Association between dysphagia, gastrointestinal and reflux symptoms, and oral intake in hospitalized patients with inflammatory rheumatic diseases

Abstract

AimDysphagia is a clinically important but often underrecognized complication in patients with inflammatory rheumatic diseases and may be associated with gastrointestinal symptoms and impaired oral intake. This study investigated the relationships between dysphagia severity, gastrointestinal symptoms, reflux symptom severity, oral intake, and diet quality in hospitalized patients with inflammatory rheumatic diseases.MethodsIn this cross-sectional study, 64 patients hospitalized in a rheumatology unit were evaluated. Dysphagia severity was assessed using the Eating Assessment Tool-10 (EAT-10), gastrointestinal symptoms with the Gastrointestinal Symptom Rating Scale (GSRS), reflux symptoms with the Reflux Symptom Index (RSI), oral intake with the Functional Oral Intake Scale (FOIS), and diet quality with the Mediterranean Diet Quality Index (KIDMED). Correlation and multiple linear regression analyses were performed.ResultsDysphagia severity was significantly associated with greater gastrointestinal symptom burden (r = 0.545, P < .001), higher reflux symptom severity (r = 0.616, P < .001), and lower oral intake (r = −0.367, P = .003). No significant association was observed between dysphagia severity and diet quality (P = .472). In multivariable regression analysis, reflux symptom severity remained the only independent factor associated with dysphagia severity (β = 0.550, P < .001), explaining 47.3% of the variance. ConclusionsDysphagia in hospitalized patients with inflammatory rheumatic diseases was associated with greater gastrointestinal and reflux symptom burden and reduced oral intake. Prospective studies are warranted to clarify the temporal and clinical significance of these associations.

Keywords

Introduction

Inflammatory rheumatic diseases are chronic autoimmune disorders characterized by multisystem involvement, including the gastrointestinal tract.¹ Gastrointestinal manifestations such as reflux symptoms, abdominal pain, bloating, and esophageal dysmotility are common, particularly in systemic sclerosis.^1,2 These manifestations may contribute to dysphagia and impaired oral intake.
Dysphagia is a clinically important complication in patients with inflammatory rheumatic diseases and may result from mechanical, inflammatory, or neuromuscular mechanisms.^3,4 Esophageal dysmotility and lower esophageal sphincter dysfunction may contribute to both dysphagia and reflux symptoms.^1,2 Dysphagia may impair oral intake and quality of life.^5-7
Hospitalized patients with inflammatory rheumatic diseases represent a vulnerable population because of disease severity and multisystem involvement. Previous studies have generally evaluated these manifestations separately. Therefore, this study investigated the relationships between dysphagia, gastrointestinal symptoms, reflux symptoms, oral intake, and diet quality in hospitalized patients.
The primary aim of this study was to investigate the relationships between dysphagia severity, gastrointestinal symptoms, reflux symptom severity, oral intake level, and diet quality in hospitalized patients with inflammatory rheumatic diseases. The secondary aim was to identify factors independently associated with dysphagia severity.

Materials and Methods

Study Design and ParticipantsThis study was designed as a cross-sectional study. A priori power analysis was performed based on an effect size of r = 0.371. To achieve 85% statistical power, a minimum of 47 participants was required for a one-tailed analysis and 59 participants for a two-tailed analysis. Participants were recruited using a consecutive sampling method. All patients admitted to the rheumatology unit between March and May 2026 were consecutively screened for eligibility. A total of 78 patients were screened, of whom 8 were excluded because they did not meet the eligibility criteria. Of the remaining 70 eligible patients, 6 declined to participate. Consequently, 64 patients provided written informed consent and were included in the final analyses. No missing data occurred.
Inclusion criteria were: diagnosis of an inflammatory rheumatic disease established by a rheumatologist according to standard clinical and/or classification criteria, hospitalization in the rheumatology unit, age ≥18 years, sufficient cognitive capacity to complete the questionnaires, and written informed consent. Exclusion criteria were neurological or psychiatric disorders affecting participation or swallowing assessment, acute disease flare precluding assessment, active gastrointestinal malignancy, gastrointestinal surgery within the previous three months, or any condition preventing reliable questionnaire completion.
All participants continued their routine medical treatment throughout the study.Outcome MeasuresParticipants were evaluated using validated instruments. All assessments were performed by members of the research team, including a physiotherapist and a rheumatologist, both of whom were familiar with the study protocol and trained in the standardized administration of the assessment instruments. Self-reported questionnaires (EAT-10, GSRS, RSI, KIDMED) were completed by the participants under the supervision of the research team when necessary. The FOIS was rated by the physiotherapist based on the participant's oral intake status obtained during the clinical assessment. Because of the cross-sectional observational design, assessor blinding was not feasible.Sociodemographic Data FormA researcher-developed form was used to collect demographic and clinical data, including age, sex, height, weight, dominant side, diagnosis, disease duration, medication use, and medical history. Ambulation level was determined by clinical observation and categorized as bed, sitting, standing or walking level.Gastrointestinal Symptom Rating Scale (GSRS)The GSRS assesses the frequency and severity of gastrointestinal symptoms across five domains: reflux, abdominal pain, indigestion, diarrhea, and constipation. Symptoms experienced during the previous week are rated using a Likert-type scale, with higher scores indicating greater gastrointestinal symptom severity. The Turkish version has been validated and shown to be reliable for clinical and research use.⁸Eating Assessment Tool (EAT-10)The EAT-10 is a 10-item self-reported questionnaire used to assess dysphagia symptom severity. Each item is scored from 0 (no problem) to 4 (severe problem), yielding a total score ranging from 0 to 40. Higher scores indicate more severe dysphagia symptoms. A score of ≥3 is generally accepted as indicating clinically significant dysphagia. The Turkish version has been validated by Demir et al..⁹Functional Oral Intake Scale (FOIS)The FOIS was used to evaluate the participants’ oral intake level. This 7-point ordinal scale ranges from total enteral feeding (Level 1) to a full oral diet without restrictions (Level 7). Higher scores indicate better oral intake. The FOIS is widely used in dysphagia management.¹⁰Reflux Symptom Index (RSI)The RSI is a 9-item self-reported questionnaire designed to assess laryngopharyngeal reflux symptoms. Each item is scored from 0 (no symptom) to 5 (severe symptom), resulting in a total score ranging from 0 to 45. Higher scores indicate greater reflux symptom severity. Scores ≥13 are generally considered clinically significant. The original scale was developed by Belafsky et al., and the Turkish adaptation has been previously used.¹¹Mediterranean Diet Quality Index (KIDMED)The KIDMED index was used to assess adherence to Mediterranean dietary patterns. Scores range from −4 to +12, with higher scores indicating better diet quality and greater adherence to Mediterranean dietary principles. Scores of ≤3, 4–7, and ≥8 indicate poor, moderate, and high diet quality, respectively.¹² Although originally developed for pediatric populations, the KIDMED index has also been used in adult epidemiological and clinical studies.Ethical ApprovalThis study was approved by the Ethics Committee of Pamukkale University (Date: 24.03.2026; Decision No: E-60116787-020-853910).Statistical AnalysisStatistical analyses were performed using IBM SPSS Statistics version 26.0 (IBM Corp., Armonk, NY, USA). Data distribution was assessed using the Shapiro–Wilk test and Q–Q plots. Continuous variables are presented as mean ± SD or median (minimum–maximum), and categorical variables as n (%).
Correlation analyses were conducted according to variable distribution. Because EAT-10 scores were not normally distributed, the associations between EAT-10 and GSRS, RSI, FOIS, and KIDMED scores were evaluated using Spearman's rank correlation coefficient.
Multiple linear regression analysis was performed to identify variables independently associated with dysphagia severity. Variables directly related to the primary study objectives (GSRS, RSI, FOIS, and KIDMED) were entered into the model. Potential confounding variables, including age, sex, body mass index, disease duration, disease subtype, disease activity, and medication use, were considered during study planning. However, because of the small sample size and heterogeneous disease subtypes, including numerous covariates could have resulted in model overfitting and unstable estimates. Therefore, the final model included only variables directly related to the primary study objectives.
Regression assumptions were evaluated. Linearity was assessed by examining scatterplots of standardized predicted values versus standardized residuals. Normality of residuals was assessed using histograms and P–P plots. Homoscedasticity was assessed by visual inspection of standardized residual plots. Independence of residuals was evaluated using the Durbin–Watson statistic. Multicollinearity was assessed using tolerance values and variance inflation factors (VIF), with VIF values <5 considered acceptable. Statistical significance was defined as P < .05 for all analyses. Reporting GuidelinesThis study was reported in accordance with the STROBE guideline.

Results

A total of 64 patients hospitalized in the rheumatology unit were included in the study. Table 1 summarizes the demographic characteristics, disease-related variables, and clinical assessment findings of the participants. Based on the established EAT-10 cut-off score (≥3), 32 participants (50.0%) were classified as having clinically significant dysphagia.
Correlation analysis revealed that dysphagia severity was positively associated with gastrointestinal symptoms (r = 0.545, P < .001) and reflux symptoms (r = 0.616, P < .001), and negatively associated with oral intake level (r = -0.367, P = .003). No statistically significant association was found between dysphagia severity and diet quality (r = -0.095, P = .472) (Table 2). In the multiple linear regression analysis, reflux symptoms (β = 0.550, P < .001) were independently associated with dysphagia severity. The model explained 47.3% of the variance in EAT-10 scores (R² = 0.473). No significant independent contributions were observed for the other variables (P > .05) (Table 2). Multicollinearity was assessed using variance inflation factor (VIF) values, and no evidence of multicollinearity was detected.

Discussion

This study investigated the associations between dysphagia severity, gastrointestinal symptoms, reflux symptom severity, oral intake, and diet quality in hospitalized patients with inflammatory rheumatic diseases. Dysphagia severity was significantly associated with greater gastrointestinal and reflux symptom burden and lower oral intake, whereas no significant association was observed with diet quality. In the multiple linear regression analysis, reflux symptom severity was independently associated with dysphagia severity. Given the cross-sectional design, these findings should be interpreted as associations rather than causal relationships and suggest that dysphagia may coexist with upper gastrointestinal dysfunction and reduced oral intake in hospitalized patients with inflammatory rheumatic diseases.
Gastrointestinal involvement is common in inflammatory rheumatic diseases and includes reflux symptoms, esophageal dysmotility, and intestinal disorders.^13-15 Consistent with previous studies, gastrointestinal symptom burden was also common in our study. Previous studies have reported that dysphagia is common but often underrecognized in patients with rheumatic diseases.^3,16 In a recent study, dysphagia was identified in 35% of patients, with the highest prevalence observed in systemic sclerosis, primary Sjögren’s syndrome, and rheumatoid arthritis.¹⁶ In the present study, clinically significant dysphagia (EAT-10 ≥3) was identified in 50% of hospitalized patients. This higher prevalence may be related to the greater disease severity and symptom burden typically observed among hospitalized individuals, although this interpretation should be confirmed in future studies.
A moderate positive association was observed between dysphagia severity and gastrointestinal symptom burden, suggesting that these conditions may share common pathophysiological mechanisms. Esophageal dysmotility, mucosal inflammation, and other gastrointestinal abnormalities have been proposed as potential contributors to both gastrointestinal symptoms and swallowing impairment.¹⁷ In addition, emerging evidence suggests that gut–joint axis and microbiota-related mechanisms may also contribute to gastrointestinal manifestations in inflammatory rheumatic diseases.¹⁸ However, because of the cross-sectional nature of this study, the direction of these associations cannot be determined.
A strong positive association was observed between dysphagia severity and reflux symptom severity. Previous studies have suggested that gastroesophageal reflux and swallowing dysfunction frequently coexist in patients with esophageal involvement.^17,19,20 Consistent with these reports, reflux symptom severity remained independently associated with dysphagia severity after adjustment for other study variables. Nevertheless, whether reflux symptoms contribute to dysphagia, result from dysphagia, or share common underlying mechanisms cannot be determined from the present findings.
Dysphagia severity was negatively associated with oral intake level. Previous studies have similarly reported that lower FOIS scores are associated with more severe swallowing impairment and poorer nutritional status.²¹ Accordingly, reduced oral intake was associated with greater dysphagia severity in our study; however, prospective studies are required to clarify the temporal relationship between swallowing impairment and oral intake.
No significant association was observed between dysphagia severity and adherence to the Mediterranean diet. Although Mediterranean dietary patterns have been associated with reduced disease activity in inflammatory rheumatic diseases,^21-24 previous studies have primarily focused on inflammatory outcomes rather than swallowing function or oral intake. The absence of a significant association in the present study may reflect the relatively homogeneous dietary conditions of hospitalized patients, where hospital food services could have reduced variability in dietary intake. However, this interpretation remains speculative and should be confirmed in future prospective studies.
Multiple linear regression analysis identified reflux symptom severity as the only variable independently associated with dysphagia severity. This finding indicates that reflux symptoms were independently associated with dysphagia severity in hospitalized patients with inflammatory rheumatic diseases. However, because several potential confounding factors, including disease activity, medication use, disease subtype, and organ involvement, were not included in the regression model, this association should be interpreted with caution and confirmed in larger prospective studies.
The present findings indicate that dysphagia, gastrointestinal symptoms, reflux symptoms, and oral intake are interrelated in hospitalized patients with inflammatory rheumatic diseases. However, because of the cross-sectional design, these findings should be interpreted as associations rather than evidence of causal relationships. Prospective studies incorporating objective swallowing assessments are needed to confirm these findings and clarify their clinical relevance.

Limitations

Several limitations should be acknowledged. First, the cross-sectional design precludes causal inference. Second, this single-center study may limit the generalizability of the findings. Third, dysphagia and gastrointestinal symptoms were assessed using self-reported questionnaires rather than objective instrumental methods, introducing potential response bias. Fourth, the relatively small sample size and heterogeneous disease spectrum limited disease-specific subgroup analyses and disease activity, organ involvement, medication use, and other potential confounders were not included. Therefore, the independent association between reflux symptom severity and dysphagia should be interpreted with caution. Finally, the KIDMED index, originally developed for younger populations, may have limited sensitivity in hospitalized adults.

Conclusion

This study demonstrated significant associations between dysphagia severity and gastrointestinal symptoms, reflux symptom severity, and oral intake level in hospitalized patients with inflammatory rheumatic diseases. Reflux symptom severity was independently associated with dysphagia severity after adjustment for other study variables. Because of the cross-sectional design, these findings should be interpreted as associations rather than evidence of causal relationships. Larger prospective studies incorporating objective swallowing assessments are needed to confirm these findings and further clarify the relationships among dysphagia, gastrointestinal symptoms, reflux symptoms, and oral intake.

Declarations

Abbreviations

References

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