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Vélez C, Neuringer I, Schwarzenberg SJ. The foregut in cystic fibrosis. Pediatr Pulmonol 2024; 59 Suppl 1:S61-S69. [PMID: 39105333 DOI: 10.1002/ppul.27123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 05/23/2024] [Accepted: 06/01/2024] [Indexed: 08/07/2024]
Abstract
The aerodigestive organs share a kindred embryologic origin that allows for a more complete explanation as to how the foregut can remain a barrier to normalcy in people with cystic fibrosis (pwCF). The structures of the aerodigestive tract include the nasopharynx, the oropharynx, the hypopharynx, the esophagus, the stomach, as well as the supraglottic, glottic, and subglottic tubular airways (including the trachea). Additional gastrointestinal (GI) luminal/alimentary organs of the foregut include the duodenum. Extraluminal foregut structures include the liver, the gall bladder, the biliary tree, and the pancreas. There are a variety of neurologic controls within these complicated anatomic compartments to separate the transit of food and liquid from air. These structures share the same origin from the primitive foregut/mesenchyme. The vagus nerve is a critical structure that unites respiratory and digestive functions. This article comments on the interconnected nature of cystic fibrosis and the GI tract. As it relates to the foregut, this has been typically treated as simple "reflux" as the cause of worsened lung function in pwCF. That terms like gastroesophageal reflux (GER), gastroesophageal reflux disease (GERD), heartburn, and regurgitation are used interchangeably to reflect pathology further complicates matters; we offer a more physiologically accurate term called "GI-related aspiration" or "GRASP." Broadly, this term reflects that aspiration of foregut contents from the duodenum through the stomach to the esophagus, into the pharynx and the respiratory tree in pwCF. As a barrier to normalcy in pwCF, GRASP is fundamentally two disease processes-GERD and gastroparesis-that likely contribute most to the deterioration of lung disease in pwCF. In the modulator era, successful GRASP management will be critical, particularly in those post-lung transplantation (LTx), only through successful management of both GERD and gastroparesis. Standardization of clinical management algorithms for GRASP in CF-related GRASP is a key clinical and research gap preventing normalcy in pwCF; what exists nearly exclusively addresses surgical evaluations or offers guidance for the management of GI symptoms alone (with unclear parameters for respiratory disease considerations). We begin first by describing the result of GRASP damage to the lung in various stages of lung disease. This is followed by a discussion of the mechanisms by which the digestive tract can injure the lungs. We summarize what we anticipate future research directions will be to reduce the impact of GRASP as a barrier to normalcy in pwCF.
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Affiliation(s)
- Christopher Vélez
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Isabel Neuringer
- Division of Pulmonology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sarah Jane Schwarzenberg
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
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2
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Patel D, Baliss M, Saikumar P, Numan L, Teckman J, Hachem C. A Gastroenterologist's Guide to Care Transitions in Cystic Fibrosis from Pediatrics to Adult Care. Int J Mol Sci 2023; 24:15766. [PMID: 37958749 PMCID: PMC10648514 DOI: 10.3390/ijms242115766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 10/04/2023] [Accepted: 10/25/2023] [Indexed: 11/15/2023] Open
Abstract
Cystic Fibrosis is a chronic disease affecting multiple systems, including the GI tract. Clinical manifestation in patients can start as early as infancy and vary across different age groups. With the advent of new, highly effective modulators, the life expectancy of PwCF has improved significantly. Various GI aspects of CF care, such as nutrition, are linked to an overall improvement in morbidity, lung function and the quality of life of PwCF. The variable clinical presentations and management of GI diseases in pediatrics and adults with CF should be recognized. Therefore, it is necessary to ensure efficient transfer of information between pediatric and adult providers for proper continuity of management and coordination of care at the time of transition. The transition of care is a challenging process for both patients and providers and currently there are no specific tools for GI providers to help ensure a smooth transition. In this review, we aim to highlight the crucial features of GI care at the time of transition and provide a checklist that can assist in ensuring an effective transition and ease the challenges associated with it.
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Affiliation(s)
- Dhiren Patel
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cardinal Glennon Children’s Medical Center, Saint Louis University School of Medicine, St. Louis, MO 63104, USA; (P.S.); (J.T.)
- The AHEAD Institute, Saint Louis University School of Medicine, St. Louis, MO 63104, USA
| | - Michelle Baliss
- Department of Gastroenterology and Hepatology, Saint Louis University School of Medicine, St. Louis, MO 63104, USA; (M.B.); (L.N.); (C.H.)
| | - Pavithra Saikumar
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cardinal Glennon Children’s Medical Center, Saint Louis University School of Medicine, St. Louis, MO 63104, USA; (P.S.); (J.T.)
| | - Laith Numan
- Department of Gastroenterology and Hepatology, Saint Louis University School of Medicine, St. Louis, MO 63104, USA; (M.B.); (L.N.); (C.H.)
| | - Jeffrey Teckman
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cardinal Glennon Children’s Medical Center, Saint Louis University School of Medicine, St. Louis, MO 63104, USA; (P.S.); (J.T.)
| | - Christine Hachem
- Department of Gastroenterology and Hepatology, Saint Louis University School of Medicine, St. Louis, MO 63104, USA; (M.B.); (L.N.); (C.H.)
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3
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Chetwood JD, Volovets A, Sivam S, Koh C. Surgical considerations in cystic fibrosis: what every general surgeon needs to know. ANZ J Surg 2022; 92:2425-2432. [PMID: 35920692 PMCID: PMC9804981 DOI: 10.1111/ans.17948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 07/12/2022] [Indexed: 01/09/2023]
Abstract
Cystic fibrosis (CF) is a complex multiorgan disease, which often affects the gastrointestinal tract. With improved CF specific therapies and multidisciplinary management, patients with CF are now living longer with a median life expectancy of around 50 years. This increased life expectancy has resulted in corresponding increase in presentations of the CF patient with comorbid surgical conditions that were never important considerations. Investigations and management of these conditions, such as distal intestinal obstruction syndrome and colorectal cancer warrant good clinical understanding of the unique challenges that CF patients present including chronic immunosuppression, impaired respiratory function and their multi-organ dysfunction. The purpose of this review is to provide general surgeons with a contemporary update on the CF related surgical issues as they are likely to become increasingly involved in the care of these complex patients and form an integral part of the multidisciplinary team.
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Affiliation(s)
- John D. Chetwood
- AW Morrow Gastroenterology and Liver CentreRoyal Prince Alfred HospitalSydneyNew South WalesAustralia,Sydney Medical SchoolUniversity of SydneySydneyNew South WalesAustralia
| | - Anastasia Volovets
- AW Morrow Gastroenterology and Liver CentreRoyal Prince Alfred HospitalSydneyNew South WalesAustralia,Sydney Medical SchoolUniversity of SydneySydneyNew South WalesAustralia
| | - Sheila Sivam
- Department of Respiratory and Sleep MedicineRoyal Prince Alfred HospitalSydneyNew South WalesAustralia
| | - Cherry Koh
- Surgical Outcomes Research Centre (SOuRCe)Royal Prince Alfred HospitalSydneyNew South WalesAustralia
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4
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Changing paradigms in the treatment of gastrointestinal complications of cystic fibrosis in the era of cystic fibrosis transmembrane conductance regulator modulators. Paediatr Respir Rev 2022; 42:9-16. [PMID: 33485777 DOI: 10.1016/j.prrv.2020.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 12/17/2020] [Indexed: 12/17/2022]
Abstract
Cystic fibrosis (CF) - although primarily a lung disease - also causes a variety of gastrointestinal manifestations which are important for diagnosis, prognosis and quality of life. All parts of the gastrointestinal tract can be affected by CF. Besides the well-known pancreatic insufficiency, gastroesophageal reflux disease, liver disease and diseases of the large intestine are important pathologies that impact on prognosis and also impair quality of life. Diagnosis and management of gastrointestinal manifestations will be discussed in this review. Since optimisation of CF therapy is associated with a significantly longer life-span of CF patients nowadays, also gastrointestinal malignancies, which are more common in CF than in the non-CF population need to be considered. Furthermore, novel evidence on the role of the gut microbiome in CF is emerging. The introduction of cystic fibrosis transmembrane conductance regulator (CFTR) protein modulators gives hope for symptom alleviation and even cure of gastrointestinal manifestations of CF.
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5
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Understanding Cystic Fibrosis Comorbidities and Their Impact on Nutritional Management. Nutrients 2022; 14:nu14051028. [PMID: 35268004 PMCID: PMC8912424 DOI: 10.3390/nu14051028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 02/23/2022] [Accepted: 02/25/2022] [Indexed: 11/17/2022] Open
Abstract
Cystic fibrosis (CF) is a chronic, multisystem disease with multiple comorbidities that can significantly affect nutrition and quality of life. Maintaining nutritional adequacy can be challenging in people with cystic fibrosis and has been directly associated with suboptimal clinical outcomes. Comorbidities of CF can result in significantly decreased nutritional intake and intestinal absorption, as well as increased metabolic demands. It is crucial to utilize a multidisciplinary team with expertise in CF to optimize growth and nutrition, where patients with CF and their loved ones are placed in the center of the care model. Additionally, with the advent of highly effective modulators (HEMs), CF providers have begun to identify previously unrecognized nutritional issues, such as obesity. Here, we will review and summarize commonly encountered comorbidities and their nutritional impact on this unique population.
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6
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Ng J, Friedmacher F, Pao C, Charlesworth P. Gastroesophageal Reflux Disease and Need for Antireflux Surgery in Children with Cystic Fibrosis: A Systematic Review on Incidence, Surgical Complications, and Postoperative Outcomes. Eur J Pediatr Surg 2021; 31:106-114. [PMID: 33202431 PMCID: PMC7853868 DOI: 10.1055/s-0040-1718750] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Gastroesophageal reflux disease (GERD) is associated with accelerated decline in lung health in children with cystic fibrosis (CF). Thus, antireflux surgery (ARS) is offered to a selected CF cohort with refractory GERD, but outcomes remain poorly investigated. This study aimed to determine the incidence of GERD in children with CF and to evaluate complications and outcomes of ARS. MATERIALS AND METHODS A systematic literature-based search was conducted using various online databases according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The number of GERD cases in pediatric CF cohorts who underwent diagnostic investigation(s) was recorded. Data on postoperative complications and outcomes (including symptoms, lung function, and nutritional status) following ARS were analyzed. RESULTS Ten articles (n = 289 patients) met the defined inclusion criteria (51% male; age range, 0.5 month-36 years). The overall incidence of GERD was 46% (range, 19-81%), derived from seven studies (n = 212 patients). Four publications (n = 82 patients) reported on ARS due to uncontrolled GERD. All ARSs were Nissen fundoplication (majority with gastrostomy placement). Major postoperative complications occurred in 15 (18%) patients, two required redo-ARS. Median follow-up time was 2 years (range, 3 months-6 years); 59% showed symptom improvement, and pulmonary exacerbations and decline in lung function were reduced. Nutritional status mainly improved in milder CF cases. There were no deaths related to ARS. CONCLUSION Approximately half of pediatric CF patients have GERD. Published data for children with CF are limited and heterogeneous in terms of GERD diagnosis and outcomes following ARS. However, ARS has shown to slow the deterioration of lung function in CF.
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Affiliation(s)
- Jessica Ng
- Department of Paediatric Surgery, Royal London Hospital, London, United Kingdom,Address for correspondence Florian Friedmacher, MD, MSc (RCSI), PhD Department of Pediatric Surgery, University Hospital Frankfurt, Goethe University FrankfurtTheodor-Stern-Kai 7, 60590 Frankfurt/MainGermany
| | - Florian Friedmacher
- Department of Paediatric Surgery, Royal London Hospital, London, United Kingdom,Department of Pediatric Surgery, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt (Main), Germany
| | - Caroline Pao
- Department of Paediatric Surgery, Royal London Hospital, London, United Kingdom
| | - Paul Charlesworth
- Department of Paediatric Surgery, Royal London Hospital, London, United Kingdom
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7
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McDonnell MJ, Hunt EB, Ward C, Pearson JP, O'Toole D, Laffey JG, Murphy DM, Rutherford RM. Current therapies for gastro-oesophageal reflux in the setting of chronic lung disease: state of the art review. ERJ Open Res 2020; 6:00190-2019. [PMID: 33693049 PMCID: PMC7927787 DOI: 10.1183/23120541.00190-2019] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 08/12/2020] [Indexed: 12/13/2022] Open
Abstract
The inter-relationship between chronic respiratory disease and reflux disease in the airway reflux paradigm is extremely complex and remains poorly characterised. Reflux disease is reported to cause or contribute to the severity of a number of respiratory tract diseases including laryngeal disorders, sinusitis, chronic cough, asthma, COPD, idiopathic pulmonary fibrosis, cystic fibrosis, bronchiectasis and bronchiolitis obliterans post lung transplant. It is now appreciated that reflux disease is not simply caused by liquid acid reflux but rather by a variety of chemical refluxates originating from the stomach and duodenum due to a number of different mechanisms. Reflux disease can be challenging to diagnose, particularly proving its role in the causation of direct respiratory epithelial damage. Significant advances in oesophageal assessment and gastric biomarkers have emerged in recent years as our understanding increases. There are a number of treatments available for reflux disease, both medical and surgical, but there is a paucity of large randomised trials to evaluate their efficacy in the setting of chronic respiratory disease. Everyday clinical practice, however, informs us that treatment failure in reflux disease is common. This clinical review summarises associations between reflux disease in the setting of chronic respiratory diseases and examines available evidence regarding potential therapeutic strategies. Gastro-oesophageal reflux disease is prevalent among patients with chronic respiratory disease. A number of medical and surgical treatment options are available for GORD. This review examines available evidence in the setting of chronic lung disease.https://bit.ly/34TcMJS
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Affiliation(s)
- Melissa J McDonnell
- Dept of Respiratory Medicine, Galway University Hospitals, Galway, Ireland.,Lung Biology Group, National University of Ireland, Galway, Ireland.,Institute of Cell and Molecular Biosciences, Newcastle University, Newcastle, UK
| | - Eoin B Hunt
- Dept of Respiratory Medicine, Cork University Hospital, Cork, Ireland.,The Clinical Research Facility, University College Cork, Cork, Ireland
| | - Chris Ward
- Institute of Cell and Molecular Biosciences, Newcastle University, Newcastle, UK
| | - Jeffrey P Pearson
- Institute of Cell and Molecular Biosciences, Newcastle University, Newcastle, UK
| | - Daniel O'Toole
- Lung Biology Group, National University of Ireland, Galway, Ireland
| | - John G Laffey
- Lung Biology Group, National University of Ireland, Galway, Ireland
| | - Desmond M Murphy
- Dept of Respiratory Medicine, Cork University Hospital, Cork, Ireland.,The Clinical Research Facility, University College Cork, Cork, Ireland
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8
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Bongiovanni A, Manti S, Parisi GF, Papale M, Mulè E, Rotolo N, Leonardi S. Focus on gastroesophageal reflux disease in patients with cystic fibrosis. World J Gastroenterol 2020; 26:6322-6334. [PMID: 33244195 PMCID: PMC7656210 DOI: 10.3748/wjg.v26.i41.6322] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 08/22/2020] [Accepted: 10/01/2020] [Indexed: 02/06/2023] Open
Abstract
Gastroesophageal reflux disease (GERD) is a common gastrointestinal disorder in cystic fibrosis (CF), and based on various studies, its prevalence is elevated since childhood. There are several pathogenetic mechanisms on the basis of association between CF and GERD. However, there are no specific guidelines for GERD in CF patients, so diagnosis is based on guidelines performed on patients not affected by CF. The aim of this review is to provide the pathophysiology, diagnostic and therapeutic options, complications, and future directions in the management of GERD patients with CF.
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Affiliation(s)
- Annarita Bongiovanni
- Department of Clinical and Experimental Medicine, Pediatric Respiratory Unit, San Marco Hospital, University of Catania, Catania 95123, Italy
| | - Sara Manti
- Department of Clinical and Experimental Medicine, Pediatric Respiratory Unit, San Marco Hospital, University of Catania, Catania 95123, Italy
| | - Giuseppe Fabio Parisi
- Department of Clinical and Experimental Medicine, Pediatric Respiratory Unit, San Marco Hospital, University of Catania, Catania 95123, Italy
| | - Maria Papale
- Department of Clinical and Experimental Medicine, Pediatric Respiratory Unit, San Marco Hospital, University of Catania, Catania 95123, Italy
| | - Enza Mulè
- Department of Clinical and Experimental Medicine, Pediatric Respiratory Unit, San Marco Hospital, University of Catania, Catania 95123, Italy
| | - Novella Rotolo
- Department of Clinical and Experimental Medicine, Pediatric Respiratory Unit, San Marco Hospital, University of Catania, Catania 95123, Italy
| | - Salvatore Leonardi
- Department of Clinical and Experimental Medicine, Pediatric Respiratory Unit, San Marco Hospital, University of Catania, Catania 95123, Italy
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9
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Chan WW, Ahuja N, Fisichella PM, Gavini S, Rangan V, Vela MF. Extraesophageal syndrome of gastroesophageal reflux: relationships with lung disease and transplantation outcome. Ann N Y Acad Sci 2020; 1482:95-105. [PMID: 32808313 DOI: 10.1111/nyas.14460] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 07/05/2020] [Accepted: 07/15/2020] [Indexed: 12/14/2022]
Abstract
Gastroesophageal reflux disease (GERD) is prevalent and may be associated with both esophageal and extraesophageal syndromes, which include various pulmonary conditions. GERD may lead to pulmonary complications through the "reflux" (aspiration) or "reflex" (refluxate-triggered, vagally mediated airway spasm) mechanisms. While GERD may cause or worsen pulmonary disorders, changes in respiratory mechanics due to lung disease may also increase reflux. Typical esophageal symptoms are frequently absent and objective assessment with reflux monitoring is often needed for diagnosis. Impedance monitoring should be considered in addition to traditional pH study due to the involvement of both acidic and weakly acidic/nonacidic reflux. Antireflux therapy may improve outcomes of some pulmonary complications of GERD, although careful selection of a candidate is paramount to successful outcomes. Further research is needed to identify the optimal testing strategy and patient phenotypes that would benefit from antireflux therapy to improve pulmonary outcomes.
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Affiliation(s)
- Walter W Chan
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nitin Ahuja
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - P Marco Fisichella
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Sravanya Gavini
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Vikram Rangan
- Division of Gastroenterology, Hepatology, and Nutrition, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Marcelo F Vela
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona
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10
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Gomes A, Lapin C, Ziegler J. Weight Gain and Growth After Fundoplication in the Pediatric Patient: A Case Report in the Pediatric Patient With Cystic Fibrosis and Literature Review. Nutr Clin Pract 2020; 35:745-754. [PMID: 32141133 DOI: 10.1002/ncp.10475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Gastroesophageal reflux (GER) is common among infants, but when symptoms become troublesome, that is defined as gastroesophageal reflux disease (GERD). Making a diagnosis of GERD is difficult because there is no gold standard. GERD can be especially problematic for infants with cystic fibrosis (CF). There are signs and symptoms (ie, malnutrition, recurring aspiration pneumonias, refusal to eat, wheezing, coughing, and asthma) in addition to invasive and noninvasive methods used to determine a diagnosis. The treatments for GERD span from nonpharmacological to surgical, with a laparoscopic Nissen fundoplication being the gold standard of surgical intervention. Although surgical interventions have been demonstrated to reduce symptoms associated with GERD, there is little known about the weight/growth-related outcomes. This case report discusses an infant with CF and GERD requiring multiple interventions and ultimately a laparoscopic Nissen fundoplication and the weight changes from presurgery to postsurgery. The case report is expanded upon with a structured literature review of fundoplication and growth studies. There were 4 available studies that assessed changes in weight/growth before and after fundoplication among children with GERD. Because of the heterogeneity of the nutrition outcomes used, the weight/growth benefits after fundoplication are unclear at this time. Further research in needed to assess the nutrition outcomes among patients with GERD requiring fundoplication.
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Affiliation(s)
- Allison Gomes
- Department of Clinical and Preventive Nutrition Sciences, School of Health Professions at Rutgers University, Newark, New Jersey, USA
| | - Craig Lapin
- Connecticut Children's Medical Center Pulmonary Division, Pediatrics University of Connecticut, Hartford, Connecticut, USA
| | - Jane Ziegler
- Department of Clinical and Preventive Nutrition Sciences, School of Health Professions at Rutgers University, Newark, New Jersey, USA
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11
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Cystic Fibrosis and gastroesophageal reflux disease. J Cyst Fibros 2018; 16 Suppl 2:S2-S13. [PMID: 28986024 DOI: 10.1016/j.jcf.2017.07.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 07/06/2017] [Accepted: 07/06/2017] [Indexed: 12/19/2022]
Abstract
Gastroesophageal reflux is common in children and adults with cystic fibrosis (CF). Pathological gastroesophageal reflux disease (GERD) is also frequent in patients of all ages with CF. This article reviews the pathophysiology, diagnostic work-up, management options, complications, and future directions in the evaluation and management of GERD - unique to and pertinent for - patients with CF in particular.
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12
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Abstract
A number of risk factors have been identified for deterioration of lung disease in children with Cystic Fibrosis (CF), and current management strategies are based on the prevention and treatment of such elements. Further challenge ensues when a patient has co-morbid disease in addition to CF, particularly when faced with rapidly deteriorating pulmonary status. It is difficult to measure the contribution of other pathologies to this decline and optimisation of both CF care and co-morbidity is paramount. This review explores the challenges faced when treating children with CF and co-morbid conditions, focussing on gastroesophageal reflux disease pre- and post-lung transplantation.
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13
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Chin M, Aaron SD, Bell SC. The treatment of the pulmonary and extrapulmonary manifestations of cystic fibrosis. Presse Med 2017; 46:e139-e164. [PMID: 28576636 DOI: 10.1016/j.lpm.2016.11.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 10/12/2016] [Accepted: 11/06/2016] [Indexed: 12/26/2022] Open
Abstract
Cystic fibrosis (CF) is a complex multisystem disease with considerable between patient variability in its manifestations and severity. In the past several decades, the range of treatments and the evidence to support their use for the pulmonary and extrapulmonary manifestations of CF have increased dramatically, contributing to the improved median survival of patients. As therapy for CF has evolved, new challenges including treatment adherence, medication intolerance and allergy, medical complications and coping with the burden of disease in the context of having a family and managing employment have arisen. While the majority of current therapy focuses primarily on improving symptoms, new therapies (CFTR modulators) target the underlying genetic defect.
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Affiliation(s)
- Melanie Chin
- Adult Cystic Fibrosis Centre, The Prince Charles Hospital, Rode Road, Chermside, Brisbane, QLD 4032, Australia
| | - Shawn D Aaron
- The Ottawa Hospital Research Institute, University of Ottawa, 501, Smyth Road, K1H 8L6 Ottawa, Canada
| | - Scott C Bell
- Adult Cystic Fibrosis Centre, The Prince Charles Hospital, Rode Road, Chermside, Brisbane, QLD 4032, Australia; QIMR Berghofer Medical Research Institute, 300, Herston Road, Herston, QLD 4006, Australia; School of Medicine, The University of Queensland, Brisbane, QLD 4006, Australia.
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14
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Reen FJ, Flynn S, Woods DF, Dunphy N, Chróinín MN, Mullane D, Stick S, Adams C, O'Gara F. Bile signalling promotes chronic respiratory infections and antibiotic tolerance. Sci Rep 2016; 6:29768. [PMID: 27432520 PMCID: PMC4949476 DOI: 10.1038/srep29768] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 06/17/2016] [Indexed: 12/29/2022] Open
Abstract
Despite aggressive antimicrobial therapy, many respiratory pathogens persist in the lung, underpinning the chronic inflammation and eventual lung decline that are characteristic of respiratory disease. Recently, bile acid aspiration has emerged as a major comorbidity associated with a range of lung diseases, shaping the lung microbiome and promoting colonisation by Pseudomonas aeruginosa in Cystic Fibrosis (CF) patients. In order to uncover the molecular mechanism through which bile modulates the respiratory microbiome, a combination of global transcriptomic and phenotypic analyses of the P. aeruginosa response to bile was undertaken. Bile responsive pathways responsible for virulence, adaptive metabolism, and redox control were identified, with macrolide and polymyxin antibiotic tolerance increased significantly in the presence of bile. Bile acids, and chenodeoxycholic acid (CDCA) in particular, elicited chronic biofilm behaviour in P. aeruginosa, while induction of the pro-inflammatory cytokine Interleukin-6 (IL-6) in lung epithelial cells by CDCA was Farnesoid X Receptor (FXR) dependent. Microbiome analysis of paediatric CF sputum samples demonstrated increased colonisation by P. aeruginosa and other Proteobacterial pathogens in bile aspirating compared to non-aspirating patients. Together, these data suggest that bile acid signalling is a leading trigger for the development of chronic phenotypes underlying the pathophysiology of chronic respiratory disease.
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Affiliation(s)
- F Jerry Reen
- BIOMERIT Research Centre, School of Microbiology, University College Cork, National University of Ireland, Cork, Ireland
| | - Stephanie Flynn
- BIOMERIT Research Centre, School of Microbiology, University College Cork, National University of Ireland, Cork, Ireland
| | - David F Woods
- BIOMERIT Research Centre, School of Microbiology, University College Cork, National University of Ireland, Cork, Ireland
| | - Niall Dunphy
- BIOMERIT Research Centre, School of Microbiology, University College Cork, National University of Ireland, Cork, Ireland
| | | | - David Mullane
- Paediatric Cystic Fibrosis Unit, Cork University Hospital, Cork, Ireland
| | | | - Claire Adams
- BIOMERIT Research Centre, School of Microbiology, University College Cork, National University of Ireland, Cork, Ireland
| | - Fergal O'Gara
- BIOMERIT Research Centre, School of Microbiology, University College Cork, National University of Ireland, Cork, Ireland.,Telethon Kids Institute, Perth, Western Australia.,School of Biomedical Sciences, Curtin Health Innovation Research Institute, Curtin University, Perth, WA 6102, Australia
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15
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16
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Virbalas J, McMullen C, Cheng J. Injection laryngoplasty in children with cystic fibrosis and abnormal swallow. Int J Pediatr Otorhinolaryngol 2015; 79:1856-9. [PMID: 26365895 DOI: 10.1016/j.ijporl.2015.08.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Revised: 08/12/2015] [Accepted: 08/14/2015] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Children with cystic fibrosis (CF) are uniquely vulnerable to the pulmonary complications of chronic aspiration. We present a case series of children with CF and evidence of chronic aspiration who underwent injection laryngoplasty to improve the safety and efficacy of their swallow. STUDY DESIGN Retrospective chart review. SETTING Tertiary care children's hospital. METHODS/SUBJECTS A chart review was performed on three consecutive cases of children with CF and evidence of aspiration on modified barium swallow (MBS) evaluated at a tertiary care, academic children's medical center. RESULTS Three patients with CF underwent injection laryngoplasty for evidence of aspiration or laryngeal penetration on MBS evaluation. Normal laryngeal anatomy was identified intraoperatively in each case. At the time of the procedure, patients were 22 months, 70 months, and 24 months old, and follow-up information was available for 7 months, 11 months, and 12 months post-procedure, respectively. Presenting symptoms included chronic cough, cough with oral liquids, and recurrent pneumonia. Each patient underwent successful injection into the interarytenoid space. Post-operatively, modified barium swallow demonstrated resolution of aspiration or penetration in all patients. No procedure-related complications were encountered. CONCLUSION Patients with CF are highly susceptible to pulmonary infections, and aggressive treatment of chronic aspiration is often necessary. Injection laryngoplasty may be effective in normalizing swallowing in these children. Future study will elucidate the duration of effect and if this technique improves long-term pulmonary outcomes in CF patients.
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Affiliation(s)
- Jordan Virbalas
- Department of Otorhinolaryngology, Albert Einstein College of Medicine, Bronx, NY, USA.
| | - Caitlin McMullen
- Department of Otorhinolaryngology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jeffrey Cheng
- Division of Pediatric Otolaryngology, Cohen Children's Medical Center, New Hyde Park, NY, USA; Department of Otolaryngology-Head and Neck Surgery, Hofstra North Shore-LIJ School of Medicine, Hempstead, NY, USA
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Brodlie M, Aseeri A, Lordan JL, Robertson AGN, McKean MC, Corris PA, Griffin SM, Manning NJ, Pearson JP, Ward C. Bile acid aspiration in people with cystic fibrosis before and after lung transplantation. Eur Respir J 2015; 46:1820-3. [PMID: 26493787 PMCID: PMC4664606 DOI: 10.1183/13993003.00891-2015] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 08/12/2015] [Indexed: 01/07/2023]
Abstract
Cystic fibrosis (CF) is a genetic condition that is caused by abnormalities in the CF transmembrane conductance regulator (CFTR) gene. People with CF experience life-long morbidity and premature mortality, the vast majority of which is associated with lung disease. Bile acids are detectable in the lower airway in advanced CF lung disease and persist after lung transplantationhttp://ow.ly/RTvNW
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Affiliation(s)
- Malcolm Brodlie
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK Department of Paediatric Respiratory Medicine, Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Ali Aseeri
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK Institute for Cell and Molecular Bioscience, Newcastle University, Newcastle upon Tyne, UK
| | - Jim L Lordan
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Andrew G N Robertson
- Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Michael C McKean
- Department of Paediatric Respiratory Medicine, Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Paul A Corris
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - S Michael Griffin
- Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Nigel J Manning
- Department of Clinical Chemistry, Sheffield Children's Hospital, The Sheffield Children's NHS Trust, Sheffield, UK
| | - Jeffrey P Pearson
- Institute for Cell and Molecular Bioscience, Newcastle University, Newcastle upon Tyne, UK
| | - Christopher Ward
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
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Prevalence of gastroesophageal reflux in cystic fibrosis and implications for lung disease. Ann Am Thorac Soc 2015; 11:964-8. [PMID: 24964289 DOI: 10.1513/annalsats.201401-044fr] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Gastroesophageal reflux (GER) is common in patients with cystic fibrosis (CF) and is often regarded as playing a role in the pathogenesis of CF lung disease. Individuals with CF have many predisposing factors to the development of GER, with a reported prevalence ranging from 35 to 81%. Several studies have suggested that patients with CF who have coexisting GER have more severe lung disease with lower pulmonary function and increased numbers of respiratory exacerbations. Furthermore, GER may alter the respiratory microbiology in CF. Both the acid and nonacid components of GER may have an effect on lung disease. More than 50% of U.S. patients with CF were being treated with proton pump inhibitors in 2012; however, data regarding safety and efficacy of these agents in CF are lacking. Pharmacologic and surgical treatment of GER may improve respiratory morbidity, although prospective controlled studies have not been performed. Given the lack of evidence-based guidelines for evaluation, diagnosis, and treatment of GER in CF, initiation of treatment for symptomatic GER should be based on standard guidelines for the general population. Because there is no clear evidence that GER leads to worse respiratory outcomes in CF or that treatment of GER improves pulmonary outcomes, invasive testing for GER in patients without reflux symptoms is not warranted. Further studies to determine the role of GER in CF lung disease and the risks and benefits of surgical and pharmacologic therapy for GER are warranted.
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Haller W, Ledder O, Lewindon PJ, Couper R, Gaskin KJ, Oliver M. Cystic fibrosis: An update for clinicians. Part 1: Nutrition and gastrointestinal complications. J Gastroenterol Hepatol 2014; 29:1344-55. [PMID: 25587613 DOI: 10.1111/jgh.12546] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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20
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Outcomes of pediatric laparoscopic fundoplication: a critical review of the literature. Can J Gastroenterol Hepatol 2014; 28:97-102. [PMID: 24288692 PMCID: PMC4071886 DOI: 10.1155/2014/738203] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND/OBJECTIVE Laparoscopic fundoplication for gastroesophageal reflux disease (GERD) is one of the most common procedures performed in children. A critical literature review was performed to evaluate the level and quality of evidence supporting the efficacy of this procedure. METHODS Systematic reviews of the EMBASE, PubMed and CENTRAL databases were conducted to retrieve all articles published over a 15-year period (1996 to 2010) reporting medium- to long-term outcomes (minimum six months follow-up) of laparoscopic fundoplication for the treatment of pediatric GERD. Articles were critically appraised using the Newcastle-Ottawa quality assessment scale and the Cochrane risk of bias assessment tool. Extracted outcomes included GERD recurrence, need for reoperation, postoperative morbidity and mortality. RESULTS A total of 5302 articles were retrieved. Thirty-six studies met inclusion and exclusion criteria, including five prospective (level 2b), four retrospective comparative (level 3b) and 27 case series (level 4). No studies compared laparoscopic fundoplication with medical treatment. Thirty-six per cent of studies did not describe the symptoms used to suspect GERD; 11% did not disclose the diagnostic modalities used; and 41% did not report the findings of diagnostic modalities. Only 17% of studies provided a definition of recurrence, and only 14% attempted to control for confounding variables. The follow-up intervals were inconsistently reported, ranging between two months and nine years. Significant heterogeneity among studies limited the ability to pool outcomes. Mean (± SD) recurrence rates varied between 0% and 48±19.6% of patients. Reoperation was required in 0.69±0.95% to 17.7±8.4% of patients. Mortality ranged between 0% and 24±16.7%. CONCLUSION The level and quality of the evidence supporting laparoscopic fundoplication are extremely poor. Higher-quality data are required before the procedure can be considered to be an effective intervention in the treatment of pediatric GERD.
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Sheikh SI, Ryan-Wenger NA, McCoy KS. Outcomes of surgical management of severe GERD in patients with cystic fibrosis. Pediatr Pulmonol 2013; 48:556-62. [PMID: 22949398 DOI: 10.1002/ppul.22630] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2011] [Accepted: 06/18/2012] [Indexed: 01/12/2023]
Abstract
BACKGROUND Patients with cystic fibrosis (CF) are at high risk for gastroesophageal reflux disease (GERD) and medical management of GERD improves pulmonary symptoms. Some patients with worsening CF and GERD symptoms undergo Nissen fundoplication, but the extent to which surgical management of GERD improves respiratory symptoms is not well studied. The purpose of this retrospective study was to evaluate the safety and efficacy of Nissen fundoplication in 48 patients with CF and uncontrolled GERD. RESULTS Patients exhibited significantly fewer pulmonary exacerbations, increased weight gain and slower decline in % predicted FEV1 at 2 years after the surgery, compared to 2 years before surgery. Mean change in % predicted FEV1 in 2 years before surgery was--13.57% and mean change in % predicted FEV1 in 2 years after the surgery was +1.5% and difference was significant P = 0.001. Better pulmonary and nutritional outcomes were noted among patients with milder lung disease compared to those with severe lung disease, and among patients who received gastrostomy tube feedings for ≥6 months compared to those with no G-tube or tube feedings for <6 months. There was no mortality associated with surgery. CONCLUSION In CF patients with worsening lung disease and uncontrolled GERD, Nissen fundoplication not only slows the decline in lung function but leads to significant improvement in weight, and decrease in CF exacerbations. Patients with milder disease and patients receiving G-tube feedings for ≥6 months after surgery benefited the most.
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Affiliation(s)
- Shahid I Sheikh
- Division of Pulmonary Medicine, Department of Pediatrics, Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA.
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22
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Higton A, Collins S, Bilton D. Gastroesophageal reflux causing nutritional failure and vomiting in a teenager with cystic fibrosis and respiratory failure. J R Soc Med 2011; 104 Suppl 1:S44-8. [PMID: 21719893 DOI: 10.1258/jrsm.2011.s11108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Affiliation(s)
- Alexandra Higton
- Department of Respiratory Medicine, Frimley Park Hospital, Frimley, Surrey, UK.
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23
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Golski CA, Rome ES, Martin RJ, Frank SH, Worley S, Sun Z, Hibbs AM. Pediatric specialists' beliefs about gastroesophageal reflux disease in premature infants. Pediatrics 2010; 125:96-104. [PMID: 20008431 PMCID: PMC2805060 DOI: 10.1542/peds.2008-3841] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Wide variation exists in the treatment of suspected gastroesophageal reflux disease (GERD) in premature infants; it is unknown to what degree diagnosis and treatment are affected by the treating physician's medical specialty or interpretation of the medical literature. METHODS This study involved an online survey of board-certified neonatologists, pediatric pulmonologists, and pediatric gastroenterologists about their beliefs regarding the symptoms, diagnosis, and treatment of GERD in premature infants in the NICU on the basis of both clinical impression and interpretation of the literature. RESULTS A total of 1021 neonatologists, 232 pediatric pulmonologists, and 222 pediatric gastroenterologists participated in the study (47.5% response rate). There was disagreement among specialists in nearly all aspects of the survey. Pulmonologists were most likely to report that respiratory symptoms are caused by GERD (P < .001). Neonatologists were least likely to report that a therapeutic trial of pharmacologic agents would be useful for diagnosing GERD (P < .001) or that lansoprazole, ranitidine, or cimetidine are safe or effective (P < .001). No pharmacologic therapy had >50% of respondents supporting its effectiveness. There was moderate correlation between physician belief based on the medical literature and belief based on clinical impression (Spearman rank correlation: 0.47-0.75). For therapies supported by multiple meta-analyses in infants versus therapies with few infant trials, physicians rated the evidence for effectiveness similarly. CONCLUSIONS There is wide variation among pediatric specialists regarding beliefs about GERD in premature infants, as well as about the weight of evidence in the medical literature for this patient population. Physician beliefs do not seem to be driven by the degree of evidence in the neonatal literature. With no agreed-on standard of care in the setting of widespread use of antireflux medications, greater understanding is needed about the ways physicians form clinical impressions, access and process medical evidence, and apply it to patient care.
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Affiliation(s)
- Catherine A. Golski
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University; Cleveland, OH,Case Western Reserve University School of Medicine; Cleveland, OH,Dept. of Epidemiology and Biostatistics, Case Western Reserve University; Cleveland, OH
| | - Ellen S. Rome
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University; Cleveland, OH,Dept. of General Pediatrics, Cleveland Clinic Children's Hospital; Cleveland, OH
| | - Richard J. Martin
- Case Western Reserve University School of Medicine; Cleveland, OH,Dept. of Pediatrics, Rainbow Babies and Children's Hospital; Cleveland, OH
| | - Scott H. Frank
- Case Western Reserve University School of Medicine; Cleveland, OH,Dept. of Epidemiology and Biostatistics, Case Western Reserve University; Cleveland, OH,Dept. of Family Medicine, Case Western Reserve University; Cleveland, OH
| | - Sarah Worley
- Dept. of Quantitative Health Sciences, Cleveland Clinic; Cleveland, OH
| | - Zhiyuan Sun
- Dept. of Quantitative Health Sciences, Cleveland Clinic; Cleveland, OH
| | - Anna Maria Hibbs
- Case Western Reserve University School of Medicine; Cleveland, OH,Dept. of Pediatrics, Rainbow Babies and Children's Hospital; Cleveland, OH
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Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). J Pediatr Gastroenterol Nutr 2009; 49:498-547. [PMID: 19745761 DOI: 10.1097/mpg.0b013e3181b7f563] [Citation(s) in RCA: 479] [Impact Index Per Article: 31.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To develop a North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) international consensus on the diagnosis and management of gastroesophageal reflux and gastroesophageal reflux disease in the pediatric population. METHODS An international panel of 9 pediatric gastroenterologists and 2 epidemiologists were selected by both societies, which developed these guidelines based on the Delphi principle. Statements were based on systematic literature searches using the best-available evidence from PubMed, Cumulative Index to Nursing and Allied Health Literature, and bibliographies. The committee convened in face-to-face meetings 3 times. Consensus was achieved for all recommendations through nominal group technique, a structured, quantitative method. Articles were evaluated using the Oxford Centre for Evidence-based Medicine Levels of Evidence. Using the Oxford Grades of Recommendation, the quality of evidence of each of the recommendations made by the committee was determined and is summarized in appendices. RESULTS More than 600 articles were reviewed for this work. The document provides evidence-based guidelines for the diagnosis and management of gastroesophageal reflux and gastroesophageal reflux disease in the pediatric population. CONCLUSIONS This document is intended to be used in daily practice for the development of future clinical practice guidelines and as a basis for clinical trials.
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Pashinsky YY, Jaffin BW, Litle VR. Gastroesophageal reflux disease and idiopathic pulmonary fibrosis. ACTA ACUST UNITED AC 2009; 76:24-9. [PMID: 19170215 DOI: 10.1002/msj.20088] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Gastroesophageal reflux disease occurs with a higher prevalence in patients with idiopathic pulmonary fibrosis than in matched controls. Silent reflux occurs in about a third of patients with significant gastroesophageal reflux disease; thus, objective measurements are required to evaluate gastroesophageal reflux disease in patients with advanced lung diseases. We provide here a detailed description of acid and non-acid reflux and the diagnostic evaluation for pulmonologists and lung transplant surgeons suspecting reflux as a contributing factor in advanced lung diseases. We review the evidence for gastroesophageal reflux disease causing idiopathic pulmonary fibrosis and other select pulmonary diseases and the potential role of antireflux surgery in the management of advanced lung disease and transplant patients.
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Mertens V, Blondeau K, Pauwels A, Farre R, Vanaudenaerde B, Vos R, Verleden G, Van Raemdonck DE, Dupont LJ, Sifrim D. Azithromycin reduces gastroesophageal reflux and aspiration in lung transplant recipients. Dig Dis Sci 2009; 54:972-9. [PMID: 19241165 DOI: 10.1007/s10620-009-0725-4] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2008] [Accepted: 01/12/2009] [Indexed: 01/28/2023]
Abstract
Azithromycin (AZI) is a macrolide antibiotic that improves lung function in lung transplant recipients (LTx). Gastroesophageal reflux (GER) has been implicated in the pathogenesis of chronic rejection after LTx. Macrolide antibiotics may affect GER by modifying esophageal and gastric motility. The purpose of this study was to evaluate the effect of AZI on GER and gastric aspiration after LTx. Acid and weakly acidic GER was measured with 24-h pH-impedance monitoring in 47 LTx patients (12 patients "on" AZI). Gastric aspiration was assessed in a separate group of 30 LTx patients before and after AZI by measurements of pepsin and bile acid in bronchoalveolar lavage fluid (BALF). Patients "on" AZI had a significant lower total number of reflux events [41 (30-61) vs. 22.5 (7-37.5)], number of acid reflux events [24 (16-41) vs. 8 (4-18)], esophageal acid exposure [2.9% (0.7-7.3) vs. 0.2% (0.1-2.0)], bolus exposure [0.73% (0.5-1.4) vs. 0.21% (0.12-0.92)], and proximal extent of reflux [14 (9-24) vs. 5 (2-7)]. AZI reduced the concentration of bile acids in BALF without affecting levels of pepsin. LTx patients "on" AZI have less GER and bile acids aspiration. This effect might be due to enhanced esophageal motility and accelerated gastric emptying.
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Affiliation(s)
- V Mertens
- Center for Gastroenterological Research, Catholic University Leuven, Leuven, Belgium
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