Study of the prevalence of gastroesophageal reflux symptoms and the role of each in relation to the GERD Impact Scale, based on a population of patients admitted for laparoscopic surgery compared to a control group

Introduction

Gastroesophageal reflux disease (GERD), with symptoms demonstrated to impair quality of life (QoL), appears to show important variation in its prevalence. When defined as at least weekly heartburn and/or acid regurgitation, the prevalence is lowest in East Asia (2.5–9.4%) and higher in Central (7.6–19.4%) and Western Asia (12.5–27.6%). The highest population-based prevalence is reported in Europe (23.7%) and the US (28.8%) [1, 2].
Estimation of the prevalence of GERD is also difficult, because many people recognize the symptoms of heartburn as “normal” and use drugs anti­acid which are widely available without any consultation with medical specialists. Moreover, many patients who present typical symptoms of GERD do not have esophagitis. On the other hand, patients with symptoms of esophagitis visible endoscopically do not have any symptoms of GERD.
The first line treatment for GERD is administration of proton pump inhibitors (PPI). Although patients treated with the drugs have reported a noticeable increase in QoL, some studies have shown the superiority of surgery over conservative treatment [3–5]. Laparoscopic Nissen fundoplication (LNF) has become the gold standard of antireflux procedures. Nevertheless, the role of other laparoscopic fundoplication such as Toupet or mesh repair is debated in parallel [6–8].
The combined treatment of patients with GERD symptoms and the attempt to estimate the prevalence of this disease seems to be wrong. Factors influencing the prevalence of GERD include place of residence, level of civilization and the condition of affluence, dietary habits, body mass index (BMI) and finally the recently raised relationship between the symptoms of GERD and Helicobacter pylori infection [9–11].
The evaluation of the frequency of GERD symptoms and clinical outcomes such as esophagitis and esophagitis complications should also be clearly distinguished.

Aim

In an effort to provide a consensus definition, a group of experts came together in Montreal in 2006 and concluded that GERD can be best defined as “a condition which develops when the reflux of stomach contents causes troublesome symptoms and/or complications” [12]. In this situation, we decided to evaluate the prevalence of GERD symptoms in the assessment of the GERD Impact Scale in two age groups of patients, young and old, who were questioned, and evaluate the incidence of individual symptoms of GERD without reference to endoscopic, radiological, pH-metric or manometric symptoms.

Material and methods

We evaluated the prevalence of GERD symptoms with the GERD Impact Scale survey (Appendix 1) in two groups of patients: younger – Campus of the University of Warmia and Mazury in Olsztyn; and older – patients hospitalized in the Department of General Surgery Hospital in Wejherowo. A total of 2,649 surveys were rated. In 1523 surveys of the university campus in Olsztyn the average age was 21.8 years and in 1126 from Wejherowo the average age was 51.5 years.

Statistical analysis

Statistical analysis was performed using the data analysis software system Statistica version 10.0 (StatSoft Inc.) and Microsoft Excel. Quantitative variables were characterized by the arithmetic mean, standard deviation, median, minimum and maximum values (range) and 95% confidence interval (CI), whereas qualitative variables were presented using frequencies and percentages. To check whether a variable quantitative came from a normally distributed population analysis the Shapiro-Wilk W test was used. To test the hypothesis of equal variances the Leven (Brown-Forsythe) test was used. The significance of differences between the two groups (model variables unrelated) was examined by Student’s t-test (or in case of absence of homogeneity the Welch variance test) or Mann-Whitney U test (in the case of non-compliance with the conditions of applicability of Student’s t-test or for variables measured on the ordinal scale). The 2 test of independence was used for qualitative variables (respectively using Yates’ correction for the number of cells below 10, the Cochran Q test, and Fisher’s exact test). In order to establish the strength and direction of the association between variables the Pearson and/or Spearman correlation tests were used. In all the calculations the level of significance was set at p = 0.05.

Results

A total of 2649 individuals were surveyed according to the GERD-IS. In the Olsztyn group (O) there were 1134 (74.5%) women and 388 (25.5%) men, while in the Wejherowo group (W) there were 619 (55.0%) women and 506 (45.0%) men. In group O there were significantly more women. The W population compared to group O was significantly older, weighed more, was shorter and had higher BMI. Hiatal hernia (HH) was significantly more frequent in group W (Table I).
Group O subjects significantly more often had chest or retrosternal pain and burning sensation, regurgitation or acid taste in the mouth, pain or burning in the upper abdomen, sore throat or hoarseness related to heartburn or acid reflux. Group W subjects significantly more often had sleeping difficulty due to symptoms, had been prevented from eating or drinking food they like because of the symptoms, were kept from being fully productive in their job or daily activities due to symptoms and took additional medication (such as Maalox, Alusal, Manti) (Table II).
Individuals with HH were significantly older than those without HH (Table III). Hiatal hernia was significantly more frequent in males than females (Table IV).
In group O with increasing age there was an increase in burning in the chest or behind the breastbone, pain or burning in the upper abdomen, avoiding eating preferred foods for fear of the onset of the symptoms and taking additional medication, whereas sore throat or hoarseness related to heartburn or reflux was decreased. In group W with increasing age there was an increase in pain in the chest or behind the breastbone, a burning sensation in the chest or behind the breastbone, sleeping difficulties and avoidance of food (Table V).
In group O with increasing weight gain there was increased burning sensation in the chest or behind the breastbone and sore throat or hoarseness associated with heartburn or reflux, and decreased pain in the chest or behind the breastbone and pain or burning sensation in the upper abdomen. In group W with increasing weight gain there was an increase in taking additional medications, and decrease in pain in the chest or behind the breastbone, regurgitation or acid taste in the mouth, pain or burning sensation in the upper abdomen, sleeping difficulties, avoidance of eating food and disruption of one’s work or daily activities (Table V).
In both groups O and W the symptoms decreased with increase in height (Table V).
In group O with increasing body mass index (BMI) there was an increase in burning sensation in the chest or behind the sternum, sore throat or hoarseness related to heartburn or reflux, while there was a decrease in pain or burning in the upper abdomen. In group W with the increase in BMI taking additional medications rose (Table V).
In group O women significantly frequently had pain in the chest or behind the sternum, regurgitation or acid taste in the mouth, pain or burning in the upper abdomen, avoidance of food because of the symptoms and disruption of one’s job or daily activities (Table VI).
In group W women significantly frequently had pain in the chest or behind the sternum, regurgitation or acid taste in the mouth, pain or burning in the upper abdomen, sore throat or hoarseness associated with heartburn or reflux, sleeping disorders because of the symptoms, avoidance of food because of the onset of the symptoms, disruption of work or daily activities and taking additional medications (Table VII).

Discussion

According to this study the symptoms of GERD included in the GERD-IS in northern Poland vary from 0.9–2.4% as daily sensations to 18.9–40.5% occurring sometimes.
A review of the literature from 2000 shows that in Europe it varies from 8.8% to 27.5% [1, 2, 10–15]. The largest report, provided by Mungan, included 8143 patients in a population-based cross-sectional study in Turkey. Participants answered the validated GERD questionnaire. In the survey 53.8% of people claimed the presence of reflux symptoms at least once in the last week; however, after adjustment for age and gender the authors reported the prevalence of GERD in 27.5% of the Turkish population [13]. In the same year Lofdahl et al. presented an article based on 1483 samples, where the prevalence of GERD is the lowest among the cited papers. Heartburn or regurgitation appears in 8.8% of the Swedish population [14].
These discrepancies of estimated values result from many reasons. There were different characteristics of participants in the studies, such as age or BMI of samples. Moreover, the social status and the behavioral factors have an influence on the occurrence of GERD [2]. Also there are papers which note a correlation between esophagitis severity and H. pylori colonization, which is also a common infection in Poland [13]. Cigarette smoking is a globally recognized causative factor for GERD, while other factors lack a consensus [9, 16].
Our study shows a positive correlation between overweight and prevalence of GERD. Similar findings are described in the literature. Hampel et al. performed a meta-analysis to compare the risk for GERD with obesity. They found 9 studies from which 6 confirmed the statistically significant relation between higher BMI and GERD, and 3 papers showed no association [10]. Likewise, an association between increasing age and GERD was revealed in our study.
Iwakiri et al. developed guidelines for GERD [17]. Proton pump inhibitors (PPI) are recommended as the first-line treatment as well as for the long-term maintenance therapy. Proton pump inhibitors are effective in most GERD patients, even though for some of them it is not necessary to resolve the symptoms. For PPI-resistant patients Iwakiri et al. proposed anti-reflux surgery (ARS). In the majority of cases the ARS is successful in reducing heartburn and regurgitation in addition to other complaints. Many studies show the superiority of ARS over PPI treatment [4–6]. Lundell et al. presented long-term outcomes after ARS and omeprazole maintenance therapy for reflux esophagitis. Twelve years of follow-up demonstrated that significantly more patients were kept in continuous clinical remission after ARS than PPI [18]. Moreover, studies demonstrated that more than half of the patients had abnormal (> 4%) acid reflux in 24-h pH tests using PPI [19]. According to the literature and own experience, ARS seems to be the best way for long-term treatment of GERD and improving QoL [20].
Two methods of ARS are commonly used worldwide – laparoscopic Nissen fundoplication (LNF) and laparoscopic Toupet fundoplication (LTF). Tan et al. conducted a meta-analysis comparing these two methods based on random clinical trials [6]. Comparing the early and later (one to 3 years after surgery) results, no statistically significant difference in occurrence of heartburn was found between LNF and LTF and there was similar patients’ satisfaction with both procedures. However, the study revealed a lower incidence of dysphagia and chest pain for patients who had received LTF. Early complications after the surgery were noted less commonly in patients undergoing LNF. Although there are several randomized clinical trials and meta-analyses, the authors did not reach a conclusion as to which of these two methods should be the gold standard. Conceivably, it is connected with differences in patients’ characteristics, selection as well as operative techniques.

Conclusions

Estimation of the prevalence of GERD is difficult, because the medications are widely available and people use them without any consultation. They do not recognize the symptoms as a disease whose treatment can also be surgical. Our analysis shows that the prevalence of symptoms of GERD in northern Poland is as high as 40.5%. That demonstrates that further investigation is warranted and people’s awareness should be raised.

Conflict of interest

The authors declare no conflict of interest.

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Received: 4.01.2018, accepted: 26.02.2018.