Got GERD after switching diets abruptly & having intense diarrhea. After drink lily of the desert stomach formula I started to have LPR symptoms on top of the stomach issues. It’s been years now dealing with these symptoms. Colonoscopy & Endoscopy came back normal. No hernia. Esophageal manometry & 24 hour ph test results if I’m reading them right it shows I’m having acid but my LES & esophagus motility is all normal. Laryngoscopy shows: mild postcricoid and interarytenoid edema & Mild cobblestoning of posterior pharyngeal wall.
So I’m having acid that is irritating my throat but the root cause?? Idk. I get reflux regardless of what I eat. PPIs haven’t helped. Sucralfate & Pepcid were the only medicines that helped & I was able to tolerate. So I’m trying everything. Baking soda water mix has been helping with LPR symptoms, which I’m so grateful for bc these symptoms are the most bothersome. But it does feel like a bandaid. The acid or pepsin is still coming up. I’m just neutralizing it after it’s there. I’m going to try & relax & get anxiety down. Do some stretches & stuff.
Main symptoms: - Heartburn & throat pain (I mainly can only feel one or the other. Either I feel the acid on my heart or in my throat) - Bloating - Burping - Frequent stomach gurgling - Needing to eat a lot of fiber to not feel constipated (before I didn’t know this & I was having frequent urination caused by the constipation) - Ears feeling stuffed - Runny nose - Nerve pain throughout body
My GI doc talks about modulator meds for the throat nerves I guess but they have side effects. GI doc has been saying from the start that I should get better. Basically my whole system was knocked out of whack. So I think I need to heal my stomach. & get whatever is making the acid/pepsin come up stop. Which is what I need to figure out. Any suggestions? Hope we all get better ❤️‍🩹

23 year old 5ft 11' male, 280lbs in the USA.
https://i.ibb.co/rM5GtRs/20240322-130736.jpg - location photo for reference
Hii everyone, so the other day when I was shaving I noticed a lump in my neck under my left ear. I visited an urgent care with the hope that they would be able to feel it and rule out anything serious. TBH I really was hoping for some imaging especially given my medical anxiety and the fact that I waited about 2 hours for a 2 minute visit. Now I get it this isn't anything too urgent, but to me I am having trouble knowing how worried I should be.
After a brief feel of the lump (the lump itself is non-visible, tender to the touch, gives a weird feeling when touching, and is a bit harder than what I would expect a node to feel like but not as hard as a marble) he spend 5 seconds giving some possibilities. He said it could be a swollen lymph node, but also said something about an infected vein and mentioned some major arteries in the neck. I told him I have been on Prilosec for about 2 years for LPR, and antibiotics the past month (10 days for sinus infection mid feb 10 day dose of Augmentin, and then a 10 day dose of Bactrim for possible UTI/prostate symptoms early march). I feel like his solution wasn't very personal or urgent. He prescribed both a antibiotic and an antiviral plus the 800mg ibuprofen. A day later I still haven't started the meds yet, but I am also feeling some pressure towards my throat, should I be worried?
I talked to my aunt who use to be an ER nurse 10+ years ago and she thought it seemed odd, I have attached some notes from the mychart post-visit summary below. He never talked to me about a cyst or skin infection so I don't know why this is on the notes. He never even looked in the adjacent ear. My aunt mentioned it could be a saliva gland of some sort (parotid gland) and mentioned that they should have taken my blood to rule infection out/in. She doesn't think I should start any meds yet and was confused on the antiviral/antibiotic at the same time ruling. I would love some second opinions on this, going to try to get into an ENT ASAP but I am a very anxious person and the sensation in my throat (which I could be mistaking for my LPR since I have been living with that for a while) is killing me haha.
I can start the medicine tomorrow asap if needed, does what he says make sense? Am I overthinking all of this? Again I will be going to the ENT ASAP, but I appreciate the insight.
"Patient is a 23 y.o. male C/o Acute L Anterior-lateral Neck Lymph node tenderness and swelling, Symptoms x 1-2 days. "
"HENT:
Head: Normocephalic and atraumatic.
Right Ear: Tympanic membrane, ear canal and external ear normal.
Left Ear: Tympanic membrane, ear canal and external ear normal.
Nose: No congestion or rhinorrhea.
Mouth/Throat:
Mouth: Mucous membranes are moist.
Pharynx: Posterior oropharyngeal erythema present.
Comments: +Ulcer-left
Skin:
General: Skin is warm and dry.
Comments: +grape-1,5cm tender lymph node left ant-lateral neck- Folliculitis"
"Assessment/Plan Diagnoses and all orders for this visit: Cellulitis and abscess of neck Comments: Left Orders: - levoFLOXacin (Levaquin) 500 MG tablet; Take 1 tablet (500 mg total) by mouth 1 (one) time each day for 7 days. Ok to stop Rx after 5 days if symptoms resolve - acyclovir (Zovirax) 800 MG tablet; Take 1 tablet (800 mg total) by mouth in the morning and 1 tablet (800 mg total) at noon and 1 tablet (800 mg total) in the evening. Take before meals. Do all this for 5 days. AC-OK to stop Rx after 3 days if symptoms resolve. - Ambulatory referral to ENT Aphthous stomatitis - acyclovir (Zovirax) 800 MG tablet; Take 1 tablet (800 mg total) by mouth in the morning and 1 tablet (800 mg total) at noon and 1 tablet (800 mg total) in the evening. Take before meals. Do all this for 5 days. AC-OK to stop Rx after 3 days if symptoms resolve. - Ambulatory referral to ENT Acute cervical lymphadenitis Comments: +left Orders: - ibuprofen 800 MG tablet; Take 1 tablet (800 mg total) by mouth every 8 (eight) hours if needed for mild pain, moderate pain or fever for up to 10 days. - levoFLOXacin (Levaquin) 500 MG tablet; Take 1 tablet (500 mg total) by mouth 1 (one) time each day for 7 days. Ok to stop Rx after 5 days if symptoms resolve - acyclovir (Zovirax) 800 MG tablet; Take 1 tablet (800 mg total) by mouth in the morning and 1 tablet (800 mg total) at noon and 1 tablet (800 mg total) in the evening. Take before meals. Do all this for 5 days. AC-OK to stop Rx after 3 days if symptoms resolve. - Ambulatory referral to ENT"

I developed LPR after a heavy course of PPIs a few years ago, and then dealt with pain speaking, the dreaded lump in throat / globular sensation, food getting stuck in throat, dry mouth, cobblestone pharynx, etc.
My initial response was to restrict my diet to identify triggers, but typical acid reflux triggers were not my biggest offenders. After years of experimentation, I'm now completely symptom-free.
What changed for me was understanding the gut microbiome. Here's the evidence:
LPR is caused by gaseous, not fluid contents, from the GI tract.
This is why lying down isn't as strong of a trigger and why LPR symptoms often don't co-exist with acid reflux symptoms and aren't alleviated by typical acid reflux treatments (PPIs or surgery). The main refluxate of LPRD is gas.
Where does this gas come from?
Bacterial fermentation. Likely in the small intestine, especially if you're experiencing symptoms 1-2 hours after meals.
The bacterial fermentation hypothesis is also supported by PPIs being attributed as a cause or exacerbating factor for LPR. Stomach acid suppression > bacterial growth / imbalance in small intestine as disturbed pH environment creates different growth conditions. By way of anecdotal evidence, after PPI treatment, I experienced significant bloating and burping after meals.
This also explains why IBS patients are more likely to have LPR.
Does this mean I have SIBO?
It's unclear the extent to which SIBO is a discrete illness from microbial dysbiosis more generally. The entire GI tract hosts microbes, and when the colon's microbial balance is disturbed, this impacts the small intestinal balance. In other words, by addressing the imbalance overall, SIBO will also be addressed. This is supported by FMT studies showing that rebalancing the gut microbiome improves SIBO.
Should I avoid food triggers?
So what did I do (and do many people in pain do)? Avoid food triggers. Great! Now my diet consists of 20 foods. Now 15. Now 10. And I'm still having symptoms. What happened?
You've selected for microbes that are able to ferment/digest those foods. This reduces microbial diversity, which is harmful for digestive health. Overgrowth of microbes that digest your "safe" foods means that now there is a large population of these microbes producing large amounts of gas unchecked.
So should I go on a low-FODMAP diet?
No, that works in the short-term but causes significant damage to intestinal health from microbial dysbiosis, and may make it difficult to recover necessary microbial strains. Basically, it makes the problem worse.
So, what do I eat?
The good news is: everything. Well, fiber-rich foods that enrich your intestinal flora.
At first, you will react to your trigger foods because your microbes are not adapted to digest fibers they aren't used to. You know how high-fiber foods like beans often cause gaseous symptoms when they're first eaten? Well, keep a regular bean habit, and you'll adapt to that high-fiber diet. In fact, it's been estimated that the ancient human diet may have included ~100 g/day fiber.
Personally, I found I had to incorporate small amounts of trigger foods gradually, and I adapted quickly. I went from a few bites of butternut squash causing hours of significant bloating to being able to eat a whole butternut squash without symptoms.
See if you can incorporate 30 plant foods a week. Nuts and seeds count. Spices count. Olive oil counts. Chocolate counts. The Fiber-Fueled Gut is an excellent read on the topic.
Also gotta plug the Eat the Rainbow Food Journal app. Super easy and fun way to see how many plant foods you're eating in a week -- my max was 68!
If you try this . . .
Please report back how it goes, successful or not. This process may not help everyone as our etiologies are not all the same. But if this helps you, sharing with this community could help others, and it would mean a lot to know this has helped others get relief from LPR.
Additional sources
Laryngopharyngeal reflux: The microbiota theory (PDF here)
SIBO, LPR and Reflux
Me (biology PhD background)
EDIT: A dietician recommended a FODMAPS Challenge to me at the time that I started reintroducing food triggers into my diet. The idea is to incorporate small amounts from each FODMAP group (don't stack a bunch of fructose foods on the same day, for instance). Instead of treating this is a test for sensitivities, treat this as training for your gut microbes. So if you're sensitive to one food group, slow down rather than abandon them, and make sure you're enriching your diet with other food groups.

28 y.o. caucasian M (5'10" 150 lbs) with PMHx of GERD, anxiety, depression had sore throat which began x2 months ago. Pain is predominantly R posterior pharynx worsened then slightly (but not significantly) improved with 7 days Augmentin, then after a week from finishing Augmentin pain was so severe (20/10 pain), worst pain ever, could barely talk and throat closing up, T=99.9 with chills/malaise. Got 10 days of Cefdinir 300mg BID which resolved things, then after ~1 week pain worsened again, got another 10 days of Cefdnir and resolved. Now ~1 week after 3rd course of abx things are starting to worsen again. Have ENT appointment in ~3 weeks. Currently temperature is fine. Have had multiple throat swabs for rapid strep, throat culture, mono, COVID, everything come back negative. Tried anti-histamines if case it is allergic, doesn't help much. PPI/H2RA also don't help much. Every time after I take Cedinir, pain is much better. Think its infectious, not sure why its not responding to abx. Thoughts?

Hello I have a 5 month old daughter who has had nasal congestion for 4 weeks and this past weekend it began to get worse. She overall has been her playful self, taking 4-5oz of breast milk 4x daily, multiple wet and poop diapers, again all her normal. Brought her to the peds doc this past Monday because she felt subjectively warm and for her continued nasal congestion but had a temp of 99F and he gave amoxicillin BID x 10 days for her nasal congestion. Then as soon as I get home She spiked her first (recordered) temp with a Tmax of 101.8. Gave her Tylenol and started the amoxicillin and again normal self no real changes except a little more tired at night. She had been 98-99F during the day but usually by afternoon hits 99-100 F and then at night 100-101F. Today is day 3 and I’m worried at what point do I forgo the peds doc advice and go to the ER for a urine culture. Her flu test was negative as well and she’s in day care (other than this week) both me and her mom are sick as well. Biggest concern is missing something but hard when she’s been so normal and at baseline. Nothing is really working for the congestion have done saline, suction, humidifier you name it. Doc says her source is viral because he also believes he saw erythema at her posterior pharynx but idk also said source cause be her nasal congestion with a sinusitis
She is vaccinated and pending 6mo shots second week of march
Thoughts?

Hi all, 28M. Never smoked. Have OSA due to weight but I am under CPAP treatment I noticed I constantly feel the need to clear mucus in my throat. Kinda feels like something is stuck. Sometimes I have irritated throat but isn't bad and I don't have difficulty swallowing.
Went to PCP and she looked at my tonsil and noticed that the L>R and also that she saw posterior pharynx erythema. Doctor said my neck lymph notes are not swollen
I googled and am scared now after seeing causes of unilateral enlarged tonsils. She said that post nasal drip could be contributing to the cause. Any insight?
FYl- I never really looked at my tonsils before, so l'm unsure if these are my baseline sizes. No I don't feel sick as well
Photo of tonsils attached

Hi all, 28M. Never smoked. Have OSA due to weight but I am under CPAP treatment
I noticed I constantly feel the need to clear mucus in my throat. Kinda feels like something is stuck. Sometimes I have irritated throat but isn't bad and I don't have difficulty swallowing.
Went to PCP and she looked at my tonsil and noticed that the L>R and also that she saw posterior pharynx erythema. Doctor said my neck lymph notes are not swollen
I googled and am scared now after seeing causes of unilateral enlarged tonsils. She said that post nasal drip could be contributing to the cause. Any insight?
FYl- I never really looked at my tonsils before, so l'm unsure if these are my baseline sizes. No I don't feel sick as well
Photo of tonsils attached

Im 27 yo female, 170cm/71 kg. No smoking, drinking or use recreational. Have health anxiety, chronic vasomotor rhinitis (since 12), sleeping disorder (last 3 years), chronic tonsillitis (since 21), BFS, mild acne and high level myopia. So I have stable enlarged thyroid since my early teen-age but never checked it (sorry). Yesterday I had idea to check supraclavicular lymph nodes and found strange lump right on my collarbone. I googled but every case was about lumps above collarbone, in supraclavicular fossa. I checked fossa itself and found nothing. Lump is a finger joint long (may be), soft, but not very soft, it feels like jellies under skin, or as if you touch an old pillow, filler of which become lumpy. Its painless. I haven't any lump in my left armpit or on neck. Infraclavicular left fossa is free too. I hadn't:

• strong weight loss (lose only 6kgs since June, only cuz of walking and fitness);
• night sweat;
• skin itching;
• nausea or appetite loss;
• ubnormal bleeding and pelvic pain;
• diarrhea;

I have:

• neck muscles asymmetry: left trapezia is a bit bigger, but it isn't a lymph node, its a muscle and I have it for ages;
• sometimes I feel pain in my neck, forearm and chest muscles, but relate it to wrong posture;
• my nasal problems are extremely hard, Im nasal spray addicted and every temperature lower +15C made my nasal mucosa swelly; I have endless mucus flow on my posterior pharynx, what lead to sore throat and sometimes voice changes and dysphagia;
• I have BFS;
• back pain in left hip after long sitting;
• mild acne;

I can't say that my condition worsened for last 5 years, exclude finding back pain. But Im serious afraid of cancer. Can supraclavicular nodes be founded right on collarbone, not in fossa?
My left collarbone https://ibb.co/dPNM53C https://ibb.co/SQBZC2P

Hi all,
28M. Never smoked. Have OSA due to weight but I am under CPAP treatment
I noticed I constantly feel the need to clear mucus in my throat. Kinda feels like something is stuck. Sometimes I have irritated throat but isn’t bad and I don’t have difficulty swallowing.
Went to PCP and she looked at my tonsil and noticed that the L>R and also that she saw posterior pharynx erythema. Doctor said my neck lymph notes are not swollen
I googled and am scared now after seeing causes of unilateral enlarged tonsils. She said that post nasal drip could be contributing to the cause. Any insight? FYI- I never really looked at my tonsils before, so I’m unsure if these are my baseline sizes. No I don’t feel sick as well
Photo of tonsils attached

It is over before it has happened. They are past the black tar, the bloated concrete, the phantom limbs of seaside brutalism caving centre-bound into an amorphous metropolitan mass, pox-marked, copied not created, Celtic, Gothic, Modern, tumbling as one into an untidiness of fecal brown streets, bursting apart at their seams, chronic, the roadwork as the antidote to the surplus, evolving horizontally, rapidly, over cobblestones and public parks and the pelicans and the zebras, never pausing for the flashing green man, ever constant, moving only on higher power, forwards. Maintaining heavy speed. Adjacent now to four tumour shaped tower blocks, strategically placed, affordable, unavoidable, but cast in the shadow of the latest architectural stillborns; photos of which remain filed on the hard drive hastily labelled REGENERATION, red sharpie on high-vis post-it note, dots not yet joined, ink dry. Inside people clot. Blow out beach front views of a publicly planned pier never built, ill funded, washed away in the redraft, posthumous, turbines that tumble beyond horizon and second generation Fiats, caked three times over in overfed seabird shit; short legged, once matrimony white, now impotent grey. Adrift, the passing world weary satanists launching limp-dicked kicks, homeward, tails between legs, hard night; the involuntary protestors of the barefoot angels clad only in miniskirt, brandishing broken heels like firearms, olive spray stained over peach pallor, acrylic nails popped cherry pink, colour chosen, applied at speed, without care, to the detuned cries of hungry child for mother’s milk, braless, legs spread; seen. The stars were out if they looked up. Glow dimmed, power saved, all indistinguishable in economic silhouette, the quiet hum of a standardised colour temperature, set 120 miles away by a committee of unseen hands; mirroring hospitals, bank rooms and underground sex addict support centres. EXPERIENCE FREEDOM WITH OUR FIXED RATE INTEREST MORTGAGES. Focus grouped slogans, cardboard celebrity smiles and doors automatic, leading you in, the free lunch, the triangular bite mark, the cartilage caught between the incisors of the vagrant who spends his nights pissing in the archways of the same doors automatic, double bolted, glass. A stickiness of crimson and stomach acid green happens in three separate parts, congealing into roadside puddles of honeysuckle that slip anonymously into sewer drains, without notice. Those in the passing drizzle grow hot potato feet, bounce from aisle to aisle, keeping exposed January trainers mostly vomit free, matching emotional haircuts, humourless, toothless, grooveless, plasticine faces living from yawn to yawn, no mud left to leave a print, a trace. Fell, destroyed. Getting ahead of us. They are past the tar plains, reaching forth to bruise the surrounding greenery, their fallen trees mechanically stacked, resting on land marked in one file as IN DEVELOPMENT and under another as UNBUILT, not yet toe tagged, but yes, without hope. Ground remains fertile, earth yet unsalted; irrelevant. Running parallel, farms backed in barbed wire fence, fields that die only for the winter, cows mounting one and other as cows do, later to the entertainment of churning school buses, teenage faces descending on gummed up windows, laughing hard. For now, roads silent, hard shoulders boast but snoring delivery trucks, overweight, a strong odour of fuel, diesel, leaking from their underside into fossilised rainbow pools, colour spectrum on full display, still glistening and glittering, even in night. All else stretches out ashen grey. Moving on; the residential towns and villages, with neat houses of drooping roofs, haemorrhaging into exposed brickwork; ugly but unremarkable enough to evade unwanted attention as they swell into “well developed” areas for several years now. Yet to stir, sedatives wearing off only in an hour or so. Around the corner, slick simplistic crowdpleasers with four wheel drive, well parked, unlocked, crew cut lawns, cast in that familiar terminal glow you’ve come to know, inflated rainwater, gathering about pavements, not tobacco brown but Americano; Macchiato, Cappuccino, all available now. Newspapers undelivered, still benign. Air listed as “clean”. Doctors, dentists, opticians and chiropractors, collecting the easiest paycheques of their lives, well nourished by an ache of loving mothers, all thinking the same thoughts, stiff, those who still tackled the school run with pushchairs, shouldering fat child after fat child, each old enough to run. Birds are yet to call. For now, all is unresponsive and as it should be. Further still, Earth rests intact, dew clinging, harmless, uncut blades of ordinary grass, tall, cold to the touch. Free from light, all anaesthetising shadow. A landscape rendered pure; mottled greens, blueish purples, sterilised red. An image available exclusively to those who ate their carrots. The delayed morning arrival moves through, clumsy like an aneurism, and the first birdcall of the day sounds aboard the 70mph rush; compressed, high end absent, castrated into waiting song Muzak and spat forth from the low quality speaker of the high priced phone with the fruit on it’s posterior side. You know. Up above HARPER SEPTEMBER-PETERS waits, device pressed tight against ear, almost impersonating the cool damp on the window frame to his left, facing the direction of travel, as he prefers it, gazing down to the shapeless horizon, waiting for something to form, eyes straining harder, staring out to forever. He does this even though he knows the best things emerge only when no one is looking at all. He too, an unseen forced portrait, show pony, talk of the town, in this quiet carriage anyway, still unconvinced that he is a full person, head above the parapet, if only to catch a glimpse of her at the table three down with the busyness, the cold coffee and the bleached bob air. Out of season. She, unaware that he exists, thinking only of the approaching five-uh-oh, not as simple as an ill-worded decoration that could be disposed of as deemed tacky eight wasted years later, this was permanent, irreversible, her future was in her past, three children, two divorces, no current husband, the previously unexplored idea that she may be asexual, unattracted to fifty something men anyways, mortgage still there, habits still there, failures from thirty years ago still there, still there, still there, still there, parents gone, too many numbers going up instead of down, faithless, irrelevant, uninterested by other people and their uninteresting lives, consumed by envy, slipping under, gone. September-Peters fixes his hair, only moments after discovery, but now, in his mind, they motorhome in Deutschland, two darling poodles, perpetual al fresco, lacking only opening titles and each year she can show him how to play the theme on piano. He was lost of the number of things he did on a daily basis just for imaginary people, conversations in his head only, private histories, ghosts that never assume material form; guiding him from place to place, job to job, person to person; he their marionette. The list was long, endless. Yet, when he died the manner in which he did so; the minuet gestures, the internalised sting, the perspiring, the shakes, the painfully conscious effort to guide himself face first onto the table before him, the thoughts still deemed selfish, the dignity, the trap, really all for the eyes of one person and one person only; her. At the next stop, she left. He had been doing well lately. Head down now, brain liquifying, tiny pieces of matter floating in the wreckage of who he had recently finished being. El Finito. Before him the autopsy reports, prematurely completed with steady hand, easing the stress of an oddly busy work week, final examinations scheduled, chances of yielding unexpected results; nil. Several days from now, the very same pages finding their way back to his secretary’s desk, resting there for several more, held in her WIP middle drawer and when they were eventually seen, promptly shredded and recycled. No need for fuss without cause. Years later, emerging through the other end of the system, and arriving amongst wood chips, trees grown with fertiliser, by us, for us, sandwiched between plastic veneer in bedside table, on sale, the budget furniture behemoth. Landfill. Here, the final remains of the autopsy reports come to rest. There is no pattern, only perpetual stew.

It is over before it has happened. They are past the black tar, the bloated concrete, the phantom limbs of seaside brutalism caving centre-bound into an amorphous metropolitan mass, pox-marked, copied not created; Celtic, Gothic, Modern, all tumbling as one into an untidiness of fecal brown streets. Bursting apart at their seams. Chronic; The roadwork as the antidote to the surplus, evolving horizontally, rapidly, over cobblestones and public parks and the pelicans and the zebras, never pausing for the flashing green man, ever constant, moving only on higher power; forwards.
Maintaining heavy speed. Adjacent now to four tumour shaped tower blocks, strategically placed, affordable, unavoidable, but cast in the shadow of the latest architectural stillborns; photos of which remain filed on the hard drive hastily labelled REGENERATION, red sharpie on high-vis post-it note, dots not yet joined, ink dry. Inside people clot. Blow out beach front views of a publicly planned pier never built, ill funded, washed away in the redraft, posthumous. Turbines that tumble beyond horizon and second generation Fiats, caked three times over in overfed seabird shit; short legged, once matrimony white, now impotent grey. Adrift, the passing world weary satanists launching limp-dicked kicks, tails between legs, hard night; the involuntary protestors of the barefoot angels clad only in miniskirt, brandishing broken heels like firearms, olive spray stained over peach pallor, acrylic nails popped cherry pink, colour chosen, applied at speed, without care, to the detuned cries of hungry child for mother’s milk, braless, legs spread; seen. The stars were out if they looked up.
Glow dimmed, power saved, all indistinguishable in economic silhouette. It’s the quiet hum of a standardised colour temperature, set 120 miles away by a committee of unseen hands; mirroring hospitals, bank rooms and underground sex addict support centres. EXPERIENCE FREEDOM WITH OUR FIXED RATE INTEREST MORTGAGES. Focus grouped slogans, cardboard celebrity smiles and doors automatic, leading you in, the free lunch, the triangular bite mark, cartilage caught between the incisors of the vagrant who spends his nights pissing in the archways of the same doors automatic, double bolted, glass. A stickiness of crimson and stomach acid green happens in three separate parts. Roadside; congealing into puddles of honeysuckle that slip anonymously into sewer drains, without notice. Those in the passing drizzle grow hot potato feet, bounce from aisle to aisle, keeping exposed January trainers mostly vomit free, matching emotional haircuts, humourless, toothless, grooveless, plasticine faces living from yawn to yawn, no mud left to leave a print, a trace. Fell, destroyed.
Getting ahead of us. They are past the tar plains, reaching forth to bruise the surrounding greenery, their fallen trees mechanically stacked, resting on land marked in one file as IN DEVELOPMENT and under another as UNBUILT, not yet toe tagged, but yes, without hope. Ground remains fertile, earth yet unsalted; irrelevant. Running parallel, farms backed in barbed wire fence, fields that die only for the winter, cows mounting one and other as cows do, later to the entertainment of churning school buses, teenage faces descending on gummed up windows, laughing hard. For now, roads silent. Hard shoulders boast but snoring delivery trucks, overweight, a strong odour of fuel, diesel, leaking from their underside into fossilised rainbow pools, colour spectrum on full display, still glistening and glittering, even in night. All else stretches out ashen grey.
Moving on; the residential towns and villages, with neat houses of drooping roofs, haemorrhaging into exposed brickwork; ugly but unremarkable enough to evade unwanted attention as they swell into “well developed” areas for several years now. Yet to stir, sedatives wearing off only in an hour or so. Around the corner, slick simplistic crowdpleasers with four wheel drive, well parked, unlocked, crew cut lawns, cast in that familiar terminal glow you’ve come to know, inflated rainwater, gathering about pavements, not tobacco brown but Americano; Macchiato, Cappuccino, all available now. Newspapers undelivered, still benign. Air listed as “clean”. Doctors, dentists, opticians and chiropractors, collecting the easiest paycheques of their lives, well nourished by an ache of loving mothers, all thinking the same thoughts, stiff, those who still tackled the school run with pushchairs, shouldering fat child after fat child, each old enough to run. Birds are yet to call. For now, all is unresponsive and as it should be.
Further still, Earth rests intact, dew clinging, harmless, uncut blades of ordinary grass, tall, cold to the touch. Free from light, all anaesthetising shadow. A landscape rendered pure; mottled greens, blueish purples, sterilised red. An image available exclusively to those who ate their carrots.
The delayed morning arrival moves through, clumsy like an aneurism, and the first birdcall of the day sounds aboard the 70mph rush; compressed, high end absent, castrated into waiting song Muzak and spat forth from the low quality speaker of the high priced phone with the fruit on it’s posterior side. You know.
Up above HARPER SEPTEMBER-PETERS waits, device pressed tight against ear, almost impersonating the cool damp on the window frame to his left, facing the direction of travel, as he prefers it, gazing down to the shapeless horizon, waiting for something to form, eyes straining harder, staring out to forever. He does this even though he knows the best things emerge only when no one is looking at all.
He too, an unseen forced portrait, show pony, talk of the town, in this quiet carriage anyway, still unconvinced that he is a full person, head above the parapet, if only to catch a glimpse of her at the table three down with the busyness, the cold coffee and the bleached bob air. Out of season.She, unaware that he exists, thinking only of the approaching five-uh-oh, not as simple as an ill-worded decoration that could be disposed of as deemed tacky eight wasted years later, this was permanent, irreversible, her future was in her past, three children, two divorces, no current husband, the previously unexplored idea that she may be asexual, unattracted to fifty something men anyways, mortgage still there, habits still there, failures from thirty years ago still there, still there, still there, still there, parents gone, too many numbers going up instead of down, faithless, irrelevant, uninterested by other people and their uninteresting lives, consumed by envy, slipping under, gone.
September-Peters fixes his hair, only moments after discovery, but now, in his mind, they motorhome in Deutschland, two darling poodles, perpetual al fresco, lacking only opening titles and each year she can show him how to play the theme on piano. He was lost of the number of things he did on a daily basis just for imaginary people, conversations in his head only, private histories, ghosts that never assume material form; guiding him from place to place, job to job, person to person; he their marionette. The list was long, endless. Yet, when he died the manner in which he did so; the minuet gestures, the internalised sting, the perspiring, the shakes, the painfully conscious effort to guide himself face first onto the table before him, the thoughts still deemed selfish, the dignity, the trap, really all for the eyes of one person and one person only; her.
At the next stop, she left.He had been doing well lately. Head down now, brain liquifying, tiny pieces of matter floating in the wreckage of who he had recently finished being. El Finito. Before him the autopsy reports, prematurely completed with steady hand, easing the stress of an oddly busy work week, final examinations scheduled, chances of yielding unexpected results; nil.
Several days from now, the very same pages finding their way back to his secretary’s desk, resting there for several more, held in her WIP middle drawer and when they were eventually seen, promptly shredded and recycled. No need for fuss without cause. Years later, emerging through the other end of the system, and arriving amongst wood chips, trees grown with fertiliser, by us, for us, sandwiched between plastic veneer in bedside table, on sale, the budget furniture behemoth. Landfill. Here, the final remains of the autopsy reports come to rest.There is no pattern, only perpetual stew.

PERPEPTUAL STEW
It is over before it has happened. They are past the black tar, the bloated concrete, the phantom limbs of seaside brutalism caving centre-bound into an amorphous metropolitan mass, pox-marked, copied not created, Celtic, Gothic, Modern, tumbling as one into an untidiness of fecal brown streets, bursting apart at their seams, chronic, the roadwork as the antidote to the surplus, evolving horizontally, rapidly, over cobblestones and public parks and the pelicans and the zebras, never pausing for the flashing green man, ever constant, moving only on higher power, forwards.
Maintaining heavy speed. Adjacent now to four tumour shaped tower blocks, strategically placed, affordable, unavoidable, but cast in the shadow of the latest architectural stillborns; photos of which remain filed on the hard drive hastily labelled REGENERATION, red sharpie on high-vis post-it note, dots not yet joined, ink dry. Inside people clot. Blow out beach front views of a publicly planned pier never built, ill funded, washed away in the redraft, posthumous, turbines that tumble beyond horizon and second generation Fiats, caked three times over in overfed seabird shit; short legged, once matrimony white, now grey. Adrift, the passing world weary satanists launching limp-dicked kicks, homeward, tails between legs, hard night; the involuntary protestors of the barefoot angels clad only in miniskirt, brandishing broken heels like firearms, olive spray stained over peach pallor, acrylic nails popped cherry pink, colour chosen, applied at speed, without care, to the detuned cries of hungry child for mother’s milk, braless, legs spread; seen. The stars were out if they looked up.
Glow dimmed, power saved, all indistinguishable in economic silhouette, the quiet hum of a standardised colour temperature, set 120 miles away by a committee of unseen hands; mirroring hospitals, bank rooms and underground sex addict support centres. EXPERIENCE FREEDOM WITH OUR FIXED RATE INTEREST MORTGAGES. Focus grouped slogans, cardboard celebrity smiles and doors automatic, leading you in, the free lunch, the triangular bite mark, the cartilage caught between the incisors of the vagrant who spends his nights pissing in the archways of the same doors automatic, double bolted, glass. A stickiness of crimson and stomach acid green happens in three separate parts, congealing into roadside puddles of honeysuckle that slip anonymously into sewer drains, without notice. Those in the passing drizzle grow hot potato feet, bounce from aisle to aisle, keeping exposed January trainers mostly vomit free, matching emotional haircuts, humourless, toothless, grooveless, plasticine faces living from yawn to yawn, no mud left to leave a print, a trace. Fell, destroyed.
Getting ahead of us. They are past the tar plains, reaching forth to bruise the surrounding greenery, their fallen trees mechanically stacked, resting on land marked in one file as IN DEVELOPMENT and under another as UNBUILT, not yet toe tagged, but yes, without hope. Ground remains fertile, earth yet unsalted; irrelevant. Running parallel, farms backed in barbed wire fence, fields that die only for the winter, cows mounting one and other as cows do, later to the entertainment of churning school buses, teenage faces descending on gummed up windows, laughing hard. For now, roads silent, hard shoulders boast but snoring delivery trucks, overweight, a strong odour of fuel, diesel, leaking from their underside into fossilised rainbow pools, colour spectrum on full display, still glistening and glittering, even in night. All else stretches out ashen grey.
Moving on; the residential towns and villages, with neat houses of drooping roofs, haemorrhaging into exposed brickwork; ugly but unremarkable enough to evade unwanted attention as they swell into “well developed” areas for several years now. Yet to stir, sedatives wearing off only in an hour or so. Around the corner, slick simplistic crowdpleasers with four wheel drive, well parked, unlocked, crew cut lawns, cast in that familiar terminal glow you’ve come to know, inflated rainwater, gathering about pavements, not tobacco brown but Americano; Macchiato, Cappuccino, all available now. Newspapers undelivered, still benign. Air listed as “clean”. Doctors, dentists, opticians and chiropractors, collecting the easiest paycheques of their lives, well nourished by an ache of loving mothers, all thinking the same thoughts, stiff, those who still tackled the school run with pushchairs, shouldering fat child after fat child, each old enough to run. Birds are yet to call. For now, all is unresponsive and as it should be.
Further still, Earth rests intact, dew clinging, harmless, uncut blades of ordinary grass, tall, cold to the touch. Free from light, all anaesthetising shadow. A landscape rendered pure; mottled greens, blueish purples, sterilised red. An image available exclusively to those who ate their carrots.
The delayed morning arrival moves through, clumsy like an aneurism, and the first birdcall of the day sounds aboard the 70mph rush; compressed, high end absent, castrated into waiting song Muzak and spat forth from the low quality speaker of the high priced phone with the fruit on it’s posterior side. You know.
Up above HARPER SEPTEMBER-PETERS waits, device pressed tight against ear, almost impersonating the cool damp on the window frame to his left, facing the direction of travel, as he prefers it, gazing down to the shapeless horizon, waiting for something to form, eyes straining harder, staring out to forever. He does this even though he knows the best things emerge only when no one is looking at all.
He too, an unseen forced portrait, show pony, talk of the town, in this quiet carriage anyway, still unconvinced that he is a full person, head above the parapet, if only to catch a glimpse of her at the table three down with the busyness, the cold coffee and the bleached bob air. Out of season.
She, unaware that he exists, thinking only of the approaching five-uh-oh, not as simple as an ill-worded decoration that could be disposed of as deemed tacky eight wasted years later, this was permanent, irreversible, her future was in her past, three children, two divorces, no current husband, the previously unexplored idea that she may be asexual, unattracted to fifty something men anyways, mortgage still there, habits still there, failures from thirty years ago still there, still there, still there, still there, parents gone, too many numbers going up instead of down, faithless, irrelevant, uninterested by other people and their uninteresting lives, consumed by envy, slipping under, gone.
September-Peters fixes his hair, only moments after discovery, but now, in his mind, they motorhome in Deutschland, two darling poodles, perpetual al fresco, lacking only opening titles and each year she can show him how to play the theme on piano. He was lost of the number of things he did on a daily basis just for imaginary people, conversations in his head only, private histories, ghosts that never assume material form; guiding him from place to place, job to job, person to person; he their marionette. The list was long, endless. Yet, when he died the manner in which he did so; the minuet gestures, the internalised sting, the perspiring, the shakes, the painfully conscious effort to guide himself face first onto the table before him, the thoughts still deemed selfish, the dignity, the trap, really all for the eyes of one person and one person only; her.
At the next stop, she left.
He had been doing well lately. Head down now, brain liquifying, tiny pieces of matter floating in the wreckage of who he had recently finished being. El Finito. Before him the autopsy reports, prematurely completed with steady hand, easing the stress of an oddly busy work week, final examinations scheduled, chances of yielding unexpected results; nil.
Several days from now, the very same pages finding their way back to his secretary’s desk, resting there for several more, held in her WIP middle drawer and when they were eventually seen, promptly shredded and recycled. No need for fuss without cause. Years later, emerging through the other end of the system, and arriving amongst wood chips, trees grown with fertiliser, by us, for us, sandwiched between plastic veneer in bedside table, on sale, the budget furniture behemoth. Landfill. Here, the final remains of the autopsy reports come to rest.
There is no pattern, only perpetual stew.

I would like to know if anyone feels the extreme throat pain, especially in the deep of the throat getting worse when doing even minimal physical effort? Any shortness of breath? It's been 6 months that I've been releasing clear mucus from my throat all day, almost every hour. I don't know what happened but this came all of sudden after a few bacterial infections. Almost everyday with depth throat pain.
I've had a chest ct, x-ray and all came back normal, apparently my lungs are normal... Also neck CT, and it shows normal larynx, pharynx...
I had a laryngoscopy in June, and only accused of silent reflux/posterior laryngitis. However, any minimal effort I make, the deep of my throat hurts so much, and a lot of mucus comes out of my throat. I start to feel intense shortness of breath.
My chest doesn't hurt, but I feel so much pain in my throat. Don't know what to do anymore... it's so weird that a silent reflux could cause these symptoms!
At the moment, I am being monitored by some doctors and I am going to have a cervical lymph node biopsy. My doctor said that the chance of having lymphoma is high... However, excluding that, I still feel the urge to stop these throat symptom :(

• Quick heads up:
  • LPR is very complicated with several comorbidities. If you post a question asking "is this LPR" without lots of details of your symptoms and what you tried and did not try, don't expect useful answers. I'd first do some research about LPR.
  • Most doctors don't know about LPR, including ENT's but especially gastroenterologists.
    • Feel free to use this guide and others to help yourself, or help you help them help you.
    • Note: That doesn't mean they don't know about reflux going to the throat. They just call it "reflux" or "GERD" or maybe "silent reflux". There is for sure some contention, however. And that is hopefully going to be cleared up with studies on non-acidic gaseous reflux, which I suspect is a major source of the confusion and/or controversy.
    • LPR was coined by Jamie Koufman, MD to describe Reflux from the stomach to the Larynx and Pharynx areas of the throat, but now it's known to enter the sinuses and lungs for some people. She often calls LPR respiratory reflux and prefers this term but most people still use LPR or silent reflux.
  • "Silent Reflux" is basically LPR without any typical heartburn.
    • it's "silent" because it seems like it's a sore throat or some other issue and can easily be confused with other issues and vice versa (e.g. phrase "We realized I did not really have postnasal drip from non-allergic rhinitis but rather from silent reflux mimicking postnasal drip").
  • Your overall goal to get rid of LPR should be to have zero LPR symptoms for 2 or weeks straight to let your epithelial tissue heal.
    • https://jamiekoufman.com/the-stages-of-reflux-and-recovery/
  • What works for traditional reflux (heartburn) doesn't often work for LPR, or isn't enough.
• Testing for LPR
  • Jamie Koufman (ENT) recommends the Transanasal Esophagraphy (TNE)
    • https://jamiekoufman.com/reflux-testing-for-respiratory-reflux-lpr-is-a-waste-of-time-and-money-2/
    • https://jamiekoufman.com/tne-transnasal-esophagoscopy-is-the-best-and-safest-endoscopy-choice-for-acid-reflux/
  • Faquier ENT recommends a multichannel impedence (pH 4+) test:
    • https://www.fauquierent.net/nonacidreflux.htm
  • Gastroenterologists will likely recommend an upper endoscopy with 24, 48+ hour pH study such as the Bravo, and manometry
    • while not for LPR per se, this is still very useful as reflux still occurs from farther below and is more concentrated there (may not require impedence testing), but not focused on LPR non-acidic reflux and location of symptoms (throat)
    • consider it valuable information and part of the puzzle
  • ENT's in general
    • can confirm your throat is damaged by laryngoscopy
    • E.g. I got a laryngoscopy and they saw what they call "cobblestone throat" to confirm damage. They can't guarantee this is from acid, but we piece the puzzle together that I do get heartburn and have done pH testing from further below
• Night time symptoms mostly (I fall into this category)?
  • burning sensation or sore throat that appears every or most night
  • gravity is your best friend
    • try to go for 45 degrees or more prop
  • finish eating for the day several hours before bed
  • go to either the below section for bloating or no bloating.
  • Try the TUMs trick overnight
    • https://www.reddit.com/LPcomments/17kxx4f/finally_sleeping_soundly_after_8_years_of_gerd/
• Daytime symptoms?
  • burning sensation or sore throat that appears during the day
  • be careful of symptoms overnight as well, particularly if you're a deep sleeper.
    • perhaps you sleep through it
  • be careful of gaseous non-acidic reflux (mentioned below) under bloating section.
  • use a nasal spray of alkaline + saline solution
    • baking soda provides the bicarbonate ion to alkalinize water. It is safe to spray into the nasal cavities in reasonable quantities. look online for numerous sources on how to do this safely and dose it correctly.
    • only use distilled water or a trusted reverse osmosis source without re-added minerals
  • commonly recommended solutions
    • alginates (gaviscon), antacids, acid blockers, ppi's
    • new acid blocker in USA (PCAB): Voquezna (vonoprazan)
• Bloating or burping?
  • there might be non-acidic pepsin and bile reflux (with some acid) being pushed upwards by aerosolized gastric juice.
    • some physics explanation on gases in relation to non-acidic reflux: Relationship between non-acidic (or mildly acidic) reflux and gas: Gas is a state of matter that is far less viscious than liquid with extremely high compressability compared to liquid. It can expand (uncompress) when released from the stomach (high pressure region) and dilute (this is what causes the acidity to decrease) to give you non-acidic (or mildly acidic) reflux when it reaches the throat (low pressure region). Gas travels from high pressure to low pressure in part through this expansion.
    • When gas bubbles from the stomach pick up some of the gastric juice contents such as bile, pepsin, enzymes, it can be considered an aerosol (a gas-like mixture of gas + liquids or solid microparticles) and an aerosol behaves much like a gas as mentioned above.
    • bile is an emulsifier that can disrupt the bilipid membrane of the mucus membrane, the first line of defense of the tissue of the pharynx.
    • pepsin is a protease that can digest the protein behind that bilipid membrane and be activated at mildly acidic environments between 4 and 6.5. It can be permanently deactivated above 8 or 9. But you still need to eliminate the source.
    • testing pH will not help very much, except for impedence testing that can test mildly acidic 4-7 pH at a much higher location (throat).
    • antacids and acid blockers (ppi's, etc.) aren't shown to help much here. no effect on pepsin and bile reflux
  • look into SIBO (and GI infection, like h. pylori)
    • Testing for FODMAPS may not be very accurate (according to SIBO sticky), but doesn't mean it can't help provide guidance. Do your own research here and make this personal choice.
    • Go low fodmaps diet, or even the more drastic measure like the elemental diet.
    • Antibiotics could help temporarily.
• No bloating or burping?
  • consider antacids and acid blockers for a specific duration to let the throat, etc. heal
    • https://med.stanford.edu/content/dam/sm/ohns/documents/voicecenteresources/Stanford_ENT_Clinic-LPR_Protocol.pdf
    • you'll likely want to fix the root cause at some point. see far bottom. Root
  • if antacids or acid blockers don't work at all
    • a few on this subreddit have mentioned hypersensitivity issues and benefited from certain antidepressants. you must work with your doctor for this.
• Treat any potential comorbidities (potentially related concerns that can exacerbate LPR)
  • UARS or sleep apnea or snoring
    • can cause a reduction in pressure in the throat area compared to pressure in the stomach, propelling a transient lower esophageal sphincter relaxation, allowing gases or gastric juice to be released
    • snoring occurs due to soft palate collapsing and vibrating intermittently up to hundreds or thousands of times a night. this adds more stress to tissue that should ideally at rest.
  • SIBO as mentioned above
  • GERD/heartburn for obvious reasons
    • get an upper endoscopy and check for hiatal hernia
  • postnasal drip due to allergies or lingering cough from a cold or flu.
    • mucus can further irritate the pharynx
  • asthma
    • can irritate the throat due to coughing
  • Anything else that can obviously worsen throat symptoms
    • extensive usage of vocal cords such as singing
    • poor air quality conditions that can cause coughing
• Do you also have typical postprandial heartburn after certain meals?
  • Definitely address this if it happens regularly. it is definitely related, even if events are separate as it is for me (daytime postproandial heartburn and nighttime LPR).
    • Frequent heartburn erodes the LES and can result in esophageal shortening, both of which are physiological changes that the likelihood of hiatal hernia (stomach being pulled upwards through the hiatus due to shortened esophagus, and eliminating the natural bend of the GEJ or Angle of His), which logically increases reflux and LPR risk.
    • Some people don’t really have heartburn (or notice it at least) but still get LPR, but if you do, you might consider this a silver lining because it lets you know what foods and other behaviors breach your LES but remain below your UES.
    • Your throat epithelium is much more sensitive than at the esophagus but much harder to reach and much more intricate where pooling can happen. If you get heartburn, it means gastric juice has breaches the LES and is closer to the UES and you’re at a higher risk for UES. Consider it a signal of warning.
• Recovery period
  • aim for 2 weeks without any symptoms to let the epithelial tissue in the throat, etc. heal.
    • then reduce medications, lifestyle changes, gradually, etc.
    • focus on longer term solutions below
• Longer term solutions
  • possibly the (short term) solutions mentioned above if needed and helpful
  • A more conservative diet
  • SIBO solutions if relevant
  • Hiatal Hernia surgery if relevant
    • estimated longevity is 5-20+ years due to available data
  • increasing conservative lifestyle changes matched to your age
    • reflux generally becomes more common the older you get
    • e.g. less alcohol drinking + less reflux trigger foods the older you get
    • e.g. potentially less weight lifting if you have hiatal hernia
    • potentially getting a more gradual wedge (<<45 degrees) or a bed that inclines to 5 or 10 degrees.
  • surgery
    • Unfortunately, generally it's not as inconclusive whether reflux surgeries such as fundoplications, TIF, Linx, and Stretta help LPR symptoms as much as for traditional heartburn. And the data that we do have is far less than what we have for traditional heartburn. I'm going to step forward and suggest it's due to the non-acidic and gaseous nature of many cases of LPR.
    • consider surgery as a last resort, as it should be for traditional heartburn as well.
• Is there a permanent lifelong cure that requires no maintenance?
  • Unlikely for most people, unless it was an acute (non-repeated, non-chronic) insult to the throat.
    • e.g. "I never had reflux before, but one day tried hanging upside down aerobatics after a meal and got a (temporary) sliding hiatal hernia and reflux for hours that day up to the throat. However, I was able to get their LPR fixed within 2 weeks and the sliding hiatal hernia disappeared, and it didn't come back for years." - This is theoretically possible. However there is no research data to support it or deny these rarer edge cases.
• My most frequently used resource:
  • jamiekoufman.com and her blogs (built on her numerous research studies and medical practice on LPR)

Moving bookshelves around today and came across this from an old Zoology course textbook. Enjoy!

I went in because of the body odor but they lied and said they couldn’t smell anything lol

I had sore, cobblestone throat following COVID infection in May 2022. It would not go away. Went to doctor in August 2022. Prescribed antibiotics. Didn’t work. Prescribed stronger antibiotics. Didn’t work. Suspected LPR, so referred to GI doc who was not able to see me until January. In the meantime, was sent to an allergy doc, who have me PPIs, steroid inhalers, and steroid shots. The only time I have experienced heartburn was while on PPIs, and it made all of my symptoms worse. The inhalers dried my throat terribly. Mucus in mouth/throat and tonsil stones soon followed. Upper endoscopy performed in January 30, 2023 Showed a normal esophagus and a tightly closing (Hill Grade 1) lower esophageal valve. Scheduled Bravo capsule to determine if there is, in fact, reflux, and the earliest it can be done is September 2023. Went to ENT in February 2023. ENT said is was psychosomatic globus, which all the other specialists agreed with me was complete BS, as I have no history of psychosomatic issues and there was obvious erythema on the posterior oropharyngeal wall. Later, saw a nurse practitioner ENT who determined in about 30 seconds that it was LPR, but offered no solutions other than suggesting that I can “manage it.” The next appointment was with try allergist/immunologist again. When I told him what the NP/ENT said, she said with LPR, ENTs tend to overcall it and GIs tend to undercall it. Meanwhile, I was having very loose, jagged stools. I suspected it was from all the mediations I was being given by the different specialists and emailed my GI. He simply said it could be indicative of fast transit time. Well, no shit. He also told me since my LES was closing tightly to the endoscope, if I was experiencing LPR, it would be due to transient LES relaxation. So, one day, I had the bright idea to ask ChatGPT what would cause both transient LES relaxation and rapid tea sit of stool. It replied with three things: 1) celiac disease; 2) non-celiac gluten sensitivity; and, 3) SIBO. I don’t think I have Celiac, as the upper endoscopy would have likely noticed damaged villae. NCGS is a possibly, so I quit eating gluten. Within three weeks, my symptoms nearly completely disappeared. My LPR-like symptoms appear to have resolved and my throat is almost completely healed. I have not ruled out SIBO, as I told a breath test and the hydrogen rose by 17 ppm on the first 30 minutes before dropping 20 ppm in the subsequent 30 minutes. A rise of 20 or more os positive. Clearly, there is some gray area here and it makes no sense that a 19 could be negative and a 20 positive. Of course, the GI is just following bureaucratic protocol and saying it is negative, even though an increase of 10 ppm is the threshold for positive in Europe.
Anyway, my point is, I had accepted I was in the path to Nissen fundulpication and none of the doctors ever thought of gluten. After mentioning it to them, they were all like, “yeah - gluten could do that.” So, please, try going gluten free first. I hope it works for you.