|Year : 2020 | Volume
| Issue : 4 | Page : 302-305
Diseases involving the lung and upper gastrointestinal tract – A Pulmonologist's perspective
Vishnu Sharma Moleyar
Department of Respiratory Medicine, A.J. Institute of Medical Sciences, Mangalore, Karnataka, IndiaDepartment of Respiratory Medicine, A.J. Institute of Medical Sciences, Mangalore, Karnataka, India
|Date of Submission||13-Aug-2019|
|Date of Decision||06-Oct-2019|
|Date of Acceptance||06-Oct-2019|
|Date of Web Publication||20-Jul-2020|
Vishnu Sharma Moleyar
Department of Respiratory Medicine, A.J. Institute of Medical Sciences, Mangalore, Karnataka
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Moleyar VS. Diseases involving the lung and upper gastrointestinal tract – A Pulmonologist's perspective. Med J DY Patil Vidyapeeth 2020;13:302-5
|How to cite this URL:|
Moleyar VS. Diseases involving the lung and upper gastrointestinal tract – A Pulmonologist's perspective. Med J DY Patil Vidyapeeth [serial online] 2020 [cited 2020 Sep 24];13:302-5. Available from: http://www.mjdrdypv.org/text.asp?2020/13/4/302/290170
| Diseases With Lung and Upper Gastrointestinal Tract Involvement|| |
A variety of conditions/diseases can involve the lung and upper gastrointestinal tract (GIT) together. Knowledge about these conditions and the respiratory and upper GIT manifestations in these conditions is essential for the early diagnosis and proper management. Some of the manifestations may be very classical where the diagnosis will be very obvious. Many a time, these combined manifestations may narrow the differential diagnosis. In some cases, GIT manifestations may indicate the severity/stage of the disease and prognosis. In some diseases with GIT manifestations, where no obvious respiratory symptoms or signs are evident, screening for the underlying lung disease may be indicated and vice versa also. Some upper GIT manifestations may indicate the underlying lung or other systemic diseases where further evaluation may be warranted even in the absence of other symptoms or signs.
In some patients, symptoms of lung disease and upper GIT may overlap. One can cause/aggravate the disease of other organs. Medications given for lung disease can precipitate or aggravate upper GIT diseases and vice versa. Hence, one should always inquire and look into GIT and respiratory symptoms in a given patient.
At 4 weeks, the respiratory diverticulum (lung bud) appears as an outgrowth from the ventral wall of the foregut. The oropharynx is common to the lung and upper GIT. Due to developmental anomaly, abnormal connections can occur between the lung and upper GIT. Some upper gastrointestinal (GI) conditions can lead to chest radiological abnormality.
| Diseases With Upper Gastrointestinal Tract and Lung Involvement Can Be Classified Into the Following Categories|| |
- Congenital/developmental disorders with upper GIT and pulmonary manifestations
- Primary upper GIT diseases with pulmonary manifestations
- Primary pulmonary diseases with upper GIT manifestations
- Miscellaneous conditions involving the upper GIT and lung
- Upper GIT diseases due to drugs used to treat respiratory diseases.
| Respiratory Symptoms in Upper Gastrointestinal Diseases|| |
Rarely, cough can be a symptom in upper GI disease, as few cough receptors are present in the esophagus and stomach. Upper GIT obstruction or gastroesophageal reflux disease (GERD) can predispose to aspiration which can present with recurrent or chronic cough, fever, sputum production, and breathlessness. Central chest pain, hemoptysis, breathlessness, stridor, and hoarseness of voice can occur in esophageal carcinoma due to tracheal/airway invasion by the tumor and recurrent laryngeal nerve invasion by the metastatic mediastinal lymph node.
| Upper Gastrointestinal Tract Symptoms in Lung Disease|| |
Some patients with basal pneumonia can present with pain abdomen and vomiting. Atypical pneumonia can present with diarrhea and vomiting. Anorexia and weight loss can be a symptom in chronic lung disease and is common in patients with pulmonary tuberculosis, bronchogenic carcinoma, and bronchiectasis. Dysphagia can occur in lung cancer and also in mediastinal mass lesion due to the compression of the esophagus by the tumor or metastatic lymph node or esophageal stricture/stenosis following radiotherapy. Drugs used for treating obstructive airway diseases such as steroids, and theophylline can aggravate/precipitate upper GIT diseases such as stress ulcers, GERD, peptic ulcer, and erosive gastritis. Patients with obstructive airway disease have increased incidence of upper GIT diseases such as malignancy, GERD, peptic ulcer, and gastritis.
| Congenital/developmental Disorders of the Upper Gastrointestinal Tract and Lung|| |
Tracheoesophageal fistula (TEF) is a congenital or acquired communication between the trachea and esophagus. TEF often leads to severe and fatal pulmonary complications due to aspiration.
Both the esophagus and trachea develop from the primitive foregut. By 4–6 weeks of embryonic stage, the caudal part of the foregut forms a ventral diverticulum that evolves into the trachea. The longitudinal tracheoesophageal fold fuses to form a septum which divides the foregut into a ventral laryngotracheal tube and a dorsal esophagus. Posterior deviation of the tracheoesophageal septum causes incomplete separation of the esophagus from the laryngotracheal tube and results in TEF. Most of the patients with congenital TEFs are diagnosed immediately after birth or during infancy. TEFs are often associated with life-threatening complications due to aspiration. Acquired TEFs can occur secondary to malignant disease of trachea, esophagus, lungs, and metastatic lymph node or due to infection (especially tuberculosis), ruptured diverticula or following prolonged intubation, and trauma.
| Diseases Affecting Both the Lung and Upper Gastrointestinal Tract|| |
- Systemic sclerosis/CREST syndrome
- Alpha-1 antitrypsin deficiency
- Cystic fibrosis.
| Upper Gastrointestinal Tract Manifestations in Systemic Sclerosis|| |
Progressive dysmotility of the entire GIT can occur in systemic sclerosis. GI symptoms in systemic sclerosis include difficulty in swallowing solid foods initially, followed by difficulty with swallowing liquids and subsequent nausea, vomiting, weight loss, abdominal cramps, blotting, diarrhea, and fecal incontinence. Esophageal involvement can be asymptomatic or can present as dysphagia, odynophagia, heartburn, regurgitation, and/or vomiting. Patients can also present with atypical symptoms of GERD such as chronic cough and asthma-like symptoms. Symptoms of gastric involvement include early satiety, abdominal pain, nausea, and vomiting which may progress to complete food intolerance, severe weight loss, and malnutrition.
Alpha-1 antitrypsin deficiency increases the risk of cirrhosis of liver and hepatocellular carcinoma.
Pancreatic insufficiency in cystic fibrosis is a risk factor for recurrent pancreatitis. In some patients, recurrent pancreatitis can be a presenting symptom of cystic fibrosis. GIT manifestations of cystic fibrosis are related to mucus inspissations and dysmotility. Thick mucus in cystic fibrosis can lead to meconium ileus, constipation, distal intestinal obstruction syndrome (DIOS), GERD, and small bowel bacterial overgrowth. DIOS is caused by inspissated intestinal contents that completely or partially block the small intestinal lumen, most commonly at the ileocecal junction. Intussusception can occur in patients with cystic fibrosis. Hepatobiliary disease in cystic fibrosis occurs as a patchy biliary disease. The risk of gallstones is also higher in cystic fibrosis.
| Upper Gastrointestinal Diseases Affecting Lung|| |
Vomiting can lead to aspiration and its complications. Upper GI obstruction, GERD, achalasia cardia, eventration of the diaphragm, and diaphragmatic hernia all can predispose to aspiration and complications due to aspiration. Esophageal rupture can present with chest pain and subcutaneous emphysema after recent vomiting or retching (Mackler's triad). Esophageal rupture can lead to mediastinitis and empyema. Esophageal rupture is a life-threatening emergency, if not diagnosed and treated early, mortality is very high due to mediastinitis.
Liver abscess can lead to a variety of respiratory symptoms and complications. Symptoms may include right upper abdominal and lower thoracic pain, dyspnea or overt respiratory insufficiency, hemoptysis and expectoration of necrotic material, sepsis, pericardial tamponade, and shock. Chest roentgenograms may show pleural effusion, basal pneumonitis, and cardiomegaly. Liver abscess can lead to pleural effusion, pneumonitis, and pericarditis by transthoracic spread of inflammation. Liver abscess can rupture into the airways, pleural cavity, pericardium, airways, pleura, and pericardium. Subphrenic abscess/subdiaphragmatic abscess can also lead to the same complications.
Hydatid cyst may be multiple involving the liver and lungs. Hydatid cyst of the liver can rupture the pleura/lung, leading to complications.
Complications of acute pancreatitis
Arterial hypoxia, pleural effusion, mediastinal abscess, pulmonary infarction, elevated diaphragm, empyema, acute lung injury, and acute respiratory distress syndrome can occur as complications of acute pancreatitis. Chronic pancreatitis and pancreatic pseudocyst can lead to pleural effusion.
Patients with chronic liver disease are more prone to develop respiratory infections and pulmonary tuberculosis due to reduced immunity. Hepatopulmonary syndrome (HPS) can occur in the cirrhosis liver.
| Chest X-Ray Abnormalities in Gastrointestinal Disease|| |
Infradiaphragmatic diseases such as liver abscess, subphrenic abscess, eventration of the diaphragm, diaphragmatic hernia, and air under the diaphragm can lead to the raised dome. Hiatus hernia can lead to retrocardiac shadow. Mediastinal widening and air–fluid level in chest X- ray can occur in achalasia cardia. Air–fluid level in chest X-ray/computed tomography chest can be due to eventration/diaphragmatic hernia, achalasia cardia, and hiatus hernia.
| Gastrointestinal and Lung Malignancy|| |
Advancing age and tobacco use are common risk factors for GI and lung malignancy. Respiratory symptoms can occur in upper GI malignancy due to airway involvement, compression, aspiration, or secondaries. Lungs are one of the most common site for secondaries in upper GI malignancy.
| Tuberculosis|| |
Malnutrition is a risk factor to develop tuberculosis (TB) and TB worsens nutritional status further. Anorexia and weight loss is a common symptom in TB.
| Gastro-Esophageal Reflux Disease and Asthma|| |
Up to 30%–80% of patients with asthma also have GERD. Asthmatics are twice more likely to have GERD than those people who do not have asthma. People with severe asthma which is resistant to treatment are more likely to have GERD. GERD may worsen asthma symptoms. Asthma and some asthma medications such as steroids, beta-2 agonists, and theophylline may worsen GERD symptoms. Treating GERD often helps to control asthma symptoms.
| Gastroesophageal Reflux Disease and the Lung|| |
GERD can cause/exacerbate/trigger lung disease. GERD can cause chronic cough, asthma or asthma-like symptoms, recurrent lower respiratory tract infection, aspiration pneumonia, lung fibrosis, bronchiectasis, interstitial lung disease (ILD), and lung abscess.
| Common Risk Factors for Lung Disease and Gastroesophageal Reflux Disease|| |
Smoking, obesity, and age more than 45 years are common risk factors for lung disease and GERD.
| Liver Disease and Lungs|| |
Pulmonary complications in patients with cirrhosis liver include basal lung atelectasis, restriction of diaphragmatic movement due to ascites, pulmonary hypertension, hepato pulmonary syndrome (HPS), pleural effusion, and pneumonia.
Chronic liver disease and portal hypertension can lead to pulmonary vascular complications, namely portopulmonary hypertension (POPH) and HPS. POPH is characterized by an elevated mean pulmonary artery pressure secondary to an increased pulmonary vascular resistance. HPS is characterized by hypoxemia due to pulmonary vasodilatation and shunting. In addition, chronic liver disease can also lead to the development of hepatic hydrothorax (HH).
A high index of suspicion is essential to diagnose POPH when evaluating patients with liver disease since POPH itself does not lead to any typical symptoms. These patients present with symptoms related to the underlying cirrhosis or portal hypertension. Primary cardiopulmonary disorders (e.g. cardiac failure, obstructive, or restrictive lung disease) can also be present in patients with cirrhosis/chronic liver disease which will lead to similar symptoms. POPH is characterized by the development of pulmonary arterial hypertension in the setting of portal hypertension. POPH may be present in 5%–10% of cirrhosis patients evaluated for liver transplantation (LT). Severe POPH is a relative contraindication for LT. Hence, all patients who are planned for LT should be screened for POPH. Patients with moderate POPH, who respond adequately to medical therapy, may benefit from LT.
HPS is the most common condition, found in 5%–30% of cirrhosis patients and manifested by abnormal oxygenation due to the development of intrapulmonary vascular dilatations. In patients with chronic liver disease, HPS increases mortality and impairs the quality of life but is reversible with LT.
HH is a transudative pleural effusion seen in 5%–10% of cirrhosis patients, in the absence of cardiopulmonary disease or other causes for hydrothorax. The diagnosis of HH should prompt consideration for LT, which is the treatment for HH. Conservative management of HH includes salt restriction and diuretics. Thoracocentesis may be done to relive dyspnea in symptomatic patients to relieve dyspnea. In intractable cases, transjugular intrahepatic portosystemic shunt can be performed.
Tracheobronchial involvement is the most prevalent respiratory presentation in patients with inflammatory bowel disease (IBD). Tracheobronchial involvement in IBD manifests with bronchiectasis, bronchitis, tracheobronchitis, and bronchiolitis. IBD-related ILD can occur in a small subset of patients but is less frequent. Latent and asymptomatic pulmonary involvement is not unusual. Pulmonary infections (mainly bacterial infections and tuberculosis) and drug-induced lung disease due to immunosuppressant drugs used to treat IBD can also occur. Environmental pollution, immunological mechanisms, and genetic factors may play a role in pulmonary involvement in IBD.
| Conclusions|| |
A variety of congenital or acquired diseases can involve both lungs and GIT together. Some diseases of the GIT and lungs can affect each other and can have some overlap in symptoms. Knowledge regarding these conditions will enable proper diagnosis and management to improve the outcome.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Schiller LR. Upper gastrointestinal motility disorders and respiratory symptoms. Am J Health Syst Pharm 1996;53:S13-6.
Pennathur A, Gibson MK, Jobe BA, Luketich JD. Oesophageal carcinoma. Lancet 2013;381:400-12.
Camidge DR. The causes of dysphagia in carcinoma of the lung. J R Soc Med 2001;94:567-72.
Keely S, Hansbro PM. Lung-gut cross talk: A potential mechanism for intestinal dysfunction in patients with COPD. Chest 2014;145:199-200.
Smith N. Oesophageal atresia and tracheo-oesophageal fistula. Early Hum Dev 2014;90:947-50.
Shreiner AB, Murray C, Denton C, Khanna D. Gastrointestinal manifestations of systemic sclerosis. J Scleroderma Relat Disord 2016;1:247-56.
Saurabh K, Anuj C, Pramod G. Gastro-intestinal involvement in systemic sclerosis. Indian J Rheumatol 2017;12:156-66.
Mitchell EL, Khan Z. Liver disease in alpha-1 antitrypsin deficiency: Current approaches and future directions. Curr Pathobiol Rep 2017;5:243-52.
Sabharwal S. Gastrointestinal manifestations of cystic fibrosis. Gastroenterol Hepatol (N
de Schipper JP, Pull ter Gunne AF, Oostvogel HJ, van Laarhoven CJ. Spontaneous rupture of the oesophagus: Boerhaave's syndrome in 2008. Literature review and treatment algorithm. Dig Surg 2009;26:1-6.
Ochsner A, DeBakey M, Murray S. Pyogenic abscess of the liver II. An analysis of forty-seven cases with review of the literature. Am J Surg 1938.;40:292-319.
Ito A, Budke CM. The echinococcoses in Asia: The present situation. Acta Trop 2017;176:11-21.
Takhar RP, Saran RK, Bunkar M, Mirdha K. Respiratory complications in acute pancreatitis. Pancreat Disord Ther 2016;6:E149.
Machicao VI, Balakrishnan M, Fallon MB. Pulmonary complications in chronic liver disease. Hepatology 2014;59:1627-37.
Cole TJ, Turner MA. Manifestations of gastrointestinal disease on chest radiographs. Radiographics 1993;13:1013-34.
Mastronarde JG. Is there a relationship between GERD and asthma? Gastroenterol Hepatol (N
Gaude GS. Pulmonary manifestations of gastroesophageal reflux disease. Ann Thorac Med 2009;4:115-23.
] [Full text]
Huffmyer JL, Nemergut EC. Respiratory dysfunction and pulmonary disease in cirrhosis and other hepatic disorders. Respir Care 2007;52:1030-6.
Savale L, O'Callaghan DS, Magnier R, Le Pavec J, Hervé P, Jaïs X, et al
. Current management approaches to portopulmonary hypertension. Int J Clin Pract Suppl 2011;(169):11-8.
Rodríguez-Roisin R, Krowka MJ, Hervé P, Fallon MB; ERS Task Force Pulmonary-Hepatic Vascular Disorders (PHD) Scientific Committee. Pulmonary-hepatic vascular disorders (PHD). Eur Respir J 2004;24:861-80.
Garbuzenko DV, Arefyev NO. Hepatic hydrothorax: An update and review of the literature. World J Hepatol 2017;9:1197-204.
Majewski S, Piotrowski W. Pulmonary manifestations of inflammatory bowel disease. Arch Med Sci 2015;11:1179-88.