Skip to main content
Download PDF
  • Research article
  • Open access
  • Published:

Association between digestive symptoms and sleep disturbance: a cross-sectional community-based study

BMC Gastroenterology volume 19, Article number: 34 (2019) Cite this article

Abstract

Background

This study was conducted to analyze the association between digestive symptoms and sleep disturbance, and to determine if any digestive symptoms are related to sleep disturbance.

Methods

This was a cross-sectional study of 5792 subjects surveyed in a community-based cohort. Subjects provided information regarding the quality of sleep as assessed by the Pittsburgh Sleep Quality Index (PSQI), as well as digestive symptoms as assessed by the Gastrointestinal Symptom Rating Scale (GSRS). Logistic regressions were used to examine factors associated with sleep quality.

Results

The mean PSQI global score of the no sleep disturbances group (n = 4948) was 3.92 (SD = 2.14), while that of the sleep disturbance group (n = 844) was 11.18 (SD = 2.17). The association between digestive symptoms and sleep disturbance was evaluated by logistic regression after adjusting for cofounding factors. The results revealed that sleep disturbances were associated with digestive symptoms (aOR = 1.29, 95% CI = 1.22–1.36), especially abdominal pains (aOR = 1.63, 95% CI = 1.19–2.25), acid regurgitation (aOR = 1.48, 95% CI = 1.17–1.86), abdominal distension (aOR = 1.80, 95% CI = 1.42–2.28), and eructation (aOR = 1.59, 95% CI = 1.24–2.03).

Conclusions

Digestive symptoms and sleep disturbances seem to be associated. These results will help medical professionals to effectively diagnose and manage patients with sleep disturbance. Furthermore, subsequent studies using comprehensive longitudinal data should be conducted to confirm the results of the present study.

Peer Review reports

Background

Sleep disturbance encompasses various sleep disorders including insomnia, hypersomnia, circadian rhythm sleep-wake disorders, sleep apnea, narcolepsy and cataplexy, parasomnia and sleep related movement disorders [1, 2].

Many people experience sleep disturbances worldwide, the most common of which is insomnia [3]. According to the American Psychiatric Association, 10–20% of people complain of significant sleep problems to their primary care physician [4]. Moreover, 16.6% of adults aged 50 years or older reported having nocturnal sleep problems in a prior study [5]. The finding that many older adults are commonly dissatisfied with sleep quality and report sleep-related diseases indicates that the prevalence of sleep disturbances increases as the population ages [6].

These sleep disturbances are associated with the occurrence of various diseases. Specifically, it has been reported that sleep disturbances may be associated with psoriasis, suicidal ideation, alcohol use disorders, mental health difficulties, and nocturnal acid reflux [7,8,9,10]. There have also been reports of sleep disturbances being associated with functional gastrointestinal disorders (FGID). In a systematic review of patients with irritable bowel syndrome (IBS), there was evidence of a positive correlation between subjectively, but not objectively, reported sleep disturbances and gastrointestinal symptom exacerbation among people with IBS [11]. In a study of 3600 Chinese patients, FGID were significantly associated with excessive daytime sleepiness [12]. Moreover, a 2002 study of Japanese people who underwent annual health checkups at a hospital revealed positive associations between gastroesophageal reflux disease and sleep disturbances [13]. Furthermore, a population-based study of 25,844 Norwegians revealed that sleep disturbances and gastroesophageal reflux symptoms (GERS) were bidirectionally associated, suggesting that sleep disturbances may lead to GERS and vice versa [14].

In the Neijing, which is an ancient oriental medical text, stomach disharmony is the major cause of the sleep disturbance [15]. Although stomach disharmony is a general term referring to various functional disorders of the stomach [16], it is uncertain if specific digestive symptoms are related to stomach disharmony.

Despite studies conducted to date, there is a lack of research regarding the relationship between sleep disturbances and digestive symptoms using large population datasets. Furthermore, we are aware of no studies that have examined the interaction between sleep disturbances and specific digestive symptoms. Therefore, this community-based study was conducted to: (a) investigate the association between digestive symptoms and sleep disturbance, and (b) analyze whether any digestive symptoms are related to sleep disturbance.

Methods

Study design and data source

We conducted a cross-sectional analysis of the community-based cohort survey of the Korean Medicine Data Center (KDC) that was conducted from June 2012 to December 2014. The KDC is a consortium project consisting of hospital, clinic, and community-based cohort data collected in the Republic of Korea and hospital data collected in Japan, China, Vietnam and the United States of America [17,18,19]. The KDC community-based cohort data was collected as part of a follow-up survey of the “The Korean Genome and Epidemiology Study (KoGES)_Ansan and Ansung cohort,” which is an ongoing, community-based cohort study that started in 2001 [17, 20]. The participants in the KoGES_Ansan and Ansung cohort were residents aged 40 to 69 who were extracted by two-stage cluster sampling based on gender, age distribution, and information regarding the governing district obtained in the 2000 census [21].

These survey data were collected through face-to-face interviews with participants using structured questionnaires after the interviewers were trained according to a pre-established protocol. During interviews, information was obtained regarding the participants’ characteristics, results of physical examinations and laboratory analyses, symptoms, etc.

Variables definition

Sleep disturbances

The quality and disturbance of sleep was evaluated by the PSQI, a self-administered questionnaire that assesses usual sleep habits during the previous month [22, 23]. The individual items generate seven component scores pertaining to subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medicine, and daytime dysfunction [22]. The sum of these seven components yields a global PSQI score that ranges from 0 to 21 [22]. The PSQI is useful for distinguishing between sleep disorders and good sleepers. The cutoff score of the original English version of the PSQI is 5 points and the diagnostic sensitivity and specificity of good or poor sleepers are 89.6 and 86.5%, respectively [22]. However, the cutoff score of the Korean version of the PSQI is 8.5, and the diagnostic sensitivity and specificity are 94.3 and 84.4%, respectively [23]. Therefore, we defined a PSQI of 8.5 or more as having sleep disturbance.

Digestive symptoms

The digestive conditions of each subject were assessed by the digestion component portion of the Gastrointestinal Symptom Rating Scale (GSRS) [24, 25]. The GSRS is a disease specific instrument consisting of 15 items combined into five Gastrointestinal (GI) symptom clusters that depict reflux, abdominal pain, indigestion, diarrhea and constipation [25]. Among the GSRS, we used the digestion component portion, which consists of seven items, abdominal pains, heartburn, acid regurgitation, sucking sensations in the epigastrium, nausea and vomiting, borborygmus, abdominal distension and eructation.

Statistical analysis

We selected gender, age, marital status, education level and lifestyle (tobacco use, alcohol use, physical activity and obesity) as covariates because we could obtain this information from our data based on previously published studies of the risk factors for sleep disturbances [26,27,28,29]. Baseline characteristics were summarized using descriptive statistics such as the proportion, mean and standard deviation. Continuous variables were categorized as appropriate categorical variables. The association between several factors and sleep disturbance was investigated using logistic regression after adjusting for confounding factors, then analyzed using two models. Model 1 was adjusted for demographic characteristics (gender, age, marital status, education level, tobacco use, alcohol use, physical activity and obesity) and total score of GSRS digestion. Model 2 was adjusted for demographic characteristics and seven items of GSRS digestion (abdominal pains, heartburn, acid regurgitation, sucking sensations in the epigastrium, nausea and vomiting, borborygmus, abdominal distension and eructation). A two-sided p-value < 0.05 was considered to indicate statistical significance. All data manipulations and statistical analyses were performed using Stata/MP version 15 (StataCorp LP, College Station, TX, USA).

Results

Demographic characteristics of participants

The total number of participants in the KDC community-based survey from 2012 to 2014 was 5805, all of whom signed an informed consent form. Among the participants, 5792 completed the Pittsburgh Sleep Quality Index (PSQI) and the Gastrointestinal Symptom Rating Scale (GSRS) (Fig. 1). The mean PSQI global score of the no sleep disturbances group (n = 4948) was 3.92 (SD = 2.14), while that of the sleep disturbance group (n = 844) was 11.18 (SD = 2.17). Demographic information describing the participants is presented in Table 1. Overall, 67.77 and 76.66% of the sleep disturbance group were female and married, respectively. (Table 1).

Fig. 1
figure 1

Selection of the cohort population. Among the participants, 5792 completed the Pittsburgh Sleep Quality Index (PSQI) and the Gastrointestinal Symptom Rating Scale (GSRS)

Full size image
Table 1 Demographic characteristics of 5,792 subjects
Full size table

Correlation between digestive symptoms and sleep disturbances

The sleep disturbances group reported significantly more intense and frequent symptoms than the no sleep disturbances group for all GSRS digestion items (Table 2). Moreover the overall magnitude of the difference between the digestive symptoms and the sleep disturbances was moderate except for the nausea and vomiting symptoms.

Table 2 Gastrointestinal Symptom Rating Scale (GSRS)-digestive items of 5,792 subjects
Full size table

Factors associated with sleep disturbances

The association between digestive symptoms and sleep disturbances was evaluated by logistic regression after adjusting for cofounding factors. In model 1, sleep disturbances were associated with being female (aOR = 1.66, 95% CI = 1.41–1.96), age (aOR = 1.02, 95% CI = 1.01–1.03), marital status (aOR = 0.72, 95% CI = 0.60–0.88), high school or above (aOR = 0.79, 95% CI = 0.66–0.94) and total score of GSRS digestion (aOR = 1.29, 95% CI = 1.22–1.36). In model 2, sleep disturbances were associated with being female (aOR = 1.66, 95% CI = 1.41–1.97), age (aOR = 1.02, 95% CI = 1.01–1.03), marital status (aOR = 0.72, 95% CI = 0.59–0.87), high school or above (aOR = 0.79, 95% CI = 0.66–0.94) and four digestive symptoms: abdominal pains (aOR = 1.63, 95% CI = 1.19–2.25), acid regurgitation (aOR = 1.48, 95% CI = 1.17–1.86), abdominal distension (aOR = 1.80, 95% CI = 1.42–2.28), eructation (aOR = 1.59, 95% CI = 1.24–2.03) (Table 3).

Table 3 Factors associated with sleep disturbance
Full size table

Discussion

In this study, we demonstrated that sleep disturbances were associated with digestive symptoms (abdominal pains, acid regurgitation, abdominal distension and eructation), with some being closely associated.

According to many previous studies, sleep disturbances comprise an independent disease and a risk factor for many other diseases, including GI disorders such as IBS, gastroesophageal reflux disease, gastric ulcer, and duodenal ulcer [11,12,13,14, 30,31,32,33,34]. Moreover, a few studies have attempted to identify the cause of the association between sleep disturbances and sereval diseases. For example, Reddy attempted to identify differences in GI symptoms among poor sleepers based on variations in genes and found that the brain-derived neurotrophic factor genotype may be related to the etiology of poor sleep quality and chronic abdominal pain [35]. In addition, sleep disturbances were significant predictors of somatic complaints [36].

Similar to our findings, recent studies have commonly regarded female and age as risk factors related to sleep disturbances [26, 27]. For example, Dalmases reported that sleep health in a European population was associated with increasing age and being female [37]. Additionally, Choi reported that the incidence of GI diseases among sleep disturbance patients was much higher in females, as well as individuals of older age and with higher income in a multivariable analysis conducted using the National Health Insurance Service–National Sample Cohort [30]. In contrast to our findings, Mullane showed that obesity and smoking were risk factors for sleep disturbances [38], while Miller found interactive effects between insomnia and alcohol use among young adult veterans [39]. Accordingly, much more research is needed to investigate the relationship between demographic factors and sleep disturbances.

It should be noted that it was difficult to compare our findings with those of previous studies because we could not locate prior investigations that examined the relationship between specific digestive symptoms and sleep disturbance. However, the specific digestive symptoms presented in patients with sleep disturbance may be related to stomach disharmony, and these can be helpful to diagnosis of disease patterns in Traditional Chinese and Korean medicine.

Several limitations need to be considered while interpreting the results of this study. First, our findings were based on an association between digestive symptoms and sleep disturbance. To accurately evaluate the causal relationships, longitudinal data should be assessed. Second, there is the potential for self-reporting bias because we used perceived digestive symptoms tools and sleep quality tools; however, the GSRS and PSQI are good tools that have been shown to be reliable and valid in many studies. Third, we did not determine why only certain digestive symptoms among several digestive symptoms may be related to poor sleep quality. Accordingly, additional research is needed to investigate the genes, pain, and other mechanisms of digestive symptoms and sleep disturbances.

Conclusions

Digestive symptoms and sleep disturbances seem to be associative. These results will help medical professionals to effectively diagnose and manage patients with sleep disturbance. Furthermore, future studies using comprehensive longitudinal data should be conducted to confirm the results of the present study.

Abbreviations

FGID:

Functional Gastrointestinal Disorders

GERS:

Gastroesophageal Reflux Symptoms

GI:

Gastrointestinal

GSRS:

Gastrointestinal Symptom Rating Scale

KDC:

Korean Medicine Data Center

KoGES:

Korean Genome and Epidemiology Study

PSQI:

Pittsburgh Sleep Quality Index

References

  1. AASM. International classification of sleep disorders, revised: Diagnostic and coding manual. Chicago, Illinois: American Academy of Sleep Medicine; 2001.

  2. Sateia MJ. International classification of sleep disorders-third edition: highlights and modifications. Chest. 2014;146(5):1387–94.

    Article  Google Scholar 

  3. Ferrie JE, Kumari M, Salo P, Singh-Manoux A, Kivimäki M. Sleep epidemiology—a rapidly growing field. In: Oxford University Press. 2011.

  4. What Are Sleep Disorders? [https://www.psychiatry.org/patients-families/sleep-disorders/what-are-sleep-disorders] or [https://www.psychiatry.org/].

  5. Stranges S, Tigbe W, Gomez-Olive FX, Thorogood M, Kandala NB. Sleep problems: an emerging global epidemic? Findings from the INDEPTH WHO-SAGE study among more than 40,000 older adults from 8 countries across Africa and Asia. Sleep. 2012;35(8):1173–81.

    Article  Google Scholar 

  6. Wolkove N, Elkholy O, Baltzan M, Palayew M. Sleep and aging: 1. Sleep disorders commonly found in older people. Can Med Assoc J. 2007;176(9):1299–304.

    Article  Google Scholar 

  7. Gaines KK. Sleepless in America: burning the candle at both ends? At what cost? Urol Nurs. 2016;36(3):109–10.

    Article  Google Scholar 

  8. Franic T, Kralj Z, Marcinko D, Knez R, Kardum G. Suicidal ideations and sleep-related problems in early adolescence. Early Interv Psychiatry. 2014;8(2):155–62.

    Article  Google Scholar 

  9. Hunt EJ, Greenberg N, Jones N. Poor sleep after military deployment: associations with mental health difficulties. Occupational Medicine. 2016;66:669–675.

  10. Henry AL, Kyle SD, Chisholm A, Griffiths CE, Bundy C. A cross-sectional survey of the nature and correlates of sleep disturbance in people with psoriasis. Br J Dermatol. 2017;177(4):1052-1059.

  11. Tu Q, Heitkemper M, Jarrett M, Buchanan D. Sleep disturbances in irritable bowel syndrome: a systematic review. Neurogastroenterol Motil. 2017;29:e12946.

  12. Wu S, Chen S, Zhao Y, Ma X, Wang R, He J. Associations Between Excessive Daytime Sleepiness and Functional Gastrointestinal Disorders: A Population-based Study in China. J Neurogastroenterol Motil. 2017;23(2):298-305.

  13. Okuyama M, Takaishi O, Nakahara K, Iwakura N, Hasegawa T, Oyama M, Inoue A, Ishizu H, Satoh H, Fujiwara Y. Associations among gastroesophageal reflux disease, psychological stress, and sleep disturbances in Japanese adults. Scand J Gastroenterol. 2016:1–6.

  14. Lindam A, Ness-Jensen E, Jansson C, Nordenstedt H, Åkerstedt T, Hveem K, Lagergren J. Gastroesophageal reflux and sleep disturbances: a bidirectional association in a population-based cohort study, the HUNT study. Sleep. 2016;39(7):1421.

    Article  Google Scholar 

  15. Tessenow PUUaH. Huang Di nei jing su wen. In: University of California Press; 2011.

    Google Scholar 

  16. WHO. WHO international standard terminologies on traditional medicine in the Western Pacific region: World Health Organization; 2007.

  17. Lee S-W. The guide book: Korean medicine data center (KDC) (2006-2014). Korea: Institute of Oriental Medicine; 2014.

    Google Scholar 

  18. Baek Y, Lee S. Development of Korean medicine data center(KDC) teaching dataset to enhance utilization of KDC. J Sasang Constitut Med. 2017;29(3):242–7.

    Google Scholar 

  19. Jin H-J, Baek Y, Kim H-S, Ryu J, Lee S. Constitutional multicenter bank linked to Sasang constitutional phenotypic data. BMC Complement Altern Med. 2015;15(1):46.

    Article  Google Scholar 

  20. Kim Y, Han BG. Cohort profile: the Korean genome and epidemiology study (KoGES) consortium. Int J Epidemiol. 2017;46(2):e20.

    Article  Google Scholar 

  21. Ifeacho S, Narula T. Association of snoring with chronic bronchitis. Arch Intern Med. 2008;168(17):1930.

    PubMed  Google Scholar 

  22. Buysse DJ, Reynolds CF 3rd, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh sleep quality index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989;28(2):193–213.

    Article  CAS  Google Scholar 

  23. Sohn SI, Kim DH, Lee MY, Cho YW. The reliability and validity of the Korean version of the Pittsburgh sleep quality index. Sleep and Breathing. 2012;16(3):803–12.

    Article  Google Scholar 

  24. Kwon S, Jung H-K, Hong JH, Park HS. Diagnostic validity of the Korean gastrointestinal symptom rating scale (KGSRS) in the assessment of gastro-esophageal reflux disease. Ewha Med J. 2008;31(2):73–80.

    Article  Google Scholar 

  25. Svedlund J, Sjödin I, Dotevall G. GSRS—a clinical rating scale for gastrointestinal symptoms in patients with irritable bowel syndrome and peptic ulcer disease. Dig Dis Sci. 1988;33(2):129–34.

    Article  CAS  Google Scholar 

  26. Smagula SF, Stone KL, Fabio A, Cauley JA. Risk factors for sleep disturbances in older adults: evidence from prospective studies. Sleep Med Rev. 2016;25:21–30.

    Article  Google Scholar 

  27. Ohayon MM. Epidemiological overview of sleep disorders in the general population. Sleep Med Res. 2011;2(1):1–9.

    Article  Google Scholar 

  28. Muscogiuri G, Barrea L, Annunziata G, Di Somma C, Laudisio D, Colao A, Savastano S. Obesity and sleep disturbance: the chicken or the egg? Crit Rev Food Sci Nutr. 2018:1–8.

  29. Lei WY, Chang WC, Wong MW, Hung JS, Wen SH, Yi CH, Liu TT, Chen JH, Hsu CS, Hsieh TC, et al. Sleep disturbance and its association with gastrointestinal symptoms/diseases and psychological comorbidity. Digestion. 2018:1–8.

  30. Choi WJ, Lee BW, Kim DW, Lee H, Lee S, Oh ST, Kim WJ, Park JY. A study on the status and characteristics of sleep disorders and comorbidities using national health insurance data. National Health Insurance Service (NJIS) Ilsan Hospital Institute of Health Insurance & Clinical Research: Ilsan, Republic of Korea; 2015.

  31. Patel A, Hasak S, Cassell B, Ciorba MA, Vivio EE, Kumar M, Gyawali CP, Sayuk GS. Effects of disturbed sleep on gastrointestinal and somatic pain symptoms in irritable bowel syndrome. Aliment Pharmacol Ther. 2016;44(3):246–58.

    Article  CAS  Google Scholar 

  32. Iwakura N, Fujiwara Y, Shiba M, Ochi M, Fukuda T, Tanigawa T, Yamagami H, Tominaga K, Watanabe T, Arakawa T. Characteristics of sleep disturbances in patients with gastroesophageal reflux disease. Internal medicine (Tokyo, Japan). 2016;55(12):1511.

    Article  Google Scholar 

  33. Jansson C, Nordenstedt H, Wallander MA, Johansson S, Johnsen R, Hveem K, Lagergren J. A population-based study showing an association between gastroesophageal reflux disease and sleep problems. Clin Gastroenterol Hepatol. 2009;7(9):960–5.

    Article  Google Scholar 

  34. Khanijow V, Prakash P, Emsellem HA, Borum ML, Doman DB. Sleep dysfunction and gastrointestinal diseases. Gastroenterology & hepatology. 2015;11(12):817–25.

    Google Scholar 

  35. Yamawaki H, Futagami S, Shimpuku M, Sato H, Wakabayashi T, Maruki Y, Kodaka Y, Nagoya H, Shindo T, Kawagoe T, et al. Impact of sleep disorders, quality of life and gastric emptying in distinct subtypes of functional dyspepsia in Japan. J Neurogastroenterol Motil. 2014;20(1):104–12.

    Article  Google Scholar 

  36. Schlarb AA, Classen M, Hellmann SM, Vogele C, Gulewitsch MD. Sleep and somatic complaints in university students. J Pain Res. 2017;10:1189–99.

    Article  Google Scholar 

  37. Dalmases M, Benítez ID, Mas A, Garcia-Codina O, Medina-Bustos A, Escarrabill J, Saltó E, Buysse DJ, Roure N, Sánchez-de-la-Torre M, et al. Assessing sleep health in a European population: results of the Catalan health survey 2015. PLoS One. 2018;13(4):e0194495.

    Article  Google Scholar 

  38. Mullane N, Bradley C. An investigation into the association between demographic and morbidity factors, and sleep disturbance. Ir J Med Sci. 2018;187(1):163-175.

  39. Miller MB, DiBello AM, Carey KB, Pedersen ER. Insomnia moderates the association between alcohol use and consequences among young adult veterans. Addict Behav. 2017;75:59–63.

    Article  Google Scholar 

Download references

Acknowledgements

Not applicable.

Funding

This work was supported by the “Establishment of Korean medicine genome and epidemiology infrastructure” of the Korea Institution of Oriental Medicine grant funded by the Korean Government [grant numbers K18091]. The role of the funding body was data collection.

Availability of data and materials

The datasets analyzed during the current study are available from a public database of the KDC upon reasonable request.

Author information

Authors and Affiliations

  1. Department of Preventive Medicine, College of Korean Medicine, Dongguk University, Gyeongju, 38066, Republic of Korea

    Min Kyung Hyun

  2. Future Medicine Division, Korea Institute of Oriental Medicine, Daejeon, 1672, Republic of Korea

    Younghwa Baek & Siwoo Lee

Authors
  1. Min Kyung Hyun
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Younghwa Baek
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Siwoo Lee
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

MKH conceptualized and designed the study, performed the statistical analysis and wrote the manuscript. SWL designed and built the Korean Medicine Data Center (KDC). SWL and YHB obtained this research data. MKH and SWL revised the manuscript. All authors approved the final manuscript.

Corresponding author

Correspondence to Siwoo Lee.

Ethics declarations

Ethics approval and consent to participate

This study was approved by the Institutional Review Board of Dongguk University, Gyeongju s (DRG IRB 20160009). Patient consent was exempted because of the total anonymity of this study data extracted from Korean Medicine Data Center (KDC) (Bioethics and safety act. Article 16).

Consent for publication

Not applicable.

Competing interests

The author has no conflicts of interest to declare with respect to the authorship and/or publication of this article.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Hyun, M., Baek, Y. & Lee, S. Association between digestive symptoms and sleep disturbance: a cross-sectional community-based study. BMC Gastroenterol 19, 34 (2019). https://doi.org/10.1186/s12876-019-0945-9

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12876-019-0945-9

Keywords

BMC Gastroenterology

ISSN: 1471-230X

Contact us