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Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. Bibliography

Background:

Patients consulting with gastro-oesophageal reflux symptoms (GORS) may differ from nonconsulters.

Aim:

To describe these differences in a UK population.

Methods:

A postal questionnaire was sent to 4432 adults. Definitions used were GORS (either heartburn or acid regurgitation on more than six occasions during the previous year), dyspepsia (upper abdominal pain or discomfort on more than six occasions during the previous year) and irritable bowel syndrome (abdominal pain with three or more Manning criteria). Socio-economic status was identified by the Standard Occupational Classification.

Results:

With a 71.7% response, GORS were reported by 28.7% of the sample, it was unaffected by gender and age but was more common among the socially disadvantaged (P < 0.005). Less than 25% of GORS patients consulted during the previous year. Increasing age (χ2 for trend; P < 0.001) and coexisting upper abdominal symptoms (χ2P < 0.001) positively influenced consultation behaviour, but it was unaffected by socio-economic status, gender, or the coexistence of irritable bowel syndrome. Dyspepsia and nausea independently predicted consultation.

Conclusions:

GORS are especially common among the deprived. Socio-economic variables do not affect consultation behaviour, but the patient’s age and the burden (number and type) of associated symptoms do.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. Bibliography

Symptoms of heartburn and acid regurgitation are common,1[2][3]–4 and most patients who experience these symptoms will not have consulted a doctor over a 6 month period.5 While it is known that many of these patients also suffer from dyspepsia5, 6 and irritable bowel syndrome7 it is unclear whether these coexisting symptoms influence consultation behaviour and whether patients who consult have a different spectrum of symptoms than those who do not. The relationship between gastro-oesophageal reflux symptoms, consultation behaviour and socio-economic variables has not previously been reported in the UK.

In separate studies of patients with irritable bowel syndrome and patients with dyspepsia, two variables have been shown to exert a particular influence on consultation behaviour. One of these is the patient’s concern about the possible serious significance of their symptoms, the other being the presence of abdominal pain.8[9]–10

Understanding why patients with gastro-oesophageal reflux symptoms (GORS) consult is important to clinicians because it allows a greater understanding of the spectrum of symptoms presented, and of which symptoms are particularly troubling to the patient. Clinical trialists will be interested to know the characteristics of patients presenting in primary care, while those involved in health service development require information about a population’s health care needs and the relationship between socio-economic status and health care access.

This paper reports on the prevalence of gastro-oesophageal reflux symptoms, the spectrum of abdominal symptoms that these patients experience, and the impact of these associated symptoms on consultation behaviour. It also describes the effect of age, gender and socio-economic status on symptom prevalence and consultation behaviour. In order to facilitate future comparisons with other populations we have standardized our prevalence figures to the 1997 UK population.

SUBJECTS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. Bibliography

We sent a symptom questionnaire constructed from individual questionnaires on dyspepsia11 and irritable bowel syndrome,12 a reply paid envelope and a covering letter to 4432 subjects selected from the practice registers of six general practices which are members of the Northern Region Research Network (NoReN). Two reminders were sent at monthly intervals. Ethical approval was granted by local research ethics committees and the return of a completed questionnaire was taken as consent to participate. Prior to randomization we stratified the study population into 10 year age bands from 20 to 69 years of age inclusive. In two practices we assigned consecutive numbers to each person on the registers and selected a 1:10 sample from each 10 year stratum using random number tables. In four practices we used a software facility on the practice computer to generate a random sample.

Although the symptoms of heartburn and acid regurgitation may predict the presence of pH positive gastro-oesophageal reflux (identified by oesophageal pH study) the specificity of these symptoms is not very good.13, 14 There is confusion regarding the clinical use of the term gastro-oesophageal reflux disease (GERD). The term is used to identify a broad range of clinical states including the asymptomatic reflux of gastric contents identified by oesophageal pH study, gastro-oesophageal reflux symptoms, gastro-oesophageal reflux associated with pathological change in the oesophagus, e.g. oesophagitis or oesophageal ulcer, and patients with severe symptoms, normal endoscopy and abnormal pH metry (endoscopy negative GERD). We propose that gastro-oesophageal reflux be used to describe the reflux of gastric contents into the oesophagus, that heartburn and acid regurgitation are gastro-oesophageal reflux symptoms (GORS) and that the term gastro-oesophageal reflux disease should be reserved for patients with a pathological change in the oesophagus thought to be caused by gastro-oesophageal reflux and those with endoscopy negative GERD.

In this study, patients with either heartburn or acid regurgitation on more than six occasions during the previous year had gastro-oesophageal reflux symptoms (GORS). We also asked about heartburn which occurred when lying supine on more than six occasions and whether this woke patients from their sleep. Respondents had dyspepsia if they complained of upper abdominal pain or discomfort on more than six occasions during the previous year. We did not attempt to classify dyspepsia into subgroups, as dyspeptic symptom subgroups overlap to a great extent and are unreliable in predicting underlying pathology.6 Dysphagia was identified in those experiencing ‘difficulty in swallowing (food sticking in the throat)’ on more than six occasions in the previous year.

We defined irritable bowel syndrome as abdominal pain occurring on more than six occasions in the previous year, with three or more of the Manning criteria.15 As the presence of abdominal pain and two Manning criteria has been shown to be reasonably accurate in diagnosing irritable bowel syndrome, we chose three Manning criteria to increase specificity.16 We did not use the Rome criteria, as these were undergoing revision at the time of survey,17 but it has been shown that both sets of criteria overlap to a great extent.18 Socio-economic status was assigned to each patient using the software program COMPUTER ASSISTED STANDARD OCCUPATION CODING in nonautomatic format.19 Each patient was asked to give their occupation and the occupation of their partner, and was assigned to one of nine major occupational groups according to the Standard Occupational Classification (SOC);20 this hierarchical classification aggregates occupations with reference to the similarity of qualifications, training and skills. Housewives, students and unemployed patients were classified by their partner’s occupation where possible. Those to whom a classification could not be ascribed were not included in the analysis when occupational classification was a variable.

Statistical methods

Data were double entered on a computer and analysed using SPSS software. Prevalences were derived with 95% confidence intervals (95% CI). This was a cross-sectional study with associations analysed by χ2 test, Odds Ratios with 95% confidence limits and stratified analysis by Mantel–Haenszel odds ratio.21 Forced entry and step-wise forward logistic regression were performed. Prevalences were calculated for the study population and by direct age and sex standardization for the 1997 UK population. The sample size was dictated by a power study carried out to answer a different survey question.7

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. Bibliography

Of the 4476 patients selected, 38 were excluded at their general practitioner’s request due to concurrent illness, and six people died during the study. The postal service identified 224 (5%) patients as no longer resident at the recorded address and returned their letters. We received 3179 questionnaires (71.7% response). Nonresponders were more likely to be male (P < 0.01) with a mean age of 38 years and to be younger than responders, mean age 42 (P < 0.001). Compared to national UK figures,22 responders are slightly under-representative of males and females aged 20–29 years, with respective sample prevalences expressed as a percentage of responders aged 20–64 years of 20.5% (95% CI: 15.8–25.2) and 21.1% (95% CI: 16.8–25.4). Males and females aged 45–59 years were over-represented with respective prevalences of 34.6% (95% CI: 30.3–39.9) and 33.6% (95% CI: 29.6–37.6). Ten inadequately completed questionnaires were excluded. Data from 3169 questionnaires were double entered on a computer, representing 1451 men and 1718 women.

In Teesside, 28.7% (28.0–29.4) of adults aged 20–69 years experienced gastro-oesophageal reflux symptoms during the previous year; 29.3% (27.0–31.6) of men and 28.2% (26.1–30.3) of women. The prevalence of GORS was relatively constant across each 10-year age band (Table 1) (χ2 for trend; P > 0.1). Most people with GORS (66.7%) experienced both acid regurgitation and heartburn. There was an association between GORS and socio-economic status (χ2=23.457, 8df, P < 0.005) the condition being less common among the affluent (Figure 1).

Table 1.  Percentage prevalence of gastro-oesophageal reflux symptoms and consultation behaviour for each age group and gender with the prevalence for 20–69-year-olds standardized to the 1997 UK populationThumbnail image of
image

Figure 1. Prevalence of gastro-oesophageal reflux symptoms by socio-economic group.

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Of those respondents with GORS, 24.9% (23.7–26.1) had consulted their GP about their symptoms during the previous year, amounting to 7.2% (6.5–7.9) of adults aged 20–69 years in Teesside. Consultation rates did not differ between men and women (Table 1), χ2, P > 0.7, nor were they influenced by socio-economic status (χ2, P > 0.7), but they did increase with the age of the patient (Table 1), χ2 for trend; P < 0.001.

Many patients with gastro-oesophageal reflux symptoms were woken from their sleep by their heartburn (28.8%), experienced heartburn while supine (45.3%), or had dysphagia (10%). In all, 48.5% of those who had consulted their general practitioner about GORS reported at least one of these symptoms.

Dyspepsia was reported by 17.1% (16.4–17.8) of the population, with a similar prevalence for men 16.6% (14.7–18.5) and women 17.6% (15.8–19.4). Gastro-oesophageal reflux symptoms and dyspepsia commonly occurred together, odds ratio=7.19 (5.85–8.86), χ2P < 0.001, an association which was unaffected by gender (Mantel–Haenszel odds ratio=7.22 (5.90–8.82), χ2P > 0.5.

The more upper abdominal symptoms (dyspepsia, nausea, vomiting, dysphagia) reported by a patient with GORS, the greater the likelihood that a patient will have consulted their General Practitioner regarding gastro-oesophageal reflux symptoms during the previous year (Table 2), χ2 for trend P < 0.001.

Table 2.  Number of other upper abdominal symptoms experienced by patients with gastro-oesophageal reflux symptoms and their relationship to consultation behaviourThumbnail image of

We performed a simple forced entry logistic regression to determine the relative importance of epigastric pain/discomfort, epigastric fullness, nausea, vomiting, dysphagia and irritable bowel syndrome with regard to consultation among patients with gastro-oesophageal reflux symptoms. Epigastric pain/discomfort was the most important variable, followed by nausea (Table 3). The other covariates were not independently predictive of consultation when they were entered into a forward stepwise logistic regression; upper abdominal pain or discomfort (Beta −1.29, significance < 0.001, residual −0.24), nausea (Beta −0.57, significance < 0.001, residual −0.10).

Table 3.  Logistic regression of upper abdominal symptoms on consultation for gastro-oesophageal refluxThumbnail image of

Although irritable bowel syndrome was more strongly associated with dyspepsia; OR=4.91 (3.97–6.09), the association between irritable bowel syndrome and GORS still held, although weakened, when the sample was stratified for the presence of dyspepsia, Mantel–Haenszel odds ratio=3.67 (2.94–4.58). Among patients with gastro-oesophageal reflux symptoms, irritable bowel syndrome did not influence consultation behaviour; odds ratio=1.24 (0.88–1.75).

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. Bibliography

The methodology used in this study was robust. General practice registers in the UK offer the best means of sampling the general population.23 As access to primary care is universal and free at the point of contact, registration with a general practitioner is almost complete for the population. The overall questionnaire response was good at 71.7%, but younger age and male gender were indicators of lower response. Nonresponders were not followed up further as the research ethics committee had required the return of the questionnaire to indicate consent to participate.

We have shown that the prevalence of gastro-oesophageal reflux symptoms is related to socio-economic status. Interestingly, socio-economic factors do not influence consultation behaviour regarding GORS, at least in the UK primary health care system. It would be helpful to return to this question with a more detailed study of the level of education of the subjects, as that may be a more direct influence on consultation behaviour. In addition, it would be interesting to conduct a similar study in a country where the health care system is configured differently, and in order to allow future comparisons we have standardized our prevalence and consultation data to a reference population (the 1997 UK general population).

Gastro-oesophageal reflux symptoms frequently coexist with other upper gastrointestinal symptoms and with irritable bowel syndrome and we have explored this association in greater detail in a different paper.7 Interestingly, although it has been claimed that patients with irritable bowel syndrome may exhibit excessive help-seeking behaviour,24, 25 we have shown that the coexistence of irritable bowel syndrome did not independently influence consultation behaviour regarding gastro-oesophageal reflux symptoms. Our results do not support the view that patients with irritable bowel syndrome are hypervigilant or consult when others would not.

In keeping with the results of studies on dyspepsia and irritable bowel syndrome,8[9]–10 we found that some symptoms, in particular epigastric pain or discomfort and nausea, are more important than others with regard to consultation behaviour and also that consultation behaviour increases with the number of associated symptoms and with the age of the patient. A Singaporean study has shown that patients with heartburn who consult a doctor are more likely to have nocturnal symptoms and will grade their heartburn as being more severe than that experienced by nonconsulters.26 We did not quantify the severity of heartburn or acid regurgitation, as a patient’s subjective response to their symptoms can be influenced by many factors such as symptom-focusing and this confuses exactly what is being measured. There is little evidence that more severe symptoms indicate a more extreme pathology, and symptom severity may be strongly influenced by a patient’s anxiety about their symptoms.

There are limits to the type of data which can be acquired by postal questionnaire, but this paper has highlighted some of the factors which influence consultation behaviour among patients with gastro-oesophageal reflux symptoms. It would be helpful to explore these findings further by interviewing patients about their illness cognitions and to investigate how symptom burden (number and nature of associated symptoms) and age conspire to result in consultation.

Acknowledgements

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. Bibliography

We thank the patients, doctors and staff of Eaglescliffe Medical Practice, Thornaby and Ingleby Barwick Medical Group, The Skelton Group Practice, Tennant Streeet Surgery, Moorland’s Surgery and Sedgefield Group Practice, also Prof. APS Hungin, Prof. P Kelly, Hilda and Rory O’Flanagan, Dr Kevin Jones and Clare Tait. This study was assisted by the Northern Research Network (NoReN).

This study was supported in part by grants from the Scientific Foundation Board of the Royal College of General Practitioners, the Research and Development Directorate of the Northern Regional Health Authority, the Cleveland Primary Care Research Panel and the Primary Care Society for Gastroenterology. Tom Kennedy held a Regional Research Training Fellowship during part of this study and was attached to the Department of Primary Health Care, University of Newcastle upon Tyne. Please send requests for a copy of the study questionnaire to the authors.

Bibliography

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. SUBJECTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. Bibliography
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