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World Journal of
Clinical Cases
World J Clin Cases 2019 June 26; 7(12): 1367-1534
ISSN 2307-8960 (online)
Published by Baishideng Publishing Group Inc
W J C C World Journal of
Clinical Cases
Contents Semimonthly Volume 7 Number 12 June 26, 2019
REVIEW
1367 Biomarkers vs imaging in the early detection of hepatocellular carcinoma and prognosis
Balaceanu LA
ORIGINAL ARTICLE
Basic Study
1383 Study on gene expression patterns and functional pathways of peripheral blood monocytes reveals potential
molecular mechanism of surgical treatment for periodontitis
Ma JJ, Liu HM, Xu XH, Guo LX, Lin Q
Case Control Study
1393 Clinical differentiation of acute appendicitis and right colonic diverticulitis: A case-control study
Sasaki Y, Komatsu F, Kashima N, Sato T, Takemoto I, Kijima S, Maeda T, Ishii T, Miyazaki T, Honda Y, Shimada N, Urita Y
Retrospective Study
1403 Feasibility of prostatectomy without prostate biopsy in the era of new imaging technology and minimally
invasive techniques
Xing NZ, Wang MS, Fu Q, Yang FY, Li CL, Li YJ, Han SJ, Xiao ZJ, Ping H
1410 Safety and efficacy of transfemoral intrahepatic portosystemic shunt for portal hypertension: A single-center
retrospective study
Zhang Y, Liu FQ, Yue ZD, Zhao HW, Wang L, Fan ZH, He FL
Observational Study
1421 Impact of gastroesophageal reflux disease on the quality of life of Polish patients
Gorczyca R, Pardak P, Pękala A, Filip R
SYSTEMATIC REVIEWS
1430 Non-albicans Candida prosthetic joint infections: A systematic review of treatment
Koutserimpas C, Zervakis SG, Maraki S, Alpantaki K, Ioannidis A, Kofteridis DP, Samonis G
META-ANALYSIS
1444 Relationship between circulating irisin levels and overweight/obesity: A meta-analysis
Jia J, Yu F, Wei WP, Yang P, Zhang R, Sheng Y, Shi YQ
CASE REPORT
1456 Cirrhosis complicating Shwachman-Diamond syndrome: A case report
Camacho SM, McLoughlin L, Nowicki MJ
WJCC https://www.wjgnet.com
June 26, 2019 Volume 7 Issue 12
I
Contents World Journal of Clinical Cases
Volume 7 Number 12 June 26, 2019
1461 Robot-assisted trans-gastric drainage and debridement of walled-off pancreatic necrosis using the
EndoWrist stapler for the da Vinci Xi: A case report
Morelli L, Furbetta N, Gianardi D, Palmeri M, Di Franco G, Bianchini M, Stefanini G, Guadagni S, Di Candio G
1467 Fulminant liver failure following a marathon: Five case reports and review of literature
Figiel W, Morawski M, Grąt M, Kornasiewicz O, Niewiński G, Raszeja-Wyszomirska J, Krasnodębski M, Kowalczyk A,
Hołówko W, Patkowski W, Zieniewicz K
1475 Gaucher disease in Montenegro - genotype/phenotype correlations: Five cases report
Vujosevic S, Medenica S, Vujicic V, Dapcevic M, Bakic N, Yang R, Liu J, Mistry PK
1483 Longitudinal observation of ten family members with idiopathic basal ganglia calcification: A case report
Kobayashi S, Utsumi K, Tateno M, Iwamoto T, Murayama T, Sohma H, Ukai W, Hashimoto E, Kawanishi C
1492 Secondary lymphoma develops in the setting of heart failure when treating breast cancer: A case report
Han S, An T, Liu WP, Song YQ, Zhu J
1499 Removal of pediatric stage IV neuroblastoma by robot-assisted laparoscopy: A case report and literature
review
Chen DX, Hou YH, Jiang YN, Shao LW, Wang SJ, Wang XQ
1508 Premonitory urges located in the tongue for tic disorder: Two case reports and review of literature
Li Y, Zhang JS, Wen F, Lu XY, Yan CM, Wang F, Cui YH
1515 Female genital tract metastasis of lung adenocarcinoma with EGFR mutations: Report of two cases
Yan RL, Wang J, Zhou JY, Chen Z, Zhou JY
1522 Novel heterozygous missense mutation of SLC12A3 gene in Gitelman syndrome: A case report
Wang CL
1529 Thoracotomy of an asymptomatic, functional, posterior mediastinal paraganglioma: A case report
Yin YY, Yang B, Ahmed YA, Xin H
WJCC https://www.wjgnet.com
June 26, 2019 Volume 7 Issue 12
II
Contents World Journal of Clinical Cases
Volume 7 Number 12 June 26, 2019
ABOUT COVER Editorial Board Member of World Journal of Clinical Cases, Amirhossein
Sahebkar, PharmD, PhD, Associate Professor, Biotechnology Research
Center, Mashhad University of Medical Sciences, Mashhad 9177948564,
Khorasan-Razavi, Iran
AIMS AND SCOPE World Journal of Clinical Cases (World J Clin Cases, WJCC, online ISSN 2307-
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NAME OF JOURNAL
World Journal of Clinical Cases
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ISSN 2307-8960 (online)
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April 16, 2013
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PUBLICATION DATE
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WJCC https://www.wjgnet.com
June 26, 2019 Volume 7 Issue 12
III
W J C C World Journal of
Clinical Cases
Submit a Manuscript: https://www.f6publishing.com World J Clin Cases 2019 June 26; 7(12): 1421-1429
DOI: 10.12998/wjcc.v7.i12.1421 ISSN 2307-8960 (online)
ORIGINAL ARTICLE
Observational Study
Impact of gastroesophageal reflux disease on the quality of life of
Polish patients
Rafał Gorczyca, Piotr Pardak, Anna Pękala, Rafał Filip
ORCID number: Rafał Gorczyca
(0000-0002-3334-557X); Piotr Pardak
(0000-0001-8489-781X); Anna Pękala
(0000-0001-6779-1909); Rafał Filip
(0000-0002-5954-151X).
Author contributions: Gorczyca R
and Filip R designed the study,
performed the data collection and
statistical analyses; Filip R, Pardak
P and Pękala A performed data
interpretation and drafted the
manuscript; All authors read and
approved the final manuscript.
Institutional review board
statement: The study protocol was
approved by the Institutional Ethic
Committee at the Institute of Rural
Health in Lublin, Poland.
Informed consent statement: All
patients gave their written
informed consent prior to study
inclusion.
Conflict-of-interest statement:
There are no conflicts of interest to
report for any of the authors.
STROBE statement: The authors
have read the STROBE Statement-
checklist of items, and the
manuscript was prepared and
revised according to the STROBE
Statement-checklist of items.
Open-Access: This article is an
open-access article which was
selected by an in-house editor and
fully peer-reviewed by external
reviewers. It is distributed in
accordance with the Creative
Commons Attribution Non
Commercial (CC BY-NC 4.0)
license, which permits others to
distribute, remix, adapt, build
upon this work non-commercially,
Rafał Gorczyca, Department of Clinical Endoscopy, Institute of Rural Health, Lublin 20-080,
Poland
Piotr Pardak, Anna Pękala, Rafał Filip, Department of Gastroenterology with IBD Unit of
Clinical Hospital 2, University of Rzeszów, Rzeszów 35-301, Poland
Corresponding author: Piotr Pardak, MD, Doctor, Department of Gastroenterology with IBD
Unit of Clinical Hospital 2, University of Rzeszów, Lwowska 60, Rzeszów 35-301, Poland.
piotrpardak@wp.pl
Telephone: +48-17-8664607
Fax: +48-17-8664702
Abstract
BACKGROUND
Gastro-esophageal reflux disease (GERD) is a serious health and social problem
leading to a considerable decrease in the quality of life of patients. Among the
risk factors associated with reflux symptoms and that decrease the quality of life
are stress, overweight and an increase in body weight. The concept of health-
related quality of life (HRQL) covers an expanded effect of the disease on a
patient’s wellbeing and daily activities and is one of the measures of widely
understood quality of life. HRQL is commonly measured using a self-
administered, disease-specific questionnaires.
AIM
To determine the effect of reflux symptoms, stress and body mass index (BMI) on
the quality of life.
METHODS
The study included 118 patients diagnosed with reflux disease who reported to
an outpatient department of gastroenterology or a specialist hospital ward for
planned diagnostic tests. Assessment of the level of reflux was based on the
frequency of 5 typical of GERD symptoms. HRQL was measured by a 36-item
Short Form Health Survey (SF-36) and level of stress using the 10-item Perceived
Stress Scale. Multi-variable relationships were analyzed using multiple
regression.
RESULTS
Eleven models of analysis were performed in which the scale of the SF-36 was
included as an explained variable. In all models, the same set of explanatory
variables: Gender, age, reflux symptoms, stress and BMI, were included. The
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June 26, 2019 Volume 7 Issue 12
1421
and license their derivative works
on different terms, provided the
original work is properly cited and
the use is non-commercial. See:
http://creativecommons.org/licen
ses/by-nc/4.0/
Manuscript source: Unsolicited
manuscript
Received: January 3, 2019
Peer-review started: January 3,
2019
First decision: January 30, 2019
Revised: April 22, 2019
Accepted: May 2, 2019
Article in press: May 2, 2019
Published online: June 26, 2019
P-Reviewer: Viswanath YKS
S-Editor: Ji FF
L-Editor: Filipodia
E-Editor: Wang J
frequency of GERD symptoms resulted in a decrease in patients’ results
according to 6 out of 8 SF-36 scales- except for mental health and vitality scales.
Stress resulted in a decrease in patient function in all domains measured using
the SF-36. Age resulted in a decrease in physical function and in overall
assessment of self-reported state of health. An increasing BMI exerted a negative
effect on physical fitness and limitations in functioning resulting from this
decrease.
CONCLUSION
In GERD patients, HRQL is negatively determined by the frequency of reflux
symptoms and by stress, furthermore an increasing BMI and age decreases the
level of physical function.
Key words: Gastroesophageal reflux disease; Stress; Psychological factors; Health-related
quality of life; Obesity
©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
Core tip: Gastro-esophageal reflux disease is a serious health problem leading to a
decrease in the quality of life. This study determines the effect of reflux symptoms, stress
and body mass index (commonly known as BMI) on the quality of life measured by a
36-item Short Form Health Survey. We demonstrate that in patients with gastro-
esophageal reflux, stress decreases the quality of life to a higher degree than the
frequency of reflux symptoms. Age and increasing BMI result in decreased physical
function. Therefore, the patient’s stress level should be considered in the diagnosis and
therapy, as well as an assessment of the progress of treatment.
Citation: Gorczyca R, Pardak P, Pękala A, Filip R. Impact of gastroesophageal reflux disease
on the quality of life of Polish patients. World J Clin Cases 2019; 7(12): 1421-1429
URL: https://www.wjgnet.com/2307-8960/full/v7/i12/1421.htm
DOI: https://dx.doi.org/10.12998/wjcc.v7.i12.1421
INTRODUCTION
Gastro-esophageal reflux disease (GERD) is a serious health and social problem,
considering the frequency and specificity of symptoms, causing an increase in
absenteeism rate, consequently creating a financial burden for health care, and above
all, leading to a considerable decrease in the quality of life of patients. According to a
1999 study, reflux disease symptoms occurred every day in 7%-10%, and once a week
in nearly 20% of the population in highly developed countries[1]. In 2003 in Poland,
based on Carlsson’s questionnaire, reflux disease was diagnosed in more than 34% of
patients aged over 15 who reported to a family physician[2]. A special problem for
patients is the noxiousness of symptoms at the phase of aggravation of the disease
and frequent recurrences after successful therapy. A decrease in perceived quality of
life is symptomatic of GERD[3-5]. The Montreal definition describes GERD as a con-
dition that develops when the reflux of stomach contents causes troublesome
symptoms and/or complications. The symptoms are considered troublesome when
they occur more frequently than once a week because only then they cause a decrease
in the perceived quality of life[3,4].
The concept of health-related quality of life (HRQL) covers an expanded effect of
the disease on a patient’s wellbeing and daily activities. To date, there is no commonly
accepted definition of this concept, and the basic problem is the specification of
contents of the domains of activities to which this definition refers. In practice, HRQL
should refer to contents included in a given measurement instrument[5-7]. HRQL is
commonly measured using a self-administered questionnaire completed by patients.
Disease-specific and general questionnaires are distinguished. The first provide
information concerning disorders and limitations typical of a given disease. However,
this limits the possibility to compare the quality of life between patients suffering
from different diseases. General (generic) questionnaires provide comparability of
results, measure the respondent’s functioning within several basic spheres (domains),
which are general enough in that they concern many types of diseases, and may also,
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Gorczyca R et al. Impact of gastroesophageal reflux disease on the quality of life
1422
within a certain scope, be reasonably measured in healthy individuals. The HRQL is
one of the measures of widely understood quality of life (QOL), which covers many
spheres of activity beyond the area of health and disease, but often related with it,
such as interpersonal relationships in a family, social and financial problems[8]. The
etiopathogenesis of GERD is multi-factorial and, in the case of individual patients, is
difficult to determine unequivocally. Among the risk factors with a documented
relation to reflux symptoms are, among others, stress[9-11], being overweight and
obesity[11,12]. Here, stress will be understood in a narrower sense as a psychological
distress, i.e. the state of strong or long-term psychological tension, connected with low
mood, emotions of fear and anxiety or aggression. The relationship between stress
and reflux symptoms and quality of life has been well documented. In a cross-
sectional controlled population study conducted among the Norwegian population
that included nearly 59000 respondents[13], the relationship was assessed between
psychiatric disorders (anxiety, depression) and reflux symptoms. It was observed that
anxiety and depression correlated to a 3- 4-fold increase in the risk of occurrence of
reflux symptoms. In a study of reflux disease patients conducted by Nojkova et al[14],
patients who had reflux symptoms and concomitant symptoms of psychological
distress, showed a significantly lower quality of life and more severe reflux symptoms
at the beginning of therapy compared to those without symptoms of distress. In a
repeated study, after the completion of therapy with a proton pump inhibitor (rabe-
prazole at a dose 20 mg/d) patients with distress continued to show a lower quality of
life and higher intensity of reflux symptoms than those without distress, despite an
improvement in both groups.
Although there is clear evidence for a relationship between stress and reflux
symptoms, a randomized experimental study did not confirm the effect of stress on
the number of reflux episodes measured using 24-h esophageal pH monitoring,
despite the fact that the group subjected to stress perceived an increased intensity of
symptoms in subjective evaluations[15]. While undertaking attempts to explain the
relationship between experiencing reflux symptoms and stress, the researchers refer
to the presence of a strong relationship between the degree of emotional tension
accompanying stress and a decreased threshold of pain sensitivity. It was also
observed that patients with reflux disease emphasize the inability to control pain and
the randomness with which pain occurs. At the same time, they are strongly
convinced that there is a relationship between their psychological condition and the
intensity of the complaints experienced[16,17]. An important study that cast light on the
relationship between stress and the heartburn symptoms was by Farré et al[18]
examining the effect of stress on the esophageal mucosa of rats. The researchers traced
changes in the esophageal mucosa using electron microscopy and concluded that
strong stress may result in an increase in permeability of the esophageal mucosa. They
also observed an enhanced effect between stress and exposure of the esophageal
mucosa to acid, leading to increased permeability and dilatation of intracellular
spaces. Additionally, obesity and being overweight are related to GERD. Epidemiolo-
gical studies demonstrate that a high percentage of GERD patients are overweight or
obese[19-21], and in a population of nurses, Jakobson et al[22] observed a nearly linear
increase in GERD risk ratio with an increase in body mass index (BMI). One factor
that correlated with GERD symptoms was lower esophageal sphincter pressure and
higher intragastric pressure[20,23]. Simultaneously, an increase in body weight is
negatively correlated with the level of HRQL, both in the case of somatically healthy
individuals[24] and in the case of a number of diseases where, apart from the
symptoms of the main disease, it is an additional factor that decreases patient
HRQL[25-28].
Aim
The primary goal of the study was to determine the independent effect of reflux
symptoms, stress and increasing BMI on the quality of life of patients using the SF-36
questionnaire.
MATERIALS AND METHODS
The study protocol was approved by the Institutional Ethic Committee at the Institute
of Rural Health in Lublin, Poland. Assessment of the level of reflux symptoms was
based on five symptoms considered typical of GERD. The frequency of each symptom
was rated by the respondent on the 5-point Likert-type scale. These were: (1)
Heartburn after meals (scores from 0- never to 4- after every meal/almost after every
meal); (2) Heartburn in a lying position (scores from 0- never to 4- always/almost
always); (3) Waking from sleep due to heartburn (scores from 0- never to 4- every
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Gorczyca R et al. Impact of gastroesophageal reflux disease on the quality of life
1423
night/almost every night); (4) Regurgitation; and (5) Acid reflux (scores from 0- never
to 4- always/almost always). The sum of ratings was transformed into a 0-100 range.
The transformed score represents the percentage of the possible maximum score
achieved. It was taken as a measure of the overall level of reflux symptoms (ORS).
Reliability measured using Cronbach’s alpha homogeneity coefficient for ORS was
0.83, which suggests a good level of homogeneity of the scale.
HRQL was measured by a generic questionnaire, 36-item Short Form Health
Survey (SF-36), which measures the quality of life across eight domains: (1) Physical
function (PF); (2) Role limitations due to physical problems (RP); (3) Bodily pain (BP);
(4) General health perceptions (GH); (5) Vitality (Vt); (6) Social function (SF); (7) Role
limitations due to emotional problems (RE); and (8) Mental health perceptions (MH).
In addition, single item scale Health Transition (HT) identifies perceived change in
health in the last year. Based on eight basic scales, two standardized summary scales
are calculated: Physical Component Summary (PCS) and Mental Component Sum-
mary (MCS), which represent the physical and mental dimensions of HRQL,
respectively. Calculating the results within these two dimensions, the authors of the
test provided the values of factor score coefficients for eight individual scales of the
test in each dimension, calculated based on a validation study in the United States.
Stress levels were measured using the S. Kohen 10-item Perceived Stress Scale (PSS-
10) as adapted by Juczyński and Ogińska-Bulik[29].
Study population
The study included 127 patients aged 19-64 diagnosed with reflux disease at various
phases of treatment, who reported to a specialist outpatient department of gastroen-
terology or a specialist hospital ward for planned diagnostic tests. Each patient who
met the preliminary criteria of age and health status and expressed consent to
participate in the study participated in a research session carried out by a psycho-
logist. The study was conducted with each patient individually or in small groups of
up to four patients. Ultimately, the results of 118 patients, 43 (36.4%) males and 75
(63.6%) females, were considered in the analyses.
Statistical analysis
Statistical analyses were performed using the statistical package SPSS v.22. The results
of eight SF-36 scales were expressed in the form of transformed scores, i.e. the
percentage of the row score to the maximum possible score in the given scale. For
each of the eight scales, the value 0 was assigned to the worst and 100 to the best
quality of functioning. Standardized results according to the PCS and MCS scales
were converted, according to the instruction, into T-scores, with the mean 50 and
standard deviation 10. Evaluations of changes in the state of health remained in raw
form, i.e. according to the 5-point scale within the range of values from 1-5. Multi-
variable relationships were analyzed using multiple regression. Eleven models of
analysis were performed in which the subsequent scale of the SF-36 was included as
an explained variable. In all models, the same set of explanatory variables (gender,
age, GERD symptoms (ORS), stress (PSS-10), and BMI) was included. Analyses were
performed using the backward elimination technique, the final effect of which is
leaving in the model only the set of variables that have a significant effect on the
explained variable.
RESULTS
In the examined population, females were older than males (P = 0.004): Mean age 48.4
± 12.09 and 41.8 ± 13.21, respectively. Also, females had a lower BMI compared to
males: 24.7 ± 4.51 and 26.0 ± 3.37), respectively (P = 0.034). However, the two groups
did not significantly differ according to the frequency of GERD symptoms (mean
value for the examined population was 45.0 ± 25.26), nor by the mean value of any of
the SF-36 scales and the stress level. The age group < 50 had a lower BMI value (24.0 ±
3.78, within the normal range) than the age group > 50 years (26.4 ± 4.25, overweight,
P = 0.003). These groups did not differ by the level of GERD symptoms or by stress
level. In the HRQL examination, the older group showed a generally lower level of PF
than the younger group (PCS: 41.7 ± 7.92 and 47.6 ± 6.33, respectively, P < 0.0001). In
the case of detailed scales, significant differences were noted to the disadvantage of
the older group in the scales: PF, RP, BP, GH, and also in the RE scale (Table 1).
The frequency of GERD symptoms resulted in a decrease in patients’ results
according to six out of eight F-36 scales. Only in two scales, MH and Vt, the effect of
GERD symptoms was insignificant. Consequently, a significant decrease in the results
under the effect of symptoms was observed according to both PSC and MSC sum-
mary scales.
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Gorczyca R et al. Impact of gastroesophageal reflux disease on the quality of life
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Table 1 Mean values of variables analyzed in the study population in general and according to gender and age
Variable
Sex Age
Total, n = 118
M, n = 43 F, n = 75 Sig.< 50 yr, n = 62 ≥ 50 yr, n = 56 Sig.
Age 41.8 (13.21) 48.4 (12.09) 0.0044 NA NA NA 46.0 (12.86)
BMI 26.0 (3.37) 24.7 (4.51) 0.034 24.0 (3.78) 26.4 (4.25) 0.003 25.2 (4.17)
GERD symptoms 47.6 (26.4) 43.6 (24.65) 0.43 44.4 (23.24) 45.7 (27.53) 0.75 45.0 (25.26)
Stress 19.9 (6.87) 18.8 (3.79) 0.65 18.5 (4.98) 20.0 (5.2) 0.13 19.2 (5.13)
PF 79.8 (19.88) 78.7 (17.69) 0.54 87.1 (12.66) 70.3 (19.85) 0.000001 79.1 (18.44)
RP 60.3 (29.06) 61.7 (22.12) 0.88 67.1 (24.59) 54.6 (23.43) 0.011 61.2 (24.76)
BP 51.3 (29.45) 42.8 (21.18) 0.12 50.4 (25.41) 40.9 (23.19) 0.027 45.9 (24.74)
GH 53.0 (20.46) 52.4 (16.44) 0.96 58.9 (18.51) 45.7 (14.5) 0.00003 52.6 (17.92)
Vt 47.7 (17.31) 51.1 (17.19) 0.42 51.7 (16.29) 47.7 (18.14) 0.21 49.8 (17.23)
SF 62.5 (23.31) 64.0 (24.05) 0.74 65.3 (24) 61.4 (23.39) 0.35 63.5 (23.69)
RE 65.5 (29.07) 68.8 (24.05) 0.70 74.5 (24.97) 60.0 (25) 0.0022 67.6 (25.92)
MH 56.5 (18.47) 55.5 (17.18) 0.49 57.4 (17.15) 54.2 (18.06) 0.39 55.9 (17.59)
HT 3.5 (1.03) 3.4 (0.84) 0.62 3.3 (0.84) 3.6 (0.97) 0.12 3.4 (0.91)
PCS 45.7 (8.69) 44.3 (7.07) 0.42 47.6 (6.33) 41.7 (7.92) 0.000068 44.8 (7.69)
MCS 39.1 (11.47) 40.4 (10.38) 0.73 40.9 (10.78) 38.9 (10.74) 0.39 39.9 (10.76)
NA: Not applicable; BMI: Body mass index; GERD: Gastro-esophageal reflux disease; PF: Physical functioning; RP: Physical problems; BP: Bodily pain; GH:
General health perceptions; Vt: Vitality; SF: Social functioning; RE: Role limitations due to emotional problems; MH: Mental health perceptions; HT: Health
Transition; PCS: Physical Component Summary; MCS: Mental Component Summary.
Stress resulted in a decrease in patient function in all domains and dimensions
measured using the SF-36. PF decreased as age increased, according to the results of
both PF scale and PCS. Age was also the factor resulting in a decrease in overall
assessment of self-reported state of health (GH). An increasing BMI exerted a negative
effect on physical fitness (PF) and limitations in functioning resulting from this
decrease (RP). Notably, it also caused limitations in social relations that resulted from
emotional disorders (RE) (Table 2).
DISCUSSION
In the present study of the quality of life of patients with GERD, the control group
was not considered. To compensate for this deficiency, the results of our studies using
SF-36 (Lublin) were compared with the results obtained in a random sample of 8801
inhabitants of Great Britain drawn from General Practitioner Records held by the
Health Authorities for Berkshire, Buckinghamshire, Northamptonshire, and Oxford-
shire (GBS), and the subpopulation of chronically ill patients in this sample (GBS-
longstanding illness)[30]. The sample covered 8,801 patients aged 18-64, including
43.4% of males and 55.6% of females. The groups (GBS and Lublin) were not
significantly different according to age or gender (Figure 1).
Patients from Lublin showed a lower quality of life in all eight domains compared
to GBS (significance of differences was analyzed using t-Student test). Compared to
the GBS long-standing illness, they did not significantly differ according to the PF and
Vt scales. The highest difference between the quality of the assessed domains was
observed for BP. It occupied the lowest position in the Lublin population, while it was
ranked 30 scores higher in the GB sample. Similarly, in American studies[31], 533 adults
with a history of heartburn symptoms showed a lower quality of functioning in all
eight domains compared to the general United States population.
Regression analysis demonstrated that stress and reflux complaints were two
separate sources of the effect on HRQL in the general measures of physical and
psychological functioning, as well as individual domains considered in SF-36. The
strength of the effect of stress is especially noteworthy, as stress was the factor that
decreased the HRQL in all domains and spheres (PCS, MCS). In the Vt and MH
domains, stress remained the only variable that caused deterioration of the results. It
is difficult to unequivocally refer to the dominant position of stress in the examined
group, especially considering the fact that the sample selection for the study was not
random, and it cannot be excluded that it favored more frequent occurrence among
respondents distressed over the general GERD patient population[32]. The effect of
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Table 2 Effect of selected variables on health-related quality of life measured using SF-36
Variable explained (percent of variability explained1) Explanatory variables2Beta Sig.
PF (41%) Stress -0.37 0.000002
Age -0.31 0.000097
BMI -0.24 0.0022
GERD Symptoms -0.15 0.045
RP (36%) Stress -0.47 < 0.000001
BMI -0.26 0.0006
GERD Symptoms -0.18 0.022
BP (29%) Stress -0.41 0.000002
GERD Symptoms -0.25 0.002
Sex (1 = M, 2 = F) -0.17 0.028
GH (37%) Stress -0.43 < 0.000001
Age -0.31 0.00005
GERD Symptoms -0.17 0.028
Vt (45%) Stress -0.67 < 0.000001
SF (32%) Stress -0.49 < 0.000001
GERD Symptoms -0.21 0.010
RE (44%) Stress -0.56 < 0.000001
GERD Symptoms -0.21 0.004
BMI -0.20 0.005
MH (59%) Stress -0.77 < 0.000001
PCS (30%) Stress -0.29 0.00041
Age -0.35 0.000017
GERD Symptoms -0.22 0.0061
MCS (53%) Stress -0.68 < 0.000001
GERD Symptoms -0.13 0.047
1Adjusted R square × 100;
2Variables: Stress, age, PF and BP were transformed to minimize their skewness. PF: Physical functioning; RP: Physical problems; BP: Bodily pain; GH:
General health perceptions; Vt: Vitality; BMI: Body mass index; GERD: Gastro-esophageal reflux disease; SF: Social functioning; RE: Role limitations due to
emotional problems; MH: Mental health perceptions; PCS: Physical Component Summary; MCS: Mental Component Summary.
stress on the domains of PF might have been partly an artifact of the method of
measuring functioning in this sphere. SF-36 does not measure the actual level of PF,
but the subjective self-evaluations of patients. These self-evaluations, under the effect
of long-term stress accompanied by low mood and overall self-esteem, might have
been subject to a disproportional decrease in actual fitness. The use of objective
measures of the quality of PF would be a desired supplementation to the study.
Notably, HRQL measurement using SF-36 questionnaire does not consider a several
domains of functioning that are potentially important for the quality of life, such as
intimate relations and sexual activity. Among patients with GERD, impaired sexual
activity and avoidance of intimacy due to the disease is often observed[33]. On the
other hand, SF-36 omits a widely-handled spiritual sphere- beliefs and religious
activity, participation in culture- reading, interests and artistic activity.
Apart from stress and reflux complaints, increasing BMI had a limited effect on
HRQL. This resulted in a decrease in the quality of life in the PF and RP domains.
However, it increased the probability of occurrence of situations when emotional
disorders lead to problems in relations with others and limitations in the frequency of
social contacts (RE). In a survey of more than 3000 adults, Carr and Friedman[34] did
not observe any deterioration in the quality of relations with others as BMI increased,
except for severely obese people who experienced a higher level of tension and less
support in family relations. Nevertheless, in a randomized British study, a negative
effect of BMI was confirmed on the level of social functioning of females[35].
Correlation analyses do not allow for conclusions to be drawn concerning the
cause-effect relationships between variables. Correlation and regression coefficients
provide quantitative estimations of common variability of the analyzed variables,
while determination of the directions of relationships between variables is of a non-
statistic character and is based mainly on essential knowledge concerning relations in
a given domain. Hence, conclusions drawn from correlation analyses do not possess
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Figure 1
Figure 1 Mean scores for the 8 scales of SF-36 for GB samples and Lublin sample. PF: Physical functioning;
RP: Physical problems; BP: Bodily pain; GH: General health perceptions; Vt: Vitality; SF: Social functioning; RE: Role
limitations due to emotional problems; MH: Mental health perceptions; GBS: General Practitioner Records held by the
Health Authorities for Berkshire, Buckinghamshire, Northamptonshire, and Oxfordshire.
the status of hypotheses, but rather the accuracy of which strengthens the scientific
plausibility of the correlations revealed. Properly planned longitudinal studies may
provide the ultimate solution.
The level of HRQL in patients with GERD is negatively determined by both the
frequency of reflux symptoms and, to an even higher degree, by stress. An increasing
BMI, irrespective of reflux symptoms, stress, and age, decreases the level of PF of
GERD patients. It also leads to an increase in limitations in functioning ascribed to
emotional disorders. The patient’s stress level should be considered in diagnosis and
therapy, as well as an assessment of treatment progress.
ARTICLE HIGHLIGHTS
Research background
Gastro-esophageal reflux disease (GERD) is a common and serious health problem leading to a
decrease in the quality of life of patients. The concept of health-related quality of life (HRQL)
covers an expanded effect of the disease on a patient’s wellbeing and daily activities. This study
evaluates the effect of GERD symptoms and factors that cause decrease in quality of life, such as
stress level, age and body weight.
Research motivation
Since GERD leads to a considerable decrease in the quality of life, we conducted an observational
study to assess the importance of its impact on the eight domains of life (physical functioning
(PF), role limitations due to physical problems, bodily pain (BP), general health perceptions,
vitality (Vt), social functioning, role limitations due to emotional problems and mental health
perceptions) measured in a generic questionnaire. Moreover, we evaluated the importance of
stress, excessive weight and age on the above-mentioned domains.
Research objectives
The research objective was to determine the independent effect of reflux symptoms, age, stress
and increasing body mass index (BMI) on the quality of life of patients using the SF-36
questionnaire.
Research methods
A total of 118 patients diagnosed with reflux disease who reported to an outpatient department
of gastroenterology or a specialist hospital ward for planned diagnostic tests were recruited.
Assessment of the level of reflux was based on five typical GERD symptoms, HRQL was
measured by a 36-item Short Form Health Survey and level of stress using the 10-item Perceived
Stress Scale. Multi-variable relationships were analyzed using multiple regression. The results of
our study were compared with the results obtained in a random sample of 8801 inhabitants of
Great Britain drawn from General Practitioner Records held by the Health Authorities for
Berkshire, Buckinghamshire, Northamptonshire, and Oxfordshire and the subpopulation of
chronically ill patients in this sample.
Research results
In the examined population, the frequency of reflux symptoms resulted in a decrease in patients’
results according to six out of eight SF-36 scales-except for mental health and Vt scales. Stress
resulted in a decrease in patient function in all domains measured using the SF-36. Age resulted
in a decrease in PF and in an overall assessment of self-reported state of health. An increasing
BMI exerted a negative effect on physical fitness and limitations in functioning resulting from
this decrease. When compared to the GBS group, patients from our study showed a lower
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quality of life in all eight life domains. In turn, compared to the GBS-longstanding illness group,
they did not significantly differ according to the PF and Vt scales. The largest difference between
the quality of the assessed domains was observed for BP, which in the Lublin population
occupied the lowest position, lower by 30 scores than in GB sample.
Research conclusions
The level of HRQL in GERD patients is negatively determined by both the frequency of reflux
symptoms and, to an even higher degree, by stress. An increasing BMI, irrespective of reflux
symptoms, stress, and age, decreases the level of PF of GERD patients. It also leads to an increase
in limitations in functioning ascribed to emotional disorders. The patient’s stress level should be
considered in the diagnosis and therapy, as well as in the assessment of treatment progress.
Research perspectives
In our study, the stress level reported by the patient turned out to be more important for HRQL
than the severity of gastroesophageal reflux disease. Future studies assessing the impact of
diseases on HRQL should take into account factors that are not symptoms of the disease.
Moreover, in assessing the effectiveness of treatment, we should take into account the impro-
vement of HRQL as well as the reduction of disease-related symptoms.
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