Stress, personality and social support in gastro-oesophageal reflux disease

Psychological symptoms do not discriminate between reflux phenotypes along the organic-functional refractory GERD spectrum

OBJECTIVE

Historically, psychological processes are associated with disorders at the functional end of the gastro-oesophageal reflux disease (GERD) spectrum. However, recent research suggests that psychological symptoms are relevant across the entire GERD spectrum. We aim to investigate whether psychological symptoms are associated with reflux phenotype (True GERD, Borderline GERD, reflux hypersensitivity, functional heartburn) along the GERD spectrum in a cohort of refractory reflux patients.

DESIGN

Consecutive adult patients with refractory reflux symptoms underwent standard 24-hour pH-impedance monitoring and completed questionnaires assessing demographic, clinical and psychological information. Bayesian one-way analysis of variance assessed whether psychological variables differed across reflux phenotypes. Next, we applied multinomial and ordinal logistic regressions with clinical, demographic and psychological variables set as independent variables and reflux phenotype as the outcome variable. The complementary machine-learning approach entered all demographic, clinical and psychological variables into models, with reflux phenotype set nominally and ordinally. Cross-validated model performance was used to select the best model.

RESULTS

393 participants (mean (SD) age=48.5 (14.1); 60% female) were included. The Bayesian analyses found no difference in psychological variables across reflux phenotypes. Similarly, age, gender and proton pump inhibitor use were the only significant variables in the multinomial logistic regression and body mass index was significant in both regressions. Machine-learning analyses revealed poorly performing models with high misclassification rates (67-68%) in both models.

CONCLUSION

Psychological symptoms do not differ between nor predict reflux phenotype membership in refractory reflux patients. Findings suggest that psychological symptoms are relevant across the spectrum of GERD, rather than specific to functional oesophageal disorders.

Gastrointestinal Quality of Life in Gastroesophageal Reflux Disease: A Systematic Review

BACKGROUND

The Gastrointestinal Quality of Life Index (GIQLI) is a well-established instrument for the assessment of quality of life (QOL) in gastrointestinal (GI) diseases. The purpose of this literature review was to investigate QOL by means of GIQLI in patients with gastroesophageal reflux disease (GERD) prior to any interventional therapy. There are several reports on GIQLI data; however, comparisons from different countries and/or different GERD cohorts assessing the same disease have to date not been conducted.

METHODS

The GIQLI uses 36 items around 5 dimensions (GI symptoms [19 items], emotional dimension [5 items], physical dimension [7 items], social dimension [4 items], and therapeutic influences [1 item]). A literature search was conducted on the application of GIQLI in GERD patients prior to interventional therapy using reports in PubMed. Data on the mean GIQLI as well as index data for the 5 dimensions as originally validated were extracted from the published patient cohorts. A comparison with the normal healthy control group from the original publication of the GIQLI validation conducted by Eypasch was performed. Data are presented descriptively as GIQLI points as well as a reduction from 100% maximum possible index points (max 144 index points = highest QOL).

RESULTS

In total, 77 abstracts from studies using the GIQLI on patients with GERD were identified. After screening for content, 21 publications were considered for further analysis. Ten studies in GERD patients comprised complete calculations of all dimensions and were included in the analysis. Data from 1,682 study patients were evaluated with sample sizes ranging from 33 to 568 patients (median age of 789 females and 858 males: 51.8 years). The median overall GIQLI for the patient group was 91.7 (range 86-102.4), corresponding to 63.68% of the maximum GIQLI. The dimensions with the largest deviation from the respective maximum score were the physical dimension (55% of maximum) followed by the emotional dimension (60% of maximum). In summary, the GIQLI level in GERD cohorts was reduced to 55-75% of the maximum possible index.

CONCLUSIONS

Severe GERD causes substantial reductions in the patient's QOL. The level of GIQLI can carry between different studied GERD cohorts from different departments and countries. GIQLI can be used as an established tool to assess the patient's condition in various dimensions.

Do patients with gastroesophageal reflux disease and somatoform tendencies benefit from antireflux surgery?

BACKGROUND

The clinical presentation of gastroesophageal reflux disease (GERD) shows a large symptom variation also in different intensities among patients. As several studies have shown, there is a large overlap in the symptomatic spectrum between proven GERD and other disorders such as dyspepsia, functional heartburn and/or somatoform disorders.

AIM

To prospectively evaluate the GERD patients with and without somatoform disorders before and after laparoscopic antireflux surgery.

METHODS

In a tertiary referral center for foregut surgery over a period of 3 years patients with GERD, qualifying for the indication of laparoscopic antireflux surgery, were investigated prospectively regarding their symptomatic spectrum in order to identify GERD and associated somatoform disorders. Assessment of symptoms was performed by an instrument for the evaluation of somatoform disorders [Somatoform Symptom Index (SSI) > 17]. Quality of life was evaluated by Gastrointestinal Quality of Life Index (GIQLI).

RESULTS

In 123 patients an indication for laparoscopic antireflux surgery was established and in 43 patients further medical therapy was suggested. The portion of somatoform tendencies in the total patient population was 20.48% (34 patients). Patients with a positive SSI had a preoperative GIQLI of 77 (32-111). Patients with a normal SSI had a GIQLI of 105 (29-140) (P < 0.0001). In patients with GERD the quality of life could be normalized from preoperative reduced values of GIQLI 102 (47-140) to postoperative values of 117 (44-144). In patients with GERD and somatoform disorders, the GIQLI was improved from preoperative GIQLI 75 (47-111) to postoperative 95 (44-122) (P < 0.0043).

CONCLUSION

Patients with GERD and associated somatoform disorders have significantly worse levels of quality of life. The latter patients can also benefit from laparoscopic fundoplication, however they will not reach a normal level.

Psychological Assessment of Women on an Early Breast Screening Program after Radiotherapy to the Chest Wall for Childhood Cancer

Aims and Background

This study investigates the psychological status in a population of female patients who received chest irradiation for a childhood cancer and were screened for second primary breast cancer.

Methods

Sixty-eight consecutive such young women were included. Compilation of the Crown-Crisp Index questionnaire was requested and 49/68 patients accepted to fill it in; 14 women in the sample had children (28%).

Results

Twenty-seven of 49 patients achieved a normal score, whereas in 22 the score was slightly above the normal range in at least one scale. Pathological scores were more frequent among the women without children.

Conclusions

Quality of life in this series of long-term survivors does not seem to be severely affected by previous treatment for cancer nor by the concern for the onset of a second primary malignancy.

Foregut symptoms, somatoform tendencies, and the selection of patients for antireflux surgery

A large variety of foregut symptoms can occur in patients with gastroesophageal reflux disease (GERD), which can overlap with other disorders such as somatoform disorders and dyspepsia. Due to unclear diagnostic situations, these patients are often not adequately treated. The aim of this study was the evaluation of patients with foregut symptoms, referred for possible antireflux surgery, regarding their relationship with GERD and somatization tendencies based on control data from an unselected population. Symptom evaluation and somatization screening were initiated both in volunteers and in patients with foregut symptoms and GERD. Unselected volunteers from a village population were also evaluated by symptom analysis and for somatisation tendency. In addition, patients with foregut symptoms were diagnosed for GERD, and symptom analysis and psychodiagnostic evaluation were performed. There is no major significant difference in the symptom-spectrum in patients with foregut symptoms, whether they have a proven pathologic acid exposure from GERD or not. The probability for the risk of somatization was 5.6% in the unselected population of nonpatient volunteers (n = 267). In patients with foregut symptoms (n = 750), the probability for the presence of somatoform tendencies was approximately 20%, independent whether these patients had a documented GERD or a normal esophageal acid exposure, implicating further diagnostic work-up for the selection of patients for antireflux surgery. There is a remarkable symptom load and variety in patients with GERD, in patients with foregut symptoms, and in an unselected population of volunteers. There is no difference in the risk for somatization between patients with foregut symptoms and those with documented GERD. Therapeutic decision making especially prior to antireflux surgery requires an awareness of mental and emotional challenges.

Sleep disorders in functional dyspepsia and future therapy

Sleep disorder is a common medical problem. Sleep disorder has been associated with several diseases, including pulmonary disease, gastroesophageal reflux disease (GERD) and fibromyalgia. Interest in sleep phenomenology and gastrointestinal functioning has recently increased, because sleep disorder causes significant morbidity, as evidenced by the increased need for general medical and mental health treatment for emotional problems. A number of studies have found an association between sleep disorders and functional gastrointestinal (GI) disorders. Although arousal from sleep serves several protective roles, such as increase in the speed of esophageal clearance and in airway refluxes to prevent aspiration, awakening from sleep unfortunately induces impairment of sleep quality. Some investigations about the relationship between psychogenic factors and gut motility are controversial. In addition, reports of alterations in gut motility during sleep have also been contradictory. We have evaluated sleep disorder in functional dyspepsia (FD) patients using Pittsburgh Sleep Quality Index (PSQI) score. In our recent data, PSQI score of FD patients was significantly higher compared to that in healthy volunteers. Another study has reported that the distribution of subjects who thought that they got enough sleep was significantly lower for the FD/irritable bowel syndrome (IBS) subjects than for control subjects. Several studies have reported that anti-acid therapy and prokinetic agents are effective for certain FD patients. In addition, previous study has reported tricyclic antidepressants (TCA) drugs are effective for some FD patients. Finally, new drug, actiamide, a muscarinic antagonist and cholinesterase inhibitor, significantly improves Postprandial Distress Syndrome (PDS) symptoms. It might be critical issues for determination of precise mechanism for functional gastrointestinal disorders to clarify the relationship between gut motility and sleep disorders.

Does acute psychological stress increase perception of oesophageal acid?

Gastro-oesophageal reflux disease (GORD) patients often report an increase in their reflux symptoms during stressful situations. The aim of this study was to assess the influence of acute psychological stress on oesophageal acid perception. In 15 healthy volunteers and 10 GORD patients with a positive symptom-reflux association an oesophageal acid perfusion test was performed, once with and once without the presence of an acute psychological stressor (IQ test). The order of the measurements was randomized. The time from onset of the acid infusion to first acid perception, discomfort and pain was noted. Blood pressure was measured to assess the effect of the stress task. In healthy volunteers, the time to first perception (control task: 617 +/- 174 s vs stress task: 561 +/- 162 s), discomfort (control task: 969 +/- 158 s vs stress task: 940 +/- 151 s) or pain (control task: 1393 +/- 122 s vs stress task: 1366 +/- 121 s) did not differ significantly between both measurements. In GORD patients, no significant differences between both measurements were found either in time to first perception (control task: 63 +/- 26 s vs stress task: 43 +/- 15 s), discomfort (control task: 153 +/- 44 s vs stress task: 249 +/- 62 s) or pain (control task: 558 +/- 139 s vs stress task: 633 +/- 118 s). Systolic blood pressure rose significantly during the stress task in both the healthy volunteers (6 +/- 1 mmHg) and the GORD patients (9 +/- 2 mmHg). Neither in the healthy volunteers nor in the GORD patients, the acute psychological stress induced by an IQ test increased oesophageal acid perception. The observed increase in systolic blood pressure shows that the experimental stressors were effective.

Influence of psychological distress on characteristics of symptoms in patients with GERD: the role of IBS comorbidity

A link between gastroesophageal reflux disease (GERD) and psychological distress has been suggested; psychological factors may modulate the characteristics of symptoms. Besides, irritable bowel syndrome (IBS) frequently coexists with GERD so it may be hypothesized that psychological distress in GERD might be an epiphenomenon of IBS comorbidity.

AIMS

Evaluate the association of psychological distress with GERD, the influence of psychological factors on symptoms, whether psychological distress is explained by a subset of GER patients, and if coexistence with IBS would be a surrogate marker.

METHODS

We performed a prospective case-control study. Cases were patients diagnosed with GERD reporting heartburn at least 2 days per week as the main complaint. Controls were matched healthy subjects without or occasional symptoms. All individuals completed a set of validated questionnaires to evaluate GERD and IBS symptoms and psychological distress (SCL-90R).

RESULTS

Ninety-two patients and 92 controls were included. Fifty-seven patients and six controls fulfilled Rome II criteria for IBS. Body mass index (BMI), somatization, and IBS were independently related to GERD. Patients with and without IBS were not different in any measure of psychological distress. Characteristics of symptoms did not correlate to psychological measures. Cluster analysis isolated a cluster of nondistressed from distressed subjects. A higher proportion of GERD patients than controls were classified as distressed (29.7% versus 7.7%). No variable (including IBS) distinguished nondistressed from distressed GERD patients, except for sex.

CONCLUSIONS

Nearly one-third of GERD patients attending a gastroenterologist office are psychological distressed; they cannot be identified by features of symptoms or IBS comorbidity so a specific anamnesis under the scope of a biopsychosocial model is warranted.

Psychological factors, quality of life, and gastrointestinal symptoms in patients with erosive and non-erosive reflux disorder

OBJECTIVE

Inconsistent findings are published regarding the psychosocial characteristics of erosive reflux disorder (ERD) and non-erosive reflux disorder (NERD) patients. The objective of this study was to determine the possible similarities and differences concerning psychosocial and somatic characteristics of these patients.

METHOD

Patients at a tertiary care center completed questionnaires on demographic characteristics, frequency of reflux symptoms, psychological distress, quality of life, and gastrointestinal symptoms. For comparative purposes, data from an age-matched healthy control group were obtained.

RESULTS

Higher proportion of female patients and a younger mean age was observed in NERD patients. No significant differences were detected regarding levels of psychological distress, gastrointestinal symptom severity, quality of life, and frequency of reflux symptoms. Both patient groups exhibited more severe psychological distress compared to healthy subjects. Only ERD patients demonstrated significant correlations between frequency of reflux symptoms and quality of life and severity of gastrointestinal symptoms. Compared to ERD patients, NERD patients showed stronger correlation between psychological distress and severity of reflux symptoms.

CONCLUSIONS

Reflux-like symptoms have a strong impact on patients' wellbeing, irrespective of endoscopical findings. The different patterns of associations between psychological, somatic and quality of life parameters in NERD and ERD patients can have theoretical and clinical implications.

Influencia del estilo de vida en la enfermedad por reflujo gastroesofágico

The prevalence of the symptoms of reflux (hearthburn and acid regurgitation) and of gastro-esophageal reflux disease is high. Numerous lifestyle modifications have been advocated in the prognosis of reflux. Obesity, the decubitus, eating rapidly, tobacco, alcohol and exercise provoke symptoms of the reflux (hearthburn and acid regurgitation). The proportion of fat in the food and stress aren't factors associated with reflux. Some works point at the chocolate, at the acid juices, at the carbonated beverages and at the onions as factors that unleash symptoms of reflux. Nevertheless larger prospective controlled trials are warranted. Gum-chewing after eating, keep standing up and to go to bed 4 h after dinner improves the symptoms of the reflux and the gastro-esophageal reflux disease.

The effect of psychological stress on symptom severity and perception in patients with gastro-oesophageal reflux

OBJECTIVE

Using an experimental paradigm this investigation explored whether exposure to psychological stress would produce a significant increase in acid-reflux episodes or modify subjective perceptions of gastro-oesophageal reflux (GOR) symptoms.

METHODS

Forty-two patients presenting with heartburn and acid regurgitation underwent 24-h oesophageal pH monitoring. During the last 90 min of this monitoring period, 21 patients received a psychological stressor, while the remaining participants were randomly assigned to a no-stress control condition. State anxiety and subjective GOR symptom ratings were obtained 1 min pretest, 1 min posttest, and 40 min posttest. Cortisol samples were collected at 10-min intervals.

RESULTS

The stressor induced a significant increase in cortisol and state anxiety; however, this was not associated with any increase in reflux. Instead, the experimental group reported a dissociation between objectively measured reflux episodes and subjective symptom ratings. A similar pattern was established for participants who reported greater state anxiety, produced larger cortisol responses, or exhibited certain stress-related personality characteristics.

CONCLUSION

The perception of symptoms in the absence of increased reflux when one is stressed may account for low response rates to traditional treatments. This highlights a need to bridge the gap between psychosomatic research and clinical practice to develop more successful GOR therapies.

Endoscopy-negative reflux disease: concepts and clinical practice

Endoscopy-negative reflux disease is used to describe a heterogeneous group of disorders with symptoms that mimic those of gastroesophageal reflux disease in the absence of visible esophageal injury at endoscopy. Compared with patients who have gastroesophageal reflux-related erosive esophagitis, those with endoscopy-negative disease are more likely to be younger, female, of lower body weight, and without a hiatal hernia. Approximately 50% of those with endoscopy-negative reflux have abnormal intraesophageal acid exposure and are considered to have nonerosive acid reflux disease. Those with symptoms of >12 consecutive or intermittent weeks' duration during the prior year, with normal acid exposure and without achalasia or other motility disorder with a recognized pathologic basis, are considered to have functional heartburn. In the absence of pathologic reflux, a number of etiologies may contribute to the symptoms of heartburn, including motor events, reflux of nonacidic gastric contents, minute changes in intraesophageal pH (pH <4), visceral hypersensitivity, and emotional or psychological abnormalities. Although persons with endoscopy-negative reflux disease experience decrements in their quality of life that are similar to those for individuals with erosive esophagitis, the response to traditional therapies for acid reflux may differ between the 2 groups. Studies have found that approximately 50% of patients with endoscopy-negative reflux disease experience complete symptom relief after 4 weeks of proton pump inhibitor treatment. In those with persistent heartburn symptoms, other structural or nonacid reflux etiologies for their symptoms should be explored.

Relationship between body mass index, diet, exercise and gastro-oesophageal reflux symptoms in a community

BACKGROUND

Body mass index (BMI) is a risk factor for gastro-oesophageal reflux but may simply be explained by diet and lifestyle.

AIM

We aimed to determine the contribution of BMI, diet and exercise to GER.

METHODS

Community subjects (n = 211, mean age = 36 years, 43% males) completed validated questionnaires on gastro-oesophageal reflux, energy expenditure (Harvard Alumni Activity Survey), dietary intake (Harvard Food Frequency Questionnaire) and measures of personality and life event stress. Diet, exercise, BMI and other potential risk factors for reflux were analysed using logistic regression analyses.

RESULTS

The overall mean (+/- s.d.) BMI was 26.6 (+/- 5.7); 79 (37%) reported infrequent (< weekly) reflux and 16 (8%) reported frequent (> or = weekly) reflux. The median caloric intake was 2097 cal/day and the median daily energy expenditure was 1753 cal/day. Among those with BMI > 25, 10% reported frequent reflux compared to 4% of those with BMI < or = 25. In a model which included age, sex and Symptom Checklist-90 somatisation T-score, BMI was associated with reflux (OR per 5 units = 1.9, 95% CI: 1.2, 3.0). In models which included diet and exercise variables, BMI but not diet or exercise was associated with reflux.

CONCLUSION

BMI may be associated with symptomatic gastro-oesophageal reflux independent of diet and exercise.

Review article: approaches to endoscopic-negative reflux disease: part of the GERD spectrum or a unique acid-related disorder?

Endoscopic-negative reflux disease (ENRD) is the most common presentation of gastro-oesophageal reflux disease (GERD)-affecting up to 70% of these individuals. In the last three decades therapeutic studies have focused solely on the treatment of patients with erosive oesophagitis. However, more recent studies have shifted our attention to defining, understanding and treating those with ENRD. GERD has traditionally been approached as a spectrum with ENRD at the mild end and complicated GERD (i.e. patients with erosive oesophagitis, stricture and Barrett's oesophagus) being at the other end, suggesting that patients' disease may progress over time along the spectrum. Current data indicate that ENRD should be approached as a unique entity rather than a part of the GERD spectrum and that over time only a few patients with ENRD will develop GERD-related complications. Patients with ENRD are a heterogenous group of patients with different aetiologies for their heartburn symptoms, including motor events, reflux of acidic or nonacidic gastric contents, minute changes in intraesophageal pH (pH < 4), mucosal hypersensitivity, and emotional or psychological abnormalities. By dropping the spectrum concept, which emphasizes oesophageal mucosal injury, we can focus our attention on the specific mechanisms that lead to symptom generation in each of the three unique groups of GERD (ENRD, erosive oesophagitis and Barrett's oesophagus) and on the specific therapeutic modalities that benefit each of these individual groups. Acid suppressive therapy with proton pump inhibitors is highly effective in healing erosions and controlling symptoms in those with erosive oesophagitis. In those with ENRD the resolution or control of heartburn with proton pump inhibitor therapy is greater than that with placebo or H2 receptor antagonist, but not as consistent nor as impressive as the results observed in studies of patients with erosive oesophagitis. By considering the mechanisms involved in ENRD symptom generation, future studies that include high-dose proton pump inhibitors, promotility agents (alone or in combination with proton pump inhibitors), transient lower oesophageal sphincter reducers, or pain modulators (e.g. tricyclic antidepressant agents) may prove beneficial.

Functional Gastroesophageal Reflux Disease (GERD)

Lack of endoscopic esophagitis does not exclude gastroesophageal reflux disease (GERD). Ambulatory pH testing is also an imperfect standard, and patients with both a normal endoscopy and a normal pH test may still have symptoms produced by acid reflux. A therapeutic trial of acid suppression is often the best approach to these patients. Ideally, therapeutic trials should use a medication with a high degree of efficacy in the treatment of GERD to avoid a false-negative test. Proton pump inhibitors (PPIs) are the best currently available medical therapy for all forms of GERD. If the patient does not respond to a once daily PPI, options include increasing the dose of PPIs, and, perhaps, adding another class of agent or studying the patient with an ambulatory pH test. Patients with a negative endoscopy, negative pH test. and those who do not respond to an adequate trial of acid suppression are unlikely to benefit from antireflux surgery.

Endoscopy-negative gastroesophageal reflux disease. The hypersensitive esophagus

Gastroesophageal reflux disease (GERD) is one of the mos common disorders of the gastrointestinal tract. Patients with GERD symptoms may exhibit a spectrum of endoscopic findings ranging from normal endoscopy (EGD negative) to severe ulcerative esophagitis. Recent evidence indicates that a large proportion of patients with GERD have normal endoscopy. The use of 24-hour ambulatory pH testing in the evaluation of symptomatic patients with EGD negative GERD allows further classification of these subjects into groups. Patients who have abnormal acid exposure and a positive symptom index constitute one group and patients who have normal acid contact time but record a convincing relationship between their symptoms and acid reflux on the pH analysis--positive symptom index--form another group. The latter group has been suggested to have a hypersensitive esophagus or "functional heartburn." This article reviews the prevalence, clinical features, origin of patient's symptoms, natural history, and treatment of patients with EGD negative GERD.

Psychosocial factors and their role in symptomatic gastroesophageal reflux disease and functional dyspepsia

Patients with symptoms of GERD and dyspepsia are among the most common consulters in general practice and are different from their counterparts in the community who choose not to consult although they suffer from similar symptoms. They represent a heterogeneous group with considerable symptom overlap. They have a relatively poor quality of life and endoscopic findings can only explain symptoms in about half of these patients. Thus psychosocial factors which could contribute to their morbidity should be explored. While some studies have methodological shortcomings, main findings are that key psychological factors are anxiety, tension, neuroticism, somatization, fears of malignancy, negative assessment of health, depression, a poor social network and less effective coping strategies. Physical illness is likely to bring on psychological distress due to discomfort or threat of ill health. Cognizance of psychosocial factors will facilitate an understanding of the underlying problems and will improve diagnosis and selection of optimal treatment.