Question: Aplogise for the detailed post. This may sound silly at times, but it is really affecting me...so be kind.

Hi I am 40, 6 feet, 67 kg of Indian origin. Drinks alcohol since last 18 years, initially at a about 240 ml per day of spirits like whisky, in the last 3-4 years reduced to about 100-150 ml/day on most days. Non-smoker. When I was young, I used to drink late into night and often skip dinner and sleep. Last 7-8 years this has stopped, however eats dinner after alcohol and just before sleeping which my doctor says contributed to GERD and now LPR (larygeal reflux).

About 5 years back started getting chest pains and went to cardio for checkups. Diagnosed as having mild hypertension, but all tests of cardio, liver, ultrasounds etc. were normal. Cardio referred me to gastro on account of drinking and slightly elevated prothrombin timings. Gastro advised upper endoscopy on account of drinking and diagnosed me with GERD and Grade II esophagitis and mentioned in the report 'Esophagus - prominent veins+? Early V , Stomach - Multiple small ulcers distal body". H. pylorie was negative. Prescribed Pantaprezole 20 mg for 8 weeks and advised stopping alcohol. Suggested acidity as reason for chest pain.

I did not start on the medication for a while. Started on Pantaprezole about 4 years back when the I started getting more chest compression, gas burping etc. Reduced on alcohol. Still used to have occasional feeling of giddiness, rising hypertension, chest compression, burping etc. These are mostly felt in the mid-day and stops by evening. I started to take 2.5 mg of Amlodipine and 20 mg Omeprezole on almost daily basis. Subsequent tests of Liver functions tests including prothrombin timings were normal. Further reduced alcohol to about 120-150 ml spirits daily.

Did a complete medical checkup 15 months back and everything was normal. Elected for upper endoscopy on my own and the findings were "Esophagus - multiple erosion at GE junction & Grade A reflux esophagitis" Other areas were normal. He advised me to continue Omeprezole.

About six month back started getting excessive bad breath and this coincided with having watery stool and involuntary passing of tiny amount of stool in the undergarments. This was normally on days when my drinking exceeded the 120-150 ml limit. The stool passage has stopped after restricting alcohol to XXXXXXX 120 ml.
In last 6 months or so I started getting excessive burping. When drinking alcohol, I used to feel the burning sensation in my stomach, which was not there before. My spouse who is a GP herself mentioned my breathing has become foul and the mouth is having fecal smell. The smell was worse on days I drink more. On hindsight I think I also may have had (not sure of this point) a burning sensation in throat while drinking alcohol. I should also add that since about 2 years, I took a fancy for drinking scotch whisky and I started drinking it with very little water. I started adding more water again since about 6 months back when what I perceived as acidity related symptoms worsened.

Now coming to what made me an 'alleged hypochondriac' is the fact that I got a cold about 35 days back. It went away in 2 days, but felt throat pain when sleeping or when the jaws touch the neck. There was a soreness of the throat as well. Reading about the symptoms made me doubt this could be throat cancer and life is not the same since. I stopped drinking alcohol completely. I took a course of antibiotics which made my stomach worse and I used to have stomach pain. A week later throat sore was there, but pain subsided. I went and so an ENT and the first thing she mentioned on doing mirror laryngoscopy was that it might be reflux. She said there was inflammation and redness in the arytenoid area and advised me to take PPI, domperidone 10 mg and citrezine 10 mg. 3-4 days later I was still freaking out and went to see another ENT. He heard the history and again did a mirror scopy and said it must be reflux only and said there is inflammation and mucous in the area. Prescribed me nexium 40 mg once a day along with domperidone. Asked me to see him after 2-4 weeks. After taking Nexium, things became better for a few days. I also changed my lifestyle. No alcohol, eats lots of fruits and vegs, avoids spicy food, eats food about 3 hours before sleeping and used to take Gaviscon advanced prior to sleeping. Sleeps with the upper torso on an raised pillow blocks etc. I learned from reading that LPR takes time to heal and was feeling OK with that.

Stopping the alcohol helped too. BP became normal and I am no longer taking the amlodipine. Sleep is good. The foul mouth odour has gone. The burping and chest compression etc. became less. Urine has become white in color. Only it has not helped the LPR yet.I have not touched alcohol since 5 weeks and I do not miss it at all.

Then again I started to feel the soreness in the throat with some swallowing etc. Occasional pain were also felt. To make things worse, for the first time in my life I saw fresh blood in my stool which came towards the end of the motion. I have been watching my stool for the nearly 3-4 years and this is the first time I saw bright red blood. Gave it for fecal analysis and the part of the feces that had blood on it tested positive for blood and occult blood. The other part of the same stool was negative for both blood and occult blood. Next day tested again and stool tested negative for FOB. I was now scared i might have colo-rectal cancer, if not upper GI cancer as well.

Went to a gastroenterologist and he did a proctoscopy and found a small bulged vein in the distal end of rectum that seemed to have bled just recently. He said it was not even an hemorrage. He advised me to do FOB test after a week or more. I am yet to do it, but I can’t see any visible blood in stool since.

The throat condition fluctuated between bad to OK and the stress of it all seemed to weigh in on me. I also feel random pains in my various areas of stomach and nowadays feel a burning feel in stomach whenever I eat late. All this made me see yet another gastroenterologist about 10 days back. He went through the history and previous reports thoroughly and said there do not seem to be anything other than reflux in play. He palpated my stomach and felt there seem to be stool buildup and advised me to take fiber supplement. I was querying him repeatedly if any of this could be cancer and I should be going for an upper endoscopy. He felt my 15 month old endoscopy report only indicated mild reflux and he did not feel an endoscopy may be indicated considering how expensive it was to do it there for an uninsured patient like me.. he also doubled my Nexium intake to 2 x 40 mg tabs for 2 weeks to be tapered down to 1 tab for 2 weeks and then 20 mg later. I started to feel better and then started double dose of the Nexium. Things were again better and I became much relieved. Motion became daily compared to once in 2-3 days since the fiber intake. I was relieved and so relieved in fact that I ate some chicken and junk food twice on two days. However couple of days later symptoms of throat were back along with feeling of cramps in stomach. Last three days throat felt worse again and I felt slight dull pain in the throat and a pain just below the area where the collar bones join. Another panic attack and fears of throat cancer spreading to may be bones.. silly as it may sound.. Fears of stomach cancer also were increasing.

Today could not bear the feeling of throat getting worse. Felt some mild pain in the throat and the gulping was back. Went to see the second ENT I had seen before. His first comments were that if it has not improved since 20 days of Nexium, may be I should 'investigate if something is active there'.. Then he did a mirror scopy and stopped it under a few seconds unlike the first time, when he took lots of time to inspect. He said the area is still red and inflammed. He then told me ' not to take Nexium 80 mg and advised me to continue with original recommendation of 40 mg a day and to use liquid antacids whenever I felt acid reflux symptoms. he was not happy that I did used domperidone only for couple of days (I stopped it after the blood in the stool incident along with the citerezine tab). He asked me to resume both (Domperidone before meals Citerezine when feeling irritation in the night) with Nexium. I specifically asked if this could be cancer and if I need to go for upper endoscopy. he said why am I getting worried despite him telling it do not look like cancer. I asked him if he can see XXXXXXX enough and he yes he could see my laryngopharyngeal area clearly and there is nothing there other than the redness that he reckon is only reflux. He said I can do endoscopy later if needed along with colonoscopy if I go to places where treatment is cheaper like in India.


Now I don't know if I have cancer, I am tempted to believe what the doctors have been saying, but I cannot. I keep worrying so much about the possibility that I have an undetected cancer that I am allowing to get worse by not diagnosing. In fact the worry has become the cancer of the mind and docs says it is contributing to the acidity and worsening the symptoms.

My immediate worries and the ones I am looking for answer from the Expert Doctor are the following:

1. Which specialty should I approach given my medical background? ENT? Gastroenterologist? oncologist?

2. Can the ENT get a complete picture of the laryngopharyngeal area by doing a mirror scopy? Should they do a proper flexible or direct laryngoscopy to be sure? Or do the clinical presentation based on mirror scopy and the symptoms sufficient to arrive at correct diagnsosis?

3. What are the chances of this being throat cancer? Or more precicsely the ENT be missing throat cancer by mistaking it for LPR?

4. Can ruling out throat cancer only be confirmed using an endoscopy? I asked today my ENT and his answer was "what can you diagnose by endoscopy? Only by taking biopsy, right? And biospy of what? There has to be something suspicious to take biopsy? I do not see anything and if I had doubt, i would have told you" Now this should have put me at ease had it not been for the fact that the first comment he said after seeing me today and hearing the soreness is coming on and off was that "may be you should investigate something is active there if nexium is not working after 3 weeks".. Now is he trying to placate me or by mirrorscopy he did not find anything that's worrying?

4. What should be my course of action to put my mind at rest by ruling out cancers of the entire GI tract? Can such elaborate procedures wait one month till I reach India, so it will be afforable for me?

5. is an upper endoscopy useful for laryngopharyngeal area diagnosis? or should I do laryngoscopy?

6. How do the clinical presentations and appearancs of LPR and throat cancer differ? What makes an ENT or a Gastro decide to take a biopsy? Can such differences seen through the mirror scopy or do they miss the magnification and recording offered by laryngoscopy or endoscopy?

7. I have lost about kilo since this all began, could be atttributed to the diet which has cut down on all fat. is this OK.

8. I keep getting cold (today it is the third time in a 35 days). May be this could be because of visit to ENT where people might have had cold. Does this signify anything?

9. Last 3-4 days I occassionally feel I am having very mild pain around the neck, behind sometimes, on sides other times. These are not very much or I could be imagining things. Does this have any significance from cancer point of view?

10. Now both the ENT clinics I went had no facility to do a direct laryngoscopy. Could this be the reason they did not do a direct scopy? Can they tell by doing only mirror scopy?
11. Despite taking 80 mg of Nexium, I still feel burning sensation in my stomach when the food is delayed. Does this sound abnormal? If I eat food and take some antacid, it helps to relieve it. Now is that a symptom of colo-rectal cancer?

Please help me and guide me. Often I think I should take a break from my work and go to India to have it all checked regardless what it means to leave now. Preferably I would like to a proper analysis next August when I am due to travel.

Thank you Dr. XXXXXXX that's certainly a well balanced reply.

I have been to two ENTs and two Gastroenterologists already and none did not seem concerned there is anything urgent that need my action. My worry has been on account of the fact that, barring indirect laryngoscopy by ENT and proctoscopy by Gastro, no other invasive investigation has been done.

Anyway, I have decided to go for an eosophagoscopy. Now the throat area affected seem to be the arytenoid area. My ENT also suggested going for an upper Endoscopy when I go to India as the choice of investigation. Will this area be visualised by doing upper gastroscopy? Do I need a laryngoscopy as well? What advantage laryngoscopy have over eosophagal endoscopy or rather do it visualise areas not visualised by the eosophagal endoscopy?

My symptoms are getting better and then going back to old level (overall I feel it has become very slightly better from the onset) after a few days. Is this more typical of reflux or cancer?

If the laryngoscopy and eosophagoscopy do not find anything, is there anything I need to do further to rule out any form of cancer? At what stage do the cancer start giving symptoms? Is there anything called a stage 0 symptom? Will dysplasia cause symptoms? After negative investigation, if the throat do not improve, how frequently should I another investigation or is it warranted?

Thanks a lot.

Thank you doctor. You have been quite helpful.

I will fix an appointment with ENT attached to an hospital first and ask them to do an laryngoscopy. I did call and ENT after your reply and the first thing he said was to 'why do you want to do go for a direct layngoscopy for reflux?'..hmm may be not sure whey they feel direct laryngoscopy is unnecessary. Just a couple of points more:

1. To re-phrase a question asked earlier, do cancerous lesions in the pharyngo-laryngeal area cause on and off symptoms? Mine seem to get better for 3-4 days and then go worse when my acid related symptoms worsen or when I get a feeling of having cold. In the latter case, the soreness soft palate area feel similar way to infection of cold and the throat feels bad with some occasional needle pains. I always feel better in the morning and the worsening of symptoms, when it occurs, happens during the 11 am - 7 pm period. This is normally the time I fell reflux problems as well.

2. Anyway as separate issue, I have had an incident of fecal blood and I have now had three stool samples (tested in different days in a period of 2 weeks) that had turned negative for occult blood. Do a colonoscopy for cancer diagnosis still warranted considering previous single instance of fecal blood which the Gastro think may have come from a dilated vein he found in the distal end of rectum on proctoscopy?

Thank a lot for your help and guidance.