All About "Silent" Reflux: Testing, Results & Answers to Your Questions
I'm sharing my full experience with LPR (silent reflux) testing, including the results and what it means for treatment, as well as a deep dive Q&A into all things LPR.
Last week, I let you know that I was in Indiana to see Dr. Inna Husain and undergo specialized testing for LPR, also called “silent reflux.” In this video, I share the full experience and my results, as well as talk about what I learned throughout the process.
If you want to skip ahead, I start talking about the results around the 8:15 mark.
For those who want to take a deep dive into LPR in general, below I’ve answered all of the questions that you submitted about symptoms, diagnosis, treatment, and how it’s related to gastroparesis.
I think this topic is really important and deserves more attention, given how many of us with gastroparesis struggle with reflux. I hope you find it helpful!
LPR (Silent Reflux) Q&A
What exactly is LPR, and how is it different from “acid reflux” or GERD?
LPR (laryngopharyngeal reflux) and GERD (gastroesophageal reflux disease) both involve stomach contents “refluxing” backward through the GI tract, but they differ in how far that reflux travels, what it’s made of, and where the symptoms show up.
With GERD, often just called acid reflux, stomach contents rise into the esophagus but don’t go any further. The esophagus is generally well-protected from occasional reflux events, but when the episodes are frequent and/or highly acidic, it can lead to irritation, inflammation, tissue damage, and symptoms like heartburn and chest pain.
LPR occurs when reflux travels higher up — past the upper esophageal sphincter and into the throat, larynx (voice box), and sometimes the nasal cavity. These tissues do not have natural reflux protections, so any amount of stomach contents reaching these areas, whether it’s acidic or not, is problematic. For this reason, LPR tends to cause symptoms in the throat, vocal cords, and upper airway, often without any esophageal symptoms.
While both GERD and LPR can involve acid or non-acid reflux, LPR is far more likely to be weakly acidic or non-acidic, which is a key reason why acid-suppressing medications often don’t work for those with LPR.
It’s important to understand that this is all “reflux,” and having “reflux” could mean you have GERD but not LPR, LPR but not GERD, or both GERD and LPR.
What are the symptoms of LPR?
Symptoms related to LPR may include:
globus sensation (the feeling of a lump in the throat)
throat clearing
hoarseness
chronic cough
sore throat
excess mucus or postnasal drip
difficulty swallowing
breathing difficulties (especially on inhalation)
Importantly, many people with LPR do not experience classic reflux symptoms like heartburn. This is in part because LPR events are more frequently weakly acidic or non-acidic compared to GERD, meaning the reflux reaching the throat often doesn't have the acidic quality that triggers the esophageal sensation of “heartburn.” For that reason, it’s sometimes called “silent reflux.”
Why is LPR often missed or misdiagnosed?
While awareness of “silent reflux” has grown, LPR is still frequently conflated with GERD — both by patients and practitioners. Patients are often correctly identified as having some form of reflux, but incorrectly treated with acid-suppressing medications that address GERD rather than LPR.
The truth is, most people are treated empirically for reflux symptoms, meaning a doctor prescribes PPIs to see if they work. The vast majority of people being treated for reflux are never actually tested for reflux. And when they are tested, many clinics only use standard impedance testing, which can diagnose GERD but not LPR.
Awareness among otolaryngologists (ENTs), gastroenterologists, and even some motility specialists regarding the indications for and interpretation of LPR testing is low, meaning even specialists may not order the right test when the signs and symptoms of LPR are present.
What is the HEMII-pH test, and how is it different from standard reflux testing?
Standard 24-hour impedance testing measures reflux events in the lower esophagus and is designed to detect GERD. Unlike the traditional catheter used for impedance testing, the HEMII-pH catheter adds sensors at the top of the esophagus near the larynx, allowing it to detect whether reflux is reaching the airway.
Either way, a thin catheter is passed through the nose, down the throat, and into the esophagus. The catheter is connected to an external monitor that you wear for 24 hours while you go about your normal activities. You record your meals, as well as any symptoms you experience during the testing period.
The catheter is uncomfortable but tolerable for most people, and most find that it becomes easier to ignore after the first few hours once the brain gets used to the sensation.
Another option for reflux testing that you might have had or been offered is the Bravo pH test. It involves a small wireless capsule clipped to the wall of the lower esophagus during an endoscopy, which measures acid levels and sends data to a recorder you wear. It can record data over a longer period than standard catheter testing (up to 96 hours), which is an advantage, but it measures acidity only at a single point in the lower esophagus.
This means the Bravo test has the same fundamental limitation as standard impedance testing for LPR purposes. It tells you what’s happening at the bottom of the esophagus, not whether reflux is reaching the larynx. Of note, unlike standard impedance testing, which can detect weakly acidic and non-acidic reflux events, the Bravo capsule only measures acidic events.
For diagnosing LPR specifically, neither standard impedance testing nor Bravo is the right tool. If you’ve had a standard impedance or Bravo test that came back normal, that does not rule out LPR.
There is one other test specifically for LPR, called the Restech (Dx-pH) measurement system. It’s a much shorter probe that sits strictly in the back of the throat to detect both liquid and aerosolized acid. Unlike the HEMII-pH test, Restech lacks full-column impedance sensors, meaning it cannot track the direction of movement and will completely miss weakly acidic or non-acidic reflux. As a test, it can confirm LPR, but cannot rule it out. (For example, in my case, nearly all of my 62 reflux events were only weakly acidic, so Restech would’ve likely returned a normal test.)
Given all of that, 24-hour impedance testing with a HEMII-pH catheter is the gold standard for a definitive LPR diagnosis.
What are the treatment options for LPR?
There is currently no causal treatment for LPR. Instead, interventions are largely aimed at symptom management and reducing the number of reflux events.
Medication — While proton pump inhibitors and other acid-blocking medications may help those who also have GERD, they tend not to be particularly helpful for LPR, as the problem is not excess acid and reflux is often only weakly acidic to start with.
Alginates — Unlike PPIs, alginates don’t reduce acid. Instead, alginates react with stomach acid to create a floating “raft” that sits at the top of the stomach and physically prevents reflux from moving up into the esophagus (and beyond). Some people find that these provide significant relief when used after meals.
Alginates are available over the counter as products like Reflux Raft, Reflux Gourmet, Khelp, and Gaviscon Advance (Canadian and UK versions only; the US version is a different formula).
Important note: alginates do produce CO2 gas as part of the raft-forming process. If you already struggle with gas and bloating, you may want to start with a smaller dose and use it just once a day to assess your tolerance. It’s possible that they may also increase feelings of fullness for those with gastroparesis. As always, individual experimentation is necessary.
Speech and voice therapy — LPR causes chronic irritation and inflammation in the throat and larynx, and the body often responds by increasing muscle tension in this area as a protective mechanism. Over time, this pattern can become habitual, leading to ongoing symptoms even after the LPR itself is being managed.
A speech-language pathologist addresses this directly through voice therapy techniques that release that tension and hypersensitivity in the throat and vocal cords. Working with a speech-language pathologist who has experience with LPR is often an overlooked but important piece of symptom management.
Lifestyle modifications — While there is a great deal of conflicting advice online, there is no specific diet that has been proven effective for reducing LPR symptoms. Keeping a food diary to identify your personal triggers is more useful than following a generic “LPR safe” food list.
Similar to gastroparesis, while we tend to focus on what we’re eating, how we’re living throughout the day can be just as much of a factor. Other lifestyle factors to consider:
Clothing and physical pressure — Anything that increases intra-abdominal pressure can contribute to reflux events. This includes restrictive clothing like tight belts, waistbands, and shapewear, which you should avoid as much as possible.
Constipation — Straining during bowel movements significantly increases intra-abdominal pressure. For many of us with gastroparesis, constipation is already a common concern, but it’s worth knowing that it can directly worsen LPR symptoms as well. This is a good reason to avoid restricting fiber too much as part of a GP-friendly diet.
Smoking and vaping — Smoking and vaping are well-established irritants to the larynx and upper airway, and smoking is associated with weakening of the esophageal sphincters. If you smoke or vape, quitting is likely one of the most impactful changes you can make.
Alcohol — Alcohol further irritates inflamed laryngeal tissues and relaxes the esophageal sphincters. It doesn’t necessarily need to be eliminated, but frequent alcohol consumption is likely to work against other management efforts.
Stress and anxiety — The larynx is highly sensitive to the nervous system, and stress and anxiety can directly worsen throat tightening and laryngeal hypersensitivity. If you’re struggling with anxious thinking, especially around food, eating, or your symptoms, that deserves attention and support as part of your treatment plan.
Exercise timing and intensity — The general recommendation for LPR is to wait at least two hours after eating before engaging in exercise, though this is complicated by gastroparesis since it’s likely that the stomach is still quite full at two hours.
Still, it’s worth knowing that high-impact activities like running, jumping, or heavy lifting increase intra-abdominal pressure in ways that can worsen LPR symptoms, particularly on a full stomach. The same is true for activities that involve repeated or sustained bending at the waist, such as abdominal crunches or yoga.
This doesn’t mean you have to stop engaging in activities that you enjoy, but you may choose to do them earlier in the day or quite a while after meals, when there is less food sitting in the stomach.
Is LPR related to gastroparesis?
Yes, delayed gastric emptying is a known cause of LPR. When food sits in the stomach, both the volume of the content and the gases produced as the food digests create pressure inside the stomach. This pressure can force the lower esophageal sphincter open and allow contents to move up into the GI tract. The gases in the stomach, in particular, can quickly rise through the esophagus to the larynx and cause irritation each time the sphincter opens for things like talking, swallowing, or belching.
Symptoms of gastroparesis itself can also contribute to LPR or LPR-like symptoms. Vomiting is the most direct in that stomach contents are being forcefully propelled all the way up through the esophagus and out of the mouth. The delicate tissues of the larynx, which again have no natural protection against stomach contents, are being exposed to pepsin, bile, and whatever acid is present repeatedly and often. Passive regurgitation, where stomach contents move back up into the throat or mouth without the force of a full vomiting episode, can cause similar issues.
If LPR is being driven by delayed gastric emptying, fine-tuning your comprehensive gastroparesis management plan should help to reduce LPR symptoms. If you need help getting started on or revisiting the idea of a comprehensive management plan, my newly updated Quick Start Guide to Gastroparesis Management is a great resource. (It’s available to all free and paid Substack subscribers; message me if you’re already subscribed and need the download link again.)
Is there a connection between LPR and Ehlers Danlos syndrome?
Yes, the likely mechanism is connective tissue laxity: the sphincters that are supposed to keep stomach contents in place can, like other tissues in EDS, be weaker than they should be, predisposing people to reflux reaching the throat and upper airway.
Research has begun to bear this out — studies have found that EDS patients report LPR symptoms at significantly higher rates and severity than the general population. If you have EDS, make sure any specialist treating your reflux or LPR symptoms is aware of your diagnosis.
What should I do if I think I have LPR?
If you’re experiencing symptoms like sore throat, hoarseness, chronic cough, throat clearing, or breathing difficulties alongside your gastroparesis, ask your doctor specifically about LPR. If you’ve been told your reflux testing came back normal, ask your doctor whether the test used a HEMII-pH or dual probe/high-probe catheter. Standard impedance and Bravo testing can rule out GERD, but they cannot rule out LPR.
As noted, not all doctors, even specialists, are currently familiar with specialized LPR testing, and it’s not available everywhere. If LPR testing isn't accessible to you right now, current guidelines support an empirical trial of alginates, meaning trying them and seeing whether your symptoms improve. If so, it provides good evidence that LPR may be present.
If you have additional questions about your personal situation, Dr. Inna Husain sometimes has availability for online consultations. You can check that here.
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So if LPR doesn’t typically involve acid, can one presume Barrett’s is unlikely to be an issue for folks with true LPR?