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Background: Idiopathic pulmonary fibrosis (IPF) is a diffuse fibrotic lung disease of unknown etiology. The association between IPF and gastroesophageal reflux disease (GERD) has been suggested. The objective of this study was to determine the prevalence of GERD and assess the proximity of reflux events in patients with histologically proven IPF.

Methods: This is a retrospective review of prospectively collected data for patients with histologically confirmed IPF (via lung biopsy) who underwent objective esophageal physiology testing including bi-positional high-resolution manometry (HRM) and hypopharyngeal multichannel intraluminal impedance (HMII). In bi-positional HRM, 10 swallows with 5ml water each were delivered in the supine position; this was followed by 5 additional swallows in the upright position. Defective LES was defined as either LES pressure of <5.0 mmHg, total length of LES of <2.4 cm or intra-abdominal length of LES of <0.9 cm. Abnormal esophageal motility was considered present when failed swallows ≥30% and/or mean wave amplitude <30 mmHg was present. HMII used a specialized impedance catheter to measure the proximal reflux events such as laryngopharyngeal reflux (LPR) and full column reflux (reflux 2 cm distal to the upper esophageal sphincter). Based on the previous study of healthy subjects, abnormal proximal exposure was considered present when laryngopharyngeal reflux (≥1/day) and/or proximal esophageal reflux (≥5/day) were present.

Results: From October 2009 to June 2011, 37 patients with IPF (male 22, female 15) including 8 patients who had undergone lung transplant prior to objective esophageal testing were examined. Mean age and BMI were 62 years (range, 41-78) and 27.6 (range, 14.8-38.1), respectively. Two patients were excluded from this study due to lack of HMII. All patients except two were symptomatic; 26 had predominately pulmonary symptoms such as cough and 9 had isolated typical GERD symptoms such as heartburn and regurgitation. Abnormal proximal exposure was present in 19/35 (54%) patients. Esophageal mucosal injury such as esophagitis and Barrett’s esophagus and/or hiatal hernia was found in 28/32 (88%) patients. However, 29/35 (83%) patients had a negative DeMeester score. All patients with IPF had reflux predominately in the upright position. Bi-positional HRM increased the diagnostic yield of defective LES from 78% (supine) to 93% (upright). Sixteen patients (50%) had abnormal esophageal motility including aperistaltic esophagus (n=9).

Conclusion: A large number of patients with IPF have objective evidence of GERD without typical symptoms. Proximal reflux was common despite a frequently negative DeMeester score. Reflux events occurred primarily in the upright position and this was associated with a decrease in LES integrity when examined with bi-positional HRM.