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[Dysphagia] GERD, aspiration, MBS etc. discussion

PPIs don't stop reflux, they just stop the production of gastric acid
although about 30% of people get breakthrough acid during sleep, the
very worst time.I have been agitating for years for recognition of the
incidence of pneumonitis in the elderly and in children, especially
those with DD.  Think of the problems common in the older person:
diabetes, parkinsonism, COPD, stroke affecting the vagus - all with
high GER. To place enteral feeding in these patients is simply nuts.
If you want to make them worse, you could hardly find a better way to
do it - I don't mean you,personally, Emiky, I should say one could
hardly do a better job.
My experience and increasingly in the literature, the use of alginates
for both children and adults is proposed (Gaviscon) cheap and
effective partly because of its "rafting" effect but most because it
protects against acid and pepsin which is now believed to be even more
See the following:
The value of a liquid alginate suspension (Gaviscon Advance)
in the management of laryngopharyngeal reflux
Julian A. McGlashan ? Lesley M. Johnstone ?
John Sykes ? Vicki Strugala ? Peter W. Dettmar
Eur Arch Otorhinolaryngol (2009) 266:243?251

Abstract Laryngopharyngeal reflux (LPR) refers to the
backflow of stomach contents into the laryngopharynx.
Increasing evidence has demonstrated that LPR is a contributing
factor in some cases of hoarseness, vocal fatigue,
voice breaks, cough and globus and chronic throat clearing.
However, several randomised placebo-controlled trials of
proton pump inhibitors in the treatment of LPR have been
reported with the majority showing no significant benefit in
patient symptom scores over placebo. The aim of this pilot
clinical study was to investigate whether any improvement
in LPR-related symptoms, using the Reflux Symptom Index
(RSI), and clinical findings, using the Reflux Finding Score
(RFS), could be achieved with treatment with a liquid alginate
suspension compared to control (no treatment).
Patients presenting with the symptoms of LPR to the Otorhinolaryngology
Outpatient Department at the Queen's
Medical Centre, Nottingham, UK were considered eligible
if they had an RSI of greater than 10 and an RFS greater
than 5 based on a fibreoptic examination of the larynx. A
total of 49 patients were randomised into the open, parallel
group study; 24 patients were randomised to receive 10 ml
liquid alginate suspension (Gaviscon(R) Advance) four times
daily after meals and at bedtime, and 25 patients into the
control group (no treatment). Patients were assessed pretreatment
and at 2, 4 and 6 months post treatment. Mean
(SD) RSI and RFS pre-treatment scores were 23.9 (7.0) and
10.4 (3.6) for the treatment group and 24.6 (7.4) and 10.3
(3.3) for the control group, respectively. Significant differences
between treatment and control were observed for RSI
at the 2-month (11.2 (7.0) vs. 16.8 (6.4), P = 0.005) and 6-
month (11.2 (8.1) vs. 18.3 (9.4), P = 0.008) assessments
and for RFS at the 6-month (7.1 (2.8) vs. 9.5 (3.4),
P = 0.005) assessment. Significant improvement in symptom
scores and clinical findings were achieved with liquid
alginate suspension (Gaviscon(R) Advance) compared to
control and further evaluation for the management of
patients presenting with LPR is warranted.

Review article: alginate-raft formulations in the treatment of
heartburn and acid reflux.
Mandel KG, Daggy BP, Brodie DA, Jacoby HI. Aliment Pharmacol Ther.
2000 Jun;14(6):669-90

Alginate-based raft-forming formulations have been marketed word-wide
for over 30 years under various brand names, including Gaviscon. They
are used for the symptomatic treatment of heartburn and oesophagitis,
and appear to act by a unique mechanism which differs from that of
traditional antacids. In the presence of gastric acid, alginates
precipitate, forming a gel. Alginate-based raft-forming formulations
usually contain sodium or potassium bicarbonate; in the presence of
gastric acid, the bicarbonate is converted to carbon dioxide which
becomes entrapped within the gel precipitate, converting it into a
foam which floats on the surface of the gastric contents, much like a
raft on water. Both in vitro and in vivo studies have demonstrated
that alginate-based rafts can entrap carbon dioxide, as well as
antacid components contained in some formulations, thus providing a
relatively pH-neutral barrier. Several studies have demonstrated that
the alginate raft can preferentially move into the oesophagus in
place, or ahead, of acidic gastric contents during episodes of
gastro-oesophageal reflux; some studies further suggest that the raft
can act as a physical barrier to reduce reflux episodes. Although some
alginate-based formulations also contain antacid components which can
provide significant acid neutralization capacity, the efficacy of
these formulations to reduce heartburn symptoms does not appear to be
totally dependent on the neutralization of bulk gastric contents. The
strength of the alginate raft is dependant on several factors,
including the amount of carbon dioxide generated and entrapped in the
raft, the molecular properties of the alginate, and the presence of
aluminium or calcium in the antacid components of the formulation.
Raft formation occurs rapidly, often within a few seconds of dosing;
hence alginate-containing antacids are comparable to traditional
antacids for speed of onset of relief. Since the raft can be retained
in the stomach for several hours, alginate-based raft-forming
formulations can additionally provide longer-lasting relief than that
of traditional antacids. Indeed, clinical studies have shown Gaviscon
is superior to placebo, and equal to or significantly better than
traditional antacids for relieving heartburn symptoms. Alginate-based,
raft-forming formulations have been used to treat reflux symptoms in
infants and children, and in the management of heartburn and reflux
during pregnancy. While Gaviscon is effective when used alone, it is
compatible with, and does not interfere with the activity of
antisecretory agents such as cimetidine. Even with the introduction of
new antisecretory and promotility agents, alginate-rafting
formulations will continue to have a role in the treatment of
heartburn and reflux symptoms. Their unique non-systemic mechanism of
action provides rapid and long-duration relief of heartburn and acid
reflux symptoms.

The suppression of gastro-oesophageal reflux by alginates
P. W. Dettmar 1 , F. C. Hampson 1 , J. Taubel 2 , U. Lorch 2 , L. M.
Johnstone 3 , J. Sykes 3 , P. J. Berry 3 International Journal of
Clinical Practice
Volume 61 Issue 10, Pages 1654 - 1662

Disclosures Peter Dettmar and Frank Hampson are consultants to Reckitt
Benckiser Healthcare. Lesley Johnstone, John Sykes and Philip Berry
are employees of Reckitt Benckiser Healthcare.
Aims: The aim of this study was to compare alginate products with the
same amount of active ingredients but different dosage forms, in the
suppression of reflux provoked by a standard meal in healthy human
volunteers, using ambulatory oesophageal pH monitoring.
Methods: This was a single centre, randomised, open, three-period
crossover, controlled study comparing Gaviscon Advance(R) (10 ml) with
a control (10 ml water) and with a new tablet product containing the
same active ingredients as Gaviscon Advance(R). Volunteers who had
oesophageal pH < 4 for at least 2% of the 4-h period after ingestion
of a test meal followed by control at a reflux screening visit were
included in the study.
Results: The difference between Gaviscon Advance(R) and control in the
mean angular transformed percentage of time for which oesophageal pH
fell below four was statistically significant (p < 0.0001)
demonstrating the sensitivity of the method. No significant difference
between the two alginate products was found based on the least squares
adjusted mean angular transformed percentage of time for which pH fell
below four. There were also no significant differences between the two
alginate dosage forms in the angular transformed percentage of time
for which oesophageal pH fell below five and in the log-transformed
number of occasions on which oesophageal pH fell below four and five.
Discussion and conclusion: The study shows that alginate reflux
suppressants containing a low amount of antacid are effective in
suppressing acid reflux and that suspension and tablet forms are able
to give equivalent acid suppression.

On Fri, Feb 20, 2009 at 12:57 PM, Emily Wells <emilymoretz at yahoo.com> wrote:
> In reading all of these postings, I'm reminded of the staggering number of patients I've seen recently for MBS studies who aspirate post-prandially.  Their prandial swallow is normal, but have LPR and/or GERD that is copiously aspirated, usually across textures.  Indeed, these are the recurrent respiratory infection hospital admissions who end up getting PEGs (as we all know, this does NOT eliminate their risk of aspiration pneumonia).  The GI docs in a number of the hospitals I've worked find the need to place PEGs simply on being consulted.  They do not address the fact that the regurgitated material is what is causing the aspiration and that if their LPR/GERD could be addressed, they could be eating by mouth. I've found that ENT is only slightly more proactive in addressing the cause instead of a "solution." My question as a therapist...
> what dialogue for GI/ENT docs (or primary medical team) should we be initiating for treatment, (other than PPIs, which these patients are usually on already).  Because the prandial swallow is often normal, they are not typical dysphagia therapy candidates from a rehab perspective, but obviously need the advocacy so that they will not be PEG dependent based on a GI doc's band-aid approach to esophageal difficulty.
> I look forward to any comments/research/opinions.
> Emily Wells, MS/CCC-SLP

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