Uses of barium meal examination in dyspeptic patients under 50

Managing the Dyspeptic Patient: Experience of a Single-Visit Dyspepsia Clinic

During a one-year period, 206 of 245 patients referred directly to a single-visit dyspepsia clinic underwent gastroscopy after clinical consultation. Endoscopic findings enabled diagnosis in the majority and no complications occurred. In 12 patients with positive endoscopies there was an unrelated clinical diagnosis, and 23 with normal endoscopies had organic disease. Such a clinic has advantages both for patients in providing single-visit diagnosis and management for the majority, and for the hospital in reducing the load on outpatient services. Prior consultation may prevent both unwarranted use of endoscopy facilities and inappropriate diagnosis.

Controlled clinical trial of treatment with cimetidine for non-ulcer dyspepsia

The effect of cimetidine (1 g daily) and placebo was studied in a controlled clinical trial comprising 50 patients with non-ulcer dyspepsia in whom an organic abnormality responsible for the dyspeptic symptoms was not disclosed by a standardized and extensive examination programme. Reduction of symptoms occurred in 13 (54%) out of 24 patients treated with cimetidine and in 16 (62%) out of 26 treated with placebo. The difference was insignificant, as were the alterations in the individual dyspeptic symptoms between the groups. Only 6 patients (25%) on cimetidine and 8 (31%) on placebo treatment had a total relief of symptoms. Of these, all cimetidine-treated patients remained free from symptoms during the successive 3-month observation period, while the dyspeptic symptoms relapsed in 3 (38%) placebo-treated patients. Subsequent resumption of placebo treatment reduced the symptoms in all 3 patients, but only one became free from symptoms. Cimetidine does not seem to be superior to placebo in the treatment of non-ulcer dyspepsia in patients without any previous history of ulcer or without any sign on endoscopy of an active or previous ulcer disease.

Policy analysis of the conversion of histamine2 antagonists to over-the-counter use

OBJECTIVES

The authors assess the costs associated with treatment of dyspepsia with histamine2 antagonists versus without availability of over-the-counter (OTC).

METHODS

A cost analysis was performed using a decision-analysis model. Patients with an initial episode of dyspepsia were studied. The model includes costs associated with consumption of OTC and prescription (Rx) medications for dyspepsia, physician visits and associated diagnostic testing, time spent for physician visits and diagnostic tests, and hospitalization costs.

RESULTS

The model is sensitive to the relative cost of histamine2 antagonists when purchased Rx or OTC, as well as to the efficacy of these drugs in relieving dyspeptic symptoms. For patients with nonulcer dyspepsia (the largest group of likely consumers), the model demonstrates a cost savings if the OTC cost of the medication is slightly less than one third the Rx cost. Costs are similar whether or not histamine2 antagonists are available OTC. If the symptom relief efficacies of histamine2 antagonists are equivalent whether purchased by prescription only or OTC, then the health-care expenditures for a typical patient with dyspepsia are $204 for OTC availability and $203 for Rx-only use. Viewing costs from the perspective of a managed-care organization, expenditures for an episode of dyspepsia are $149 regardless of whether or not histamine2 antagonists are available OTC. Restricting the analysis to patients with underlying nonulcer dyspepsia yields similar results. Variation of numerous assumptions and probabilities other than histamine antagonist cost and efficacy, including costs associated with physician visits and diagnostic tests, and the likelihood of seeking medical care, do not substantially affect the results of the model.

CONCLUSIONS

Health-care costs associated with initial treatment of dyspepsia are similar regardless of the availability of histamine2 antagonists OTC. This is due largely to the similar efficacy of these drugs compared with antacids and the predicted increase in diagnostic testing that may result if a patient visits a physician after failure to achieve symptom relief with OTC use of histamine2 antagonists.

Secretory abnormalities in functional dyspepsia

During the past 30 years much interest has been focused on gastric acid as a possible causative factor in functional dyspepsia. The similarities to duodenal ulcer with regard to the symptoms, previous reports of a high risk of subsequent ulcer development, and a growing number of clinical therapeutic trials showing a significant advantage for acid-reducing drugs over placebo--although challenged by many investigators--have all contributed to a common notion that the gastric acid may play an equally important pathogenic role in functional dyspepsia as in peptic ulcer disease. However, recent studies in patients with well-defined functional dyspepsia indicate quite clearly that hypersecretion of hydrochloric acid is a rare finding. Available data also contradict the hypothesis that patients with functional dyspepsia are abnormally sensitive to their gastric acid. Those dyspeptic individuals who benefit from antacids purchased over the counter usually do not have functional dyspepsia but rather organic diseases such as esophagitis or peptic ulcer. The association or pathophysiologic parallelism between functional dyspepsia and peptic ulcer implied by the results of some studies of functional dyspepsia in the past might be explained by unintended inclusion of overlooked or subclinical cases of peptic ulcer disease in those studies.

Open access gastroscopy: too much to swallow?

OBJECTIVES

To ascertain the proportion of endoscopic examinations with normal findings in patients referred for gastroscopy through hospital medical staff or directly by their general practitioner and to assess the likely effect of targeting endoscopy in older patients.

DESIGN

Retrospective audit of the gastroscopy practice of one consultant from 1986 to 1988 from information recorded on a standard form completed at the time of the examination, which contained details of patients, their endoscopic findings, and mode of referral (open access or clinic).

SETTING

One district general hospital.

PATIENTS

1545 Consecutive patients from primary catchment area attending for their first gastroscopy; 454 were referred through the outpatient clinic or by hospital colleagues (clinic group) and 1091 were accepted for endoscopy solely on their general practitioner's clinical diagnosis (open access group).

RESULTS

Similar numbers (about 40%) of examinations with normal findings were performed in each group, although in patients aged over 40 the proportion with normal findings was significantly higher in the clinic group (p less than 0.03). Endoscopic evidence of gastro-oesophageal reflux disease, peptic ulceration, and gastroduodenal inflammation was equally common in each group; upper gastrointestinal malignancy, however, was significantly more common in patients referred through hospital doctors (5%, 23/454 v 2%, 22/1091 respectively; p less than 0.005) (although many of these patients had already been extensively investigated).

IMPLICATIONS

Open access gastroscopy does not increase the number of unnecessary examinations and should become more widely available. Targeting this service to patients aged over 40 would reduce the number of requests but increase the diagnostic yield.

Diagnostic and therapeutic efficacy of barium meal examination: a prospective evaluation in general practice

OBJECTIVE

To assess the efficacy of barium meal examinations in managing patients with dyspepsia in general practice.

DESIGN

Prospective study by questionnaires completed by general practitioners before and within three to six months after the barium meal examination. Information was requested about the patients' symptoms, current treatment, reason for requesting the examination, and the working diagnosis, including degree of certainty and, after the examination, about any change in diagnosis, diagnostic confidence, or management and to determine whether the examination was judged to be helpful or not.

SETTING

Inner city health district.

PATIENTS

133 Patients with dyspepsia referred by general practitioners for outpatient barium meal examination, 31 of whom failed to attend for the examination, or refused it on arrival, or did not have fully completed questionnaires. Two patients were not available for follow up.

MAIN OUTCOME MEASURES

Prevalence of radiological abnormalities and the influence of the examination result on management, particularly changes in drug treatment.

RESULTS

Fully completed pairs of questionnaires were available for 100 patients, 58 of whom were aged below 50. Most of the barium meal reports (64) were to confirm the clinical diagnosis; only 22 were to exclude serious disease. Ninety nine patients were already receiving treatment, with 39 taking an H2 receptor antagonist. Fifty eight barium meal examinations showed abnormalities (31 major abnormalities); there were no cancers and in only 18 patients was the working diagnosis changed as a result of the findings. Although the barium meal result increased management confidence (63 patients) and allayed patients' anxiety (46), changes in management attributed directly to the examination occurred in only 22 patients. Management changes were minor, usually comprising interchange of antacids and H2 receptor antagonists.

CONCLUSIONS

Young patients (aged below 50) with dyspepsia are still being overinvestigated. Although barium meal examination improves diagnostic confidence and allays patients' anxiety, fully utilising communication skills at the initial consultation might allay anxiety more economically.

Do young patients with dyspepsia need investigation?

During 1986, 1386 patients with simple dyspepsia were referred by general practitioners for endoscopy (686) or double-contrast barium meal examination (700) at Leicester General Hospital. 618 (45%) were under the age of 45 years. Abnormal findings were more common in older than younger dyspeptic patients (58% vs 40% at endoscopy, 69% vs 25% by barium meal). Malignant disorders were diagnosed in 5% at endoscopy and 3% at barium meal, but in no patient under 45 years old. The incidence of malignant disorders at endoscopy was analysed for the 6 years 1980-86. Of 707 cases identified, only 13 (1.8%) occurred in patients under 45 years old; all 13 had symptoms suggesting pathology more serious than simple dyspepsia. It can be concluded that young patients with simple dyspepsia are overinvestigated. A majority can be treated safely with antacids and/or histamine receptor type 2 antagonists.

Sucralfate versus placebo in treatment of non-ulcer dyspepsia

One hundred fifty-one patients with non-ulcer dyspepsia, defined as chronic epigastric pain without concomitant symptoms of the irritable bowel syndrome and with no evidence of any organic disease other than macroscopic or microscopic gastritis/duodenitis seen at endoscopy on entry into the trial, were randomly assigned to treatment for four weeks with sucralfate or a placebo, 1 g three times a day one-half hour before meals, according to a double-blind model. Seventy-nine patients received sucralfate and 72 patients received a placebo. According to patients' subjective assessment of their symptoms at four weeks, 61 patients (77 percent) in the sucralfate group and 40 patients (56 percent) in the placebo group had become symptom-free or showed improvement, whereas the condition of 18 (23 percent) in the former group compared with 32 (44 percent) in the latter group remained unchanged or deteriorated. The difference between the groups was significant (p less than 0.01). The best response to sucralfate treatment (84 percent or more symptom-free or improved) was achieved in patients with mild or moderate symptoms and without macroscopic or microscopic inflammation of their gastric mucosa--a typical patient with non-ulcer dyspepsia. Our results indicate that sucralfate is significantly more effective than placebo in the treatment of non-ulcer dyspepsia.

Cisapride in non-ulcer dyspepsia. Results of a placebo-controlled trial

The effect of cisapride, 10 mg three times daily, was evaluated in a double-blind randomized study in 118 patients with non-ulcer dyspepsia. Peptic ulcer disease was excluded by endoscopy, gallstones by ultrasonography, and chronic pancreatitis by a series of non-invasive tests. Symptomatic improvement was evaluated by interview after 2 and 4 weeks; the patients also kept a diary. Cisapride caused significant improvement compared with placebo with regard to frequency and severity of symptoms and may therefore be useful in the therapy of non-ulcer dyspepsia.

Epigastric distress syndrome

The term 'non-ulcer dyspepsia' lacks a generally accepted definition. A broad spectrum of symptoms could be included under this heading. Therefore, a subclassification with strict and reproducible lines of demarcation is needed. The aim of a recently concluded study was to delineate the category of patients who suffer from chronic or recurrent epigastric pain without symptoms of Irritable Bowel Syndrome and without any anatomical correlates. In order to emphasize the distinction between the studied condition and the less well-defined diagnosis of non-ulcer-dyspepsia we have proposed an alternative designation, "Epigastric Distress Syndrome". The admixture of initially overlooked organic diseases seems to be almost negligible when strict criteria are used for the diagnosis. Gastric acid is probably not involved in the etiology but psychological factors seem to be crucial for the development of this condition. When specifically asked, about every third person report abdominal symptoms. Their complaints are commonly referred to as dyspepsia, but the term lacks a generally accepted definition. In practice, every possible symptom arising from the gastrointestinal tract except jaundice and bleeding could be gathered under this heading. A large number of organic diseases are conceivable causes of dyspepsia, but conditions with presumed functional etiology dominate, at least in outpatient care. In fact, the clinical diagnosis of 'gastritis', which is used to describe upper abdominal complaints without any apparent organic causes, accounts for 2% of all outpatient consultations in Sweden, and it is by far the most commonly used gastroenterological diagnosis in this country.

Prospective testing of a scoring system designed to improve case selection for upper gastrointestinal investigation

A recently described scoring system designed to assess the individual risk of finding serious pathology in patients referred for upper gastrointestinal investigation has been prospectively tested in 1279 patients undergoing first-time endoscopy and 321 patients undergoing radiologic examination. The scoring system has been confirmed to give a reasonable prediction of the likelihood of finding serious pathology in two hospitals with differing endoscopic practice, and also to be applicable to patients attending for radiology. The system works best at defining a low-risk group (score less than 412, 26% of total) in which the incidence of serious pathology was 3%. All cases of malignancy (n = 55) occurred in patients scoring greater than 464 (50% of total). A simple table is described that allows for the easy calculation of score at a glance without the use of a computer. We believe that this scoring system, which can be implemented in seconds, is the simplest yet described and that it could prove to be a useful educational aid.

General practice and teaching hospital use of barium meal examinations in the City and Hackney Health District

The value of barium meal examination in the management of younger patients with dyspepsia has been seriously questioned as diagnostic yield is reported to be low with only minor abnormalities detected. Our 9 month survey of general practice and hospital out-patient use of barium meal examination in the City and Hackney Health District during 1983-84 shows that 51% of patients investigated were less than 50 years and 20% less than 30 years of age, suggesting that clinicians have not heeded these warnings. However, 30% of the younger patients had barium meal mucosal abnormalities. Over all age groups abnormalities were more prevalent in men and in general practice rather than hospital out-patient referrals (59% vs 45%; P less than 0.02). Previous studies may therefore have underestimated the prevalence of barium meal abnormalities in younger patients, and continued use of this examination in such patients may indicate that clinicians have found the results helpful in patient management.

Absence of therapeutic benefit from antacids or cimetidine in non-ulcer dyspepsia

We randomly assigned 159 patients with non-ulcer dyspepsia, defined as chronic or recurrent epigastric pain without concomitant symptoms of the irritable bowel syndrome and with no evidence of organic disease, to treatment for three weeks with an antacid suspension one and three hours after meals, 400 mg of cimetidine twice a day, or placebo, according to a double-blind, double-dummy model. The intensity and duration of epigastric pain were recorded by the patients four times daily during a one-week period without therapy and during the three weeks of treatment. The mean reduction in pain intensity after three weeks in the placebo group was 25 percent. Neither antacid nor cimetidine treatment resulted in more than a 4 percent better effect. The reduction of pain was statistically significant (P less than 0.01) in all three groups. The time course of the pain scores in the groups receiving active drugs followed closely those in the placebo group, and there were no significant differences between the groups at any stage of the treatment. We conclude that the neutralization or suppression of gastric acid is of no clinical value in patients with this syndrome.

Chronic dyspepsia pain in general practice--its causes and diagnosis

One hundred consecutive patients who had consulted their general practitioner because of upper abdominal pain related to eating, were investigated after initial interviews by the general practitioner, a medical registrar and the same consultant physician. Thirty seven had active upper gastrointestinal or biliary tract diseases, including 29 with peptic ulcers. The general practitioner and consultant correctly distinguished between organic and non-organic dyspepsia (NOD) in 51 and 65 cases respectively. Although the sensitivity of the general practitioner diagnosis of organic disease was high (95%), the specificity (23%) and predictive value (42%) were low. There were fewer organic diagnoses amongst the patients under the age of 30 (P less than 0.05) and those with symptoms for less than 3 months (P less than 0.01). No patient under 30 with symptoms for less than 3 months had organic dyspepsia. We suggest that if dyspeptic patients over the age of 30 and those under 30 with symptoms for longer than 3 months are investigated, about one-third will be found to have organic diseases.

Can preliminary screening of dyspeptic patients allow more effective use of investigational techniques?

A total of 1041 patients with undiagnosed dyspepsia were interviewed to determine whether they required investigation for organic disease. The interviewer, a research assistant without medical qualifications, used a standard data sheet. The information obtained was analysed by computer, and, according to the results, patients were predicted to be at high, medium, or low risk. They were then followed up and the final diagnosis was compared with the risk predicted by computer. Patients predicted to be at low risk had a 10% chance of having ulcer disease and a 0.3% chance of having cancer, whereas patients predicted to be at high risk had a 20% chance of having ulcer disease and a 10% chance of having cancer. Appropriate preliminary screening of patients with acute dyspepsia can separate a group at low risk who will require investigation only if their symptoms do not resolve and a group at high risk requiring urgent outpatient consultation.

The Diagnosis and Therapy Survey October 1978-March 1983, health care consumption and current drug therapy in Sweden with respect to the clinical diagnosis of gastritis

Demographic epidemiology, current drug therapy and the health care resources required by patients clinically considered to have gastritis were studied during a four and a half year period-October 1978 to March 1983. The investigation was based on data from the Diagnosis and Therapy Survey, an on-going nation-wide sample study covering all out-patient care in Sweden. Gastritis was found to account for 1.9% of all out-patient consultations and for 30% of those for gastrointestinal disorders. The corresponding figures for peptic ulcer disease were 0.2% and 4%, respectively. The estimated minimum number of annual consultations for gastritis was 47 per 1,000 inhabitants. The majority of the consultations were dealt with in general practice, where gastritis was the fifth most common diagnosis. Drug therapy was considered to be indicated in 92% of the consultations. Antacids were prescribed in 77%, anticholinergic/spasmolytic drugs in 36% and histamine H2-receptor antagonists in 4%. The clinical diagnosis of gastritis was found to be the major indication for antacids and anticholinergic drugs and accounted for a substantial proportion of H2-receptor antagonist prescriptions. The patient groups with gastritis and duodenal ulcer showed a similar age distribution, with a mean age of about 50 years. In the gastritis group, the two sexes were equally represented, but in the duodenal ulcer group there was a predominance of men. The results of the Diagnosis and Therapy Survey indicate that the patient group with symptoms traditionally denoted as gastritis in clinical practice constitutes a major health care problem in our community.(ABSTRACT TRUNCATED AT 250 WORDS)

Scoring system to improve cost effectiveness of open access endoscopy

The introduction of an open access general practitioner endoscopy service may result in many unnecessary examinations being performed. In an attempt to prevent this, 235 patients attending for endoscopy were interviewed and the results analysed to determine which factors best discriminated between those with major disease (ulcers, cancers, oesophageal strictures; n = 48) and those without (n = 187). The six characteristics which best discriminated between the two groups were increasing age, history of vomiting, male sex, smoking, and a past history of peptic ulcer or hiatus hernia. With the use of these six features a scoring system was devised, designed to give an indication of the likelihood of finding such disease in an individual patient. This was assessed prospectively in a further 356 patients. The results showed that by utilising this scoring system it would be possible to reduce the number of examinations performed by 30% yet still detect 98% of serious disease. If confirmed in further prospective studies, this scoring system (or a modification) could more accurately assess individual priority for endoscopy and enable optimum use to be made of limited resources.

Diagnosis and treatment of dyspepsia. A cost-effectiveness analysis

Dyspepsia is a common problem in ambulatory care. While many authorities recommend ordering upper gastrointestinal x-ray series (UGI) before therapy, there is evidence that clinicians frequently treat dyspepsia without diagnostic procedures. Decision analysis was performed to select optimal management based on probabilities and outcome values from the published literature. The choices evaluated were Symptomatic Therapy (low dose antacids or anticholinergics), Ulcer Therapy (high dose antacids or cimetidine), or UGI followed by further tests or therapy. Our model indicates that mortality is minimized if UGI is performed prior to selection of therapy, and if endoscopy is performed when the x ray shows gastric ulcer. Weeks of pain are minimized if Ulcer Therapy is begun immediately, but direct health care costs are minimized by beginning with Symptomatic Therapy. The marginal cost per additional life saved by performing a UGI rather than beginning with Ulcer Therapy was +1.6 million to +2.3 million, depending on whether endoscopy followed the finding of gastric ulcer. Mortality advantages of the strategies beginning with UGI were sensitive to assumptions regarding the incidence of gastric cancer and the benefits of early diagnosis. With slight reductions in these base case values, the Ulcer Therapy strategy appeared to minimize all outcomes except dollar cost.

The use of barium meals by general practitioners and hospital doctors

A random sample of the records of patients having barium meal examinations at a district general hospital was reviewed. In both males and females, there was no significant difference in the proportions of abnormalities between referrals from hospital doctors and general practitioners. Younger males were less likely to show abnormalities than older males, but there was no age difference in the proportions of abnormal barium meals in females. There was a smaller proportion of major abnormalities (19 per cent) in female than male patients (28 per cent). This study does not suggest that any reduction of direct access barium meal examinations for general practitioners is necessary.

Upper gastrointestinal endoscopy: its effects on patient management

Out of 95 patients referred for upper gastrointestinal endoscopy after a barium-meal examination, 44 underwent a change in management. Some changes were minor but in 12 patients a decision on surgery was required. Seven of these patients were among a group of 13 for whom the referring consultant would have recommended laparotomy had endoscopy not been available, while the other five were subjected to an unplanned laparotomy. These findings support the practice of performing endoscopy on patients whose symptoms are not fully explained by barium-meal examination, especially patients aged over 45. In such cases the procedure also seems to be cost-effective.