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Gastroesophageal Reflux Disease (GERD) and Irritable Bowel Syndrome (IBS)-Is It One Disease or an Overlap of Two Disorders?

Authors:

Abstract

Up to 79% of IBS patients report gastroesophageal reflux disease (GERD) symptoms, and up to 71% of GERD patients report irritable bowel syndrome (IBS) symptoms. There are two principal hypotheses for the common presence of IBS symptoms in GERD patients. The first theory suggests that GERD and IBS overlap in a significant number of patients. The second theory suggests that IBS-like symptoms are part of the spectrum of GERD manifestation. The first theory is supported by genetic studies and similarities in gastrointestinal sensory-motor abnormalities potentially due to general gastrointestinal disorder of smooth muscle or sensory afferents. The other theory is primarily supported by studies demonstrating improvement of IBS-like symptoms in GERD patients receiving anti-reflux treatment. The close relationship between GERD and IBS could be explained by either GERD affecting different levels of the GI tract or a high overlap rate between GERD and IBS due to similar underlying GI dysfunction.
REVIEW
Gastroesophageal Reflux Disease (GERD) and Irritable Bowel
Syndrome (IBS)—Is It One Disease or an Overlap of Two
Disorders?
Anita Gasiorowska ÆChoo Hean Poh Æ
Ronnie Fass
Received: 27 August 2008 / Accepted: 17 October 2008
ÓSpringer Science+Business Media, LLC 2008
Abstract Up to 79% of IBS patients report gastroesoph-
ageal reflux disease (GERD) symptoms, and up to 71% of
GERD patients report irritable bowel syndrome (IBS)
symptoms. There are two principal hypotheses for the
common presence of IBS symptoms in GERD patients. The
first theory suggests that GERD and IBS overlap in a sig-
nificant number of patients. The second theory suggests that
IBS-like symptoms are part of the spectrum of GERD
manifestation. The first theory is supported by genetic
studies and similarities in gastrointestinal sensory-motor
abnormalities potentially due to general gastrointestinal
disorder of smooth muscle or sensory afferents. The other
theory is primarily supported by studies demonstrating
improvement of IBS-like symptoms in GERD patients
receiving anti-reflux treatment. The close relationship
between GERD and IBS could be explained by either
GERD affecting different levels of the GI tract or a high
overlap rate between GERD and IBS due to similar
underlying GI dysfunction.
Keywords Gastroesophageal reflux disease (GERD)
Irritable bowel syndrome (IBS) Pathophysiologic
mechanism Symptom assessment Visceral hyperalgesia
Introduction
Gastroesophageal reflux disease (GERD) and irritable
bowel syndrome (IBS) are very common in the general
population. The prevalence of IBS in North America
ranges from 3–20%, with most prevalence estimates
ranging from 10–15% [1]. Thus far, there is limited
information about the epidemiology of IBS in specific
patient populations such as the elderly and ethnic groups
other than Caucasians. IBS has a female predominance,
and it peaks from the ages 20 to 45 years [13]. IBS
accounts for 25–50% of referrals to gastroenterologists
[4].
GERD is also very common. Population-based studies
demonstrated that 32–57% of the general adult population
in Western countries demonstrated typical GERD-related
symptoms within the last year. The community prevalence
of weekly heartburn ranges from 10–21% [5]. Both GERD
and IBS are less common in Asia than in Western popu-
lations. The reported population prevalence of GERD in
East Asia ranges from 3 to 7% for weekly symptoms of
heartburn and/or acid regurgitation [6,7].
Most epidemiologic studies show a significant overlap
between the different functional disorders of the digestive
tract in the general population [811]. Consequently, the
presence of IBS-related symptoms in patients with GERD
may suggest an overlap between two distinct disorders that
share a similar pathophysiologic mechanism, such as vis-
ceral hypersensitivity or gastrointestinal (GI) dysmotility
[2,12]. Alternatively, lower abdominal symptoms may be
part of the overall clinical presentation of GERD, sug-
gesting that the underlying mechanism for GERD may lead
to upper as well as lower gut symptoms.
The classic symptoms of GERD are heartburn, acid
regurgitation, dysphagia, and belching. Extra-esophageal
and atypical symptoms of GERD may include wheezing,
chronic cough, hoarseness, chest pain, and sleep deprivation.
However, a variety of other symptoms have been seen in
GERD patients. Some appear to originate from other levels
A. Gasiorowska C. H. Poh R. Fass (&)
Neuroenteric Clinical Research Group, Southern Arizona VA
Health Care System, University of Arizona, GI Section
(1-111G-1), 601 S. 6th Avenue, Tucson, AZ 85723-0001, USA
e-mail: Ronnie.Fass@va.gov
123
Dig Dis Sci
DOI 10.1007/s10620-008-0594-2
of the gastrointestinal tract. These include flatulence,
abdominal discomfort, and alteration in bowel movement
[13].
Irritable bowel syndrome is a chronic, relapsing, gas-
trointestinal disorder commonly presenting with abdominal
pain, bloating, and alteration in bowel movement. Although
IBS is not known to lead to serious disease or excess
mortality, it has a significant impact on patients’ quality of
life and social functioning. The clinical presentation of IBS
is quite diverse. Many of the patients report a wide range of
colonic and extra-colonic symptoms [2,14,15].
This article reviews two principal hypotheses about the
potential relationship between GERD- and IBS-related
symptoms. The first theory suggests that GERD and IBS
overlap in a significant number of patients, and the second
theory proposes that IBS-like symptoms are part of the
spectrum of GERD presentation.
The Prevalence of IBS in GERD
Many epidemiologic studies have demonstrated that
patients with GERD frequently report IBS-related symp-
toms (see Table 1).
Kennedy et al. [16] in a population-based study,
explored the relationship between IBS, GERD, and bron-
chial hyper-responsiveness (BHR) using a symptom
questionnaire. The 12-month prevalence of IBS-related
symptoms for men and women was 10.5% and 22.9%,
respectively. The 12-month prevalence of GERD-related
symptoms was 29.4% and 28.2%, respectively. Of the 910
subjects who were found to have GERD, 19% reported IBS-
like symptoms and of the 546 IBS patients, 32% were found
to have GERD. The authors revealed that IBS and GERD
symptoms occur more frequently together than expected
and that the conditions are associated with each other.
De Vries et al. [17] studied GERD patients seeking care
and demonstrated that IBS is more prevalent in GERD
patients than in the general population (35% vs. 0.6–6%).
In another study, Pimentel et al. [12] determined the
prevalence of IBS, as defined by Rome I criteria, in sub-
jects with GERD as compared with non-GERD controls.
Of the 35 GERD subjects, 71% were positive for IBS,
whereas only 35% of the 49 non-GERD control subjects
had IBS. The study demonstrated that the prevalence of
IBS was significantly more common in the GERD group
than in the non-GERD group. Additionally, in this study, a
subset of GERD patients underwent 24-h esophageal pH
monitoring, and 64% of those with IBS had abnormal pH
test results.
Zimmerman [18] evaluated the prevalence of IBS in non-
erosive reflux disease (NERD) patients. In this study, half of
the NERD patients met the diagnostic criteria for IBS as
defined by the Rome I criteria. The authors also reported
that the extent of esophageal acid exposure, as measured by
24-h esophageal pH monitoring, was unrelated to symptoms
of irritable bowel syndrome. Interestingly, Fass et al. [19],
who summarized the results of 14 clinical therapeutic trials,
demonstrated that lower abdominal complaints were pres-
ent in 60% of both erosive esophagitis and NERD patients.
In a large epidemiologic study that evaluated 3,318 adult
patients from general practice clinics, 72% of the GERD
patients were found to have functional bowel disorders
[20]. Among these patients, 27% had symptoms suggestive
of IBS according to the Rome II criteria, 16% functional
dyspepsia, and 57% had varied functional bowel symp-
toms. The most commonly reported symptoms were gas
and flatulence (81%), transit disorders (62%), and
abdominal distension (58%).
Recently, Nastaskin et al. [21] conducted a systematic
review of the literature evaluating the prevalence of IBS and
GERD in the general population and the rate of overlapping
symptoms between the 2 disorders. The average prevalence
of GERD was 19.4% and IBS 12.1%. Several of the included
studies determined that the GERD maximum mean preva-
lence in patients already diagnosed with IBS was 39.3%.
There was a significant variability in the GERD prevalence,
ranging from 17 to 80%. The likely reason for the wide
range of GERD prevalence in IBS patients appeared to
depend on the method for diagnosing GERD. The maximum
mean prevalence of IBS in subjects with already-known
GERD was 48.8%. The prevalence of IBS in GERD patients
also had a wide range (31–71%) and was clearly dependent
on the criteria used to diagnose IBS (Manning, Rome I, or
Table 1 The prevalence of IBS
in GERD
a
The maximum mean
prevalence
Sample size Prevalence of IBS (%) IBS definition
Kennedy et al. [16] 910 19 Modified Manning
De Vries et al. [17] 263 35 Rome II
Pimentel et al. [12] 35 71 Rome I
Zimmerman [18] 256 50 Rome I
Fass et al. [19] 6,810 60 ReQuest
Gillemot et al. [20] 3,318 27 Rome II
Nataskin et al. [21] Systematic review 48.8
a
Dig Dis Sci
123
Rome II). This systematic review demonstrated that IBS and
GERD appear to overlap to a degree that is greater than their
individual prevalence in the community. The authors con-
cluded that the prevalence of IBS in the non-GERD
community was only 5.1%. These data suggested strong
overlap between GERD and IBS and postulated that IBS
appears to be relatively uncommon in the absence of GERD.
The Prevalence of GERD in IBS
Several studies examining extra-colonic features of IBS
clearly demonstrated that these patients frequently report
typical GERD-related symptoms (see Table 2). The rela-
tionship between GERD and functional GIdisorders has been
primarily studied in IBS patients. The prevalence of GERD is
higher in IBS patients than what has been observed in the
general population and varies from 40 to 79% [2,16,22].
Smart et al. [22] assessed the nature and frequency of
gastroesophageal reflux symptoms in 25 patients with IBS.
Symptoms like heartburn, acid regurgitation, and dyspha-
gia were significantly more common in the IBS patients
than in an age- and sex-matched control group. Esophageal
symptoms were present daily in 28% and once a week in
52% of the IBS patients. Ambulatory 24-h esophageal pH
monitoring showed abnormal esophageal acid exposure in
50% of the IBS patients. This study also demonstrated that
significant reduction in lower esophageal sphincter pres-
sure accompanies irritable bowel syndrome, but no
disturbances of esophageal body motor activity could be
found. The results of this study provided clear confirmation
that esophageal symptoms are significantly more common
in IBS patients than in the general population [22].
In contrast, some authors showed that heartburn, which
is a common complaint in IBS, was reported by nearly a
third of the patients but is observed as frequently as in the
control group [23].
Talley et al. [8] enrolled consecutive patients with IBS,
who were classified according to their leading complaint
(constipation or diarrhea predominant). Overlap with
GERD-related symptoms was observed in 32.9% of the
IBS-constipation predominant and 40.9% of the IBS-diar-
rhea predominant patients. In another study, reflux
symptoms were found to be significantly higher in IBS
patients as compared with patients with inflammatory
bowel disease [15].
Recently, Cheung et al. [6] examined the association
between GERD and IBS in a Chinese population in Hong
Kong. The prevalence of IBS, according to Rome I criteria,
and GERD were 4% and 5%, respectively. These findings
were consistent with other studies in this region. Thirteen
percent of the subjects with GERD and 11% with IBS
suffered from both GERD and IBS. Gender did not have a
significant effect on the chances of having IBS or GERD,
but overlap of the two disorders occurred predominantly in
male subjects. In this study, younger subjects were also
more prone to having both IBS and GERD. The prevalence
of IBS has been shown to be higher in younger subjects in
the Chinese population as it was documented in Caucasians
and gradually decreases with age. In contrast, the preva-
lence of GERD increases with age. However, Agreus et al.
[10] found a different pattern in a sample of a Swedish
population. Over 7 years, they described the prevalence of
gastroesophageal reflux symptoms as stable, whereas IBS
increased over time independent of aging of the study
sample.
Hypothesis 1. IBS and GERD: Two Different Disorders
with a Common Pathophysiology
The first hypothesis proposes that IBS and GERD are two
distinct disorders that share a common pathophysiologic
process [24,25]. Consequently, each disorder requires
specific treatment, and one therapeutic intervention direc-
ted towards GERD or IBS will have limited effect on the
symptoms of the other disorder.
Recent studies in twins have suggested that there is
probably a distinct genetic contribution to the development
of IBS and GERD. Genetic modeling confirmed the inde-
pendent additive genetic effects in GERD and IBS [26].
Estimates for genetic variance were 22% for IBS and 13%
for GERD.
Some authors have postulated that IBS patients may
have motility disturbances similar to those seen in GERD
in the upper GI tract. Ineffective esophageal motility and
Table 2 The prevalence of
GERD in IBS
a
The maximum mean
prevalence
Sample size Prevalence of GERD (%) IBS definition
Smart et al. [22] 25 52 Manning
Whorwell et al. [23] 100 33 Authors determined
Talley et al. [8] 76 (constipation predominant) 32.9 Rome II
45 (diarrhea predominant) 40.9 Rome II
Cheung et al. [6] 79 11 Rome I
Nataskin et al. [21] Systematic review 39.3
a
Dig Dis Sci
123
impaired primary peristalsis have been suggested to be
contributing factors to the pathophysiology of GERD [27].
In IBS, alteration in colonic transit and small-bowel
motility are demonstrable. Thus, some authors speculated
that a general smooth-muscle dysfunction of the GI tract
may explain the close relationship between IBS and GERD
[28]. Smart et al. [22] performed esophageal manometry in
IBS subjects and demonstrated a significant reduction in
lower esophageal sphincter basal pressure, which could
explain GERD-related symptoms in these patients.
Several other studies suggested that GERD and IBS
overlap because of general visceral hyperalgesia [6,9,29,
30]. Visceral hyperalgesia, particularly rectal hyperalgesia,
has long been associated with IBS. Trimble et al. [31]
showed that IBS subjects had lower rectal sensory thresholds
for pain as compared with healthy controls and concomi-
tantly exhibited significantly lower sensory thresholds for
both perception and discomfort in the esophagus.
Another study by Costantini et al. [29] demonstrated
that IBS subjects have a significantly lower threshold for
esophageal symptoms during esophageal provocative test-
ing (bethanechol subcutaneously and balloon distension
test), but there was no difference in esophageal motility or
lower esophageal sphincter basal pressure when compared
with controls. The authors hypothesized that IBS subjects
do not have pathologic reflux but are rather more sensitive
to physiologic reflux.
Proton pump inhibitors (PPIs) provide the most effective
form of medical therapy for patients with GERD. Despite
this fact, it has been estimated that between 10 and 40% of
patients with GERD fail to respond or respond only partially
to standard-dose proton pump inhibitors [32]. Patients with
typical GERD symptoms including heartburn and regurgi-
tation are more likely to respond to PPI therapy than those
with extra-esophageal symptoms such asthma, hoarseness,
or cough. Additionally, patients with NERD are less likely
to respond to PPI therapy than those with erosive esopha-
gitis. The predictors of response to PPI therapy have only
been partially characterized. There are several putative
mechanisms for refractory GERD including weakly acidic
reflux, duodeno-gastroesophageal reflux, delayed gastric
emptying, psychologic comorbidity and concomitant func-
tional bowel disorders [33]. GERD patients who also had
IBS perceived their symptoms as more severe and tended
not to achieve the same degree of improvement in GERD
symptoms while treated with PPI as those without IBS.
Rubenstein et al. [30] found that esophageal hypersen-
sitivity is associated with features of psychiatric disorders
and IBS, which might partly explain the etiology of
heartburn symptoms that are refractory to PPI therapy. This
study suggested that visceral afferent hypersensitivity is a
general gastrointestinal phenomenon that is not limited to a
particular segment of the gastrointestinal tract.
Recently, Zimmerman and Hershcovici [9] estimated
the presence of IBS features in NERD patients. The authors
demonstrated that bowel symptoms were associated with
reflux symptom scores but not with esophageal acid
exposure. In this study, the presence of IBS features in a
large proportion of the NERD patients may further suggest
that visceral hypersensitivity could aggravate symptoms
resulting from the exposure of the esophageal mucosa to
acid. The findings of this study are in accordance with
previous observations about the association between vis-
ceral hypersensitivity and GERD.
Jung et al. [34] conducted a population-based cross-
sectional survey to determine the prevalence and risk fac-
tors for the overlap of GERD and IBS (as defined by Rome
III criteria). This study confirmed previous observations
that IBS and GERD occurred more commonly together
than expected by chance. The authors also revealed that
higher body mass index (BMI) is a predictor for increasing
IBS and GERD overlap. The authors identified specific
subgroups of people with both IBS and GERD. Self-
reported insomnia and frequent abdominal pain were risk
factors for IBS-GERD overlap as compared with IBS alone
and GERD alone.
Nojkov et al. [35] evaluated the influence of comorbid
IBS and psychologic distress on the response to PPI ther-
apy of patients with GERD. Patients with IBS reported
more severe GERD symptoms at baseline but experienced
a similar magnitude of improvement in GERD symptoms
as compared to patients without IBS while on PPI therapy.
The authors found that comorbid IBS and psychologic
distress, but not the presence or absence of erosive
esophagitis, influenced symptom perception and disease-
specific quality of life before and after PPI therapy.
Hypothesis 2. IBS-Like Symptoms Are Part of GERD
Manifestations
Some studies suggest that IBS-like symptoms are part of
the symptom spectrum of GERD and can represent an
extra-esophageal, but GI-related, manifestation of GERD
[20,36]. Evidence to support this hypothesis originates
from therapeutic trials in GERD patients. In these studies,
lower abdominal symptoms, suggestive of IBS, signifi-
cantly improved after medical or surgical anti-reflux
treatment. In one study, up to 24% of patients with GERD
reported a significant or complete improvement of their
bowel symptoms following acid suppressive therapy,
mainly proton pump inhibitors [20]. In another study, 30%
of GERD patients who underwent laparoscopic fundopli-
cation were found to have IBS using Rome II criteria and,
of those, 81% reported significant improvement of their
IBS symptoms postoperatively [36].
Dig Dis Sci
123
Kountouras et al. [37] demonstrated that 41% of
patients with GERD and IBS reported complete resolution
of their IBS symptoms after receiving esomeprazole
20 mg daily for 3 months. However, the results of this
study should be interpreted cautiously because of lack of
a placebo arm.
The underlying pathophysiologic mechanism that
explains how gastroesophageal reflux can cause IBS-like
symptoms has yet to be elucidated. It is likely that the
recently growing interest in the full spectrum of GERD
symptoms, which includes atypical and extra-esophageal
manifestations as well as sleep abnormalities, has led to the
recognition that lower abdominal complaints may also be
encountered in patients with GERD.
Additional support for the concept that GERD is a more
systemic disorder than is currently accepted was provided
by the recently introduced GERD questionnaire, the
ReQuest (Nycomed; Constance, Germany). The developers
of the ReQuest incorporated lower GI complaints sugges-
tive of IBS into the questionnaire after demonstrating that
patients and physicians perceive that these symptoms are
part of the symptom spectrum of GERD [38]. Therapeutic
studies that used the ReQuest as an evaluative tool clearly
demonstrated a significant reduction in lower abdomen and
dyspepsia-like symptoms in response to proton pump
inhibitor (PPI) therapy. [3941].
Summary
Studies clearly demonstrate that GERD is prevalent in IBS
patients and vice versa. The reason for this close rela-
tionship between the two disorders remains unknown.
Presently, there are two leading hypotheses that attempt to
explain this relationship. The first suggests that IBS-like
symptoms are part of the spectrum of GERD manifesta-
tions. The other suggests that IBS and GERD are two
different disorders with a similar underlying pathophysi-
ology. Both hypotheses need to be further evaluated.
Acknowledgments The authors wish to acknowledge the grant
support from AstraZeneca, Eisai, TAP, and Vecta.
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... 66 This overlap is not simply explained by the fact that both of these gastrointestinal conditions are common in the general population; the overlap occurs more than expected by chance suggesting shared pathophysiology. 67 A meta-analysis confirmed that there is substantial overlap between IBS and GERD that exists beyond the probability of chance alone. 68 A nationwide study conducted in Sweden (n = 49 706), reported that 11.2% had GERD and 10.5% had IBS based on a self-report questionnaire. ...
Article
Full-text available
Symptoms of irritable bowel syndrome (IBS) characteristically fluctuate over time. We aimed to review the natural history of IBS and IBS subgroups including bowel habit disturbances, and the overlap of IBS with other gastrointestinal disorders. The community incidence of IBS is approximately 67 per 1000 person years. The prevalence of IBS is stable over time because symptoms fluctuate and there is a portion who experience resolution of their GI symptoms similar in number to those developing new‐onset IBS. The proportion who report resolution of symptoms varies amongst population‐based studies from 17% to 55%. There is evidence of substantial movement between subtypes of IBS. For example in a clinical trial cohort, only one in four patients retained their baseline classification throughout the study periods, two in three moved between IBS‐C (constipation) and IBS‐M (mixed), while over half switched between IBS‐D (diarrhoea) and IBS‐M. The least stable group was IBS‐M. There are very limited data on drivers of bowel habit change in IBS. There are emerging evidence fluctuations in intestinal immune activity might account for symptom variability over time. It is of clinical importance to recognise the substantial overlap of IBS symptoms with other gastrointestinal syndromes including gastro‐oesophageal reflux disease. This is important to ensure the correct clinical diagnosis of IBS is made and patients are not over investigated. Knowledge of the natural history, stability of subgroups and overlap of IBS with other gastrointestinal conditions should be considered in therapeutic decision making.
... [22][23][24][25][26][27][28][29][30] According to the present study, IBS was frequently associated with other FGIDs: dyspepsia 6,31-34 and GERD. 7,30,35,36 The physiopathological signification of these overlap disorders remained discussed: IBS could be the clinical manifestation of several different disorders 37 or a possible shared disease process in a subset of patients. 38 The presence of multiple FGIDs is essential to detect because these patients, as in the present study, report a higher symptom severity 39 and a lack of stability. ...
Article
Background/Aims Functional gastrointestinal disorders (FGID) are frequently overlapped. The present study was designed to i) search the clinical differences between patients with single FGID and overlap FGIDs, ii) define the most common FGIDs associations to identify homogenous subgroups of patients. Patients and methods 3555 FGID outpatients filled out the Rome III adult diagnostic questionnaire, Bristol stool form, and four 10‐points Likert scale to report the severity of constipation, diarrhea, bloating, and abdominal pain. An unsupervised algorithm was used to estimate the number of groups directly from the data. A classification tree separated patients into different subgroups, according to FGIDs. Multinomial logistic regression was used to characterize the groups of patients with overlap disorders. Results Patients reported 3.3±1.9 FGIDs (range 1‐10, median=3); 736 reported only one FGID, while 2819 reported more than one FGID (3.8±1.7). Patients with single FGID had higher BMI (P<0.001) and never report irritable bowel syndrome, and rarely report fecal incontinence, anorectal pain (<1% for each disorder). The non‐supervised clustering of the 2819 patients with overlap FGIDs divided this population into 23 groups, including five groups associated with only one disorder (IBS‐Diarrhea, Dysphagia, Functional Constipation, Levator Ani Syndrome, and IBS‐Unspecified). Ten groups were related to two overlap disorders and eight groups to three or more disorders. Three disorders were not explicitly associated with a given group: IBS‐Mixed, Proctalgia Fugax, and Nonspecific anorectal pain. Conclusion FGID patients mostly report overlap disorders in a limited number of associations, each significantly associated with a few disorders.
... Большое количество популяционных исследований с использованием валидизированных опросников показало, что как ГЭРБ возникает у большой части больных с СРК [3,4,5], так и, наоборот, СРК часто отмечается у больных с ГЭРБ [6,7]. Некоторыми исследователями даже было высказано предположение о том, что СРК и ГЭРБ -это проявления одной болезни, а не сочетание двух разных заболеваний [8]. Несомненным, однако, являлся тот факт, что имеются общие патофизиологические механизмы, лежащие в основе формирования СРК и ГЭРБ [1,9,10]. ...
... Gasiorowska et al. reported the prevalence of IBS in GERD patients ranges from 11% to 52% using ROME I and II or Manning criteria. 25 Based on the Rome-III criteria, a population-based study revealed GERD-IBS overlap was 3.6%, 26 while our previous survey showed 10% of GERD individuals overlapping IBS. 9 Similarly, many studies have described a substantial overlap of GERD and dyspepsia. One study from a major referral center showed that 23% overlap of dyspepsia with GERD. ...
Article
Full-text available
Background: Patients with gastroesophageal reflux disease (GERD) frequently report symptoms like dyspepsia or/and irritable bowel syndrome (IBS). The aim of the study was to investigate the impact of symptom overlap on GERD symptom burden. We also investigate whether GERD overlapping dyspepsia or/and IBS would have different clinical and psychological features as compared with GERD alone. Methods: A total of 2752 subjects were screened from a health check-up population. We compared the clinical and psychological factors among subjects with GERD alone and with overlap of two or all three diseases. All participants underwent an evaluation with questionnaires including Reflux Disease Questionnaire score, Pittsburgh Sleep Quality Index, Taiwanese Depression Questionnaire, and State-Trait Anxiety Inventory before receiving endoscopic exam. Results: Among the GERD population, we identified 26 with IBS (GERD-IBS), 60 with dyspepsia (GERD-D), and 25 subjects with overlap of all three conditions (GERD-D-IBS). GERD-D and GERD-D-IBS subjects had more severe GERD symptoms as compared subjects with GERD alone (p < 0.001). Subjects with overlapping dyspepsia or/and IBS showed a significant increase in the severity of depression and poorer sleep quality than subjects with GERD alone. Notably, anxiety scores did not differ significantly between subjects with overlapping diseases and GERD alone. Conclusion: Our study demonstrates that disease overlap in GERD population is associated with greater symptom burden, higher depression and poorer sleep quality, but not with anxiety. This study highlights the importance of identifying overlapping conditions as a therapeutic strategy for better management of GERD.
... From a pathophysiological point of view, FGIDs are defined as gut-brain interaction disorders, characterized by visceral hypersensitivity, motility disturbance, altered mucosal and immune function, altered gut microbiota and altered central nervous system processing [41]. Notably, previous studies suggested that visceral hypersensitivity, minimal abnormalities of motility, and peripheral and central neural mechanisms could be considered the main common pathophysiological mechanisms among GERD and FGIDs [73,74]. ...
Article
Full-text available
Several studies have indicated an overlap between gastroesophageal reflux disease (GERD) and various functional gastrointestinal disorders (FGIDs). The overlapping conditions reported have mainly been functional dyspepsia (FD) and irritable bowel syndrome (IBS). The available literature is frequently based on symptomatic questionnaires or endoscopic procedures to diagnose GERD. Rarely, among patients with heartburn, pathophysiological evaluations have been considered to differentiate those with proven GERD from those without. Moreover, both GERD and IBS or FD showed enormous heterogeneity in terms of the criteria and diagnostic procedures used. The GERD-IBS overlap ranges from 3-79% in questionnaire-based studies and from 10-74% when GERD has been diagnosed endoscopically. The prevalence of functional dyspepsia (after normal upper endoscopy) is 12-15% and an overlap with GERD has been reported frequently. Only a few studies have considered a potential overlap between functional heartburn (FH) and IBS using a 24-h pH-metry or impedance-pH evaluation. Similar data has been reported for an overlap between FH and FD. Recently, a revision of the Rome criteria for esophageal FGIDs identified both FH and hypersensitive esophagus (HE) as potential functional esophageal disorders. This might increase the potential overlap between different FGIDs, with FH and HE rather than with GERD. The aim of the present review article was to appraise and discuss the current evidence supporting the possible concomitance of GERD with IBS and FD in the same patients and to evaluate how various GERD treatments could impact on the quality of life of these patients.
... 6 Due to the serious complications of GERD such as erosive esophagitis and esophageal cancer, which are associated with high morbidity and mortality, its follow-up and treatment seem very important. 38 Various studies have reported the accompaniment of GERD with other bowel movement disorders especially with irritable bowel syndrome, 23,[39][40][41][42] and thus treatment of associated disease that result in treatment of GERD is recommended. 27,[43][44][45] Perveen et al 25 reported the accompaniment of GERD with dyspepsia to be in the range of 22% to 25%, about 29% with constipation and about 40% with irritable bowel syndrome, but the relationship between constipation and GERD is yet to be investigated by researchers. ...
Article
Full-text available
Gastroesophageal reflux disease (GERD) is one of the most common gastrointestinal diseases. Several studies have been carried out on the treatment of symptoms associated with GERD. The present study aimed to compare the effect of Psyllium seed and oral omeprazole on GERD in patients with functional constipation. In this trial, 132 patients were divided into 2 groups. The impact of omeprazole and Psyllium seed on the treatment and recurrence of GERD was studied. Among the patients, the rate of response to treatment was 89.2% (n = 58) in the Psyllium seed group, while in omeprazole group, it was 94% (n = 63; P = .31). The recurrence rates of Psyllium seed and omeprazole groups were 24.1% (n =14) and 69.8% (n = 44), respectively (P < .001). The results showed that treatment of functional constipation by Psyllium seed in patients with GERD leads to improvement of GERD and its recurrences in comparison with omeprazole.
... Some other questionnaires are more comprehensive still. Dyspepsia, throat symptoms (sore throat, hoarseness, throat clearing, cough) and irritable bowel syndrome all occur more commonly in patients with GORD than would be predicted by chance [11][12][13][14] and failure of these symptoms to respond to a PPI obviously constitutes an ongoing symptom burden for the patient. ...
Article
Some patients with gastro-oesophageal reflux disease (GORD) experience symptoms despite proton pump inhibitor (PPI) treatment. In the early years of their availability, these drugs were thought to be a highly effective treatment for GORD and realisation that symptom relief was often incomplete came as a disappointment. This review considers the evolution of thinking with the aid of the Gartner hype cycle -A graphical depiction of the process of innovation, evolution and adoption of new technologies. Acknowledging that over-simplistic concepts of GORD have been largely responsible for inflated expectations of PPI therapy is an important step forward in establishing how patients with persistent symptoms, despite PPIs, should be assessed and treated.
Article
Objective To investigate the characteristics of patients with reflux diseases in the otorhinolaryngology-head and neck surgery clinics through the Reflux Symptom Scale-12 (RSS-12) and the Gastroesophageal Reflux Disease Questionnaire (GERD-Q). Methods All included patients completed the RSS-12 and GERD-Q scales and were considered to have LPR with an RSS-12 score >11 and GERD with a GERD-Q score >7. Data were analyzed according to genders (male and female) and age (18-40, 41-60, and >60 years). Results A total of 977 patients were included. the mean RSS-12 and GERD-Q score were 11.32±21.34 and 6.31±1.21, and the positive rate of LPR and GERD were 28.76% and 8.90%, respectively. Males had a higher positive rate of LPR and GERD than females, and there were more males with LPR who also had GERD. Among those with both LPR and GERD, males had significantly higher ear-nose-throat (ENT) symptom scores such as hoarseness and excess throat mucus than females. However, females had significantly higher scores of gastrointestinal (GI) symptoms, mainly indigestion and abdominal pain, and elder patients (>60 years) had higher scores of ENT, GI, respiratory symptoms, as well as the impact of symptoms on quality of life than the young patients (18-40, and 41-60 years). Conclusion Patients in the otorhinolaryngology-head and neck surgery clinics have different reflux characteristics by gender and age in the Chinese population. Males had more severe ENT-related symptoms of distress, while females had more complaints of GI symptoms. Older patients had higher scores for ENT, GI and respiratory symptoms.
Article
The review presents literature data concerning the rate and clinical features in cases of the gastroesоphageal refl ux disease (GERD) and irritable bowel syndrome (IBS )overlapping. The mean rate of GERD and IBS overlapping is 36–48 .8%, but in individual articles varies from 8–11% to 71–79%. A signifi cant variation in the rate is explained by diff erent approaches to the diagnosis of GERD and IBS in various studies (use of questionnaires, endoscopic examination, esophageal pH-impedancemetry). The high rate of GERD and IBS overlapping is related to the common pathogenetic mechanisms of both diseases (disorders оf gastrointestinal motility, visceral hypersensitivity). The features of the clinical picture and treatment in cases of GERD and IBS overlapping are studied insuffi ciently and require further research.
Article
Full-text available
Symptomatic assessment and oesophageal investigations were done in 25 consecutive patients with the irritable bowel syndrome attending a gastroenterological clinic. Symptoms of gastro-oesophageal reflux, dysphagia, and a globus sensation were significantly commoner than in a control group of fracture clinic patients. Ambulatory oesophageal pH monitoring showed clearly abnormal reflux in 11 of 22 patients (50%). Nine patients had macroscopic endoscopic changes and a further 11 biopsy changes alone, of oesophagitis which was thus present in 80% overall. Lower oesophageal sphincter pressure was significantly less in irritable bowel patients than in age and sex matched controls, but upper oesophageal sphincter pressure was comparable in the two groups and disordered peristalsis was not found. Oesophageal symptoms in the irritable bowel syndrome are mainly caused by gastro-oesophageal reflux predisposed to by a subnormal lower oesophageal sphincter pressure, rather than by oesophageal spasm.
Article
Background: Nonerosive gastroesophageal reflux disease (NERD) patients frequently show features of the irritable bowel syndrome (IBS). Aims: To investigate the prevalence and intensity of bowel symptoms and their relationship to esophageal acid exposure in NERD patients. Methods: Bowel and reflux symptoms and IBS status were assessed in NERD patients (normal upper endoscopy; esophageal pH < 4 for >= 5% of the time on 24-h pH monitoring,n = 326), in relation to nonpatient controls. Bowel symptoms were scored on the 3 scales: diarrhea, constipation, and pain/gas symptoms. Results: NERD and age were independently associated with bowel symptoms. NERD patients scored significantly higher than controls on all bowel scales. In a multivariate analysis, the scores on the pain/gas scale were independently associated with NERD. In NERD patients, reflux symptoms independently predicted the bowel symptoms while acid exposure did not. Forty-nine percent of the NERD patients and 18% of the controls met the criteria for IBS [IBS(+)NERD]. IBS(+) NERD patients scored significantly higher than those not meeting IBS criteria [IBS(-)] on all bowel scales. Yet IBS(-) patients scored significantly higher than controls on the scales of constipation and pain/gas. IBS(+)NERD patients scored higher than IBS(-) also on the GERD symptoms scale. Conclusions: (1) NERD patients scored significantly higher than controls on all the bowel scales; (2) Bowel symptoms were associated with reflux symptom scores, but not with acid exposure. (3) The presence of IBS features in a large proportion of NERD patients reflects a high prevalence of visceral hypersensitivity that may aggravate acid reflux symptoms.
Article
Distinguishing between irritable bowel syndrome (IBS) and functional dyspepsia can be challenging because of the variations in symptom patterns, which commonly overlap. However, the overlap is poorly quantified, and it is equally uncertain whether symptom patterns differ in subgroups of IBS arbitrarily defined by primary bowel patterns of constipation (IBS-C) and diarrhea (IBS-D). We aimed to determine and to compare the distribution of GI symptoms, both, upper and lower, among IBS-C and IBS-D patients.
Article
Background: Although the Rome criteria define a number of individual functional gastrointestinal disorders, people may have symptoms of multiple disorders at the same time. In addition, therapies may be effective in subsets of people with specific disorders, yet at the same time help people with multiple disorders. Aim: To estimate the prevalence of combinations of gastrointestional (GI) symptom complexes. Methods: A valid self report questionnaire which records GI symptoms was mailed to an age- and gender-stratified random sample of Olmsted County, MN residents aged 30-64 years. Standard definitions were used to identify people with gastro-oesophageal reflux, dyspepsia, irritable bowel syndrome (IBS), constipation and diarrhoea. The prevalence of people meeting multiple symptom complexes was estimated. Specifically, combinations of dyspepsia, IBS and constipation were compared to dyspepsia, IBS and diarrhoea. Results: A total of 657 (69%) of 943 eligible subjects responded; 643 provided data for each of the necessary symptom questions. Each two-way combination of symptom group was present in between 4 and 9% of the population; each three-way combination was present in 1-4% of the population. The overlap between dyspepsia, IBS and constipation was similar to dyspepsia, IBS and diarrhoea, except body mass index was higher in the diarrhoea overlap group (P = 0.03). Conclusion: Symptom complex overlap is common in the community; for each condition, the majority of sufferers reported an additional symptom complex. This overlap of symptoms challenges the current paradigm that functional GI disorders represent multiple discreet entities.
Article
Gut motility disorders and altered pain perception were reported in patients with irritable bowel syndrome (IBS). To verify foregut involvement in IBS, we studied 30 patients using esophageal manometry and 24-hr pH monitoring of the distal esophagus. Two subgroups of patients underwent esophageal provocative tests (bethanechol 50 g/kg subcutaneously and esophageal balloon distension test). Twelve healthy volunteers formed a control group. A pain threshold on esophageal distension significantly lower than in healthy subjects (11.51 ml vs 22.21.7 ml,P
Article
To determine the prevalence of symptoms compatible with a clinical diagnosis of irritable bowel syndrome in the general population. Validated postal questionnaire sent to 2280 subjects randomly selected in 10 year age bands from the lists of eight general practitioners. The Manning criteria were used to define irritable bowel syndrome. Urban population in Southampton and mixed urban-rural population in Andover, Hampshire. A response of 71% yielded 1620 questionnaires for analysis, of which 412 (25%) reported more than six episodes of abdominal pain in the preceding year, with 350 (22%) reporting symptoms consistent with the diagnosis of irritable bowel syndrome. The male: female ratio was 1:1.38. More subjects with irritable bowel syndrome had constipation and diarrhoea and 35% with the syndrome reported rectal bleeding compared with an overall prevalence of 20%. Other symptoms and conditions including heartburn, dyspepsia, flushing, palpitations, migraine, and urinary symptoms were significantly more common in the group with irritable bowel syndrome. Abdominal pain in childhood was more common in the subjects with irritable bowel syndrome (12%) than without (3%). One third of the group with irritable bowel syndrome had sought medical advice during the study period (male:female ratio 1:1.21); consultation behaviour was influenced by age and the presence of associated symptoms, varied considerably among patients registered with different general practitioners, and was poorly correlated with symptom severity. Symptoms consistent with a diagnosis of irritable bowel syndrome are present in almost one quarter of the general population and tend to be associated with a number of other complaints and conditions, some of which may reflect smooth muscle dysfunction.
Article
In 100 patients with irritable bowel syndrome a wide variety of non-gastrointestinal symptoms were significantly more common than in a group of 100 age, sex, and social class matched controls. Nocturia, frequency and urgency of micturition, incomplete bladder emptying, back pain, an unpleasant taste in the mouth, a constant feeling of tiredness and in women dyspareunia were particularly prominent (p less than 0.001). With reference to non-colonic gastrointestinal symptoms nausea, vomiting, dysphagia and early satiety were very common (p less than 0.0001). This symptom diversity was observed irrespective of whether the patient had a psychiatric disorder or not. Patients smoked more than controls (p = 0.02) drank more caffeine containing drinks (p = 0.03) and 26% had taken at least one week off work in the previous 12 months. Thirty three per cent of patients had a family history of irritable bowel syndrome. Cognisance of these diverse symptoms may prevent referral to the wrong medical specialty and inappropriate investigation. They may also be indicative of a much more diffuse disorder of smooth muscle than has previously been appreciated.
Article
Alteration in visceral sensation locally at the site of presumed symptom origin in the gastrointestinal tract has been proposed as an important etiopathological mechanism in the so-called functional bowel disorders. Patients presenting with one functional gastrointestinal syndrome, however, frequently have additional symptoms referable to other parts of the gut, suggesting that enhanced visceral nociception may be a panintestinal phenomenon. We measured the sensory thresholds for initial perception (IP), desire to defecate (DD), and urgency (U) in response to rectal balloon distension, and the thresholds for initial perception and for discomfort in response to esophageal balloon distension in 12 patients with irritable bowel syndrome (IBS) and 10 patients with functional dyspepsia (FD), in comparison with healthy controls. As expected, IBS patients exhibited lower rectal sensory thresholds than controls (P < 0.0001), but in addition had significantly lower sensory thresholds for both perception and discomfort evoked by balloon distension of the esophagus (mean +/- SEM: 8.8 +/- 1.3 ml vs 12.1 +/- 1.5 ml (P < 0.05) and 12.2 +/- 1.4 ml vs 16.4 +/- 1.4 ml (P < 0.02) respectively. Patients with FD showed similarly enhanced esophageal sensitivity, with thresholds for perception and discomfort of 8.1 +/- 0.9 ml (P < 0.02), and 10.1 +/- 1.0 ml (p < 0.001), respectively, but were also found to have sensory thresholds for rectal distension similar to those observed in the IBS group, significantly lower than in controls: IP 45.0 +/- 17.6 vs 59.3 +/- 1.5 ml (P < 0.001), DD 98.0 +/- 17.9 vs 298.7 +/- 9.0 ml (P < 0.0001), U 177.2 +/- 25.4 vs 415.1 +/- 12.6 ml (p < 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)