Xun Huang, Hui-Ming Zhu, Chuan-Zhen Deng, Porro G Bianchi, Sangaletti O, Pace F, ¹Department of Gastroenterology, Shenzhen People′s Hospital, Shen zhen 518020, Guangdong Province, China
²Gastrointestinal Unit, L. Sacco, Milan University, Milan, Italy
Xun Huang, female, born on 1960-05-19 in Shanghai, graduated from Shan ghai Medical University, now associate professor of gastroenterology, having 5 papers published.
Correspondence to: Xun Huang, Department of Gastroenterology, Shenzhen People′s Hospital, Shenzhen 518001, Guangdong Province, China
Telephone: +86-755-5533018, Fax.+86-755-5533497
Received: 1999-03-06

Subject headings: gastroesophageal reflux; esophagitis; hiatal hernia

Huang X, Zhu HM, Deng CZ, Porro GB, Sangaletti O, Pace F.Gastroesophageal reflux: the features in elderly patients.
World J Gastroentero,1999;5(5):421-423

Abstract
AIM: To compare the features of gastroesophageal reflux diseas e between elderly and younger patients.

METHODS: Twenty-four hour pH-monitoring and endoscopy were per formed for the 66 elderly patients with typical gastroesophageal reflux symptoms , and the results were compared with 112 symptomatic younger patients.

RESULTS: The results of 24-h pH-monitoring and endoscopy showe d that the elderly patients had pathological reflux and reflux esophagitis more frequently than the younger patients. Percentage time with pH＜4 in elderly pati ents with reflux esophagitis was 32.5% in 24 hours, as compared with 12.9% in the younger patients with reflux esophagitis (P＜0.05). The elderly patient s with reflux esophagitis have longer periods of acid reflux in both upright and supine positions than the younger patients. Endoscopy showed that 20.8% of elderly patients had grade Ⅲ/Ⅳ esophagitis, whereas only 3.4% of younger p atients had grade Ⅲ/Ⅳ esophagitis (P＜0.002). Percentages of grades Ⅰ/Ⅱ esophagitis in the two groups were 12.5% and 26.5%, respectively (P＜0.002).

CONCLUSION: Elderly patients, as compared with younger patients , have more severe gastroesophageal reflux and esophageal lesions. The incompete nce of lower esophageal sphincter and the presence of hiatal hernia may be impor tant factors leading to the difference in incidence and severity of reflux esoph agitis between elderly and younger patients.

INTRODUCTION
With the introduction of intraesophageal 24-h pH-monitoring in clinical practi ce, it is now possible to identify patterns of gastroesophageal reflux (GER) in the healthy people and patients and to assess the effect of H2 blockers and H⁺ /K⁺ adenosine triphosphatase (ATPase) inhibitors on GER diseases^［1-7］. It is increasingly recognized that symptomatic GER may occur in the patients of all ages. However, little information is available on symptomatic GER patterns in the elderly. Recently, Mold et al, investigated GER disease (GERD) in pat ients aged over 62 years in a primary care setting^［8］. However, the focu s of this study was not on patterns of GER, but on prevalence of GER in the elde rly. Therefore, the aim of the present study was to identify patterns and featur es of symptomatic GER in the elderly patients.

PATIENTS AND METHODS
Patients
One hundred and seventy-eight consecutive patients who had experienced heartbur n, regurgitation and chest pain for at least 6 months were studied. These includ ed 66 elderly patients (36 men, 30 women) ranging in age from 65 to 76 years (mean age 67 years), and 112 younger patients (64 men, 48 women) aged from 21 to 64 years (mean age 41 years). None had undergone upper gastrointestinal surge ry such as gastric resection and selective proximal vagotomy. None had taken H2 -blockers or H⁺/K⁺-ATPase inhibitors in the 2-week period before 24-h pH-monitoring.

Endoscopy
All patients underwent upper gastrointestinal endoscopy. Esophagitis grade was assessed endoscopically by using the Savary & Miller Criteria^［9］, that is, from grade Ⅰ to Ⅳ. Of these patients, very few presented with grades Ⅱ and Ⅲ esophagitis, and therefore grade Ⅰ and Ⅱ, and Ⅲ and Ⅳ were grouped together.

Twenty-four hour intraesophageal pH-monitoring
Twenty-four hour intraesophageal pH-monitoring was carried out by a routine method used in our laboratory^［10］. Patients were advised to take a stand ard 2200 kilocalories meal during 24-h intraesophageal pH-monitoring. A glass pH-electrode with an incorporated potassium chloride reference electrode (Ingol d electrode, No 440) was introduced via the naso-esophageal route and positione d with the tip 5cm above the gastroesophageal junction identified by the pH-metry^［11,12］. The output from the pH probe was recorded on a solid-s tate recorder (Autronicord CM 18), which could be carried on a belt by the patie nts. Data were analyzed on a computer by means of a dedicated computer program. The parameters recorded included the frequency and duration of GER in 24 hours, upright and supine positions, and frequency of GER longer than 5 minutes. Pathol ogical reflux was diagnosed if 1) the pH value in the regurgitated contents was ＜4.0, and 2) the complete reflux duration was more than 7% in 24 hours^{［10 -12］}. Reflux esophagitis was diagnosed if the patient with pathological GER h ad inflammatory esophageal lesions.

Statistical methods
Anamnestic data and endoscopic findings were analysed by means of the Chi-squar e test. The Mann-Whitney test and Fisher exact test were used to evaluate GER p arameters.

RESULTS
Endoscopic findings showed that elderly patients had more severe esophageal lesions and a higher incidence of hiatal hernia than younger patients (Table 1) (P＜0.002).
      On the basis of the results of the endoscopy and intraesophageal 24-h pH-monit oring, patients can be divided into three subgroups: physiologic reflux, patholo gic reflux and reflux esophagitis. Table 2 lists the percentages of the three groups in elderly and younger patients. The incidence of pathologic reflux and r eflux esophagitis in elderly patients was higher than that in younger patients (P＜0.05).
      Figure 1 shows the percentage time of GER episodes in 24 hours. In the reflux esophagitis group, percentage time of GER episodes in the elderly and younger patients during the entire 24-h period was 36.2% and 17.8%, respectively (P ＜0.05). No statistically significant differences in the percentage time with GER episodes were found between the elderly and younger patients in either the physiologic or pathologic reflux subgroups.
      Figures 2 and 3 show the percentage time of GER episodes in upright and supine positions. Elderly patients with reflux esophagitis had significantly greater percentage time of GER episodes than younger patients with reflux esophagitis (upright position, 32.4% versus 13.6% supine position, 30.7% versus 11.7%; P＜0.05).

Table 1 Endoscopic findings in elderly and younger patients

^bP＜0.001, elderly patients vs younger patients .
Table 2 Percentages of physiological reflux (PhR), pathological refl ux and reflux esophagitis (RE) in elderly and younger patients

^aP＜0.05, elderly patients vs younger patients; PhR=p hysiological reflux; PR=pathological reflux; RE=reflux esophagitis.

Figure1(PDF) Percentige time of GER episodes in 24 hours.-PhR: physiological reflux; PR: pathological reflux; RE: reflux esophagitis.
Figure2(PDF) Percentage time of GER episodes in upright position.
Figure3(PDF) Percentage time of GER episodes in supine positions.
 Elderly patients with reflux esophagitis had a higher frequency of GER episodes than younger patients with reflux esophagitis, the difference being statistically significant (Table 3). There was no significant difference between elderly and younger patients in frequency of GER episodes lasting more than 5 minutes (Table 4).

Table 3 Frequency of GER episodes in elderly and younger patients (mean±SD)

^aP＜0.01, elderly vs younger; ^cP＜0.05, eld erly vs younger; ^dP＜0.01, elderly vs younger; ^eP＜ 0.05, elderly vs younger.
Table 4 Frequency of GER episodes lasting more than 5 mintues in eld erly and younger patients (mean±SD)

P＞0.05, elderly patients vs younger patients; PR=pathologic al reflux; RE=reflux esophagitis.

DISCUSSION
Although several studies of GER patterns have been carried out in healthy subjects and patients, the GER profile in the elderly has not been investigated. Many older people, as a result of physiological change or disease, have decreased salivary flow, gastric acid production, esophageal motility, gastric emptying, and/or lower esophageal sphincter tone. These changes may affect the features of symptomatic GER in the elderly patients.
      The present study demonstrated that patterns of GER and esophageal lesions in elderly patients with GER symptoms showed different features from those presented by the younger patients. Firstly, the incidence of pathological reflux and reflux esophagitis in the elderly patients with GER symptoms was significantly higher than in the younger patients (66.7% vs 46.9%).Secondly, the elderly patients with GER symptoms have more severe esophageal lesions than younger patients. In the elderly patients, 20.8% of patients had grades Ⅲ/Ⅳ esophagitis , as against only 3.4% of patients in the younger group. In addition, elderly p atients had a higher incidence of hiatal hernia than their younger counterparts. Thirdly, 24-h intraesophageal pH-monitoring showed that elderly patients with reflux esophagitis had a more severe acid reflux than younger patients with ref lux esophagitis.This is due to prolonged periods of acid reflux in both upright a nd supine positions. Similarly, in elderly patients with reflux esophagitis, the frequency of GER episodes in both upright and supine positions is higher than t hat in younger patients with reflux esophagitis. It is generally agreed that eso phagitis may be the result of abnormal acid GER in most patients. Our results su ggest that more severe patterns of GER in elderly patients leads to more severe esophageal lesions.
      The present results showed that there was no statistically significant difference between the elderly and younger patients regarding frequency of GER episodes lasting more than 5 minutes (Table 4). This suggests that an impaired esophag eal clearing function is not responsible for the difference in incidence and sev erity of reflux esophagitis observed between elderly and younger patients. Therefore, different pathogenetic mechanism such as the incompetence of lower esophag eal sphincter and the presence of hiatal hernia may be important factors leading to the difference in incidence and severity of reflux esophagitis between elder ly and younger patients.

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