CLINICAL CHARACTERISTICS, ENDOSCOPIC IMAGE OF GASTROESOPHAGEAL REFLUX DISEASE IN THE ELDERLY

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1 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 , with a range from 6-92 years old. The majority of participants suffered from GERD for less than one year (5%). The most common clinical symptoms were burning (67.7%), epigastric pain (63.5%) and heartburn (63.5%). Other symptoms included persistent cough (3.2%) and dysphasia (25.%). The most common risk factors for GERD were being overweight or obese (4.6%) 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 3.3%. In conclusion, popular signs of GERD in this elderly patient population included burning, epigastric 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 I. BACKGROUND scopy an America center, the rate of GERD Gastroesophageal reflux disease (GERD) disease was found to be 15-2% [3]. It is less occurs when high levels of gastric juice reflux common in Asian countries, with an overall into the esophagus due to transient lower eso- rate of approximately 6% [14]. However, in phageal sphincter relaxations (TLESRs). This recent years, studies have revealed increasing is a physiological phenomenon that commonly rates of GERD in Vietnam. According to sur- occurs at night, especially after meals. Often- veys done by the Department of Functional times, reflux occurs at low frequencies with no Examination at Bach Mai Hospital in Hanoi, clinical symptoms, and does not cause 7.8% of all patients endoscoped in 214 were esophagitis. reflux found to have GERD. Gastroesophageal be- Elderly patients with comes pathological when the esophageal GERD have unique clinical characteristics, relaxation becomes persistent and frequent, endoscopic imaging and histopathology. Their causing unpleasant symptoms and/or medical typical clinical symptoms are commonly com- complications [1; 2]. GERD is a common bined with severe complications such as disease globally, especially in developed ulcers, esophageal stricture, Barrett's esopha- countries. Among patients receiving endo- gus, and esophageal cancer [4]. Barrett's esophagus is a serious complication of GERD. Corresponding author: Ho Thi Kim Thanh, Hanoi Medical University thanhhokim@yahoo.com Received: 2 October 216 Accepted: 1 December In Barrett's esophagus, the normal tissue lining the esophagus - the tube that carries food from the mouth to the stomach - transforms into tissue that resembles the lining of

2 the intestine. Risk factors for the development specific examination to rule out cardiac-related of GERD in the elderly include esophageal diseases. tumors, being male, smoking, advanced age, and obesity [5]. GERD is a common gastrointestinal 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 characteristics and endoscopic imaging findings of + Cough, sore throat, pharyngeal paresthesia. + 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 duration is not compulsory), at least once a GERD in elderly patients in Vietnam. week. II. SUBJECTS AND METHODS - Endoscopy highlighting esophageal injuries at various levels. 1. Subjects 2. Study design Inclusion Criteria Age 6, consenting to participate in the research, and receiving digestive endoscopy. A descriptive, cross-sectional study was conducted. Patients were interviewed and examined by doctor. Patients with nasogastric tubes. Patients with a narrow esophagus, superior esophageal ulcers or tumors or stomach tumors. We used a CV - 15 Video processor to conduct an endoscopy on all participants. We used an assembled camera to account for any problems that might occur during endoscopy. Patients suffering from severe accompanying diseases: acute heart failure, acute myo- Esophageal injury images were assessed cardial infarction, or gastrointestinal burns due using the Los Angeles classification system to alkali or acid. [7]. Histopathology was examined by biopsy Being diagnosed with GERD using Rome II criteria: at least one of the following symtoms - Experiencing one of following digestive symptoms: sion 15.. All study procedures complied with the + Burning behind the sternum. And/or The data was analyzed using SPSS ver- 3. Reseach ethics + Heartburn. - obtained during endoscopy. reporting one ethical principles of biomedical research. Parin following symptoms outside of the digestive system: + Chest pain (cardiac-related diseases excluded): Patients were required to have a 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. 97

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 6 years of age to 92 years of age.

3 III. RESULTS A total of 96 patients participated in the study. The percentage of female patients was 58.3%. Patients mean age was ± 8. 22, with a range from 6 years of age to 92 years of age. The majority of respondents had suffered from GERD for less than one year (5%). Table 1. Clinical characteristics of GERD among the elderly patients included in this study Symptoms N % Heartburn Burning Nausea, vomiting Epigastric pain Difficulty swallowing Odynophagia Persistent cough Sorethroat Difficulty breathing 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 (3.2%) and difficulty swallowing (25.%) 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 drinking beer or alcohol (21.2%). 98

4 Images of injured esophagus obtained during endoscopy Grade A Grade B Grade C Grade Figure 2. Esophageal injuries classified by the Los Angeles classification system The majority of esophageal injuries were mild pharyngitis grade A (49.%) and pharyngitis grade B (34.4%). Table 2. Accompanying duodenal and stomach injuries Stomach Duodenum Injury n % n % Normal Inflammation Ulcer Total Most respondents were found to have accompanying inflammation in stomach (96.9%). GERD complications Barrett Ulcer hemorrage Cancer Figure 3. Complications of gastroesophageal reflux among the elderly patients included in this study 99

5 The rate of Barrett s esophagus was relatively high (3.3%). Bleeding was rare (1.1%). No cases of esophageal cancer were detected. IV. DISCUSSION Previous research has revealed two com- GERD include alcohol consumption, smoking, mon and typical symptoms of GERD: burning being overweight or obese, and several medi- behind the sternum and heartburn [5; 8]. En- cations (including calcium channel blockers doscopy, biopsy, 24 hour PH calculation, and and NSAIDs). In our study, 21.9% of patients X-ray imaging of the esophagus with contrast with GERD reported a history of alcohol use, are not common parts of the investigation of 14.6 % reported a history of smoking, 4.6% GERD. Therefore, it is difficult to document of patients reported being overweight or accurately disease rates in the community. obese, 18.8% used calcium channel blockers, Rates of GERD in high income countries were and 1.4% used NSAIDs. The rate of alcohol reported to be between 1-48% [15]. In Xian and tobacco use was lower than that found in (China), the proportion of individuals experi- other studies, possibly due to the characteris- encing burning behind the sternum at least tics of our patient population. Our patients once a day was found to be 1.66%, at least were 6 years old and above and the majority once a week was 4.6% and at least once a were female. month was 1.98% [16]. In a study by Dent et Results of stomach and esophageal endo- al., where residents in Minnesota, USA were scopy showed the following levels of esophag- randomly interviewed via telephone, eal injuries, based on the Los Angeles classifi- 2% of respondents were found to have burn- cation system: pharyngitis grade A (49.%), ing behind the sternum and/or heartburn every pharyngitis grade B (34.4%), pharyngitis grade week % of these respondents C (13.5%) and pharyngitis grade D (3.1%). reported a single burning sensation occurring These results highlighted the fact that in our every week; rates of daily acid reflux were 6.3 patients, GERD developed slowly and gradu- 6.6 % [9]. ally. We found considerable rates of gastroe- Among the elderly patients in our study, sophageal reflux among the older patients in common clinical symptoms of GERD included our sample, which is consistent with a previ- epigastric pain (63.5%), burning (67.7%) and ous study by Huang et al [1]. It is also note- heartburn (63.5%). Digestive symptoms were worthy that 3.3% of the patients in our study not frequent. Extra - esophageal symptoms had Barrett s esophagus, one patient was included persistent cough (3.2%), chronic found to have an esophageal ulcer and 1.4% sore throat (27,1) and dysphasia (25.%). The of patients had esophageal bleeding. No proportion of patients reporting odynophagia patient and difficulty breathing were lower than that cancer. The rate of Barrett s esophagus found in previous studies, but the rate of eso- among our respondents was relatively high, phageal injuries was still high [4; 6; 8; 9]. Pre- which may suggest an association between vious research showed that risk factors for the age of a patient with GERD and the risk of 1 was found to have esophageal

6 development of Barrett's esophagus. Because 3. Charler F (1998). Oesophageal disease, the risk of esophageal cancer is 3-12 times in The Washington manual of medical Thera- higher in those who experience Barrett s peutics, esophagus than in those without Barrett s 4. Maxwell Chaite (25). Gastroesophag- esophagus, an endoscopic monitoring pro- eal Reflux Disease in elderly, in Praticalgastro- gram is needed for elderly patients with GERD enterology, Columbia University, New York, 52 [4; 11]. Our results showed that 96.9% of - 6. GERD patients had accompanying gastritis, 3% experienced stomach ulcers, 14% had 5. Marco Patti (25). Gastrosophageal Reflux Disease. Journal of Gastroenterology. duodenal ulcers, and 5.2 % experienced duo- 6. Collen MJ, A. JD, C. YK (1995). Gas- denitis, which are rates comparable with those troesophageal reflux disease in the elderly, found in past studies [12; 13]. Am J Gastroenterol, Los Angeles Symposium on classifica- V. CONCLUSION Gastroesophageal tion of oesophagitis World congres of Gastroreflux disease was enterology, found to occur more frequently in elder 8. Howard P.J, Heading R.C (1992). Epi- females than in elderly males. The most com- demiology of gastroesophageal reflux disease. mon symptoms were burning (67.7%), epigas- Word J Surg, 16, tric pain (63.3%) and heartburn (63.%). The 9. Dent J (25). Epidemiology of gastroe- were sophageal reflux disease: a systematic review. pharyngitis grade A (49.%) and grade B BMJ Publishing Group Ltd & British Society of (344%), frequently accompanied by gastritis Gastroenterology. most common esophageal injuries (96.9%). 3.3% of patients experienced Bar- 1. Huang X, Zhu HM, E.A. Deng CZ rett s esophagus, though it was not closely (1995). Gastroesophageal reflux: The features monitored. in elderly patients. World J Gastroenterol, Acknowledgement 11. Joel E. Richter (2). Gastroe- I would like to express my deepest grati- sophageal Reflux Disease in the Older Pa- tude to the National Geriatric Hospital's Ana- tients: Presentation, Treatment, and Complica- tomical Pathology Department for supporting tion, The Armerican juornal of gastroenterol- us in the data collection process. ogy, 95(2), Eisen G.M, Sandler R.S l (1997). The REFERENCES 1. Mark Fox (26). Gastroesophageal reflux disease. BMJ, 332, Vakil N (26). The montreal definition relationship between gastroesophageal reflux disease and its complications with Barrettt esophagus, Journal of Gastroenterology, 39, and classification of gastroesophageal reflux 13. Cammeron AJ (22). Epidemiology disease: A globan evidence-based consensus. of Barrettt's esophagus and adenocarcinoma, The American Journal of Gastroenterology, Journal of Gastroenterology and Hepatology. 11, (2),

7 14. Khean-Lee G, Kwong-Ming F, Meigure K (2). Gastroesophageal reflux disease of Asia. Journal of Gastroenterology and Hepatology, 15, Maxwell Chaite (25). Gastroesophageal Reflux Disease in elderly, Pratical- 12 gastroenterology, Columbia University, New York, Jin Hai Wang (23). Epidemiology of gastroesophageal reflux disease: a general population-based in Xian of Northwest China. The World Journal of Gastroenterology.

GERD. Gastroesophageal reflux disease, or GERD, occurs when acid from the. stomach backs up into the esophagus. Normally, food travels from the

GERD. Gastroesophageal reflux disease, or GERD, occurs when acid from the. stomach backs up into the esophagus. Normally, food travels from the GERD What is GERD? Gastroesophageal reflux disease, or GERD, occurs when acid from the stomach backs up into the esophagus. Normally, food travels from the mouth, down through the esophagus and into the