A Population-Based Survey of Gastroesophageal Reflux Disease in a Region with High Prevalence of Esophageal Cancer in China
Gastroesophageal reflux disease (GERD) is a common condition characterized by the backward flow of stomach contents into the esophagus, leading to symptoms such as heartburn and acid regurgitation. While GERD is widely recognized as a risk factor for esophageal adenocarcinoma (EAC), its relationship with esophageal squamous cell cancer (ESCC) remains unclear. This study aimed to investigate the epidemiology of GERD in a region with a high prevalence of ESCC in China, specifically in Anyang, Henan Province. The findings provide valuable insights into the prevalence, risk factors, and subtypes of GERD in this population.
Background and Rationale
The relationship between GERD and ESCC is not well understood. While Western studies have shown a decline in ESCC prevalence with the increasing incidence of GERD, experimental models have demonstrated that duodenal reflux can induce ESCC. This suggests that GERD may play a role in the development of ESCC, although the exact mechanisms remain unclear. Understanding the prevalence and risk factors of GERD in regions with high ESCC incidence is essential to clarify this relationship.
Anyang, located in the Tai-hang Mountains, is one of the areas with the highest ESCC incidence globally. Despite efforts to reduce risk factors such as drinking shallow well water and consuming hot foods, ESCC remains a significant public health concern in this region. While the general prevalence of GERD in China is relatively low (around 5.2%), the prevalence in high ESCC areas like Anyang has not been previously investigated. This study aimed to fill this gap by conducting a population-based survey of GERD subtypes, including reflux esophagitis (RE) and non-erosive reflux disease (NERD), in Anyang.
Study Design and Methods
The study was conducted as part of the Endoscopic Screening for Esophageal Cancer in China (ESECC) randomized controlled trial. A total of 2918 residents from Hua County, Anyang, were enrolled between July 2013 and March 2014. Participants completed questionnaires, including the Chinese version of the Gastroesophageal Reflux Disease Questionnaire (GerdQ) and the Rome III functional gastrointestinal disorders questionnaire. They also underwent esophagogastroduodenoscopy (EGD) with routine esophageal biopsies.
GERD was classified into two subtypes: RE, characterized by visible esophageal mucosal injury, and NERD, where mucosal injury is absent despite symptoms. Silent RE was defined as the presence of esophageal mucosal injury in individuals without typical or atypical GERD symptoms. The study excluded participants with upper gastrointestinal organic diseases such as cancer and gastric ulcers. Statistical analyses were performed to identify risk factors for RE and NERD.
Results
Prevalence of GERD and Its Subtypes
Out of 2844 participants included in the analysis, the overall prevalence of GERD (RE + NERD) was 17.3%. Specifically, 9.53% of participants were diagnosed with RE, and 7.77% were diagnosed with NERD. The prevalence of RE increased with age, from 7.09% in the 45–50 age group to 9.53% in the 61–69 age group. Silent RE was diagnosed in 2.36% of participants, representing 24.72% of all RE cases.
Risk Factors for GERD Subtypes
The study identified several risk factors for RE and NERD. For RE, independent risk factors included age, male gender, high body mass index (BMI), smoking, and frequent liquid food consumption. Age was the only independent risk factor for NERD. H. pylori infection was found to be a protective factor for RE, with a lower prevalence of RE observed in individuals with H. pylori infection.
Frequent liquid food consumption was a significant risk factor for RE, particularly silent RE. This finding contrasts with the common belief that liquid foods are easier to digest and less likely to cause reflux. The study suggested that liquid foods may increase gastric volume and pressure, leading to ineffective neutralization of gastric acid and subsequent esophageal injury.
Comparison of Silent and Symptomatic RE
Among participants with RE, 24.72% had silent RE, while the remaining 75.28% had symptomatic RE. There were no significant differences in the severity of esophageal injury (as classified by the Los Angeles Classification) between silent and symptomatic RE cases. Risk factors for silent RE included age, male gender, and frequent liquid food consumption.
Discussion
High Prevalence of GERD in ESCC-Prevalent Areas
The study found a significantly higher prevalence of GERD in Anyang (17.3%) compared to the general Chinese population (2.3% to 5.2%). The prevalence of RE (9.53%) was also higher than in other regions of China and similar to rates reported in Western countries. This high prevalence may be attributed to unique environmental and lifestyle factors in Anyang, such as dietary habits and water sources.
The inverted proportion of RE/NERD observed in this study (more RE than NERD) is unusual and contrasts with findings from other regions where NERD is more common. This suggests that RE and NERD may represent distinct disease entities rather than different stages of the same condition. Further research is needed to understand the natural history of GERD in this population.
Risk Factors for GERD
The study confirmed several known risk factors for GERD, including age, male gender, high BMI, and smoking. Frequent liquid food consumption emerged as a novel risk factor, particularly for silent RE. This finding highlights the importance of dietary habits in the development of GERD and suggests that dietary interventions may help reduce the burden of GERD in high-risk populations.
H. pylori infection was found to be a protective factor for RE, consistent with previous studies. The inverse relationship between H. pylori and RE may be due to the bacterium’s ability to reduce gastric acid secretion. However, the widespread use of H. pylori eradication therapy in China may contribute to the increasing prevalence of GERD.
Implications for ESCC Prevention
The high prevalence of GERD in Anyang raises concerns about its potential role in the development of ESCC. While GERD is a well-established risk factor for EAC, its association with ESCC is less clear. The study suggests that GERD, particularly RE, may contribute to the high incidence of ESCC in this region. Future studies should investigate the mechanisms linking GERD to ESCC, including the role of reflux content and extent.
Conclusion
This population-based survey revealed a high prevalence of GERD in a region with a high incidence of ESCC in China. The study identified age, male gender, high BMI, smoking, and frequent liquid food consumption as risk factors for RE, while age was the only risk factor for NERD. H. pylori infection was found to be protective against RE. The findings underscore the importance of understanding the epidemiology of GERD in high-risk populations and its potential role in the development of ESCC. Further research is needed to explore the relationship between GERD and ESCC and to develop targeted prevention strategies.
doi.org/10.1097/CM9.0000000000000275
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