MHGCJ – 2020
Mental Health: Global Challenges Journal
Disorders of social functioning and quality of life in
patients with gastroesophageal reflux disease while
combined with undifferentiated connective tissue
dysplasia
Iryna Romash
Ivano-Frankivsk National Medical University, Ukraine
Abstract
Introduction. It has been scientifically confirmed that the risk of developing gastroesophageal
reflux disease (GERD) increases especially with generalized or regional disruption of connective
tissue structure, which is widespread among the population. Patients with such comorbid
pathology may have a wide range of symptoms that may go beyond the general symptoms of
heartburn and regurgitation. The symptoms and complications of GERD affect general health,
daily and social functioning, physical and emotional activity. It also affects the quality of life
(QoL) associated with health through frequent breaks during sleep, work and social activities.
Purpose. study the dynamics of the level of quality of life and social functioning in patients with
gastroesophageal reflux disease in combination with the syndrome of undifferentiated
connective tissue dysplasia.
Methodology. A total of 120 patients were included in the study: 65 men and 55 women: in 75
of them (Group II) GERD occurred on the background of UCTD, in 45 (Group I) as an
independent disease. The control group consisted of 12 healthy individuals. The study was
comprehensive. The Medical Outcomes Study 36-Item Short-Form Health Status (SF-36),the
Gastrointestinal Symptom Rating Scale (GSRS) and the scale of "Personal and social
performance" (PSP) - were used to study patients in detail.
Results and Discussion. Analyzing the results obtained on the basis of the GSRS questionnaire
(Table 1), in patients with GERD on the background of UCTD, compared with patients of group I
and the control group, there is a significant increase in three and four from the five scales. QoL
in patients of Group II on the scale "Abdominal pain" were 14.3 ± 0.4 points, in Group I - 5.6 ±
1.3 points, in the Control Group - 2.4 ± 0.8 points, on the scale "Reflux syndrome": 13.7 ± 0.9,
10.5 ± 1.3 and 3.1 ± 0.9, respectively. "Dyspeptic syndrome" - 15.3 ± 0.4 points in Group II,
12.2 ± 0.6- in Group I and 6.1 ± 0.3- in the control group. "Constipation syndrome" 9.5 ± 0.8,
5.6 ± 1.03 and 5.7 ± 0.4, respectively (p <0,05).
Conclusions: In this research we investigated the effect of comorbid pathology on QoL in
patients with GERD, which developed against the background of UCTD. The results confirm that
patients with such combined pathology have a lower level of quality of life and social
functioning, and the tactics of treatment of such patients should take into account these
changes.
Keywords
Gastroesophageal reflux disease, undifferentiated connective tissue dysplasia, quality of life,
social functioning.
Address for correspondence:
Iryna Romash, Department Propaedeutics of Internal Medicine, Ivano-Frankivsk National
Medical University, Ukraine. e-mail: iromash@ifnmu.edu.ua
This work is licensed under a Creative Commons Attribution-
NonCommercial 4.0 International License (CC BY-NC 4.0).
©Copyright: Romash, 2020
Licensee NDSAN (MFC- Coordinator of the NDSAN), Italy
DOI http://doi.org/10.32437/mhgcj.v3i1.100
Submitted for publication: 21
July 2020
Received: 21 July 2020
Accepted for publication: 06
November 2020
MHGCJ – 2020
Mental Health: Global Challenges Journal
Introduction
The number of patients suffering from
undifferentiated connective tissue dysplasia
(UCTD) has been steadily increasing in recent
decades and ranges from 9 to 85%, depending
on the population. As a premorbid background
for the development of many pathological
conditions and chronic diseases, the syndrome of
UCTD requires more attention from clinicians.
Especially often, against the background of this
syndrome, there are disorders of the digestive
system, in particular - the esophagus. The reason
is the mesenchymal nature of its origin. Against
the background of inflammatory diseases of the
upper gastrointestinal tract more often than in
patients without signs of dysplasia, motor
dysfunction, in particular, gastro-oesophageal
and duodeno-gastric reflux .
It has been scientifically confirmed that the risk
of developing gastroesophageal reflux disease
(GERD) increases especially with generalized or
regional disruption of connective tissue structure,
which is widespread among the population.
Patients with such comorbid pathology may have
a wide range of symptoms that may go beyond
the general symptoms of heartburn and
regurgitation (Kumar, A. et.al., 2020). The
prevalence of GERD ranges from 5.2-8.5% in East
Asia to 6.3-18.3% in Iran. And Arshad Kamal Butt
et.al. in their study among Pakistanis note a much
higher prevalence - 22.2% - 24.0%. There is a
worldwide increase in the incidence of GERD and
its complications, including Barrett's esophagus
and esophageal adenocarcinoma. Back in
2008, GERD was classified as one of the 5
diseases, which significantly impairs the quality of
life of patients. Recent studies by Michele Ludici
on the quality of life (QoL) of patients with UCTD
once again drew our attention to the comorbidity
of these two conditions. This is because
according to J. B. Marshall, most often in
diseases of the connective tissue affect the
esophagus. And V. Kondoh et. al. diagnosed with
pathological reflux in 29.0% of patients with UCTD,
while in its absence it was registered in 2.0% of
those examined with GERD. Even more often
manifestations of the gastroesophageal system
were detected against the background of
connective tissue pathology, which included its
undifferentiated dysplasia, among which
gastroesophageal reflux (GER) was observed in
68.0%, regurgitation - in 43.0%, dysphagia - in
33.0% of patients. Also, in UCTD, the balance
between the factors of aggression and protection
of the esophageal mucosa is disturbed by
weakening the latter. According to the results of
lower esophageal manometry, in 55% of patients
with connective tissue pathology, there was a
decrease in the tone of the lower esophageal
sphincter, a symptom of which may be reflux
(Denaxas et.al., 2018).
The symptoms and complications of GERD
affect general health, such as daily and social
functioning, physical and emotional activity. It
also affects the quality of life associated with
health through frequent breaks during sleep, work
and social activities (Iudici, M. et.al., 2017;
Kumar, A. et.al., 2020).
These data are comparable with our previous
data, according to which in adults with
developed GERD on the background of UCTD,
arthralgia, Raynaud's phenomenon, low body
weight, bone, joint and skin phenotypic traits that
correlate with the frequency and duration of GER.
(Romash I.B et.al.,2020).
QoL research is a highly informative tool that
determines the effectiveness of the health care
system and allows to give an objective
assessment of the quality of health care at the
level of its main consumer - the patient. From the
point of view of the principles of evidence-based
medicine, the patient's QoL is the only noteworthy
criterion and the main goal of the effectiveness
of treatment of long-term, chronic diseases.
(Romash I.R et. al., 2019; Moskalenko V. F et.al.,
2014).
Purpose
The aim of the study was to study the
dynamics of the level of quality of life and social
functioning in patients with gastroesophageal
reflux disease in combination with the syndrome
of undifferentiated connective tissue dysplasia.
Methodology
From June 2017 to December 2019, 378
patients with GERD were examined in the
University Clinic of Ivano-Frankivsk National
Medical University and in the therapeutic
department № 2 of the municipal enterprise
"Central City Clinical Hospital" of Ivano-Frankivsk.
The study included 134 patients. All of them
provided written informed consent. During the
study, 9 patients were lost for follow-up (at one
stage or another expressed a desire not to
continue to participate in the study).
During follow-up, 5 patients were diagnosed
with certain differentiated connective tissue
disease (1-scleroderma, 3-systemic lupus
erythematosus and 1 Sjogren's syndrome), which
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were excluded from the study. 120 patients were
included in the study: 65 men and 55 women: in
75 of them (group II) GERD occurred on the
background of UCTD, in 45 (group I) as an
independent disease. The control group
consisted of 12 healthy individuals, without signs
of UCTD, randomized by age and sex. The mean
age of the subjects was 42.0 ± 6.5 years. The
majority of patients (62%) received higher and
secondary special education, 75% of those
surveyed were employed, and 7.3% retired.
When entering the study, the most common
clinical manifestations were arthralgia / arthritis
(45.6%), Raynaud's phenomenon (45.6%), dry
eyes and/or mouth (32.6%), frequent
gastroesophageal reflux disease (32.6%),
myalgia (26.0%) and asthenia (26.0%).
The study was comprehensive. The Medical
Outcomes Study 36-Item Short-Form Health Status
(SF-36) (Ware et al., 1993), the Gastrointestinal
Symptom Rating Scale and PSP - the scale of
"Personal and social performance " (Morosini P. L.,
Magliano L., Brambilla L., Ugolini S., Pioli R., 2000)
were used to study patients in detail.
Each patient was asked to complete a
questionnaire SF-36.10, consisting of 36 questions
grouped into 8 domains: physical functioning
(PF), social functioning (SF), role limitations related
to physical problems (RP), role limitations
associated with emotional problems (RE), mental
health (MH), vitality (VT), body pain (VP) and
perception of general health (GH). The indicators
of each scale are compiled in such a way that
the higher the value of the indicator (from 0 to
100), the better the score on the selected scale.
From them form two parameters that estimate
eight concepts of health: psychological and
physical components. The physical component
includes: GH - the general perception of health,
PF - limitations in physical activity due to health
problems, RP - limitations in normal role activities
due to physical health problems, BP - physical
pain. The mental component includes: SF -
limitations in social activities due to physical or
emotional problems, MH - general mental health,
psychological distress and well-being, RE -
limitations in normal role activities due to
emotional problems, VT - viability (energy and
fatigue). The scores of each scale vary between
0 and 100, where 100 represents complete
health, and the results are presented as scores
compiled in such a way that the higher score
indicates a higher QoL level. This questionnaire is
general, can be used for patients with various
pathologies, as well as for population studies. It
has proven itself in many clinical studies, easy to
use.The questionnaire SF-36 is multidimensional,
fairly simple, short, reliable, valid and sensitive.
Peculiarities of social dysfunction were
assessed on the basis of the Personal and social
performance (PSP) scale, which assesses the
degree of impairment in four main areas: (a)
socially useful activities, including work and study;
(b) personal and social relationships; (c) self-
service; (d) restless and anxious behavior. The
level of dysfunction was assessed by the severity
of these areas from 0 to 5 (absent, weakly
expressed, markedly expressed, significantly
expressed, strongly expressed).
GSRS is a specific questionnaire consisting of
15 questions grouped into five clusters for a
detailed study of symptoms reflecting reflux,
abdominal pain, indigestion, diarrhea and
constipation. GSRS has a seven-point Likert-type
scale, where 1 means no problem symptoms
and 7 means very problematic symptoms.
The reliability and validity of GSRS are well
documented (Dimenäs, E et.al., 2008), and the
values of the norms are available for the general
population. In working with patients, we adhered
to the ethical principles of the Declaration of
Helsinki of the World Medical Association (Helsinki
1964, 2000 ed.). The study was approved by the
Bioethics Committee of Ivano-Frankivsk National
Medical University. Before inclusion in the study, all
patients signed voluntary informed consent. All
patients agreed to participate in the study and
provided written informed consent
Statistical analysis of the results was performed
using software packages STATISTICA 7.0., And a
package of statistical functions of the program
"Microsoft Excel, 2016". The reliability of the
obtained indicators was confirmed by calculating
errors for relative values, and the probability of
data difference in the compared groups was
proved based on calculating the coefficient t
(Student) and determining the accuracy of the
error forecast. The arithmetic mean (M), standard
error (± m) were used to describe quantitative
features.
Results and Discussion
In the study and comparison groups, the
analysis of QoL parameters was performed. The
comparative analysis revealed a probable
decrease in QoL in patients with GERD, which
occurred against the background of connective
tissue dysplasia. compared with the control group
who did not have concomitant pathology.
When assessing the social functioning of
patients with GERD comorbid with UCTD on the
PSP scale, the most pronounced violations were
found in the module "restless, anxious behavior"
on average in Group I - 4.8 ± 0.18 points (95% CI
4.6-4.9); Group II - 4.1 ± 0.37 (95% CI 3.73-4.47);
MHGCJ – 2020
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Control Group - 4.9 ± 0.1 (95% CI 4.79-5.0). The
cluster "personal and social relations" is presented
as follows: 4.2 ± 0.46 points (95% CI from 4.2 to
4.78); 3.2 ± 0.18 (95% CI 3.15-3.92), 4.8 ± 0.16
(95% CI 4.53-5.0), respectively. The module
“socially useful activity” and “self-service” was less
affected, where group differences were not
statistically significant.
Analyzing the results obtained based on the
GSRS questionnaire (Table 1), in patients with
GERD on the background of UCTD, compared
with patients of group I and the control group,
there is a significant increase in three and four of
the five scales. QoL in patients of group II on the
scale "Abdominal pain" was 14.3 ± 0.4 points, in
group I - 5.6 ± 1.3 points, in the control group -
2.4 ± 0.8 points, on the scale "Reflux syndrome":
13.7 ± 0.9, 10.5 ± 1.3 and 3.1 ± 0.9,
respectively; "Dyspeptic syndrome" - 15.3 ± 0.4
points in the main (II) group 12.2 ± 0.6- in the
comparison group and 6.1 ± 0.3- in the control
group;"Constipation syndrome" 9.5 ± 0.8, 5.6 ±
1.03 and 5.7 ± 0.4, respectively (p <0,05).
In the study and comparison groups, the
analysis of quality of life indicators was
performed. The comparative analysis revealed a
probable decrease in QOL, both among its
physical and mental components, in patients of
group II in comparison with group I who did not
have concomitant pathology and control group.
A comparative assessment of the dynamics of
the physical components of the quality of life of
patients with GERD against the background of
NDST is presented in Figures 1a) and 1b).
Table 1. Assessment of the quality of life in patients with GERD in combination with UCTD and as an
independent disease.
Clinical group
n
Quality of life according to the GSRS questionnaire, points
abdominal
pain
reflux
syndrome
diarrhea
syndrome
dyspeptic
syndrome
constipatio
n
syndrome
I Group (GERD)
45
5.6±1.3*
10.5±1.3*
4.8±0.7
12.2±0.6*
5.6±1.03
II Group
(GERD+UCTD)
75
14.3±0.4*^
13.7±0.9*^
5.1±1.08
15.3±0.4*^
9.5±0.8*^
Control Group
12
2.8±0.4
3.1±0.9
3.4±1.07
6.1±0.3
5.7±0.4
p1 (ІI Gr / I Gr.)
<0.01
<0.01
0.81
<0.01
<0.01
p2 (ІI Gr./Contr. Gr)
<0.05
<0.05
0.26
<0.01
<0.01
Notes:
1. ^ - (p <0,05) data are reliable between the study groups.
2. *- (p <0,05) data are reliable relative to the control group.
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Mental Health: Global Challenges Journal
Fig. 1a) Dynamics of quality of life indicators
(physical component of health) in patients with
GERD.
Notes:
1. ^ - (p <0,05) data are reliable between the study groups.
2. *- (p <0,05) data are reliable relative to the control group.
Fig 1b) Dynamics of quality of life indicators
(mental component of health) in patients with
GERD.
Notes:
1. ^ - (p <0,05) data are reliable between the study groups.
2. *- (p <0,05) data are reliable relative to the control group.
Conclusion
In this research we investigated the effect of
comorbid pathology on QOL in patients with
GERD, which developed against the background
of UCTD. The results confirm that patients with
such combined pathology have a lower level of
quality of life and social functioning, and the
tactics of treatment of such patients should take
into account these changes.
Conflict of interest
The author declares that she has no conflict of
interests.
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