UCLA questionnaire may shed light on gastrointestinal burdens of systemic sclerosis
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A questionnaire developed at the University of California, Los Angeles, can discriminate patients with systemic sclerosis who have an indication for esophago-gastro-duodenoscopy, according to data published in Arthritis Research & Therapy.
However, there appears to be no association between patients’ score on the questionnaire, called the University of California, Los Angeles, Scleroderma Clinical Trial Consortium Gastrointestinal Tract Instrument 2.0 (UCLA GIT 2.0), with endoscopic esophagitis or pathologic findings on esophago-gastro-duodenoscopy. The researchers concluded that the instrument may be used in routine care to help rheumatologists better understand the burden of gastrointestinal symptoms in scleroderma, but should not be treated as a standalone tool to identify esophago-gastro-duodenoscopy.
“In patients with systemic sclerosis (SSc), gastrointestinal (GI) tract involvement is very frequent, and a major cause of serious morbidity, affecting health-related quality of life (HRQoL) and even survival,” Carina Mihai, MD, PhD, of University Hospital Zurich, at the University of Zurich, in Switzerland, told Healio Rheumatology. “The UCLA GIT 2.0 is a patient-completed questionnaire validated to assess GI symptoms severity and related HRQoL in SSc. Several clinical trials of GI treatments in patients with SSc already used this questionnaire as an outcome measurement.
“Data on the performance of the UCLA GIT 2.0 in unselected patients with SSc are scarce,” she added. “More research is needed in order to understand how this instrument performs in real life, and if it may be helpful in clinical practice.”
To examine whether UCLA GIT 2.0 could identify patients with SSc who could be recommended for EGD, and if it could discriminate those with endoscopically proven esophagitis or any pathologic EGD finding, Mihai and colleagues conducted an observational, post hoc analysis of data from the University Hospital Zurich’s SSc cohort. In all, the researchers included at total of 346 patients from the European Scleroderma Trials and Research Group database who fulfilled the American College of Rheumatology/EULAR 2013 criteria for SSc and completed at least one UCLA GIT 2.0 questionnaire.
Using these data, the researchers collected information on gastrointestinal symptoms and EGD from patients’ medical charts. Their analysis used general linear mixed effect models to assess whether UCLA GIT 2.0 parameters were associated with an indication for EGD, endoscopic esophagitis and any pathologic finding on EGD.
According to the researchers, UCLA GIT 2.0 recommended EGD at 169 of the 940 total visits in which a questionnaire was completed. In the multivariable analysis, UCLA GIT 2.0 and some of its subscales — reflux, distention/bloating and social functioning — were associated with the indication of EGD.
However, across the 177 EGDs performed in 145 patients, neither the total ULCA GIT 2.0 score, nor any of its subscales, were associated with endoscopic esophagitis, or with any pathologic EGD findings.
“In our cohort, the UCLA GIT 2.0 identified patients who were referred to EGD by their rheumatologist, with a sensitivity of over 70% and a specificity of about 50%,” Mihai said. “Moreover, the recommendation to perform EGD was significantly associated with several subscales of the questionnaire — reflux, distension/bloating and social functioning. However, neither the total UCLA GIT 2.0 score nor any of its subscales were associated with endoscopic esophagitis, nor with any pathologic EGD findings. Even the correlation between single symptoms, such as heartburn, and endoscopic esophagitis, were poor.”
“Our findings show, on the one hand, that the UCLA GIT 2.0 has clear limitations in reflecting objective GI findings, such as endoscopic esophagitis,” she added. “On the other hand, the instrument reflects the subjective burden of GI disease, and as such it provides the rheumatologist with detailed information on the GI symptoms and the HRQoL in the individual patient. While it should not be used as a stand-alone instrument to select patients for further investigation by EGD, we consider the UCLA GIT 2.0 useful in clinical practice.”
Perspective
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David A. McLain, MD, MACR, FACP, FRCP
Gastrointestinal tract (GIT) involvement is seen frequently in scleroderma patients in clinical practice (approximately 90%). We frequently see reflux, but lately, I have seen patients diagnosed by GI with gastric antral vascular ectasia (GAVE) or ‘watermelon stomach’.
A consortium led by UCLA developed a questionnaire to evaluate the GIT involvement in SSc, which only takes 6-8 minutes to complete and evaluates reflux, distention/bloating, diarrhea, fecal soilage, constipation, emotional well-being and social functioning. The validation of this GIT 2.0 — as it is referred to — was published in 2009 and validation of minimally-important differences in the score (MID) was published in 2011. The present paper evaluated whether the GIT 2.0 could select which patients needed esophago-gastro-duodenoscopy (EGD).
Unfortunately, this was not the case. The questionnaire, while helpful in managing SSc patients, was not able to select patients with an abnormal EGD. The endoscopies were not without pathology. Esophagitis was found in 52/177 EGD, biopsy-verified Barrett’s esophagus in 24/177 and GAVE in 15/177. Other endoscopy findings included fungal esophagitis in seven patients, esophageal strictures in two, peptic ulcers of the stomach or duodenum in three and gastritis in six, for a total of 94/177 pathologic endoscopies.
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