Characterization of Gender-Related Disparity in Gastroesophageal Reflux Disease: Surgical Perspective from a Rural High-Volume Antireflux Program

Gastroesophageal reflux disease (GERD) is a common condition which affects both women and men. Clinicians frequently evaluate patients who present with opposite gender family members also suffering from GERD. They often ask whether their disease is different because of their gender. There are scarce data addressing the similarities and differences of GERD in both genders. It is difficult to draw a conclusion from the few existing studies, given the variability in study designs, population, and country of origin. The aim of this study was to characterize the clinical manifestations, diagnostic findings, completion of workup, and progression to surgical intervention. This is an institutional review board–approved retrospective chart review of patients who presented with GERD symptoms to a rural surgical clinic between November 2015 and November 2017. Standardized workup included upper gastrointestinal (GI) study and esophagogastroduodenoscopy, with concomitant wireless pH capsule placement. High-resolution impedance manometry and gastric emptying scan were selectively used. A total of 397 patients (261 women and 136 men) were evaluated. Female patients had statistically significantly higher body mass index (BMI) and GERD questionnaire scores, whereas male patients had a higher incidence of hiatal hernias. Other factors such as demographic characteristics, symptoms, use of proton pump inhibitors (PPI), and diagnostic findings were similar in both groups (Table 1). GERD management is fragmented between gastroenterologists and foregut surgeons, with the published literature reflecting their unique perspective. Our structured antireflux program with diagnostic and therapeutic capabilities bridges the gap and avoids fragmentation of GERD patients. Some of the findings in this study are consistent with what was previously published. There were no genderrelated differences in age, duration of GERD, or duration of use of PPI. There were more female patients presenting to the antireflux program than male patients, and their BMIs were significantly higher than those of men. The relationship between obesity and GERD is well established. We used the GERD symptom score questionnaire and Reflux Symptom Index questionnaire to objectively evaluate their GERD symptoms. The scores were significantly higher in women. It is debatable whether women have different sensory pathways or whether men underreport their symptoms.1 The 24-hour esophageal pH scores were reported to be similar in men and women.2 This was reproduced in our study using wireless 48-hour testing. There are four findings of this study that are different from the previously published data. First, it is reported that women experience more extraesophageal symptoms than men.3 In this study, there was no significant difference in esophageal or extraesophageal GERD symptoms between these two groups. Second, our data showed that men have more hiatal hernias than women. This is different from the existing studies showing that the rate of hiatal hernia is either equal or women have more hiatal hernias than men.2, 4 This could be due to the skill of the radiology team and implementation of radiology protocols in high-volume antireflux centers. Another possible explanation is that men presenting to antireflux clinics tend to be more symptomatic, which could be related to the presence of hiatal hernia. Third, this study showed no difference in the prevalence of Barrett’s esophagus (BE) between men and women (13.2 vs 13%). Multiple previous reports showed that men have a higher incidence of BE.1 This finding could be explained by this high representation Address correspondence and reprint requests to Medhat Fanous, M.D., Department of Surgery, Aspirus Iron River Hospital and Clinics, 1400 West Ice Lake Road, Iron River, MI 49935. E-mail: medhat.fanous@gmail.com.