GERD and extraesophageal symptoms
Many patients seek care from pulmonologists and otolaryngologists for what are referred to as extraesophageal symptoms of GERD. In these patients, the typical symptoms of heartburn and regurgitation are usually mild. Otolaryngologic symptoms that have been attributed to GERD include chronic cough, hoarseness, change in voice, dental erosion, and halitosis. It is not uncommon for many of these patients to have a normal laryngeal examination, which does not rule out the potential for underlying reflux disease. GERD is thought to cause cough and to serve as a potential trigger for asthma due to increased bronchial reactivity, increased vagal tone, and the microaspiration of small amounts of gastric refluxate. One systematic review of 28 studies of asthma patients found that 59% had GERD symptoms and 51% had abnormal pH testing [44]. GERD also has been found to be an independent predictor associated with future risk of asthma attacks [45] and is a frequent comorbidity (46%) in patients with difficult‐to‐treat or severe asthma [46]. In patients who have regurgitation, the presence of recurrent pneumonias, fever, and chronic cough is suggestive of aspiration. For many extraesophageal symptoms, however, causality has not been established. The role that GERD plays as the unifying diagnosis of these symptoms is often overestimated, and in many patients, the underlying etiology is often multifactorial. It is therefore important that the management of patients with extraesophageal symptoms includes a collaboration with otolaryngology and pulmonology. As part of their evaluation, many patients undergo an empiric trial of acid‐suppressive therapy, followed by formal ambulatory pH testing in those who fail therapy. The evaluation and management of otolaryngologic and pulmonary symptoms and complications of GERD are discussed further in Chapters 11, 31, and 32.
Healthcare utilization and quality of life
Esophageal disease is a significant source of symptoms for patients worldwide, and as a result, its impact on the health care system and quality of life (QoL) is significant. In one study of almost 72,000 patients who reported experiencing at least one GI symptom within the previous week, nearly one‐third experienced heartburn or regurgitation [47]. In the United States in 2015, health care expenditures for gastrointestinal diseases totaled $135.9 billion, and esophageal disease was the second most expensive category ($18.1 billion). Prescription medications accounted for 54% of the total expenditures for esophageal disorders, and from 2011 to 2015, approximately $60 billion was spent on acid‐suppressing medications. In 2014, GERD was the second‐leading gastrointestinal disease diagnosed by physicians in the ambulatory care setting [48].
GERD symptoms also have been shown to have a significant impact on workplace productivity. One retrospective case‐control analysis of employee health care and payroll data in the United States showed that employees with GERD had 41% more sick leave days, 4.4% lower objective productivity per hour, and 6% lower annual objective productivity [49]. This was shown in an additional US study in which 41% of GERD patients reported lost work productivity due to their disease, with the calculated average loss per GERD patient equaling $237 over a three‐month period. A major cited reason was needed time off for physician visits [50]. Similar findings have also been seen in other US [51, 52] and European studies. One German study estimated that the loss of gross domestic product due to GERD symptoms amounted to 668 million euros/year [53]. The average sick leave time attributable to reflux was 1.4 workdays in a three‐month span [54].
Symptom and quality of life assessment tools
The impact that symptoms have on a patient’s QoL can be assessed in several ways. A general questionnaire, such as the Short Form (SF)‐36 [55], evaluates QoL irrespective of the disease state. However, a generic measurement tool does not allow for the assessment of symptoms specific to certain diseases. Instead, symptom‐based assessment, or disease‐specific instruments, take into account the important features of a certain disease state, which are not captured by the more generic assessment tools.
The use of symptom and QoL assessment tools has been extensively evaluated in patients with GERD, a group that has consistently scored lower on all domains of the SF‐36 [56]. While many questionnaires have been developed, there has been an overall lack of valid, reliable, and easy‐to‐use assessment tools to evaluate GERD symptoms and to monitor response to treatment [57]. Each symptom or QoL assessment tool has its own advantages and disadvantages, and this reflects the difficulty in developing a tool that captures GERD symptoms that often vary significantly across patients. An ideal assessment tool should be able to (i) monitor symptoms both daily and over time; (ii) evaluate both daytime and nocturnal symptoms; (iii) assess both typical and atypical symptoms; (iv) incorporate questions regarding general well‐being; (v) be able to be used before, during, and after treatment to assess for response; (vi) allow for self‐assessment; and (vii) be available across multiple languages. In addition, an ideal tool should have proven psychometric properties (validity, reliability, and sensitivity), have the flexibility to respond to changes in patient symptoms, and be easy to understand [57]. A summary of different GERD assessment tools, along with some strengths and weaknesses of each, is presented in Table 1.6.
Improvement in patient symptoms and QoL is an important treatment outcome, and further tools have been developed to assess response to treatment including the GERD Treatment Satisfaction Questionnaire [58] and the Gastroesophageal Reflux Disease‐Health Related Quality of Life (GERD‐HRQL) instrument [59], which measures symptom severity and assesses treatment response to medications and surgery for GERD. Numerous studies have shown the positive effect that acid‐suppressive medications [60–64] and antireflux surgery [65, 66] have on GERD patients’ QoL. Proton pump inhibitor (PPI) use has been shown to restore patient QoL to levels comparable with that seen in a healthy population [60]. While the use of H2‐receptor antagonists does improve QoL, PPIs have been shown to have a more pronounced effect [67, 68].
While numerous GERD assessment and QoL instruments have been developed, fewer have been developed to assess symptoms and QoL in patients with dysphagia. As in GERD, patients with dysphagia also have been found to score lower on the SF‐36. The 27‐item Mayo Dysphagia Questionnaire (MDQ) broadly assesses esophageal dysphagia, but not dysphagia due to any specific underlying disease state [69]. The Swallowing Quality of Life questionnaire (SWAL‐QOL) [70] and M.D. Anderson Dysphagia Inventory [71] measure QoL in patients with oropharyngeal dysphagia and head and neck cancer. Two symptom and QoL assessment tools have been used in adult [72] and pediatric [73] patients with eosinophilic esophagitis. In achalasia, as is common in other diseases, symptom severity and health‐related QoL as experienced by the patient are often independent of the patient’s physiologic parameters [74]. The Measure of Achalasia Disease Severity (ADS) questionnaire is a 10‐question survey that assesses achalasia on health‐related QoL and evaluates dysphagia to both liquids and solids, specific types of food, other associated symptoms, and impact of symptoms on overall health [74, 75]. The Eckardt score, which is a widely‐used four‐question survey, assesses the burden of weight loss, dysphagia, retrosternal pain, and regurgitation [76]. Both are valid surveys that can be used to assess achalasia patient symptoms and QoL pre‐ and post‐treatment [77]. Heller myotomy and pneumatic dilation have both been shown to improve patient QoL [78–82].
Table 1.6 Available assessment tools for patients with GERD.
Source: Adapted from Fass [57].
| Instrument name | Brief summary | Strengths | Weaknesses |
|---|---|---|---|
| GERD score [83] |
|