Impact of Patients' Basic Characteristics on Incidence of Gastroesophageal Reflux Disease among Patients of Zagazig University Hospitals: A Cross-Sectional Study

1. Older age, male gender, obesity, and smoking are strongly linked to a higher risk of GERD and more severe symptoms in the studied group.
2. Regurgitation and heartburn are the most common symptoms, while vomiting, anemia, and dysphagia are less frequent but indicate more advanced or complex disease.
3. Obesity and metabolic comorbidities (diabetes, hypertension) are very common among GERD patients, highlighting the importance of early risk assessment and lifestyle changes.

INTRODUCTION

Gastroesophageal reflux disease (GERD) is one of the most common upper gastrointestinal disorders, characterized by the reflux of gastric contents into the esophagus, which can result in symptoms such as heartburn, regurgitation, chest pain, dysphagia, and chronic cough [1]. GERD is highly prevalent worldwide and poses a significant healthcare burden, impacting quality of life, work productivity, and healthcare costs [2].

Several risk factors have been linked to GERD, including age, sex, obesity, smoking, dietary habits, alcohol consumption, and hiatal hernia [3,4]. Obesity, in particular, raises intra-abdominal pressure, which promotes reflux and damages the esophageal mucosa [5]. Hiatal hernia is another key anatomical risk factor that contributes to reflux by impairing the function of the lower esophageal sphincter [6]. Additionally, smoking and alcohol intake contribute to esophageal mucosal damage and worsen GERD symptoms [7].

Although GERD itself is generally benign, chronic and uncontrolled disease can lead to complications such as esophagitis, Barrett’s esophagus, and ultimately esophageal adenocarcinoma [8,9]. Early identification of patients at higher risk of developing GERD, based on their basic demographic and clinical characteristics, may enable better preventive strategies and improve long-term outcomes.

The current study aimed to assess how patients’ basic characteristics influence the occurrence of GERD.

PATIENTS AND METHODS

Study Design and Setting

This prospective cross-sectional study was conducted in the Hepatology, Gastroenterology, and Infectious Diseases Department at Zagazig University hospitals from February 2024 to June 2025. The protocol received approval from the Institutional Review Board of Zagazig University (ZU-IRB #11176), and written informed consent was obtained from all participants before enrollment [10].

Study Population

A total of 350 adult patients (≥18 years) with chronic symptoms indicative of gastroesophageal reflux disease (GERD) were included. The sample size was calculated based on an expected prevalence of 15% in a population of 10,000, with a 95% confidence level and a 5% margin of error.

Inclusion criteria were:

• Adults (≥18 years) who have clinical signs of GERD, such as heartburn, regurgitation, chest pain, or dysphagia.
• Patients exhibiting alarm symptoms such as dysphagia, anemia, GI bleeding, or weight loss.

• Exclusion criteria were:

• Age under 18 years.
• Pregnant women.
• Patients with other gastrointestinal or systemic illnesses.

Clinical and Diagnostic Evaluation

All patients underwent:

1. Complete history taking, including demographic information (age, sex, residence), duration of GERD symptoms, smoking status, BMI, comorbidities (such as diabetes, hypertension, liver disease, cardiac disease), and medication history (NSAIDs, anticoagulants).
2. Clinical examination (general and abdominal), focusing on signs of anemia and reflux disease complications.
3. An upper gastrointestinal endoscopy was performed using a Pentax EG-3840 gastroscope to confirm GERD and rule out Barrett’s esophagus, ulcers, or other esophageal conditions. The diagnosis of GERD was based on endoscopic findings such as erosive esophagitis, mucosal inflammation, and the presence of a hiatal hernia.
4. Laboratory tests included a complete blood count, liver and kidney function tests, and a coagulation profile, mainly to assess comorbidities and rule out other systemic diseases.

Statistical Analysis

Data were coded and analyzed using SPSS version 21.0. Categorical variables were presented as frequencies and percentages, while quantitative variables were expressed as mean ± standard deviation (SD). Associations between GERD and patients’ characteristics (age, sex, BMI, smoking, presence of hiatal hernia, comorbidities) were assessed using the Chi-square test for categorical data and Student’s t-test or ANOVA for continuous variables. A p-value <0.05 was considered statistically significant.

RESULTS

A total of 350 cases with a mean age of 42.3±10.4 were included in the study; 202 (57.7%) were males and 148 (42.3%) were females. The patients were classified into four age groups: under 30 years, under 40 years, under 50 years, and 50 years or older, accounting for 11.14%, 12%, 34.86%, and 42%, respectively (Table 1). Regarding sex, 57.7% were males, and 42.3% were females. Regarding smoking, 60.3% of the patients were smokers. Based on body mass index, 43.7% were obese, 41.1% were overweight, and only 15.1% had a normal weight. Concerning comorbidities, 28.6% of the patients had DM, and 29.1% had HTN (Table 1).

Table 2 shows that regurgitation was the most common symptom among the studied patients, accounting for 89.4%, followed by heartburn at 83.7%. In contrast, vomiting, upper GIT bleeding, unexplained anemia, and dysphagia occurred in 7.25%, 6.9%, 14.6%, and 10.9%, respectively.

 Table 3 shows that regurgitation was more common in males, with 190 (94.06%) compared to 125 (84.5%) in females, and the difference was statistically significant (P < 0.05). Among male patients, 182 (90.19%) had heartburn, 20 (9.9%) experienced vomiting, and 34 (16.83%) had unexplained anemia, all higher than in females, which had 114 (77.03%) with heartburn, 4 (2.7%) with vomiting, and 9 (6.1%) with unexplained anemia, with a statistically significant difference (P <0.05). There was no statistically significant difference between males and females regarding upper GIT bleeding and dysphagia (P >05).

Symptoms of regurgitation and heartburn were more common among obese patients, with 148 (96.7%) and 140 (91.5%), respectively. Overweight patients showed slightly lower prevalence, with 129 (89.6%) and 122 (84.7%), respectively. The lowest prevalence was among patients with normal BMI, at 67.9% and 60.4%. A statistically significant difference was observed (P < 0.05) (Table 4). BMI was not a substantial factor in vomiting, upper GI bleeding, unexplained anemia, and dysphagia (p= 0.27, p= 0.13, p= 0.62, and 0.2, respectively) (Table 4).

Table 5 shows that symptoms were more common among older patients over 50 years old, including regurgitation (97.3%), heartburn (93.88%), vomiting (14.29%), unexplained anemia (21.8%), and dysphagia (17%), compared to younger patients, with a statistically significant difference (P < 0.05). Age was not a major factor in upper GIT bleeding (P > 0.05).

Table 1: Basic characteristics of studied patients.

DM: diabetic mellitus, HTN: hypertension

BMI: Body Mass Index              IQR: interquartile range

Table 2: Distribution of Symptoms among the Studied Patients.

Table (3): Distribution of symptoms regarding sex among the studied patients.

RR: Relative Risk          OR: Odds ratio          C.I: confidence interval

 Table 4: Distribution of symptoms regarding BMI among the patients studied.

Table 5: Distribution of symptoms regarding age group among the studied patients.

DISCUSSION

Gastroesophageal reflux disease (GERD) is one of the most common upper gastrointestinal disorders, characterized by the reflux of gastric acid into the esophagus, resulting in symptoms such as heartburn, chest pain, dysphagia, and chronic cough [14]. Long-term GERD can result in complications, especially Barrett’s esophagus (BE), a precancerous lesion for esophageal adenocarcinoma (EAC), marked by the metaplastic change of squamous epithelium into specialized columnar epithelium [15]. Current clinical guidelines recommend regular endoscopic surveillance and biopsies for BE patients, as dysplasia is a key biomarker for predicting EAC development [16].

 Age and GERD incidence

In our study, the average age of patients with GERD was 42.3 years, with a higher occurrence among older individuals, confirming age as a significant risk factor. These results align with previous reports, which have found that the average age of GERD patients ranges from 44 to 52 years [17–19]. Changes associated with aging, such as weakening of the lower esophageal sphincter (LES) and reduced esophageal motility, may explain this trend [20]. Additionally, age-related conditions like obesity, diabetes, and hypertension, along with lifestyle factors, probably contribute to the development of GERD in older adults. However, recent evidence shows a growing prevalence among younger people, possibly due to modern dietary habits, stress, and psychosocial factors [21].

Sex distribution

Our data showed a male predominance (58%), consistent with previous studies reporting higher prevalence and severity of GERD in men [22]. This may be due to higher rates of central obesity, alcohol use, and smoking among men. However, other research has indicated greater GERD prevalence in women, often linked to hormonal effects such as estrogen and progesterone, which relax the LES and affect esophageal motility [23,24]. This difference suggests that sex-related variations in GERD epidemiology may differ by region, lifestyle, and health conditions.

Smoking as a risk factor

Smoking was present in 60.3% of our GERD patients, confirming its strong link to reflux disease. Nicotine promotes LES relaxation and decreases salivary bicarbonate, which facilitates esophageal acid exposure [25]. Meta-analyses have consistently shown that smoking increases GERD risk by 1.5–2 times [26,27]. However, some studies found no independent association after adjusting for obesity [28]. These differences highlight the importance of considering cumulative smoking exposure (pack-years), alcohol intake, and obesity when evaluating smoking’s role in GERD development.

Comorbidities: Diabetes and Hypertension

Diabetes mellitus was identified in 28.6% of our cohort. Proposed mechanisms include diabetic autonomic neuropathy leading to gastroparesis and hyperglycemia-induced LES dysfunction [29]. However, several extensive studies suggest that obesity, rather than diabetes itself, may mediate this association [30,31]. Similarly, hypertension was present in 29.1% of patients. While shared metabolic factors (such as obesity and a sedentary lifestyle) may explain this link, antihypertensive drugs like calcium channel blockers could also contribute to reflux by decreasing LES tone [32]. Nonetheless, other studies found no independent correlation after adjusting for obesity [33].

Obesity and GERD symptoms

A notable finding in our study was the very high prevalence of overweight (41%) and obesity (44%) among GERD patients. Obesity, particularly central adiposity, is a well-known risk factor for GERD, erosive esophagitis, and BE [34,35]. Mechanistically, increased intra-abdominal pressure, changes in gastric physiology, and systemic inflammation contribute to reflux. Weight loss has been shown to significantly improve GERD symptoms and reduce esophageal acid exposure [36].

Symptom profile

Regurgitation (89.4%) and heartburn (84%) were the most common symptoms, consistent with the Montreal consensus definition of GERD [37]. Their high prevalence highlights their diagnostic importance. Less common but clinically significant symptoms included vomiting (7%), dysphagia (10.9%), unexplained anemia (14.6%), and upper GI bleeding (6.9%). These “alarm features” indicate severe or complicated GERD, such as strictures or neoplastic changes [38,39].

Influence of sex, BMI, and age on symptoms

Symptom distribution significantly varied across subgroups. Males reported more frequent regurgitation, heartburn, vomiting, and anemia compared to females. Obese patients showed a higher prevalence of regurgitation and heartburn than normal-weight individuals, reinforcing obesity’s role in symptom burden [40]. Older age was linked to increased occurrences of regurgitation, heartburn, vomiting, anemia, and dysphagia, consistent with age-related esophageal dysfunction and the accumulation of comorbidities [41].

Clinical implications

These findings underscore the importance of early GERD risk assessment based on individual patient characteristics. Obesity, smoking, and metabolic conditions like diabetes and hypertension are modifiable risks. Lifestyle changes and weight loss should be prioritized in managing GERD. Older age and male sex may require closer monitoring for complications such as BE.

CONCLUSION

GERD incidence is closely linked to patient characteristics, with older age, male gender, obesity, smoking, and metabolic comorbidities acting as key risk factors. Regurgitation and heartburn are the most common symptoms, while vomiting, anemia, and dysphagia indicate more advanced disease. Recognizing these connections highlights the importance of lifestyle modifications and targeted follow-up to prevent complications.

Ethical considerations: All participants provided written informed consent before their involvement in the research. The protocol of the study was approved by the IRB at Zagazig University, Egypt.

No conflict of interest.

No funding sources