Gastroesophageal reflux disease (GERD) is a very prevalent disease entity that has a significantly high burden of cost to health care worldwide. Unfortunately, the pathophysiology behind GERD is very complex and not well understood. Symptoms can range from annoying indigestion all the way to serious respiratory tract infections, such as pneumonia and bronchiectasis. In the latter group, symptoms of reflux may be absent. In other words, because patients do not experience typical “heartburn” symptoms, they do not make the association between their recurrent infections and GERD. This is what is considered the extra-esophageal manifestations of GERD, or what is better known as silent reflux.
Basic pathophysiology associated with GERD related respiratory tract infections is due to mucosal damage from gastric contents traveling to non-gastric areas such as the larynx bronchioles, sinuses and lung parenchyma. The mucosal damage that occurs leads to a significant amount of inflammation, which then allows pathogenic bacteria of the gastric contents to proliferate, creating an infectious process.
Reflux has been associated with causing infections of sinuses and lungs. Recent work by Dr. Rachel Rosen of Boston’s Children’s Hospital has suggested that the same bacteria associated in the stomach, may be found in the lungs of patients with GERD. This is providing evidence of gastric aspiration as being a risk factor for chronic respiratory tract infections and some patients.
Over the last ten years, Taiwan had done a nationwide population-based cohort study on the association of chronic sinusitis and GERD. The study was a prospective study which demonstrated that patients diagnosed with GERD have a higher risk of developing chronic sinusitis. This is the first study of its type that demonstrates that GERD is a risk factor for chronic sinusitis.
Recently there has been work done on the association of bronchiectasis and reflux. Bronchiectasis is a condition where there are thickening of the walls of the bronchi due to both inflammation and infection. Usually, bronchiectasis is associated with late-stage lung disease, which in many cases is terminal.
In one recent study, several patients with bronchiectasis were diagnosed with reflux. These patients were then treated for reflux disease. All patients involved in the study showed some degree of improvement in their respiratory status when reflux was treated. In addition, all seven patients had various degrees of GERD related symptoms.
As already stated, there has been some association with bacteria of the gastric tract and that has been found in the lungs of patients with GERD. Recently there have been improvements in the technology of the identification of bacteria which has helped significantly in demonstrating this association. In my practice, using both PCR and DNA sequencing has shown a strong correlation between chronic respiratory tract infections and the digestive tract.
Moving forward, it is my belief that technology will demonstrate a strong correlation between GERD and chronic respiratory tract infections. The challenge will be to improve techniques in managing reflux in order to better manage chronic respiratory tract infections. Especially in the era of antibiotic stewardship, whereby reducing the impact of a risk factor such as GERD, we can reduce the number of exacerbations of chronic infections, thereby reducing the need for antibiotics which will help reduce the risk of developing resistance.