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Official Journals By StatPerson Publication

Table of Content - Volume 12 Issue 3 - December 2019


 

Clinical presentation and endoscopic findings in gastroesophageal reflux disease

 

Ramprabhu N Tidake1*, Kalpana Chate2, Sudhir Deshmukh3

 

1Assistant Professor, 3Associate Professor, Department of Surgery, SRTR Ambejogai, Beed, Maharashtra, INDIA.

2Consutlant Physician and Intensivist, Spandan Critical Care Unit, Barshi Road, Beed, Maharashtra, INDIA.

Email: ramtidake@rediffmail.com

 

Abstract               Background: Gastroesophageal reflux disease (GERD) is a symptom-complex comprising of a variety of symptoms. Endoscopy has often been used as a tool for diagnosis for GERD. Aim: To study the clinical presentation and to determine those subsets of patients in whom endoscopy would be beneficial to determine the early diagnosis of esophagitis. Material and Methods: Total of 75 patients were included. Detailed history of the patient was taken with regards to the symptoms. Endoscopy was done in all cases with flexible Fujinon fibreoptic endoscope. Endoscopic findings were graded as according to severity and the grade of esophagitis was decided as per Los Angeles classification. Results: Heartburn (93.33%) and regurgitation (82.66%) were the most frequent symptoms followed by Watery brash (33.3%) and dysphagia (28%). Los Angeles grade A esophagitis was the most common finding found in 15 cases (41.7%) followed by grade B in 14 cases (38.9%). Conclusion: Heartburn and regurgitation were the most frequent symptoms of GERD and Los Angeles grade A esophagitis was the most common finding found followed by grade B.

Key Words: Gastroesophageal reflux disease, endoscopy, Heartburn, Los Angeles grade

 

INTRODUCTION

Gastroesophageal reflux disease (GERD) is a symptom-complex comprising of a variety of symptoms. Prominent symptoms amongst them are heartburn and regurgitation. Reflux symptoms are commonly experienced by many people. As per Asian studies, the prevalence of gastroesophageal disease in the general population is 2.5-7.1%. This trend is however increasing due to changing lifestyles and more westernized diet.1 Gastroesophageal reflux disease has a wide spectrum where at one end it is purely symptomatic while at the other end it consists of severe esophagitis and its complications. Endoscopy has often been used as a tool for diagnosis for GERD.2 There is a wide disparity in clinical practice where at one side there is overuse of endoscopy as a diagnostic tool causing discomfort as well as expense to the patient and burden on the health service, while at other end underutilization of endoscopy led to diagnosis of esophagitis at an advanced and often complicated stage. The present study is to study the clinical presentation and to determine those subsets of patients in whom endoscopy would be beneficial to determine the early diagnosis of esophagitis.

 

MATERIAL AND METHODS

A cross-sectional study was conducted using a self-administered structured questionnaire over a period of two years after obtaining the ethical approval from Institutional Ethics committee. A case definition of gastroesophagal reflux disease (GERD) as a group of symptoms was formed. Symptoms such as heartburn, regurgitation, dysphagia, epigastric pain, watery brash, nausea, bloating sensation, sore throat, hoarseness of voice and persistant cough were considered. A total of 75 patients coming to medicine OPD with complains of upper abdominal pain were selected as symptomatically diagnosed cases of GERD if they had 2 or more of the above symptoms for more than one month. Detailed history of the patient was taken with regards to the symptoms and precipitating factors. Thorough clinical examination of the patients was done. Routine hematological examination of the patient was done. ECG and USG abdomen was done to rule out cardiac and abdominal pathologies respectively.

Inclusion criteria

  • Patients who had symptoms consistent with symptoms of gastroesophageal reflux disease (GERD).
  • At least 2 symptoms were occurring for more than one month.

Exclusion criteria

  • Patients with history of intake of drugs known to cause oesophageal motility disorders.
  • Patients with age less than 14 yrs.
  • Patients with co-morbid diseases like severe IHD, cervical spondylosis, trismus etc.
  • Patients with haematemesis.

Endoscopy procedure

Patients were asked not to take any food or drink from night prior to endoscopy. On the day of endoscopy, a written informed consent was taken. Patients were asked to swallow viscous xylocaine solution (a surface/ topical anaesthetic agent 5min prior to endoscopy. Endoscopy was done in all cases with flexible Fujinon fibreoptic endoscope. Endoscopic findings were graded as according to severity and the grade of esophagitis was decided as per Los Angeles classification.3 Presence of incompetent LES or hiatus hernia were also looked for. Stomach and duodenum were also visualized to find out, any other local pathology which gave symptoms similar to GERD.

 

RESULTS

Out of the 75 patients, the most common age group was 31-40 years 18 (24%) followed by 21-30 years 16 (22%) and 41-50 years 16 (22%). 11 (14.7%) patients were between 51-60 years of age group whereas, 9 (12%) were between 14-20 years and 5 (6.7%) were more than 60 years of age. There were 39 (52%) males and 36 (48%) females with male to female ratio of 1.08:1.

 

Table 1: Symptom profile in GERD patients

Symptoms

No. of cases

Percentage

Heartburn

70

93.33%

Regurgitation

62

82.66%

Water brash

25

33.3%

Dysphagia

21

28%

Epigastric pain

13

24%

Vomiting

15

20%

Odynophagia

8

10%

Others

4

5.3%

Erosive esophagitis was found in 36 total patients (48%) and non-erosive esophagitis was found in 31 patients (41.3%). The hiatus hernia with esophagitis was found in 3 patients (4%). Growth was found in 4 patients total (5.3%). Biopsy was taken and samples were sent for histopathological analysis.

 

Table 2: Endoscopic findings in patients with GERD

Endoscopic Findings

No. of cases

Percentage

Erosive Esophagitis (grade 1-4)

32

42.66%

Barrett’ s esophagus

01

1.33%

Gastric ulcer andantral gastritis

04

5.33%

Growth

03

4%

Hiatus hernia and erosive esophagitis

03

4%

Growth and erosive esophagitis

01

1.33%

Within normal limits

31

41.33%

Heartburn (93.33%) and regurgitation (82.66%) were the most frequent symptoms followed by Watery brash (33.3%) and dysphagia (28%). Other symptoms include hiccoughs, pulmonary symptoms etc. (Table 1).


Table 3: Endoscopic grading of GERD cases

Grade of esophagitis

No. of cases

Percentage

LA Grade A

15

41.7%

LA Grade B

14

38.9%

LA Grade C

6

16.7%

LA Grade D

1

2.8%

 

 

Los Angeles grade A esophagitis was the most common finding found in 15 cases (41.7%) followed by grade B in 14 cases (38.9%). (Table 2).

 

DISCUSSION

Due to varied diagnostic criteria and unavailability of modes of objective diagnosis (pH monitoring and impedence manometry) there are no clear-cut diagnostic criteria which are available and accessible to the treating physician. Gastroesophageal reflux disease (GERD) thus remains under-diagnosed and is treated many a times when complications have arisen. In our study we found heartburn, regurgitation, dysphagia and watery brash as the most common symptoms associated with erosive esophagitis as detected on endoscopy. If such symptoms were seen in patients, then they should be subjected to upper gastro-intestinal endoscopy. In our study, we found that heartburn was the most common symptom associated with all grades of esophagitis and most common with grade A (38.9%) followed by regurgitation (36.1%). In a study by Faiyaz et al. 196 patients were selected and endoscopically examined. Most common grade given by patients to epigastric pain was grade-4 (42.9%), retrosternal burning as grade-4 (41.8%) and reflux grade-5 (36.7%).4 Studies from Ewha Womans University, Seoul, Korea by Song et al. shows that heartburn of moderate to severe degree was a universal complaint and frequency of regurgitation was noticed to be more than thrice a week to daily intermittent in all the patients.5

 

REFERENCES

  1. Ho KY, Cheung TK, Wong BC. Gastroeophageal reflux disease in Asian countries: Disorder of nature or nurture?: J Gastroenterol Hepatol. 2006 Sep;21(9):1362-5.
  2. Shaheen NJ, Weinberg DS, Denberg TD, et al, for the Clinical Guidelines Committee of the American College of Physicians. Upper Endoscopy for Gastroesophageal Reflux Disease: Best Practice Advice from the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med. 2012;157:808–816.
  3. Sami SS, Ragunath K. The Los Angeles Classification of Gastroesophageal Reflux Disease. Video Journal and Encyclopedia of GI Endoscopy 2013;1(1):103-104.
  4. Faiyaz ZB, Nabiha F, Saeed QM, Salahuddin A, Ali G KL, Erum K. Correlation between clinical, endoscopic and histological findings at Oesophago-gastric junction in patients of gastro oesophageal reflux disease. Journal of the College of Physicians and Surgeons Pakistan. 2005; 15(12):774-7.
  5. Song HJ, Shing KN, Yoon SJ, Kim SE, Oh HJ, Ryu KM, et al. The Prevalence and Clinical characteristics of Reflux Oesophagitis in Koreans and its possible relation to metabolic syndrome. J Korean Med Sci. 2009; 24:197-202.