Digestion and respiration are often thought of as discrete systems in the human body. But as Walter W. Chan, MD, MPH, Director of the Center for Gastrointestinal Motility at Brigham and Women’s Hospital (BWH) and colleagues have demonstrated, there is a significant interplay between gastrointestinal disorders such as gastrointestinal reflux disease (GERD) and pulmonary function, and this interaction may have important consequences for patients with severe asthma and for those with chronic lung diseases such as idiopathic pulmonary fibrosis (IPF) who are candidates for lung transplants.
There has long been a suspected association between gastroesophageal reflux disease, or GERD, and respiratory problems such as asthma, but research into a possible connection has been largely inconclusive.
“Patients with chronic lung diseases like idiopathic pulmonary fibrosis are more likely to have reflux, and there’s some thought that the reflux itself may be contributing to damages in the lungs through aspiration. However, this has not been clearly established in past studies, because people who have poor lung function from their lung disease are more likely to have reflux to begin with due to the change in breathing mechanics and the change in pressure between the chest and abdomen,” Dr. Chan said. “The question is: Is reflux causing the lungs to be worse or is the lung disease causing reflux to be worse?”
“A big focus of our clinical research is the airway and pulmonary complications of GERD, so we get a lot of patients referred to us specifically because they have a lung problem such as severe asthma, and reflux is suspected to be potentially affecting their lung disease,” Dr. Chan said.
He and colleagues have conducted a study of adults with suspected laryngopharyngeal reflux (LPR) for whom an empiric trial of therapy with a proton-pump inhibitor failed. They found that traditional diagnostic criteria using standard reflux monitoring catheters has only fair-to-poor sensitivity for identifying abnormal pharyngeal reflux events in patients with refractory throat symptoms. Their practice-changing recommendation is to use specialty pH-impedance catheters with pharyngeal impedance channels for evaluating patients with suspected LPR.
Results of the study were presented in April 2016 at Digestive Disease Week (DDW; Gastroenterology. 150;4(suppl 1): Abstract 141).
The Center for Gastrointestinal Motility is also one of only a few in the United States to offer multidisciplinary specialty diagnosis and care of adults with eosinophilic esophagitis.
A recent study by Center investigators, also presented at DDW 2016 (Gastroenterology. 150;4(suppl 1): Abstract 667), showed that standard PPI doses currently used in attempts to identify esophageal eosinophilia responsive to PPI therapy (PPI-responsive esophageal eosinophilia or PPI-REE) may not be sufficient.
“If these patients are not PPI responsive, then the treatment is either lifelong steroid therapy or very restrictive diets. But if we can identify patients that are PPI responsive, they can be managed on PPIs alone. The problem is that even in the most recent published treatment guidelines, there is no consensus as to what dosage of PPI you need to use to identify these patients,” Dr. Chan said.
He and colleagues looked at a cohort of patients diagnosed with esophageal eosinophilia on mucosal biopsies from esophagoduodenoscopy (EGD). All patients underwent a PPI trial for at least eight weeks in one of four PPI dosing arms: standard dose (omeprazole 20 mg or equivalent), once-daily moderate dose (omeprazole 40 mg or equivalent), twice-daily moderate dose (omeprazole 20 mg twice daily or equivalent), or high dose (omeprazole 40 mg twice daily or equivalent).
The patients underwent repeat EGD after the trial, and were then classified based on histologic responses into PPI-REE versus conventional eosinophilic esophagitis.
The investigators found that compared to standard dose PPI, the twice daily moderate dose and high-dose groups had significantly higher prevalence of PPI-REE diagnoses in both univariate analysis and multivariate analysis controlling for potential confounders.
“What we found was that taking a PPI twice a day is important, and probably more important than being on the highest dose. We’re hoping that this work will help to establish a standard in managing these patients upfront, so that we’re not underdosing and missing these patients, and forcing some to get steroids or be on a restrictive diet when they could be managed with a PPI alone,” he said.
At Brigham and Women’s Hospital, our gastroenterologists are available for timely consultations and will work with you to develop treatment plans for complex cases. Our Physician Liaison Ellen Steward can provide direct assistance with patient referrals and consultations. Ellen can be reached at 617-582-4733 or esteward@partners.org.
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