October 18, 2020
If It Doesn’t Walk Like a Duck or Talk Like a Duck… Maybe It’s Not a Duck?!!
Magda was a new patient who was referred by one of my ENT colleagues for “refractory reflux”. She’d been on the proton pump inhibitor Nexium at a dose of twice daily for over a year, and was still complaining of symptoms. She’d cut out caffeine, alcohol, chocolate and late-night eating when the symptoms first began, and was a pretty healthy eater at baseline: oatmeal or fruit for breakfast; a salad for lunch, and chicken or fish with rice or quinoa plus veggies for dinner. At 5’8” she weighed 126 pounds, and was an avid exerciser. Magda was 29, didn’t take any other medications besides Nexium, and had no other medical problems. Hmmm. Why would a lean, active, healthy 29-year-old woman with good eating habits suddenly start having acid reflux? The symptoms had developed seemingly out of the blue, on the heels of a bad viral upper respiratory tract infection 14 months before.
One of the things I noticed during our appointment was that Magda kept clearing her throat and coughing; both of which can be “atypical” manifestations of reflux. But on further questioning, it turned out that Magda didn’t have any “typical” manifestations of reflux: no heartburn, epigastric discomfort, regurgitation, difficulty swallowing, excessive salivation, bad breath, or sour taste in her mouth. Her main symptom was a dry cough. She had tested negative for seasonal allergies, and the ENT told her she had acid reflux based on redness in the larynx. An upper endoscopy done earlier this year showed a normal upper GI tract, save for a little inflammation right at the junction between the stomach and esophagus.
I told Magda that before I could help her get her reflux under control, we needed to be sure the diagnosis was correct, and I definitely had my doubts.
Doubt #1: she’d been on high dose PPIs for over a year with no real improvement in her symptoms. That means that even in the absence of any stomach acid, she was still having “acid reflux”. Unlikely.
Doubt #2: she was the anti-poster child for reflux: not overweight, not sedentary, not a smoker, not a drinker, not a late-night eater, not a consumer of high fat foods or large meals, and not taking any medications that could be contributing (antibiotics like Clindamycin or Tetracycline, or Bisphosphonates like Fosamax or Boniva).
“What about my upper endoscopy?” she asked. “Doesn’t that tell you whether I’m having reflux or not?” I reminded Magda that an upper endoscopy isn’t a diagnostic test for acid reflux. It can show damage to the esophagus as a result of active reflux: inflammation in the esophagus (esophagitis) or a potentially pre-cancerous condition called Barrett’s esophagus, but in most people with acid reflux, the upper endoscopy is normal or shows minimal inflammation that’s not clinically significant, like in Magda’s case.
I told Magda that I thought the reason for her dry cough might be chronic inflammation of her trachea and bronchi (tracheobronchitis) that may have developed after the viral respiratory tract infection the year before. Acute tracheobronchitis is usually caused by a bacteria or virus, and is often accompanied by fever and phlegm, but a more chronic indolent version after the acute infection, or triggered by chemical or physical allergens can occur.
We tapered Magda off the Nexium and arranged for her to have a 24 hour pH test, which gave us critical information: she had normal “physiologic” acid exposure in the esophagus associated with the lower esophageal sphincter opening after swallowing to let food into the stomach, and a little when lying flat, but nothing that met the criteria for acid reflux. I referred her to a pulmonary specialist, who offered up a course of steroids as one possible treatment path for the tracheobronchitis, but Magda elected the other: keeping her throat moist with lozenges and a humidifier, and watchful waiting. 3 months into it, she’s still experiencing some coughing spells, especially when exposed to cold air, or if she’s talking a lot, but she’s definitely on the mend, and glad to be off the PPIs.