, airway reflux, is a term for stomach juice backflow into the breathing passages, including the ears, nose, throat, and lungs.

Reflux is increasing so rapidly that one wonders if we all will have it soon. Since the 1970’s, prevalence of reflux has increased an average of 4% per year. Reflux is now epidemic, affecting 40% of the American population. Twenty-two percent have GERD (gastroesophageal reflux disease) with heartburn and indigestion, and another 18% have silent reflux, also called LPR or laryngopharyngeal reflux.

A frightening implication of this increase is that millions of Americans may be at risk for the development of reflux-related cancer. That’s right—reflux causes cancer! During this same period of time, the prevalence of esophageal cancer has increased 850% and now is the fastest growing cancer in the U.S. In addition, as many as 10% of people with reflux symptoms have Barrett’s esophagus, a reflux-caused, pre-cancerous condition.

So why do we have a reflux epidemic? ACID! It now seems likely that the primary cause of this reflux/cancer epidemic can be traced to acidification of foods/beverages, which until now has been virtually ignored as a problem. In 1973, following an outbreak of food poisoning, Congress enacted Title 21 and charged the FDA (Food and Drug Administration) with providing “Good Manufacturing Practices” to insure that bottled and canned foods and beverages crossing state lines would not be contaminated by bacteria. Thus, for two generations, almost everything bottled and canned has had acid added to discourage bacterial growth and prolong shelf-life. After all this time, it appears that the most dangerous food additive of all may have been simply overlooked.

Recognizing and understanding “silent reflux” is crucial. The symptoms of reflux are not just digestive—like indigestion and heartburn (chest pain after eating)—they also include hoarseness, chronic cough, post-nasal drip, a lump-in-the-throat sensation, difficulty swallowing, choking episodes, shortness of breath, sinusitis, and asthma. If you have any of those symptoms, you probably have silent reflux. The term “silent” is derived from the observation that the reflux (backflow from the stomach) can easily be overlooked if it occurs at night while people are asleep or during the day in small amounts with no heartburn. It just may go unnoticed.

Remember, if you have unexplained or mysterious throat, breathing, airway, or digestive symptoms, think of silent reflux. The dots are now connected: The reflux and esophageal cancer epidemics are related to too much acid in our foods and beverages. BTW, the average 12-29-year-old in the United States consumed 160 gallons of soft drinks last year; that’s almost a half-gallon a day! We must have a national dialog about not only reflux and unhealthy eating but about food additives, especially ACID, and also about how we preserve food.

If you have reflux, you personally must become active, because this must be a grass roots movement. It is the role of government to protect its people; and we the people have gotten reflux and cancer from the unintended consequences of acid in our food. I believe that the end game is clear. If we insist on having FDA-mandated acidity (pH) on all food and beverage labels, the American people will solve the reflux/cancer problem for themselves.

Nov. 8, 2011 New York Times Articles by Tara Parker-Pope: Tired of the Burn? Low-Acid Diet May Help and A Heartburn-Free Thanksgiving

The figure at the top of this post is a biopsy of Barrett’s esophagus, the reflux-related, precancer. This specimen is stained in a special way, using IHC (immunohistochemistry) for human pepsin. This photo shows that pepsin is produced in Barrett’s. The implications of this have a bearing on the potential importance of long-term low-acid diet in people with Barrett’s.  In other words, dietary acid can activate the pepsin. Indeed, although only anecdotal at this point, the author has seen the regression of Barrett’s in some of her patients on a long-term low-acid diet. This is an exciting new conceptual breakthrough!

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FIX HEALTHCARE & HEAL THE NATION (see Dr. Koufman’s CV)

Click the title above to view the slide show (which may be viewed full screen by clicking the expand icon on the bottom-right of the slide).  There are 40 slides in the show. The synopsis is below and the accompanying manuscript is in preparation.

Synopsis

Most Americans clearly favor free-market systems, but in healthcare we don’t have a free market. “Capitalism” can not fix the healthcare crisis because for-profit medicine is intrinsically unethical. Indeed since the 1970s, market forces have evolved a dangerous, powerful, and self-perpetuating corporate behemoth. The transformation of healthcare has been driven by market power over prices—due to price inelasticity of demand—and perverted (hegemonic) investment strategies.

The American “medical-industrial complex” can itself be likened to a cancer that will soon outgrow its own blood supply and die. The two choices appear to be national healthcare or national bankruptcy. Creation of an actual National Health Service would bolster economic development, reboot rational markets (creating competitive cost containment), and would form the cornerstone first tier of a rational (likely three-tier) healthcare delivery system.

Jamie A. Koufman, M.D., F.A.C.S., Director of The Voice Institute of New York was awarded the 2011 James E. Newcomb Award at the American Laryngological Association (ALA) during the recent 132^nd Annual ALA Meeting April 27th in Chicago, Illinois. This award, established in 1939, is given annually to a member of the Association in recognition of  outstanding contributions to research and the medical literature in the field of laryngology.

The list of distinguished past winners includes Dr. Chevalier Jackson, Dr. Joseph Ogura, Dr. John Kirchner, Dr. John Conley, Dr. Stuart Strong, and Dr. Gerald Healy.  The Newcomb Award has been likened to a “Lifetime Achievement Award” for research and publications in laryngology.

Presidential Address of Jamie A. Koufman, M.D., F.A.C.S.
American Broncho-Esophagological Association (President 2008-09)
Presented at the Annual Meeting of the Society, Scottsdale, AZ, April 29, 2009

Dear members and guests of the American Broncho-Esophagological Association, it has been my honor and pleasure to be president of this society. During this past year, among other things I have examined the advantages, disadvantages, and influences of medical specialization on healthcare in America with a particular focus on how this impacts our patients with aerodigestive tract symptom. The title of my talk is “Specialization: When Being the Best Isn’t Good Enough,” because I believe that medical over-specialization is a problem. Many complex patients have a committee of non-communicating doctors with no one doctor actually taking responsibility for the patient’s care. Here is a multiple choice question for your consideration that makes the point:

A 55-year-old school teacher has chronic cough and vocal fatigue since onset of symptoms with an upper respiratory infection in 1997. Which is the best doctor to diagnose and treat her problems?

A.  Pulmonologist
B.  Otolaryngologist
C.  Gastroenterologist
D.  Allergist
E.  None of the above.

With a normal chest x-ray, the patient’s primary care doctor sends the chronic cough patient to a pulmonologist for evaluation.  The lung doctor does a PPD, spirometry, bronchoscopy, and finds nothing. Thinking that the patient might have “atypical reflux disease” (laryngopharyngeal reflux, LPR), the pulmononlogist sends the patient to an otolaryngologist who examines the patient and concurs that the diagnosis may be LPR. So, the otolaryngologist refers the patient to a gastroenterologist who performs upper endoscopy, and finding a normal esophagus, declares the patient does not have reflux disease. The GI doctor speculates that the likely cause of the patient’s cough is allergy, and therefore, the patient is sent to an allergist-immunologist. The latter physician, finding no allergies, sends the patient back to the primary care physician. So, the correct answer to the question above is “E. None of the above.”

You may not know this, but chronic cough is one of the most common symptoms for which a patient seeks medical attention in the United States. Chronic cough patients, most often referred to me by gastroenterologists and pulmonologists, account for 20% of my practice. Indeed, in my experience, these patients are often passed from doctor to doctor; and even though they are referred to me for evaluation for LPR, not all of them have reflux, but the majority do. There are many patients who have reflux as the only cause of cough and those patients, even on proton pump inhibitors and other medications, may continue to have cough for as long as they reflux, even neutral-pH reflux. Such patients often will tell you that reflux is the cause of their cough. They may report, for example, that they have regurgitation when they bend over, that they cough after meals, and that they sometimes awake in the night from a sound sleep coughing violently and gasping for air.

In addition to LPR-related coughers, there is a significant group of patients who have “neurogenic cough,” which is a kind of “sick nerve syndrome” usually related to a post-viral vagal neuropathy (PVVN). People with PVVN and neurogenic cough usually have a history of having had an upper respiratory infection weeks, months, or years prior, around the time of the onset of symptoms.

The typical pattern of neurogenic cough is daytime (all day long), but not at night. Specific things like change in temperature (e.g., going from warm to cold), and certain odors (e.g., perfume, diesel fuel or gasoline smell) may precipitate cough. In addition, such patients often describe having a “hair trigger” cough, and that speaking or chuckling may precipitate coughing. When patients have cough associated with voice use, it is almost always a neurogenic cause. It is important to note that neurogenic and reflux-related cough patients form a very large population of patients, and that these patients are essentially without a doctor/specialist.

Specialization is a very America idea, in spite of the fact that it results in fragmentation of medicine; after all, everyone wants to see the “best.” So, you do actually get things like this inane example: “Yes, I’m the very best doctor in the country for doing a stapedectomy on the right ear for otosclerosis. And no matter; if you have similar trouble in your left ear, my partner who happens to be left-handed, is the best surgeon in the country for fixing otosclerosis of the left ear. Between us, we are the best if you have otosclerosis in either ear.”

The problem with patients who have symptoms like chronic cough or other reactive airway diseases is that the patients often don’t fit any of the specialists’ boxes. Just think about it for a moment: globus, dysphagia and many otolaryngologic symptoms cross both anatomic and medical specialty lines. And the concept that diseases fit within the boundaries of our medical specialties – nose/sinuses, throat, lung, esophagus – is preposterous. It would seem that the creation of certain medical specialties was predominantly for the convenience of physicians.

Reactive Airways Disease

Asthma
Allergic rhinitis
Vasomotor rhinitis
Paroxysmal laryngospasm
Paradoxical vocal fold movement
Vocal cord dysfunction (“VCD”)
Neurogenic (“neuropathic”) cough
Gastroesophageal reflux disease
Laryngopharyngeal reflux (“silent reflux”)

It is likely that allergic rhinitis, post-nasal drip, vasomotor rhinitis, paroxysmal laryngospasm, paradoxical vocal fold movement, asthma, and neurogenic cough are all manifestations of reactive airway disease and that reflux is a common feature in many patients. It is amazing to me how many patients have sinus disease and asthma related to LPR.

As I was flying out here for this meeting, I opened my New Yorker Magazine (dated June 1, 2009), and found an article, “The Cost Conundrum” by Atul Gawande. This was an amazing article and coincidence, and a real eye-opener. The bottom line: Overutilization of specialists was one of the main reasons for the high cost of healthcare in the United States. Here is essence of the story. In 2006, the median income for McAllen, Texas was $12,000; however, Medicare spent over $15,000 per enrollee in McAllen. In nearby El Paso County, which has similar demographics, only $7,000 per year was spent on each Medicare enrollee.

But by all contemporary metrics, McAllen’s health care was not as good as El Paso’s. Healthcare services in McAllen were found to be grossly overutilized. In McAllen, for example, if you had chest pain having eaten 16 tacos, instead of getting an antacid in the emergency room you might be admitted and end up having a cardiac workup including cardiac catheterization. If you had numbness of your fingers, you would probably end up having nerve conduction studies. As a matter of fact, overutilization also resulted in high rates of unnecessary surgery.

In McAllen, there was this complex medical network in which most patients went from doctor to doctor to doctor, having “all of the most advanced tests and treatments.” It was profoundly wasteful. Dr. Gawande concluded, “Someone has to be responsible for the totality of care; otherwise, you get a system that has no brakes.”

Integrated Aerodigestive Medicine

It is my belief that reactive airways disease is really just one complex syndrome and we as otolaryngologists need to be responsible for managing patients who have diseases of the nose, sinuses, and aerodigestive tract including the esophagus and lower airway. For us to defer to gastroenterologists and pulmonologists makes no sense whatsoever as many of our patients are not going to get effective treatment at the hands of those specialists.

We need to create a new “specialty” perhaps called “Integrated Aerodigestive Medicine.” This is not a new concept, the idea of a holistic approach to the management of patients with confounding symptoms. Its time has come. I urge you, my colleagues, to learn more about things like neurogenic pain, chronic cough, swallowing disorders, “asthma,” and reflux. These conditions are all within our domain.

It is also time for otolaryngologists to begin routinely assessing the aerodigestive tract using modern technology. When Chevalier Jackson invented modern endoscopy, over a hundred years ago, he did not accept limits based upon arbitrary anatomic subdivisions. He examined the esophagus and the lungs, larynx, and sinuses as though they were all part of the same system. They are. With the availability of distal chip technology, modern endoscopes allow complete evaluation of the aerodigestive tract, including biopsies, in the comfortably awake patient … in the office.  Manometry and reflux testing are also essential. These are all part of our specialty.

At present, esophageal cancer and precancer are epidemic, and it is our responsibility to screen our patients for potentially life-threatening neoplasia. As a matter of fact, attention to the lifestyle/dietary issues and needs of our patients also now needs to fall within our domain. It is time for otolaryngologists to become “integrated aerodigestive tract physicians” – otherwise we will continue to fragment our own patients’ medical care.

Recommended Reading

Gawande, Atul. The Cost Conundrum. New Yorker Magazine (June 1, 2009)

Koufman JA, Stern J Bauer M, “Science You Can Digest,” from Dropping Acid: The Reflux Diet Cookbook & Cure, pages 159-185, Brio Press, Minneapolis, 2010. ( Available on Amazon)

www.refluxcookbookblog.com (“The Missing Link”)

www.chronic-cough.net