Dysphagia Resource CenterServing the Dysphagia professional since 1995.
Resources for swallowing and swallowing disorders.

[Date Prev][Date Next] [Chronological] [Thread] [Top]

[Dysphagia] GERD and pulmonary fibrosis


  • Subject: [Dysphagia] GERD and pulmonary fibrosis
  • From: eripley@yahoo.com (Irene Campbell-Taylor)
  • Date: Wed, 30 Jul 2003 06:30:58 -0700 (PDT)

--0-719853365-1059571858=:4134
Content-Type: text/plain; charset=us-ascii

There have been questions from time to time about the potential for lung damage from chronic microaspiration of GER. The short answer is, we don't know.
I recommend the following .Please note the comments about the early work in aspiration pneumonia/pneumonitis. These are the articles that used to be quoted as illustrating the potential "lethal" aspect os aspiration - they were describing aspiration of stomach contents, that may, indeed be lethal under certain circumstances. They were not describing oropharyngeal aspiration:
This information is current:
 
Optimizing Care for Atypical Manifestations of Upper GI Diseases

 

http://www.medscape.com/viewprogram/2224_pnt

 
Case Discussion
Dr. Fass: How often do you see in your practice gastroesophageal reflux disease (GERD)-related chronic cough? What are the possible causes for chronic cough?

Dr. Raghu: When any individual presents with chronic cough, the usual situations in the absence of infectionary pneumonia one needs to entertain smoking-associated cough conditions such as respiratory bronchiolitis, associated interstitial disease, asthma and chronic bronchitis especially if the patient is a smoker.

If you eliminate chronic bronchitis, postnasal drip, and sinusitis-related problems, one has to entertain acid gastroesophageal reflux for unexplained chronic cough, whether they have symptoms suggestive of heartburn or not. A vast majority of these patients have physiological evidence of acid gastroesophageal reflux.

Approximately 30% of patients with unexplained cough, in at least my practice at the University of Washington Medical Center, which is a tertiary-based referral practice, happen to have gastroesophageal reflux when examined from a physiologic standpoint.

???????????

Dr. Fass: I was also impressed with the high acid exposure that you recorded in the proximal esophagus of this patient. Is that something you commonly see in patients with pulmonary manifestations of GERD?

Dr. Raghu: At the University of Washington Medical Center we have documented this carefully in prospective studies using 2-probe monitoring as well as quadruple probe monitoring.

So we are finding more and more that many patients with interstitial lung disease or otherwise unexplained cough do have proximal reflux all the way back into the cricopharynx, and these are all provocative observations that warrant further, careful elucidation with prospective studies.

Dr. Fass: I was very intrigued by the information you presented about the patient's mother and the fact that she had a history of pulmonary fibrosis. The first question I want to ask is what data do we have about the relationship between pulmonary fibrosis and GERD?

Dr. Raghu: That's a very good question that is currently being debated and is controversial among those of us who are working to try to understand the mechanisms and the causative factors of pulmonary fibrosis of unknown etiology.

The evidence goes back to the literature in the 1930s with clinical evidence that initially started out as case reports. Remember, the triple-threat risk for aspiration pneumonia is the Bartlett's theory for aspiration pneumonias, which was aspiration pneumonias, chemical pneumonitis, and bacterial pneumonias. Those used to be overt aspiration pneumonias in the proximal airways, which is a bronchopneumonia-type situation.[Note: ?Overt? aspiration refers to witnessed inhalation of gastric contents.]

There's ample clinical evidence for an association between acid gastroesophageal reflux and GERD with pulmonary fibrosis; 1 large case-controlled study done at the Letterman Medical Center in California, and the University of California, San Francisco, several years ago demonstrated this. It was not only the gastroesophageal reflux or GERD that were associated with pulmonary fibrosis, but other pulmonary problems such as bronchitis, bronchiectasis, are all associated with gastroesophageal reflux. We undertook a prospective study in idiopathic pulmonary fibrosis. We documented about 3 or 4 years ago that 90% of patients, who were prospectively observed for gastroesophageal reflux based on 24-hour pH monitoring, had significant acid gastroesophageal reflux.

There's also ample experimental evidence to show that instillation of acid into the airway and the acidity of which correlates with recurrent inflammation and fibrotic response in the lung.

So this kind of evidence is there in the literature, and is provocative enough to warrant future studies to establish whether it is because of the fibrosis that there is an increased mechanical pressure to induce gastroesophageal reflux, or whether it is because of the reflux itself that the fibrotic response occurs in the lung. Remember that in pulmonary fibrosis of unknown etiology we really have no known causative factors. But on the other hand, the conceptual pathogenesis is that somehow the recurrent insult to the epithelial barrier occurs over years, and the epithelial-mesenchymal interactions lead to fibrosis.

 

 

 


Dr I Campbell-Taylor
Clinical Neuroscientist
Suite 209, 134 Lawton Blvd
Toronto, ON, M4V 2A4
416-932-1443
Exclusive Distributor:
www.interactivetherapy.com
--0-719853365-1059571858=:4134
Content-Type: text/html; charset=us-ascii

<DIV>There have been questions from time to time about the potential for lung damage from chronic microaspiration of GER. The short answer is, we don't know.</DIV>
<DIV>I recommend the following .Please note the comments about the early work in aspiration pneumonia/pneumonitis. These are the articles that used to be quoted as illustrating the potential "lethal" aspect os aspiration - they were describing aspiration of stomach contents, that may, indeed be lethal under certain circumstances. They were not describing oropharyngeal aspiration:</DIV>
<DIV>This information is current:</DIV>
<DIV>&nbsp;
<P class=MsoNormal>Optimizing Care for Atypical Manifestations of Upper GI Diseases</P>
<P class=MsoNormal>&nbsp;<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p></P>
<P class=MsoNormal><A href="http://www.medscape.com/viewprogram/2224_pnt";>http://www.medscape.com/viewprogram/2224_pnt</A></P>
<P class=MsoNormal>&nbsp;<o:p></o:p></P>
<H4>Case Discussion</H4>
<P><U>Dr. Fass</U>: How often do you see in your practice gastroesophageal reflux disease (GERD)-related chronic cough? What are the possible causes for chronic cough?</P>
<P><U>Dr. Raghu</U>: When any individual presents with chronic cough, the usual situations in the absence of infectionary pneumonia one needs to entertain smoking-associated cough conditions such as respiratory bronchiolitis, associated interstitial disease, asthma and chronic bronchitis especially if the patient is a smoker.</P>
<P>If you eliminate chronic bronchitis, postnasal drip, and sinusitis-related problems, one has to entertain acid gastroesophageal reflux for unexplained chronic cough, whether they have symptoms suggestive of heartburn or not. A vast majority of these patients have physiological evidence of acid gastroesophageal reflux.</P>
<P>Approximately 30% of patients with unexplained cough, in at least my practice at the University of Washington Medical Center, which is a tertiary-based referral practice, happen to have gastroesophageal reflux when examined from a physiologic standpoint.</P>
<P style="TEXT-ALIGN: center" align=center>???????????</P>
<P><U>Dr. Fass</U>: I was also impressed with the high acid exposure that you recorded in the proximal esophagus of this patient. Is that something you commonly see in patients with pulmonary manifestations of GERD?</P>
<P><U>Dr. Raghu</U>: At the University of Washington Medical Center we have documented this carefully in prospective studies using 2-probe monitoring as well as quadruple probe monitoring.</P>
<P>So we are finding more and more that many patients with interstitial lung disease or otherwise unexplained cough do have proximal reflux all the way back into the cricopharynx, and these are all provocative observations that warrant further, careful elucidation with prospective studies.</P>
<P><U>Dr. Fass</U>: I was very intrigued by the information you presented about the patient's mother and the fact that she had a history of pulmonary fibrosis. The first question I want to ask is what data do we have about the <B>relationship between pulmonary fibrosis and GERD?</B></P>
<P><U>Dr. Raghu</U>: That's a very good question that is currently being debated and is controversial among those of us who are working to try to understand the mechanisms and the causative factors of pulmonary fibrosis of unknown etiology.</P>
<P>The evidence goes back to the literature in the 1930s with clinical evidence that initially started out as case reports<B>. Remember, the triple-threat risk for aspiration pneumonia is the Bartlett's theory for aspiration pneumonias, which was aspiration pneumonias, chemical pneumonitis, and bacterial pneumonias. Those used to be overt aspiration pneumonias in the proximal airways, which is a bronchopneumonia-type situation.[Note: ?Overt? aspiration refers to witnessed inhalation of gastric contents.]<o:p></o:p></B></P>
<P>There's ample clinical evidence for an association between acid gastroesophageal reflux and GERD with pulmonary fibrosis; 1 large case-controlled study done at the Letterman Medical Center in California, and the University of California, San Francisco, several years ago demonstrated this. It was not only the gastroesophageal reflux or GERD that were associated with pulmonary fibrosis, but other pulmonary problems such as bronchitis, bronchiectasis, are all associated with gastroesophageal reflux. We undertook a prospective study in idiopathic pulmonary fibrosis. We documented about 3 or 4 years ago that 90% of patients, who were prospectively observed for gastroesophageal reflux based on 24-hour pH monitoring, had significant acid gastroesophageal reflux.</P>
<P>There's also ample experimental evidence to show that instillation of acid into the airway and the acidity of which correlates with recurrent inflammation and fibrotic response in the lung.</P>
<P>So this kind of evidence is there in the literature, and is provocative enough to warrant future studies to establish whether it is because of the fibrosis that there is an increased mechanical pressure to induce gastroesophageal reflux, or whether it is because of the reflux itself that the fibrotic response occurs in the lung. <B>Remember that in pulmonary fibrosis of unknown etiology we really have no known causative factors</B>. But on the other hand, the conceptual pathogenesis is that somehow the recurrent insult to the epithelial barrier occurs over years, and the epithelial-mesenchymal interactions lead to fibrosis.</P>
<P>&nbsp;<o:p></o:p></P>
<P class=MsoNormal>&nbsp;<o:p></o:p></P></DIV>
<DIV>&nbsp;</DIV><BR><BR>Dr I Campbell-Taylor<br>Clinical Neuroscientist<br>Suite 209, 134 Lawton Blvd<br>Toronto, ON, M4V 2A4<br>416-932-1443<br>Exclusive Distributor:<br>www.interactivetherapy.com
--0-719853365-1059571858=:4134--



Please send sugestions and comments to ppalmer@dysphagia.com."This site blew me away, I nearly choked!"
© 1996-2006 Phyllis M. Palmer, Ph.D.