Relationship of Gastroesophageal Flap Valve with Gastroesophageal Reflux Disease Assessed Based on GerdQ Scores and Endoscopic Images

Abstract

Background: Gastroesophageal reflux disease (GERD) is a condition where reflux of stomach contents causes troublesome symptoms or complications. The gastroesophageal flap valve (GEFV) is one of the protective structures against esophageal reflux. This study aimed to determine the relationship between GEFV, measured by Gastroesophageal Reflux Disease Questionnaire (GerdQ) scores, and the endoscopic features of GERD patients. Method: This observational cross-sectional study was performed at Wahidin Sudirohusodo Hospital Makassar from August 2021 to October 2021. The participants were GERD patients who met the inclusion criteria. They were diagnosed using GerdQ scores and endoscopic features based on the Los Angeles criteria. The GEFV was assessed using retroflection endoscopy according to Hill’s criteria. Data analysis used SPSS version 25. The Kolmogorov–Smirnov test was used to assess data normality, along with the Chi-square test and calculation of odds ratio (OR). The results of the statistical tests were significant if p<0.05. Results: This study included 100 GERD patients: 49 men and 51 women. They had a mean age of 40.5±12.8 years and a mean body mass index of 22.4±3.8 kg/m2. Abnormal GEFV was a risk for a GerdQ score of ≥8 compared to <8 (OR 4.56; 95% CI 1.53–13.52). Both normal and abnormal GEFV in esophagitis reflux were higher than in non-erosive reflux disease (p=0.943). Conclusion: Abnormal GEFV was a risk factor for GERD based on a GerdQ score of 8, at 4.56 times higher than with normal GEFV. No statistically significant relationship existed between GEFV and endoscopic images.

Full text

Open Access Maced J Med Sci. 2022 May 12; 10(B):1991-1995. 1991
Scientic Foundation SPIROSKI, Skopje, Republic of Macedonia
Open Access Macedonian Journal of Medical Sciences. 2022 May 12; 10(B):1991-1995.
https://doi.org/10.3889/oamjms.2022.9817
eISSN: 1857-9655
Category: B - Clinical Sciences
Section: Gastroenterohepatology
Relationship of Gastroesophageal Flap Valve with Gastroesophageal
Reux Disease Assessed Based on GerdQ Scores and Endoscopic
Images
Andi Fithrani Neilufar1*, Fardah Akil2, Nu’man A. S. Daud2, Syakib Bakri3, Haerani Rasyid3, Hasyim Kasim3,
Andi Makbul Aman4, Arin Seweng5
1Department of Internal Medicine, Faculty of Medicine, Hasanuddin University, Makassar, Indonesia; 2Division of
Gastroenterohepatology, Department of Internal Medicine, Faculty of Medicine, Hasanuddin University, Makassar, Indonesia;
3Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Hasanuddin University, Makassar, Indonesia;
4Division of Metabolic Endocrine, Department of Internal Medicine, Faculty of Medicine, Hasanuddin University, Makassar,
Indonesia; 5Department of Biostatistics, Public Health Faculty, Hasanuddin University, Makassar, Indonesia
Abstract
BACKGROUND: Gastroesophageal reux disease (GERD) is a condition where reux of stomach contents causes
troublesome symptoms or complications. The gastroesophageal ap valve (GEFV) is one of the protective structures
against esophageal reux.
AIM: This study aimed to determine the relationship between GEFV, measured by GERD questionnaire (GerdQ)
scores, and the endoscopic features of GERD patients.
METHODS: This observational cross-sectional study was performed at Wahidin Sudirohusodo Hospital Makassar
from August 2021 to October 2021. The participants were GERD patients who met the inclusion criteria. They were
diagnosed using GerdQ scores and endoscopic features based on the Los Angeles criteria. The GEFV was assessed
using retroection endoscopy according to Hill’s criteria. Data analysis using SPSS version 25. The Kolmogorov–
Smirnov test was used to assess data normality, along with the Chi-square test and calculation of odds ratio (OR).
The results of the statistical tests were signicant if p < 0.05.
RESULTS: This study included 100 GERD patients: 49 men and 51 women. They had a mean age of 40.5 ±
12.8 years and a mean body mass index of 22.4 ± 3.8 kg/m2. Abnormal GEFV was a risk for a GerdQ score of ≥8
compared to <8 (OR 4.56; 95% CI 1.53–13.52). Both normal and abnormal GEFVs in esophagitis reux were higher
than in non-erosive reux disease (p = 0.943).
CONCLUSION: Abnormal GEFV was a risk factor for GERD based on a GerdQ score of 8, at 4.56 times higher than
with normal GEFV. No statistically signicant relationship existed between GEFV and endoscopic images.
Edited by: Ksenija Bogoeva-Kostovska
Citation: Neilufar AF, Akil F, Daud NAS, Bakri S,
Rasyid H, Kasim H, Aman AM, Seweng A. Relationship
of Gastroesophageal Flap Valve with Gastroesophageal
Reux Disease Assessed Based on GerdQ Scores and
Endoscopic Images. Open-Access Maced J Med Sci.
2022 May 12; 10(B):1991-1995.
https://doi.org/10.3889/oamjms.2022.9817
Keywords: Gastroesophageal reux disease;
Gastroesophageal reux disease questionnaire; Reux
esophagitis; Helicobacter pylori; Body mass index
*Correspondence: Andi Fithrani Neilufar. Department
of Internal Medicine, Faculty of Medicine, Hasanuddin
University, Makassar, Indonesia.
E-mail: thranineilufar@gmail.com
Received: 15-Apr-2022
Revised: 26-Apr-2022
Accepted: 02-May-2022
Copyright: © 2022 Andi Fithrani Neilufar, Fardah Akil,
Nu’man A. S. Daud, Syakib Bakri, Haerani Rasyid,
Hasyim Kasim, Andi Makbul Aman, Arin Seweng
Funding: This research did not receive any nancial
support
Competing Interest: The authors have declared that no
competing interest exists
Open Access: This is an open-access article distributed
under the terms of the Creative Commons Attribution-
NonCommercial 4.0 International License (CC BY-NC 4.0)
Introduction
Gastroesophageal reux disease (GERD),
which is commonly found in Western countries, has
recently been reported to have an increased incidence
in Asian countries [1]. Although it rarely causes death,
GERD is associated with considerable morbidity and
complications such as peptic stricture and Barrett’s
esophagus in up to 20% of cases. GERD is also a
condition that can signicantly impair quality of life,
especially since it is accompanied by irritative bowel
syndrome and psychological stress in 36% and 41% of
patients, respectively, due to failure to respond to acid
antisecretory therapy [2], [3].
Many tests are available to evaluate patients
with suspected GERD, including questionnaire tests,
proton-pump inhibitor trials, radiology, endoscopy, and
impedance manometry. Some tests are sometimes
unnecessary because the classic symptoms of
heartburn and acid regurgitation are specic enough
to identify reux disease and initiate medical therapy.
The GERD questionnaire (GerdQ) is an easy-to-use
6-item objective clinical questionnaire developed
as a diagnostic tool for GERD in patients in primary
facilities [4], [5], [6].
The pathogenesis of GERD is complex and
results from an imbalance between the defensive
factors that protect the esophagus (antireux
protection, esophageal acid clearance, and tissue
resistance) and the aggressive factors of gastric reux
(gastric acidity, duodenal volume, and contents). The
gastroesophageal ap valve (GEFV) is one of the
protective structures against reux of the esophagus
and plays a role in the development of hiatal hernia as
a pathophysiological factor that triggers reux in GERD.
Since gastroesophageal reux is primarily caused
by gastroesophageal junction (GEJ) incompetence,
Since 2002

B - Clinical Sciences Gastroenterohepatology
1992 https://oamjms.eu/index.php/mjms/index
the estimated GEJ opening based on retroexed
endoscopic examination can provide useful information
in the evaluation of cases with suspected GERD [7], [8].
The GEFV in GERD has not been widely
studied. In Indonesia, GEFV as a predictor of reux
and its relationship with GERD scores and endoscopic
features have not been studied to date. This study
aimed to investigate the distribution of GEFV in patients
with suspected GERD and any relationship between
GEFV and GERD incidence based on GerdQ score and
GERD endoscopic appearance.
Methods
Research design
This was an observational cross-sectional
study based on medical record data. The research
was carried out at Dr. Wahidin Sudirohusodo Hospital
Makassar, Indonesia, following a protocol approved
by our institution’s ethics committee (number: 546/
UN4.6.4.5.31/PP36/2021). The study was carried out
from August 2021 to October 2021. Our work is reported
following the criteria of Strengthening the Reporting of
Cohort Studies [9], [10].
The population of this study included all patients
with a diagnosis of GERD who were outpatients or
inpatients and underwent endoscopy at our institution.
The research sample was taken from the population
meeting the research inclusion criteria: Patients aged
>18 years, with typical symptoms of GERD, who
underwent esophagogastroduodenoscopy (EGD)
examination, were not pregnant, and had no history of
gastric surgery. In purposive sampling, the data were
already available and taken according to the inclusion
criteria.
A total of 100 patients were selected using
purposive sampling. From the calculations obtained,
a minimum sample size of 100 patients was identied.
Clinical diagnosis of GERD can be made using the
GerdQ questionnaire, according to the Diamond
study [4]. A low chance of GERD is reected by scores
<8, and GERD is suggested by scores ≥8. Endoscopic
examination of GERD patients evaluated the presence
of complications in the esophageal mucosa distal to the
lower esophageal sphincter (LES) in the form of mucosal
damage, strictures, or Barrett’s esophagus. Assessment
of the severity of mucosal damage used the Los Angeles
classication of Grades A, B, C, and D [8], [11].
The GEFV is a morphological component of
the GEJ in the form of a musculomucosal fold created
by the angle of entry of the esophagus into the stomach,
extending 3–4 cm along the curve of the curvature
minor [12]. The degree of GEFV and its signicance
on endoscopic retroection were assessed according
to Hill’s classication [6], [13], [14]. We classied age
according to the World Health Organization (WHO).
The body mass index (BMI) was calculated using the
following formula: Weight (kg)/[height (m)]2 [15]. We
classied BMI according to the WHO [8].
Data analysis
Data analysis was performed using SPSS
version 25 (IBM Corp. Released 2017. IBM SPSS
Statistics for Windows, Version 25.0. Armonk, NY,
USA: IBM Corp.). The statistical analysis performed
was descriptive statistical calculation and frequency
distribution, using the Kolmogorov–Smirnov test to
assess the normality of the data as well as the Chi-
square test. The results of the statistical tests were
signicant if p <0.05 was considered.
Results
Participant characteristics
Data analysis was performed on 100 GERD
patients (Table 1) aged 19–77 years, with a mean
age of 40.5 ± 12.8 years. The majority were aged
<35 years (42; 42%). Based on BMI, with a mean of
22.4 ± 3.8 kg/m2, 43% of participants had a normal
weight, and 42% were overweight.
Table 1: Participant characteristics
Variable n%
Gender
Female 51 51
Male 49 49
Age (years)
35 42 42
35–50 37 37
>50 21 21
BMI (kg/m2)
<18.5 15 15
18.5–24.9 43 43
>25 42 42
H. pylori
Positive 5 5
Negative 95 95
GerdQ score
<8 17 17
≥8 83 83
GERD on endoscopy
NERD 31 31
eGERD A 54 54
eGERD B 10 10
eGERD C 3 3
eGERD D 2 2
GEFV
113 13
223 23
352 52
4 12 12
BMI: Body mass index, GerdQ: GERD questionnaire, GERD: Gastroesophageal reux disease,
GEFV: Gastroesophageal ap valve.
Helicobacter pylori were found in 5 participants
(5%), and 95 (95%) had GERD without H. pylori
infection. The majority of participants had a GerdQ
score of ≥8 (83; 83%), and 17 (17%) had a GerdQ score
of <8. The results of the EGD examinations showed
that the most common GERD grade was GERD A (54;

Neilufar et al. Relationship of gastroesophageal ap valve
Open Access Maced J Med Sci. 2022 May 12; 10(B):1991-1995. 1993
54%), followed by non-erosive reux disease (NERD;
31; 31%), GERD B (10; 10%), GERD C (3; 3%), and
GERD D (2; 2%). Based on the distribution of GERD
grades, 69 participants (69%) had erosive GERD.
The results of the retrograde EGD examinations
showed that the most common GEFV degree was
Grade 3 (52; 52%), followed by Grade 1 (13; 13%),
Grade 2 (23; 23%), and Grade 4 (12; 12%). Therefore,
64 participants (64%) belonged to the abnormal GEFV
group.
Relationship of GEFV with GerdQ score
Based on the degree of normal and abnormal
GEFV, in normal GEFV, more subjects had a GerdQ score
of ≥8 than <8 (66.7% vs. 33.2%). In abnormal GEFV,
more subjects had a GerdQ score of ≥8 than <8 (92.2%
vs. 7.8%). This di󰀨erence was statistically signicant
(p = 0.001). Abnormal GEFV had a 4.56 times greater
risk of a GerdQ score of ≥8 compared to <8. Abnormal
GEFV was a risk for a GerdQ score of ≥8 compared to
<8 odds ratio (OR) 4.56; 95% CI 1.53–13.52; Table 2.
Table 2: Relationship of GEFV with GerdQ score
GEFV GerdQ score
<8 ≥8
Normal
n 12 24
% 33.3 66.7
Abnormal
n 5 59
% 7.8 92.2
Chi-square test (p = 0.001); OR 4.56; 95% CI (1.53–13.52).
Relationship of GEFV with the endoscopic
appearance
In both normal and abnormal GEFVs, the
incidence of esophagitis reux (ER) was greater
than NERD (69.4% vs. 30.4% and 68.8% vs. 31.3%,
respectively). This di󰀨erence was not statistically
signicant (p > 0.05; Table 3).
Table 3: Relationship of GEFV with endoscopic features of GERD
GEFV GERD end endoscopic picture
NERD Esophagitis reux
Normal
n11 25
% 30.6 69.4
Abnormal
n 20 44
% 31.3 68.8
Chi-square test (p = 0.943).
Discussion
GERD is dened as a symptom or complication
resulting from reux of gastric contents into the
esophagus or further. GERD can be further classied
as the presence of symptoms without erosions on
endoscopic examination (NERD) or symptoms of
GERD in the presence of erosion ER [16]. The GEFV
is a musculomucosal fold at the lower part of the GEJ,
which is seen in the lowest curvature through retrograde
endoscopy [12]. Reux can be caused by disruption
of the esophageal reux protection system, including
the GEFV. The GerdQ is one of the objective clinical
questionnaires developed as an easy-to-use GERD
diagnostic tool in primary care [5].
The GerdQ score indicates the severity of
reux complaints experienced by the patient. The
GEFV is one of the protective anti-esophageal reux
structures and plays a role in the development of hiatal
hernia as a pathophysiological factor that triggers reux
in GERD, so the GerdQ score increases along with the
severity of the GEFV disorder.
This study found that the GerdQ score was
signicantly higher than the severity of GEFV (p = 0.001;
OR 4.56; 95% CI 1.53–13.52). This is in line with Quach
et al. (2018) [11] who found a higher percentage of a
GerdQ of ≥8 in abnormal GEFV.
A previous study by Kaplan et al. [17]
found a relationship between the Reux Symptom
Index Score, a questionnaire that can be used for
laryngopharyngeal reux, with GEFV. In the present
study, a highly signicant relationship existed between
GEFV and GerdQ scores. Abnormalities of the GEFV
are associated with reduced LES length and pressure,
which can increase mechanical damage to the
esophageal sphincter, in turn, increasing exposure to
reux, including acid, which causes heartburn [18], [19].
The rst level of esophageal defense against acid
damage, the antireux barrier, is a complex anatomical
region including the intrinsic LES, crural diaphragm, intra-
abdominal location of the LES, pharyngoesophageal
ligament, and GEFV [20]. The sphincter and valve work
together and prevent strong reux in normal situations.
If the valve that normally feeds the sphincter gives way,
in hernias, smooth muscle abnormalities may lead to
loss of the GEFV and sphincter, then a hiatal hernia
occurs [12], [20]. Acid is considered the main ingredient
that reuxes into the esophagus and causes damage
to the esophageal mucosa or symptoms of GERD.
The acidic component of reux is responsible for ER
development and heartburn complaints [19].
Analyzing the relationship between GEFV and
endoscopic images of GERD patients found that both
normal and abnormal GEFVs had more ER than NERD
(p = 0.943). In normal GEFV, the proportion of NERD
was 30.6%, and ER was 69.4%. In abnormal GEFV,
the proportion of NERD was 31.3%, and ER 68.8%.
This result is not in line with the study by Quach et al.
(2018), where the prevalence of abnormal GEFV also
increased gradually among patients with dyspepsia
and NERD [11]. Lin et al. (2006) [21] demonstrated
a signicantly higher proportion of abnormal GEFV
in patients with ER than in those with NERD. A study
by Pelechas et al. (2013) [22] showed a signicant

B - Clinical Sciences Gastroenterohepatology
1994 https://oamjms.eu/index.php/mjms/index
relationship between the prevalence of mucosal
damage and the degree of GEFV in 406 patients. Wu
et al. (2019) [23] also found that abnormal GEFV was
more common in patients with esophagitis.
Theoretically, more ER should occur in
abnormal GEFV, but in this study, it was also found in
normal GEFV. This may be since, in the normal GEFV
group, many risk factors play a role, but unfortunately,
these factors were not analyzed.
The relatively large sample size and di󰀨erent
methods of data collection add to the strength of the study
and allow the generalizability of its ndings. However,
recall bias, which is common in such studies, and the
use of the GerdQ, which has not yet been validated
in the studied population, are important limitations.
Nonetheless, our ndings highlight the high prevalence
of GERD without H. pylori infection and its association
with sociodemographic and lifestyle characteristics,
which need to be validated by further research.
Our research suggestions are: (a) The GerdQ
score is used to diagnose GERD by assessing the
clinical course of reux patients, but it cannot be used
to diagnose GEFV, because many other factors cause
a high GerdQ score. (b) Abnormal GEFV should be
further treated to overcome GERD problems, especially
in patients with a GerdQ score of ≥8.
Conclusion
Abnormal GEFV was a risk factor for GERD
based on a GerdQ score of ≥8, at 4.56 times higher
than normal GEFV. Although abnormal GEFV ER
incidence was higher than in normal GEFV, ER
incidence was also higher in normal GEFV. This was
probably because other factors also played a role. No
statistically signicant relationship existed between
GEFV and endoscopic images.
Acknowledgments
The authors would like to thank Muhammad
Faruk, MD for his assistance in language polishing and
formatting of this manuscript.
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