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Gastroesophageal Reflux and Idiopathic Pulmonary Fibrosis

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Gastroesophageal Reflux and Idiopathic Pulmonary Fibrosis World J Surg (2017) 41:1691–1697 DOI 10.1007/s00268-017-3956-0 SURGICAL SYMPOSIUM CONTRIBUTION Gastroesophageal Reflux and Idiopathic Pulmonary Fibrosis 1 1 1 2 Marco E. Allaix • Fabrizio Rebecchi • Mario Morino • Francisco Schlottmann • Marco G. Patti2 Published online: 3 March 2017 Ó Socie´te´ Internationale de Chirurgie 2017 Abstract Background Idiopathic pulmonary fibrosis (IPF) is a progressive interstitial lung disease of unknown origin that affects about 40,000 new patients every year in the USA. Albeit the disease is labelled as idiopathic, it is thought that pathologic reflux, often silent, plays a role in its pathogenesis through a process of microaspiration of gastric contents. Aims The aim of this study was to review the available evidence linking reflux to IPF, and to study the effect of medical and surgical therapy on the natural history of this disease. Results Medical therapy with acid-reducing medications controls the production of acid and has some benefit. However, reflux and aspiraion of weakly acidic or alkaline gastric contents can still occur. Better results have been reported after laparoscopic anti-reflux surgery, as this form of therapy re-establishes the competence of the lower esophageal sphincter, therefore stopping any type of reflux. Conclusions A phase II NIH study in currently in progress in the USA to determine the role of antireflux surgery in patients with GERD and IPF. The hope is that this simple operations might alter the natural history of IPF, avoiding progression and the need for lung transplantation. Introduction development of the disease. Chronic microaspiration of gastric refluxate might be one of these insulting factors Idiopathic pulmonary fibrosis (IPF) is a chronic and irre- involved in the pathogenesis of IPF [3]. GERD is much more versible interstitial pneumonia of unknown origin that prevalent in IPF patients than in the general population, in affects approximately 38,000 individuals every year in the patients affected by cystic fibrosis, asthma, or chronic USA [1]. It progressively leads to lung fibrosis, respiratory obstructive pulmonary disease [4–9]. In addition, a laparo- failure, and eventually to death [2]. scopic fundoplication in the management of patients with Even though the etiology of IPF is still unclear, the lung IPF and GERD has been reported to both control reflux and exposure to factors that might cause injury to the pulmonary avoid aspiration of refluxate, thus slowing the progression of parenchyma inducing an inflammatory response and subse- this disease [10–12]. Finally, a role of proton pump inhibitors quent fibrosis has been suggested to be key for the (PPI) slowing down the impairment of lung function, decreasing the number of episodes of acute exacerbation of the disease and prolonging the transplant-free survival has & Marco G. Patti [email protected] been shown in IPF patients [13]. This manuscript reviews the current knowledge avail- 1 Department of Surgical Sciences, University of Torino, able on the relationship between IPF and GERD, focusing Turin, Italy on clinical presentation, esophageal motility and reflux 2 Center for Esophageal Diseases and Swallowing, University profile of patients with IPF. The effects of both acid of North Carolina at Chapel Hill, Chapel Hill, USA 123 1692 World J Surg (2017) 41:1691–1697 suppressing therapy and anti-reflux surgery in patients with a mechanically defective LES represent the pathophysio- IPF are also discussed. logical mechanism of abnormal reflux of gastric contents into the esophagus. On the contrary, the upper esophageal sphincter (UES) pressure is frequently lower in IPF patients GERD and IPF: clinical presentation and this might be associated with an increased risk of and gastroesophageal function aspiration. Studies comparing GERD patients with or without IPF showed that the amplitude of esophageal Symptoms peristalsis in both proximal and distal esophagus is not impaired in IPF patients: ineffective esophageal motility, While heartburn and regurgitation are the most common that is frequently detected in patients with other lung dis- symptoms reported by GERD patients without IPF, reflux is eases, is uncommon in patients with IPF [4, 14, 18]. In often asymptomatic in GERD patients with IPF. A study particular, Raghu et al. [4] found in an analysis of 65 IPF from the University of Chicago evaluated the clinical pre- patients that mean LES length, pressure and percentage of sentation in 80 patients with GERD only and in 22 patients relaxation were within the normal range, and the vast with GERD and IPF [14]. The prevalence of heartburn was majority of patients had normal esophageal peristalsis. significantly lower in patients with IPF than in patients with These pathophysiological findings lead to a tailored GERD only (59 vs. 84%, P = 0.028), while the two groups approach in patients with pulmonary disorders who are did not differ in terms of prevalence of regurgitation. Extra- scheduled for anti-reflux surgery: while patients with esophageal manifestations of GERD, including hoarseness, connective tissue disorders more frequently undergo a cough and chest pain were significantly more common partial fundoplication in order to minimize the risk of among patients with IPF. Duration of symptoms was also postoperative dysphagia, patients with IPF have a total similar in the two groups. These results are consistent with fundoplication. There is evidence that a total wrap is those reported by other authors [4, 15–17]. For instance, associated with better reflux control than a partial wrap: it Sweet et al. [16] determined the prevalence of reflux symp- increases LES pressure, decreases TLESR and improves toms in 109 patients awaiting lung transplantation for end- the amplitude of the esophageal peristalsis [19–27]. stage lung disease (27 patients with IPF). All patients underwent esophageal manometry and ambulatory 24-pH Reflux profile monitoring. A total of 74 patients had pathologic reflux, while 35 had a normal 24-pH study. The main symptoms Several studies using a dual-channel pH probe have were respiratory. Reflux was asymptomatic in 33% of those reported frequent proximal reflux events in IPF patients, with distal reflux and in 38% of those with proximal reflux. with pathological proximal esophageal acid exposure to At least one typical GERD symptom, such as heartburn, acid refluxate in up to two-thirds of patients [4, 28, 29]. For regurgitation, or dysphagia was reported by 69% of subjects. instance, Raghu et al. [4] studied the reflux profile in 65 There was no difference in the prevalence and severity of consecutive IPF patients with 24-hour pH monitoring. heartburn or regurgitation among patients with and without Overall prevalence of pathological reflux was 87%, and GERD. Only half of the patients with GERD had dysphagia. only 47% of these patients were symptomatic for reflux. There was no correlation between severity of typical symp- Among the 46 (71%) IPF patients who were not taking toms, and the DeMeester score or the percentage of time the PPIs at the time of the pH monitoring, the prevalence of pH was \4.0 in the proximal esophagus. Moreover, the pathologic distal and proximal esophageal acid exposure sensitivity and specificity of typical symptoms of GERD was 76 and 63%, respectively. Recently, Hoppo et al. [30] were 67 and 26%, respectively, for distal reflux, and 62 and analyzed the reflux profile in 28 IPF patients by using the 26%, respectively, for proximal reflux. 24-hour hypopharingeal multichannel intraluminal impe- These findings show that typical symptoms do not allow dance (HMII): 15 patients had abnormal proximal expo- to distinguish between patients with and without patho- sure. Proximal reflux was defined as laryngopharyngeal logical reflux. Since abnormal reflux is silent in more than reflux C1/day and/or full column reflux C5/day. About one-third of cases, 24-hour pH monitoring should be rou- 25% of proximal reflux events were non-acid. These tinely obtained to screen these patients for GERD regard- patients had a higher rate of esophageal mucosal injury, less of the absence of symptoms. higher numbers of total and distal reflux events and a trend toward longer acid clearance time than the patients without Esophageal manometry abnormal proximal exposure. However, there were no significant differences in the clinical presentation, and the The LES pressure is normal in most IPF patients, sug- DeMeester score was within the normal values in more gesting that transient LES relaxations (TLESR) rather than than 80% of patients in both groups. Further large studies 123 World J Surg (2017) 41:1691–1697 1693 are needed to validate the routine use of HMII in the when a temporarily defined correlation between aspiration functional evaluation of patients with IPF. and esophageal acid exposure was found. In 1979, Pelle- The evidence coming from studies comparing GERD grini et al. [35] assessed the incidence of pulmonary patients with or without IPF suggest that the total aspiration and the esophageal pathophysiology in 100 DeMeester score is usually not significantly different patients with GERD diagnosed by ambulatory 24-pH between the two groups of patients. However, the total monitoring with the pH probe that was positioned 5 cm esophageal acid exposure in the proximal esophagus is above the upper border of the manometrically determined significantly higher in IPF patients. This difference is LES. Aspiration was suspected to occur in 48 GERD mainly detected in the supine position, while the acid patients based on the reported symptoms. A total of 9 exposure in the upright position is not significantly dif- patients were considered to be potential aspirators because ferent. Similarly, total and supine acid clearances are sig- of reported oral acid regurgitation without developing nificantly slower in IPF patients, while no significant pulmonary symptoms, while 8 patients were identified as differences are usually observed in the upright position aspirators according to the detection of reflux episodes in [14]. the distal esophagus temporally followed by acid taste in Based on the recent detection of both pepsin and bile the mouth with cough or wheezing.
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