Clinical characteristics, endoscopic image of gastroesophageal reflux disease in the elderly

96 JMR 105 E1 (7) - 2016
JOURNAL OF MEDICAL RESEARCH
CLINICAL CHARACTERISTICS, ENDOSCOPIC IMAGE OF
GASTROESOPHAGEAL REFLUX DISEASE IN THE ELDERLY
Ho Thi Kim Thanh, Vu Thi Kim Ngoc
Hanoi Medical University, National Geriatric Hospital
This study aimed to examine the clinical features and endoscope imagery of gastroesophageal reflux
disease (GERD) in the elderly. We conducted a cross - sectional study of 96 elderly patients from Bach Mai
hospital’s gastroscopy unit. 58.3% of the patients were female. The mean age was 73.12 + 8.22, with a
range from 60 - 92 years old. The majority of participants suffered from GERD for less than one year (50%).
The most common clinical symptoms were burning (67.7%), epigastric pain (63.5%) and heartburn (63.5%).
Other symptoms included persistent cough (30.2%) and dysphasia (25.0%). The most common risk factors
for GERD were being overweight or obese (40.6%) and alcohol or beer consumption (21.9%). Most of the
patients were found to have pharyngitis grade A (49.9%) or pharyngitis grade B (34.4%). Patients commonly
had accompanying gastritis symptoms. Additionally, the proportion of patients with Barrett’s esophagus was
high at 30.3%. In conclusion, popular signs of GERD in this elderly patient population included burning, epi-
gastric pain and heartburn. Given the high percentage of patients found to have Barrett's esophagus, there
may be a need for continued monitoring of these patients with endoscopy to prevent future complications.
Key words: gastroesophageal reflux disease, the elderly
Corresponding author: Ho Thi Kim Thanh, Hanoi Medical
University
E-mail: thanhhokim@yahoo.com
Received: 20 October 2016
Accepted: 10 December 2016
I. BACKGROUND
Gastroesophageal reflux disease (GERD)
occurs when high levels of gastric juice reflux
into the esophagus due to transient lower eso-
phageal sphincter relaxations (TLESRs). This
is a physiological phenomenon that commonly
occurs at night, especially after meals. Often-
times, reflux occurs at low frequencies with no
clinical symptoms, and does not cause
esophagitis. Gastroesophageal reflux be-
comes pathological when the esophageal
relaxation becomes persistent and frequent,
causing unpleasant symptoms and/or medical
complications [1; 2]. GERD is a common
disease globally, especially in developed
countries. Among patients receiving endo-
scopy an America center, the rate of GERD
disease was found to be 15 - 20% [3]. It is less
common in Asian countries, with an overall
rate of approximately 6% [14]. However, in
recent years, studies have revealed increasing
rates of GERD in Vietnam. According to sur-
veys done by the Department of Functional
Examination at Bach Mai Hospital in Hanoi,
7.8% of all patients endoscoped in 2014 were
found to have GERD. Elderly patients with
GERD have unique clinical characteristics,
endoscopic imaging and histopathology. Their
typical clinical symptoms are commonly com-
bined with severe complications such as
ulcers, esophageal stricture, Barrett's esopha-
gus, and esophageal cancer [4]. Barrett's
esophagus is a serious complication of GERD.
In Barrett's esophagus, the normal tissue
lining the esophagus - the tube that carries
food from the mouth to the stomach - trans-
forms into tissue that resembles the lining of
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the intestine. Risk factors for the development
of GERD in the elderly include esophageal
tumors, being male, smoking, advanced age,
and obesity [5]. GERD is a common gastroin-
testinal disorder in the elderly, considerably
affecting patients’ quality of life [6]. Accessing,
close monitoring, and early recognition of
GERD in the elderly are essential to treat the
disease and prevent complications. The aims
of this study were to review the clinical charac-
teristics and endoscopic imaging findings of
GERD in elderly patients in Vietnam.
II. SUBJECTS AND METHODS
1. Subjects
Inclusion Criteria
Age ≥ 60, consenting to participate in the
research, and receiving digestive endoscopy.
Patients with nasogastric tubes.
Patients with a narrow esophagus, superior
esophageal ulcers or tumors or stomach
tumors.
Patients suffering from severe accompany-
ing diseases: acute heart failure, acute myo-
cardial infarction, or gastrointestinal burns due
to alkali or acid.
Being diagnosed with GERD using Rome II
criteria: at least one of the following symtoms
- Experiencing one of following digestive
symptoms:
+ Heartburn.
+ Burning behind the sternum.
- And/or reporting one in following
symptoms outside of the digestive system:
+ Chest pain (cardiac-related diseases
excluded): Patients were required to have a
specific examination to rule out cardiac-related
diseases.
+ Cough, sore throat, pharyngeal paresthe-
sia.
+ Lung symptoms: difficulty breathing at
night
Nose symptoms: pain as having a strange
thing in the nose.
- Symptoms occurring at least 12 times
during a period of 12 months (continuous du-
ration is not compulsory), at least once a
week.
- Endoscopy highlighting esophageal inju-
ries at various levels.
2. Study design
A descriptive, cross-sectional study was
conducted. Patients were interviewed and ex-
amined by doctor.
We used a CV - 150 Video processor to
conduct an endoscopy on all participants. We
used an assembled camera to account for any
problems that might occur during endoscopy.
Esophageal injury images were assessed
using the Los Angeles classification system
[7]. Histopathology was examined by biopsy
obtained during endoscopy.
The data was analyzed using SPSS ver-
sion 15.0.
3. Reseach ethics
All study procedures complied with the
ethical principles of biomedical research. Par-
ticipants consented to take part in the study
and were told that they could withdraw at any
time. Participants’ information was kept secure
and confidential.
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III. RESULTS
A total of 96 patients participated in the study. The percentage of female patients was 58.3%.
Patients’ mean age was 73.17 ± 8. 22, with a range from 60 years of age to 92 years of age. The
majority of respondents had suffered from GERD for less than one year (50%).
Table 1. Clinical characteristics of GERD among the elderly patients included in this study
Symptoms N %
Heartburn 61 63.5
Burning 65 67.7
Nausea, vomiting 24 25.0
Epigastric pain 61 63.5
Difficulty swallowing 24 25.0
Odynophagia 5 5.2
Persistent cough 29 30.2
Sorethroat 26 27.1
Difficulty breathing 3 3.1
The most common symptoms endorsed by respondents were burning (67.7%), epigastric pain
(63.5%) and heartburn (63.5%). Symptoms outside of digestive system included persistent cough
(30.2%) and difficulty swallowing (25.0%).
Alcohol Smoking Over
weight
NSAIDS CCB
Figure 1. Risk factors of GERD
The most common risk factors for GERD were being overweight or obese (39.4%) and drink-
ing beer or alcohol (21.2%).
18.2
10.1
39.4
14.1
21.2
50
25
37.5
12.5
0
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Images of injured esophagus obtained during endoscopy
Figure 2. Esophageal injuries classified by the Los Angeles classification system
The majority of esophageal injuries were mild pharyngitis grade A (49.0%) and pharyngitis
grade B (34.4%).
Table 2. Accompanying duodenal and stomach injuries
Injury
Stomach Duodenum
n % n %
Normal 0 0 77 80.2
Inflammation 93 96.9 5 5.2
Ulcer 3 3.1 14 14.6
Total 96 100 96 100
Most respondents were found to have accompanying inflammation in stomach (96.9%).
GERD complications
4.1
34.3
47.5
GradeGrade BGrade A
50
40
30
20
10
0
0
CancerUlcer
hemorrage
1.01
30.3
Barrett
35
30
25
20
15
10
5
0
Figure 3. Complications of gastroesophageal reflux among the elderly patients
included in this study
14.1
Grade C
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The rate of Barrett’s esophagus was relatively high (30.3%). Bleeding was rare (1.01%). No
cases of esophageal cancer were detected.
IV. DISCUSSION
Previous research has revealed two com-
mon and typical symptoms of GERD: burning
behind the sternum and heartburn [5; 8]. En-
doscopy, biopsy, 24 hour PH calculation, and
X-ray imaging of the esophagus with contrast
are not common parts of the investigation of
GERD. Therefore, it is difficult to document
accurately disease rates in the community.
Rates of GERD in high income countries were
reported to be between 10 - 48% [15]. In Xian
(China), the proportion of individuals experi-
encing burning behind the sternum at least
once a day was found to be 1.66%, at least
once a week was 4.06% and at least once a
month was 10.98% [16]. In a study by Dent et
al., where residents in Minnesota, USA were
randomly interviewed via telephone, 19.8-
20% of respondents were found to have burn-
ing behind the sternum and/or heartburn every
week. 17.4 - 17.8% of these respondents
reported a single burning sensation occurring
every week; rates of daily acid reflux were 6.3
– 6.6 % [9].
Among the elderly patients in our study,
common clinical symptoms of GERD included
epigastric pain (63.5%), burning (67.7%) and
heartburn (63.5%). Digestive symptoms were
not frequent. Extra - esophageal symptoms
included persistent cough (30.2%), chronic
sore throat (27,1) and dysphasia (25.0%). The
proportion of patients reporting odynophagia
and difficulty breathing were lower than that
found in previous studies, but the rate of eso-
phageal injuries was still high [4; 6; 8; 9]. Pre-
vious research showed that risk factors for
GERD include alcohol consumption, smoking,
being overweight or obese, and several medi-
cations (including calcium channel blockers
and NSAIDs). In our study, 21.9% of patients
with GERD reported a history of alcohol use,
14.6 % reported a history of smoking, 40.6%
of patients reported being overweight or
obese, 18.8% used calcium channel blockers,
and 10.4% used NSAIDs. The rate of alcohol
and tobacco use was lower than that found in
other studies, possibly due to the characteris-
tics of our patient population. Our patients
were 60 years old and above and the majority
were female.
Results of stomach and esophageal endo-
scopy showed the following levels of esophag-
eal injuries, based on the Los Angeles classifi-
cation system: pharyngitis grade A (49.0%),
pharyngitis grade B (34.4%), pharyngitis grade
C (13.5%) and pharyngitis grade D (3.1%).
These results highlighted the fact that in our
patients, GERD developed slowly and gradu-
ally. We found considerable rates of gastroe-
sophageal reflux among the older patients in
our sample, which is consistent with a previ-
ous study by Huang et al [10]. It is also note-
worthy that 30.3% of the patients in our study
had Barrett’s esophagus, one patient was
found to have an esophageal ulcer and 1.04%
of patients had esophageal bleeding. No
patient was found to have esophageal
cancer. The rate of Barrett’s esophagus
among our respondents was relatively high,
which may suggest an association between
the age of a patient with GERD and the risk of
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development of Barrett's esophagus. Because
the risk of esophageal cancer is 30 - 120 times
higher in those who experience Barrett’s
esophagus than in those without Barrett’s
esophagus, an endoscopic monitoring pro-
gram is needed for elderly patients with GERD
[4; 11]. Our results showed that 96.9% of
GERD patients had accompanying gastritis,
3% experienced stomach ulcers, 14% had
duodenal ulcers, and 5.2 % experienced duo-
denitis, which are rates comparable with those
found in past studies [12; 13].
V. CONCLUSION
Gastroesophageal reflux disease was
found to occur more frequently in elder
females than in elderly males. The most com-
mon symptoms were burning (67.7%), epigas-
tric pain (63.3%) and heartburn (63.0%). The
most common esophageal injuries were
pharyngitis grade A (49.0%) and grade B
(344%), frequently accompanied by gastritis
(96.9%). 30.3% of patients experienced Bar-
rett’s esophagus, though it was not closely
monitored.
Acknowledgement
I would like to express my deepest grati-
tude to the National Geriatric Hospital's Ana-
tomical Pathology Department for supporting
us in the data collection process.
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