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Millions of people in the UK experience the symptoms of reflux at least once every week. For many this is linked to something they have eaten and settles quickly, but for others the symptoms are more frequent and many use PPI medication daily to manage it. There is a smaller group for whom their symptoms are much worse and have a major impact on their quality of life every day, interfering with their eating habits, exercise and sleep.
It can be difficult for people to gauge how severe their symptoms are compared to other reflux sufferers. &lsquo;Are my symptoms normal or severe ?&rsquo;, &lsquo;Is my reflux doing permanent damage ?&rsquo; and &lsquo;should I be considering surgery ?&rsquo; are common questions that people are asking themselves.
It&rsquo;s helpful therefore to have an objective basis upon to decide how severe your reflux symptoms are, and the reflux health related quality of life questionnaire (HRQL) is designed to do this.
Over many years and based on thousands of responses it has developed to become a robust tool that can be used to grade the severity of your reflux. It is also structured in a way that enables us to measure both your digestive symptoms (heartburn type symptoms) and LPR symptoms (for example those occurring in the throat).
We use this questionnaire to identify people with more severe symptoms who would typically benefit from surgery. In fact, we collect this questionnaire from every patient to whom we recommend surgery as part of their pre-operative screening. We also do so at regular intervals after surgery to monitor the improvement in symptoms.
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How severe is my reflux?

how-severe-is-my-reflux

Gastro-oesophageal Reflux Disease, GORD or GERD is generally considered to be caused by reflux of acid into the oesophagus from the stomach. This can then cause a variety of symptoms, including heartburn, regurgitation and chest pain as well as symptoms in the throat (known as LPR) including a cough, sore throat, excessive mucous and voice weakness and even respiratory problems such as chest infections.
But, what causes GORD and is every GORD patient the same? Well, clearly this is not the case although in our experience many clinicians treat them as if they are.
In many of the patients we see the lower oesophageal sphincter (LOS) has failed, usually because of a hiatus hernia. This then allows reflux and dependent upon the degree of failure people will experience different and varying symptoms. Sometimes small hiatus hernias are not identified at endoscopy and in other cases the valve can fail because of neuro-muscular problems. And in some people symptoms of reflux may actually not be caused by reflux at all - conditions called functional heartburn or oesophageal hypersensitivity are associated with identical symptoms. But, in all cases of LOS failure we would classify the problem as &ldquo;primary&rdquo; GORD.
We see many who are treated for reflux, usually with PPI&rsquo;s at increasing doses, often seeing either no improvement or even a deterioration in their symptoms. Our observations are supported by a prospective randomised study published in 2022 which demonstrated no benefit from treating LPR symptoms with PPIs when compared to placebos&nbsp;<a class="link" href="https://evidence.nihr.ac.uk/alert/throat-symptoms-should-not-be-treated-with-ppis/">NIHR Alert PPIs and LPR BMJ 2021;372:m4903</a>. Reflux symptoms can include heartburn and especially regurgitation but more often LPR. There are so many symptoms described by people with LPR including, but not limited to, cough, sore throat, sense of a lump in the throat (globus), voice problems as well as mouth symptoms such as a bad taste. These patients may well have been told that they have reflux by an ENT surgeon. In these patients the lack of response to PPIs doesn&rsquo;t mean they don&rsquo;t have primary reflux, it suggests that acid is not the only problem.
We know from scientific studies that reflux symptoms are often associated with SIBO (Small Intestinal Bacterial Overgrowth). Indeed we published a paper in 2021 that showed that 60% of patients referred for reflux surgery test positive on breath tests&nbsp;<a class="link" href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8599257/">SIBO in reflux patients Surg Endosc. 2021; 35(12): 7112&ndash;7119</a>. Other studies suggest that treatment of SIBO by reducing carbohydrates from the diet can help reflux symptoms and in one this objectively reduced oesophageal acid exposure when measured with pH studies.
So how does SIBO cause reflux symptoms? It seems that there may be several mechanisms involved. Probably the fermentation of carbohydrates in the gut that is associated with SIBO causes hydrogen or methane gas to distend the small bowel which increases abdominal pressure, and which is then &ldquo;vented&rdquo; from the stomach by belching. Distension of the stomach also causes increased&nbsp;transient lower oesophageal sphincter relaxations (TLOSRs). These are defined as lower oesophageal sphincter relaxation that is induced spontaneously without swallowing. They are a physiological mechanism that enables venting of gas from the stomach. These relaxations and associated reflux events are observed in normal subjects. However, when there are an increased number of TLOSRs, as can occur in patients with SIBO, abnormal numbers of reflux events and associated acid or non-acidic reflux in the oesophagus is typically observed. We would define this as &ldquo;pathological&rdquo;, as its abnormal and associated with GORD, the D of which is the abbreviation of disease. Interestingly, colonic distension which often occurs with Irritable Bowel Syndrome (IBS) has been shown to increase the number of TLOSRs. Fascinatingly, patients with IBS are more likely to have GORD which is difficult to treat with PPIs and up to 70% of patients with IBS have SIBO. So, it seems that there is a connection between IBS, SIBO and reflux.
The process of belching literally is analogous to spraying an &ldquo;aerosol&rdquo; of gastric juices up the oesophagus and into the throat. This gaseous aerosol may be primarily non-acidic especially after eating and this may explain the poor response to PPIs. However, the aerosol may include other substances including the enzyme pepsin which is highly corrosive and irritating to the sensitive lining of the throat and causes the typical symptoms associated with LPR. Pepsin remains biochemically active at relatively high pH and isn&rsquo;t influenced by PPIs. Of course, patients may develop reflux symptoms because they&rsquo;ve developed SIBO for multiple reasons, perhaps following a course of anti-biotics to treat another infection or following a gastro-intestinal infection for instance. However, we also see many patients who have primary GORD and who are treated with PPIs that causes secondary SIBO. The consequent wind and belching may exacerbate the reflux symptoms, but in these patients SIBO is not the primary cause.
Reaching a diagnosis can be difficult and require several tests to disentangle exactly what the cause of symptoms is. Impedance reflux testing may show an increased number of non-acidic events associated with belching. That&rsquo;s why a simple pH test can be sub-optimal in these situations as not only do these fail to measure non-acidic reflux but also fail to distinguish gas, liquid or solid reflux from each other. Critically, we have a very low threshold for performing breath tests for SIBO especially in patients with LPR and very often these are positive.
Interpreting all the results against the clinical history is crucial to formulate the right treatment plan. In particular consideration of whether a positive SIBO test is co-incidental to symptoms or that it is the primary problem is essential. For instance, did the symptoms occur after starting PPIs? Does the patient have IBS? The history usually is the key.
When we&rsquo;re convinced that SIBO is the primary cause of reflux symptoms, we advise patients to stop PPIs. In our experience eradication of SIBO whilst on these powerful antacids is difficult and sometimes simply stopping them can result in an improvement in symptoms. Even so eradication can be difficult. We would usually advise treatment of SIBO using the current guidelines&nbsp;<a class="link" href="https://journals.lww.com/ajg/fulltext/2020/02000/acg_clinical_guideline__small_intestinal_bacterial.9.aspx">ACG Clinical Guideline: Small Intestinal Bacterial Overgrowth</a>&nbsp;with anti-biotics and dietary modification, especially the low-FODMAP diet. Sometimes drugs that improve gastro-intestinal motility can help and in some cases patients will benefit from the advice of a nutritionist.
So, the key lessons are
<ul>
<li>Think about SIBO in a patient with reflux symptoms</li>
<li>Always consider the relationship between reflux symptoms and SIBO&nbsp;</li>
<li>The clues are usually in the history</li>
<li>Testing is paramount to reach the right diagnosis</li>
<li>PPIs will not help patients with LPR</li>
<li>PPIs will usually not help patients with reflux symptoms caused by SIBO</li>
<li>SIBO treatment will cure most people.</li>
</ul>

SIBO, LPR and Reflux

sibo-lpr-and-reflux

<h3>Proton Pump Inhibitors</h3>
Proton Pump Inhibitors (PPIs) are the mainstay of treatment for gastro-oesophageal reflux. They are one of the most prescribed group of drugs in the western world. A study published in 2020 that evaluated their use in the UK over 15 years found that 20% of adults had been prescribed these powerful drugs and in most western countries 5-10% of the adult population take them regularly. Worldwide annual sales amount to nearly $15billion. First line treatment of anyone complaining of symptoms possibly caused by reflux in the absence of alarm symptoms suggesting cancer is PPIs, and often at increasing doses even if they don&rsquo;t initially help. And yet while PPIs are undoubtedly effective for many people they are not without problems and increasingly doctors and patients are deciding they&rsquo;d prefer not to prescribe or take them. So, what are the facts?
<h4>What are Proton Pump Inhibitors?</h4>
PPIs are very powerful antacid drugs. Taken twice a day they virtually halt all acid production from the stomach. Since acid can be the cause of symptoms and indeed injury to the lining of the stomach and oesophagus, by preventing its production PPIs are very useful in patients suffering with gastro-oesophageal disease, stomach or duodenal ulcers as well as preventing problems for instance when taking other drugs such as anti-inflammatory pain killers.
<h4>How effective are PPIs?</h4>
PPIs are not the universal panacea that some doctors would have you believe. The symptomatic response depends on what is being treated. Studies have shown that when used to treat inflammation of the oesophagus caused by reflux, called oesophagitis, PPIs are extremely effective; in 80-90% the oesophagus will heal and symptoms of heartburn and chest pain resolve. As inflammation gets more severe, reflecting more advanced reflux disease, response diminishes but many people will still enjoy reasonable symptom control even with high grades of oesophagitis.
However, in other situations the evidence is that PPIs are less effective. In patients suffering with regurgitation, perhaps only 10-20% will experience symptom resolution. And when used to treat laryngo-pharyngeal (LPR) symptoms, 70-80% of patients will find that they don&rsquo;t help significantly. Overall, about 20-30% of patients treated with PPIs will find that their symptoms either do not respond or do so only incompletely and that they continue to be troubled by them.
<h4>Why is this?</h4>
Firstly, when the Lower Oesophageal Valve (LOS) fails to the extent that stomach contents regurgitate up the oesophagus and sometimes to the throat and mouth, PPIs can reduce the acid content but not the volume of the refluxate. So, patients will often observe that their heartburn is improved but that they still experience troubling regurgitation. And in many patients with reflux, especially LPR it&rsquo;s thought that other components of the stomach contents including bile and the enzyme Pepsin which is produced in the stomach are partly responsible for irritating the throat and mouth and these remain biologically active even in nearly neutral acid environments; consequently, preventing acid production doesn&rsquo;t help prevent symptoms when this is the case. And of course, sometimes patients have conditions causing symptoms which aren&rsquo;t primarily caused by excessive reflux and so often respond incompletely if at all to PPIs. These include so-called reflux hypersensitivity, functional heartburn and eosinophilic oesophagitis as well as non-oesophageal disease including gastritis, ulcers and gallbladder disease all of which can cause symptoms similar that can be attributed to reflux.
<h4>The problems with PPIs</h4>
Side effects&nbsp;It&rsquo;s always been recognised that some people just can&rsquo;t take PPIs as they experience side effects. Usually, if one type of PPI causes this type of problem, they all will. These can include aching joints, dizziness, rashes, depression and gastrointestinal symptoms including bloating, pain, constipation and diarrhoea (see below).
Serious associated conditions&nbsp;However, in recent years there have been a series of scientific studies that have associations PPIs with other serious health conditions.
These include:
<ul>
<li>Osteoporosis</li>
<li>Bone fractures</li>
<li>Liver disease</li>
<li>Dementia</li>
<li>Renal disease</li>
<li>Cardiac disease</li>
<li>Stomach cancer</li>
<li>Drug interactions</li>
<li>Vitamin and mineral deficiencies</li>
</ul>
Many of these studies have shown statistical associations in populations taking PPIs. And because PPIs can potentially influence the functioning of virtually every cell in the body, not just acid producing gastric parietal cells, there are plausible physiological mechanisms by which they may influence disease beyond the gut. However, this doesn&rsquo;t prove causation and in most cases the existing evidence for risk is either not strong or conflicting. But clearly these reports do raise concern and current guidance advises doctors to prescribe PPIs only when necessary and if possible, only in the short term. At the very least anyone considering taking PPIs long-term should ensure they&rsquo;re taking them for the right reasons and be made aware of the potential risks and alternative treatment options.
What we do know from published studies with reasonable certainty is that taking PPIs long-term are associated with an approximately 45% increased chance of developing stomach cancer compared with less powerful antacid H2- blockers. There is a 65% chance of developing the serious gastro-intestinal infection&nbsp;c. difficleas well as other infections such as campylobacter and respiratory infections in some specific groups of patients. In some people low levels of calcium, folate, vitamin B12 and magnesium have all been reported. This last problem, although rare can be life-threatening. Low magnesium can cause muscle weakness, dizziness, seizures, mental illness, ataxia, neurological problems, tetany and cardiac arrhythmias. In anyone taking PPIs who develop these symptoms this problem should be considered and the drugs stopped while magnesium levels in the blood are measured.

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