Prevalence, risk factors, and healthcare-seeking among subjects with esophageal symptoms: A community-based study in a rural Bangladeshi population.

BACKGROUND AND AIM: As there is a scarcity of data on overall prevalence, risk factors, and health-care utilization of esophageal symptoms using the Rome criteria in the rural population in Asia, we undertook a study with the aims to evaluate: (i) the prevalence of heartburn, chest pain, globus, and dysphagia of presumed esophageal origin; (ii) the prevalence of functional esophageal disorders by Rome III criteria; (iii) the risk factors for esophageal symptoms; and (iv) the health-care utilization.
METHODS: This door-to-door survey was conducted in three villages (Charcharia, Churain of Dhaka district, and Kharrah of Munshiganj district of Bangladesh) among the adult population (≥18 years) using the translated and validated Enhanced Asian Rome III questionnaire.
RESULTS: Of 3559 individuals, 3351 (94.15%) responded (mean age 40.41 ± 16.04 years, female, 1924 [57.4%]). Heartburn was the most common symptom, 863 (25.8%), followed by chest pain, 367 (11%); globus, 285 (8.5%); and dysphagia, 146 (4.4%). At least one symptom was present in 1108 (33.1%) respondents. Based on Rome III criteria, 428 (12.8%), 41 (1.2%), 49 (1.5%), 26 (0.8%), and 524 (15.6%) had heartburn, chest pain, globus, dysphagia, and at least one functional esophageal disorder, respectively. Female gender, lower family income, presence of functional dyspepsia-irritable bowel syndrome (FD-IBS) overlap, FD only, and psychological distress were found to be risk factors for esophageal symptoms on multivariate analysis. Among the subjects with any esophageal disorders, 156 (14.1%) consulted any health-care provider, and 517 (46.6%) took antisecretory medications.
CONCLUSION: Esophageal symptoms are common in the rural community of Bangladesh and are associated with substantial health resource utilization.

Introduction

Esophageal symptoms are common in clinical practice. These may affect the quality of life (QoL) adversely and are associated with health‐care resource utilization and economic burden from consultation, use of medications, and absence from work. , Heartburn, chest pain, globus, and dysphagia of presumed esophageal origin may result from structural lesions, mucosal inflammation, or esophageal motor abnormalities. Endoscopy of the upper gastrointestinal tract (UGIT) with or without biopsy, pH monitoring, and esophageal manometry are often carried out to diagnose esophageal symptoms in clinical practice. Even after extensive investigations to identify structural, inflammatory, motor, or metabolic abnormalities, no cause is found in a proportion of such patients. These groups of patients are labeled as having functional esophageal disorders, which are a spectrum of functional gastrointestinal disorders (FGIDs) characterized by chronic recurrent symptoms in the absence of identifiable causes; these are currently diagnosed by Rome criteria .

A handful of studies have described the prevalence of noncardiac chest pain (NCCP), gastroesophageal reflux disease (GERD), globus, or dysphagia in the general population. , , , , However, the studies that have addressed the overall frequency of esophageal disorders of presumed functional origin using Rome criteria in the community are minimal and have been reported from Western countries. , There is a scarcity of such data from Asia, particularly from the rural community where most people live. Such a study is essential as the dietary, cultural, psychological, and socioeconomic factors; health‐care systems; and religious beliefs may affect symptom burden, perceptions, QoL, health‐care utilization, and treatment. , Hence, we conducted a door‐to‐door survey among a rural community of Bangladesh with the aims (i) to study the prevalence of heartburn, chest pain, globus, and dysphagia of presumed esophageal origin; (ii) to study the prevalence of esophageal disorders of presumed functional origin based on Rome III criteria; (iii) to determine the risk factors for esophageal symptoms; and (iv) to determine the consultation rate, medications use, and QoL issues among the subjects with esophageal symptoms.

Methods

Study design and population

This cross‐sectional study was performed during the period between November 2012 and November 2013 among the adult population (≥18 years) in three villages (Charcharia, Churain of Nawabganj upazila of Dhaka district and Kharrah of Srinagar upazila of Munshiganj district of Bangladesh). A manual census was conducted through a house‐to‐house survey by three trained field research assistants. Interviews of the subjects were taken using the Enhanced Asian Rome III questionnaire (EAR3Q) translated and validated in the Bengali language. During the survey, each subject filled up the questionnaire himself/herself, except when assistance was needed from the field workers due to illiteracy or visual impairment or difficulty understanding the questionnaire. Figure 1 shows the study protocol. A data entry operator entered the data, 10% of which were cross‐checked by the two investigators (M. Masudur Rahman and Nigar Sultana). The Institutional Ethics Committee approved the study protocol. Written informed consent was obtained from each study subject.

Figure 1

Study outline. EAR3Q, Enhanced Asian Rome 3 Questionnaire; FD, functional dyspepsia; FGIDs, functional gastrointestinal disorders; GHQ‐28, General Health Questionnaire‐28; IBS, irritable bowel syndrome.

The questionnaire

The questionnaire was translated and validated in Bengali. It had subsections on (i) sociodemographic information, (ii) clinical profile including EAR3Q, and (iii) General Health Questionnaire‐28 (GHQ‐28). Apart from the Rome III diagnostic questionnaire, the EAR3Q included questions related to (i) consultation with any specific health‐care providers, (ii) use of medications for the last 3 months for the concerned gastrointestinal problems, and (iii) QoL issues. QoL questions assessed to what extent a specific symptom affected the QoL of a subject. Of the five probable answers (not at all, a little, somewhat, a lot, and a great deal), the presence of “a lot” or “a great deal” was considered to demonstrate the significant impairment of QoL. GHQ‐28 was also translated and validated in Bengali. It had four subclasses: somatic symptoms, anxiety and insomnia, social dysfunction, and depression. Each question of the four domains of GHQ 28 was scored from 0 to 3. The scores of all the 28 questions were added to calculate the total score. A score of 23 or more was considered abnormal and demonstrated the presence of significant psychological distress.

Definitions

The prevalence and frequency of heartburn, globus, chest pain, and dysphagia in the last 3 months were assessed using the EAR3Q. The Rome III functional esophageal disorders are functional heartburn, functional chest pain of presumed esophageal origin, functional dysphagia, and globus. Functional esophageal disorders cannot be explained by structural diseases, histopathology‐based motor disturbances, or GERD. Hence, for the diagnosis of functional esophageal disorders, endoscopy of the UGIT, pH monitoring, and esophageal manometry are required to exclude structural disorders, motor abnormalities and GERD. In the present study, only the symptom‐based conditions that fulfill the frequency threshold and the duration criteria for the diagnosis of functional esophageal disorders were applied, but no investigations, such as endoscopy, pH monitoring, or manometry, were used. Functional dyspepsia (FD) and irritable bowel syndrome (IBS) were defined according to the Rome III criteria. ,

Statistical analysis

Normally distributed continuous data were presented as mean and standard deviation and non‐parametric data as median and interquartile range. Categorical data were presented as proportion. Normally distributed continuous data were analyzed using unpaired t‐test. Nonparametric continuous and categorical data were analyzed using Mann–Whitney U tests and Chi‐squared tests, respectively. Binary logistic regression analysis was used for the adjusted odds ratio and 95% confidence interval calculation. All the factors considered to be associated with the dependent variable on univariate analysis were entered into the logistic regression analysis. P values less than 0.05 were considered significant. Statistical analysis was carried out using SPSS version 15 (SPSS, Inc., Chicago, IL, USA).

Results

The total adult population of the study areas was 3559; of them 3351 (94.15%) responded. Figure 1 shows the study enrolment. The mean age of the study subjects was 40.41 ± 16.04 years. Of 3351, 1924 (57.4%) were female.

Prevalence of esophageal symptoms

Heartburn was the most frequent symptom, 863 (25.8%), followed by chest pain, 367 (11%); globus 285 (8.5%); and dysphagia, 146 (4.4%). Of the respondents, 1108 (33.1%) had at least one esophageal symptom. Of them, one, two, three, and all four symptoms were present in 711 (21.2%), 275 (8.2%), 88 (2.6%), and 34 (1%), respectively. Esophageal symptoms were more common among females compared to males, as shown in Figure 2. Symptom frequency is shown in Figure 3. Heartburn was present at a frequency of at least once a week in 465 (13.9%) subjects. By the frequency threshold and duration standards of Rome III criteria, 428 (12.8%), 41 (1.2%), 49 (1.5%), and 26 (0.8%) had heartburn, chest pain, globus, and dysphagia of presumed functional origin, respectively. At least one functional esophageal disorder was present in 524 (15.6%) subjects. The prevalence of esophageal disorders of presumed functional origin was 17.6% and 13% in females and males, respectively (<0.001).

Figure 2

Gender‐specific and the overall prevalence of esophageal symptoms. (P‐value = *<0.05, **<0.01, ***<0.001). (), Male; (), female; (), overall.

Figure 3

Frequency of esophageal symptoms. (), No symptoms; (), less than one day a month; (), one day a month; (), two or three days a month; (), one day a week; (), more than one day a week; (), everyday.

Esophageal symptoms, only, only, and overlap

Among the subjects with any esophageal symptoms, FD only was present in 25.9%, FD‐IBS overlap in 7.8%, and IBS only in 1.2% subjects (Table 1). Presence of FD only, FD‐IBS overlap, and IBS only was more common among subjects with heartburn, chest pain, dysphagia, and globus compared to subjects without any esophageal symptoms, as shown in Table S1. Overlap with FD only was most common among subjects with globus (48.1%), followed by chest pain (32.4%), dysphagia (29.5%), and heartburn (22.7%). Overlap with both FD and IBS was most common among subjects with dysphagia (19.2%), followed by globus (16.1%), chest pain (16.7%), and heartburn (8.6%). Subjects with heartburn had significantly higher FD only or FD‐IBS overlap but not IBS (Table S1).

Table 1

Sociodemographic, clinical, and psychological parameters of the subjects with and without esophageal symptoms

Characteristics	Subjects without esophageal symptoms (n = 2243)	Subjects with esophageal symptoms (n = 1108)	P value
Age, (years, mean ± sd)	39.82 ± 16.39	41.59 ± 15.25	0.002
Gender, n (%)
Male	1012 (45.1)	415 (37.5)	<0.001
Female	1231 (54.9)	693 (62.5)
Marital status, n (%)			0.123
Married	1775 (79.9)	903 (82.2)
Single	446 (20.1)	196 (17.8)
Education, n (%)			<0.001
Illiterate and up to class V	1141 (50.9)	657 (59.3)
Class V and above	1102 (49.1)	451 (40.7)
Family income†
Lower family income	1388 (63.8)	808 (75)	<0.001
Higher family income	786 (36.2)	270 (25)
Occupation, n (%)
Housewife	1189 (61.2)	650 (63.7)	0.176
Cultivation	218 (11.2)	121 (11.9)
Others	536 (27.6)	249 (24.9)
Religion, n (%)
Muslim	1479 (66.0)	742 (67.1)	0.519
Hindu	763 (34.0)	364 (32.9)
Smoker (current or past), n (%)	363 (19.3)	188 (18.4)	0.546
Nonsmoker, n (%)	1520 (80.7)	836 (81.6)
Presence of psychosocial stress, n (%) (Cut‐off value 23)	17 (0.8)	44 (4)	<0.001
Presence of FD‐IBS overlap, n (%)	24 (1.1)	86 (7.8)	<0.001
Presence of FD only, n (%)	150 (6.7)	287 (25.9)	<0.001
Presence of IBS only, n (%)	18 (0.8)	13 (1.2)	0.292
Somatic symptoms, (median score, interquartile range)	1.0 (0–2)	2.0 (1–3)	<0.001
Anxiety & insomnia, (median score, interquartile range)	0.0 (0–2)	0.0 (0–2)	0.001
Social dysfunction, (median score, interquartile range)	7.0 (4–7)	7.0 (5–7)	<0.001
Depression (median score, interquartile range)	0.0 (0–0)	0.(0–0)	<0.001
Total score (median score, interquartile range)	8 (6–9)	8 (7–11)	<0.001

Lower family income≤ taka 10 000/month, higher family income ≥ taka 10 000/month.

FD, functional dyspepsia; IBS, irritable bowel syndrome.

Factors associated with esophageal symptoms

Increasing age, female gender, education less than class V, lower family income, presence of psychological distress, and presence of FD‐IBS overlap and dyspepsia only were found to be associated with esophageal symptoms in the univariate analysis as shown in Table 1. The presence of IBS was not found to be associated with esophageal symptoms. The somatic symptom, social dysfunction, anxiety and insomnia, and the depression scores were higher among subjects with esophageal symptoms (all P < 0.05). The total GHQ‐28 score was also higher among these subjects, as shown in Table 1. On logistic regression analysis, female gender, lower family income, presence of psychological distress, presence of FD‐IBS overlap, and FD only were found to be risk factors for esophageal symptoms, as shown in Table 2.

Table 2

Logistic regression analysis for risk factors of esophageal symptoms

Characteristics	Adjusted odds ratio (OR)	95% confidence interval (CI)	P‐value
Increasing age	1.003	0.998–1.008	0.299
Gender
Male	Reference
Female	1.29	1.09–1.51	0.002
Marital status
Single	Reference
Married	0.985	0.803–1.21	0.889
Education
More than class V	Reference
Illiterate and up to class V	1.19	0.996–1.42	0.055
Family income†
Higher family income	Reference
Lower family income	1.45	1.20–1.74	<0.001
Presence of FD‐IBS overlap	5.36	2.63–10.93	<0.001
Presence of FD only	5.15	4.13–6.41	<0.001
Presence of IBS only	1.82	0.888–3.88	0.119
Presence of psychosocial stress (Cut‐off value 23)	2.56	1.32–4.9.	0.005

Lower family income ≤ taka 10 000/month, higher family income ≥ taka 10 000/month.

FD, functional dyspepsia; IBS, irritable bowel syndrome.

Factors associated with heartburn

On univariate analysis, increasing age, female gender, lower education status, lower family income, presence of FD‐IBS overlap, FD only, and psychological distress were associated with heartburn. On logistic regression analysis, lower family income, FD‐IBS overlap, FD only, and psychological distress were found to be risk factors for heartburn, as shown in Table 3.

Table 3

Logistic regression analysis for risk factors of heartburn

Characteristics	Unadjusted odds ratio, 95% confidence interval	P value	Adjusted odds ratio, 95% confidence interval	P value
Increasing age	1.007 (1.002–1.011)	0.003	1.005 (0.99–1.11)	0.76
Gender
Male	Reference		Reference
Female	1.37 (1.19–1.89)	<0.001	1.31 (0.94–1.83)	0.103
Marital status
Single	Reference		Reference
Married	1.15 (0.96–1.39)	0.12	0.85 (0.66–1.07)	0.17
Education
More than class V	Reference		Reference
Illiterate and up to class V	1.40 (1.21–1.63)	<0.001	1.17 (0.96–1.42)	0.11
Family income†
Higher family income	Reference		Reference
Lower family income	1.70 (1.44–1.99)	<0.001	1.46 (1.18–1.78)	<0.001
Occupation
Housewife	Reference		Reference
Cultivation	1.01 (0.079–1.29)	0.90	0.73 (0.51–1.03)	0.79
Others	0.85 (0.71–1.01)	0.07	0.91 (0.65–1.20)	0.58
Religion
Hindu	Reference	0.51	Reference
Muslim	1.05 (0.90–1.2)		0.87 (0.72–1.05)	0.15
Smoking
Nonsmoker	Reference		Reference
Smoker (current or past)	0.94 (0.78–1.1)	0.54	0.96 (0.73–1.24)	0.76
Presence of FD‐IBS overlap	7.78 (4.91–12.03)	<0.001	4.95 (3.90–6.28)	<0.001
Presence FD only	4.88 (3.44–6.03)	<0.001	4.95 (3.90–6.28)	<0.001
Presence of IBS only	1.46 (0.71–3.00)	0.294	1.77 (0.75–4.14)	0.18
Presence of psychosocial stress‡	5.42 (3.08–9.52)	<0.001	2.87 (1.43–5.75)	0.003

Lower family income ≤ taka 10 000/month, higher family income ≥ taka 10 000/month.

General Health Questionnaire 28‐ score 23 or more.

FD, functional dyspepsia; IBS, irritable bowel syndrome.

Esophageal symptoms, healthcare utilization, and quality of life

Consultation

Figure 4a shows the consultation rates for different symptoms of presumed esophageal origin and the consultation rates of different esophageal disorders of presumed functional origin. Among 1108 individuals with any esophageal disorders and 2243 subjects without esophageal disorders, 156 (14.1%) and 71 (3.2%) consulted any health‐care provider for their problems, respectively (P < 0.001). Of 534 subjects considered to have presumed functional esophageal disorders based‐on Rome III criteria, 97 (18.5%) consulted healthcare provider for their problems.

Figure 4

(a) Consultations for esophageal symptoms. (), Heartburn; (), globus; (), chest pain; (), dysphagia; (), overall. (b) Satisfaction with treatments. (), Satisfied; (), not satisfied due to lack of explanation; (), not satisfied due to lack of investigations; (), not satisfied due to lack of medications.

Medication use

Among the subjects with and without esophageal symptoms, 517 of 1108 (46.6%) and 237 of 2243 (10.5%) subjects took a proton pump inhibitor (PPI) or Histamine 2 receptor antagonist (H2RA) in the last 3 months for their problems (