Esophagitis symptoms may not match severity of disease

American Family Physician,  Nov 1, 2004  by Richard Sadovsky

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Erosive disease causes 40 to 60 percent of the symptoms of gastroesophageal reflux disease (GERD) among persons of all ages, with a higher percentage occurring among elderly persons. Complications of GERD, specifically Barrett's esophagus and esophageal adenocarcinoma, increase with age. However, the severity of reflux symptoms may not increase with age and, as confirmed by some studies, may actually decrease. Johnson and Fennerty used a post hoc analysis of pooled baseline data from five large studies that involved more than 11,000 patients with GERD to examine the change in grades of esophagitis as well as the change in symptoms occurring as patients age.

The baseline symptom assessment included questions about the severity of symptoms, and all patients underwent esophagogastro-duodenoscopy. Helicobacter pylori positivity increased with advancing age, as did the prevalence of severe esophagitis. In contrast, severe heartburn decreased with increasing age. The negative association between age and severe heartburn in participants with severe esophagitis was statistically significant (P < .0001). The association may be caused by an age-related decrease in esophageal sensitivity to pain. When elderly patients had severe heartburn, the correlation with severe esophagitis was high. Hiatal hernia, a risk factor for more severe erosive esophagitis, also was more common among older persons.

The authors conclude that the severity of heartburn symptoms often fails to match the severity of erosive esophagitis in older patients. Because GERD more frequently is associated with significant pathology in older patients, more aggressive evaluation and treatment of older patients with GERD may be warranted, regardless of symptom severity.

RICHARD SADOVSKY, M.D.

Johnson DA, Fennerty MB. Heartburn severity underestimates erosive esophagitis severity in elderly patients with gastroesophageal reflux disease. Gastroenterology March 2004;126:660-4.

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