Gastroesophageal reflux disease in adults : the Kalixanda study: a population-based endoscopic study

Abstract: Gastroesophageal reflux disease (GERD) is a common burden on health care resources in the Western world and deteriorates the health-related quality of life of those affected, but its manifestations in the general population are as yet unclear. Also, the impact of gastroesophageal reflux symptoms (GERS) on health-related quality of life in the general population is poorly characterized. Barrett's esophagus (BE), a complication of GERD is associated with esophageal adenocarcinoma, the incidence of which has been increasing dramatically in the Western world during the last decades. Eosinophilic esophagitis (EE) is thought to be a very rare inflammatory condition in adults (estimated prevalence 0.2-3 in 10,000) but patient studies suggest its incidence may be increasing. Furthermore, its association with GERD is uncertain. However, the prevalence of these conditions in the general population remains unknown, as endoscopy, including biopsy, is required in a random population sample to acquire this knowledge. The aims of this study were to estimate the prevalence of and to identify risk factors for GERS, erosive esophagitis, BE and EE, and to identify the frequency of troublesome reflux symptoms associated with impaired health-related quality of life (HRQoL) in the adult population of two Swedish municipalities. A random sample (n=3,000) of the adult population (20-81 years of age) of two Swedish municipalities (n=21,610) was surveyed using a validated postal questionnaire assessing gastrointestinal symptoms. The response rate was 74%. A representative sub-sample (n=1,000, mean age 54 years, 49% men) of the responders was subsequently invited, in random order, for esophagogastroduodenoscopy with biopsy, evaluation of GERS, HRQoL, risk factors, and tests for Helicobacter pylori (H. pylori). Troublesome GERS, at any time during the last three months, were reported by 40% and at least weekly by 20%, erosive esophagitis was found in 16%, BE in 1.6% and EE in 0.4% of the population. Of those with GERS, 25 % had erosive esophagitis while 37% of those with erosive esophagitis reported no GERS. Those with a current H. pylori infection had a statistically significantly increased risk for GERS without esophagitis (OR = 1.58, 95% CI 1. 14-2.19). Hiatus hernia and obesity were significant risk factors for GERS and/or erosive esophagitis as were alcohol and smoking for BE and dysphagia for EE. Most aspects of health-related quality of life were impaired in individuals with daily or weekly GERS. However, the presence or absence of esophagitis did not predict the impairment of HRQoL. In Conclusion: GERS and erosive esophagitis were highly prevalent in the Swedish adult population. Furthermore, asymptomatic erosive esophagitis was present in 6% of the adult population. BE was found in 1.6% and EE was more common than has been estimated earlier. Troublesome reflux symptoms at least weekly may identify gastroesophageal reflux disease.