Mental Health and Quality of Life among Egyptian Patients with Esophageal Motility Disorders: A Psychiatric Assessment

INTRODUCTION

The most widely known and studied esophageal motility disorder is achalasia. In spite of that, investigations and management workup for other primary esophageal motility disorders are increasing and becoming more relevant and updated [1].

Esophageal symptoms such as dysphagia, non-cardiac chest pain, and regurgitation can arise from primary esophageal motor disorders like achalasia. Yet, these symptoms can also arise from disorders of impaired relaxation across the lower esophageal sphincter (LES) and other disorders of esophageal peristalsis, in addition to other unclassified conditions with abnormal manometric findings [2].

A lot of studies have found that the motility pattern of esophageal body in GERD patients is mainly ineffective esophageal motility (IEM) [3]. It has been evident that it is a significant correlation between hypomotile esophagus and GERD [4,5].

Due to the wide spectrum of esophageal motility disorders, and the long course of the disease from diagnosis to definitive management (medical, endoscopic, or surgical); Many patients are at risk of developing psychological distress and other mental health symptoms. Previous studies have focused on relation of individual motility disorders with psychological stress and mental disorders.

At the same time, psychological stress is known to play a crucial role in the pathogenesis of gut motility disorders. It was believed that stress could be a precipitating factor of gastrointestinal symptoms in patients with functional gastrointestinal disorders. However, little research has been done to evaluate the effect of stress in exacerbating the symptoms associated with gastroesophageal reflux and it is still debatable [6].

Gastroesophageal reflux disease (GERD), as considered a disorder of esophageal motility, has an evident effect on the health-related quality of life (QOL), affecting daily social activities and physical and emotional aspects of patients. It also interferes with healthy sleep and work [7,8].

The most common mental disorders known among patients with gastroesophageal reflux disease (GERD) were depression, anxiety, bipolar disorder and sleep disorders [6,9,10].Previous studies concluded that achalasia alone irrespective of other comorbidities was associated with an increased incidence of depression [9, 11].It also has been observed that achalasia patients have impaired quality of life that improves generally after interventions like Heller’s cardiomyotomy [12].

This study aimed to evaluate mental health outcomes and Quality of life among Egyptian patients suffering from esophageal motility disorders.

PATIENTS/MATERIALS AND METHODS

This was a cross-sectional study registered at the Faculty of Medicine Ain Shams Research Institute (MASRI) and approved by the Research Ethics Committee of the Faculty of Medicine, Ain Shams University (FMASU REC no. R48/2022). The study conducted at the department of tropical medicine, Ain Shams University Hospital, and the GIT motility unit at Ain Shams Specialized hospital, Cairo, Egypt.

Informed consent was included, explaining in details the study design and aim prior to respondents’ enrollment. Participants could terminate at any time they desired. Moreover, confidentiality of information was assured, and they were informed that this study could be used for scientific publication without the disclosure of the participants’ personal identity.  Patients were asked to participate in psychiatric evaluation after completing the required esophageal motility studies.

Assuming the expected population standard deviation to be 10, and employing t-distribution to estimate sample size, the study would require a sample size of 19 to estimate a mean with 95% confidence and a precision of 5 [13]. However, the sample size was later upgraded to 30 by the Ain Shams University reviewing board. Thirty-eight patients who visited the motility unit from April 2022 to November 2022 and accepted to participate in the study were included. The patients with previous evident psychiatric disorders and those who refused participation in the study were excluded.

Study Tools:

Full history taking (personal and history of present illness)

1. Patients with non-cardiac chest pain referred (NCCP) for manometry after exclusion of cardiac cause by ECG and echocardiogram.
2. Upper GI endoscopy and Barium swallow.
3. High-resolution esophageal manometry using Laborie MMS software.

HRM:

Type of Catheter: Water perfusion.  

Type of software: MMS, Laborie, Chicago Classification version III.

The participants were instructed to fast at least 8 hours before performing the esophageal Manometry procedure [1].

1. At the start of the procedure the patient lied in supine position, one nostril is anesthetized with a numbing lubricant. A water perfused catheter approximately one-eighth inch in diameter was then passed through the anesthetized nostril down into the back of the throat then into the esophagus as the patient swallows, following catheter placement, a minimum of 60 seconds of quiet rest allows for an adaptation period.
2. Next, a baseline period of at least 30 seconds to enable identification of anatomic landmarks including the upper esophageal sphincter (UES), lower esophageal sphincter (LES), respiratory inversion point (RIP) and basal EGJ pressure, once the catheter reaches the lower esophageal sphincter (LES) which was clearly shown by an altered color on the color plot, we fix it in that zone exactly. We gave the patient ten 5-ml wet swallows of liquid solutions every 20 second, then MRS sequence involving five 2-ml swallows every 2-3 seconds in the supine position will be done. The procedure usually takes 15 to 20 Minutes. During The procedure HRM metrics were identified including [1]:
3. Integrated Relaxation Pressure (IRP) (mmHg) which is the mean lower esophageal sphincter (LES) pressure for four contiguous or non-contiguous seconds of relaxation in the ten second window following deglutitive UES relaxation, it assesses the relaxation pressure across the esophagogastric junction in response to deglutition and considered normal if
4. Distal latency (DL) (second) which is the interval between UES relaxation and contractile deceleration point (CDP) it assesses latency of deglutitive inhibition, normal DL > 4.5 seconds. 
5. Multiple Rapid Swallows (MRS) response considered to be normal when the esophageal body contractility is absent (DCI < 100 mmHg•s•cm) with complete deglutitive inhibition of the LES during the repetitive swallows, and presence of post-MRS contraction augmentation (DCI post-MRS greater than single swallow mean DCI) [1].
6. Beck depression inventory (BDI) [14]:is a 21-question multiple-choice self-report inventory, one of the most widely used psychometric tests for measuring the severity of depression. The score of depression was calculated by summing the answers degrees for the twenty-one questionnaire items, also each answer was graded either 0= no at all, 1= mild, 2= moderate, 3= severe (total score from 0 to 9 was considered negative for depression, 10-15 mild depression, 16 to 23 moderate depression, 24 to 36 severe depression, above this is considered extreme degree). Arabic validated version was used [15].
7. Beck anxiety inventory (BAI) [16]: is a 21-question multiple-choice self-report inventory that is used for measuring the severity of anxiety in adolescents and adults ages 17 and older. The score of anxiety was calculated with the sum of twenty-one items, each answer was graded either 0= no at all, 1= mild, 2= moderate, 3= severe, and so (total score from 0 to 7 was considered negative for anxiety, from 7 to 15 was considered mild anxiety, from 16-25 was considered moderate, and above is considered severe). Arabic validated version was used [17].
8. Quality of life assessment through the World Health Organization Quality of Life Brief Version [18]:The World Health Organization Quality of Life Brief Version (WHOQOL-BREF) is an abbreviated, 26-item version of the 100-item WHOQOL-100 quality of life measure.
   The WHOQOL-BREF addresses four quality of life domains: physical health, psychological health, social relationships and environment, each domain was evaluated by summing the points values for questions corresponding to each domain, and then transforming the score to 0 -100 point interval. Arabic validated version was used [19].
9. According To Chicago IV classifications1, Manometric diagnosis was classified to:
10. Patients with disorders of out flow obstruction:
11. Achalasia with its subtypes.
12. Esophagogastric out flow obstruction.
13. Patients with disorders of peristalsis:
14. Hypomotility: absent contractility, ineffective motility, and inconclusive ineffective motility.
15. Spastic disorders: Distal esophageal spasm and Hypercontractile esophagus.

Statistical Analysis

Data were collected and entered to the computer using SPSS (Statistical Package for Social Science) program for statistical analysis, (BM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp.). Data from questionnaires were entered as numerical or categorical, as appropriate. Two types of statistics were done:

Descriptive statistics:

-          Quantitative data were shown as mean, SD, and range.

-          Qualitative data were expressed as frequency and percent.

Analytical statistics:

-     Chi-square test was used to measure association between qualitative variables, while Fisher exact test was used for 2x2 qualitative variables when more than 25% of the cells have expected count less than 5.

-     Student t-test was used to compare mean and SD of 2 sets of quantitative normally distributed data, while Mann Whitney test was used when this data is not normally distributed.

-     Pearson's correlation was used to study correlation between two variables having normally distributed data, while Spearman's correlation was used when this data is not normally distributed.

-     The Friedman test was used for one-way repeated measures analysis having quantitative not normally distributed.

-     Kruskal-Wallis test was used for comparison between three or more groups having quantitative not normally distributed.

-     P-value was considered statistically significant when it is less than 0.05.

RESULTS

3.1. Participants’ Characteristics

Thirty-eight patients who visited GIT motility at Ain Shams specialized hospitals from April 2022 to November 2022, accepted to participate in the study. Mean age of the patients was 36.63 ± 9.719 years, twenty-four of them (63.2%) were males, twenty-eight (75.7%) received higher education, twenty-eight (75.7%) were from urban cities, twenty-six (70.3%) were employed (Table 1.).

3.2. Clinical symptoms of studied Egyptian patients complaining of esophageal motility disorders.

Twenty-nine (76.3%) were complaining of chest pain, twenty (52.6%) were complaining of heart burn, eighteen (47.4%) were complaining of regurgitation and vomiting, sixteen (42.1%) were complaining of dysphagia.

On the other side, thirteen (34.2%) were diagnosed to have disorders of out flow, and twenty-two (57.9%) had hypomotility peristaltic disorders (Table 1).

3.3. WHOQOL-BREF assessment

Mean score of studied Egyptian patients complaining of esophageal motility disorders was 56.08 ± 19.267 for Domain 1 (Physical health), 60.74 ± 19.857 for domain 2 (Psychological health), 61.95 ± 25.929 for domain 3 (Social relationships) and 57.79 ± 18.822 for domain 4 (environmental) (Table 2)

3.3.1 Comparing sociodemographic data and clinical symptoms with different domains of WHOQOL-BREF,

As regard quality of life assessment, environmental domain was significantly more affected in males (52.63 ± 16.741) than females (66.64 ± 19.464) p value = 0.027.  Also, the female physical health domain was significantly the lowest score in all other quality-of-life assessment domain scores with mean (56.07 ± 17.265), p value 0.038. On the other side, Males, living in urban areas, being employed and experiencing chest pain and heart burn were more likely to experience anxiety and depression symptoms yet with no statistical significance. Although the fact that there is no other statistical significance, we cannot deny the affection of all different domains of quality-of-life assessment scores. Table (3)

Moreover, Environmental, and social quality of life domains were more affected in patients from rural areas, their medians scores were both 50, while Environmental and physical domain was more affected in those from urban areas their medians scores were 59.50 and 56 respectively (Table 3).

Physical and environmental domains were more affected in all patients regardless of the main presenting symptom. All quality-of-life domains were more affected in patients with outflow disorders than other categories (Fig. 1) (Table 3).

3.4 Beck Depression inventory and Beck anxiety inventory assessments:

As regard anxiety, sixteen (42.1%) had moderate degree anxiety, eight (21.1%) had severe degree and four (10.5%) had extreme degree, while 28.9% and 26.3% were mild and moderate scoring levels respectively in BDI (Table 2.). In addition, patients with flow disorders, four (30 .8%) had severe anxiety, 3 patients (23%) had moderate anxiety, also 3 patients (23 %) had mild degree, and 2 patients (15.4%) had extreme anxiety. Moreover, patients with hypomotility peristaltic disorders, 12 patients (54.5%) had moderate anxiety, 3 patients (13.6%) had severe anxiety, and 2 patients (9 %) had extreme anxiety (Table 4).

As regard depression, ten patients (26.3%) had moderate degree depression, seven (18.4%) had severe degree and nine (23.7%) had extreme degree (Table 2) In patients with outflow disorders; 5 patients (38.5%) had extreme depression and 4 patients (30.8 %) had moderate degree depression. Additionally, patients with hypomotility peristaltic disorders, 8 patients (36.4%) had mild depression, and 6 patients (27 .3%) had moderate degree depression (Table 5).

Patients mean age 41.6±8.43 showed statistical significance on experiencing moderate levels of severity on the BDI P value =0.031* (Fig. 1) (Table 5).

^(*) one missing case

1-Disorders of out flow (achalasia and out flow obstruction)

2-Disorders of peristalsis(spastic): (jackhammer and distal esophageal spasm)

3-Disorders of peristalsis (hypomotility): Absent peristalsis. Ineffective.  Inconclusive ineffective

Table 2. Descriptive presentation of WHOQOL-BREF, BAI and BDI scores of studied Egyptian patients complaining of esophageal motility disorders (n=38)

Table 3: Comparative Sociodemographic data and clinical symptoms with different domains of WHOQOL-BREF: