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(GERD) in Patients with Liver Cirrhosis Taha M Hassanin et al. Egyptian Liver Journal (2021) 11:27 https://doi.org/10.1186/s43066-021-00096-6 Egyptian Liver Journal ORIGINAL RESEARCH ARTICLE Open Access Prevalence and risk factors of endoscopically confirmed gastroesophageal reflux disease (GERD) in patients with liver cirrhosis Taha M. Hassanin1* , Yasser Foaud1, Hala Mohamed1, Zienab Saad1, Amr Elsayed1, Sara Refaei2 and Wael Soliman1 Abstract Background: Gastroesophageal reflux disease (GERD) is one of the most common diseases in modern civilization that originates basically from a disturbance in the structure and function of the lower esophageal sphincter (LES). Liver cirrhosis with or without esophageal varices (EV) may predispose to GERD, and GERD may precipitate rupture of esophageal varices. As variceal bleeding is a serious life-threatening complication of liver cirrhosis, GERD prevalence among cirrhotic patients is continuously subjected to research. We aimed to determine the prevalence of endoscopy-confirmed GERD in patients with liver cirrhosis and its possible risk factors. So, one hundred patients with HCV-related liver cirrhosis were consecutively enrolled in this study. They were subjected to history taking {including Reflux Disease Questionnaire}, thorough clinical examination, abdominal ultrasound, and lab investigations and then referred for upper endoscopy to screen for GERD and/or esophageal varices. Results: GERD was endoscopically confirmed in 83 patients (83%) and the highest prevalence was in patients with Child B and C. Among 82 patients with esophageal varices, there were 68 patients who had endoscopic GERD (82.9%), and among 62 patients with ascites, there were 56 patients who had endoscopic GERD (90.3%). Conclusion: We found a high prevalence of GERD (83%) among patients with liver cirrhosis. The severity of GERD was significantly related to the Child grade, the grade of varices, and the degree of ascites but ascites was the only significant risk factor for GERD development in cirrhotic patients. Keywords: Liver cirrhosis, Gastroesophageal reflux disease, Prevalence, Risk factors, Ascites * Correspondence: [email protected] 1Endemic Medicine and Gastroenterology Department, Minia University Faculty of Medicine, Minia, Egypt Full list of author information is available at the end of the article © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Hassanin et al. Egyptian Liver Journal (2021) 11:27 Page 2 of 7 Main points as the increased contact time between acid reflux and EV may lead to erosion of the esophageal mucosa and in- 1- Endoscopically confirmed GERD is highly prevalent crease the risk of variceal rupture [15–17]. This study was among cirrhotic patients (83%). designed to evaluate the prevalence of endoscopy 2- Ascites, Child grade, and esophageal varices grade confirmed GERD in patients with liver cirrhosis and its were significantly related to the grade of GERD in possible risk factors. cirrhotic patients. 3- Ascites was the only independent predictor for Methods presence of GERD, and it correlates significantly The present study included 148 patients with HCV- with the presence of GERD and the severity of related liver cirrhosis. They were consecutively enrolled GERD. from those attending the liver cirrhosis clinic at Minia 4- Accordingly, cirrhotic patients should be advised to University Hospital for regular medical follow-up. Only do upper endoscopy to screen for GERD; otherwise, 100 patients completed the study (48 patients refused to physician should empirically treat cirrhotic patients participate in the study or refused to do endoscopy). as GERD especially if they are symptomatic. Patients with other systemic diseases like systemic scler- osis, diabetes mellitus, hypertension or neuromuscular Background disorders, alcohol abusers, and chronic users of drugs Gastroesophageal reflux disease (GERD) is one of the that influence esophageal motility like calcium channel most common diseases in modern civilization, which blockers, theophylline, or nitrates were excluded from greatly affects people’s health and quality of life [1]. the study. Patients included in the study were subjected GERD originates from a disturbance in the structure and to history taking {including Reflux disease questionnaire function of the lower esophageal sphincter (LES). [18], emphasizing on typical GERD symptoms, such as Disturbed esophageal motility in addition to weak LES heartburn and/or acid regurgitation}, thorough clinical can cause regurgitation of gastric and/or duodenal con- examination, abdominal ultrasound, and lab investiga- tents into the esophagus [2]. Many factors are involved tions and then referred for upper endoscopy to screen in the GERD pathophysiology including prolonged lower for GERD and/or esophageal varices. All patients had esophageal sphincter relaxation, presence of hiatus blood drawn for routine investigations including liver hernia, low basal LES pressure, delayed esophageal clear- function tests using an OLYMPUS automatic biochem- ance, and delayed gastric emptying [3, 4]. In Egypt, liver ical analyzer (OLYMPUS-AU640). The diagnosis of liver cirrhosis is a major health problem owing to high preva- cirrhosis was based on clinical examination, laboratory lence of HCV infection [5]. Liver cirrhosis with or without findings, and ultrasonographic study, while its severity esophageal varices was found to decrease the LES pres- was assessed by Child-Turcotte-Pugh scoring system sure, worsen the esophageal motility, delay the esophageal [19]. Ascites was classified as mild, moderate, or marked clearance, and delay the gastric emptying and eventually according to clinical and ultrasonographic criteria [20]. lead to reflux [6–8]. Some studies reported high incidence of GERD in patients with liver cirrhosis (65%) [9, 10], Upper gastrointestinal endoscopy while others reported a lower percentage (33%) [6]. More- All patients underwent upper gastrointestinal endoscopy over, asymptomatic GERD was found to be common in (Olympus XQ260; Olympus, Japan). GERD was classified patients with liver failure [11]. The highest prevalence of according to Los Angeles Classification into grade A— GERD was found among patients with Child B and C liver mucosal erosion < 5 mm, which does not extend be- cirrhosis with positive relationship between the severity of tween the tops of two mucosal folds; grade B—mucosal liver damage and GERD [12]. A significant relationship erosion > 5mm, but does not extend between the tops of between ascites and GERD was reported as ascites two mucosal folds; grade C—confluent erosion that is increases the intra-abdominal pressure, compressing the continuous between the tops of two or more mucosal stomach and its contents, and this may alter the anatomic folds but involves < 75% of the esophageal circumference; anti-reflux measures naturally occurring against reflux and grade D—confluent and circumferential erosion that [11, 12], and reflux symptoms tend to decrease when involves 75% or more of the esophageal circumference intra-abdominal pressure was reduced by paracentesis [21]. Esophageal varices were classified into grade 1 [13]. Esophageal varices—independent of liver cirrhosis— (small), straight small caliber varices; grade 2 (medium), lead to LES dysfunction, which make the stomach con- moderately enlarged, beady varices covering less than one tents reflux easily, and also EV lead to delay in esophageal third of the lumen; and grade 3 (large), markedly enlarged, clearance, which increases the contact time of acid reflux nodular or tumor-shaped varices occupying more than with the esophageal mucosa [8, 14]. On the other hand, one third of the lumen [22]. Esophageal varices and GERD GERD may be a risk factor for esophageal varices bleeding grading were evaluated by 2 senior endoscopists. Hassanin et al. Egyptian Liver Journal (2021) 11:27 Page 3 of 7 Statistical analysis Table 1 Demographic data, symptoms, signs, and lab findings The collected data were coded, tabulated, and statistically of the studied patients analyzed using SPSS program (Statistical Package for Variable Cirrhotic patients (n=100) Social Sciences) software version 23. Descriptive statistics Age, range / mean ± SD 41–72 / 57.2±7.91 were done for parametric quantitative data by mean, Sex, male / female 68 (68%) / 32 (32%) standard deviation. Categorical variables were given as Smokers 43 (43%) number and percentages and chi-square test and Fisher’s Typical GERD symptoms 42 (42%) exact test were used for comparison between categorical (heart burn and regurgitation) variables. Multivariate logistic regression analysis model Ascites (n = 62) was performed using endoscopic GERD as a dependent variable. P value ≤ 0.05 was considered significant.
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