Original Paper

Received: January 12, 2009

Accepted: February 25, 2009
Published online: April 3, 2009

Digestion 2009;79:196201
DOI: 10.1159/000211715

Prevalence and Risk Factors for Overlaps between

Gastroesophageal Reflux Disease, Dyspepsia, and
Irritable Bowel Syndrome: A Population-Based Study
Soon Young Lee a Kwang Jae Lee b Soo Jeong Kim a Sung Won Cho b
Departments of a Preventive Medicine and Public Health, and b Gastroenterology, Ajou University School of Medicine,
Suwon, South Korea

Key Words
Dyspepsia Gastroesophageal reflux disease Irritable
bowel syndrome

Abstract
Background/Aims: People may have symptoms of multiple
disorders at the same time. We aimed to determine prevalence and risk factors for overlaps between gastroesophageal reflux disease (GERD), dyspepsia and irritable bowel
syndrome (IBS) in a Korean population. Methods: A crosssectional survey was performed on 1,688 randomly selected Korean subjects. Data on 1,443 subjects could be analyzed. Dyspepsia and IBS were diagnosed using modified
Rome II criteria. Results: The prevalences of GERD, dyspepsia and IBS were 8.5, 9.5 and 9.6%. Overlaps between GERD
and dyspepsia, GERD and IBS, and dyspepsia and IBS were
observed in 2.3 (95% CI 1.43.0), 2.0 (95% CI 1.22.6%) and
1.3% (95% CI 0.61.8%) of the population. 27 and 24% of
GERD subjects suffered from dyspepsia and IBS. 24 and 14%
of dyspeptic subjects had GERD and IBS. 21 and 14% of IBS
subjects had GERD and dyspepsia. Anxiety was significantly associated with GERD overlap (OR 2.73, 95% CI 1.136.57),
dyspepsia overlap (OR 3.19, 95% CI 1.337.63) and IBS overlap (OR 4.92, 95% CI 2.0411.84), compared with GERD alone,
dyspepsia alone and IBS alone. Conclusions: Overlaps be-

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tween GERD, dyspepsia, and IBS are common in the general population. These overlaps occur predominantly in individuals with anxiety.
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Introduction

Gastroesophageal reflux disease (GERD), dyspepsia

and irritable bowel syndrome (IBS) are common gastrointestinal disorders in the general population. Twenty percent of the general adult population have GERD-related
symptoms at least once a week [1, 2]. The prevalence of
dyspepsia is reported to be 15% in the general population
[3]. IBS is experienced by up to 20% of the general population [4]. Since these disorders are very prevalent, coexistence of two or more conditions may often be observed
[57]. Evidence shows a strong overlap between GERD
and IBS that exceeds the individual presence of each condition [7, 8]. A recent study demonstrated that the overlap
of these two conditions occurs more commonly than expected by chance [9]. Disturbances of gastrointestinal sensory and motor function are commonly accepted as the
underlying pathogenesis of GERD, functional dyspepsia,
and IBS. Thus, these conditions may have more in common than once appreciated and may be linked to each
Kwang Jae Lee, MD
Department of Gastroenterology, Ajou University Hospital
Ajou University School of Medicine, San5, Wonchon-dong, Yeongtong-gu
443-721 Suwon (Korea)
Tel. +82 2 219 5102, Fax +82 2 219 5999, E-Mail kjleemd@hotmail.com

other. A subgroup with two or more of these conditions

may have a common pathophysiology and share risk factors. Thus, an understanding of the overlap between
GERD, dyspepsia, and IBS could provide valuable insights
into the pathophysiologies of these conditions.
Although these disorders include common symptoms
affecting many people throughout the world, their prevalences are thought to vary in different populations. In
particular, in the case of GERD, several population studies have shown that GERD is less common in the East
than in the West [1012]. Outpatient observations in
Western studies have shown that IBS is prevalent among
patients diagnosed as having GERD, whereas IBS is relatively uncommon in the absence of GERD [7, 9]. However, little population-based data are available to confirm
the presence of overlaps between GERD, dyspepsia, and
IBS in the East. Furthermore, there is a paucity of information on risk factors that might explain overlaps. Since
more life stress and psychological distress have been reported in patients with these common disorders than in
healthy controls [1317], psychological factors might be
implicated in their overlaps.
Thus, in the present study, we aimed to determine if
overlaps between GERD, dyspepsia, and IBS occur in a Korean population at levels that cannot be simply explained
by chance, and to identify risk factors for these overlaps.

Subjects and Methods

Study Population
This study was a cross-sectional and population-based study
conducted from November 2005 to February 2006 in the city of
Gwangju, which is located in the northwest region of South Korea, where approximately 167,000 citizens reside. The Koreans are
mostly homogeneous in ethnicity and regional differences in
terms of sociodemographic environments are minimal. Gwangju
City represents a mixture of urban and rural lifestyles, and its habitants sociodemographically reflect the general Korean population. A documented list of citizens was provided by the regional
public health office of city hall. Those older than 19 years of age
were considered eligible. The goal of sampling was to obtain a
manageable community sample representative of non-institutionalized persons residing in Gwangju City, which has average
characteristics in terms of demographic and socioeconomic status. To achieve this goal, 1,000 households were randomly selected by multistage systemic sampling, using a computerized sampling procedure. The community is stratified into 10 smaller administrative areas (sampling unit 1, SU1). Based on the number
of households in each area, the sample size was assigned to each
SU1, which was again divided into smaller units of administrative
areas (SU2). The final sample size of households in each SU2 was
determined proportionally by the number of households. The
households in each PS2 were randomly sampled.

Overlaps between GERD, Dyspepsia,

and IBS

Before conducting the interview, interviewers explained the

purpose of the questionnaire to all eligible individuals and obtained informed consent. The study protocol was approved by the
Institutional Review Board of Ajou University Hospital.
Questionnaire
The questionnaire requested information on demographics,
lifestyle factors, a hospital anxiety and depression scale [18], the
presence and frequency of heartburn, and Rome II criteria used to
diagnose functional dyspepsia and IBS [19]. BMIs were calculated
as weight in kilograms divided by height in meters squared. For
analysis purposes, we categorized BMI into two groups namely,
!25 and 625. The questionnaire also included questions on lifestyle factors including smoking (never or former smoker, current
smoker), alcohol drinking (abstainer or former drinker, current
drinker), and regular exercise (!3 or 63 days per week for 630
min of exercise/day). The hospital anxiety and depression scale is a
self-assessment measure of anxiety and depression severities. This
scale consists of 14 items, allocated to anxiety and depression subscales containing 7 items apiece. Four-grade Likert scale scores (0
3) were awarded to each item, where a higher score indicated greater levels of depression or anxiety. Definite anxiety and depression
were defined as anxiety or depression scores of 11 or more.
GERD was diagnosed when subjects reported that heartburn
and/or acid regurgitation had occurred at least once a week during the preceding 12 months. Heartburn was defined as a burning
sensation that rises through the chest. Acid regurgitation was defined as the regurgitation of bitter or sour liquid into the mouth.
The definition of dyspepsia was based on modified Rome II criteria as follows: discomfort (postprandial fullness, early satiety,
nausea, or upper abdominal bloating) or pain centered in the upper abdomen present at least once a week during the preceding 12
months without any evidence that dyspepsia was exclusively relieved by defecation or associated with onset of a change in stool
frequency or stool form. IBS was also defined, using modified
Rome II criteria as follows: abdominal discomfort or pain, present
at least once a week during the preceding 12 months, with two of
the following three features: relief after defecation, an onset associated with a change in stool frequency, or an onset associated
with a change in stool form. Symptom frequency was measured
using the following scale: 1 = none during the past year; 2 = less
than once a week, and 3 = at least once a week.
Study Conduct
The subjects were also asked to complete a self-administered
questionnaire on health habits, disease history and present symptoms including anxiety and depression and bring it with them to
the Community Health Center on the date of their appointment.
The survey consists of an interview and the self-administered
questionnaire. Our interviewers, who were well-trained health
personnel, visited selected households and conducted an initial
face-to-face interview at each home for the identification of eligible
family members over 19 years old. Subsequently, the interviewers
asked eligible subjects to participate in the survey, and explained
details of the questionnaire to those who wanted to participate.
Subjects were excluded if they could not be contacted, if they had
a history of major psychotic episodes, mental retardation, dementia, a history of a major abdominal operation, or a significant illness that impaired ability to complete the questionnaire. The interviewers handed the survey questionnaires to the participants,

Digestion 2009;79:196201

197

and asked them to fill them in. The interviewers assisted those who
had difficulties in reading or understanding the questions. The
working status of the interviewed person is shown in table 1. The
percentage of the unemployed including housewives was 36.8%,
which is not different from the average percentage in Korea.
Of the selected eligible subjects, 1,688 individuals (778 men
and 910 women, aged 1979 years) completed the survey. The data
of subjects who inadequately completed the questionnaire were
excluded. Finally, the data of 1,443 individuals (672 men and 771
women, aged 1979 years) were available for analysis.

Neither (n = 1,121)

IBS
(n = 95)

Statistical Analysis
The Students t test and the 2 test were carried out to compare
continuous and categorical variables between two independent
groups. Risk factors were evaluated by logistic regression analysis
adjusted for age. Confidence intervals (CI) of odds ratios (OR)
were obtained from the asymptotic 2 distributional properties of
the log-likelihood ratio. p values of !0.05 were considered statistically significant.

Results

The Prevalence of GERD, Dyspepsia, IBS, and Their

Overlaps
Figure 1 shows the prevalence of GERD, dyspepsia, IBS,
and their overlaps. The proportion of subjects with at least
one of these three disorders among the 1,443 study subjects
was 22.3%. The prevalences of GERD, dyspepsia, and IBS
were 8.5, 9.5 and 9.6%. The prevalences of GERD alone,
dyspepsia alone, and IBS alone were 4.6 (95% CI 3.45.7),
6.3 (95% CI 4.97.6) and 6.6% (95% CI 5.27.9). The observed prevalence of an overlap between two or more conditions was 4.8%. Overlaps between GERD and dyspepsia,
GERD and IBS, and dyspepsia and IBS were observed in
2.3 (95% CI 1.43.0), 2.0 (95% CI 1.22.6%) and 1.3% (0.6
1.8%) of the study population. Among those subjects diagnosed as having GERD, the proportions of subjects who
suffered from dyspepsia or IBS were 27 and 24%. Among
those subjects diagnosed as having dyspepsia, the proportions of subjects who suffered from GERD or IBS were 24
and 14%. Of those with IBS, the proportions of subjects
with GERD or dyspepsia were 21 and 14%.
Demographic and Clinical Characteristics of the
Study Subjects
No significant differences were observed between the
following subgroups in terms of age and gender: subjects
without any of the three disorders, with one disorder,
and with two or more disorders. Furthermore, there was
no significant association of BMI, smoking, alcohol
drinking, exercise and depression with the presence of
one disorder in isolation or the presence of two or more
198

Digestion 2009;79:196201

Dyspepsia
(n = 91)

13

23

27

GERD
(n = 67)

Fig. 1. The observed prevalences of gastroesophageal reflux disease (GERD), dyspepsia, irritable bowel syndrome (IBS), and
their overlaps in the 1,443 study subjects.

Table 1. The working status of the study participants

Occupations

Executive, administrative, and managerial

Professional
Engineering and technical
Administrative support, including clerical
Service
Sales
Farming, fishing, and forestry
Precision production, craft, and repair
Machine operators, assemblers, and inspectors
Transportation and material moving
Military
Students
Unemployed and housewives
Missing (no response)
Total

1.6
3.5
6.1
10.7
11.6
5.1
3.9
2.1
0.3
3.0
0.4
11.4
36.8
3.5
100.0

disorders. However, anxiety was significantly more

prevalent in those with one disorder or two or more disorders than in those without any of the three disorders.
The prevalence of anxiety in those with two or more disorders was significantly greater than in those with one
disorder (table 2).
Lee /Lee /Kim /Cho

Table 2. Demographic and clinical characteristics of the study population

Mean age, years

Female
Mean BMI
Current smoker
Current alcohol user
Regular exercise
Anxietya
Depression

None
(n = 1,121)

GERD
alone (n = 67)

Dyspepsia
alone (n = 91)

IBS
alone (n = 95)

Overlap
(n = 69)

49815
589 (52)
2583
258 (25)
184 (17)
125 (11)
113 (10)
99 (9)

48814
32 (48)
2483
12 (20)
14 (22)
10 (15)
28 (42)b
8 (12)

50815
47 (52)
2583
19 (22)
10 (11)
12 (13)
27 (30)c
13 (14)

47815
56 (59)
2483
24 (26)
12 (13)
16 (17)
38 (40)d
10 (11)

43814
43 (62)
2484
9 (13)
8 (12)
10 (14)
44 (64)d
8 (12)

Figures are numbers with percentages in parentheses or means 8 SD. BMI = Body mass index; none = subjects without any of the three disorders; overlap = subjects with two or more disorders.
a p < 0.001 using 2 tests; b p < 0.05, c p < 0.005, d p < 0.001 compared with the none subgroup, using the
2
tests.

Table 3. Risk factors for overlaps between two or more disorders as compared with a single disorder

Female gender
High BMI (25)
Current smoker
Current alcohol user
No regular exercise
Anxiety
Depression
a

GERD overlap
vs. GERD alone

Dyspepsia overlap
vs. dyspepsia alone

IBS overlap
vs. IBS alone

OR

95% CI

OR

95% CI

OR

95% CI

2.47
1.61
1.71
0.41
0.61
2.73
1.04

0.936.56
0.654.00
0.426.87
0.101.67
0.182.03
1.136.57a
0.283.90

2.17
0.86
0.71
0.69
0.81
3.19
1.57

0.795.98
0.352.14
0.212.39
0.153.23
0.252.67
1.337.63a
0.435.72

1.33
1.06
0.36
0.53
0.98
4.92
0.90

0.493.62
0.432.67
0.101.39
0.093.22
0.273.51
2.0411.84a
0.223.66

Statistically significant by logistic regression analysis adjusted for age.

Risk Factors for Overlaps between Two or More

Disorders
Anxiety was found to be significantly more associated
with the presence of two or more disorders as opposed to
one disorder by logistic regression analysis. The other parameters such as gender, BMI, smoking, alcohol, and exercise were not found to be significantly associated with
the overlap between two or more conditions (table 3).

Discussion

This population-based, case-control study suggests

that overlaps between GERD, dyspepsia, and IBS are
greater than predictions based on coincidence. Actually,
Overlaps between GERD, Dyspepsia,
and IBS

the overlap between two or more conditions was observed

in 4.8% of our study subjects. The prevalences of GERD
in dyspepsia or IBS, of dyspepsia in GERD or IBS and of
IBS in GERD or dyspepsia were substantially higher than
their prevalences in the general population. The population prevalences of GERD, dyspepsia, and IBS were 8.5,
9.5 and 9.6%, while the observed prevalences of GERD
alone, dyspepsia alone, and IBS alone were 4.6, 6.3 and
6.6%. Thus, after eliminating patients with two or more
conditions, the prevalences of each condition in the population are clearly low.
The age and gender distribution in our sample population was in line with the data of the most recent national
census. In addition, Gwangju City consists of urban and
rural areas. Thus, its population seems to be reasonably
Digestion 2009;79:196201

199

representative of the Korean population. Misclassification bias in relation to the exclusion of organic disease in
this community survey may be an important issue. However, the medical histories of all subjects were examined
as completely as possible, and chronic and recurrent
symptoms were considered to be an essential factor in
diagnosing these disorders. Accordingly, we believe that
organic conditions were reliably excluded in diagnosing
GERD, dyspepsia, and IBS. The Rome II criteria state 12
nonconsecutive weeks of symptoms during the past 12
months. This study defined IBS and dyspepsia as at least
once a week during the preceding 12 months in order to
make the questions understandable and easily completed. Since these modified criteria were tighter than original Rome II criteria, our IBS or dyspepsia population may
have been underestimated.
In the present study, GERD was defined as heartburn
and/or acid regurgitation at least once a week. GERD
prevalence as determined by the present survey was
8.5%. In a population-based study carried out in South
Korea in 2000, the prevalence of GERD is reported to be
3.5% [12], and thus, the incidence and prevalence of
GERD appears to be rapidly increasing in Korea. Of
these three disorders, IBS was most prevalent; dyspepsia
ranked second, followed by GERD. GERD was diagnosed in 24% of subjects with dyspepsia and in 21% subjects with IBS, which suggests that GERD is related to
dyspepsia and IBS. Probably, a common pathophysiological mechanism is responsible for these conditions. For
example, diffuse motor disturbances, altered visceral
sensitivity, and/or brain-gut dysfunction may be shared.
Overlaps between these disorders may be manifestations
of a widespread functional gut disturbance. If they have
visceral hypersensitivity, they are probably hypersensitive to physiologic reflux rather than having pathologic
reflux. However, IBS is also reported to be common in
true GERD patients with abnormal 24-hour pH study
findings [20]. Accordingly, further investigation on the
pathogenesis of GERD symptoms in patients with dyspepsia or IBS is warranted.
The mechanism of how these different problems occur
concomitantly is important and requires further study.
In the present study, we investigated risk factors, particularly psychological factors, for the overlap between two or
more conditions. In particular, anxiety was found to be
significantly more prevalent in the subjects with GERD
alone, dyspepsia alone, or IBS alone than in subjects without these conditions. Anxiety was significantly more
common in individuals with two or more of these conditions than in those with a single condition. Multiple lo200

Digestion 2009;79:196201

gistic regression analysis revealed that anxiety, but not

depression, was independently associated with the presence of two or more conditions. In keeping with our findings, psychological factors have been reported to be associated with functional gastrointestinal disorders. Psychiatric diseases are found to be diagnosed in 65.5% of
patients with functional gastrointestinal disorders and
conversely, 48% of psychiatric patients are found to have
a functional gut disorder [21]. In addition, clinic-based
studies have shown that functional dyspepsia patients report more life stress and psychological distress than
healthy controls [1315]. Similarly, patients with IBS,
who presented to tertiary referral centers, have higher
prevalences of psychological distress, major depression,
somatization, hypochondriasis and anxiety than healthy
controls [16]. Furthermore, experimentally induced anxiety has been shown to alter gastric sensorimotor function [22], and auditory stress to modulate visceral perception in IBS patients [23]. Thus, it appears that anxiety may
be linked to etiopathogenesis rather than just healthcare
seeking. Pathogenetic mechanisms related to anxiety
seem to contribute to the development of overlaps between GERD, dyspepsia, and IBS.
In the present study, a high BMI (625) was not identified as a risk factor for overlap. However, in a previous
study, a higher BMI is reported to be a risk factor for IBSGERD overlap [9]. Unlike that study, the overlap subgroup of the present study included GERD-dyspepsia
and dyspepsia-IBS, and IBS-GERD overlaps. Furthermore, the proportion of the Korean population with a
BMI of 625 is substantially lower than that found in the
West. These differences may have contributed to this discrepancy. Thus, the negative conclusions about the role
of obesity may be understated by the population of
study.
We conclude that overlaps between GERD, dyspepsia,
and IBS are common in the general population. Furthermore, our findings show that anxiety is an independent
risk factor for these overlaps, but that depression is not.
Our results suggest that a common pathophysiological
mechanism related to anxiety is likely to be involved in
patients with overlaps between these three disorders.
Acknowledgment
This study was partially supported by a grant of the Korea
Health 21 R&D Project, Ministry of Health and Welfare, Republic
of Korea (A010383).

Lee /Lee /Kim /Cho

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