Waking up suddenly with a sensation of choking can be a distressing experience, often accompanied by a burning feeling in the chest or throat. This common symptom for many individuals requires understanding its underlying reasons to find effective management and prevention strategies. This article explains the physiological mechanisms, common contributing factors, and practical approaches for relief and prevention.
Understanding the Phenomenon
The choking sensation experienced at night results from the backflow of gastric contents from the stomach into the esophagus, throat, and airway. This process, known as aspiration, involves inadvertently inhaling stomach acid, digestive enzymes, undigested food, and sometimes bile. Gravity, which helps keep stomach acid down during the day, is less effective when a person lies flat, allowing stomach contents to travel upwards.
A muscular ring, the lower esophageal sphincter (LES), acts as a barrier between the esophagus and stomach, preventing reflux. The LES relaxes to allow food into the stomach, then closes to keep contents from flowing back. If this sphincter weakens or relaxes inappropriately, stomach acid can escape into the esophagus. During sleep, decreased swallowing and reduced saliva production hinder the clearance of refluxed material, increasing its contact time with esophageal and airway tissues.
Common Medical Conditions and Contributing Factors
Gastroesophageal Reflux Disease (GERD), a chronic condition where stomach acid frequently flows back into the esophagus, is linked to nocturnal reflux and choking. Laryngopharyngeal Reflux (LPR) is a related condition where reflux reaches the throat and voice box, causing symptoms like chronic cough or a sensation of a lump in the throat. A hiatal hernia, where part of the stomach pushes up through the diaphragm, can also compromise the LES, making reflux more likely.
Conditions that delay stomach emptying, such as gastroparesis, increase the volume of stomach contents available for reflux. Obesity, especially abdominal weight, puts pressure on the stomach and forces contents upward. Certain foods and beverages trigger or worsen reflux by relaxing the LES or increasing stomach acid. These include fatty foods, spicy foods, citrus, tomatoes, chocolate, caffeine, and carbonated drinks.
Lifestyle choices also contribute to nocturnal reflux. Eating large meals or consuming food too close to bedtime means more undigested material is in the stomach when lying down. Alcohol and smoking relax the LES, increasing reflux risk. Additionally, some medications, such as certain antidepressants or benzodiazepines, can relax the LES, predisposing individuals to reflux episodes.
Managing and Preventing Episodes
Adjusting dietary habits helps reduce nocturnal reflux. Avoid trigger foods, especially in the evening. Eating smaller, more frequent meals prevents the stomach from becoming overly full. Stop eating at least three hours before bedtime to allow for adequate digestion.
Elevating the head of the bed by 6 to 8 inches uses gravity to keep stomach contents down. This can be achieved using bed risers or a wedge pillow that elevates the entire upper body. Sleeping on the left side is often recommended because it positions the stomach below the esophagus, making it harder for reflux to occur. Avoiding tight clothing around the abdomen, particularly at night, also prevents pressure on the stomach.
Losing excess weight reduces abdominal pressure on the stomach. Limiting or avoiding alcohol and quitting smoking significantly improve LES function and reduce reflux. Incorporating stress reduction techniques, such as mindfulness or deep breathing exercises, can also help, as stress exacerbates reflux symptoms.
When to Seek Professional Help and Medical Interventions
Consult a healthcare professional if nocturnal choking on bile or reflux symptoms are persistent, severe, or interfere with sleep quality. Warning signs include difficulty swallowing, unexplained weight loss, or chest pain, which could indicate more serious conditions. A doctor can conduct diagnostic procedures to assess the severity and cause of reflux.
Common diagnostic tests include an upper endoscopy, which uses a camera to view the esophagus and stomach, and pH monitoring, which measures acid levels in the esophagus over 24 to 96 hours. Esophageal manometry assesses the function and pressure of the LES. These tests help determine the most appropriate course of treatment.
Medical treatment often begins with medications. Proton pump inhibitors (PPIs) are prescribed to reduce stomach acid production and allow the esophagus to heal. H2 blockers are another class of medication that reduces acid secretion. For severe cases where lifestyle modifications and medications are insufficient, surgical options are available. Procedures like Nissen fundoplication involve wrapping a portion of the stomach around the lower esophagus to strengthen the LES. The LINX device involves placing a ring of magnetic beads around the esophagus to prevent reflux.