A 62 year-old male presented to my office this past week with a 12 year history of recurrent attacks of shortness of breath, chest tightness, wheezing and difficulty breathing. The patient has been diagnosed with COPD. He has never smoked or been exposed to harmful gas or fumes. For years he has been treated with multiple inhalers as well as steroids to control his lung disease. Secondary to steroids he has gained around 50 pounds, has developed central obesity, hypertension and became insulin resistance. He has received many antibiotic treatments for pneumonia and bronchitis. On average, he has received an antibiotic/steroid treatment every 6 to 7 weeks over the past 12 years. Concomitantly, the patient suffers from GERD with occasional heartburn and food regurgitation and silent reflux related symptoms like chronic sore throat, hoarseness and cough. He has recently been diagnosed with Barrett’s esophagus and is currently maintained on Dexilant and Famotidine. Recently, his gastroenterologist has recommended LINX™ procedure for GERD treatment.
This case is particularly interesting for several reasons:
- The patient suffers from laryngospasm or laryngeal stridor that is easily heard on physical exam and reported by the patient himself. While he may have some distal bronchiolar involvement it is obvious that his main airway problem is more proximal and involves the trachea and larynx. There are very few causes of laryngospasm in a 62 year-old male.
- The underlying cause of all these symptoms is GERD. Yet not a single physician including his primary care physician, gastroenterologist and pulmonary specialist has made this connection. They labeled the patient with COPD and treated him with steroids and antibiotics for twelve years, and masked his heartburn with proton pump inhibitors and H2 receptor blockers. Silent reflux and GERD for many physicians seems like a nuisance rather than a true medical problem. No one wants to give it any serious attention or make the effort to understand it, diagnose it and properly treat it. For twelve years a Band-Aid was placed over the patient’s symptoms
- Silent reflux causes Barrett’s esophagus and proton pump inhibitors do not protect the esophagus and prevent the development of Barrett’s metaplasia. Gastric juice contains many other substances like bile acids and pepsin besides acid that can damage the delicate esophageal and laryngeal lining. Proton pump inhibitors are clearly not the gold standard of GERD treatment. For GERD is not a state of acid hypersecretion but rather a condition of gastric juice reflux into the esophagus, throat, voice box and lungs.
- Nissen surgery is the most reliable and durable treatment for GERD. Nissen procedure recreates the barrier against reflux keeping gastric juice in the stomach. There is no role for LINX™ surgery in this severe GERD case. There are no data on the long-term efficiency of LINX™ procedure in the setting of Barrett’s esophagus. LINX™ may actually exacerbate Barrett’s esophagus and laryngeal symptoms by delaying esophageal clearance of gastric juice. I wholeheartedly invite my gastroenterology colleagues to look closely at the complexity of GERD, its underlying pathophysiology and conclude that a stricture made of magnetic beads is not a treatment for a complex multifactorial problem like GERD.
This patient will finally undergo the treatment that he deserves: a laparoscopic Nissen fundoplication with hiatal hernia repair after weaning his steroids and optimizing his cardio-pulmonary status in preparation for general anesthesia. I hope that the laryngeal damage that he has suffered from over the past 12 years is still reversible after stopping gastric juice reflux into his esophagus.