Prevalence of Gastroesophageal Reflux Disease in Saudi Arabia

Background Gastroesophageal reflux disease (GERD) is a condition when stomach acid comes up into esophagus and induce symptoms or complications. Methods: We enrolled 584 in a cross-sectional community-based study to assess the prevalence of GERD symptoms in Saudi Arabia in addition to determine the risk factors associated with GERD occurrence. Data were conducted and randomly distributed through electronic questionnaire translated by the researchers to the Saudi population. We included the Saudi population above age of 18 years old and we excluded population under age of 18 years from our study. The Questionnaire was about 27 Arabic questions to assess the knowledge, prevalence and associated risk factors related to GERD symptoms. Results: A total of 584 subjects participated in the study from different regions in Saudi Arabia. Most of them were between 18 – 51 age group, majority were females and 57.4 from the west region. The mean height of the sample was 158.57 cm with a standard deviation of 58.72 cm, and the mean weight was 68.28 kg with standard deviation 19.21 kg. Most of the participants have no disease. The majority of the sample participants were non-smokers 84.6%, while there were 12 % of participants were smokers and 3.4 were former smokers. Half of the study group has a family member with GERD. Approximately 50% of the sample were experiencing heartburn or bitterness in the throat.19% of the sample has been diagnosed with GERD. Most of the participants think that taking medications and the type of food alleviates the symptoms of GERD. The most used mediations to relieve the symptoms of GERD are Gaviscon, Nexium, and Pantoprazole. Conclusion: Prevalence of GERD is increasing in our society due to the multiple factors we discussed, mainly lifestyle. These modifiable factors should be highlighted by educating the community and rising awareness about this condition before establishing complications.


Introduction Definition
Gastroesophageal reflux disease (GERD) is a condition when stomach acid comes up into esophagus and induce symptoms or complications (Antunes and Curtis, 2019). patients. Gender does not affect the spread of the disease, but complications are more common in men than women. The rate of esophagitis is 2:1 and the rate of Barrett's is 0:1 in males compared to females; whereas on other study, female gender has been reported as risk factor (Antunes and Curtis, 2019). GERD incidence increases with age, especially after age forty; where in some studies no significant association between age and GERD symptoms (Antunes and Curtis, 2019) (Almadi, et al., 2014). Many studies have agreed that obesity, overweight and smoking increase symptoms of GERD. In a previous study, they found the relation between marital status effect and GERD symptom where it was obvious among divorced/widow approximately 34.9-31.7% and followed by the single approximately 25.1%. Another study has reported the relation between low educational level and GERD (Altwigry, Almutairi, and Ahmed, 2017).
Different studies done in Saudi Arabia to assess the prevalence of GERD among cities communities. A study was done at Riyadh in which GERD prevalence was 45.4% also more significant among older individual, obesity and smoker. There was no difference between male and female (Almadi, at.al., 2014). Also, another study was done in Qassim region among 200 Saudi school-teachers has reported the overall prevalence was 55%, more prevalence between female high school teachers and teachers age group 30-41 years (Altwigry, Almutairi, and Ahmed, 2017). A study conducted in southern Saudi Arabia to diagnose and measure the complications of GERD by using upper gastrointestinal endoscopy in which the GERD prevalence was 15% in Abha and the prevalence of Barrett's oesophagus was 0.003% in Jizan (Alsuwat, et al., 2018).
The typical symptoms of GERD are heartburn which is the cardinal feature of GERD and the diagnosis will be easily if present, regurgitation of gastric contents into the oropharynx, difficulty swallowing, excessive salivation, gas and bloating, pain or discomfort in the chest, bad breath or a sour taste in the mouth. In some cases, patients with no history of heartburn may have atypical symptoms such as hoarseness or laryngitis, persistent cough, asthma or asthma -like symptoms, dental erosion and discomfort in the ears and nose. GERD affects quality of life and may cause erosive esophagitis, esophageal strictures, and Barrett esophagus, a precursor to esophageal adenocarcinoma (Andreoli, et al., 2010).
The association between the age or gender with GERD symptoms is not clear until now, but the risk of GERD complications is associated with advancing age, male gender and white race. There are conflicting results about the gender who have high prevalence of GERD symptoms. Also, there is association between tobacco smoking which cause weakness of lower esophageal sphincter or alcohol consumption and GERD symptoms. Obesity and hiatus hernia are a strong risk for GERD and its complications. GERD is common during pregnancy due to decrease lower esophageal sphincter pressure by progesterone hormone. Some of foods as fat, sweets, chocolate and salt may aggravate acid reflex (Granderath, et al., 2006).

Investigations
GERD is one of GI diseases that can be diagnosed clinically based on a good history and physical examination. To confirm the diagnosis or to detect the complication of GERD doctor may request some medical tests.

Treatment
The goal is to relive symptoms and to prevent complications. Treatment is divided into: 1) Lifestyle modification: Weight loss, smoking cessation, reduce hot drinks, alcohol cessation, reduce spicy food, caffeine, raise bed head, avoid sleep immediately after eating (eat 3-4 hrs before bedtime).
NOTE: long term use of antacids is dangerous, it can result in serious side effect, include: Diarrhea, electrolyte imbalance (alter calcium metabolism that causes heart disease, also it ↑magnesium in the body can cause kidney disease) (Patti, 2019).

Objectives
This study was conducted to evaluate the prevalence of GERD symptoms in Saudi Arabia and the causes behind it's prevalence. We will be evaluating and answering questions of whether or not GERD is associated with a certain group of age, the role of gender in association to symptoms and the commonest risk factors in our community population. With our main aim in improving the general health by raising awareness and educating the public before the occurrence of complications.

Methodology
A cross sectional community-based study was conducted and designed to assess the prevalence of GERD symptoms in Saudi Arabia in addition to determine the risk factors associated with GERD occurrence. The study carried out from July to August 2019. The sample size was 584 participants from different regions in Saudi Arabia. Data were conducted and randomly distributed through electronic questionnaire translated by the researchers to the Saudi population. We included the Saudi population above age of 18 years old and we excluded population under age of 18 years from our study. The Questionnaire was about 27 Arabic questions to BENEFIT INDICATION Help in GERD diagnosis when endoscopy is normal Before surgery to ensure intact esophageal function Recurrence of symptoms while or after use of acid-reducing medications Diagnose abnormal peristalsis or ↓ LES tone assess the knowledge, prevalence and associated risk factors related to GERD symptoms. We included all participants above age of 18 years, and we excluded the participants below age of 18 years from our study population. The questionnaire was formulated and designed based on previous study was done on prevalence of GERD symptoms. The online questionnaire was formed in multiple choice questions and yes -no questions. We started our questionnaire involving 4 questions on the demographic data including the age, gender, nationality and residence area. Also, 2 questions about the Anthropometric measurements length (cm) and weight (kg). In addition to 4 questions about the risk factors such as smoking, drinking caffeine, pregnancy and associated co morbidities. Moreover, we involved 5 questions about positive GERD predictors and its frequency such as heartburn, food regurgitation and sleep disturbances from those symptoms. In addition to 2 questions about the negative GERD predictors such as nausea and epigastric pain. We included 4 questions about the awareness of GERD, aggravating factors, reliving factors and the medication used for decreasing GERD symptoms. Also, we added 2 questions about if the participant is diagnosed with GERD and the duration of symptoms occurrence. Finally, we ended our questionnaire with 3 questions about the presence of family history of GERD symptoms especially the first-degree relatives and one question about the presence of these alarming symptoms such as dysphasia, weight loss and chest pain. The scoring of GERD symptoms was depending on the frequency of these symptoms during the week if its once per week, 2 -3 times or 4 -7 times per week respectively. Where the scores ranging from 1 to 3 for the positive GERD predictors. After summation of the scores the patient who got score of 8 or more was considered to have positive GERD symptoms and patients who got less than 8 was less likely to have positive GERD symptoms. Based on our findings we can say that the majority of the participants was preferring to have medical treatment commonly than surgical interventions.

Results
A total of 584 subjects participated in the study from different regions in Saudi Arabia. Table 1 shows the sociodemographic characteristics of the study participants, the mean height of the sample was 158.57 cm with a standard deviation of 58.72 cm, and the mean weight was 68.28 kg with standard deviation 19.21 kg. Table 2 shows that most of the participants have no disease. The majority of the sample participants were non-smokers 84.6%, while there were 12 % of participants were smokers and 3.4 were former smokers, also approximately half of the sample participants were frequent drinkers of caffeine. Figure 1 shows that almost half of the study group has a family member with GERD. Table 3 illustrates the symptoms of GERD, approximately half of the sample were experiencing heartburn or bitterness in the throat, and half of the sample participants who suffer from heartburn or bitterness in the throat experience it one time a week, while 33.5% of the sample feel the symptoms from 2 to 3 times a week, and 16.8% of the sample feel the symptoms from 4 to 7 times a week. According to table 3, almost two-thirds of the sample participants do not suffer from the reflux of food to the throat or mouth. Also, almost one-quarter of the sample have difficulty sleeping due to heartburn and reflux. And almost two-thirds of the sample participants do not suffer from pain in the upper stomach. 19% of the sample has been diagnosed with GERD. Table 4 shows the period of time they have been experiencing it. Participants were asked regarding factors that aggravate the symptoms of GERD from their point of view, most of the participants think that eating fatty or spicy food increases the symptoms, while 21.4% of them think that tea and coffee are the main reasons. According to figure 2, most of the participants think that taking medications and the type of food alleviates the symptoms of GERD, while 13.01% of them thought that position during sleeping alleviates the symptoms. Table 5 illustrates that the most used mediations to relieve the symptoms of GERD are Gaviscon, Nexium, and Pantoprazole, while the less commonly used is Maalox.

Discussion
Our study could be considered descriptive in nature. We found that Many factors have shown an association with GERD but still controversial. Nearly all epidemiologic studies have found a relationship between increasing body mass index due to obesity and changes in gastroesophageal anatomy and physiology. But we found that the mean weight was 68.28 kg with standard deviation 19.21 kg. The age group of most our participants is between (18-25) years. Our study has shown a significant correlation with the drinking caffeine in which half of the sample participants were frequent drinkers of caffeine. Also, half of the study group has a family member with GERD symptoms so, we can say it may runs in family. Most of the participants think that taking medications and the type of food alleviates the symptoms of GERD, while 13.01% of them thought that position during sleeping alleviates the symptoms. The most used mediations to relieve the symptoms of GERD are Gaviscon, Nexium, and Pantoprazole, while the less commonly used is Maalox among our study sample.

Conclusion
The prevalence of GERD is increasing in our society due to the multiple factors we discussed, mainly lifestyle. These modifiable factors should be highlighted by educating the community and rising awareness about this condition before establishing complications.