Journal of Gastrointestinal Surgery

, Volume 20, Issue 1, pp 104–110 | Cite as

Pathophysiology of Gastroesophageal Reflux in Patients with Chronic Pulmonary Obstructive Disease Is Linked to an Increased Transdiaphragmatic Pressure Gradient and not to a Defective Esophagogastric Barrier

  • Leonardo M. Del Grande
  • Fernando A. M. Herbella
  • Amilcar M. Bigatao
  • Henrique Abrao
  • Jose R. Jardim
  • Marco G. Patti
2015 SSAT Plenary Presentation


The association of gastroesophageal reflux disease (GERD) and pulmonary diseases is well known.1 Early studies showed that gastroduodenal contents may reflux up to the proximal esophagus2 and cause aspiration.3 Other studies showed a higher incidence of GERD in patients with asthma,4 interstitial fibrosis,5 chronic cough,6 and chronic obstructive pulmonary disease (COPD).7, 8, 9, 10

Esophageal (or typical) GERD symptoms (heartburn, regurgitation, and dysphagia) are not always present in these patients, and even when they are reported, they yield a low accuracy for GERD diagnosis.11 Extra-esophageal symptoms such as cough are common and thus represent a confounding factor. As a consequence, clinical questionnaires are insufficient and objective determination of GERD is mandatory for the correct management of these patients.

COPD is attributed to tobacco smoking in the majority of cases, different from adult asthma and pulmonary fibrosis that, although still considered...


Gastroesophageal reflux Chronic obstructive pulmonary disease High-resolution esophageal manometry Esophageal pH monitoring 



We are indebted to Ms. Vanessa Horich Tuxen for her invaluable assistance with the esophageal tests.

Authors’ contribution

LMDG participated in the analysis and interpretation of data as well as final approval of the version to be published

FAMH participated in the conception and design, acquisition of data, analysis and interpretation of data, drafting the article, and final approval of the version to be published

AMB participated in the acquisition of data, analysis and interpretation of data, and final approval of the version to be published

HA participated in the analysis and interpretation of data, final approval of the version to be published

JRJ reviewed the manuscript for intellectual content and for final approval of the version to be published

MGP participated in the conception and design, analysis and interpretation of data, review for intellectual content, and final approval of the version to be published


The study protocol was approved by the local ethics committee (#1960/11) and written informed consent was obtained from each subject. No financial compensation was provided to the individuals.


  1. 1.
    Allaix ME, Fisichella PM, Noth I, Mendez BM, Patti MG. The pulmonary side of reflux disease: from heartburn to lung fibrosis. J Gastrointest Surg. 2013 Aug;17(8):1526–35.Google Scholar
  2. 2.
    Pellegrini CA, DeMeester TR., Johnson, LF, Skinner DB. Gastroesophageal reflux and pulmonary aspiration: incidence, functional abnormality, and results of surgical therapy. Surgery 1979;86:110–118.PubMedGoogle Scholar
  3. 3.
    Sweet MP, Patti MG, Hoopes C, Hays SR, Golden JA. Gastro-oesophageal reflux and aspiration in patients with advanced lung disease. Thorax. 2009 Feb;64(2):167–73Google Scholar
  4. 4.
    Harding SM. Recent clinical investigations examining the association of asthma and gastroesophageal reflux. Am J Med. 2003 Aug 18;115 Suppl 3A:39S-44S.Google Scholar
  5. 5.
    Allaix ME, Fisichella PM, Noth I, Herbella FA, Borraez Segura B, Patti MG. Idiopathic pulmonary fibrosis and gastroesophageal reflux. Implications for treatment. J Gastrointest Surg. 2014 Jan;18(1):100–5.Google Scholar
  6. 6.
    Kahrilas PJ, Smith JA, Dicpinigaitis PV. A Causal Relationship Between Cough and Gastroesophageal Reflux Disease (GERD) has been Established: A Pro/Con Debate. Lung. 2014 Feb;192(1):39–46.Google Scholar
  7. 7.
    Gadel AA, Mostafa M, Younis A, Haleem M. Esophageal motility pattern and gastro-esophageal reflux in chronic obstructive pulmonary disease. Hepatogastroenterology. 2012 Nov-Dec;59(120):2498–502.Google Scholar
  8. 8.
    Kamble NL, Khan NA, Kumar N, Nayak HK, Daga MK. Study of gastro-oesophageal reflux disease in patients with mild-to-moderate chronic obstructive pulmonary disease in India. Respirology. 2013 Apr;18(3):463–7.Google Scholar
  9. 9.
    Kempainen RR, Savik K, Whelan TP, Dunitz JM, Herrington CS, Billings JL. High prevalence of proximal and distal gastroesophageal reflux disease in advanced COPD. Chest. 2007 Jun;131(6):1666–71.Google Scholar
  10. 10.
    Casanova C, Baudet JS, del Valle Velasco M, Martin JM, Aguirre-Jaime A, de Torres JP, Celli BR. Increased gastro-oesophageal reflux disease in patients with severe COPD. Eur Respir J. 2004 Jun;23(6):841–5.Google Scholar
  11. 11.
    Sweet MP, Herbella FA, Leard L, Hoopes C, Golden J, Hays S, Patti MG. The prevalence of distal and proximal gastroesophageal reflux in patients awaiting lung transplantation. Ann Surg. 2006 Oct;244(4):491–7.Google Scholar
  12. 12.
    Kahrilas PJ, Bredenoord AJ, Fox M, Gyawali CP, Roman S, Smout AJ, Pandolfino JE; International High Resolution Manometry Working Group. The Chicago Classification of esophageal motility disorders, v3.0. Neurogastroenterol Motil. 2015 Feb;27(2):160–74. doi:  10.1111/nmo.12477. Epub 2014 Dec 3.
  13. 13.
    Pandolfino JE, Kim H, Ghosh SK, Clarke JO, Zhang Q, Kahrilas PJ. High-resolution manometry of the EGJ: an analysis of crural diaphragm function in GERD. Am J Gastroenterol. 2007 May;102(5):1056–63. Epub 2007 Feb 23.Google Scholar
  14. 14.
    Johnson LF, Demeester TR. Twenty-four-hour pH monitoring of the distal esophagus. A quantitative measure of gastroesophageal reflux. Am J Gastroenterol. 1974 Oct;62(4):325–32.Google Scholar
  15. 15.
    Lindberg A, Larsson LG, Rönmark E, Lundbäck B. Co-morbidity in mild-to-moderate COPD: comparison to normal and restrictive lung function. COPD. 2011 Dec;8(6):421–8.Google Scholar
  16. 16.
    Neto SC, Herbella FA, Silva LC, Patti MG. Ratio Between Proximal/Distal Gastroesophageal Reflux Does Not Discriminate Abnormal Proximal Reflux. World J Surg. 2014 Apr. 38(4):890–896.Google Scholar
  17. 17.
    Dobhan R, Castell DO. Normal and abnormal proximal esophageal acid exposure: results of ambulatory dual-probe pH monitoring. Am J Gastroenterol. 1993;88:25–29.PubMedGoogle Scholar
  18. 18.
    Bello B, Zoccali M, Gullo R, Allaix ME, Herbella FA, Gasparaitis A, Patti MG. Gastroesophageal reflux disease and antireflux surgery-what is the proper preoperative work-up? J Gastrointest Surg. 2013 Jan;17(1):14–20: discussion p. 20. Google Scholar
  19. 19.
    Riedl O, Gadenstätter M, Lechner W, Schwab G, Marker M, Ciovica R. Preoperative lower esophageal sphincter manometry data neither impact manifestations of GERD nor outcome after laparoscopic Nissen fundoplication. J Gastrointest Surg. 2009 Jul;13(7):1189–97.Google Scholar
  20. 20.
    Orr WC, Shamma-Othman Z, Allen M, Robinson MG. Esophageal function and gastroesophageal reflux during sleep and waking in patients with chronic obstructive pulmonary disease. Chest. 1992 Jun;101(6):1521–5.Google Scholar
  21. 21.
    Lindberg A, Bjerg A, Rönmark E, Larsson LG, Lundbäck B. Prevalence and underdiagnosis of COPD by disease severity and the attributable fraction of smoking Report from the Obstructive Lung Disease in Northern Sweden Studies. Respir Med. 2006 Feb;100(2):264–72.Google Scholar
  22. 22.
    Lundbäck B, Lindberg A, Lindström M, Rönmark E, Jonsson AC, Jönsson E, Larsson LG, Andersson S, Sandström T, Larsson K; Obstructive Lung Disease in Northern Sweden Studies. Not 15 but 50 % of smokers develop COPD?--Report from the Obstructive Lung Disease in Northern Sweden Studies. Respir Med. 2003 Feb;97(2):115–22.Google Scholar
  23. 23.
    Salvi S. Tobacco Smoking and Environmental Risk Factors for Chronic Obstructive Pulmonary Disease. Clin Chest Med. 2014 Mar;35(1):17–27.Google Scholar
  24. 24.
    Herbella FA, Patti MG. Gastroesophageal reflux disease: From pathophysiology to treatment. World J Gastroenterol. 2010 Aug 14;16(30):3745–9.Google Scholar
  25. 25.
    Patti MG, Tedesco P, Golden J, Hays S, Hoopes C, Meneghetti A, Damani T, Way LW. Idiopathic pulmonary fibrosis: how often is it really idiopathic? J Gastrointest Surg. 2005 Nov;9(8):1053–6; discussion 1056–8.Google Scholar
  26. 26.
    Hoppo T, Komatsu Y, Jobe BA. Gastroesophageal reflux disease and patterns of reflux in patients with idiopathic pulmonary fibrosis using hypopharyngeal multichannel intraluminal impedance. Dis Esophagus. 2012 Oct 26.Google Scholar
  27. 27.
    Hurst JR, Vestbo J, Anzueto A, et al. Susceptibility to exacerbation in chronic obstructive pulmonary disease. New Engl J Med 2010;363:1128–38.PubMedCrossRefGoogle Scholar
  28. 28.
    Sasaki T, Nakayama K, Yasuda H, Yoshida M, Asamura T, Ohrui T, Arai H, Araya J, Kuwano K, Yamaya M. A randomized, single-blind study of lansoprazole for the prevention of exacerbations of chronic obstructive pulmonary disease in older patients. J Am Geriatr Soc. 2009 Aug;57(8):1453–7.Google Scholar
  29. 29.
    Eryuksel E, Dogan M, Olgun S, Kocak I, Celikel T. Incidence and treatment results of laryngopharyngeal reflux in chronic obstructive pulmonary disease. Eur Arch Otorhinolaryngol. 2009 Aug;266(8):1267–71.Google Scholar
  30. 30.
    Herbella FA. Critical analysis of esophageal multichannel intraluminal impedance monitoring 20 years later. ISRN Gastroenterol. 2012;2012:903240.PubMedPubMedCentralCrossRefGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2015

Authors and Affiliations

  • Leonardo M. Del Grande
    • 1
  • Fernando A. M. Herbella
    • 1
  • Amilcar M. Bigatao
    • 2
  • Henrique Abrao
    • 1
  • Jose R. Jardim
    • 2
  • Marco G. Patti
    • 3
  1. 1.Department of Surgery, Escola Paulista de MedicinaFederal University of Sao PauloSao PauloBrazil
  2. 2.Department of Medicine, Respiratory Division, Escola Paulista de MedicinaFederal University of Sao PauloSao PauloBrazil
  3. 3.Department of Surgery, Pritzker School of MedicineUniversity of ChicagoChicagoUSA

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