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Gastroesophageal reflux is transformed from a physiologic process to a disease (GERD) when the reflux events have clinical consequences. Studies show that GERD negatively affects quality of life, we know little about the frequency of symptoms required to induce clinically meaningful impairment.
In this industry-supported study, investigators mailed the Abdominal Symptom Questionnaire (ASQ) to 3000 randomly selected adults in two adjacent Swedish communities. Of the 2212 respondents, 999 (mean age, 54; 51% female) underwent upper endoscopy and completed a short questionnaire (the SF-36) measuring eight dimensions of quality of life: physical functioning, role-physical, bodily pain, general health, mental health, vitality, social functioning, and role-emotional. The recall period was 1 week for the SF-36 and 3 months for the ASQ. A 5-point difference in SF-36 scores was considered to be clinically meaningful.
Forty percent of all subjects reported reflux symptoms (20% less than weekly, 14% weekly, and 6% daily). The more frequent the symptoms, the greater the number of quality-of-life dimensions that were affected. Compared with subjects who did not have symptoms, those with less than weekly symptoms had clinically relevant impairment in only one dimension (vitality). Those with weekly symptoms had impairment in five dimensions (physical functioning, role-physical, bodily pain, general health, and vitality), and those with daily symptoms had impairment in all eight dimensions.
Fifteen percent of all subjects had evidence of endoscopic esophagitis (with 95% being Los Angeles grade A or B). The prevalence of esophagitis increased with frequency of reflux symptoms — from 10% in those without symptoms to 36% in those with daily symptoms (P<0.001). One third of patients with esophagitis were asymptomatic. SF-36 scores did not differ significantly between those with esophagitis and those without.
Ronkainen J et al. Gastro-oesophageal reflux symptoms and health-related quality of life in the adult general population — The Kalixanda study. Aliment Pharmacol Ther 2006 Jun 15; 23:1725-33.
Comment
This study is one of the first to involve endoscopy in the general population and to correlate findings with reflux symptom frequency and quality of life. The findings confirm those of previous studies, which showed that patients with reflux can have impaired quality of life even without esophagitis. Although previous studies suggested that quality of life was not affected unless patients had at least two episodes of reflux symptoms weekly, the present study suggests that even one weekly episode can be detrimental, thereby transforming GER into GERD. Clinicians should be reminded that GERD is more than just a little heartburn, and it can have global implications for patients. We should set our treatment plans accordingly.