“Silent” Gastroesophageal Reflux: An Important but Little Known Cause of Pulmonary Complications

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SUMMARY

A series of 25 patients with proved gastroesophageal reflux with or without roentgenographically-demonstrable hiatus hernia in whom the digestive abnormality came to light in the course of study for chronic pulmonary suppuration, has been presented. The pulmonary symptoms included bronchitis, often accompanied by hemoptysis, bronchiectasis, unresolved pneumonitis and in one, empyema. While the possibility that these are two relatively frequent co-existing disease states cannot be completely excluded, the fact that esophageal diseases producing dysphagia are known to produce pulmonary sequelae has made it reasonable to reach the same conclusion regarding chronic nocturnal aspiration of gastric contents in the patient with an incompetent cardioesophageal junction. Of 15 patients surgically treated, of whom nine had only repair of their hiatus hernia, both the pulmonary and gastrointestinal symptoms were relieved in all. This experience reaffirms that all patients with pulmonary infection or disease of obscure etiology should be investigated for occult gastroesophageal reflux.

Section snippets

INTRODUCTION

THE CLINICAL PICTURE OF SYMPTOmatic hiatus hernia with its protean symptoms, including: heartburn, acid regurgitation with postural aggravation, dysphagia, nausea, vomiting, and pain, which may be cervical, substernal or epigastric, is well recognized and has been discussed in detail by others.1, 2, 3 That esophageal obstruction resulted in pulmonary complications has been recognized since the late 19th century, when Mermod4 observed pulmonary complications in a patient with diffuse dilatation

MATERIALS AND METHODS

Between January 1, 1959 and June 30, 1960, 21 patients who were admitted to the thoracic unit, Frenchay Hospital, Bristol, England for investigation of their pulmonary symptoms were found to have evidence of an incompetent cardioesophageal junction with or without roentgenologically-demonstrable hiatus hernia. To this group have been added four patients seen in the author's private practice, bringing the total to 25 for study. The diagnosis of gastroesophageal reflux was established either by

DISCUSSION

Symptoms: Since several of the patients in this group would admit to symptoms suggestive of gastroesophageal reflux only on retrospective questioning, one cannot’ be certain that every patient was asked every pertinent question regarding symptoms. Symptoms and their frequency, as recorded in the hospital records, are shown in Table 1. It will be noted that while 100 per cent of the patients had cough as one of their prominent symptoms, only 40 per cent had heartburn.

Pulmonary Complications:

RESUMEN

Se presenta una serie de 25 enfermos en quienes se demostró reflujo gastroesofagico con o sín hernial hiatal en los que se evidenció alguna anormalidad digestiva en el curso del estudio por una enfermedad crónica pulmonar supurante. Los síntomas pulmonares incluyeron bronquitis, a menudo acompañados de hemoptisis, bronquiectasia, neumonía no resuelta y en uno, empiema. Si bien no puede excluirse la posibilidad de que se trate de dos enfermedades coexistentes, el heco de que la enfermedad

RESUMÉ

L'auteur présente un groupe de 25 malades atteints de reflux gastro-oesophagien démontré, avec ou sans hernie hiatale mise en évidence radiologiquement, chez lesquels l'anomalie digestive fut mise en lumière lors de l'examen complet à l'occasion d'une suppuration pulmonaire chronique. Les symptômes pulmonaires consistaient en bronchite, souvent accompagnée d'hémoptysies, en bronchiectasies, en pneumopathie persistante, et dans un cas, en une pleurésie purulente. Comme il s'agit dans les deux

ZUSAMMENFASSUNG

Bericht über eine Serie von 25 Patienten mit nachgewiesenem gastro-oesophagealen Reflux. Mit oder ohne röntgenologisch nachweisbarer Hiatushernie, bei denen Abnormaliäten der Verdauung im Verlauf einer Untersuchung wegen chronischer eitriger Lungenerkrankung ans Licht kam. Die pulmonalen Symptome umfaßten Bronchitis; oft begleitet von Haemoptysen, Bronchiektasie, nicht gelöste Pneumonie und in einem Fall ein Empyem. Während die Möglichkeit nicht völlig ausgeschlossen werden kann, daβ beide

ACKNOWLEDGMENT

The author gratefully acknowledges the kind cooperation of Ronald H. R. Belsey, M.S., F.R.C.S., Surgeon in Charge, Thoracic Unit, Frenchay Hospital, Bristol, England for permission to include 18 patients collected by the author during his stay in Bristol. The author is likewise indebted to D. Mearns Milne, F.R.C.S. (Ed.) for permission to include Cases 5, 6, 13 and 14, and to Herman F. Froeb, La Jolla, California for permission to include Case 25 in this study.

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Presented at the 27th Annual Meeting, American College of Chest Physicians, New York City, June 22-26, 1961.

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