Chest
Volume 69, Issue 4, April 1976, Pages 512-515
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Clinical Investigations
Pulmonary Fibrosis Associated with Tracheobronchial Aspiration: A Study of the Frequency of Hiatal Hernia and Gastroesophageal Reflux in Interstitial Pulmonary Fibrosis of Obscure Etiology

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Tracheobronchial aspiration of gastric secretions has been suggested in published reports as a possible cause for idiopathic pulmonary fibrosis. Forty-eight of 131 patients with roentgenographic evidence of pulmonary fibrosis had no established etiologic diagnosis after individualized evaluations. They were prospectively studied by upper gastrointestinal series to determine the incidence of gastroesophageal reflux. The incidence of both hiatal hernia and reflux were statistically higher in the study group than in a group of 270 age-matched controls who had upper gastrointestinal series for the usual indications; (2) a subgroup of 15 patients who had pulmonary fibrosis and serologic evidence which suggested immune-mediated diseases; and (3) a subgroup of 23 patients with pulmonary fibrosis of established etiology. The patients in the study group could be further characterized by clinical and roentgenographic presentations, low maximum-mid-expiratory flow rates, and lung biopsies compatible with interstitial fibrosis. These observations and other cited evidence are supportive of the concept that repeated, small tracheobronchial aspirations of gastric acid secretions over a long period of time may cause interstitial pulmonary fibrosis.

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MATERIALS AND METHODS

Over a one-year period, we identified 131 patients with roentgenographic shadows which were compatible with minimal to severe pulmonary fibrosis. Each case was evaluated by methods which we deemed individually appropriate for diagnosis, including: geographic, occupational, and drug usage histories; physical examinations; pulmonary physiologic testing; routine and specific laboratory tests; lung and other tissue biopsies; and repeated clinical and chest x-ray followup over the subsequent

RESULTS

Both hiatal hernia and gastroesophageal reflux occurred predominantly in the middle-aged and older population (Table 2). The incidence of both hiatal hernia and reflux were statistically higher in patients with idiopathic pulmonary fibrosis than in the control population.

The majority of patients in the idiopathic study group were overweight or of mesomorphic build. Sixty-three percent of patients were men, a reflection of the Army hospital population. Eighty-seven percent had episodes of

DISCUSSION

In the three decades since the original description of idiopathic interstitial pulmonary fibrosis by Hamman and Rich,8 the viral etiology proposed by them has not been proved. The usual clinical course, initially described as acute, fulminating and fatal within six months, is now widely recognized to be protracted with varying activity and severity.9, 10 The most current theory of etiology is that the lung condition is part of a spectrum of disease mediated by autoimmune mechanisms.11, 12, 13,

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Presented in part at the 41st Annual Meeting, American College of Chest Physicians, Anaheim, October 26-30, 1975.

The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.

Manuscript received September 8; revision accepted November 5.

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