Influence of Co-Morbid IBS & Psychological Distress -GERD
Background: A subset of patients with gastro-oesophageal reflux disease (GERD) does not achieve complete symptom resolution with proton pump inhibitor (PPI) therapy. The factors which affect response to PPI therapy in GERD patients remain unclear.
Aims: To determine the prevalence and impact of irritable bowel syndrome (IBS) and psychological distress (PD) on GERD symptoms and disease-specific quality of life (QoL) before and after PPI therapy and to assess the same outcomes before and after PPI therapy in non-erosive reflux disease (NERD) and erosive oesophagitis (EO) GERD patients.
Methods: Patients undergoing oesophago-gastroduodenoscopy (OGD) for heartburn were recruited. Participants completed validated surveys: Digestive Health Symptom Index, Reflux Disease Questionnaire, Quality of Life in Reflux and Dyspepsia and Brief Symptom Inventory (BSI). IBS was defined as >3 Manning criteria and PD as BSI score >63. At OGD, patients were classified as NERD or EO. Patients were treated with rabeprazole 20 mg/day for 8 weeks before completing follow-up surveys.
Results: Of 132 GERD patients enrolled, 101 completed the study. The prevalence rates of IBS and PD were 36% and 41%, respectively. IBS independently predicted worse QoL before and after PPI therapy. PD independently predicted worse GERD symptoms and QoL before and after PPI therapy. There were no differences in symptoms or QoL between NERD and EO patients before or after PPI therapy.
Conclusions: IBS and PD impacted GERD symptoms and QoL before and after PPI therapy. Symptoms and QoL before and after PPI therapy were similar in NERD and EO patients.
Symptoms of gastro-oesophageal reflux disease (GERD) including heartburn and regurgitation are common, affecting approximately 20% of the general population on a weekly basis. A variety of medications are currently available to treat GERD. Proton pump inhibitors (PPIs) have proven more effective than histamine receptor antagonists and placebo both for the healing of erosive oesophagitis (EO) and for improvement of symptoms. Although a majority of treated patients experience symptom improvement or resolution, a significant subset report persistent symptoms despite PPI therapy. The predictors of response to PPI therapy have been only partially characterized. Practical issues can confound the effectiveness of PPI therapy. For example, medical noncompliance is an important issue for some patients. The manner in which a patient is instructed to take PPI therapy can also influence treatment efficacy. Further, patients with typical GERD symptoms including heartburn and regurgitation are more likely to respond to PPI therapy than those with extraoesophageal symptoms such as asthma, hoarseness or cough.
When patients fail to improve with PPI therapy, detailed diagnostic testing with ambulatory oesophageal pH monitoring and/or impedence testing to exclude persistent acid or non-acid reflux have been recommended. Despite such invasive testing, more than half of patients will have no identifiable relationship between acid or non-acid reflux episodes and GERD symptoms. In aggregate, these observations underscore the importance of understanding the factors which influence response of patients with GERD symptoms to PPI therapy.
Patients with symptoms suggestive of GERD often report multiple symptoms referable to the gastrointestinal (GI) tract. For example, a recent study reported that a significant proportion of patients with GERD symptoms also experienced symptoms compatible with the diagnosis of the irritable bowel syndrome (IBS) and functional dyspepsia. Co-morbid psychological distress (PD) is reportedly more common in patients with GERD symptoms. A recent work suggests that major life stressors are associated with more severe and frequent GERD symptoms. Whether co-morbid IBS or PD influences the response to PPI therapy in patients with GERD symptoms has not been prospectively studied.
Traditionally, patients with GERD have been classified as suffering from either EO or non-erosive reflux disease (NERD) by upper endoscopy. There is some evidence to suggest that patients with EO are more likely to respond to PPI therapy than those with NERD. As EO is almost uniformly acid-related while NERD probably represents a heterogeneous group of abnormalities, this suggestion is mechanistically attractive. Unfortunately, there are few published studies which have directly compared the efficacy of PPI therapy on heartburn relief in EO and NERD patients from the same population. Further, a number of practical issues limit a clinician’s ability to distinguish between patients with EO and patients with NERD in clinical practice. For example, a vast majority of patients with GERD symptoms never undergo upper endoscopy. For the minority of affected patients who undergo upper endoscopy, the procedure is typically performed after initiation of PPI therapy, which would be expected to confound the endoscopist’s ability to detect EO.
The aims of this study were to identify prospectively the percentage of GERD patients with co-morbid IBS and PD and to determine the impact of these co-morbidities on response of reflux symptoms to PPI therapy. We further assessed baseline symptom severity and quality of life (QoL) before and after PPI therapy in patients stratified by the presence or absence of EO.
Background: A subset of patients with gastro-oesophageal reflux disease (GERD) does not achieve complete symptom resolution with proton pump inhibitor (PPI) therapy. The factors which affect response to PPI therapy in GERD patients remain unclear.
Aims: To determine the prevalence and impact of irritable bowel syndrome (IBS) and psychological distress (PD) on GERD symptoms and disease-specific quality of life (QoL) before and after PPI therapy and to assess the same outcomes before and after PPI therapy in non-erosive reflux disease (NERD) and erosive oesophagitis (EO) GERD patients.
Methods: Patients undergoing oesophago-gastroduodenoscopy (OGD) for heartburn were recruited. Participants completed validated surveys: Digestive Health Symptom Index, Reflux Disease Questionnaire, Quality of Life in Reflux and Dyspepsia and Brief Symptom Inventory (BSI). IBS was defined as >3 Manning criteria and PD as BSI score >63. At OGD, patients were classified as NERD or EO. Patients were treated with rabeprazole 20 mg/day for 8 weeks before completing follow-up surveys.
Results: Of 132 GERD patients enrolled, 101 completed the study. The prevalence rates of IBS and PD were 36% and 41%, respectively. IBS independently predicted worse QoL before and after PPI therapy. PD independently predicted worse GERD symptoms and QoL before and after PPI therapy. There were no differences in symptoms or QoL between NERD and EO patients before or after PPI therapy.
Conclusions: IBS and PD impacted GERD symptoms and QoL before and after PPI therapy. Symptoms and QoL before and after PPI therapy were similar in NERD and EO patients.
Symptoms of gastro-oesophageal reflux disease (GERD) including heartburn and regurgitation are common, affecting approximately 20% of the general population on a weekly basis. A variety of medications are currently available to treat GERD. Proton pump inhibitors (PPIs) have proven more effective than histamine receptor antagonists and placebo both for the healing of erosive oesophagitis (EO) and for improvement of symptoms. Although a majority of treated patients experience symptom improvement or resolution, a significant subset report persistent symptoms despite PPI therapy. The predictors of response to PPI therapy have been only partially characterized. Practical issues can confound the effectiveness of PPI therapy. For example, medical noncompliance is an important issue for some patients. The manner in which a patient is instructed to take PPI therapy can also influence treatment efficacy. Further, patients with typical GERD symptoms including heartburn and regurgitation are more likely to respond to PPI therapy than those with extraoesophageal symptoms such as asthma, hoarseness or cough.
When patients fail to improve with PPI therapy, detailed diagnostic testing with ambulatory oesophageal pH monitoring and/or impedence testing to exclude persistent acid or non-acid reflux have been recommended. Despite such invasive testing, more than half of patients will have no identifiable relationship between acid or non-acid reflux episodes and GERD symptoms. In aggregate, these observations underscore the importance of understanding the factors which influence response of patients with GERD symptoms to PPI therapy.
Patients with symptoms suggestive of GERD often report multiple symptoms referable to the gastrointestinal (GI) tract. For example, a recent study reported that a significant proportion of patients with GERD symptoms also experienced symptoms compatible with the diagnosis of the irritable bowel syndrome (IBS) and functional dyspepsia. Co-morbid psychological distress (PD) is reportedly more common in patients with GERD symptoms. A recent work suggests that major life stressors are associated with more severe and frequent GERD symptoms. Whether co-morbid IBS or PD influences the response to PPI therapy in patients with GERD symptoms has not been prospectively studied.
Traditionally, patients with GERD have been classified as suffering from either EO or non-erosive reflux disease (NERD) by upper endoscopy. There is some evidence to suggest that patients with EO are more likely to respond to PPI therapy than those with NERD. As EO is almost uniformly acid-related while NERD probably represents a heterogeneous group of abnormalities, this suggestion is mechanistically attractive. Unfortunately, there are few published studies which have directly compared the efficacy of PPI therapy on heartburn relief in EO and NERD patients from the same population. Further, a number of practical issues limit a clinician’s ability to distinguish between patients with EO and patients with NERD in clinical practice. For example, a vast majority of patients with GERD symptoms never undergo upper endoscopy. For the minority of affected patients who undergo upper endoscopy, the procedure is typically performed after initiation of PPI therapy, which would be expected to confound the endoscopist’s ability to detect EO.
The aims of this study were to identify prospectively the percentage of GERD patients with co-morbid IBS and PD and to determine the impact of these co-morbidities on response of reflux symptoms to PPI therapy. We further assessed baseline symptom severity and quality of life (QoL) before and after PPI therapy in patients stratified by the presence or absence of EO.
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