Gastroesophageal reflux disease (GERD), previously uncommon in Asia, has now become an important disease in the region. Although much variability exists between studies, most endoscopy-based studies show a prevalence of erosive esophagitis of more than 10%. Symptom-based studies also show a prevalence of 6-10%. Two longitudinal follow-up studies on GERD symptoms have shown an increase with time, and several endoscopy-based time trend studies have also shown a significant increase in erosive reflux esophagitis. Studies on Barrett's esophagus have been confounded by the description of short (SSBE) and long segment (LSBE) Barrett's esophagus. Great variation in prevalence rates has been reported. SSBE vary from 0.1% to more than 20% while LSBE vary from 1-2%. Of the putative causative factors, obesity has been the most important. Many studies have linked GERD-esophagitis as well as occurrence of reflux symptoms with an increase in body mass index (BMI), obesity, especially visceral or central obesity, and metabolic syndrome. A decline in Helicobacter pylori infection with growing affluence in Asia has been broadly thought to result in healthier stomachs and a higher gastric acid output resulting in reflux disease. However, variable results have been obtained from association and H. pylori eradication studies.
The aim of the present study was to determine the risk factors for Helicobacter pylori in a dyspeptic Malaysian population. A cross-sectional survey of 1060 consecutive patients presenting with dyspepsia at the Endoscopic Unit, University Hospital, Kuala Lumpur, Malaysia from January 1994 to July 1995 was undertaken. All patients answered a detailed questionnaire and underwent endoscopy, with two antral biopsies taken for diagnosis of H. pylori using a rapid urease test. An overall H. pylori prevalence of 49.0% was recorded. Helicobacter pylori prevalence in relation to the major endoscopic diagnoses were as follows: non-ulcer dyspepsia (NUD) 31.2%; duodenal ulcer (DU) 91.4%; and gastric ulcer (GU) 74.1%. The prevalence among the races were as follows: Malay 16.4%; Chinese 48.5%; and Indians 61.8%. Multiple logistic regression analysis identified the following as independent risk factors: > 45 years old 1.5 (1.1,2.0); male gender 1.6 (1.2,2.1); ethnic group: Chinese 2.5 (1.7,3.7); Indians 4.9 (3.2,7.5); level of education: low 2.3 (1.5,3.5); middle 1.7 (1.1,2.6); and smoking 1.6 (1.2,2.3). Analysis was also performed on DU, GU and non-UD patients separately; in both DU and GU patients, H. pylori prevalence was high regardless of age, sex, race or level of education. However, in DU patients, Indian race had an independent risk factor (Odds ratio = 7.8 (1.2,48.4)). The findings in the NUD group reflected the findings in the ¿all patients' group; > 45 years old, male gender, Indian and Chinese race, and low level of education were also significant, independent risk factors. The overall differences in H. pylori prevalence between the different subgroups were mainly due to differences in the NUD group. The increased risk of H. pylori infection in Chinese and Indians points to either an inherent ethnic genetic predisposition or to socio-cultural practices peculiar to the particular race which may be responsible for transmission of the infection.
Recent studies indicate that the prevalence of gastroesophageal reflux disease in Asia is either increasing or better recognized. There is a paucity of reliable data on the prevalence of reflux disease in the various races in general and in Malaysia, in particular. The prevalence of erosive esophagitis and Barrett's esophagus in a multiethnic Malaysian population was studied, as well as the relationship of various factors associated with reflux disease. Chinese, Malay, and Indian patients undergoing gastroscopy in a tertiary referral center were assessed for the presence of esophagitis, hiatus hernia, and Barrett's esophagus. Patient demographics and risk factors associated with gastroesophageal reflux disease were also documented. The prevalence of endoscopically documented esophagitis among 1985 patients was 6.1%, the majority of which were mild, Grade I or II (88%). There was a preponderance of Indians with esophagitis, as well as males (P < 0.05) and those with the presence of a hiatus hernia (P < 0.01). Long-segment Barrett's esophagus was found in 1.6% of patients, and short-segment Barrett's in 4.6%. Indians had the highest prevalence of Barrett's esophagus compared with Chinese (P < 0.05) or Malays (P < 0.01). Hiatus hernia and erosive esophagitis were both positively associated with Barrett's metaplasia (P < 0.01). A significant proportion of Malaysian patients undergoing endoscopy has mild reflux esophagitis and Barrett's esophagus. Indian ethnicity and the presence of a hiatus hernia were significantly associated with endoscopic esophagitis and Barrett's metaplasia. These observed racial differences warrant further study.