Symptoms questionnaire, bronchoalveolar lavage fluid, and exhaled breath condensate for the identification of lung transplant patients with gastroesophageal reflux disease

Christopher S Davis, MD, MPH, Nicholas Reder, MPH, Elizabeth J Kovacs, PhD, P Marco Fisichella, MD

Loyola University Medical Center

Background: Gastroesophageal reflux disease (GERD) is approximately twice as prevalent in patients with end-stage lung disease or after lung transplantation. Recent findings indicate that these patients may be at risk for GERD-related aspiration which may heighten inflammation and hasten the fibrosing process. Furthermore, laparoscopic antireflux surgery (LARS) appears to minimize GERD-related aspiration and to stabilize, if not improve, pulmonary function. Our aim was to determine if measuring bile acids and pepsin in the bronchoalveolar lavage fluid (BALF) and exhaled breath condensate (EBC) is effective for identifying lung transplant patients with GERD.

Methods: From November 2009 to November 2010, 68 lung transplant patients were prospectively enrolled in this study. GERD status was assessed by 24-hour ambulatory pH monitoring, a 21-point symptoms questionnaire was performed, and the levels bile acids and pepsin were measured in the EBC and BALF of patients undergoing surveillance or diagnostic bronchoscopy.

Results: Of the 68 patients, 21 were GERD (+), 12 were GERD (-), and 13 had undergone LARS. All others had not undergone ambulatory pH monitoring. The sensitivity and specificity of BA in the BALF for the presence of GERD were 78% and 82%, respectively. However, the sensitivity and specificity of GERD were < 70% for BA in the EBC and pepsin in the BALF or EBC. The most sensitive item on the symptoms questionnaire for the presence of GERD was coughing (96%), whereas heartburn and belching were also highly sensitive (80% and 88%, respectively). Along these lines, the most specific symptoms for the presence of GERD were dysphagia (77%), odynophagia (90%), chest pain (78%), lump in the throat (78%), hoarseness (76%), laryngitis (100%), aspiration (82%), choking (94%), asthma (100%), bronchitis (100%), and pneumonia (88%).

Conclusions: These data indicate that the measurement of bile acids and pepsin in the BALF and EBC is not, by itself, an effective method to identify lung transplant patients at risk for GERD-related aspiration. We believe that all lung transplant patients should be regarded at risk for GERD, and that identification of candidates for LARS should involve a multimodal approach that includes esophageal function testing, symptoms questionnaires, and assessing the BALF for the presence of pepsin and bile acids.

Session: Poster Presentation

Program Number: P267

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