Frequency of Clinical symptoms of Gastroesophageal Reflux Disease in Asthmatic Patients

Background: Gastroesophageal reflex is known as an acid reflex, is long term condition where stomach contents back into the oesophagus resulting in either symptoms or complications. GERD disease is caused by weakness or failure of the lower oesophageal sphincter. Symptoms include the acidic taste behind the mouth, heart burn, chest pain, difficult breathing and vomiting. Complication includes esophagitis, oesophageal strictures and barrettes oesophagus. Objective: The aim of this research was to introduce the symptoms of GERD disease in asthmatic patients and how these symptoms worsen the symptoms of asthma disease and what clinical pictures present with the asthmatic disease. Methodology: A designed performa was used to collect the data and after filling the performa, results were drawn and conclusion through the facts and the information given by patients. Results: In the present study among all 164 asthmatic patients, 70 (42.7%) patients showed dyspepsia, 58 (35.4%) were with chest burning, 23 (14%) were asking about chest pain, with acidic mouth taste were 39 (23.8%), 22 (13.4%) were feeling sore throat and 44 (26.8%) showed regurgitation reflex. Among these 164 patients 16 (9.8%) were smokers and 148 (90.2 %) were non-smokers. 47 (28.7%) were males and 117 (71.3%) were females. Conclusion: It is concluded that gastroesophageal reflux disease in asthmatic patients present symptoms of acidic mouth taste, chest burning, chest pain, dyspepsia, regurgitation reflex and sore throat.


Introduction:
Gastroesophageal reflex is known as an acid reflex, is long term condition where stomach contents back into the oesophagus resulting in either symptoms or complications (1). GERD disease is caused by weakness or failure of the lower oesophageal sphincter (2). Symptoms include the acidic taste in back of the mouth, heart burn, chest pain, difficult breathing and vomiting.
Complication include esophagitis, oesophageal strictures and barrettes oesophagus (1). Risk factors are obesity, pregnancy, smoking, hiatus hernia, antidepressants and sleeping medications (1). The gold standard test for the diagnosis of GERD disease is 24 hours Ph monitoring. Another test in which improvement of symptoms occur after giving a proton pump inhibitors is a positive test for GERD disease (3). Oesophageal manometry is required only prior to surgery (4). Investigations may need gastroduodenoscopy and endoscopy (4). Lying down on bed at least three hours after meal, reduce weight, avoids certain foods, stop smoking, not lying down on bed after eating. antacids, H2 receptor blocker, Proton pump inhibitors, Prokineti. Surgery is recommended in severe cases (5). In western world 10 to 20 % population are affected by a GERD disease (5). The GERD condition was first described by an American gastroenterologist ASHER WINKELSTEIN 1935 (6). A common long term inflammatory disease of the airways of the lungs is called asthma (7). It is characterized by reversible airflow obstruction and bronchospasm (8). The symptoms of asthma include episodes of coughing, wheezing, shortness of breath, and chest tightness (9). These episodes of asthma occur mostly in day time or per week or in the night time. Thy symptoms of asthma may worse at night or during exertion (10). Asthmatic disease usually occurs due to various environmental and genetic factors. Environmental factors are exposure to air, pollution and various allergens. The other triggers include medications such as aspirin and beta blockers (10). The diagnosis of the asthma depend on major symptoms, response to therapy over time, and spirometry values (11). The classification of the asthma is on the basis of the frequency of symptoms, (FEV1) values, and peak expiratory flow rate (12). Asthmatic disease may be classified as atopic or non-atopic. Atopy refers to a predisposition toward developing type 1 hypersensitivity reaction (13,14). There is no treatment or cure for asthma (15). The symptoms of the asthma can be prevented by avoiding from the triggering factors, such as irritants and allergens, and with the use of inhaled corticosteroids (16,17). The rapid treatment for worsening symptoms of asthma is usually with an inhaled short-acting beta-2 agonist such as salbutamol and corticosteroids. (18). In very severe cases intravenous drugs used e.g corticosteroids, magnesium sulfate and hospitalization may be required (19). In 2015, 358 million people globally had asthma, up from 183 million in 1990 (19,20). It caused about 397,100 deaths in 2015, most of which occurred in the developing world (10). It often begins in childhood (21). The rate of asthma have increased significantly since the 1960s (22). Asthma was recognized as early as Ancient Egypt (23). A total of 20 articles that described 5706 patients fulfilled the inclusion and exclusion criteria. Seventeen studies used objective methods for documenting reflux (e.g., pH probe, contrast imaging, impedance, and esophagogastroduodenoscopy), 2 studies relied on symptom-based questionnaires, and 1 study used diagnostic codes. Most studies (n = 19) examined the prevalence of GERD in 3726 individuals with asthma and reported highly variable estimates (19.3%-80.0%) and a pooled average of 22.8% with GERD symptoms, 62.9% of 789 patients with abnormal oesophageal pH, and 34.8% of 89 patients with esophagitis. Only 5 studies included controls and enrolled 1314 casepatients with asthma and 2434 controls without asthma. The average prevalence of GERD was 22.0% in asthma cases and 4.8% in controls (pooled odds ratio: 5.6 [95% confidence interval: 4.3-6.9]) (24). The aim of this research is to introduce the symptoms of GERD disease in asthmatic patients and how these symptoms worsen the symptoms of asthma disease. And what clinical pictures presents with the asthmatic disease.

Material and Methods: Study design:
This was Cross-sectional study. Setting: Ward, OPDs and ICUs of Gulab Devi Chest Hospital. Duration: The duration of study was 6 months. Sample size: 164 asthma patients were required for the purpose to complete this research. Sample was calculated using p=16% (25), d=5% using the following formula: n= Z 2 1-α/2 P (1-P) d 2 Sampling technique: Purposive sampling technique was used to collect the data. Sample selection criteria: Inclusion criteria: Cases of brochial asthma were taken on the basis of clinical symptoms, sign and pulmonary function test showing airway reversibility of 12 percent and 200 ml in FEV1. Exclusion criteria: COPD patients and Asthmatic patients taking any medications known to cause upper gastro intestinal adverse effect like oral steroids and theophylline. Methodology: A designed performa was used to collect the data and after filling the performa we draw results and conclusion through the facts and the information given by patients. Analysis procedure: The data was entered and analysed by using SPSS version 20. The quantitative data like age was presented in the form of mean ± SD. While the qualitative data like GERD symptoms and gender were presented in the form of charts along its percentage.

Operational definitions:
GERD is a digestive disorder that affects the lower oesophageal sphincter (LES), the ring of muscle between the oesophagus and stomach. Asthma is a chronic (long-term) lung disease that inflames and narrows the airways. Asthma causes recurring periods of wheezing (a whistling sound when you breathe), chest tightness, shortness of breath, and coughing. Dyspepsia is a common condition and usually describes a group of symptoms rather than one predominant symptom. These symptoms include Belly pain or discomfort, Bloating, feeling uncomfortably full after eating, Nausea, Loss of appetite, Heartburn, Burping up food or liquid (regurgitation) and Burping.

Regurgitation of food or acid reflex:
In 164 patients 44 patients showed anti-reflex and 120 showed normal characteristics related to this aspect. Symptoms distribution: The symptom distribution is shown in Error! Reference source not found. and in this figure, "a" shows dyspepsia that was 42.7%, "b" wass chest burning 35.4%, "c" was chest pain found in 14%, "d" was used for acidic taste in mouth its 23.8%, "e" was sore throat and was 13.4% and 'f'was the regurgitation of food that was 26.8%.
According to a research conducted in 2003, chest burn and acid regurgitation of moderate severity or above were present in 12.1% and 19.6%, respectively. And among 659 patients, dyspepsia were informed in 29.3 % patients, acidic feeling in mouth was shown in 45.52 % patients (26) In a study (n = 19) examined the prevalence of GERD in 3726 individuals with asthma and reported highly variable estimates (19.3%-80.0%) and a pooled average of 22.8% with GERD symptoms, 62.9% of 789 patients with abnormal oesophageal pH, and 34.8% of 89 patients with esophagitis (24).
There is a great difference between this research and the previous researches. The main reason of this difference is that there are highly improved facilities, related to health and medications. There is a change in awareness of treatment and prevention of GERD. The asthmatic patients use medications, therapies and facilities to cure asthma and to reduce the symptoms of GERD disease.
The prevalence rates of heartburn and acid regurgitation over the past year were 8.9% and 25.9%, respectively. The 1-year prevalence of GERD was 29.8%. The age, gender distribution and socio-economic status were similar between subjects with GERD and subjects without. For subjects with GERD over the past year, the prevalence rates were similar between males and females, except for subjects ≥55 years of age, in whom the prevalence was higher in males. For subjects with frequent GERD (at least monthly), the prevalence rates were similar between males and females. The prevalence of GERD was similar between different occupations. For subjects with GERD over the past year, heartburn and acid regurgitation of moderate severity or above were present in 12.1% and 19.6%, respectively. GERD symptoms (heartburn and/or acid regurgitation) of moderate severity or above were significantly more frequent in subjects with frequent GERD (at least monthly) (28.5% vs. 50.5%, P < 0.001). The annual, monthly and weekly prevalence rates of non-cardiac chest pain were 19.5%, 5% and 1%, respectively, and dyspepsia was present in 17.1% of the study subjects. There was a considerable overlap between dyspepsia, non-cardiac chest pain and GERD symptoms over the past year.