Gastric Intestinal Metaplasia May Attenuate Reflux Symptoms – Analysis of a Large Observational Prospective Cohort

Authors:
Si Ying TANG¹, Kewin SIAH^1,2, Calvin J KOH^1,2,3, Jonathan LEE^1,2,3, Feng ZHU^2,3, Jimmy SO^3,4, Khek Yu HO^1,2, Supriya SRIVASTAVA², Stephen TSAO⁵, Christopher KHOR⁶, Kwong Ming FOCK⁷, Wee Chian LIM⁵, Khoon Lin LING⁸, Tiing Leong ANG⁷, Ming TEH^3,9, Khay Guan YEOH^1,2,3


Affliations:
¹Division of Gastroenterology and Hepatology, National University Hospital, Singapore
²Department of Medicine, National University of Singapore, Singapore
³Singapore Gastric Cancer Consortium, Singapore
⁴Department of Surgery, National University of Singapore, Singapore
⁵Department of Gastroenterology & Hepatology, Tan Tock Seng Hospital, Singapore
⁶Department of Gastroenterology & Hepatology, Singapore General Hospital, Singapore
⁷Department of Gastroenterology & Hepatology, Changi General Hospital, Singapore
⁸Mount Elizabeth Medical Centre, Singapore
⁹Department of Pathology, National University of Singapore, Singapore


Corresponding email address:
Khay Guan YEOH (mdcykg@nus.edu.sg)

Objectives: Gastric intestinal metaplasia (GIM) is a precancerous lesion associated with dysplasia and gastric cancer (GC). Annually, 1.8%, 10%, and 73% of patients with atrophic gastritis, GIM, and dysplasia progress to GC. While dyspepsia is associated withHelicobacter Pylori and active gastritis, GIM is not thought to be associated with specific symptoms. The aim of the study is to evaluate the correlation between GIM and pre-endoscopy symptoms.

Subjects and Methods: 2874 participants underwent 7480 gastroscopies with updated Sydney System gastric mucosal sampling from January 2004 – to December 2010 with GIM graded using the Operative Link in Gastric Intestinal Metaplasia (OLGIM) staging. Prior to each endoscopy, the participants completed a medical history interview reporting symptoms of dyspepsia, acid brash, heartburn, dysphagia, nausea, vomiting, early satiety, indigestion, loss of weight, loss of appetite, coffee ground vomitus, and melena. Results were compiled and statistics calculated using R for chi-square and logistic regression analysis.

Results: GIM was present in 53.3% (n=3992) of the gastroscopies. One-third of the patients (37.1%, n=2781) were symptomatic prior to the endoscopy, with the most common symptoms being dyspepsia (n=1860, 24.9%), acid brash (n=838, 11.2%) and heartburn (n=520, 7%).

Compared to controls, patients with GIM have lower proportions of symptoms (34.2% vs 39.8%, p<0.01). Of note, patients with GIM reported significantly less acid brash (9.5% vs 12.7%, p<0.01), and heartburn (5.2% vs 8.5%, p<0.01), whereby H. pylori status was not significantly different in these subgroups.

Conclusion: We hypothesize that patients with intestinal metaplasia and atrophic gastritis may have less acid secretion and correspondingly fewer reflux symptoms. Although many patients in clinical practice are scoped for dyspepsia and reflux symptoms, our data suggest that patients with GIM are less likely to have these symptoms and yet harbour this pre-malignant condition of the stomach.