eMedicine Feature Series

Gastroesophageal Reflux Disease Newsletter _________ Series 1, Issue 8, 2007

IMPACT OF GERD ON QUALITY OF LIFE AND THE ROLE OF MEDICAL AND SURGICAL THERAPY

Fernando N Gamarra, MD
Providence Hospital and Medical Center
Southfield, Mich

Roberto M Gamarra, MD
Providence Hospital and Medical Center
Southfield, Mich

Luis Carlos Maas, MD, FACP, FACG, AGAF, FASGE
Wayne State University
Detroit, Mich

INTRODUCTION

Gastroesophageal reflux disease (GERD) is a chronic disease that affects up to 20% of the population in Western countries and is a common reason for medical visits and expenses. Many facets of health-related quality of life (QOL) may be affected in patients who experience daily or weekly reflux symptoms, and the literature published on the QOL of patients who endure GERD-related problems is quite extensive.^1,2

The consequences of GERD on QOL may be assessed by means of several validated questionnaires, such as the Gastrointestinal Quality of Life Index (GIQLI) and the GERD Health-Related Quality of Life questionnaire (HRQL), among several others. In fact, an extensive review of system-based outcome measures of GERD trials was recently published, describing 26 existing GERD-specific questionnaires and their outcome measures and limitations.³ The conclusion of this review highlighted that, although multiple indices have been developed, comparison between them is difficult because of differences in data collection (ie, patient self-completion vs researcher-assisted completion), data analysis (ie, univariable vs multivariable), insufficient evidence to support reliability and validity, and various standard statistical biases (eg, recall bias). The difficulties in using different instruments to directly compare QOL in patients with GERD should be kept in mind when summarizing some of the more important studies that have added to the understanding of the evidence of GERD’s effects on QOL and the role that medical and surgical therapies may have.

QUALITY OF LIFE IN UNTREATED GERD

The results of multiple QOL studies have shown that patients with GERD experience substantial reductions in physical and psychosocial aspects of health-related QOL⁴ as well as in work productivity.⁵ Relevant differences in symptoms and quality of life are not present among patients with Barrett esophagus, erosive GERD, and nonerosive GERD, which indicates that endoscopy results have little or no relevance to the QOL of these patients.⁶ The impairment to QOL in these patients is comparable to or worse than that seen in patients with other chronic diseases such as heart disease, diabetes, and cancer.⁷

Surveys of patients with GERD highlight many symptoms, including disturbances in sleep, reduced mental concentration, and interference with physical activities such as exercise and housework. Psychosocial aspects of patient well-being are also impaired, including enjoyment of social functions, intimacy, and sex. Considerable economic loss to society has also been noted in this group of patients, due to absence from work, reduced productivity while working, and reductions of regular daily activities.⁸

Unfortunately, the agreement between clinicians and patients in their assessment of the severity of reflux symptoms is poor. This divergence in symptom assessment is particularly evident for pretreatment severity and for extremely severe symptoms.⁹ Improvements in communication between doctors and patients may help to overcome this problem.

QUALITY OF LIFE IN GERD AFTER MEDICAL OR SURGICAL THERAPY

The controversies of medical and surgical approaches are not part of the scope of this review, but both approaches coincide in the concept that improving reflux symptoms improves QOL in most, if not all, parameters that have been studied. Medical and surgical therapies are both able to improve QOL in patients with GERD.¹⁰ Direct comparison between medical and surgical studies can be challenging and should be taken in the context of the heterogeneity that exists in the study designs and instruments used to measure QOL outcomes.³

Effective medical treatment of GERD that completely resolves heartburn results in clinical improvement in patient QOL. Revicki et al performed a secondary analysis of 3 clinical trials that compared ranitidine and omeprazole and their effects on QOL. In their study, patients who achieved 7 consecutive heartburn-free days reported improvement in their psychological well-being and general health and vitality, regardless of the treatment group.¹¹ Comparative evaluations demonstrate superiority of proton pump inhibitors (PPI) over H2 blockers in efficacy¹² and health-related QOL.¹³ A similar superiority of PPIs over antacids on QOL has also been demonstrated.¹⁴

Fundoplication surgery is an important treatment option for many patients with GERD. Several controlled studies have demonstrated improved QOL scores following both laparoscopic and open fundoplication. Ciovica et al recently evaluated the QOL in patients with GERD without therapy, under continuous medical treatment with PPIs, and following laparoscopic reflux surgery. To evaluate the QOL in their patients, they used the questionnaires described above (ie, the GIQLI and the GERD HRQL). They concluded that, although QOL scores were improved in both medical and surgical treatment groups, the outcomes were significantly better after surgery.¹⁰ In a 5-year follow-up study, Lundell et al randomized 310 patients to medical therapy with a PPI or to open antireflux surgery. When time to treatment failure, as defined by various clinical and endoscopic criteria, was analyzed by an intention-to-treat approach, the curves significantly favored the surgery group. However, the results did not achieve statistical significance when allowing for dose adjustments for medical therapy.¹⁵

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The long-term outcomes of medical and surgical therapies have been analyzed in a randomized controlled trial. Spechler et al performed a follow-up study of medically and surgically treated patients. No significant difference was found in the 36-item Short Form health survey (SF-36) scores at a median follow-up of 10.6 years in the medical group and 9.1 years in the surgical group. Antisecretory medication was being used regularly at follow-up by 92% of the medically treated group and 62% of the surgical group. Spechler et al concluded that antireflux surgery should not be advised with the expectation that patients with GERD will not require continued antisecretory medication.¹⁶

CONCLUSION

GERD clearly has a significant impact on the health-related QOL of patients with this condition. Available studies support that the treatment of these patients has profoundly positive impacts on their QOL. In fact, 7 heartburn-free days appears to be the critical number that has the most profound impact on the QOL of patients with GERD. This can be readily achieved with medical therapy as well as surgical therapy. Limitations of current pharmacological therapies and the skill and experience of surgeons are important determinants in the efficacy of these therapies; therefore, these factors indirectly affect QOL of patients with GERD.

Many aspects of GERD independent of QOL may affect the management of these patients. These include, but are not limited to, the presence of Barrett esophagus, strictures, adenocarcinoma, bleeding, and extraesophageal manifestations. In addition, concerns about cost-effectiveness must be taken into account before blanket recommendations can be made with respect to GERD treatment strategies.

Although available medical and surgical therapies have proven efficacy, refinements in surgical techniques, endoscopic interventions, and pharmacotherapeutics should play an important role in the future treatment of GERD and may offer even better QOL for patients with this condition.

REFERENCES

1. Rankainen J, Aro P, Storskrubb T, et al. Gastro-oesophageal reflux symptoms and health-related quality of life in the adult general population-the Kalixandra study. Aliment Pharmacol Ther. 2006;23(12):1725-33.

2. Wiklund I, Carlsson J, Vakil N. Gastroesophageal reflux symptoms and well-being in a random sample of the general population of a Swedish community. Am J Gastroenterol. 2006;101:18-28.

3. Fraser A, Delaney B, Moayyedi P. Symptom-based outcome measure for dyspepsia and GERD trials: a systematic review. Am J Gastroentrol. 2005;100:442-52.

4. Liker H, Hungin P, Wiklund I. Managing gastroesophageal reflux disease in primary care: the patient perspective. J Am Board Fam Pract. 2005;18(5):393-400.

5. Wahlqvist P, Carlsson J, Stalhammar NO, Wiklund I. Validity of a Work Productivity and Activity Impairment questionnaire for patients with symptoms of gastro-esophageal reflux disease (WPAI-GERD) – results from a cross-sectional study. Value Health. 2002;5(2):106-13.

6. Eloubeidi MA, Provenzale D. Health-related quality of life and severity of symptoms in patients with Barrett’s esophagus and gastroesophageal reflux disease patients without Barrett’s esophagus. Am J Gastroenterol. 2000;95(8):1881-7.

7. Kulig M, Leodolter A, Vieth M, et al. Quality of life in relation to symptoms in patients with gastro-oesophageal reflux disease – an analysis based on the ProGERD initiative. J Clin Epidemiol. 2004;57(6):580-9.

8. Wahlqvist P. Symptoms of gastroesophageal reflux disease, perceived productivity, and health-related quality of life. Am J Gastroenterol. 2001;95(8 Suppl):S57-61.

9. McColl E, Junghard O, Wiklund I, Revicki DA. Assessing symptoms in gastroesophageal reflux disease: how well do clinicians’ assessments agree with those of their patients? Am J Gastroenterol. 2005;100(1):11-8.

10. Ciovica R, Gadenstatter M. Quality of life in GERD patients: medical treatment versus antireflux surgery. J Gastrointest Surg. 2006;10:934-9.

11. Revicki DA, Crawley JA, Zodet MW, Levine DS, Joelsson BO. Complete resolution of heartburn symptoms and health-related quality of life in patients with gastro-oesophageal reflux disease. Aliment Pharmacol Ther. 1999;13(12):1621-30.

12. Festen HP Schenk E, Tan G, Snel P, Nelis F. Omeprazole versus high-dose ranitidine in mild gastroesophageal reflux disease: short-and long-term treatment: The Dutch Reflux Study Group. Am J Gastroenterol. 1999;94:931-6.

13. Wiklund I, Bardhan KD, Muller-Lissner S, et al. Quality of life during acute and intermittent treatment of gastro-oesophageal reflux disease with omeprazole compared with ranitidine. Results from a multicentre clinical trial. The European Study Group. Ital J Gastroenterol Hepatol. 1998;30(1):19-27.

14. Goves J, Oldring JK, Kerr D, et al. First line treatment with omeprazole provides an effective and superior alternative strategy in the management of dyspepsia compared to antacid/alginate liquid: a multicentre study in general practice. Aliment Pharmacol Ther. 1998;12:147-57.

15. Lundell L, Miettinen P, Myrvold HE, et al. Continued (5-year) follow-up of a randomized clinical study comparing antireflux surgery and omeprazole in gastroesophageal reflux disease. J Am Coll Surg. 2001;192(2):172-9.

16. Spechler SJ, Lee E, Ahnen D, et al. Long-term outcome of medical and surgical therapies for gastroesophageal reflux disease: follow-up of a randomized controlled trial. JAMA. 2001;285:2331-8.

AUTHOR SPOTLIGHT

	Fernando N Gamarra, MD Resident, Internal Medicine Providence Hospital and Medical Center Southfield, Mich
	Roberto M Gamarra, MD Fellow, Internal Medicine Section of Gastroenterology and Hepatology Providence Hospital and Medical Center Southfield, Mich
	Luis Carlos Maas, MD, FACP, FACG, AGAF, FASGE Wayne State University Detroit, Mich