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“Dropping Acid” Blog

Acid Reflux (LPR and GERD) Articles

F. Hvid-Jensen, L. Pedersen, P. Funch-Jensen, A. M. Drewes.  Proton pump inhibitor use may not prevent high-grade dysplasia and oesophageal adenocarcinoma in Barrett’s oesophagus: a nationwide study of 9883 patients. Alimentary Pharmacology and Therapeutics, pp. 1-8, 2014.

The first line of the conclusions in the abstract say it all, “No cancer-protective effects from PPI’s were seen. In fact, high-adherence and long-term use of PPI were associated with a significantly increased risk of cancer.” In other words, PPIs are NOT primary treatment for reflux disease and do not prevent esophageal cancer. PPIs do not stop progression of disease. Nothing replaces dietary and lifestyle modifications; see Dropping Acid: The Reflux Diet Cookbook & Cure. Click to see full article

Koufman J, Johnston N. Potential Benefits of pH 8.8 Alkaline Drinking Water as an Adjunct in the Treatment of Reflux Disease. Annals Otol Rhinol Laryngol 121:431-434, 2012.

Evamor natural, artesian drinking water at pH 8.8 appears to instantaneously denature pepsin in vitro. In addition, it buffers acid as it contains bicarbonate. This water appears to have potential therapeutic benefits for people with airway and esophageal reflux. (Indeed, it has already show itself to be a useful clinical adjunctive therapy.) Click to see full article

Koufman J. Low-Acid Diet for Recalcitrant Laryngopharyngeal Reflux: Therapeutic Benefits and Their Implications. Ann Otol Rhinol Laryngol 120:281-287, 2011.

Why has acid reflux become epidemic among all age groups since the 1970s, including more 20-30-year-olds than ever before? Why during this same period has esophageal cancer increased 850%? And why has reflux treatment become increasingly ineffective?

In America, we are already experiencing sky-rocketing reflux-related cancer rates and health costs ($90 billion annually for reflux alone). How food is preserved needs to become a public health concern in order to quell the rising tide of the reflux epidemic. In the meanwhile, reflux patients benefit from a low-acid diet, a diet that may be the key to improving and saving the lives of millions of Americans.

In addition to explaining the basic science behind reflux, Dr. Koufman’s article, “Low-Acid Diet for Recalcitrant Laryngopharyngeal Reflux: Therapeutic Benefits and Their Implications,” reports the therapeutic benefits of a two-week “acid detox,” called the Induction Reflux Diet. There are, for example, no carbonated beverages, alcohol, prepackaged foods, and almost no fruits on the detox diet. Twenty patients who were failing reflux treatment on maximum-dose proton pump inhibitors (PPIs), like Nexium and Prilosec, were put on the Induction Reflux Diet.  Nineteen of the twenty improved significantly, and three became completely asymptomatic.  Click to see full article

Koufman JA, Block C. Differential diagnosis of paradoxical vocal fold movement. American Journal of Speech and Hearing. 17:327-34, 2008.

Breathing difficulties, including shortness of breath, chronic cough, “asthma,” laryngospasm (choking episodes), and paradoxical vocal fold movement (PVFM) are all associated with laryngeal disorders. And the most common and sometimes difficult to diagnose condition is acid-reflux-related PVFM.

This paper provides concise descriptions of all of the causes of PVFM and outlines key points that differentiate each of the different conditions … and, the incorrect diagnoses with which PVFM may be confused.  Indeed, most people with PVFM are misdiagnosed as having asthma. In addition, in the age of intense medical specialization, many doctors seem to have overlooked the fact that most reactive airway diseases are interrelated, and that acid reflux is often a common feature.  Click to see full article

Koufman JA, Belafsky PC, Daniel E, Bach KK, Postma GN.  Prevalence of esophagitis in patients with pH-documented laryngopharyngeal reflux.  Laryngoscope 112:1606-1609, 2002.

Fifty-eight patients with clinical and pH-documented LPR underwent transnasal esophagoscpy (TNE); only 12% had esophagitis and 7% had Barrett’s esophagus. This paper confirms that the mechanisms and patterns of LPR and GERD are different; most LPR patient have neither heartburn nor esophagitis.

In addition, it is important to recognize that esophagoscopy is not a good way to diagnose LPR because most LPR patients do not have esophagitis. On the other hand, once a patient has a diagnosis of LPR, then the patient should have TNE esophagoscopy to screen for Barrett’s and/or cancer.  Click to see full article

Johnston N, Bulmer D, Gill GA, Panetti M, Ross PE, Pearson JP, Pignatelli M, Axford A, Dettmar PW, Koufman JA.  Cell biology of laryngeal epithelial defenses in health and disease: Further studies Ann Otol Rhinol Laryngol 112:481-491, 2003.

This is the single most important paper on the cell biology of LPR. The cellular impact of reflux was studied in test tubes,  animals, and humans. Studies include e-cadherin, stress proteins, and carbonic anhydrase. The conclusions are: (1) Cellular damage is due to pepsin, the principle enzyme of the stomach; (2) reflux causes depletion of cells’ most important defensive proteins; (3) laryngeal cell damage occurs at pH 5 or below; and (4) by protein depletion analysis, reflux and laryngeal cancer are very similar.    Click to see full article

Johnston N, Knight J, Dettmar PW, Lively MO, Koufman J. Pepsin and carbonic anhydrase isoenzyme III as diagnostic markers for laryngopharyngeal reflux disease. Laryngoscope 114:2129-34, 2004.

This important landmark paper showed that gastric (stomach) pepsin is found in the laryngeal tissue of patients with LPR but not controls. It appears that tissue-bound pepsin is the difference between health and disease when it comes to LPR.   Click to see full article

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

While GERD is associated with obesity, LPR is not. The data of this study confirm that patients with LPR are usually NOT obese. Click to see full article

Knight J, Lively MO, Johnston N, Dettmar PW, and Koufman J.  Sensitive pepsin immunoassay for detection of laryngopharyngeal reflux. Laryngoscope 115:1473-78, 2005.

This paper highlights the use of pepsin as a marker for reflux disease. This is now being developed as a spit-in-a-cup test for reflux.  Click to see full article

Johnston N, Dettmar PW, Bishwokarma B, Lively MO, Koufman JA. Activity/stability of human pepsin: implications for reflux attributed laryngeal disease. Laryngoscope. 117:1036-9, 2007.

Human pepsin is active across the pH range. At pH 6.5, there is still some peptic activity. In addition, pepsin is not easily denatured. This paper provides the essential information about pepsin’s activity and stability.   Click to see full article

Koufman JA.  The Otolaryngologic manifestations of gastroesophageal reflux disease (GERD):  A clinical investigation of 225 patients using ambulatory 24-hour pH monitoring and an experimental investigation of the role of acid and pepsin in the development of laryngeal injury. Laryngoscope 101 (Suppl. 53):1-78, 1991.

This 78-page publication was a supplement to The Laryngoscope in 1991. It was the first comprehensive scientific paper on the relationship between reflux (GERD, gastroesophageal reflux disease) and the larynx (voice box) and airway. I reviewed the entire world’s literature, some 8,000 papers. I also performed reflux testing on182 of my patients with laryngeal cancer, chronic cough, sensation of a lump in the throat, post-nasal drip, and difficulty swallowing.

I found that reflux was common in all of the groups tested and I postulated that reflux was an important factor in the development of laryngeal cancer. In animal experiments, I determined that pepsin (the primary digestive enzyme of the stomach), and not acid, was primarily responsible for tissue injury, and that as few as three reflux episodes per week could produce serious laryngeal (vocal cord) damage. This paper is the most cited paper in the history of otolaryngology. BTW, I did not introduce the term laryngopharyngeal reflux (LPR) in this paper, but the term was already in use in my clinic by 1987.

Article too large to upload – New PDF under construction

Koufman JA, Amin M, Panetti M.  Prevalence of reflux in 113 consecutive patients with laryngeal and voice disorders. Otolaryngol Head Neck Surg  123:385-388, 2000.

Of 113 consecutive patients with voice disorders reported, 50% (57/113) had documented acid reflux by reflux testing (pH monitoring). (Indeed, in my experience, reflux laryngitis is the most common cause of hoarseness.)  Click to see full article

Belafsky PC, Postma GN, Koufman JA.  The validity and reliability of the reflux finding score (RFS).  Laryngoscope  111:1313-1317, 2001.

This paper describes the findings of reflux laryngitis, laryngopharyngeal reflux (LPR), and the RFS is a validated outcomes instrument for reflux research.  Click to see full article

Amin MR, Postma GN, Johnson P, Digges N, Koufman JA.  Proton pump inhibitor resistance in the treatment of laryngopharyngeal reflux. Otolaryngol Head Neck Surg 125:374-378, 2001

This paper was a retrospective review of reflux (pH monitoring) testing results of 1.053 adult patients (of the author) with clinical and pH-documented laryngopharyngeal reflux (LPR). It appeared that 16% of the patients failed medical treatment with proton pump inhibitors (PPIs) such as Prilosec, Nexium, Protonix, Aciphex, Zegerid, etc. Of those who appeared to fail, increasing the dose of PPI did not result in improvement. It appears that some LPR patients are just resistant to PPI therapy.   Click to see full article

Belafsky PC, Postma GN, Daniels E, Koufman JA. Transnasal esophagoscopy. Otolaryngol Head Neck Surg;125:588-589;2001.

This is one of the very first relatively large series of patients reported having had awake esophageal endoscopy, transnasal esophagoscopy (TNE). This has become the state of the art for screening exams of the esophagus to rule out esophageal cancer, which has increased 500% in the last two generations. Barrett’s esophagus, esophageal precancer, may also be detected by TNE.

Today, people who are concerned about possible cancer can be checked sitting in a chair, comfortable, without pain, and awake. The idea that you can only be checked for cancer under anesthesia and in a special facility is archaic.   Click for (2005) series follow-up TNE publication and for “Position Paper of the American Broncho-Esophagological Association on TNE (2008)

Koufman JA, Aviv JE, Casiano RR, Shaw GY.  Position statement of the American Academy of Otolaryngology-Head and Neck Surgery on laryngopharyngeal reflux. Otolaryngol Head Neck Surg 127:32-35, 2002.

This paper summarizes and focuses on how laryngopharyngeal reflux (LPR) and gastroesophageal reflux disease (GERD differ. It was written by experts on LPR. It is also an important paper that helps LPR patients who may need twice-daily medication dosing, because until this paper, most insurance companies would not cover such treatment.   Click to see full article

Smoak BR, Koufman JA. Effects of gum chewing on pharyngeal and esophageal pH. Ann Otol Rhinol Laryngol 110:1117-1119, 2001.

This study evaluated the effects of chewing gum on reflux. It turn out, that gum chewing increases swallowing rates, saliva, and salivary bicarbonate concentration — yes, there is acid-neutralizing bicarbonate in human saliva. Gum chewing is an excellent “adjunctive” treatment for reflux. It really helps, particularly people who have symptoms (e.g., hoarseness, heartburn, cough, etc.) after meals.  Click to see full article

Koufman JA, VanHorn G. Prevalence of Acid Reflux in America: The Times Square Study (Preliminary Results) — This paper has not yet been submitted for publication. (At present, data from 656 respondents have been analyzed.)


Background: The prevalence of reflux-related diseases is unknown; however, it is clear that not all refluxers have classic gastroesophageal reflux disease (GERD). Many people have exrtraesophageal symptoms and manifestations without having heartburn or indigestion. The latter group has laryngopharyngeal reflux (LPR), also called “silent reflux.” The purpose of this study was to estimate the prevalence of reflux (LPR and GERD) in the American population.

Materials & Methods: Trained interviewers were sent to Times Square to randomly interview adult (over 18 years) U.S. citizens, most of whom were standing near the pedestrian plazas surrounding the TKTS discount theater line. The questionnaires were completed by interviewers and not by the subjects. The questionnaire contained 24 questions and was usually completed in 2-3 minutes per respondent.

Results: Of the 656 study subjects, 55% were female and 45%) were male. The mean age of the study population was 41 ± 18.4 years (range 18-89 years). Twenty-two percent (131/656) were self-identified refluxers, and another 18% (118/656) had two or more reflux symptoms and/or took reflux medications despite not having a known diagnosis. (The latter were termed “silent refluxers”) Of the 249 subjects with reflux, 55% were female and 45% were male. The mean age of the refluxers was 42 ± 17.9 years (range 18-82 years). Within the reflux group, the most common symptoms (in decreasing order of occurrence) were: Heartburn 62%, indigestion 44%, post-nasal drip 33%,  morning hoarseness and sore throat 21%, chronic throat clearing 20%, hoarseness 14%, chronic cough 14%, a sensation of a lump in the throat 13%, difficulty swallowing 13%, and choking episodes 8%.

With the above data analysis, there were no significant differences between men and women, between caucasians and non-caucasians, nor were there significant differences between the different age groups; 18 to 29 years 37%, 30-39 years 31%, 40-49 years 43%, 50-59 years 44%, 60-69 years 41%, and over 70 years 43%.

Conclusions: The data, representing a reasonable geographic distribution of the United States, reveal that 40% have symptoms of reflux. Assuming that the population of the U.S, is 320 million, then as many as 128 million Americans may suffer from reflux. In addition, almost half of the subjects with reflux had silent/undiagnosed reflux.

Printable version of  Prevalence of Reflux in America: The Times Square Study (Preliminary Data)

Key words: Gastroesophageal reflux, GERD, laryngopharyngeal reflux, LPR, acid reflux, prevalence of reflux, American population, heartburn, indigestion, hoarseness, post-nasal drip.