Consuming the Main Meal at Lunch and an Earlier, Smaller-Sized Dinner Reduced Pre-Bedtime and Nocturnal Refractory Gastro-Oesophageal Reflux but Was Less Effective for Early-Morning Laryngopharyngeal Reflux: A Case Report with Discussion

A case is reported where consuming the main meal at lunch and an earlier, smaller-sized dinner reduced averaged, refractory pre-bedtime reflux scores (over 5 days and, three months later, over 8 days) from a maximum of 3 (significant symptoms) to 0.23 ± 0.44, nocturnal reflux scores from 1 or 2 (mild to moderate symptoms) to 0.69 ± 0.85, and sore throat and cough scores from 1 or 2 to 0.85 ± 0.90. Anecdotal evidence suggested that mealtime and meal volume changes brought significant benefits for pre-bedtime and nocturnal gastro-oesophageal reflux (GER) but were less effective for laryngopharyngeal reflux (LPR) symptoms of early morning sore throat and cough. A review of the literature found that early meals before bedtime and reduced meal volumes were likely to reduce the risk of GER and developing GERD. When recumbent, it was reported that meals were digested more slowly and gastric emptying rates decreased. Meals were also digested faster in the morning than in the evening, even when awake, with circadian rhythm and air swallowing also influencing the metabolism and the absorption of food. These reports indicate a biochemical basis for the benefit of early meals before bedtime and reduced meal volumes to reduce the risk of GER. It was also reported that when recumbent, for meals close to bedtime or large meals, gravity could assist the backflow of stomach contents into the oesophagus, indicating a biophysical basis for GER. To understand the role of gravity in GER, values for hydrostatic pressure were calculated for pre-meal to meal volumes of 1000 ml and found to be from 2–23 mmHg, in the same order of magnitude as the reported tonically contracted lower oesophageal sphincter pressure of 15–30 mmHg. Hypothetical models are developed to show how gastric content (GC) and body orientation change the hydrostatic pressure on the lower oesophageal sphincter and influence the risk of GER in the fed state. In summary, it is likely there is both a biochemical and a biophysical basis for GER and LPR, with meals 5 hours before bedtime, or smaller meals before bedtime, over 5 consecutive days, together with a raised bed head and sleeping dominantly on the left-hand side, all likely to reduce refractory GER symptoms.