Unveiling the intricacies:Insight into gastroesophageal reflux disease

Gastroesophageal reflux disease(GERD)poses a substantial global health challenge,with prevalence rates exhibiting geographical variation.Despite its widespread recognition,the exact prevalence and associated risk factors remain elusive.This article comprehensively analyzed the global burden of GERD,shedding light on its risk factors,underlying pathophysiological mechanisms,current diagnostic modalities,evolving management strategies tailored to diverse patient profiles,and complex determinants contributing to treatment failures.A deeper comprehension of GERD is achieved by dissecting these intricate facets,paving the way for enhanced clinical management and improved patient outcomes.

Four-dimensional flow magnetic resonance imaging for noninvasive diagnosis of clinically significant portal hypertension and high-risk gastroesophageal varices in patients with cirrhosis

Introduction:Noninvasive diagnoses of clinically significant portal hypertension(CSPH)and high-risk gastroesophageal varices are clinically relevant but challenging.Four-dimensional(4D)flow magnetic resonance imaging(MRI)provides comprehensive flow information and is a promising alternative.This study evaluated the efficacy of 4D flow MRI as a noninvasive method for diagnosing CSPH and high-risk varices in patients with liver cirrhosis.Methods:This prospective study enrolled consecutive patients diagnosed with liver cirrhosis at a tertiary referral center between October 2020 and March 2021.Each participant underwent abdominal 4D flow MRI.Hemodynamic parameters within the portal vein,including the average and peak flow velocities,normalized flow volume(Q_(normal)),and regurgitant fraction(R%),were extracted and compared between healthy individuals and patients with CSPH and between participants with high-and low-risk varices.Subsequently,these parameters were incorporated into a logistic regression(LR)model refined using L1 regularization and validated using five-fold cross-validation.The diagnostic efficacy was evaluated using receiver operating characteristic(ROC)curves.Results:Eighty-two participants were enrolled(71 patients diagnosed with liver cirrhosis and 11 healthy individuals serving as controls).Among hemodynamic parameters,patients with CSPH exhibited a notable increase in Q_(normal)of 0.66±0.19 ml*m^(2)/[cycle*kg](P=0.001)and an R%of 1.98(2.05)(P=0.002).Similarly,patients with high-risk varices showed a higher Q_(normal)of 0.61±0.15 ml*m^(2)/[cycle*kg](P<0.001)and R%of 1.88(2.81)(P=0.006).ROC analysis revealed an area under the curve(AUC)for Q_(normal)of 0.93 and 0.91 for R%for diagnosing CSPH,while the LR model showcased a superior AUC of 0.95.For high-risk varices,Q_(normal)and R%showed AUC values of 0.75 and 0.70,respectively,whereas the LR model showed a higher AUC of 0.84.Conclusion:As a noninvasive imaging modality,4D flow MRI exhibits considerable potential for the diagnosis of CSPH and high-risk gastroesophageal varices;thus,it may minimize the reliance on invasive procedures in patients with cirrhosis.

Diagnosis and treatment of gastroesophageal reflux disease

Gastroesophageal reflux disease(GERD) is a common disease with a prevalence as high as 10%-20% in the western world. The disease can manifest in various symptoms which can be grouped into typical,atypi-cal and extra-esophageal symptoms. Those with the highest specificity for GERD are acid regurgitation and heartburn. In the absence of alarm symptoms,these symptoms can allow one to make a presumptive diagnosis and initiate empiric therapy. In certain situations,further diagnostic testing is needed to confirm the diagnosis as well as to assess for complications or alternate causes for the symptoms. GERD complications include erosive esophagitis,peptic stricture,Barrett's esophagus,esophageal adenocarcinoma and pulmonary disease. Management of GERD may involve lifestyle modification,medical therapy and surgical therapy. Life-style modifications including weight loss and/or head of bed elevation have been shown to improve esophageal pH and/or GERD symptoms. Medical therapy involves acid suppression which can be achieved with antacids,histamine-receptor antagonists or proton-pump inhibitors. Whereas most patients can be effectively managed with medical therapy,others may go on to require anti-reflux surgery after undergoing a proper pre-operative evaluation. The purpose of this review is to discuss the current approach to the diagnosis and treatment of gas-troesophageal reflux disease.

24-hour esophageal pH-monitoring in children suspected of gastroesophageal reflux disease: Analysis of intraesophageal pH monitoring values recorded in distal and proximal channel at diagnosis

AIM: To assess values of 24-h esophageal pH-monitoring parameters with dual-channel probe (distal and proximal channel) in children suspected of gastroesophageal reflux disease (GERD). METHODS: 264 children suspected of gastroesophageal reflux (GER) were enrolled in a study (mean age χ = 20.78 ± 17.23 mo). The outcomes of this study, immunoallerrgological tests and positive result of oral food challenge test with a potentially noxious nutrient, enabled to qualify children into particular study groups. RESULTS: 32 (12.1%) infants (group 1) had physiological GER diagnosed. Pathological acid GER was confirmed in 138 (52.3%) children. Primary GER was diagnosed in 76 (28.8%) children (group 2) and GER secondary to allergy to cow milk protein and/or other food (CMA/FA) in 62 (23.5%) children (group 3). 32 (12.1%) of them had CMA/FA (group 4-reference group), and in remaining 62 (23.5%) children neither GER nor CMA/FA was confirmed (group 5). Mean values of pH monitoring parameters measured in distal and proximal channel were analyzed in individual groups. This analysis showed statistically significant differentiation of mean values in the case of: number of episodes of acid GER, episodes of acid GER lasting > 5 min, duration of the longest episode of acid GER in both channels, acid GER index total and supine in proximal channel. Statistically significant differences of mean values among examined groups, especially between group 2 and 3 in the case of total acid GER index (only distal channel) were confirmed. CONCLUSION: 24-h esophageal pH monitoring confirmed pathological acid GER in 52.3% of children with typical and atypical symptoms of GERD. The similar pH-monitoring values obtained in group 2 and 3 confirm the necessity of implementation of differential diagnosis for primary vs secondary cause of GER.

Assessment of gastroesophageal reflux disease by serodiagnosis of Helicobacter pylori-related chronic gastritis stage

AIM:To evaluate the association of Helicobacter pylori(H.pylori)-related chronic gastritis stage with upper gastro-intestinal symptoms and gastro-eso-phageal reflux disease(GERD).METHODS:Subjects underwent upper gastrointestinal endoscopy,a questionnaire using a frequency scale for symptoms of GERD(FSSG),and measurements of serum H.pylori-antibody and pepsinogen(PG)levels.They were classified into the following 4 groups in terms of H.pylori-related chronic gastritis stage:Group A(n = 219),H.pylori(-)PG(-);Group B(n = 310),H.pylori(+)PG(-);Group C(n = 279),H.pylori(+)PG(+);and Group D(n = 17),H.pylori(-)PG(+).RESULTS:Reflux esophagitis occurred in 30.6% of Group A,14.5% of Group B,6.8% of Group C,and 0% of Group D(P < 0.001).Scores for acid reflux sympto-ms decreased significantly with chro-nic gastritis stage(from Group A to D)(P < 0.05),while scores for dysmotility symptoms did no-t differ significantly.The prevalence of nonerosive reflux disease(NERD)did not differ amo-ng groups.However,in subjects with GERD,the prevalence of NERD tended to increase with chronic gastritis stage(P = 0.081).CONCLUSION:Acid reflux sympto-ms and the prevalen-ce of reflux esophagitis can be assessed by measuring both serum H.pylori-antibody and PG levels.

Diagnosis and Treatment of Chronic Cough due toGastroesophageal Reflux Disease

Gastroesophageal reflux disease is one of most common causes of chronic cough. Medical history offers few clues as to the cause of cough induced by this disease. 24-h esophageal ph monitoring is considered as the most sensitive and specific test for the diagnosis. When it is unavailable or unsuitable, upper gastrointestinal endoscopy and barium esophagography can be used as an alternative examination. Combined multichannel intraluminal impedance and pH testing is promising because of its ability to detect non-acid reflux as well as acid reflux. Empiric therapy trial is a simple and cheap way to identify suspected patients. Drug therapy is effective in most of the patients, in which proton pump inhibitors is the most powerful. Antireflux surgery is the last choice,used only when intensive drug therapy fails. The definitive diagnosis of cough due to gastroesophageal reflux disease can be established only after cough improves or cc.npletely disappears with antireflux therapy.

Prediction,prevention and management of gastroesophageal reflux after per-oral endoscopic myotomy:An update

Achalasia cardia,the most prevalent primary esophageal motility disorder,is predominantly characterized by symptoms of dysphagia and regurgitation.The principal therapeutic approaches for achalasia encompass pneumatic dilatation(PD),Heller's myotomy,and the more recent per-oral endoscopic myotomy(POEM).POEM has been substantiated as a safe and efficacious modality for the management of achalasia.Although POEM demonstrates superior efficacy compared to PD and an efficacy parallel to Heller's myotomy,the incidence of gastroesophageal reflux disease(GERD)following POEM is notably higher than with the aforementioned techniques.While symptomatic reflux post-POEM is relatively infrequent,the significant occurrence of erosive esophagitis and heightened esophageal acid exposure necessitates vigilant monitoring to preclude long-term GERD-related complications.Contemporary advancements in the field have enhanced our comprehension of the risk factors,diagnostic methodologies,preventative strategies,and therapeutic management of GERD subsequent to POEM.This review focuses on the limitations inherent in the 24-h pH study for evaluating post-POEM reflux,potential modifications in the POEM technique to mitigate GERD risk,and the strategies for managing reflux following POEM.

Association between physical activity and risk of gastroesophageal reflux disease:A systematic review and meta-analysis

Background:Lifestyle plays an important role in preventing and managing gastroesophageal reflux disease(GERD).In response to the conflicting results in previous studies,we performed a systematic review and meta-analysis to investigate this association.Methods:Relevant studies published until January 2023 were retrieved from 6 databases,and the prevalence of symptomatic gastroesophageal reflux(GER)or GERD was determined from the original studies.A random effects model was employed to meta-analyze the association by computing the pooled relative risk(RR)with 95%confidence intervals(95%CIs).Furthermore,subgroup and dose-response analyses were performed to explore subgroup differences and the association between cumulative physical activity(PA)time and GERD.Results:This meta-analysis included 33 studies comprising 242,850 participants.A significant negative association was observed between PA and the prevalence of symptomatic GER(RR=0.74,95%CI:0.66-0.83;p<0.01)or GERD(RR=0.80,95%CI:0.76-0.84;p<0.01),suggesting that engaging in PA might confer a protective benefit against GERD.Subgroup analyses consistently indicated the presence of this association across nearly all subgroups,particularly among the older individuals(RR_(<40 years):RR_(≥40 years)=0.85:0.69,p<0.01)and smokers(RR_(smoker):RR_(non-smoker)=0.67:0.82,p=0.03).Furthermore,a dose-response analysis revealed that individuals who engaged in 150 min of PA per week had a 72.09%lower risk of developing GERD.Conclusion:Maintaining high levels of PA decreased the risk of GERD,particularly among older adults and smokers.Meeting the recommended PA level of 150 min per week may significantly decrease the prevalence of GERD.

Laryngopharyngeal reflux disease:Updated examination of mechanisms,pathophysiology,treatment,and association with gastroesophageal reflux disease

Laryngopharyngeal reflux disease(LPRD)is an inflammatory condition in the laryngopharynx and upper aerodigestive tract mucosa caused by reflux of stomach contents beyond the esophagus.LPRD commonly presents with symptoms such as hoarseness,cough,sore throat,a feeling of throat obstruction,excessive throat mucus.This complex condition is thought to involve both reflux and reflex mechanisms,but a clear understanding of its molecular mechanisms is still lacking.Currently,there is no standardized diagnosis or treatment protocol.Therapeutic strategies for LPRD mainly include lifestyle modifications,proton pump inhibitors and endoscopic surgery.This paper seeks to provide a comprehensive overview of the existing literature regarding the mechanisms,pathophysiology and treatment of LPRD.We also provide an in-depth exploration of the association between LPRD and gastroesophageal reflux disease.

Thresholds of gastroesophagea reflux i the diagnosis of esophageal reflux diseases

AIMS To establish optimal thresholds of pH variation(pH fluc- tuations and reflux episodes)in separating physiological and pathological gastroesophageal reflux(GER),and to evaluate their significance in the diagnosis of GER disease. METHODS Twenty-four-hour intraesophageal pH monitoring and endoscopy were performed in 400 patients with GER symptoms and in 100 healthy controls. RESULTS The results showed that the percentages of the time with pH fluctuations in patients with and without esophagitis,and in healthy controls were,on average,12.65%,9.5% and 2. 76% in 24h,respectively,and the respective percentages of the time with reflux episodes in the same groups in 24h were,on average,3.12%,2.04% and 0.18%,respectively.Using a receiver-operating-characteristic curve analysis,<6.7% of the time with pH fluctuations and<0.1% of the time with reflux episodes were defined as the combined thresholds for physiologi- cal versus pathological reflux.The sensitivity of the combuned thresholds for the detection of GER patients with and without esophagitis was 96.7% and 90.0%,respectively,and their specificity for the diagnosis of patients with abnormal GER disease was 100%. CONCLUSIONS pH flucuations and reflux episodes,when e- valuated together,are more useful for classifying patients with GER and their combined thresholds yield higher diagnostic accura- cy in assessing patients with GER disease.

Causal associations between gastroesophageal reflux disease and essential hypertension: A bidirectional Mendelian randomization study

BACKGROUND Clinical studies have reported that patients with gastroesophageal reflux disease(GERD)have a higher prevalence of hypertension.AIM To performed a bidirectional Mendelian randomization(MR)analysis to investi-gate the causal link between GERD and essential hypertension.METHODS Eligible single nucleotide polymorphisms(SNPs)were selected,and weighted median,inverse variance weighted(IVW)as well as MR egger(MR-Egger)re-gression were used to examine the potential causal association between GERD and hypertension.The MR-Pleiotropy RESidual Sum and Outlier analysis was used to detect and attempt to reduce horizontal pleiotropy by removing outliers SNPs.The MR-Egger intercept test,Cochran’s Q test and“leave-one-out”sen-sitivity analysis were performed to evaluate the horizontal pleiotropy,heterogen-eities,and stability of single instrumental variable.RESULTS IVW analysis exhibited an increased risk of hypertension(OR=1.46,95%CI:1.33-1.59,P=2.14E-16)in GERD patients.And the same result was obtained in replication practice(OR=1.002,95%CI:1.0008-1.003,P=0.000498).Meanwhile,the IVW analysis showed an increased risk of systolic blood pressure(β=0.78,95%CI:0.11-1.44,P=0.021)and hypertensive heart disease(OR=1.68,95%CI:1.36-2.08,P=0.0000016)in GERD patients.Moreover,we found an decreased risk of Barrett's esophagus(OR=0.91,95%CI:0.83-0.99,P=0.043)in essential hypertension patients.CONCLUSION We found that GERD would increase the risk of essential hypertension,which provided a novel prevent and therapeutic perspectives of essential hypertension.

Diagnostic value associated with the combination of saliva pepsin and microorganisms in functional heartburn and gastroesophageal reflux disease

Heartburn is a common symptom shared by both gastroesophageal reflux disease(GERD)and functional heartburn(FHB),which can make it challenging to differentiate between the two conditions.However,examining oral manifestations of GERD can be a cost-effective and readily available method to aid in this differentiation process.It may serve as a valuable tool in distinguishing GERD from FHB.

Recent progress of gastroesophageal reflux after endoscopic myotomy

Per-oral endoscopic myotomy(POEM)is an innovative minimally invasive technique and has emerged as the preferred modality for treating achalasia and spastic esophageal disorders in numerous specialized centers worldwide.Gastroesophageal reflux(GER)is a common complication following POEM procedures.Recently,an article in the World Journal of Gastroenterology,providing a comprehensive update on post-POEM GER.In this article,the authors present novel insights and strategies that offer valuable implications for endoscopy.

Clinical features of gastroesophageal reflux disease and erosive esophagitis:Insights from patients undergoing esophagogastroduodenoscopy in resource-limited Ethiopia

BACKGROUND Gastroesophageal reflux disease(GERD)is a common disease worldwide with varying clinical presentations and risk factors.Prevalence data for Africa is lacking,but an increasing trend is expected due to demographic and epidemiological transitions.Although endoscopic studies for general gastrointestinal disorders have shown some patients with erosive esophagitis(EE),no studies in Ethiopia have investigated the clinical characteristics,risk factors,and severity of GERD using esophagogastroduodenoscopy(EGD).AIM To assess the clinical features of GERD in Ethiopian patients who underwent EGD and determine the severity and risk factors of EE.METHODS We conducted a multicenter,retrospective cross-sectional study of 221 patients diagnosed with GERD and endoscopic findings of EE at Trauma Associated Severe Hemorrhage and Amniotic Membrane Stem Cell between January 2019 and August 2022.Data were collected from electronic medical records and phone call interviews.We used descriptive statistics and binary logistic regression analysis with SPSS version 26 to identify the association between variables with a statistical significance set at P value<0.05.RESULTS The mean±SD age of the patients was 44.8(±15.9)years,with a male-to-female ratio of 1.6:1.The most commonly reported symptom was epigastric pain(80.5%),followed by heartburn(43%).Los Angeles(LA)-A EE was diagnosed in 71.1%of patients,followed by LA-B(14.9%),LA-C(7.7%),and LA-D(5.9%).Multivariate analysis showed that age 50 or above,presence of bleeding,and endoscopic findings of duodenitis/duodenopathy were significantly associated with severe EE(P<0.05).Stricture and Barrett’s esophagus were observed in 4.5%and 1.36%of patients with EE,respectively.CONCLUSION Most of the patients had milder EE with fewer complications.However,severe EE was more prevalent in older patients and those with duodenitis/duodenopathy.

Therapeutic effect of Wendan Decoction combined with mosapride on gastroesophageal reflux disease after esophageal cancer surgery

BACKGROUND Gastroesophageal reflux disease(GERD)is a common complication of esophageal cancer surgery that can affect quality of life and increase the risk of esophageal stricture and anastomotic leakage.Wendan Decoction(WDD)is a traditional Chinese herbal formula used to treat various gastrointestinal disorders,such as gastritis,functional dyspepsia,and irritable bowel syndrome.Mosapride,a prokinetic agent,functions as a selective 5-hydroxytryptamine 4 agonist,enhancing gastrointestinal motility.AIM To evaluate the therapeutic effects of WDD combined with mosapride on GERD after esophageal cancer surgery.METHODS Eighty patients with GERD were randomly divided into treatment(receiving WDD combined with mosapride)and control(receiving mosapride alone)groups.The treatment was conducted from January 2021 to January 2023.The primary outcome was improved GERD symptoms as measured using the reflux disease questionnaire(RDQ).The secondary outcomes were improved esophageal motility(measured using esophageal manometry),gastric emptying(measured using gastric scintigraphy),and quality of life[measured via the Short Form-36(SF-36)Health Survey].RESULTS The treatment group showed a notably reduced RDQ score and improved esophageal motility parameters,such as lower esophageal sphincter pressure,peristaltic amplitude,and peristaltic velocity compared to the control group.The treatment group showed significantly higher gastric emptying rates and SF-36 scores(in both physical and mental domains)compared to the control group.No serious adverse effects were observed in either group.CONCLUSION WDD combined with mosapride is an effective and safe therapy for GERD after esophageal cancer surgery.It can improve GERD symptoms,esophageal motility,gastric emptying,and the quality of life of patients.Further studies with larger sample sizes and longer follow-up periods are required to confirm these findings.

Investigating causal links between gastroesophageal reflux disease and essential hypertension

Gastroesophageal reflux disease(GERD)is a prevalent global health concern with a rising incidence.Various risk factors,including obesity,hiatal hernia,and smo-king,contribute to its development.Recent research suggests associations bet-ween GERD and metabolic syndrome,cardiac diseases,and hypertension(HTN).Mechanisms linking GERD to HTN involve autonomic dysfunction,inflammatory states,and endothelial dysfunction.Furthermore,GERD medications such as pro-ton-pump inhibitors may impact blood pressure regulation.Conversely,antihy-pertensive medications like beta-blockers and calcium channel blockers can exacerbate GERD symptoms.While bidirectional causality exists between GERD and HTN,longitudinal studies are warranted to elucidate the precise relationship.Treatment of GERD,including anti-reflux surgery,may positively influence HTN control.However,the interplay of lifestyle factors,comorbidities,and medications necessitates further investigation to comprehensively understand this relation-ship.In this editorial,we comment on the article published by Wei et al in the recent issue of the World Journal of Clinical Cases.We evaluate their claims on the causal association between GERD and HTN.

Gastroesophageal reflux following peroral endoscopic myotomy for achalasia:Bumps in the road to success

Achalasia can significantly impair the quality of life.The clinical presentation typically includes dysphagia to both solids and liquids,chest pain,and regurgitation.Diagnosis can be delayed in patients with atypical presentations,and they might receive a wrong diagnosis,such as gastroesophageal reflux disease(GERD),owing to overlapping symptoms of both disorders.Although the cause of achalasia is poorly understood,its impact on the motility of the esophagus and gastroesophageal junction is well established.Several treatment modalities have been utilized,with the most common being surgical Heller myotomy with concomitant fundoplication and pneumatic balloon dilatation.Recently,peroral endoscopic myotomy(POEM)has gained popularity as an effective treatment for achalasia,despite a relatively high incidence of GERD occurring after treatment compared to other modalities.The magnitude of post-POEM GERD depends on its definition and is influenced by patient and procedure-related factors.The longterm sequelae of post-POEM GERD are yet to be determined,but it appears to have a benign course and is usually manageable with clinically available modalities.Identifying risk factors for post-POEM GERD and modifying the POEM procedure in selected patients may improve the overall success of this technique.

Gastroesophageal reflux after per-oral endoscopic myotomy:Management literature

In this editorial,we respond to a review article by Nabi et al,in which the authors discussed gastroesophageal reflux(GER)following peroral endoscopic myotomy(POEM).POEM is presently the primary therapeutic option for achalasia,which is both safe and effective.A few adverse effects were documented after POEM,including GER.The diagnostic criteria were not clear enough because approximately 60%of patients have a long acid exposure time,while only 10%experience reflux symptoms.Multiple predictors of high disease incidence have been identified,including old age,female sex,obesity,and a baseline lower esophageal sphincter pressure of less than 45 mmHg.Some technical steps during the procedure,such as a lengthy or full-thickness myotomy,may further enhance the risk.Proton pump inhibitors are currently the first line of treatment.Emerging voices are increasingly advocating for the routine combining of POEM with an endoscopic fundoplication method,such as peroral endoscopic fundoplication or transoral incisionless fundoplication.However,more research is necessary to determine the safety and effectiveness of these procedures in the long term for patients who have undergone them.

Epidemiological, Clinical Aspects and Factors Associated with Typical Gastroesophageal Reflux Disease in the General Population of Parakou, Republic of Benin

Introduction: Gastroesophageal reflux disease (GERD) is a benign and chronic disease that can impair the quality of life. Objective: To study the epidemiological, clinical aspects and factors associated with typical GERD in the general population of Parakou in the Republic of Benin. Methods: This was a descriptive and analytical cross-sectional study with prospective data collection which took place from May 1, 2019 to June 30, 2019. The study population consisted of any subject aged at least 15 years and living in Parakou. Subjects aged at least 15 years, present on the day of the survey and having given their free and informed verbal consent were included. The Short form of QRS®(Reflux-Qual Short form) questionnaire and the “Hospital Anxiety and Depression” score were used to assess the quality of life and anxiety/depression, respectively. The sampling was probabilistic through a 2-stage cluster sampling. The variable of interest was the presence of GERD. Results: Out of 390 subjects surveyed, 28 had symptoms of typical GERD, representing a prevalence of 7.18%. The average age of these subjects was 27.11 ± 7.88 years. Fifteen subjects (53.57%) were male, giving a sex ratio of 1.15. Fourteen (50%) had a secondary level of education, 12 (42.86%) were pupils/students, 18 (64.29%) were single. The monthly income of 22 subjects (78.57%) was lower than the guaranteed interprofessional minimum wage (40,000 FCFA). The average duration of progression of symptoms was 15.89 ± 4.97 months. Symptoms occurred less than twice a week in 22 subjects (78.57%). The clinical manifestations were both diurnal and nocturnal in 12 subjects (42.86%). None of the 28 subjects with GERD had clinical warning signs. Asthma, diabetes, consumption of high fat or spice foods, carbonated drinks, non-steroidal anti-inflammatory drugs, alcoholic beverages and tobacco were statistically associated with the occurrence of GERD. Each of the 28 subjects had at least one associated factor. A significant impair in quality of life was observed in 27 patients (96.43%). Conclusion: Typical GERD is relatively common in the general population of Parakou in the Republic of Benin. It often affects young males. Among the risk factors identified, the most common are carbonated drinks, spicy meals and diabetes. GERD significantly impairs quality of life. Raising awareness about the disease and its associated factors is necessary among the general population.