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Is there a correlation between scoring of gastroesophageal reflux disease and the prevalence of symptoms?
R.M. Bremner, S.F. Hoeft, T.R. DeMeester (Los Angeles),
M. Costantini (Padova)
An attempt at scoring the severity of gastroesophageal reflux disease (GERD) in terms of anatomical, functional and endoscopic abnormalities was first made by Feussner et al. in 1991 [1]. This scoring system was developed to enable comparison of results of antireflux surgery performed at different centers. To investigate whether the severity of symptoms correlates with the severity of the disease, this classification system was applied to patients with GERD presenting to a surgical esophageal clinic at the University of Southern California.
Methods
One hundred and sixty patients with GERD confirmed by pH monitoring were studied. Patients completed a detailed questionnaire regarding symptoms which were scored according to Table I. They underwent endoscopy, videoesophagography, esophageal motility and 24-hour pH monitoring. The score was based on three components of the disease, namely endoscopic anatomy, functional abnormalities (esophageal acid exposure), and pathologic mucosal injury. The final AFP score was a sum of the three components as seen in Table II. Patients were categorized into three groups according to the total AFP score representing mild (score 0-2), moderate (3-5), and severe disease (score 7-9). The prevalence of the symptoms in patients with GERD was related to these categories. Further comparison was made with the severity of symptoms and the AFP categories. The Fisher exact test was used to compare prevalence data and the Kruskall-Wallis test was used to compare scores for the different groups.
Results
The prevalence of symptoms were most common in patients with a score of 0-2 (Figure 1). More patients with mild disease experienced heartburn than those with severe disease although patients with severe disease had more severe symptoms (Figure 2). The symptom of dysphagia was most severe in patients with severe disease (high AFP score).
Discussion
Symptoms are an unreliable guide to the presence of GERD. We previously showed that only 60% of patients presenting with typical symptoms suggestive of GERD have objective evidence of increased esophageal acid exposure [2]. Similarly, the results of antireflux surgery do not appear to be related to the severity of disease when using this scoring system [1]. In the present study, the prevalence of symptoms did not increase with the severity of disease as assessed by the AFP score. Rather, there was a greater prevalence of symptoms in those with mild disease. This indicates that patients with mild disease have an increased sensitivity to esophageal acid exposure. This increased sensitivity may serve a protective role. That is, the low threshold for the symptom of heartburn that accompanies esophageal acid exposure results in increased salivation and swallowing which clears the esophagus rapidly [3]. We have previously shown that the normal response to naturally occurring reflux episodes is to increase the swallowing frequency [4]. This acts to quickly clear the esophagus of refluxed acid, diminishing the overall esophageal exposure to gastric juice and the risk of mucosal injury.
Figure 1. The relationship of the prevalence of symptoms to the severity of disease in patients with GERD.
* p < 0.05. (AFP 0-2 = mild disease, AFP 3-5 = moderate disease, AFP 6-9 = severe disease).
Figure 2. The relationship of the severity of symptoms to the severity of disease in patients with GERD.
* p < 0.05 (AFP 0-2 = mild disease, AFP 3-5 = moderate disease, AFP 6-9 = severe disease).
Some patients, however, may have a decreased sensitivity to esophageal acid exposure. The decreased sensitivity is associated with a poor swallow response to refluxed acid, with the consequence of a prolonged acid exposure and a greater threat of injury. We have recently shown that patients with end-stage reflux disease and Barrett's esophagus have a compromised swallow response to reflux. This may be secondary to destruction of mucosal nociceptors by the metaplastic process, or to a protective role of the columnar cells to influx of hydrogen ions. These findings of a decreased sensitivity are in keeping with the reported decreased subjective pyrosis in patients with Barrett's esophagus [5-7].
Although patients with severe disease had a lower prevalence of symptoms, the overall severity of symptoms was greater. This suggests that although some patients have relatively few symptoms, symptoms are generally more severe in this subgroup of patients. The prevalence of dysphagia was notably greater in patients with severe disease reflecting the stenosis and motility abnormalities associated with severe disease.
References
1. Feussner H, Petri A, et al. The modified AFT score: an attempt to make the results of anti-reflux surgery comparable. Br J Surg 1991;78:942-946.
2. Costantini M, Crookes PF, Bremner RM, et al. Value of physiologic assessment of foregut symptoms in a surgical practice. Surgery 1993;114:780-6; discussion 786-7.
3. Helm JF, Dodds WJ, Hogan WJ. Salivary responses to esophageal acid in normal subjects and patients with reflux esophagitis. Gastroenterology 1982;93:1393-1397.
4. Bremner RM, Hoeft SF, Costantini M, Crookes PF, Bremner CG, DeMeester TR. Pharyngeal swallowing: The major factor in clearance of esophageal reflux episodes. Ann Surg 1993;218:364-370.
5. Katzka DA, Castell DO. Successful elimination of reflux symptoms does not insure adequate control of acid reflux in patients with Barrett's esophagus. Am J Gastroenterol 1994;89:989-991.
6. Iascone C, DeMeester TR, Little AG, Skinner DB. Barrett's esophagus. Functional assessment, proposed pathogenesis, and surgical therapy. Arch Surg 1983;118:543-549.
7. Johnson DA, Winters C, Spurling TJ, Chobanian SJ, Cattau EL Jr. Esophageal acid sensitivity in Barrett's esophagus. J Clin Gastroenterol 1987;9:23-27.
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