Critical Care: Global Case Report Poster - Miscellaneous |

Esophageal Aperistalsis-Induced Diffuse Aspiration Bronchiolitis FREE TO VIEW

Ashok Arbat, MD; Sneha Tirpude, MD; Mitesh Dave, MBBS; Manoj Vyawahare, MD; Sukhant Bagdia, MD; Sameer Arbat, MD
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Department of Pulmonology, KRIMS Hospitals, Nagpur, India

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):268A. doi:10.1016/j.chest.2016.08.281
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SESSION TITLE: Global Case Report Poster - Miscellaneous

SESSION TYPE: Global Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Pulmonary aspiration can cause mortality and morbidity. Diffuse aspiration bronchiolitis (DAB) is one of the aspiration syndromes which often gets undernoticed. In this case the cause of aspiration was complete paralysis of the esophagus, with symptoms ongoing since childhood indicating misdiagnosed syndrome and suboptimal treatment. There is hardly any mention about esophageal motility disorder other than classic achalasia causing DAB.

CASE PRESENTATION: A 32 year old woman had symptoms since childhood of intermittent increase in cough with mucopurulent expectoration and breathlessness on exertion. She also had difficulty in swallowing, non cardiac chest pain and hiccups. In view of increased complaints, and fever she was hospitalised at our centre. On clinical examination her respiratory rate was 22 cycles per minute with use of accessory muscles of respiration, blood pressure of 100/70 mm of mercury, oxygen saturation of 94 %, and chest auscultation showed bilateral infrascapular coarse crackles. Chest radiograph showed bilateral mid zone and lower zone reticulonodular opacities (Figure1). High resolution computed tomography (HRCT) Thorax (Figure 2) showed diffuse ground glass haziness and discreet tiny nodules and tree in bud in the perihilar region and proximal lower lobes, rest of the lung showed air trapping. She also had a dilated esophagus all along its length with a probable gastro-esophageal (GE) junction narrowing. Spirometry showed severe restriction, FVC 0.60L (20.3%). Gastroendoscopy and biopsy from the lower end of esophagus revealed no abnormality. However, manometry showed a hypotensive lower esophageal sphincter (LES), in contrast to elevated LES pressures seen in achalasia, and an absent contractility of complete esophagus. Diagnosis: Diffuse aspiration bronchiolitis (DAB) in esophageal aperistalsis.

DISCUSSION: The patient had several episodes of repeated aspirations, leading to chronic inflammation of the bronchioles. Diffuse aspiration bronchiolitis (DAB) has been proposed to define a clinical entity that is characterized by a chronic inflammation of bronchioles caused by recurrent aspiration of foreign bodies.1 DAB was originally recognized in the elderly, but can occur in younger patients with achalasia or GERD with similar manifestations. In this condition, the sphincter does not close completely, after food enters the stomach. In absence of concomitant peristalsis, the acid goes back up from the stomach into the esophagus and trachea. In primary/idiopathic esophageal aperistalsis there is failed esophageal contractility and a hypotensive lower esophageal sphincter without a known systemic cause as with our patient. The word secondary is applied to esophageal disorders in systemic disorders such as connective tissue disease, diabetes, dermatomyositis, amyloidosis, and Chagas’ disease.3 Endoscopy may not be the best test to evaluate LES especially in connective tissue disease.3 Esophageal manometry was the diagnostic test in our case. Patient received antibiotics, bronchodilators, and bethanecol, which stimulates parasympathetic receptors to increase muscle tone, and leads to contraction of the sphincter. Lower esophageal sphincter and the crural diaphragm represent the major antireflux barrier, hence a specific inspiratory muscle training2 was started. At follow up she continued to show improvement.

CONCLUSIONS: Radiological features consistent with bronchiolitis and a long history of recurrent aspiration are important clues to the diagnosis of DAB1. Management of patients with DAB focuses on prevention of recurrent aspiration by addressing the underlying risk factors.

Reference #1: Xiaowen Hu, Eunhee Suh Yi, Jay Hoon Ryu, Diffuse aspiration bronchiolitis: analysis of 20 consecutive patients. J Bras Pneumol. 2015 Mar-Apr; 41(2): 161-166.

Reference #2: Chaves RC, Suesada M, Polisel F, Cristina de Sá C, Rodriguez TN. Respiratory physiotherapy can increase lower esophageal sphincter pressure in GERD patients. Respiratory Medicine, Volume 107, Issue 3, March 2013, Pages 476-477

Reference #3: Paterson WG, Goyal RK, Habib FI. Esophageal motility disorders. In: Goyal R, Shaker R, eds. GI Motility Online 2006; doi:10.1038/gimo20. Available at: http://www.nature.com/gimo/contents/pt1/authors/gimo20.html (online).

DISCLOSURE: The following authors have nothing to disclose: Ashok Arbat, Sneha Tirpude, Mitesh Dave, Manoj Vyawahare, Sukhant Bagdia, Sameer Arbat

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