ACG: Psychological Distress Increases GERD Severity

October 16, 2007

PHILADELPHIA -- Apparent treatment-resistant gastroesophageal reflux disease may reflect comorbid psychological distress that results in more severe symptoms, results of a study reported here suggest.

PHILADELPHIA, Oct. 16 -- Apparent treatment-resistant gastroesophageal reflux disease may reflect comorbid psychological distress that results in more severe symptoms, results of a study reported here suggest.

About 40% of patients with GERD have comorbid psychological distress, William Chey, M.D., of the University of Michigan at Ann Arbor said at the American College of Gastroenterology meeting. As a consequence, many of the patients will have residual symptoms despite acid-suppressive therapy with PPIs.

"The residual symptoms could be mistakenly interpreted as lack of treatment response when, in fact, they represent more severe GERD," said Dr. Chey.

The exacerbating effect of psychological distress could help explain why about 30% of GERD patients have incomplete symptom relief with PPI therapy, he added.

To determine the prevalence of comorbid psychological distress and assess its impact on response to PPI therapy, Dr. Chey and colleagues studied 101 patients who underwent esophagogastroduodenoscopy for evaluation of persistent heartburn. Testing revealed that 67 patients had nonerosive reflux disease and 34 had erosive esophagitis.

At enrollment each patient completed health-related surveys designed to assess GERD symptoms and severity, quality of life, and psychological status. Patients with a score greater than 63 on the Brief Symptom Inventory were defined as having psychological distress.

"A BSI of 63 actually defines significant psychological distress," said Dr. Chey. "We set the bar pretty high. These patients were significantly distressed."

All patients received treatment with open-label rabeprazole (Aciphex) 20 mg/d. After eight weeks of PPI therapy, the health-related surveys were administered again.

Overall, 39% of the patients had comorbid psychological distress. The prevalence of concomitant psychological symptomatology did not differ between patients with nonerosive or erosive disease, said Dr. Chey. Although some of the patients were on antidepressants, most had not been diagnosed with psychological disorders.

Patients with comorbid psychological distress had more severe GERD symptoms at enrollment, reflected in a mean Digestive Health Symptom Index score of 41.8 versus 33.6 for patients without psychological distress (P=0.02).

After eight weeks of PPI therapy, patients with comorbid psychological distress remained significantly more symptomatic (DHSI 23.1 versus 13.6, P=0.01).

However, patients with and without psychological distress had the same degree of symptom improvement with PPI therapy (P

The findings, Dr. Chey said, suggest a more generalized process, such as increased visceral hypersensitivity resulting from differences in cortical processing, a hypothesis proposed for irritable bowel syndrome.