How Many Hours After Eating Is Gerd Worst

πŸ”₯+ How Many Hours After Eating Is Gerd Worst 10 Jul 2020 How is reflux diagnosed? Your doctor will begin by discussing your symptoms. Not everyone who has an episode of reflux has GERD. Your ...

How Many Hours After Eating Is Gerd Worst Feeding patterns. Babies with reflux are often β€œsnackers,” eating frequently. They may fuss often and seem to be hungry, but feed briefly and poorly. They may ...

Surgery Of Acid Reflux
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How Many Hours After Eating Is Gerd Worst Treatments For (β˜‘ What Causes Heartburn) | How Many Hours After Eating Is Gerd Worst Causeshow to How Many Hours After Eating Is Gerd Worst for VANITA AHUJA, M.D., National Naval Medical Center, Bethesda, Maryland

MYRON W. YENCHA, M.D., Naval Hospital, Pensacola, Florida

LORENZ F. LASSEN, M.D., Naval Medical Center, Portsmouth, Virginia

Am Fam Physician.Β 1999Β SepΒ 1;60(3):873-880.

Β  See related patient information handout on gastroesophageal reflux disease, written the 1 last update 10 Jul 2020 by the authors of this articleSee related patient information handout on gastroesophageal reflux disease, written by the authors of this article.

Gastroesophageal reflux disease (GERD) is the most common esophageal disease. Besides the typical presentation of heartburn and acid regurgitation, either alone or in combination, GERD can cause atypical symptoms. An estimated 20 to 60 percent of patients with GERD have head and neck symptoms without any appreciable heartburn. While the most common head and neck symptom is a globus sensation (a lump in the throat), the head and neck manifestations can be diverse and may be misleading in the initial work-up. Thus, a high index of suspicion is required. Laryngoscopy can confirm the diagnosis of laryngopharyngeal reflux. Erythema of the posterior larynx may be seen, and the true vocal cords may be edematous. Treatment should be initiated with a histamine H2 receptor blocker or proton pump inhibitor. Lifestyle changes are also beneficial. Untreated, GERD can lead to chronic laryngitis, dysphonia, chronic sore throat, chronic cough, constant throat clearing, granuloma of the true vocal cords and other problems.

Gastroesophageal reflux is defined as the movement of gastric contents into the esophagus without vomiting. Laryngopharyngeal reflux is the movement of gastric contents into the laryngopharyngeal area. Gastroesophageal reflux disease (GERD) occurs when gastric contents irritate mucosal surfaces of the upper aerodigestive tract.

Pathophysiology of GERD

How Many Hours After Eating Is Gerd Worst List Of (πŸ‘ What Causes Heartburn) | How Many Hours After Eating Is Gerd Worst Diet Forhow to How Many Hours After Eating Is Gerd Worst for The primary barrier to gastroesophageal reflux is the lower esophageal sphincter, which is located at the level of the diaphragmatic hiatus and acts as the main deterrant to reflux1Β  (Figures 1a,1b and 1c). Other structures that may be involved in preventing reflux are the intra-abdominal segment of the esophagus, the gastroesophageal angle, the diaphragmatic crura and the phrenoesophageal ligament. Gastric motility also plays a role, with delayed emptying predisposing the patient to GERD. The upper esophageal sphincter consists mainly of the cricopharyngeal muscle and a small portion of the circular muscle fibers of the esophagus immediately distal to it. The upper esophageal sphincter is referred to as the pharyngoesophageal junction and serves as the main barrier in preventing laryngopharyngeal reflux.

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FIGURE 1A

Upper aerodigestive tract, demonstrating the anatomic narrowings (cricopharyngeus, aortic arch, diaphragmatic hiatus), upper esophageal sphincter (cricopharyngeus), lower esophageal sphincter and the relationship of the esophagus to the surrounding structures.


FIGURE 1A

Upper aerodigestive tract, demonstrating the anatomic narrowings (cricopharyngeus, aortic arch, diaphragmatic hiatus), upper esophageal sphincter (cricopharyngeus), lower esophageal sphincter and the relationship of the esophagus to the surrounding structures.

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FIGURE 1B

Upper esophageal sphincter area. Note that Killian''s area is located between the inferior pharyngeal muscle superiorly and the cricopharyngeal muscle inferiorly.

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FIGURE 1C

Lower esophageal sphincter area. Note that the lower esophageal sphincter is not a true sphincter for 1 last update 10 Jul 2020 but merely a zone of increased pressure.Lower esophageal sphincter area. Note that the lower esophageal sphincter is not a true sphincter but merely a zone of increased pressure.


FIGURE 1C

Lower esophageal sphincter area. Note that the lower esophageal sphincter is not a true sphincter but merely a zone of increased pressure.

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The pathophysiology of GERD in patients with gastrointestinal symptoms differs from that in patients with head and neck symptoms. Patients with gastrointestinal symptoms have esophageal dysmotility and dysfunction of the lower esophageal sphincter, whereas patients with head and neck manifestations have dysfunction of the upper esophageal sphincter but good esophageal motility.2 Patients with gastrointestinal symptoms usually experience esophageal reflux when they are supine, whereas patients with head and neck manifestations have laryngopharyngeal reflux during the daytime when they are upright. Interestingly, one study revealed that only 18 percent of patients with head and neck manifestations of GERD had esophagitis.2

Heartburn, the classic symptom of GERD, is common in patients with gastrointestinal symptoms but uncommon in those with head and neck manifestations. One study3 reported only a 20 to 43 percent incidence of heartburn in patients with head and neck symptoms.

Diagnosis

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The diagnostic work-up of patients presenting with symptoms of laryngopharyngeal reflux begins with a thorough history and a meticulous physical examination. Patients with laryngopharyngeal reflux present with symptoms related to the upper aerodigestive tract (Table 1). The most common symptom reported by patients is a “lump in the throat” (globus sensation). Studies35 have shown that in 23 to 60 percent of patients presenting with globus sensation, GERD is the etiologic factor.

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TABLE 1

Head and Neck Symptoms in Patients with GERD

the 1 last update 10 Jul 2020 AerophagiaAerophagia

Buccal for 1 last update 10 Jul 2020 burningBuccal burning

Cervical pain

Choking sensation

Chronic cough

Constant throat clearing

Dysphagia

Food sticking in throat

Globus sensation (the most common symptom)

Halitosis

Hoarseness (dysphonia)

Otalgia

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Sore throat

Water brash


GERD = Gastroesophageal reflux disease.

TABLE 1

Head and Neck Symptoms in Patients with GERD

Aerophagia

Buccal burning

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Choking sensation

Chronic cough

Constant throat clearing

Dysphagia

Food sticking in throat

Globus sensation (the most common symptom)

Halitosis

Hoarseness (dysphonia)

Otalgia

Pharyngeal tightness

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GERD = Gastroesophageal reflux disease.

Other symptoms include constant throat clearing (caused by increased secretions and irritation of the laryngeal mucosa); dysphonia (caused by edema or inflammatory lesions of the true vocal cords); chronic sore throat (often misdiagnosed as recurrent or chronic tonsillitis); coughing; cervical dysphagia (caused by dysfunction of the upper esophageal sphincter); halitosis; buccal burning; otalgia (explained by the common sensory innervation of the esophagus and external auditory canal by the 10th cranial nerve); food sticking in the throat; pharyngeal tightness; a choking sensation; aerophagia; and water brash (hypersalivation). Laryngopharyngeal reflux should be suspected in patients who present with any of these symptoms.

Although oropharyngeal (cervical) dysphagia can result from GERD, other causes must be considered, especially if this symptom persists despite adequate treatment for GERD. Of course, this principle applies to all of the symptoms listed above, since they can also have other causes.

LARYNGOSCOPY

How Many Hours After Eating Is Gerd Worst Reflux Disease (β˜‘ Which Foods To Avoid) | How Many Hours After Eating Is Gerd Worst Home Remedieshow to How Many Hours After Eating Is Gerd Worst for Indirect or direct laryngoscopy can be performed to confirm the diagnosis of GERD. Laryngoscopic findings suggestive of laryngopharyngeal reflux include the following: erythema of the arytenoid, interarytenoid area or laryngeal surface of the epiglottis; a cobblestone appearance of the interarytenoid area; edema of the true vocal cords; inflammatory lesions of the true vocal cords, such as granuloma and contact ulcer; and pooling of secretions in the hypopharynx (Figures 2,3,4a4a and 4b).

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FIGURE 2.

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FIGURE 2.

Photograph of the endolarynx, demonstrating arytenoid erythema and a small polyp of the left true vocal cord. (a = true vocal cord, b = false vocal cord, c = arytenoid, d = interarytenoid area, e = aryepiglottic fold)

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FIGURE 3.

Photograph of the endolarynx, demonstrating Reinke''s edema of the true vocal cords.

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FIGURE the 1 last update 10 Jul 2020 4AFIGURE 4A

Photograph of the endolarynx, demonstating a left true vocal cord granuloma (arrow) in the patient in illustrative case 2. (a = true vocal cord)


FIGURE 4A

Photograph of the endolarynx, demonstating a left true vocal cord granuloma (arrow) in the patient in illustrative case 2. (a = true vocal cord)

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FIGURE 4B

Photograph of the endolarynx immediately following excision of a left true vocal cord granuloma. (a = true vocal cord)


FIGURE 4B

Photograph of the endolarynx immediately following excision of a left true vocal cord granuloma. (a = true vocal cord)

Edema of the true vocal cords can range from mild to severe; severe edema has the appearance of polypoid masses. Vocal cord edema of this degree can result in severe dysphonia, stridor or airway compromise. The edema develops in the superficial layer of the lamina propria of the true vocal cords, also called Reinke''s edema. The presence of edema of the true vocal cords is highly suggestive of laryngopharyngeal reflux, even in the absence of laryngeal erythema.2

EMPIRIC THERAPY AND ADDITIONAL STUDIES

If the history and physical examination fail to uncover serious pathology, patients with suspected GERD may begin empiric therapy, which consists mainly of lifestyle modifications and drug therapy (Tables for 1 last update 10 Jul 2020 2(Tables 266 and 3)and 3). Further evaluation is required if patients do not respond to empiric therapy or if they present with recurrent GERD or its complications. Surgical intervention may be required in such patients.

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TABLE 2

Lifestyle Changes That May Help in the Treatment of GERD

Avoid fatty foods, caffeinated beverages (colas, coffee, etc.), chocolate, mint, spicy foods, tomato-based foods, garlic and onions

Stop smoking

Stop or decrease alcohol use

Lose weight if overweight

Elevate the head of the bed by placing 4- to 8-inch blocks under the bed posts at the head of the bed (adding additional pillows is insufficient)

Eat smaller meals

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Avoid eating within four hours of bedtime

Avoid recumbency within three hours of meals

Avoid medications that decrease the lower esophageal sphincter pressure (theophylline, anticholinergic agents, alpha-adrenergic antagonists, beta-adrenergic agonists, calcium channel blockers, nitrates)6


GERD = Gastroesophageal reflux disease.

TABLE 2

Lifestyle Changes That May Help in the Treatment of GERD

Avoid fatty foods, caffeinated beverages (colas, coffee, etc.), chocolate, mint, spicy foods, tomato-based foods, garlic and the 1 last update 10 Jul 2020 onionsAvoid fatty foods, caffeinated beverages (colas, coffee, etc.), chocolate, mint, spicy foods, tomato-based foods, garlic and onions

Stop smoking

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Lose weight if overweight

Elevate the head of the bed by placing 4- to 8-inch blocks under the bed posts at the head of the bed (adding additional pillows is insufficient)

Eat smaller meals

Avoid wearing tight-fitting clothes

How Many Hours After Eating Is Gerd Worst Remedies (β˜‘ GERD) | How Many Hours After Eating Is Gerd Worst Stops Acid Refluxhow to How Many Hours After Eating Is Gerd Worst for Avoid eating within four hours of bedtime

Avoid recumbency within three hours of meals

Avoid medications that decrease the lower esophageal sphincter pressure (theophylline, anticholinergic agents, alpha-adrenergic antagonists, beta-adrenergic agonists, calcium channel blockers, nitrates)6


GERD = Gastroesophageal reflux disease.

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TABLE 3

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DrugDosage the 1 last update 10 Jul 2020 Cost* (generic)Cost* (generic)

Histamine H2 receptor antagonistHistamine H2 receptor antagonist

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400 mg twice daily

$101 (76 to 79)

Ranitidine (Zantac)

150 mg twice daily

105 (89)

Famotidine (Pepcid)

20 mg twice daily

102

Nizatidine (Axid)

150 mg twice daily

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Mucosal cytoprotectantsMucosal cytoprotectants

Sucralfate (Carafate)

1 g four times daily

102 (82 to 86)

Cholinergic agentsCholinergic agents

Bethanecol (Urecholine)

25 mg four times daily

134 (7 to 9)

Prokinetic the 1 last update 10 Jul 2020 agentsProkinetic agents

for 1 last update 10 Jul 2020 Metoclopramide (Reglan)Metoclopramide (Reglan)

10 mg four times daily

88 (12 to 25)

Cisapride (Propulsid)

10 mg four times daily

89

Proton pump inhibitorsProton pump inhibitors

Omeprazole (Prilosec)

20 mg once daily

116

Lansoprazole (Prevacid)

30 mg once daily

108


* —Estimated cost to the pharmacist for one month of treatment, rounded to the nearest dollar, based on average wholesale prices in Red book. Montvale, N.J., Medical Economics Data, 1999. Cost to the patient will be higher, depending on prescription filling fee.

Adapted with permission from Fass R, Hixson LJ, Ciccolo ML, Gordon P, Hunter G, Rappaport W. Contemporary medical therapy for gastroesophageal reflux disease. Am Fam Physician 1997;55:205–12.

TABLE 3

Drug Therapy for Gastroesophageal Reflux Disease

DrugDosageCost* (generic)

Histamine H2 receptor antagonist

Cimetidine (Tagamet)

400 mg twice daily

$101 (76 to 79)

Ranitidine (Zantac)

150 mg twice daily

for 1 last update 10 Jul 2020 105 (89)105 (89)

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20 mg twice daily

102

Nizatidine (Axid)

150 mg twice daily

99

Mucosal cytoprotectants

Sucralfate (Carafate)

1 g four times daily

102 (82 to 86)

Cholinergic the 1 last update 10 Jul 2020 agentsCholinergic agents

Bethanecol (Urecholine)

25 mg four times daily

134 (7 to 9)

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for 1 last update 10 Jul 2020 Metoclopramide (Reglan)Metoclopramide (Reglan)

10 mg four times daily

88 (12 to 25)

Cisapride (Propulsid)

10 mg four times daily

89

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Omeprazole (Prilosec)

20 mg once daily

the 1 last update 10 Jul 2020 116116

Lansoprazole (Prevacid)

30 mg once daily

108


How Many Hours After Eating Is Gerd Worst Disease (πŸ”΄ Treatments) | How Many Hours After Eating Is Gerd Worst Acid Refluxhow to How Many Hours After Eating Is Gerd Worst for * —Estimated cost to the pharmacist for one month of treatment, rounded to the nearest dollar, based on average wholesale prices in Red book. Montvale, N.J., Medical Economics Data, 1999. Cost to the patient will be higher, depending on prescription filling fee.

Adapted with permission from Fass R, Hixson LJ, Ciccolo ML, Gordon P, Hunter G, Rappaport W. Contemporary medical therapy for gastroesophageal reflux disease. Am Fam Physician 1997;55:205–12.

Further work-up may include an esophagram, manometry, endoscopy, a modified Berstein''s edema, contact ulcer, contact granuloma, leukoplakia and carcinoma of the true vocal cords; and subglottic stenosis.2,3,712

Contact granulomas arise from the vocal process (cartilaginous posterior portion) of the true vocal cords and are considered an inflammatory response from injury to the underlying perichondrium. In addition to antireflux therapy, botulinum toxin injection is used in the treatment of true vocal cord granulomas.13 Botulinum toxin paralyzes the true vocal cord, preventing forceful closure of the arytenoids during phonation and coughing, which allows the traumatized site to heal.Contact granulomas arise from the vocal process (cartilaginous posterior portion) of the true vocal cords and are considered an inflammatory response from injury to the underlying perichondrium. In addition to antireflux therapy, botulinum toxin injection is used in the treatment of true vocal cord granulomas.13 Botulinum toxin paralyzes the true vocal cord, preventing forceful closure of the arytenoids during phonation and coughing, which allows the traumatized site to heal.

Antireflux surgery may be a consideration in patients with chronic symptoms that do not respond to adequate medical therapy. In one study10 of patients with GERD and laryngeal disease, 82 percent of the patients had resolution of laryngeal symptoms and normalization of laryngoscopic findings by six months or more after antireflux surgery. Patients in this study had GERD documented by 24-hour pH monitoring and laryngoscopic evidence of laryngeal pathology. They were referred for surgical therapy (Nissen fundoplication) because of an unsatisfactory response to medical therapy.

Studies have shown that GERD is implicated in 40 to 75 percent of patients with both laryngeal symptoms and laryngoscopic evidence of laryngeal pathology. However, GERD is implicated in only 20 to 40 percent of patients with laryngeal symptoms and a normal laryngoscopic examination.3,10,14

GERD has also been implicated in the development of leukoplakia and squamous cell carcinoma of the true vocal cords.3,10,11 Leukoplakia, defined as the presence of a whitish plaque on a mucosal surface, in itself does not carry any diagnostic implications. However, in the presence of GERD, leukoplakia is considered to be precancerous. In the study mentioned above, five patients with GERD were found to have laryngeal squamous cell carcinoma and underwent either surgical or radiation therapy; edema and leukoplakia persisted after treatment.10 All patients subsequently underwent antireflux surgery, and the laryngeal abnormalities resolved in three of four patients. (The fifth patient was lost to follow-up.) The findings suggest that premalignant lesions may be associated with GERD and may resolve after appropriate antireflux therapy. Although some evidence suggests that GERD is a cofactor in the development of squamous cell carcinoma of the larynx, research is needed to determine the importance of GERD in the pathogenesis.

PHARYNGEAL

The pharyngeal complications of GERD include cricopharyngeal dysfunction, chronic pharyngitis and Zenker''s diverticulum is a posterior pulsion pseudodiverticulum that arises from Killian''s diverticulum.

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Radiograph demonstrating a Zenker''s diverticulum. Note the barium filling the diverticular pouch.

Zenker''s diverticulum. A small asymptomatic Zenker''s esophagus and carcinoma.18,19 Barrett''s esophagus has also been described.6 Barrett''s edema: phonatory mechanisms and management strategies. Ann Otol Rhinol for 1 last update 10 Jul 2020 Laryngol. 1997;106:533–43.Zenker''s diverticulum. A small asymptomatic Zenker''s esophagus and carcinoma.18,19 Barrett''s esophagus has also been described.6 Barrett''s edema: phonatory mechanisms and management strategies. Ann Otol Rhinol Laryngol. 1997;106:533–43.

How Many Hours After Eating Is Gerd Worst Tests (πŸ”΄ Diet Changes For) | How Many Hours After Eating Is Gerd Worst Herbal Remedieshow to How Many Hours After Eating Is Gerd Worst for 13. Nasri S, Sercarz JA, McAlpin T, Berke GS. Treatment of vocal fold granuloma using botulinum toxin type A. Laryngoscope. 1995;105:585–8.

14. McNally PR, Maydonovitch CL, Prosek RA, Collette RP, Wong RK. Evaluation of gastroesophageal reflux as a for 1 last update 10 Jul 2020 cause of idiopathic hoarseness. Dig Dis Sci. 1989;34:1900–4.14. McNally PR, Maydonovitch CL, Prosek RA, Collette RP, Wong RK. Evaluation of gastroesophageal reflux as a cause of idiopathic hoarseness. Dig Dis Sci. 1989;34:1900–4.

15. Baredes S, Shah the 1 last update 10 Jul 2020 CS, Kaufman R. The frequency of cricopharyngeal dysfunction on videofluoroscopic swallowing studies in patients with dysphagia. Am J Otolaryngol. 1997;18:185–9.Baredes S, Shah CS, Kaufman R. The frequency of cricopharyngeal dysfunction on videofluoroscopic swallowing studies in patients with dysphagia. Am J Otolaryngol. 1997;18:185–9.

16. Feussner H, Siewert JR. Zenker''s esophagus and esophageal adenocarcinoma. Gastroenterol Clin North Am. 1991;20:817–34.16. Feussner H, Siewert JR. Zenker''s esophagus and esophageal adenocarcinoma. Gastroenterol Clin North Am. 1991;20:817–34.

20. Little JP, Matthews BL, Glock MS, Koufman JA, Reboussin DM, Loughlin CJ, et al. Extraesophageal pediatric reflux: 24-hour double-probe pH monitoring in 222 children. Ann Otol Rhinol Laryngol Suppl. 1997;169:1–16.

How Many Hours After Eating Is Gerd Worst 7 Foods That Cause (⭐️ Heartburn Relief) | How Many Hours After Eating Is Gerd Worst Remedieshow to How Many Hours After Eating Is Gerd Worst for 21. McMurray JS, Holinger LD. Otolaryngic manifestations in children presenting with apparent life-threatening events. Otolaryngol Head Neck Surg. 1997;116(6 pt 1):575–9.

22. Bauman NM, Sandler AD, Smith RJ. Respiratory manifestations of gastroesophageal reflux disease in pediatric patients. Ann Otol Rhinol Laryngol. 1996;105:23–32.

23. Contencin P, Narcy P. Gastroesophageal reflux in infants and children: a pharyngeal pH monitoring study. Arch Otolaryngol Head Neck Surg. 1992;118:1028–30.

24. How Many Hours After Eating Is Gerd Worst Treatment Of (πŸ”₯ Warnings) | How Many Hours After Eating Is Gerd Worst Treatment Forhow to How Many Hours After Eating Is Gerd Worst for Holinger LD. Chronic cough. In: Cotton RT, Meyer CM, eds. Practical pediatric otolaryngology. New York: Lippincott-Raven, 1999:117–28.

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