Gastroesophageal reflux disease (GERD) is an extremely common pathology in the general population and one of the main reasons for consultation in gastroenterology. There are different instruments for detecting its symptoms, but few studies comparing one tool with another have been conducted in Mexico.Aims
To compare the effectiveness of the Carlsson-Dent questionnaire (CDQ) and the GERD-Q questionnaire (GQQ) in detecting GERD symptoms in a general population.Materials and methods
A prospective, descriptive, cross-sectional study was conducted on 220 individuals in an open population within the time frame of May-June 2015. The subjects were evaluated through the self-assessment CDQ and GQQ. The positive scores from the CDQ (≥ 4) were compared with those of the GQQ (≥ 8), to determine which of the two instruments more easily detected patients with GERD symptoms.Results
Fifty-seven percent of the patients were men and the mean patient age was 38.1 years. Fifty percent of the subjects presented with GERD symptoms with a positive score in at least one questionnaire; 45% had positive CDQ results and 23% had positive GQQ results. Fifty-seven percent of the patients with a positive CDQ score presented with overweight/obesity, as did 72% of the patients with a positive GQQ result. Finally, 20% of the individuals had positive results for reflux symptoms in both questionnaires.Conclusions
There was a prevalence of GERD symptoms in 50% of the individuals studied from a general population. The GQQ detected a greater number of GERD symptoms in patients that presented with overweight/obesity and the CDQ was considered easier for patients to understand and answer. It is striking that there was only 20% agreement between the two questionnaires, suggesting that they may be useful for identifying GERD symptoms in different populations.
La enfermedad por reflujo gastroesofágico (ERGE) es una patología altamente común en población general y una de las principales causas de consulta gastroenterológica. Existen diversos instrumentos para detectar sus síntomas, sin embargo pocos estudios en México los comparan entre sí.Objetivos
Comparar la efectividad de los cuestionarios Carlsson-Dent (CDQ) y GERD-Q (GQQ) en la detección de síntomas de ERGE en población general.Materiales y métodos
Estudio prospectivo, descriptivo, transversal; durante el periodo de mayo a junio del 2015; 220 individuos de población abierta se evaluaron a través de CDQ y GQQ autoaplicables. Se compararon los resultados positivos del CDQ (≥ 4) con los del GQQ (≥ 8), para establecer cuál detecta con mayor facilidad pacientes con síntomas de ERGE.Resultados
El 57% de los pacientes fueron del género masculino y la media de 38.1 años. El 50% presentaron síntomas de ERGE con al menos un cuestionario positivo; el 45% de ellos fueron positivos con CDQ y el 23% con GQQ. El 57% con CDQ positivo presentaron sobrepeso/obesidad en comparación con el 72% con GQQ positivo. Finalmente, el 20% presentó positividad para síntomas de reflujo en ambos cuestionarios simultáneamente.Conclusiones
Hubo una prevalencia del 50% con síntomas de ERGE en población general. El GQQ detectó un mayor número de síntomas de ERGE en pacientes con obesidad/sobrepeso. El CDQ fue calificado como más fácil de comprender y contestar por los pacientes. Es importante mencionar que solo hubo una concordancia del 20% entre ambos cuestionarios, lo que indica que tal vez sean de utilidad para identificar síntomas de ERGE en poblaciones distintas.
Gastroesophageal reflux disease (GERD) is defined as the ascent of gastric or gastroduodenal content above the gastroesophageal junction, causing symptoms and/or structural damage and affecting the well-being and quality of life of the individuals that present with it. Symptoms and quality of life are the 2 most sensitive aspects in all the phenotypical varieties,1 making them common objectives for its diagnosis and treatment. Heartburn and regurgitation are considered typical symptoms,1–3 whereas cough, laryngitis, asthma, dental erosions, and chest pain of presumed esophageal origin are considered atypical or extra-esophageal symptoms.1,3 Current diagnostic methods have been developed that can be classified into: noninvasive (clinical attention, questionnaires, PPI test response) and invasive (endoscopy, barium esophagogram, 24-h pH study, multichannel intraluminal impedance study, biopsy when eosinophilic esophagitis or Barrett's esophagus are suspected). Some of the invasive methods can be costly and often are not available,2 and none of them alone is considered a “gold standard”.2,4 The worldwide prevalence of GERD is varied. In Mexico the most frequent variant is nonerosive reflux disease2 according to the Montreal Classification.5 However, the exact prevalence figure for patients with GERD is unknown. Therefore, the initial use of noninvasive methods in primary care is recommended, especially the application of sensitive questionnaires as diagnostic aids.6–11 The Carlsson-Dent questionnaire8 (CDQ) and the GERD-Q questionnaire10 (GQQ) are currently the most widely used. They have been validated and possess the majority of the characteristics required.4,12
The aim of the present study was to compare the value and diagnostic efficacy of the CDQ and GQQ in detecting positive GERD symptoms in a general population in Mexico.Materials and methods
A randomized, prospective, descriptive, cross-sectional study was conducted within the time frame of May to June 2015 at the Hospital General de Zona y Medicina Familiar 1 “Dr. Alfonso Mejía Schroeder” in Pachuca de Soto, Hidalgo, Mexico. Individuals from an open population were selected that met the following inclusion criteria: 18 years and older, male or female, with positive symptoms for reflux disease (heartburn or regurgitation) within the last 3 months, no previous GERD diagnosis, and no current GERD treatment. The nature of the study was explained and the individuals signed statements of informed consent. The two questionnaires were handed out and instructions of how to complete them were given. The Spanish version of the GQQ13 was employed and it consists of 6 multiple choice questions and a cut-off point ≥ 8 as a positive result. The questionnaire evaluates the symptoms associated with GERD, their frequency in days, and their repercussions on wellbeing and quality of life (Figure 1). The Spanish version of the CDQ14 includes 7 multiple choice questions and its cut-off point for a positive result is ≥ 4. This questionnaire qualitatively evaluates symptoms associated with GERD and their triggering factors such as diet, posture, and medications used (Figure 2). The two instruments are self-assessment questionnaires, with medical personnel providing assistance only if the subject has a question about an item or has doubts about how to answer it, or is unable to read. The variables of sex, age, height and weight measurements to determine the presence of overweight or obesity (BMI ≥ 25), and the scores from the two questionnaires were obtained. The patients were classified according to the questionnaire results and other variables. The exclusion criteria were: age under 18 years, refusal to participate in the study, GERD diagnosis during the past year with an established treatment, the presence of alarm symptoms (unintentional weight loss, severe and/or progressive dysphagia, or gastrointestinal bleeding), and a past history of GERD-related surgical procedures (open or laparoscopic treatment). Finally, the positive CDQ results were compared with the positive GQQ results to determine which instrument more easily detected the prevalence of patients with symptoms consistent with GERD.ResultsSample total
Two hundred and twenty randomly selected individuals answered the CDQ and GQQ. Of that total, 125 (57%) were men and 95 (43%) were women and their mean age was 38.1 years (18 to 76 years). One hundred ten (50%) individuals presented with symptoms consistent with GERD, with positive results in at least one of the questionnaires applied. The patients were organized into 12-year age groups as follows: 18-29 years=84 (38.18%), 30-41 years=49 (22.27%), 42-53 years=47 (21.36%), 54-65 years=35 (15.90%), and 66-77 years=5 (2.27%). Figure 3 shows the comparison by ages of the individuals with a positive CDQ or GQQ. One hundred fourteen (52%) patients presented with overweight or obesity (BMI ≥ 25), whereas 106 (48%) were normal weight (Figure 4). During the application of the questionnaires, a high percentage of the patients considered the GQQ more difficult to understand and answer. In both questionnaires, the majority of the patients with reflux-consistent symptoms presented with overweight or obesity. Finally, 38 (20%) of the individuals in the sample had a positive score for reflux symptoms in both questionnaires (Figure 5).
Ninety-eight (45%) of the total number of individuals that answered the questionnaires had a score equal to or greater than 4, which was consistent with gastroesophageal reflux disease, and the remaining 122 (55%) individuals had a negative score under 4. Of the 98 subjects with a positive score for GERD symptoms, 53 were men (54%) and 45 were women (46%).
Fifty-six of the 98 positive cases presented with overweight or obesity (57%) and 42 had normal weight (43%) (Figure 6).
With respect to age, in the positive cases arranged into 12-year age groups from 21 to 80 years of age, there was no significant difference in the presentation of GERD symptomatology from 21 to 56 years of age, given that there were 32, 29, and 26 positive cases in those age groups. In contrast, there were 9 positive cases in the age group of 57-68 years and 2 cases in the age group of 69-80 years (Figure 3).Gerd-Q questionnaire
Of the 220 individuals that answered the questionnaires, 50 (23%) presented with positive results for GERD symptomatology, with a score equal to or greater than 8. One hundred seventy (77%) subjects had a score under 8 and thus were reported as negative for GERD symptomatology.
Of the 50 individuals with a positive result for GERD symptomatology, 29 were men (58%) and 21 were women (42%).
Thirty-six of the 50 positive cases presented with overweight or obesity (72%) and 14 had normal weight (28%) (Figure 7).
Likewise, we grouped the positive cases by age range, which reflected a greater incidence in the first 3 age groups, with 18, 14, and 13 individuals, respectively, whereas 3 and 2 individuals were positive in the 57-68 and 69-80 age groups, respectively (Figure 3).Discussion
There are currently many methods for diagnosing GERD and the use of questionnaires directed at detecting the patients with positive symptomatology is a method that has gained ground due to their easy application and low cost.12 They are mainly used in primary care centers and their sensitivity as auxiliary instruments in the Mexican population has been demonstrated.3 However, no studies have been found in the medical literature that compare one questionnaire with another to demonstrate their efficacy and usefulness in daily practice.
There are a variety of questionnaires with different characteristics and focuses. For example, some evaluate the impact of symptoms on the quality of life of the patient, rather than diagnosis, such as the GERD Impact Scale.11 Likewise, Gómez-Escudero et al. state that the CDQ does not evaluate the severity or impact of symptoms on wellbeing and quality of life, but it is highly sensitive for detecting patients with positive GERD symptoms. It has a high correlation with positive endoscopy and pH study in Mexican patients and a greater sensitivity in populations that have a high prevalence of the disease.3 In regard to the GQQ, in addition to evaluating symptom severity, it has a scale for measuring the impact on wellbeing and quality of life. Its usefulness in patient follow-up has also been demonstrated, evaluating the progression of patients that have received treatment.
In our study we observed a higher number of individuals with positive scores in the CDQ than in the GQQ. There could be several reasons for this. The first is that the patients with positive CDQ results could have a higher number of acid exposures in the esophagus, consistent with erosive reflux disease,3 compared with the patients with positive results in the GQQ. The latter questionnaire has shown sensitivity in detecting patients with functional heartburn or esophageal hypersensitivity with scores under 8.4 Another reason could be that the GQQ evaluates different parameters from the CDQ and that the quality of life in our study population was not greatly affected. However, future studies are required to corroborate or discard the abovementioned points with objective diagnostic methods such as endoscopy, 24-h pH study or pH/multichannel intraluminal impedance monitoring for atypical cases, and thus determine the sensitivity, specificity, positive predictive value, and negative predictive of these methods. Our research center is currently conducting such investigation.
It should be mentioned that despite the fact that there was a 50% prevalence of patients with GERD symptoms, these questionnaires only evaluated the typical or classic symptomatology, ignoring extra-esophageal or atypical symptoms. Therefore, the study population that presented with this type of symptomatology would remain undiagnosed. It has also been demonstrated that these instruments do not have high specificity and thus could over-diagnose patients that present with esophageal hypersensitivity or functional heartburn3,15 that is not strictly GERD. Nevertheless, a recent study by Zavala-González et al.4 demonstrated a high sensitivity in patients that presented with these 2 varieties when they had a score under 8. We hope that questionnaires focusing on these conditions will be developed in the future.
There was no difference between the sexes in the sample total, but there was a slight increase in men with positive scores in the two questionnaires. This differs from other published results that manifest a greater prevalence of positive symptomatology in women.15
Positive symptomatology was observed in both questionnaires in younger individuals, but this could be due to the fact that the sample did not have the same number of subjects in each age group. In studies conducted on a Mexican geriatric population,15 there was a high prevalence of patients with symptomatology consistent with GERD, as well as greater complications. The importance of carrying out studies on target geriatric populations is also mentioned.
In general the difference in weight in the sample total was minimal between subjects with overweight/obesity and those whose weight was within normal parameters. However, the significant increase in the percentage of overweight/obesity was striking in the patients that had a positive score in the GQQ. This could be interpreted as the GQQ being more sensitive in patients whose wellbeing and quality of life was affected and the relation of this to overweight/obesity.16–18
Finally, the low frequency of the same patient having a positive score in both questionnaires should be underlined. This can possibly be explained by the fact that each questionnaire examines different aspects of the disease that are not necessarily mutually exclusive.
This study paves the way for new ones that can compare the positive results of the two questionnaires through objective tests, such as 24-h pH study and/or endoscopy to determine the sensitivity and specificity of each one in a Mexican general population and their usefulness as follow-up tools in patients undergoing treatment.
Our study's limitations include the fact that it was a screening study on an open population. Nevertheless, it shows the prevalence of patients with positive GERD symptoms in Mexico, which is currently unknown.19 And even though our study had a sound sample size, further studies should have larger samples.
In conclusion, we observed a 50% prevalence of GERD symptoms in a general population. The GQQ detected a greater number of GERD symptoms in patients with overweight and the CDQ was rated as easier for the patients to understand and answer. It is striking that there was only 20% agreement between the two questionnaires, suggesting that they may be useful in identifying GERD symptoms in different populations.Ethical responsibilities
Protection of persons and animals. The authors declare that the procedures followed conformed to the ethical standards of the responsible committee on human experimentation and were in accordance with the World Medical Association and the Declaration of Helsinki.Data confidentiality
The authors declare that no patient data appear in this article.Right to privacy and informed consent
The authors declare that no patient data appear in this article.Financial disclosure
No financial support was received in relation to this study.Conflict of interest
The authors declare that there is no conflict of interest.
The authors wish to thank the gastroenterologists that participated in the study.
Please cite this article as: Contreras-Omaña R, Sánchez-Reyes O, Ángeles-Granados E. Comparación de los cuestionarios Carlsson-Dent y GERD-Q para detección de síntomas de enfermedad por reflujo gastroesofágico en población general. Revista de Gastroenterología de México. 2017;82:19–25.