Gastroesophageal reflux disease: prevalence and quality of life of health science undergraduate students

Alexandre L Cardoso,¹ Ana G A Figueiredo,¹ Lara G D Sales,¹ Adozina M Souza Neta,¹ Íkaro D C Barreto,² Leda M D F Trindade¹

¹Medicine Department, Tiradentes University. Aracaju.
²Estatistics. Rural Federal University of Pernambuco. Recife, Brazil.

Acta Gastroenterol Latinoam 2018;48(3):197-205
Recibido: 24/09/2017 / Aprobado: 24/04/2018 / Publicado en www.actagastro.org el 17/09/2018

Summary

Background & aims. gastroesophageal reflux disease elapses from a backflow of gastroduodenal contents. It causes symp­toms that compromise quality of life. The study aims to de­fine the prevalence of the disease, sociodemographic profile, clinical manifestation and quality of life. Material and methods. Cross-sectional study. Probabilistic sample of 501 university students with clinical manifestation. It was used clinical, sociodemographic and disease-related quality of life questionnaires. Results. 59 (11.8%) students with the dis­ease, median age 24.5 (range: 20-29), female 49 (83%). Asian: 3.35-fold higher risk, 32% ingested alcoholic bev­erages. Signs and symptoms: heartburn 40%, regurgitation 41%, throat clearing 36%, chronic cough 53%, chest pain 33%; tonsillitis 44%, hoarseness 45%, asthma 19% and laryngitis 80%. Higher risk: heartburn 2 or more times per week (CI95%: 7.93-418.7; p < 0.001), 3 or more times per week (CI95%: 6.87-419.0; p < 0.001), and regurgita­tion 2 or more times per week (CI95%: 2.45-16.89; p < 0.001), 3 or more times per week (CI95%: 2.16-19.13; p < 0.001) up to 8 weeks (CI95%: 1.21-10.14; p < 0.006). Higher means to the group Pain (SD: 1.45) and Functional aspect (SD: 1.20). Conclusion. It is worrying the prevalence of gastroesophageal reflux disease and the contribution for impairment of the individuals’ quality of life.

Key words. Gastroesophageal reflux disease, typical and atypical symptoms, quality of life.

Enfermedad por reflujo gastresofági­co: prevalencia y calidad de vida en estudiantes universitarios del área de la salud

Resumen

La enfermedad por reflujo gastroesofágico (ERGE) se pro­duce como consecuencia del reflujo patológico del contenido gástrico al esófago, y causa signos y síntomas que compro­meten la calidad de vida. El estudio desea definir la pre­ valencia de la enfermedad, el perfil sociodemográfico, las manifestaciones clínicas y la calidad de vida del estudiante universitario que sufre esta patología. Material y métodos. Diseño: estudio de corte transversal. Muestra probabilística: 501 estudiantes universitarios con manifestaciones clínicas. Fueron utilizados cuestionarios clínicos, sociodemográficos y de calidad de vida relacionados con la enfermedad. Resulta­dos. 59 estudiantes tenían ERGE (11,8%), edad mediana de 24,5 años (rango: 20-29), 49 de sexo femenino (83%). Los asiáticos tuvieron 3,35 más riesgo; se registró ingesta de alcohol en el 32% de los estudiantes. Signos y síntomas: pi­rosis el 40%; regurgitación el 41%; cosquilleo crónico de la garganta el 36%; tos crónica el 53%; dolor en el pecho el 33%; amigdalitis 44%; ronquera el 45%; asma el 19% y laringitis el 80%. Mayor riesgo: pirosis 2 o más veces por semana (IC95%: 7,93-418,7; p < 0,001), 3 o más veces por semana (IC95%: 6,87-419.0; p < 0,001), y regurgitación 2 o más veces por semana (IC95%: 2,45-16,89; p < 0,001), 3 o más veces por semana (IC95%: 2,16-19,13; p < 0,001), hasta 8 semanas (IC95%: 1,21- 10,14; p < 0,006). Más altos valores del grupo para el síntoma dolor (SD: 1,45) y el aspecto funcional (1,20). Conclusiones. Preocupa la pre­valencia de la enfermedad por reflujo gastroesofágico en los estudiantes y cómo afecta de forma negativa su calidad de vida.

Palabras claves. Enfermedad por reflujo gastroesofágico, síntomas típicos y atípicos, calidad de vida.

Abbreviations
GERD: gastroesophageal reflux disease.
GERD-HRQoL: quality of life scale health related to gastro­esophageal reflux disease.
HBQoL: heartburn specific quality of life instrument.
PPI: proton-pump inhibitors.

The gastroesophageal reflux disease (GERD) is a chronic condition that elapses from a backflow of gastro­duodenal contents to the esophagus or adjacent organs, causing a variable range of symptoms and signs either associated or not with tissue lesions and quality of life impairment.¹ Most episodes are postprandial, occurs on distal esophagus, and are short and asymptomatic.²

GERD is a highly prevalent condition in western countries,³ in Brazil correspond to 12% of people who lives in urban areas.⁴ This disease is more frequent among people 55 years and older and its complications, like ero­sive esophagitis, are common in white males.⁵

GERD is a multifactorial process that depends on the anti-reflux barrier, esophageal clearance, esophageal mu­cosa resistance or emptying and intragastric pressure or both.⁶

Studies report a connection of heartburn between complains of “sour or bitter taste in the mouth” and dietary intake, higher prevalence in females, stress, low well-being index, low educational levels, affective prob­lems, insomnia, fatty food, fried food, seasonings and overweight/obesity.^{7, 8}

The clinical picture is generally characterized by heartburn and regurgitation, considered typical symp­toms. Heartburn is presented like a burning sensation on retrosternal portion that radiates from the sternal manu­brium to the base of the neck, can reach the throat and/or acid regurgitation.9 Stress is widely recognized as a nega­tive factor for heartburn, most likely for an amplifying effect of the symptom instead of gastroesophageal reflux increase.¹⁰

Atypical manifestation might appear individually, be­coming even harder the diagnostic investigation.¹¹ Some patients report dyspeptic associated symptoms like post­prandial bloating, gastric fullness, belching and nausea. If the patient report typical symptoms at least two times per week in a four to eight weeks period or more, GERD di­agnosis should be suspected.⁹ The proton-pump inhibi­tors therapeutic test can empirically diagnose GERD.¹¹ The upper gastrointestinal endoscopy should be indi­cated specially in response to alarming manifestations, besides severe symptoms or worsening at night.^{9, 12} Func­tional evaluation methods like esophageal manometry and esophageal pH-metry are used to offer better accu­racy in GERD diagnostic.¹³

The impact on affected individual’s quality of life and negative consequences on the social and working activi­ties is considered an important factor in GERD evalua­tion.^{11, 14} Such, impact is associated with pain, discom­fort, sedentariness, impairment of daily life and social relations, diet patterns, impact on productivity, especially when associated to sleep deprivation.¹⁵

This study aims at assessing GERD prevalence, epi­demiologic profile, clinical manifestation and health sci­ences students of a private university quality of life.

Material and methods

Cross-sectional study conducted from January to May 2016 in Tiradentes University, Aracaju, Sergipe, Brazil, the sample consisted of 750 graduate students in medicine, odontology, nursing and physiotherapy in the last two years of college. Of those students, only 501 an­swered the research tools. Probability sampling. Diagnos­tic criteria for GERD: previous diagnostic; presence of heartburn or regurgitation or both at least two times per week during four to eight weeks; individual that present­ed regurgitation or not, since they meet the heartburn criteria. Were included in the research all students that presented previous diagnostic and typical and/or atypical manifestation of the disease.

It was used three self-administered questionnaires: sociodemographic and clinical profile (elaborated by the authors), quality of life scale health related to gas­troesophageal reflux disease (GERD-HRQoL) and heart­burn specific quality of life instrument (HBQoL), both validated into Portuguese.

For the individuals that presented heartburn and/ or regurgitation clinical criteria it was used the GERD-HRQoL questionnaire and for those regardless of present­ing regurgitation or not, but presented heartburn/pyrosis it was used HBQoL, which is an instrument to evaluate the heartburn influence in nine domains of quality of life. The studied domains were: pain, sleep diet, vitality, so­cial aspect, physical aspect, work, general state of health and mental health. There is a question for which domain of HBQoL, except for physical aspect, pain, sleep and diet that presents two or more questions. An individual score was received for each Quality of Life domain, just one question for GERD-HRQoL and nine for HBQoL. The results were reported using simple and percentage frequency for categorical data, mean and standard de­viation for continuous data. It was used Mann-Whitney test to evaluate differences of mean and for possible asso­ciations between variables chi-square test. The statistical significance level was established as 5% and the software used was R Core Team 2016. The study was approved by Universidade Tiradentes Research Ethics Committee (Comitê de Ética e Pesquisa da Universidade Tiradentes), CAAE 48329215.6.0000.537. All participants signed a written informed consent.

Results

The groups were classified accordingly to the semes­ter: 154 nursing students and 91 physiotherapy students were among seventh, eighth, ninth and tenth semester; 100 medicine students were between ninth and eleventh semester and odontology students among sixth, seventh, eighth and ninth semester. The groups were classified accordingly to the semester/year of admission, and 161 (32.1%) were in the ninth semester.

From the students, 59 (11.8%) were classified with GERD and/or had been previously diagnosed, while 442 (88.2%) did not meet the clinical criteria for the diagnos­tic. The odontology students presented higher symptoms frequency 19 (12%).

The median age was 24.5 years (range: 20-29). From the disease carriers, 49 (83%) were represented by fe­males; 51 (86%) were single. Concerning ethnic groups, according to Brazilian Institute of Geography and Sta­tistics, 44 (74%) students identified themselves white and brown and 9 (18%) black. For those that identified themselves as yellow (Asian), presented a 3.35-fold great­er risk for GERD than white students. 19 (32%) used alcoholic beverages. Only 1 (25%) student was detected with obesity. Those who used proton-pump inhibitor, 14 (64%) presented higher risk for GERD (Table 1).

It was associated with higher relative risk of typical symptoms those who had heartburn two or three times per week in a period of three or more weeks. Claimed to have regurgitation 32 (41%), also associated with higher risk of GERD (p < 0.001) those with symptoms manifes­tation 2 times per week and 3 or more times per week. The time of disease was associated with higher risk for 23 (56%) of those who presented symptoms up to 8 weeks (Table 2).

All signs and atypical symptoms presented by the in­terviewees exhibited statistical relevance when applied the chi-squared test to evaluate the higher risk of associa­tion with GERD. Chronic cough 8 (53%), tonsillitis 8 (44%) and throat clearing 12 (36%) were more preva­lent (Table 3).

Quality of life and health condition of patients with GERD, regarding the patient satisfaction level with their current situation showed that 20 (33.9%) expressed dis­satisfaction and 25 (42.4%) offered a neutral opinion. Only 1 (1.7%) considered himself disabled.

When assessed the relation between symptoms and quality of life, the mean values for GERD-HRQoL was 9.81. On HBQoL was observed higher means for pain domain (5.15) and functional aspects (4.77) and lower means for general state of health (1.64), social aspect (1.67) and vitality (1.68). Analysis of social aspect (p = 0.012) and work (p = 0.005), according the GERD-HRQoL and HBQoL domains to the positive, negative, strong or weak correlation showed statistical significance (Table 4).

Table 1. Absolute sample distribution according to sociodemographic profile and student’s habits with or without clinical diagnostic for GERD.

Table 2. Absolute sample distribution according to sociodemographic profile and student’s habits with or without clinical diagnostic for GERD.

Table 3. Absolute sample distribution according to atypical symptoms on students with or without diagnostic for GERD.

Table 4. Correlation between symptoms and quality of life re­lated to health according to GERD-HRQoL and HBQoL do­mains.

Discussion

GERD can compromise the quality of life of its pa­tients.¹⁴ In this study, prevalence of GERD was 11.8%, corroborating data in literature. Population survey con­ducted in 22 cities of Brazil, with 13,950 individuals sample identified a prevalence of 11.8%.⁹

Odontology (19-12%) and medicine (15-15%) stu­dents were those who presented the most clinical diag­nostic for GERD, however, odontology students were more affected by symptoms. It was not found studies comparing GERD among the assessed groups. Higher disease frequency was identified among females, corre­lated to stress factors and single individuals.¹⁶ According to Suzuki et al.⁴ the disease is more frequent in individu­als above 55 years, however, in our study, the main age was 24.5 years, yet must be consider that it is a younger population. White and brown skin were statistically rel­evant (p = 0.001). The study data showed students that identified themselves as yellow (Asian) presented 3.35- fold higher risk for GERD than white skin students. Some authors report a prevalence of 43% black, 34% white and 23% other ethnic groups,¹⁷ though other au­thors point out higher prevalence among white.^18-19

There was no statistical significance related to life habits, which differs from Fraga et al. that claimed that tobaccoism and excessive alcohol consumption were risk factors for GERD development.¹⁶

In a western population controlled, study showed that heartburn and/or regurgitation was prevalent around 20 to 40% related to occurrence time being at least one time per week.^{11, 16} However, in the studied group, the dis­ease time was associated with higher risk to 23 (56%) of those that presented heartburn and regurgitation up to 8 weeks.

All signs and atypical symptoms presented by the in­terviewees showed statistical relevance, besides higher risk of GERD association and the most prevalent was chronic cough 8 (53%), tonsillitis 8 (44%) and throat clearing 12 (36%). Nasi et al. evaluated 200 patients and identi­fied the presence of atypical symptoms in 23.5% of them, while 52.5% presented typical symptoms.²⁰

Obesity, comorbidity considered risk factor, was iden­tified in one student 1 (25%). Overweight is associated to increased intra-abdominal pressure that elevates the gastroesophageal pressure gradients and intragastric pres­sure.^6-16

Inhibition of gastric acid secretion is indeed benefic on GERD treatment^{11, 21} and it is considered first-line therapy in several studies.²²

In a study with 111 patients comparing use of ant­acids and placebo was observed that the use of medica­tion relieved 62% of cases of chest pain associated with GERD.²³ According to Brazilian Federation of Gastroen­terology.²⁴ such medications are recommended for treat­ment of patients with symptomatic GERD. However, in the study in question, use of proton-pump inhibitors (PPI) did not present a positive impact on affected stu­dent’s life. For those on PPI, 14 (64%) of them presented higher risk for GERD.

There are only five questionnaires in the medical liter­ature to evaluate symptoms and quality of life of patients with GERD, although none of them present a full evalu­ation.²⁵ In the studied group, the main of values found in GERD-HRQoL was 9.81, with a standard deviation of 5.20 that indicates a slightly compromise in quality of life. Regarding the degree of patient satisfaction in the moment of the interview, 20 (33.9%) were unsatisfied and 25 (42.4%) neutral.

A significant statistical difference (p < 0.001) was found among all domains assessed by HBQoL. The do­ main with higher value was pain, revealing that students suffer from severe to moderate heartburn. GERD pres­ence seems to negatively impact on student’s quality of sleep and diet.

Concerning the physical domain, the patients related a reduction of time spent in work. Another domain that was affected was the social disease which seemed to inter­fere on social activities.

Vitality and general state of health domains from in­dividuals with GERD was compromised on those that re­lated fatigue. The work and mental health domains were also compromised, while in the later, students reported that heartburn worry and afflicted them in moderate to mild degrees. Such findings confirm evidences observed, which GERD patients present some degree of quality of life impairment, both in general and in relation to several domains.²⁶

Suzuki et al.⁴ suggest that for a better population anal­ysis, other criteria must be used, such as diet pattern and medication use. In a study conducted by Almeida et al. when applied HBQoL questionnaire, could be observed quality of life impairment in GERD patients and how treatment can cause a positive effect on this group.^18-19

As regard to the satisfaction level, showed divergent data from those observed for Andrade et al.14 in which much of studied patients were satisfied with their condi­tion, whereas in this study, 25% claimed to be neutral considering the symptoms impact on quality of life.

The anamnesis was the prime tool to select the sam­ple of this study. However, some limitations are to be considered, such as, sample size, concrete data of specific exams (Ph-metry and endoscopy), absence of question­ing related to non-pharmacological practices and possible surgical procedures, which in some studies present posi­tive impact on symptomatic patient’s quality of life.^{20, 27}

Conclusion

From medical history is possible to identify GERD patients. The prevalence of the disease kept in accor­dance with other studies of general population. Typical symptoms like heartburn and regurgitation and atypical symptoms like chronic cough, tonsillitis and throat clear­ing were more prevalent, while other pulmonary and oto­rhinolaryngology symptoms are responsible for the inci­dence of disease. Added to this, female, single and alcohol consumption. The general state of health was more com­promised on those who presented heartburn. Quality of life can be impaired as the symptoms limit daily activities, depending on symptoms intensity and disease progress.

Funding. The funding of this study was totally financed by the authors.

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Correspondencia: Ana Galrão de Almeida Figueiredo
Av Beira Mar, number 1704, apto 801 (Zip code: 49025040) Aracaju, Sergipe, Brasil.
Tel.: +5579999746465
Correo electrónico: anagalrao.f@gmail.com

Acta Gastroenterol Latinoam 2018;48(3):197-205