Esophageal Disorders Program Tackles GERD-Related Aspiration

Team develops novel technique to assess and prevent common problem that can be serious in some patients.

The Esophageal Disorders Program at NewYork-Presbyterian/ Columbia University Medical Center has wide experience in treating adults and children with esophageal diseases. According to Frank D’Ovidio, MD, PhD, Surgical Director of the Lung Transplant Program, the esophageal team’s expertise, now world-renowned, has developed over decades of multidisciplinary collaboration.

Now, Dr. D’Ovidio is drawing on that expertise to address a significant complication associated with severe gastroesophageal reflux disorder (GERD). Approximately 20% of Americans have some degree of GERD, leading to approximately 65 million prescriptions and 4.7 million hospitalizations per year in the United States.* But despite these staggering numbers, even severe GERD can go undetected for long periods of time. Whether GERD occurs on its own or in association with other esophageal and lung conditions, it can lead patients to aspirate stomach content into their lungs.

Aspiration of stomach juices into the lungs is a particularly dangerous problem because it can damage the lining of the lungs, leading to presentations of lung disease ranging from asthma to lung fibrosis. “This problem is seldom recognized and often not appropriately treated,” says Dr. D’Ovidio. Moreover it is of great concern and a significant challenge in lung transplant patients, who are often affected by severe GERD. Aspiration can cause early lung dysfunction to newly transplanted lungs in such patients.

As a result of increased awareness of the dangers of prolonged non-classic GERD symptoms, the program is now working on an approach to help detect and prevent GERD-related aspiration so that patients can avoid developing associated lung disease. Their approach entails a new methodology to assess aspiration secondary to GERD. Specifically, Dr. D’Ovidio is developing a way to measure the presence of bile acids in the airways. Bile acids are components of the gastrointestinal juices and should not be present in the lungs. If they are found in the airway, this indicates the presence of severe GERD and recurrent aspiration.

The procedure works like this: doctors obtain fluid samples during bronchoscopy procedures (and in the future, they could potentially use sputum, expectorated secretions, or exhaled breath condensate as well). They then use the mass spectrometer to test the samples for the presence of duodenal gastric juices such as bile acids. This assessment can objectively monitor whether micro-aspiration is occurring, which would then help to guide treatment decisions. The mass spectrometry approach to test for bile acids in lung fluids has been developed and will be performed in partnership with Serge Cremers, PharmD, PhD. Director of the Biomarkers Core Laboratory of the Irving Institute for Clinical and Translational Research.

As Dr. D’Ovidio explains, “Lung transplant and other patients cannot tell when they are aspirating fluid into their lungs. They know if they are aspirating large volumes of fluid, called macro-aspiration, but they often can not tell if they are inhaling smaller quantities, called micro-aspiration. The ability to detect micro-aspiration could significantly improve the health of thousands of patients with otherwise asymptomatic GERD.” The new approach was made possible by combining the knowledge available in Dr. Cremers’ special chemistry laboratory with the esophageal team’s expertise in pathophysiology and clinical presentation of esophageal and lung disorders.

“We are initially looking to help a relatively small population affected by GERD, those who have undergone lung transplant or patients with gastroesophageal motor disorders. However, this test could potentially be used to help the broader population of people who suffer from GERD but do not have typical GERD-like symptoms (cough, asthma and others), and therefore go undiagnosed for many years. Of note, pulmonary fibrosis and COPD have been associated with GERD and possible aspiration,” says Dr. D’Ovidio. This new methodology is now being cross-tested in a multicenter study.

*http://digestive.niddk.nih.gov/statistics/statistics.aspx#specific

For information on treatment of GERD at NewYork-Presbyterian/Columbia, please visit www.columbiasurgery.org/esophageal, or email info@columbiasurgery.org.

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