European Journal of Cardiovascular Medicine

Abdominal symptoms are frequently encountered in clinical practice. Mostly patients seek medical attention after attempting various dietary modifications and sometimes even after self-medicating.1 These patients express dissatisfaction when they receive similar advice in their subsequent hospital visits. Studies suggests that a significant proportion of patients coming to hospital with abdominal symptoms would have already consulted a doctor and would be hoping for alternative treatment or advices in the current visit.²

This study aims to investigate the relationship between specific abdominal symptoms and their potential risk factors. The goal is to identify possible risk factors that may be contributing to a specific symptom. Understanding these relationships will be useful in improving patient management and outcomes.

This was an observational cross-sectional study conducted in Vydehi Institute of Medical Sciences and Research Centre, Bangalore over a period of 6 months and was designed to examine the relationship between abdominal symptoms and their potential risk factors. 100 patients who reported abdominal symptoms that were outlined in the structured questionnaire were included in the study.

     The interview collected information on the presence or absence (Yes/No) of various abdominal symptoms that were categorized into four main groups:

1. Gastro-Esophageal Reflux Disease (GERD) or Acid reflux symptoms: heartburn (burning sensation in the chest or upper abdomen), water brash (sour taste in the mouth), halitosis (unpleasant breath odour), belching (expelling air through the mouth)
2. Acid peptic disease symptoms: abdominal pain (unspecified or dull aching), early satiety, feeling uncomfortably full after food, nausea (vomiting like sensation), vomiting, dark/black stool.
3. Bowel symptoms: cramps (sudden, painful tightening within abdomen), bloating (sensation of abdomen being full), flatulence (farting), hard/dry stool
4. Anorectal disease symptoms: straining during defecation, Sense of incomplete evacuation of stools, mass per rectum, blood in stool, mucus in stool

Additionally, data on potential risk factors, such as dietary habits, lifestyle factors, stressors and medication use were collected using standardized questionnaires. The questionnaire was administered in both online and hard copy formats.

Statistical methods:

The data were analyzed using JASP version 0.18.3. Data

was organized using binary coding (1 for present, 0 for absent) for both symptoms and risk factors. Non-parametric Chi-square test with Standardized residuals and Logistic regression were used for performing statistical analysis and to assess the association between risk factors and symptoms. The analysis of the co-occurrence of abdominal symptoms and co-occurrence of risk factors were conducted using the Chi-square test and standardized residuals. Logistic regression analysis was employed to assess the relationship between each symptom and potential risk factors. Statistical significance was assumed with a p-value of ＜ 0.05. Standardized residual values greater or lesser than ±1.96 were considered as significant contributors to the Chi-square test.

Symptom Profile

The study population consisted of 100 participants with a mean age of 37.48 years (SD = 12.12), ranging from 19 to 70 years. The prevalence of various abdominal symptoms among the study participants is presented in Table 1.

Table 1: Prevalence of abdominal symptoms

GERD or Acid reflux symptoms:

 61 participants reported symptoms belonging to this category. The most common symptoms were heartburn (42%), water brash (21%), halitosis (20%), and belching (26%).

Acid peptic disease symptoms:

67 participants reported symptoms belonging to this category. The most frequently reported symptoms were abdominal pain (40%), feeling uncomfortably full after eating (47%), and early satiety (34%) followed by nausea (22%), vomiting (9%), and dark/black stool (9%).

Bowel symptoms:

75 participants reported symptoms belonging to this category. Bloating (54%) was the most common symptom, followed by cramps (31%), flatulence (28%), and hard/dry stool (23%).

Anorectal disease symptoms:

51 participants reported symptoms belonging to this category. The most frequently reported symptoms were a sense of incomplete evacuation of stools (39%) and straining during defecation (32%). Less common symptoms included mass per rectum (8%), blood in stool (6%), and mucus in stool (3%).

 The analysis of the co-occurrence of abdominal symptoms revealed the following significant associations among various symptoms and the findings have been summarized in Table 2.

Table 2: Symptom co-occurrence with p value and Standardized residuals

Risk profile

The risk profile of participants in this study was assessed to identify lifestyle factors, dietary dietary habits, stress and medication use. The findings are summarized below in Table 3.

Table 3: Prevalence of risk factors

The most common dietary risk factors were irregular mealtimes (64%), consumption of spicy foods (57%), and eating late at night (54%). The most common lifestyle factors were sleeping immediately after food (45%), inadequate sleep (44%), and high levels of stress (62% reporting stress either at home or workplace).

The analysis of the co-occurrence of the risk factors showed some significant associations between dietary, lifestyle, and psychosocial factors and are summarized in Table 4 with their respective significance levels.

Table 4: Risk factor co-occurrence with p value and Standardized residuals

Relationship between symptoms and risk factors

The analysis of the relationship between abdominal symptoms and associated risk factors was conducted using logistic regression analysis. This also revealed significant associations between various symptoms and dietary, lifestyle, and medication-related risk factors and the findings are summarized in Table 5.

Table 5: Risk factors significantly associated with symptoms with p values

Prevalence and Co-occurrence of Symptoms and Risk Factors

The prevalence of specific abdominal symptoms and potential risk factors found in the study aligned with the existing literature on abdominal symptoms and their impact on quality of life.

GERD or Acid Reflux Symptoms

In the study, 61 participants reported symptoms belonging to this group, with heartburn being the most common (42%). This is consistent with a study that reports heartburn and regurgitation as the most common manifestations of GERD. The presence of water brash (21%) and halitosis (20%) in our study shows that symptoms associated with GERD are diverse and can also include atypical symptoms such as chronic cough and dental erosions.³

Risk Factors

The study identified several risk factors associated with acid reflux symptoms, including eating spicy foods (p = 0.006), consuming large meals (p = 0.034), and sleeping without pillows (p = 0.035). These findings are consistent with a study that reported that dietary habits like consumption of spicy and fatty foods, and large meal sizes can significantly increase the risk of acid reflux.4 The study showed that use of over-the-counter painkillers (p = 0.003) and medications like aspirin (p = 0.047) were strong risk factors and therefore these medications should be used judiciously in patients with high risk of developing abdominal symptoms. Reflux symptoms associated with nonsteroidal anti-inflammatory drugs (NSAIDs) could be due to irritation of gastric mucosa leading to increased acid secretion.^{3, 5}

Heartburn and Water Brash

Heartburn was associated with consumption of spicy foods (p = 0.027) and the use of over-the-counter painkillers (p = 0.002). This aligns with findings from a study which reported that dietary factors and certain medications can trigger heartburn episodes. Water brash symptoms were associated with stress at home or the workplace (p = 0.028), indicating that stress can exacerbate GERD symptoms through increased gastric acid production as previously reported in other studies.^5,6

Acid Peptic Disease Symptoms

The study showed that abdominal pain (40%) and a feeling of fullness after eating (47%) were common complaints in this category. These findings are supported by another study that has documented similar complaints in patients with acid-related disorders.⁷

Risk Factors

The study found that acid peptic disease symptoms were linked to dietary habits like eating spicy foods (p = 0.031) and pickled foods (p = 0.017). Studies in the past have highlighted that diet high in salt and preservatives contribute to gastric mucosal damage and increase the risk of peptic ulcer disease.^5,8,9

Other Contributing Factors

Eating large meals (p = 0.007), eating too quickly (p = 0.036), sleeping without pillows (p = 0.002), stress at workplace (p = 0.030), use of over-the-counter painkillers (p = 0.003), and medications like Aspirin (p = 0.047) were also significant risk factors reflecting findings from previous study.5  Decreased water intake (p = 0.007) and physical inactivity (p = 0.034) were other risk factors for acid peptic disease related symptoms and are substantiated by the evidence that hydration and regular physical activity are crucial for maintaining gastrointestinal health.^10,11

Bowel Symptoms

Among bowel symptoms, bloating (54%) was the most common symptom, followed by cramps (31%) and flatulence (28%). The high incidence of these symptoms in our study could be suggesting a potential overlap of bowel symptoms in patients with functional gastrointestinal disorders which are also commonly characterized by symptoms like bloating and discomfort.¹²

Risk Factors

Bowel symptoms were associated with stress (at workplace, p = 0.033), eating large meals (p = 0.050 for cramps and p = 0.029 for bloating), and the use of over-the-counter painkillers (p = 0.042 for cramps and p = 0.020 for flatulence). These findings are supported by studies that indicate that large meals can lead to discomfort and NSAIDs can disrupt gut motility and by exacerbating bowel symptoms.^5,12

Anorectal Disease Symptoms

A sense of incomplete evacuation (39%) and straining during defecation (32%) were the most common anorectal disease symptoms found in the study. 

Risk Factors

The study found that straining during defecation was strongly associated with eating spicy foods (p = 0.043). This is consistent with the evidence that dietary irritants can lead to bowel dysmotility and straining.¹³

Overall, the prevalence of gastrointestinal symptoms and associated risk factors reported in this study reflects the trends observed in the existing literature. The statistical approach used in the study provided a framework for identifying patterns of symptoms, risk factors and their relationship with each other. Certain risk factors found to co-occur in the study could be suggesting that these risk factors act synergistically resulting in the development of particular abdominal symptoms. Understanding such co-occurrences of symptoms and risk factors can guide clinicians in anticipating future symptoms and complications as well as help in planning for the required investigations. This can assist in efficient use of healthcare resources.

Limitation

Recall bias is inherent to the design of the study as it relies on the details reported by the patients.

The findings emphasize the need to identify specific risk factors associated with particular symptoms while interviewing patients. This will enable healthcare providers to tailor the interventions to address the unique needs of patients.

Also, the methodology employed in this study can be extended to study symptoms and risk factors related to different medical conditions. For example, similar studies could be conducted with respiratory or cardiovascular symptoms utilizing statistical tests to significant associations and co-occurrences of symptoms and risk factors. This can help us in developing models that can improve the overall find management of patients in clinical settings.

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