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Esophageal hypervigilance common across GERD spectrum
SAN DIEGO — Regardless of physiologic symptoms and acid exposure, patients across the GERD spectrum regularly experience esophageal hypervigilance and symptom-specific anxiety, according to study results presented at Digestive Disease Week.
“People that are hypervigilant are highly focused on the esophagus, on the sensations and any foods that may cause symptoms,” Livia Guadagnoli, a clinical psychology doctoral candidate at the Northwestern University Feinberg School of Medicine, said in her presentation. “There is also typically an activation of the body’s stress system.”
Researchers conducted a retrospective data analysis on a cohort of patients with GERD who underwent 96-hour wireless pH monitoring (n = 117). The primary outcome of the study was to evaluate the differences between positive acid exposure time (AET) and symptom-reflux association (SRA) using the esophageal hypervigilance and anxiety scale (EHAS). Patients also completed questionnaires to assess their symptom severity (GerdQ).
Investigators collected information on pH monitoring according to number of days (0, 1-2, 3-4) of positive AET (time pH < 4 greater than 6%), the number of days with positive SRA (symptom index > 50%). Over the course of pH monitoring, patients would record whenever they experienced GERD symptoms, and researchers compared those reports to acid levels recorded on the implanted chip used during monitoring.
Researchers found that EHAS scores were not different between the number of days of positive AET (29.4 vs. 33.5) or number of days with positive SRA (29.2 vs. 35.3). GerdQ scores were higher for the 3 to 4-day positive groups compared with the 0-day groups in both AET (P = .032) and SRA (P = .008).
Researchers found that that median self-reported symptom frequency was also different among the three AET (5 vs. 10 vs. 6; P = .042) and SRA (4 vs. 7 vs. 12; P < .001) groups.
Guadagnoli said their findings show that psychological processes are present across the GERD spectrum, whether or not patients had active acid exposure.
“Someone that is experiencing 4 straight days of abnormal acid exposure who is consistently experiencing frequent and sever symptoms might be at risk for developing some hypervigilance or even anxiety around those symptoms,” Guadagnoli said. “Just because someone has abnormal acid, doesn’t mean they are exempt from developing the psychological and behavioral processes that might be maintaining the symptoms even despite acid being there.” – by Alex Young
Reference:
Guadagnoli L, et al. Abstract 270. Presented at: Digestive Disease Week; May 18-21, 2019; San Diego.
Disclosures: Guadagnoli reports no relevant financial disclosures. Please see the meeting disclosure index for all other authors’ relevant financial disclosures.
Perspective
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Reflux has recently been subdivided into four phenotypes:
- erosive esophagitis;
- -non-erosive reflux disease (NERD);
- reflux hypersensitivity; and
- functional heartburn.
It is held that the degree of acid exposure decreases, and the likelihood of esophageal hypersensitivity increases as you go down that list. This paper challenges that concept.
The researchers added questionnaires designed to identify esophageal hypervigilance (increased awareness of esophageal symptoms) and anxiety to the routine evaluation of patients undergoing extended (96-hour) wireless pH monitoring. They grouped patients by the number of days with increased esophageal acid exposure and number of days with a positive symptom index (SI). Surprisingly, hypersensitivity and anxiety were not different among those with fewer days of excess acid or those with increase days with a positive SI.
This interesting study challenges the standard teaching in gastroesophageal reflux disease where only patients with normal acid exposure are considered to have functional disease. It has long been known that healing of esophagitis or control of esophageal acid exposure as determined by ambulatory pH testing does not ensure symptom resolution. It has been assumed that is related to incomplete acid suppression or continued reflux of “non-acidic” material. This paper adds another consideration as it suggests hypervigilance to not be isolated to those with less severe acid exposure. What is not clear is how these patients come to be hypervigilant. It is possible that they have baseline hypervigilance that is exacerbated by reflux events, but it is also possible that symptoms of reflux itself may lead to hypervigilance. It has also been demonstrated that infusing acid into the esophagus lowers subsequent tolerance to both acid infusion and balloon distention. This complex interaction between acid reflux and symptoms deserves further study to develop strategies to better control symptoms in reflux patients with difficult to control symptoms.