Managing dyspepsia without alarm signs in primary care: new national guidance for England and Wales

A Simple Pre-endoscopy Score for Predicting Risk of Malignancy in Patients with Dyspepsia: A 5-Year Prospective Study

BACKGROUND

The guidelines for performing endoscopy in dyspeptic patients based on clinical parameters alone have shown variable performance, and there is a need for better prediction tools.

AIM

We aimed to prospectively develop and validate a simple clinical-cum-laboratory test-based scoring model to identify dyspeptic patients with high risk of upper gastrointestinal malignancy (UGIM).

METHODS

Adult patients with dyspeptic symptoms were prospectively recruited over 5 years. Clinical details including alarm features were recorded, and blood tests for hemoglobin and albumin were done before endoscopy. The presence of UGIM was the primary outcome. Risk factors for UGIM were assessed, and based on the OR of significant factors, a predictive scoring model was constructed. ROC curve was plotted to identify optimal cutoff score. The model was validated using bootstrapping technique.

RESULTS

The study included 2324 patients (41.9 ± 12.8 years; 33.4% females). UGIM was noted in 6.8% patients. The final model had following five positive predictors for UGIM-age > 40 years (OR 3.3, score 1); albumin ≤ 3.5 g% (OR 3.4, score 1); Hb ≤ 11 g% (OR 3.3, score 1); alarm features (OR 5.98, score 2); recent onset of symptoms (OR 8.7, score 3). ROC curve had an impressive AUC of 0.9 (0.88-0.93), and a score of 2 had 92.5% sensitivity in predicting UGIM. Validation by bootstrapping showed zero bias, which further strengthened our model.

CONCLUSION

This simple clinical-cum-laboratory test-based model performed very well in identifying dyspeptic patients at risk of UGIM. This can serve as a useful decision-making tool for referral for endoscopy.

Biodegradable stent or balloon dilatation for benign oesophageal stricture: pilot randomised controlled trial

AIM

To undertake a randomised pilot study comparing biodegradable stents and endoscopic dilatation in patients with strictures.

METHODS

This British multi-site study recruited seventeen symptomatic adult patients with refractory strictures. Patients were randomised using a multicentre, blinded assessor design, comparing a biodegradable stent (BS) with endoscopic dilatation (ED). The primary endpoint was the average dysphagia score during the first 6 mo. Secondary endpoints included repeat endoscopic procedures, quality of life, and adverse events. Secondary analysis included follow-up to 12 mo. Sensitivity analyses explored alternative estimation methods for dysphagia and multiple imputation of missing values. Nonparametric tests were used.

RESULTS

Although both groups improved, the average dysphagia scores for patients receiving stents were higher after 6 mo: BS-ED 1.17 (95%CI: 0.63-1.78) P = 0.029. The finding was robust under different estimation methods. Use of additional endoscopic procedures and quality of life (QALY) estimates were similar for BS and ED patients at 6 and 12 mo. Concomitant use of gastrointestinal prescribed medication was greater in the stent group (BS 5.1, ED 2.0 prescriptions; P < 0.001), as were related adverse events (BS 1.4, ED 0.0 events; P = 0.024). Groups were comparable at baseline and findings were statistically significant but numbers were small due to under-recruitment. The oesophageal tract has somatic sensitivity and the process of the stent dissolving, possibly unevenly, might promote discomfort or reflux.

CONCLUSION

Stenting was associated with greater dysphagia, co-medication and adverse events. Rigorously conducted and adequately powered trials are needed before widespread adoption of this technology.

Effect of licorice versus bismuth on eradication of Helicobacter pylori in patients with peptic ulcer disease

Background:

Different therapeutic regimens were used for eradication of Helicobacter pylori, based on the cost, effectiveness and patient's compliance. The aim of this study was the evaluation of licorice compared with bismuth in quadruple regimen on eradication of H. pylori in patients with peptic ulcer disease (PUD).

Materials and Methods:

In a double-blind clinical trial study, 60 patients with PUD and positive rapid urease test were enrolled. The patients were randomly allocated into two equal groups. In first group, licorice, amoxicillin, metronidazole and omeprazole and in the second (control) group, bismuth subsalicylate, amoxicillin, metronidazole and omeprazole were prescribed respectively, and 4 weeks after treatment, in order to evaluate H. pylori eradication, urea breath test was done in all patients. The outcome of the study was the preference usage of licorice as an effective medication for H. pylori eradication.

Results:

Mean age of the patients in the control and case groups were 40.8 ± 15.5 and 42.2 ± 15.8 years, respectively (P = 0.726). Seventeen (56.7%) patients in control group and 16 (53.3%) in the case group were female (P = 0.795). Both groups were similar based on frequency of gastric or duodenal ulcer. Response to treatment were seen in 20 (67%) and 17 (57%) patients of case and control groups, respectively (P > 0.05).

Conclusion:

Our study showed that licorice is as effective as bismuth in H. pylori eradication; therefore, in patients whom bismuth is contraindicated, licorice can be used safely instead.

Proton pump inhibitors: potential cost reductions by applying prescribing guidelines

BACKGROUND

There are concerns that proton pump inhibitors (PPI) are being over prescribed in both primary and secondary care. This study aims to establish potential cost savings in a community drug scheme for a one year period according to published clinical and cost-effective guidelines for PPI prescribing.

METHODS

Retrospective population-based cohort study in the Republic of Ireland using the Health Services Executive (HSE) Primary Care Reimbursement Services (PCRS) pharmacy claims database. The HSE-PCRS scheme is means tested and provides free health care including medications to approximately 30% of the Irish population. Prescription items are WHO ATC coded and details of every drug dispensed and claimants' demographic data are available. Potential cost savings (net ingredient cost) were estimated according to UK NICE clinical guidelines for all HSE-PCRS claimants on PPI therapy for ≥3 consecutive months starting in 2007 with a one year follow up (n=167,747). Five scenarios were evaluated; (i) change to PPI initiation (cheapest brand); and after 3 months (ii) therapeutic switching (cheaper brand/generic equivalent); (iii) dose reduction (maintenance therapy); (iv) therapeutic switching and dose reduction and (v) therapeutic substitution (H2 antagonist).

RESULTS

Total net ingredient cost was €88,153,174 for claimants on PPI therapy during 2007. The estimated costing savings for each of the five scenarios in a one year period were: (i) €36,943,348 (42% reduction); (ii) €29,568,475 (34%); (iii) €21,289,322 (24%); (iv) €40,505,013 (46%); (v) €34,991,569 (40%).

CONCLUSION

There are opportunities for substantial cost savings in relation to PPI prescribing if implementation of clinical guidelines in terms of generic substitution and step-down therapy is implemented on a national basis.

Therapeutic effects of famotidine on chronic symptomatic gastritis: subgroup analysis from FUTURE study

BACKGROUND

A therapeutic strategy for symptomatic patients with chronic gastritis has not been established. Gastric acid has been reported to induce a variety of unpleasant abdominal symptoms. We investigated whether the histamine H2 receptor antagonist famotidine attenuated upper abdominal symptoms in patients with chronic gastritis.

METHODS

In this multicenter prospective single-arm open-label study, 10,311 patients with a clinical diagnosis of chronic symptomatic gastritis were enrolled and each patient was administered famotidine at 20 mg/day for 4 weeks. The intensity levels of upper abdominal symptoms, epigastralgia, epigastric fullness, and heartburn were evaluated using a face scale (grade 0-4). Abdominal symptom-related quality of life (QOL) impairment was also evaluated, using an Izumo scale before and after famotidine administration. In a subgroup analysis, symptomatic responses in patients diagnosed with functional dyspepsia (FD) according to the Rome III criteria were analyzed.

RESULTS

In 8,460 patients who completed the protocol, famotidine administration significantly attenuated epigastralgia, epigastric fullness, and heartburn, and famotidine also attenuated abdominal symptom-related QOL impairment in all patients with chronic symptomatic gastritis, in those with FD-like symptoms without organic disease, and in those with FD as defined by the Rome III criteria.

CONCLUSION

Famotidine is effective to relieve abdominal symptoms and improve QOL, not only in patients with Rome III-defined FD, but also in those with chronic symptomatic gastritis.

Can clinical features stratify use of endoscopy for dyspeptic patients with high background prevalence of upper gastrointestinal cancer?

BACKGROUND

Whether clinical features can stratify priority of endoscopy remains controversial for dyspeptic patients with high background prevalence of upper gastrointestinal cancer.

AIM

To examine the predictive performance of clinical features for cancerous lesions in dyspeptic patients in Taiwan.

METHODS

Between April 2008 and July 2009, 2530 consecutive dyspeptic outpatients underwent prospective evaluation with standardized questionnaire and then upper gastrointestinal endoscopy. Performance of using age thresholds and alarm symptoms to predict malignancy was determined. Independent risk factors associated with malignancy and those with negative endoscopic findings were identified.

RESULTS

Malignant lesions were found in 31 patients (1.2%) and were independently associated with age, male gender, gastrointestinal bleeding, weight loss, and alcohol consumption. Any symptom of weight loss, bleeding and dysphagia, or simply age >45 years predicted 97% of cancer cases, with the sensitivity, specificity, positive and negative predictive values being 96.8%, 29.3%, 1.7%, and 99.9%, respectively. This strategy achieved a low negative likelihood ratio (0.11) and a high diagnostic odds ratio (12.45). Negative endoscopic finding (n=1377, 54.4%) was independently associated with younger age, female gender, no use of non-steroidal anti-inflammatory drug, and no tobacco or alcohol consumption.

CONCLUSIONS

Absence of weight loss, dysphagia, and gastrointestinal bleeding predicts low likelihood of malignancy in dyspeptic Taiwanese patients aged <45 years.

Efficacy of a simethicone, activated charcoal and magnesium oxide combination (Carbosymag®) in functional dyspepsia: results of a general practice-based randomized trial

BACKGROUND

A simethicone, activated charcoal and magnesium oxide combination (Carbosymag(®)) has been used for almost 20 years in functional dyspepsia, but there is limited scientific evidence of efficacy.

AIM

We evaluated the efficacy of Carbosymag(®) in 18- to 49-year-old patients with functional dyspepsia.

METHODS

A total of 276 dyspeptic patients consulting a general practitioner and meeting the Rome III criteria were included in this prospective placebo-controlled study. Variations in overall and individual dyspeptic symptoms were evaluated after 1 month of treatment.

RESULTS

At the end of the treatment period, overall dyspeptic symptom intensity was significantly lower in the Carbosymag(®) group (P=0.01). The intensity of post-prandial fullness, epigastric pain, epigastric burning and abdominal bloating was significantly reduced in the Carbosymag(®) group relative to the placebo group (P<0.05). The number need to treat to induce a 70-% decrease in overall dyspeptic symptoms by Carbosymag(®) was 7 (IC 95%: 4-32).

CONCLUSION

A simethicone, activated charcoal and magnesium oxide combination (Carbosymag(®)) was significantly more effective than a placebo on overall symptom intensity in dyspeptic patients consulting a general practitioner.

Indications to upper gastrointestinal endoscopy in children with dyspepsia

OBJECTIVES

The objective of the study was to ascertain the appropriateness of indications for upper gastrointestinal (UGI) endoscopy in children with dyspepsia.

METHODS

We used the RAND/University of California at Los Angeles method to investigate the appropriateness of the opinions of a panel of experts. The panel judged 2304 theoretical patient scenarios defined by a combination of demographic and clinical variables. Descriptive and multivariate logistic regression analyses were performed.

RESULTS

The panel rated UGI endoscopy as appropriate in 27.2% of cases, inappropriate in 14.3%, and dubious in 58.5%. Disagreement emerged for 21% of cases. UGI endoscopy was considered increasingly appropriate in cases with a positive family history of peptic ulcer and/or Helicobacter pylori infection (odds ratio [OR] 8.518, P < 0.0001), when dyspepsia interfered with activities of daily living ("sleep" OR 7.540, P < 0.0001; "normal activities" OR 5.725, P < 0.0001), and when patients were older than 10 years ("<or=10 years" OR 0.310, P < 0.0001) the longer the duration ("0-2 months" OR 0.002, P < 0.0001; "3-5 months" OR 0.059, P < 0.0001; "6-11 months" OR 0.516, P = 0.0005) and the greater the severity ("mild" OR 0.002, P < 0.0001; "moderate" OR 0.013, P < 0.0001) of their dyspeptic symptoms.

CONCLUSIONS

UGI endoscopy is not appropriate for all children with dyspeptic symptoms, but only for cases with a family history of peptic ulcer and/or Helicobacter pylori infection, older than 10 years of age, with symptoms persisting for more than 6 months and severe enough to affect activities of daily living.

Dyspeptic symptoms and endoscopic findings in the community: the Loiano-Monghidoro study

OBJECTIVES

We aimed to evaluate the prevalence of endoscopic findings and their association with dyspeptic symptoms in the community.

METHODS

A total of 1,533 inhabitants of two villages were invited to participate in a cross-sectional survey, and 1,033 were recruited. Participants underwent a validated dyspepsia questionnaire, upper gastrointestinal endoscopy, and a (13)C-urea breath test.

RESULTS

Endoscopic findings were present in 17.6% of asymptomatic subjects and in 27.4% of those with dyspeptic symptoms. The prevalence of esophagitis and Barrett's esophagus in subjects with dyspeptic symptoms and without prominent reflux symptoms was 8.1 and 1.5%, respectively, and was similar to that of asymptomatic subjects (8.5 and 0.7%, respectively). Esophagitis was significantly associated with dyspeptic symptoms only in subjects with concomitant prominent reflux symptoms. Peptic ulcer (PU) was present in 8.8% of subjects with dyspeptic symptoms without reflux symptoms and similarly in 9.4% of those with prominent reflux symptoms. Subjects with dyspeptic symptoms and concomitant prominent reflux symptoms had an increased risk of having an underlying PU (odds ratio 2.74, 95% confidence interval 1.30-5.78).

CONCLUSIONS

Almost three-quarters of subjects with dyspeptic symptoms do not have endoscopic findings and, in addition, esophagitis may not be the cause of dyspeptic symptoms in subjects without prominent reflux symptoms. PU may be the cause of dyspeptic symptoms in a subgroup of subjects with prominent reflux symptoms.

Helicobacter pylori test and treat versus proton pump inhibitor in initial management of dyspepsia in primary care: multicentre randomised controlled trial (MRC-CUBE trial)

OBJECTIVE

To determine the cost effectiveness of Helicobacter pylori "test and treat" compared with empirical acid suppression in the initial management of patients with dyspepsia in primary care.

DESIGN

Randomised controlled trial.

SETTING

80 general practices in the United Kingdom.

PARTICIPANTS

699 patients aged 18-65 who presented to their general practitioner with epigastric pain, heartburn, or both without "alarm symptoms" for malignancy.

INTERVENTION

H pylori 13C urea breath test plus one week of eradication treatment if positive or proton pump inhibitor alone; subsequent management at general practitioner's discretion.

MAIN OUTCOME MEASURES

Cost effectiveness in cost per quality adjusted life year (QALY) (EQ-5D) and effect on dyspeptic symptoms at one year measured with short form Leeds dyspepsia questionnaire.

RESULTS

343 patients were randomised to testing for H pylori, and 100 were positive. The successful eradication rate was 78%. 356 patients received proton pump inhibitor for 28 days. At 12 months no significant differences existed between the two groups in QALYs, costs, or dyspeptic symptoms. Minor reductions in costly resource use over the year in the test and treat group "paid back" the initial cost of the intervention.

CONCLUSIONS

Test and treat and acid suppression are equally cost effective in the initial management of dyspepsia. Empirical acid suppression is an appropriate initial strategy. As costs are similar overall, general practitioners should discuss with patients at which point to consider H pylori testing.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN87644265.

Management of the dyspeptic patient: anything goes?

Guidelines on the initial management of dyspeptic patients are remarkably conflicting or ambiguous and recommend a variety of initial approaches and no single strategy has been successfully implemented in primary care. In this issue of the American Journal of Gastroenterology, Jarbol and colleagues report the results of a large Danish trial comparing a test-and-treat strategy, an empiric PPI strategy, and a combined strategy with Helicobacter testing if symptoms improved after the PPI. Patient-related outcomes at 1 yr did not differ, but the use of endoscopy was highest in the PPI strategy. From the patient's perspective it seems that anything goes as long as the clinician sticks to a well-defined and proven strategy. Helicobacter pylori testing is still recommendable owing to the long-term benefits, but the rapidly decreasing Helicobacter prevalence will soon make the test-and-treat strategy cost-ineffective as the initial step.

Role of Helicobacter pylori in functional dyspepsia

The aetiology of dyspepsia is unknown in the majority of patients. Helicobacter pylori (H pylori) is the cause in a subset of patients. A non invasive test to assess the presence of H pylori is recommended in the management of patients under the age of 50 presenting to a family practitioner with dyspepsia. A urea breath test or a stool antigen test are the most reliable non invasive tests. Eradication of H pylori will reduce the risk to the patient with dyspepsia of developing a peptic ulcer, reduce the complication rate if prescribed non-steroid anti-inflammatory drugs and later reduce the risk of gastric cancer. The recommended treatment for non ulcer dyspepsia associated with a H pylori infection should be a 10-d course of treatment with a PPI and two antibiotics. Treatment efficacy should be assessed four weeks after completing treatment with a urea breath test or a stool antigen test.