Sep 2016
Vol. 2, No.1
ISSN: 2410-1605
JKBMS
JOURNAL OF KURDISTAN BOARD
OF MEDICAL SPECIALTIES
P.O.Box: 0845/32, Ziraa square, KBMS, Erbil, Kurdistan Region, Iraq.
Tel: 000964-662646881
Email: journal@kbms.org
Journal of Kurdistan Board of Medical Specialties (2016) Vol. 2, No.1: 22-27
Menstrual and Hormonal Changes in Breast Cancer Patients Treated By Adjuvant, Adriamycin and Cyclophosphamide Chemotherapy
Jangi Shawkat Muhialdin Salai*, Nermin Jamal Abdulqadr**, Kawa Faeq Dizaye***
JKBMS, 2016
Abstract
Background and objectives: The long term effects of adjuvant chemotherapy are very important in
patients with breast cancer. Cytotoxic chemotherapy may induce changes in menstrual cycle to variable
extents and even may induce amenorrhea. This study was designed to ind out the effect of adjuvant
chemotherapy, Doxorubicin and Cyclophosphamide, on ovarian function in patients with early stages
breast cancer. Methods: Thirty premenopausal women with newly diagnosed early breast cancer enrolled
in this study. In addition to a proper menstruation history, the following parameters FSH, LH, Estrogen,
Progesterone, were estimated before and after 4 cycles of chemotherapy with another follow up for
menstrual history after 6 months, in each patient. Results: After 4 cycles of adjuvant Doxorubicin and
Cyclophosphamide chemotherapy the mean level of FSH and LH was increased and Estrogen level was
decreased, signiicantly. While, Progesterone level was decreased non-signiicantly. Menstrual changes
detected in most patients after receiving chemotherapy but only %47 of them developed amenorrhea
which was persistent after 6 months in %33 of the patients. The induced amenorrhea has found to be
related positively with the age of the patient but has no any relation with receptor status, estrogen,
progesteron and Her2 (human epidermal growth factor receptor 2), of the tumor and neither with the
menstrual phase at which chemotherapy has been given nor with the body mass index. Conclusions:
Adjuvant chemotherapy changes ovarian hormonal levels signiicantly and induces transient and
permanent amenorrhea in patients with early stages breast cancer.
Keywords: Doxorubicin and Cyclophosphamide, Hormonal changes, Amenorrhea.
Introduction
According to the National Comprehensive Cancer
Network (NCCN) guide line, breast cancer can be
treated by one or more of the following steps: surgery, radiation therapy, chemotherapy (CT), hormone
therapy, and monoclonal antibody therapy. Several
large studies have shown, conclusively, that adjuvant
CT improves survival, especially in premenopausal
women 1-5. One of the beneicial adverse effect of chemotherapy for premenopausal women is the induction
of amenorrhea 6-7. Chemotherapy induced amenorrhea
(CIA) is the term used to describe the cessation of
menses for several months during or soon after the
use of chemotherapy due to ovarian atrophy and loss
of primordial follicle which leads to ovarian failure,
however, these effects is not an “all or nothing phenomenon” 7-8. A review of the literature reveals inconsistencies regarding the deinition of chemotherapy-related amenorrhea, with some authors deining
it as a cessation of menses lasting ≥ 3–6 months and
others deining it as a cessation lasting 12 months
8
. The impact of various deinitions is illustrated by
Padmanabhan et al, 1986, who reported the incidence
of amenorrhea from the beginning of CMF (Cyclophosphamide, Methotrexate and 5-Fluorouracil) chemotherapy at 3 months, 6 months, and 12 months later as 50%, 70%, and 80%, respectively 9.
It is well known that evaluation of ovarian function
can be assessed by different method like menstrual
history taking and laboratory measurements. So, history of menstrual bleeding is a convenient method of
assessment in determining ovarian function. However, menstrual status cannot thoroughly relect actual
ovarian function. The serial measurement of serum
ovarian biochemical markers is an acceptable method
to relect ovarian function 10-11. Previous studies preferred FSH as a biochemical marker to predict ovarian
reserve, but currently Other than FSH, anti-Müllerian
*Department of Pharmacology and Biophysics, College of Medicine, Hawler Medical University. Department of Oncology at Rizgary Teaching
Hospital
** Department of pharmacy, Rizgary Teaching Hospital
*** Department of Pharmacology and Biophysics, College of Medicine, Hawler Medical University
22
Kurdistan Board of Medical Specialties
Journal of Kurdistan Board of Medical Specialties (2016) Vol. 2, No.1: 22-27
hormone (AMH) and inhibin B are used as predictive
capacity of ovarian function, they appear to be superior to FSH because they are not affected by the administration of tamoxifen. Moreover, AMH and inhibin B
relect subtle changes in menstrual transition, which
has been compared with FSH. AMH is also strongly
recommended for its sensitivity in predicting ovarian
function and stable expression over the menstrual cycle 12-16.
The incidence of CIA differs with respect to patient
age and chemotherapeutic regimens used 13-14. For
this reason the incidence of CIA has varied across
studies from 27% to 94% in patients treated with
older cyclophosphamide based or doxorubicin-based
regimens. The CIA can be regarded as an important
clinical sequences of adjuvant chemotherapy because
it produces menopausal symptoms like hot lushing,
night sweats, sleep disturbance, palpitation, depression, agitation and vaginal atrophy, also might cause
cardiovascular morbidity, early bone mineral loss and
fertility impairment 12-13,17. The objectives of the study
were to evaluate hormonal changes after adjuvant
chemotherapy (AC), ind out the incidence of menstrual pattern changes in early stage breast cancer patients treated with AC and evaluate the effect of the
molecular characters of the tumor on CIA.
Patients and methods
This prospective study; was carried at Rizgary Teaching Hospital, from January 2014 to February 2015,
after obtaining scientiic committee approval from
college of medicine. Thirty newly operated breast
cancer women aged (23-50 years old), who had indication for adjuvant chemotherapy, were enrolled in
this study after obtaining their consent. All of these
patients were planned to receive an adjuvant Cyclo-
phosphamide and Doxorubicine (AC) chemotherapy protocol for 4 cycles. The criteria of inclusions
were recent breast cancer, pre-menopause, no history of previous chemotherapy, hormonal therapy, oral
contraceptive. Postmenopausal women, recurrence
breast cancer, patients with gonadotropin-releasing
hormone (GnRH) agonist administration or hysterectomy/bilateral oophorectomy histories, and history of
chemotherapy for other malignancy were excluded.
Before starting irst cycle of adjuvant chemotherapy
AC and after inishing four cycles, peripheral venous
blood was drawn from each patient, exactly at the day
after her menstruation (if she was menstruating). The
blood has been centrifuged at 2500 rpm for 10 min,
the sera were divided into two aliquot and kept in
tubes without anticoagulant. One tube used for hormonal assay including serum: (FSH, LH, Progesterone, Estradiole), and other tube used for biochemical
assays including: (liver function test, renal function
test and lipid proile). The obtained results were evaluated and comparison was done between pre and post
chemotherapy values. Another follow up was carried
out after 6 months to evaluate the menstrual pattern
of the patients.
All results were expressed as mean ± SE. the data
were analyzed by using student t test and chi square.
Software SPSS program version 20 was used. P values ≤ 0.05 were considered statistically signiicance.
Results
In this study, giving 4 cycles of adjuvant AC to patients with early stages breast cancer signiicantly increased both FSH and LH levels and decreased the
level of estrogen, while did not affect the level of progesterone as shown in Table 1.
Table (1): Mean FSH, LH, Estrogen and Progesterone in pre- chemotherapy (basal value) and after
administration of four cycles of AC.
Parameter
Before chemotherapy
After chemotherapy
(Mean FSH (mIU/ml
2.982 ± 11.295
*
(Mean LH (mIU/ml
2.27 ± 12.04
*
(Estrogen (pg/ml
11.20 ± 77.37
*
(Progesterone (ng/ml
0.557 ± 1.978
0.852 ± 1.136
6.28 ± 42.61
3.93 ± 31.99
9.779 ± 32.56
(Note: * is sign of signiicance, P values < 0.05).
Kurdistan Board of Medical Specialties
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Journal of Kurdistan Board of Medical Specialties (2016) Vol. 2, No.1: 22-27
Among a total of 30 patients enrolled in this study, 14
cases developed CIA and 16 cases were menstruating
normally, after inishing four cycles AC. However,
six months later we found that 4 patients (28.57%)
among CIA resumed their menstruation (temporary
CIA) and only 10 patients (71.42%) stayed with deinite CIA. While between 16 patients with no CIA, 7
patients (43.75%) stayed with normal menstruation
and 9 patients (56.25%) were suffering from oligomenorrhea Table 2.
Table (2): Number and percent of patients with different pattern of menstruation. Number and percent of
patients with different pattern of menstruation.
CIA 14 patients
No CIA 16 patients
Deinite CIA
Temporary CIA
Normal menstruation
Oligomenorrhea
10 (71.42%)
4 (28.57%)
7 (43.75%)
9 (56.25%)
33.3%
13.33%
23.33%
30%
The mean FSH, LH and progesteron levels in 14 pa- the mean Estrogen level in patients with CIA was sigtients with CIA were signiicantly greater than the niicantly less than the mean Estrogen level of menmean FSH and LH of 16 patients without CIA. While struating patients, as shown in Table 3.
Table (3): Mean FSH, LH, Estrogen and Progesterone level in (CIA) patients and patients with no (CIA)
after administration of four cycles of adjuvant AC chemotherapy.
Parameters
CIA patients
Patients with no CIA
(Mean FSH(mIU/ml
63.01±9.96
*24.75±4.71
(Mean LH(mIU/ml
42.73±6.32
*22.6±3.62
(Mean Estrogen(pg/ml
10.81±4.83
*51.6±16.65
(Mean progesterone(ng/ml
2.07±1.82
*0.31±0.48
(Note: * is sign of signiicance, P values < 0.05).
In this study, the relation between age and CIA has
been studied and statistical analysis showed that the
age was affecting the induction of amenorrhea signiicantly (p value 0.04). Among a total of 14 patients
with CIA only 2 (14.3%) patients were younger than
35 years old, while 12 (85.7%) patients were older
than 35 years. In contrast, among 16 patients with no
CIA 11 (68.7%) patients were younger than 35 and
only 5 (31.3%) of the cases were more than 35 years
old, Figure (1).
A
B
Figure (1): Percent of patients with (A) and without
(B) CIA within each age group after four cycles of
chemotherapy
In CIA patients, chemotherapy has been given
during the follicular phase of the menstruation in
eight (57.1%) patients and during luteal phase in six
(42.9%) of them. However, in those 16 patients who
maintained their menstruation, AC has been adminis-
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Kurdistan Board of Medical Specialties
Journal of Kurdistan Board of Medical Specialties (2016) Vol. 2, No.1: 22-27
tered during follicular face in six (37.5%) and during association was found between CIA and menstrual
luteal phase in ten (62.5%), patients. No signiicant phase at which chemotherapy been given, Table 4.
Table (4): Number and percent of patients developed (CIA) related to the phases of menstruation at which
chemotherapy has been administered.
Menstrual state
Follicular phase
Luteal phase
CIA
(57.1%) 8
(42.9%) 6
No CIA
(37.5%) 6
(62.5%) 10
In this study we assessed the association between CIA
and hormonal receptors and Her2 receptor status. The
statistical analysis showed that there is no signiicant
association between amenorrhea induced by chemotherapy and receptor status (data not shown-negative
results)
Other factor which has been studied in this work was
the effect of BMI of the patient with the possibility
of developing CIA. Our indings show that BMI has
no statistically signiicant effect on CIA. We have
found that in 14 patients with CIA the mean BMI was
(30.13 ± 1.83), 4 patients (28.6%) were within normal range BMI and 10 patients (71.4%) had abnormal
BMI (over normal range). Almost the same results
have been found in other 16 patients with no CIA,
the mean BMI was (30.07 ± 1.49), 3 (18.8%) of them
were within normal range (BMI) and 13 (81.3%) had
high BMI (data not shown-negative results).
Discussion
Of more than 230,000 new diagnoses breast carcinoma in the US each year, 25% occur before menopause,
and 15% of women are diagnosed in the reproductive
age group (age 45 yrs. or younger)18. It has been found
that adjuvant chemotherapy prolongs disease-free
and overall survival for patients with breast carcinoma 3-4 but also can induce long-term side effects, such
as suppression of ovarian function with subsequent
premature menopause. This results in loss of childbearing potential and prolonged exposure to the risks
of menopause and psychological distress 19-21.
It is well known that chemotherapy decreases ovarian
reserve rapidly and dramatically, although, ovarian
function may recover to some extent and menses may
return after the completion of chemotherapy treatment 7. In this study, we assessed ovarian function
deterioration in response to adjuvant AC by taking
menstrual history and measuring serum biomarkers
of ovarian function like FSH, LH Estrogen and Progesterone levels, before and after completion of che-
motherapy. We have found that adjuvant AC causes
CIA in a good percentage of the patients particularly
those above 35 years old. In accordance to Peterek J
et al, 2006, the diagnosis of CIA was applied to those
patients who developed cessation of menstruation
for 3 consequent months after receiving chemotherapy AC 13. As well as, we found that AC signiicantly
increased the levels of FSH and LH, while Estrogen
level decreased signiicantly, the mean level of above
hormones except progesterone reached to menopausal range after giving four cycles of AC. These results
are in agreement with other studies, showing that adjuvant chemotherapy induces CIA 22-26. Furthermore,
as in Park et al 15, in current study other follow up
done to know if there was recovery from CIA and
resumption of menstruation, therefore the history of
menstruation without estimation of hormones has
been used after 12 months of starting chemotherapy.
We have found that between the 14 CIA patients 4
of them resumed their menstruation and the remained
10 were still in amenorrhea, while regarding patients
with no CIA 7 patients were still has normal menses
and 9 patients have developed oligomenorrhea during
follow up time. Many studies used menstrual calendar to evaluate ovarian function 5, 8, 22-24.
Reproductive aging in women is a natural progression through 3 stages: reproduction, the menopausal transition and post menopause. The early stage of
menopausal transition begins on around age 42 and
late stage which begins on average around age 46
and ends on average at age 51 with the inal menstrual period 25-26. In sight of the above physiology
of menstruation pattern and age of women, in this
study association of age and CIA has been studied.
In agreement with other studies 22, 27-30, we have found
that the age of the patient at the time of diagnosis was
signiicantly associated with the occurrence of CIA.
The signiicant increase in incidence of amenorrhea
seen in older women more than 35 yrs. treated with
chemotherapy, this may be due to the relatively lowKurdistan Board of Medical Specialties
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Journal of Kurdistan Board of Medical Specialties (2016) Vol. 2, No.1: 22-27
er number of existing oocytes. Approximately 2 million oocytes are present at birth; they have decreased
to 200,000 by puberty and to 400 at menopause 25-26,
following treatment with chemotherapy, the ovaries
have a decreased number of oocytes available for follicular recruitment, along with evidence of ibrosis,
these changes are similar to those observed in natural
postmenopausal ovaries 10, 31.
In accordance with our study, other researchers have
found that different types of chemotherapy are associated with different rate of menopausal incidence.
Bines et al (1996) reported that 40% of women younger than age 40 years and 76% of women older than
age 40 years become menopausal during adjuvant
chemotherapy with cyclophosphamide plus methotrexate and 5-luorouracil.Other authors reported
a lower risk with anthracycline-containing regimes,
such as doxorubicin and cyclophosphamide (AC)
or 5-lurouracil, epirubicin, and cyclophosphamide
combinations 31. This difference in the incidence rate
of CIA may be related to that, in addition to the age of
the patient, cumulative dose and type of the cytotoxic
agents are the most important factors that determine
the likelihood of gonadal failure 28, 32. It is not clear if
the duration and dose intensity of chemotherapy independently affect the risk for gonadal failure. Alkylating agents, such as cyclophosphamide, are extremely
gonadotoxic because they are not cell cycle-speciic
and can damage resting primordial follicles, whereas
cycle-speciic agents such as methotrexate and 5-luorouracil do not have any effect on ovarian reserve.
In a mouse study, cyclophosphamide induced follicular damage in a dose-dependent manner through a
dose range of 20–100 mg/kg, whereas destruction of
primordial follicles occurred even at the lowest cyclophosphamide dose 10. With each additional dose
of cyclophosphamide administration, an incremental
number of primordial follicles are lost and the incidence of ovarian failure increases. Patients who receive cyclophosphamide have a 4- to 9.3-fold greater
risk for the development of premature ovarian failure
than healthy controls 10, 31-33. In this study, AC typically consists of 4 cycles delivered over 12 weeks with
a lower cumulative dose of cyclophosphamide compared with CMF and less anthracycline exposure than
many other typical combination regimens.
The relation of CIA and phases of menstruation during
which chemotherapy has been given was studied by
Di Cosimo et al, 2004, they have found that the incidence of CIA higher between the patients received
irst cycle CT during follicular phase of menstrual
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Kurdistan Board of Medical Specialties
cycle, because chemotherapy administered within the
follicular phase could be responsible for the follicular
maturation impairment, primordial follicle depletion
and ampliication of physiological apoptotic mechanisms occurring in this phase 34. However, in the current study, we did not ind any signiicant association
between incidence of CIA and phase of menstruation
at which irst cycle of chemotherapy has been administered. This opposite result might be due to small
sample size of the current study and or might be due
to patient’s uncertainty of their menstrual cycle dates.
Although, the effect of molecular characters of the tumor on the CIA has not been studied widely, in this
work we tried to ind out relation between hormonal status (ER and PR) and Her2 with CIA. However,
we did not ind any positive effect of these molecular
features of the tumor on the incidence of CIA. These
results are in agreement with those found by Perez-Fidalgo et al, 2010, 35. Furthermore, in this study,
the association between number of cycles of CT at
which patients developed amenorrhea and persistence
of amenorrhea, although it has been noted that the
majority of the patients with permanent amenorrhea
developed cessation of menstruation during irst two
cycles of chemotherapy but the result was not statistically signiicant (data not shown). Unfortunately
there is no enough study about this relation in the literature and this issue needs more study with a larger
sample size to be clariied.
Conclusions
Through this study, it has been found that adjuvant
chemotherapy, adriamycin and cyclophosphamide,
in early breast cancer induces menstrual changes and
even permanent amenorrhea in some patients associated with the ovarian hormonal changes. However,
these chemotherapies did not cause any signiicant
biochemical changes. This study delights the way for
further investigation, with a bigger sample size and
for a longer period of follow up, to ind out the prognostic effects of CIA on the overall survival and progression free survival.
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16. Su HI, Sammel MD, Green J, et al. Anti-mullerian hormone and
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Journal of Kurdistan Board of Medical Specialties (2016) Vol. 2, No.1: 28-31
Effect of Body Mass Index on Gastroesophageal Relux Disease
Sabah Jalal Shareef *
JKMBS, 2016
Abstract
Background and objectives: The gastroesophageal relux disease is a diagnostic and therapeutic
challenge in surgery because of its complicated etiology and pathophysiology. Its incidence is increasing
parallel with obesity throughout the world. This study tried to ind a relation between body mass index
and gastroesophageal relux disease. Methods: This study done on one hundred gastroesophageal relux
disease patients in Rizgary teaching hospital, Erbil city Kurdistan region of Iraq from Jan 2014 to June
2014, the study attempted to access the relation between body mass index and symptom severity of
gastroesophageal relux disease through relux episodes known by number of episodes per week, and
also impact of body mass index on endoscopic changes. Results: This study was carried out on 100
patients (%45 male) and (%55 female), the mean age ± SD of participants was 12.5 ± 37.13 from 75-17
years, the body mass index (BMI) classiied to normal <25, overweight between (30-25), obese patients
>30.The symptoms severity increased with increase body mass index , but its relation with endoscopic
indings were not signiicant. Conclusions: The effect of increased body mass index on gastroesophageal
relux disease is an increase in relux episodes, but its relation to endoscopic inding was not signiicant.
Keywords: Gastroesophageal relux disease symptoms, body mass index, endoscopic indings.
Introduction
The Gastroesophageal relux disease (GERD) was
not recognized as a signiicant clinical problem until the mid-1930s and was not identiied as a precipitating cause for esophagitis until after World War
II. In the early twenty-irst century, it has grown to
be a very common problem and now accounts for a
majority of esophageal pathology. It is recognized as
a chronic disease, and when medical therapy is required, it is often lifelong treatment 1. The etiology of
GERD is complicated. One of the important factors is
abnormal competence of lower esophageal sphincter
(LES). Normal LES is required preventing the relux.
This is inluenced by both its physiological function
and its anatomical location relative to the diaphragm
and the esophageal hiatus 2. The competence of the
LES and its ability to establish a barrier to relux depends on several factors. For example: adequate pressure and length, radial symmetry, and motility of the
esophagus and stomach. Competent sphincter should
be at least 2 cm length and carries a pressure tone
between 6 and 26 mm Hg 3. Gastroesophageal relux
disease (GERD) means the presence of symptoms or
mucosal damage from gastroesophageal relux, it is a
common, morbid, and costly medical condition 4.
The relation between the increase in body mass index
and symptom severity of GERD which is identiied
by a number of heartburn attacks per week was one
of the long-standing debates 5. The increase in body
* Department Of Surgery, College Of Medicine, Hawler Medical University
28
Kurdistan Board of Medical Specialties
mass index is associated with an increase of esophageal acid exposure 6. The parallel rise in GERD and
obesity suggests a link between the two. A recent meta-analysis of 20 studies reported a positive association between increasing body mass index (BMI) and
the presence of GERD within the USA6. Elevated
BMI and greater waist circumference are associated
with increased intragastric pressure and lower esophageal pressure, the greater likelihood for a hiatal hernia, impaired lower esophageal sphincter function
and more frequent, more prolonged and more proximal episodes of esophageal acid exposure7-12.
Patients and methods
the current study was done in Rzgary teaching hospital on one hundred GERD patient from January 2014
to 30th June 2014 on different age groups from (1775) years, 45% were male and 55% were female patients whom they agreed on the study the study was
approved by research ethics committee at college of
medicine, Hawler medical university.
Diagnosis of patients depends on full history taking
and thorough clinical examination with esophagogastro duodenoscopy (OGD). The procedures were explained to the patients and informed verbal consent
was taken from each participant, most of these patients had heartburn and acid regurgitation, with variable number of attacks per week, the BMI of patient
calculated by measuring the height with meter and
Journal of Kurdistan Board of Medical Specialties (2016) Vol. 2, No.1: 28-31
weight with kg. Patient classiied into normal BMI
<25 and overweight BMI between 25-30, and obese
patients BMI >30. Esophagogastroduodendoscopy
had done for all patient with Xylocaine spray to the
throat and those who didn’t tolerate OGD with this
procedure they had been scoped with midazolam 5 mg
slow iv injection, and the result was classiied to erosive esophagitis or non-erosive esophagitis(NERD),
(normal looking OGD) a hiatus hernia and lax lower
esophageal sphincter.
Those patients in whom other indings like duodenal
ulcer or gastric ulcer, and 2 cases were carcinoma of
stomach were excluded from the study, all patients
were sent for H pylori Ag in stool, abdominal ultrasound had done for all patients to exclude Gall bladder disease, serum amylase, and serum lipase were
done to all patients to exclude pancreatitis and ECG
for those above 40 years old to exclude cardiac problems, 24 hour ph studying and manometer was not
done because it was not available
Results
This study was carried out on 100 patients (45% male)
and (55% female), Fig1, the mean age ± SD of participants was 37.13 ± 12.5 ranged from 17-75 years.
Figure (1): Gender distribution of study sample.
Regarding the relation between frequency of heartburn attacks (relux episodes) and BMI, the current
study revealed that the number of heartburn attacks
was signiicantly (<0.001) increasing with increasing
BMI, in which 20 patient with BMI >30 had 5 attacks
per week, while only 5 patients with BMI <25 had 5
attacks per week, Table 1.
Table (1): Relation between BMI and number of heartburn attacks
BMI group
No. and % within BMI group
1.00
2.00
3.00
4.00
5.00
Normal (<25)
No.
7
19
7
1
5
39
%
17.9
48.7
17.9
2.6
12.8
100
No.
2
6
9
1
10
28
%
7.1
21.4
32.1
3.6
35.7
100
No.
0
1
6
6
20
33
%
0.0
3.0
18.2
18.2
60.6
100
No.
9
26
22
8
35
100
%
9.0
26.0
22.0
8.0
35.0
100
Overweight (25-29.9)
Obese (>30)
Total
No. of heartburn attacks
The relation between Increasing BMI and endoscopic
inding was not signiicant (p value=0.749) as 12 patients with normal BMI <25 had hiatus hernia with lax
sphincter and esophagitis, comparing to 16 patients
with BMI >30 had hiatus hernia with lax sphincter
Total
and esophagitis, 48% of patients on endoscopy were
normal looking indicating non-erosive esophagitis
(NERD). And 52% of patients showing esophagitis as
shown in Table 2
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Journal of Kurdistan Board of Medical Specialties (2016) Vol. 2, No.1: 28-31
Table (2): Relation between BMI and Endoscopic inding
Endoscopic inding
Hiatus
Lax
No. and
hersphincter+
BMI group % within
nia+ lax
erosive
BMI group
sphincter+
esophagitis
esophagitis
Normal
Overweight
Normal
looking
esophagus +lax
sphincter
Normal
Total
No.
5
12
11
11
39
%
12.8
30.8
28.2
28.2
100
No.
5
10
7
6
28
%
17.9
35.7
25.0
21.4
100
No.
4
16
8
5
33
%
12.1
48.5
24.2
15.2
100
No.
14
38
26
22
100
%
14.0
38.0
26.0
22.0
100
P value
0.749
Obese
Total
Discussion
Endoscopic inding was not signiicant as shown in
Table 2. And there is 48% normal looking endoscopy might be non-erosive esophagitis (NERD), and
52% were showing Esophagitis of variable grades
according to Los Angeles classiication of esophagitis which is of 4 grades (A.B.C.D). Normal looking
OGD might be due to non-erosive esophagitis which
called (NERD) or due to the Liberal use of Proton
pump inhibitor (PPI) by most of Medical and Paramedical Personnel before diagnosing with endoscopy
and this will lead to healing of most cases of esophagitis which shows normal Endoscopy.
The incidence of NERD in Gastroesophageal Relux
disease patients in this study was 48% while in western
countries are 50%, and in china, 66.2% showed erosive esophagitis and 38.8% were NERD and in Nigeria 74.4%.as the study was done in Nigeria 17. Other
study done in Budapest revealed a strong correlation
between BMI and GERD severity. This inding suggests that obesity and increased BMI is not the only
necessarily the primary cause of GERD but it could
be a risk factor for more serious mucosal lesions in
the esophagus 18.
This study demonstrates that obese patients (BMI>30)
are associated with more severe symptoms of GERD
than those of normal BMI <25 demonstrated by increase in frequency of heartburn attacks per week as
shown in table 1, this might be due to the fact that
obesity has negative association with lower esophageal sphincter tone leading to increasing esophageal
acid exposure 13. Much evidence exists to support an
association between obesity and GERD symptom
severity. The pathophysiology of this association is
an increase in the intragastric pressure and decrease
in intraesophageal pressure with disruption of lower
esophagogastric junction structures and that attributed to the crural diaphragm. This study was consistent
with study done Hashem El-Serag 14. Any excess body
fat gives excess risk for heartburn; this is true because
fat or obesity causes increase in intra-abdominal pressure and increase in intragastric pressure and decrease
in intraesophageal pressure with disruption of lower
esophageal structure results in relux of acid to esophagus and esophagitis 15.
This study is also consistent with a study done in California USA, which they demonstrate positive association between increasing BMI and presence of GERD Conclusions
16
.
The obesity and GERD are increasing in the world,
Regarding the relation between increasing BMI and
30
Kurdistan Board of Medical Specialties
Journal of Kurdistan Board of Medical Specialties (2016) Vol. 2, No.1: 28-31
as the increase in BMI is a high-risk factor for the
development of gastroesophageal relux disease with
the complication of esophagitis as barrette esophagus
and carcinoma of the esophagus, so decreasing weight 14.
is strongly advisable for symptomatic improvement
15.
of GERD and decreasing the incidence of complications.
16.
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