Abstract
Background: Despite the availability of safe and effective outpatient treatments for alcohol use disorder (AUD), primary care physicians screen and treat only a fraction of their patients with AUD. To better detect AUD, it may be effective to evaluate whether the known gastrointestinal consequences of heavy alcohol consumption are linked to subsequent AUD diagnoses. This study examined whether irritable bowel syndrome (IBS), gastroesophageal reflux disease (GERD) and gastritis/ulcer were associated with a new AUD diagnosis.
Methods: Deidentified medical record data from a large Midwestern health care system was used to identify primary care patients without an AUD diagnosis in 2020 and 2021. Separate multivariate regression models were computed to estimate the association between each GI condition measured in 2020 and 2021 and odds of AUD diagnoses in follow-up (2022 to 2023).
Results: The average age was 56.0 (SD 17.1) years old. Patients were most commonly White race (87.6%). Gastroesophageal reflux disease (GERD) (24.8%) was much more prevalent than either IBS (3.4%) or gastritis/ulcer (2.5%). After adjusting for covariates, there was no significant association between gastritis/ulcer or IBS and a new diagnosis of AUD within 2 years. However, after adjusting for all covariates GERD was significantly associated with new AUD diagnoses (OR = 1.18; 95% CI: 1.10-1.26).
Conclusions: This study suggests that primary care physicians should screen their GERD patients for AUD, as these patients are at higher risk of being diagnosed with AUD within 2 years. Further research is needed to determine patient acceptability to discussing AUD following a GERD diagnosis as compared with standard screening.
- Alcohol Drinking
- Alcohol Use Disorder
- Gastritis
- Gastroesophageal Reflux Disease
- Irritable Bowel Syndrome
- Mental Health
- Primary Health Care
Introduction
Alcohol use disorder (AUD) is prevalent in the US population, affecting at least 12% of males and 8% of females over age 12.1 Excessive alcohol use contributes to approximately 178,000 deaths per year in the US.2 Primary care clinicians are uniquely positioned to identify AUD, as they are often a patient’s first or only contact with the medical system.3 In addition, primary care clinicians are well qualified to begin AUD treatment. AUD medications are effective and safe for outpatient use.4 Patients may accept counseling from their primary care physician more readily than from a dedicated alcohol use counselor.5 However, screening for alcohol use disorder with a validated questionnaire is rarely performed during primary care visits6 and commonly used primary care diagnostic tools have limited sensitivity.7 Primary care physicians often use blood biomarkers such as aspartate aminotransferase (AST) or γ-glutamyl transferase (GGT) as indirect markers of alcohol use,8 but these biomarkers are imperfect indicators of the pattern and longevity of drinking and may miss many patients with AUD. For example, with a specificity of 90% for each marker, the sensitivity of GGT for predicting excessive alcohol use is 44%, and the sensitivity of AST is 27%.9
Some diseases such as depression, other mental health disorders, smoking, and drug use occur at higher rates in patients with AUD and may indicate the need for further evaluation and testing in patients at risk.10 Several sleep disorders, including insomnia, disrupted sleep-wake cycles, and sleep apnea are strongly associated with alcohol use.11–13 In addition, gastrointestinal (GI) illnesses frequently occur as a consequence of long-term heavy alcohol consumption. AUD is associated with liver cirrhosis and chronic liver disease, with positive predictive values of up to 88% and 78%, respectively.14 Alcohol consumption is associated with irritable bowel syndrome (IBS),15–18 and with peptic ulcer disease.19–21 A 2018 meta-analysis showed an odds ratio of 1.48 for having gastroesophageal reflux disease (GERD) among drinkers versus non/occasional with a dose-response effect demonstrated.22 However, to our knowledge, it is not known if patients who present with gastrointestinal illness have a higher risk for a new AUD diagnosis. Given barriers to detecting AUD in primary care, initiating discussions about AUD in the context of physical problems, particularly GI conditions, may be a novel and less stigmatizing approach to identifying new AUD cases. Using a large retrospective cohort of primary care patients, we determined if IBS, GERD and gastritis/ulcer diagnoses were associated with a new AUD diagnoses after controlling for traditional AUD risk factors such as psychiatric diagnoses.
Methods
Historic, deidentified electronic health records for this project were obtained from Saint Louis University-SSM (SLU-SSM) health care system’s Virtual Data Warehouse (VDW). SLU-SSM’s VDW was created and is maintained per Health Care Systems Research Network (HCSRN) (www.hcsrn.org) specifications. The SSM health care system includes locations in 4 states: Missouri, Illinois, Oklahoma, and Wisconsin. The VDW contains deidentified clinical data for over 5 million patients dating back to 2008. This study was approved as nonhuman subjects research by the Saint Louis University Institutional Review Board because patients do not actively participate and all data are deidentified. Study variables were created from diagnostic codes, procedure codes, health services utilization and limited demographics.
For this retrospective study, we selected adult patients age 18 and older as of January 1, 2020, that had an in-person primary care visit in the baseline period from 2020 through 2021, and at least one primary care visit in follow-up which was 2022 through 2023. Both Family Medicine and General Internal Medicine departments were considered primary care. Visits in both years were required to ensure patients were regular users of the SSM system. Patients were excluded if records indicated AUD diagnosis during the baseline period of 2020 to 2021 or if demographic information (age, sex, race) was missing. Full details of the cohort definition are provided in Figure 1 (cohort flowchart). After applying eligibility criteria, there were 355,020 patients free of AUD diagnoses at baseline.
Sampling approach. Abbreviation: AUD, Alcohol use disorder.
Variable Definitions
The outcome of interest was a new diagnosis of AUD during the follow up period. The primary exposures measured during baseline were 3 GI conditions, defined using diagnostic ICD-10 codes: IBS, GERD, and gastritis/ulcer. Demographics included age as of 1/1/2020, sex, and self-identified race. To control for detection bias, that is, more health care use is associated with more diagnoses, we controlled for health care utilization. High health care utilization was defined by the top quartile of the number of unique outpatient visit dates during the observation period. We controlled for the following comorbid conditions defined using diagnostic ICD-10 codes: insomnia, sleep apnea, drug abuse/dependence, severe mental health disorder, smoking, depression, and anxiety. Detailed definitions for all variables are included in the Appendix.
Analytic Approach
Continuous variables were summarized by mean and standard deviation. Categorical variables were summarized by percent and count. Due to the large sample size, the Standardized Mean Difference Percent (SMD%) was calculated to quantify the association between each variable and the outcome. Any SMD% greater than 10 was considered a meaningful difference between outcome groups. Three separate sets of unadjusted and adjusted logistic regression models were computed to estimate the association between each GI condition and AUD diagnosis. Measures of association were expressed as odds ratios and 95% confidence intervals. α of 0.05 was used for all tests and SAS v9.4 (Cary, NC) was used for all analyses.
Results
As seen in Table 1, the average age for this cohort of primary care patients was 56.0 (S.D. 17.1) years old. Patients were most commonly White race (87.6%). GERD (24.8%) was much more prevalent than either IBS (3.4%) or gastritis/ulcer (2.5%). The most common diagnoses included anxiety (15.7%), smoking (14.9%) and sleep apnea (14.7%). Overall, only 1.3% of the sample (n = 4,468) received a new AUD diagnosis during the follow up period.
Summary of Sample Characteristics, Overall and by Alcohol Use Disorder
Several of the factors investigated showed a meaningful association with AUD diagnosis. Those with an AUD diagnosis were younger (54.0 years vs 56.0 years, SMD% 12.35) and more likely to be male (60.5% vs 40.8%, SMD% 40.18). All comorbid diagnoses were associated with higher likelihood of AUD diagnosis, with the exception of sleep apnea. None of the GI conditions had an SMD% of 10 or higher.
Unadjusted and multivariate logistic regression models estimating the association between IBS and a new AUD diagnosis are shown in Table 2. Before control for confounding, IBS had a significant inverse association with AUD (OR = 0.82; 95% CI: 0.69–0.98). The odds ratio was attenuated and no longer significant after adjusting for demographics and health care utilization (OR = 0.95; 95% CI: 0.79–1.14). After further adjusting for comorbid conditions, the association was no longer significant (OR = 0.86; 95% CI: 0.72–1.04). Males were more likely to be diagnosed with AUD and except for sleep apnea, all comorbidities were positively associated with a new AUD diagnosis.
Logistic Regression Summary for Irritable Bowel Syndrome (IBS)
Unadjusted and adjusted logistic regression results estimating the association between GERD and a new AUD diagnosis are shown in Table 3. GERD was significantly associated with an increased likelihood of receiving an AUD diagnosis both before (OR = 1.23; 95% CI: 1.15–1.31) and after adjusting for all covariates (OR = 1.18; 95% CI: 1.10–1.26). Covariates associations with AUD were similar as those shown in Table 2.
Logistic Regression Summary for GERD
Unadjusted and adjusted associations between gastritis/ulcer and odds of a new AUD diagnoses are shown in Table 4. Before adjusting for covariates, gastritis/ulcer was significantly associated with a new AUD diagnosis (OR = 1.27; 95% CI: 1.07–1.51). This association remained largely unchanged after controlling for demographics and health services use, but after controlling for comorbid conditions, gastritis/ulcer was no longer significantly associated with AUD (OR = 1.12; 95% CI: 0.94–1.33).
Logistic Regression Summary for Gastritis/Ulcer
Subgroup analyses of fully adjusted models revealed that IBS was not associated with AUD diagnoses among females but was inversely associated with AUD diagnoses among males (OR = 0.61;95% CI: 0.43–0.89). GERD was significantly associated with AUD diagnoses in both females and males but gastritis/ulcer was not associated with AUD.
Table 5 shows there was no association between IBS and AUD or between gastritis/ulcer and AUD among both age groups, that is, those ≤58 years of age and >58 years of age. GERD was significantly associated with new AUD diagnoses (OR = 1.27; 95% CI: 1.15–1.39) among patients ≤58 years of age but not among those >58 years of age.
Logistic Regression Summary of Stratified Analysis*
Discussion
Several established risk factors, such as insomnia, mental health disorders, and use of substances other than alcohol were significantly associated with new-onset AUD. After controlling for these numerous known risk factors for AUD, we observed GERD was significantly associated with a new AUD diagnosis. Those with GERD had an 18% greater odds of a new AUD diagnoses compared with those without GERD. This association was similar for both males and females and was strongest among patients ≤58 years. IBS and gastritis/ulcer were not associated with AUD after controlling for confounding. Overall, these findings suggest the presence of GERD, especially among younger to middle aged adults, is an indicator of undiagnosed AUD and is associated with greater risk for new onset AUD.
There is already a robust body of literature showing an association between heavy alcohol use and GERD.22 A credible mechanism of action has been demonstrated. Experimental models show that ingesting alcohol decreases the clearance of acid from the esophagus,23 and inhibits gastric emptying24 and the effect follows a dose-response curve.22 However, all these studies merely demonstrate an association between alcohol use and GERD. One study discusses AUD as a predictive factor for GERD.25 To our knowledge, this is the first study to demonstrate that GERD is associated with subsequent AUD diagnoses.
GERD is prevalent (approximately 10 to 20% in ages 40 to 69) and the incidence is increasing in all age groups other than age >70.26 Knowing that this group of people is at higher risk of a new AUD diagnosis, suggests a large number of patients may be identified for early detection and intervention. However, despite the association between AUD and various medical conditions, evidence indicates that patients with multiple medical conditions have similar or lower rates of screening for AUD than their well counterparts.27 This emphasizes the need to screen for AUD during sick visits as well as during annual wellness exams, especially when patients present with GERD.
Due to the many barriers to screening and detecting AUD in primary care, early intervention may be enabled and destigmatized by initiating a discussion around the impact of alcohol on physical health. In addition, recognizing the presence of alcohol-related conditions among patients without an established AUD diagnosis could be a novel approach to detection and diagnosis. There is a need to identify primary care diagnoses which are predictors of development of a new diagnosis of alcohol use disorder, so that primary care doctors can intervene with prevention or early detection.
Limitations
These data were generated from a Midwestern sample of medical patients. It is possible that samples taken in other geographic areas would yield different findings. The authors used the entire F10.x series (disorders of alcohol use) to capture the spectrum of disordered drinking in this study. However, given patients’ reluctance to self-disclose heavy drinking to their physicians,28 cases of AUD may still have been missed. Unmeasured confounding is a potential limitation but our results are robust to confounding from many strong, established risk factors for AUD. Some clinicians may not record AUD diagnoses due to concern about insurance or employment and this could lead to misclassifying AUD. If we misclassified AUD cases as unaffected, it is possible that point estimates were biased to be conservative. Finally, we lack data on specific symptoms or symptom severity. The sample may disproportionately represent patients with severe GERD symptoms, as patients with mild symptoms may not have received a formal diagnosis of GERD.
Conclusions
A diagnosis of GERD is associated with an increased chance of receiving a new diagnosis of AUD within 2 years. Physicians should recognize that a new diagnosis of GERD points to an opportunity to open a discussion about alcohol use with the patient, and to screen for alcohol use disorder with a validated tool. Patients may be more willing to discuss their alcohol use in the context of a newly diagnosed GI disorder, and physicians may be more likely to perform formal screening. Because general screening rates are low, this may be the only time that the patient is formally screened. Further research is needed to prospectively evaluate the process of care and acceptability of discussing AUD in the context of GERD as compared with standard screening approaches.
Appendix: Variable Definitions
Notes
This article was externally peer reviewed.
Funding: No external funding was used in this research.
Conflict of interest: The authors have no conflicts of interest to report.
- Received for publication November 27, 2024.
- Revision received February 18, 2025.
- Accepted for publication March 3, 2025.
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