The features of psycho-vegetative disorders and their role in the pathogenesis of gastroesophageal reflux disease with obesity

Background: Gastroesophageal reflux disease (GERD) is a disease of the XXI century, affecting the population in the developed countries. There is a clear tendency to increasing of gastroesophageal reflux disease among people of young age. Aim: The aim of the study is to determine the characteristics and role of psychosomatic and vegetative state disorders in the pathogenesis of GERD with concomitant obesity. Materials and methods: 50 young patients with GERD were examined during the study. Depending on the presence or absence of concomitant obesity, two groups were formed. They underwent pH-metery, ultrasonic scanning. State of psychosomatic, vegetative statuses and quality of life we determined by the questionnaires of Beck, Spielberg, Sheehan, Wayne. Results: During the ultrasound examination we determined the esophageal opening diameter, the thickness of esophageal wall, the esophagus width in the lower one third of the esophagus differed significantly in 2 groups of patients (p<0.05). In the group of the GERD patients with concomitant obesity the sharp increase of depression level was found, comparing with both the standard and the second group (p<0.05). It wasn’t found the significant difference amount other figures of vegetative and psychosomatic statuses in 2 groups of patients (p>0.05). The patients with GERD of both groups had significantly higher level of motor-evacuation and psycho-vegetative disorders comparing with healthy people (p<0.05). Conclusion: GERD patients have pronounced motor-evacuation disorders and significantly greater manifestations of psycho-vegetative disorders which were more pronounced in gastroesophageal reflux disease patients with concomitant obesity.


Introduction:
According to recent epidemiological data, there is a clear tendency to increasing of gastroesophageal reflux disease (GERD) rate 1,2 and its spreading espe-cially among young people.At this stage, GERD is not only a medical but also a social problem, leading to the formation of significant complications, including Barrett's esophagus, the decrease of quality of DOI: http://dx.doi.org/10.3329/bjms.v14i2.20272Bangladesh Journal of Medical Science Vol.14 (2) 2015 p. 142-145  life similar to mental illnesses 3 .GERD is also an economic problem caused by the necessity of a long and very expensive treatment that does not always take into account the presence of comorbidity.Today the prompt comprehensive diagnostic, prevention and treatment of gastroesophageal reflux disease are among the most important problems in the clinic of internal diseases 2,3 .At the same time, a number of patients with GERD with comorbid disorders, including obesity, is growing [4][5][6] .Overweight and obesity trigger the development of both short-and long-term adverse effects on the physical and psychosocial health, strengthen disorders of emotional and vegetative state, which occur in gastroesophageal reflux disease.The aim of the study is to determine the characteris-aim of the study is to determine the characteris-of the study is to determine the characteristics and role of psychosomatic and vegetative state disorders in the pathogenesis of GERD with concomitant obesity.

Materials and methods: Subjects
This study was conducted at the gastroenterological departments of Kharkiv Medical Academy of Postgraduate Education and City Student Hospital, Kharkiv.The diagnosis of GERD is established according to ICD-10 based on a detailed survey, evaluation of complaints, history of the disease and the patient's life.For diagnosis was performed following condition: the presence of heartburn that bother the patient, one or more times a week for the past 6 months (as recommended by the Mayo Clinic and the Montreal Consensus, 2005), as well as the data endoscopy, radiological and pH-metric methods .Medical history of GERD ranged from 1 year to 4 years.The criteria for exclusion from the examination can be regarded as the presence of neoplastic lesions in the patient's digestive tract, Barrett's esophagus, active stomach ulcers or duodenal ulcers, or postponed surgery on the organs of the alimentary canal.The study was approved by the Institutional Ethic Committee of Kharkiv Medical Academy of Postgraduate Education and City Student Hospital.Written informed consents were obtained from all the subjects.We made a comprehensive examination of 50 young patients with GERD.Depending on the presence or absence of concomitant obesity, two groups were formed.The first group included patients with GERD and obesity, 14 (56%) men and 11 (34%) women aged from 19 to 27 years old, the average age was 22±1.96 years old.
The second group included patients with GERD without comorbidity, 15 (60%) men and 10 (40%) women aged from 18 to 25 years old, the average age was 21±0.56 years old.To estimate gastric secretion, the intragastric pH-metery method was used with application of calomelantimony electrodes (antral and framed) on the AI-2 (the Acidity Indicator machine, made in Ukraine) with the standard method.
To investigate motor activity disorders, the ultrasonic scanning was made on the machine ALOKA SSD-650 (made in Japan) on an empty stomach, and in 5, 10 and 15 minutes after intake of 0.5 liters of fluid.We determined the diameter of esophageal opening (hiatus esophageus) (normal 1.51±0.05cm) the thickness of the esophagus wall (normal 0.31±0.02cm), the esophagus width in the lower one third of the esophagus (normal 2.13±0.16cm), and also the presence or absence of reflux (reverse fluid flowing from the stomach into the esophagus).The presence of obesity, is established after getting anthropometric measurements of height and body weight of the patient, and the calculation of their body mass index (BMI) using conventional methods.BMI is calculated by the Quetelet formula as the ratio of weight in kilograms to the square of height in meters (kg/m2).We can consider a patient 'obese' if their BMI is bigger than 25 (as concluded by WHO).State of psychosomatic status we determined by the questionnaires of Beck, Spielberg, Sheehan.The vegetative nervous system was investigated with the help of Wayne questionnaire, taking into account the frequency of subjective vegetative symptoms, such as headache, weakness, dizziness, lethargy, emotional lability, rapid fatigability and sweating.As the standard, we took mean values of 20 healthy students of the same age and sex who were the control group (14 men and 6 women) aged 18 to 24.We processed the research results by the variation statistics method with application of correlation analysis standard programs with M, m average values calculation.Results were expressed as mean±standard deviation (SD).Student's t-test was performed to assess the reliability indices.Pearson's correlation coefficients (r) was used to identify the associations between figures.With 95% confidence interval (CI), statistical significance was defined as a р<0.05.
During the ultrasound examination we determined the esophageal opening diameter (normal 1.51±0.05cm, the patients of the first group 2.03±0.15cm, the second group 1.79±0.09cm), the thickness of esophageal wall (normal 0.31±0.02cm, the patients of the first group 0.46±0.03cm, the second group 0.40±0.04cm), the esophagus width in the lower one third of the esophagus (normal 2.13±0.16cm, the patients of the first group 2.9±0.2cm, the second group 2.56±0.26cm) (p<0.05) and the presence or absence of reflux (reverse fluid flowing from the stomach into the esophagus).The study found that concomitant obesity aggravates the clinical manifestations of GERD, ultrasonic parameters and causes higher levels of depression 6,7 .
In the group of the GERD patients with concomitant obesity the sharp increase of depression level was found 8 , comparing with both the standard and the second group (20±3.72 points at the first group and 14.72±3.3-at the second group according to the Beck's scale, that corresponds to moderate depression level and significantly higher than in healthy individuals) (p<0.05).Also, the patients had high level of anxiety, which reached 41.28±5.82points for personal anxiety and 40.36±6.68 points for reactive one in the first group and 40.12±7.18points for personal anxiety and 38.24±8.3 for reactive anxiety in the second group.On the average, in the first group the selfesteem alarm indicator according to the Sheehan's scale was 56.36±9.95 points and 50.88±15.31-in the second group, corresponding to abnormal levels of anxiety and significantly higher ones, than in the group of healthy individuals (p>0.05).At the same time, we thoroughly studied the vegetative status, investigated the frequency of subjective autonomic symptoms, such as headache, weakness, dizziness, emotional lability, fatigue and sweating.It was found that the general vegetative tone of 48% of patients from the first group and 53% patients from the second group was shifted accordingly toward parasympathotonia.The most severe complaints of the gastroesophageal reflux disease patients with concomitant obesity were about emotional lability, rapid fatigability and sweating, comparing with the GERD patients without comorbidity.Thus, we found the reliable differences in the indices of the ultrasound examination and psychosomatic condition of the GERD patients with concomitant obesity compared with the control group, and we did not found any significant differences in the indices between the patients of the first and second groups.

Conclusions:
1.It was shown that GERD patients have pronounced motor-evacuation disorders, which were significantly more pronounced in gastroesophageal reflux disease patients with concomitant obesity.
2. GERD patients with concomitant obesity had significantly greater manifestations of psycho-vegetative disorders comparing with GERD patients without comorbidity.Thus, GERD patients with concomitant obesity have much higher level of depres-sion comparing with the control group, and the group of GERD patients without comorbidity.3. We found the clear correlation between features of vegetative and psychosomatic disorders and characteristics of the motor-evacuation disorders of the gastrointestinal tract of GERD patients with concomitant obesity.4. The obtained results let us to consider the psychovegetative disorders as a factor that leads to motorevacuation disruption of the gastrointestinal tract function, which takes one of the leading places in the GERD pathogenesis.
5. The obtained data allow us to develop additional pathogenetic therapy, applying the means of correcting the motor-evacuation disorders, emotional and autonomic disorders of GERD patients with concomitant obesity.