Clinical lung and heart/lung transplantation
Gastroesophageal Reflux (Symptomatic and Silent): A Potentially Significant Problem in Patients With Cystic Fibrosis Before and After Lung Transplantation

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Background

The significance of gastroesophageal reflux (GER) and aspiration are unclear in cystic fibrosis (CF) and may contribute to declining lung function before and after lung transplantation (LTx).

Methods

We sought to establish whether GER occurs in patients with CF on the LTx waiting list and after LTx. We then investigated whether GER correlates with patients’ symptoms. Adults with CF on the waiting list and after LTx were prospectively recruited. Completion of a valid, structured symptom questionnaire was followed by ambulatory, dual-probe, 24-hour esophageal pH monitoring.

Results

Twenty-four patients were studied, including 11 (6 males) in the pre-LTx group and 13 (9 males) in the post-LTx group. The pre-LTx group was 29.3 ± 8.2 years of age, and the post-LTx group was 32.7 ± 8.2 years of age. DeMeester score (normal value <14.7) was 36.6 ± 22.3 for the pre-LTx group and 40.0 ± 37.3 for the post-LTx group. Proximal esophageal acid exposure was significantly higher in both CF groups compared with normal. Symptom scores (normal <4, range −2 to 18) were: pre-LTx group, 5.8 ± 6.5; post-LTx group, 7.7 ± 5.4. Percent forced expiratory volume in 1 second (FEV1%) predicted was: pre-LTx group, 31.3 ± 7.8; post-LTx group, 65.2 ± 29.3. In the pre-LTx group, 10 of 11 (90.9%) patients had significant GER on monitoring, including 4 (40%) with symptomatic GER and 6 (60%) with silent GER. In the post-LTx group, 11 of 13 (84.6%) had significant GER on monitoring, including 9 (82%) with symptomatic GER and 2 (18%) with silent GER.

Conclusions

GER, symptomatic and silent, is a significant problem in CF. This condition should be aggressively treated and surgery should be considered if GER persists on re-testing.

Section snippets

Methods

All patients with CF on the transplant waiting list and at least 2 months after bilateral sequential lung transplantation (LTx) for CF were invited to participate in a prospective study, which was approved by the Alfred Hospital ethics committee. All patients gave written informed consent for study participation. Patients with esophageal strictures or esophageal varices were excluded. Patients were investigated while off anti-reflux medication for at least 3 days (72 hours) during baseline

Results

A total of 24 patients were studied. In the group of patients on the lung transplant waiting list, the pre-LTx group, a total of 11 patients (6 males) completed the study. Thirteen patients (9 males) who underwent LTx for CF, and agreed to participate, formed the post-LTx group. One patient who initially agreed to be in the pre-LTx group was unable to tolerate the probe in situ for >30 minutes and had to be withdrawn from the study. No patients in the pre-LTx group were included in the post-LTx

Discussion

Before lung transplantation, factors such as chronic cough, hyperinflation, hyperalimentation, high-fat diet, overnight PEG feeds, delayed gastric emptying, postural drainage in head-down-tilted position and some medications may cause or exacerbate GER.4, 12, 14, 21 Alternatively, GER may cause cough and subsequent lung disease.14 Lung transplantation is widely accepted and practiced as a treatment modality for end-stage lung disease. The long-term outcomes remain limited, with 5-year survival

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