Guidelines on appropriate indications for upper gastrointestinal endoscopy. Working Party of the Joint Committee of the Royal College of Physicians of London, Royal College of Surgeons of England, Royal College of Anaesthetists, Association of Surgeons, the British Society of Gastroenterology, and the Thoracic Society of Great Britain

Diagnostic yield of upper endoscopy according to appropriateness: A systematic review

BACKGROUND/AIM

Despite some official guidelines are available, a substantial rate of inappropriateness for upper gastrointestinal (UGI) endoscopies has been reported. This study aimed to estimate the inappropriate rate of UGI in different countries, also including the diagnostic yield.

METHODS

A systematic review of studies on UGI endoscopy appropriateness was performed by adopting official guidelines as reference standard. Diagnostic yield of relevant endoscopic findings and cancers was compared between appropriate and inappropriate procedures. The Odd Ratio (OR) values and the Number-Needed-to-Scope (NNS) were calculated.

RESULTS

Data of 23 studies with a total of 53,392 patients were included. UGI indications were overall inappropriate in 21.7% (95% CI = 21.4-22.1) of the patients. The inappropriateness rate significantly (P < 0.0001) decreased from 35.1% in the earlier studies to 22.1%-23% in the more recent ones. A relevant finding was found in 43.3% of appropriate and in 35.1% of inappropriate endoscopies (P < 0.0001; OR: 1.42, 95% CI = 1.36-1.49; NNS = 12). Prevalence of cancers was also higher in appropriate than in inappropriate UGIs (2.98% vs. 0.09%, P < 0.0001; OR = 3.33; NNS = 48). The prevalence of detected cancers significantly (P < 0.004) increased from 1.38% in the earlier studies to 2.11% in the more recent ones, whilst prevalence of other relevant findings remained similar.

CONCLUSIONS

Rate of inappropriate UGI endoscopies is still high. Diagnostic yield of appropriate endoscopies is higher than that of inappropriate procedures, including upper GI cancers. Therefore, implementation of guidelines in clinical practice is urged.

Appropriateness of American Society for Gastrointestinal Endoscopy Guidelines for Upper Gastrointestinal Endoscopy: A Prospective Analytical Study

Introduction

Extensive use of upper gastrointestinal endoscopy (UGE) with the advent of open access centers has resulted in inappropriate endoscopies. Our study aimed to evaluate the appropriateness of American Society for Gastrointestinal Endoscopy (ASGE) guidelines for UGE and to assess the diagnostic yield of endoscopy in a tertiary care center in South India.

Methods

The study was conducted as a prospective analytical study. Indications for endoscopy were classified as “ASGE appropriate” and “ASGE inappropriate”. The significance of association of ASGE guidelines and other categorical variables with endoscopic findings were assessed.

Results

ASGE appropriate indications and inappropriate indications accounted for 85.9% and 14.1% of endoscopies, respectively. The most common appropriate indication was persistent dyspepsia despite adequate proton-pump inhibitor (PPI) therapy (28.1%) and the only inappropriate indication for endoscopy was isolated dyspepsia without adequate PPI therapy (14.1%). The diagnostic yield of endoscopy for appropriate indications was 69.5% and for inappropriate indications was 55.1%, the difference was statistically significant (P= 0.003; OR-1.857). The sensitivity and specificity of ASGE guidelines was 88.5% and 19.5%, respectively.

Conclusion

According to our study, ASGE guidelines may be considered as appropriate guidelines for UGE in our population and these guidelines were followed 85.9% of the times in referring patients for the same. However, the high diagnostic yield even in inappropriate endoscopies indicates the necessity of further studies that might identify other relevant indications for endoscopy, thus avoiding misutilization of resources without missing out on relevant cases.

Upper and lower gastrointestinal endoscopies in patients over 85 years of age: Risk-benefit evaluation of a longitudinal cohort

After age 85, upper and lower gastrointestinal (GI) endoscopy may be indicated in 5% to 10% of inpatients, but the risk-benefit ratio is unknown. We studied patients older than 85 years undergoing upper and lower GI endoscopy.We analyzed a retrospective cohort of inpatients older than 85 years between 2004 and 2012, all explored by upper and complete lower GI endoscopy. Initial indications, including iron deficiency anemia (IDA), other anemias, GI bleeding, weight loss, and GI symptoms, were noted, as were endoscopy or anesthesia complications, immediate endoscopic diagnosis, and the ability to modify the patients' therapeutics. Deaths and final diagnosis for initial endoscopic indication were analyzed after at least 12 months.We included 55 patients, 78% women, with a median age, reticulocyte count, hemoglobin, and ferritin levels of 87 (85-99), 56 (24-214) g/L, 8.6 (4.8-12.9) g/dL, and 56 (3-799) μg/L, respectively. IDA was the most frequent indication for endoscopy (60%; n = 33). Immediate diagnoses were found in 64% of the patients (n = 35), including 25% with GI cancers (n = 14) and 22% with gastroduodenal ulcers or erosions (n = 12). Cancer diagnosis was associated with lower reticulocyte count (45 vs. 60 G/L; P = .02). Among the 35 diagnoses, 94% (n = 33) led to modifications of the patients' therapeutics, with 29% of the patients deciding on palliative care (n = 10). No endoscopic complications lead to death. Follow-up of >12 months was available in 82% (n = 45) of the patients; among these patients, 40% (n = 27) died after an average 24 ± 18 months. Cancer diagnosis was significantly associated with less ulterior red cell transfusion (0% vs. 28%; P = .02) and fewer further investigations (6.7% vs. 40%; P = .02).Upper and complete lower GI endoscopy in patients older than 85 years appears to be safe, and enables a high rate of immediate diagnosis, with significant modifications of therapeutics. GI cancers represented more than one-third of the endoscopic diagnoses.

Anxiety Levels in Patients Undergoing Sedation for Elective Upper Gastrointestinal Endoscopy and Colonoscopy

BACKGROUND

Anxiety is a common preprocedural problem and during processing especially in interventional medical processes.

AIM

Aim of this study was to assess the level of anxiety in patients who will undergo upper gastrointestinal endoscopy and coloscopy.

METHODS

Five hundred patients scheduled to undergo sedation for elective upper gastrointestinal endoscopy and colonoscopy were studied. Beck Anxiety Inventory (BAI) was administered to each patient before brought to the endoscopy room. Demographic data of patients were collected.

RESULTS

BAI scores and anxiety levels were significantly lower in; males compared to females, patients with no comorbidity compared to patients with comorbidity (both P values < 0.001). BAI scores were significantly lower in patients educational status university and upper compared to patients educational status primary-high school (p=0.026). There were no significant difference between BAI and anxiety levels compared to procedures (Respectively, P=0.144 P=0.054). There were no significant difference between BAI scores and anxiety levels compared to age groups (Respectively, P=0.301 P=0.214).

CONCLUSIONS

We think that level of anxiety in patients who will undergo upper gastrointestinal endoscopy and colonoscopy was effected by presence of comorbidities and gender but was not effected by features such as age, procedure type and educational status.

Incidence of gastric cancer among patients with gastric precancerous lesions: observational cohort study in a low risk Western population

OBJECTIVE

To accurately measure the incidence of gastric cancer among patients with gastric precancerous lesions, and to quantify the excess incidence in comparison with people with normal mucosa on endoscopy and a general population.

DESIGN

Population based cohort study.

SETTING

Population of Sweden using data from its national disease registers.

PARTICIPANTS

405,172 patients who had gastric biopsy samples taken for non-malignant indications between 1979 and 2011.

MAIN OUTCOME MEASURES

Incidence of gastric cancer, reported separately for patients with different mucosal changes in biopsy samples. Standardised incidence ratios provided estimation of the relative risk, using the general Swedish population as reference; and hazard ratios were derived from Cox regression modelling for internal comparisons with patients with normal gastric mucosa.

RESULTS

After excluding the first two years of follow-up, 1599 cases of gastric cancer were identified. The annual crude incidence of gastric cancer was 20 × 10(-5) for those in the normal mucosa group (standardised incidence ratio 1.0), 42 × 10(-5) for those with minor changes (1.5), 59 × 10(-5) for the gastritis group (1.8), 100 × 10(-5) for the atrophic gastritis group (2.8), 129 × 10(-5) for the intestinal metaplasia group (3.4), and 263 × 10(-5) for the dysplasia group (6.5). Cox regression modelling confirmed that excess risks increased monotonically with progressive severity of gastric lesions, with the highest hazard ratio of 10.9 (dysplasia versus normal mucosa, 95% confidence interval 7.7 to 15.4). The increased incidence was stable throughout the follow-up period, and the gaps between cumulative incidence curves grew continuously.

CONCLUSIONS

Among patients who undergo gastroscopy with biopsy for clinical indications, approximately 1 in 256 with normal mucosa, 1 in 85 with gastritis, 1 in 50 with atrophic gastritis, 1 in 39 with intestinal metaplasia, and 1 in 19 with dysplasia will develop gastric cancer within 20 years. These numbers, along with cost-benefit analyses, should guide future surveillance policies for these particular patient groups.

Inappropriate use of proton pump inhibitors among medical inpatients: a questionnaire-based observational study

Objectives

To evaluate the appropriateness of proton pump inhibitor (PPI) prescribing by conducting an audit of medical inpatients against recommended guidelines.

Design

Questionnaire-based study. All medical wards were audited and different information was documented by patients' medical records review (both hospital visit notes and general practitioner's letters) and short interview, where we asked them to name the clinical reason for using PPI.

Setting

This study was carried out in the setting of a regional hospital (537-bed, secondary care referral centre) in Ireland.

Participants

The study participants were all consecutive medical patients admitted to the medical wards at Waterford Regional Hospital, Waterford.

Main outcome measures

The appropriateness of PPI usage in our regional hospital by assessing the level of its prescribing against published guidelines (NICE, 2000).

Results

During the audit period, 205 consecutive medical inpatients were assessed. Seventy-nine percent (162 out of 205) of the studied patients were found to be using PPI. For 45% (n = 73) of patients, there was no documentation of valid indication for being on PPI. Overall, 64% of patients were prescribed PPI by hospital doctors, either during their current or previous admissions. We noted that 31% (n = 51) of patients were taking PPI for ≥2 years and another 25% of patients were using PPI for about one year. Only 12% (n = 20) of patients had undergone endoscopy procedures.

Conclusion

Inappropriate use of PPI remains common in hospital practice. The risks of using long-term PPI must be weighed against the benefits.

Helicobacter Pylori "Test-and-Treat" Strategy for Management of Dyspepsia: A Comprehensive Review

OBJECTIVES:

Deciding on whether the Helicobacter pylori test-and-treat strategy is an appropriate diagnostic–therapeutic approach for patients with dyspepsia invites a series of questions. The aim present article addresses the test-and-treat strategy and attempts to provide practical conclusions for the clinician who diagnoses and treats patients with dyspepsia.

METHODS:

Bibliographical searches were performed in MEDLINE using the keywords Helicobacter pylori, test-and-treat, and dyspepsia. We focused mainly on data from randomized controlled trials (RCTs), systematic reviews, meta-analyses, cost-effectiveness analyses, and decision analyses.

RESULTS:

Several prospective studies and decision analyses support the use of the test-and-treat strategy, although we must be cautious when extrapolating the results from one geographical area to another. Many factors determine whether this strategy is appropriate in each particular area. The test-and-treat strategy will cure most cases of underlying peptic ulcer disease, prevent most potential cases of gastroduodenal disease, and yield symptomatic benefit in a minority of patients with functional dyspepsia. Future studies should be able to stratify dyspeptic patients according to their likelihood of improving after treatment of infection by H. pylori.

CONCLUSIONS:

The test-and-treat strategy will cure most cases of underlying peptic ulcer disease and prevent most potential cases of gastroduodenal disease. In addition, a minority of infected patients with functional dyspepsia will gain symptomatic benefit. Several prospective studies and decision analyses support the use of the test-and-treat strategy. The test-and-treat strategy is being reinforced by the accumulating data that support the increasingly accepted idea that “the only good H. pylori is a dead H. pylori”.

Evaluating the clinical efficacy and cost effectiveness of direct access endoscopy

INTRODUCTION

Direct access endoscopy (DAE) allows primary care physicians (PCPs) to refer patients with concerning symptoms for endoscopy in a timely manner. Guidelines are available to assist PCPs in appropriately selecting patients for DAE. The objective of this study was to evaluate both the clinical benefit and cost effectiveness of an upper gastrointestinal (UGI) DAE program.

METHODS

The diagnostic yield of DAE patients attending for UGI studies was evaluated using a prospectively maintained database from 2004 to 2011. The diagnosis of UGI neoplasia, Barretts oesophagus, peptic ulcer disease or other conditions were recorded. In addition the age of the patient and the indication for the UGI endoscopy as per the PCP was compared with National Institute of Clinical Excellence (NICE) guidelines for UGI endoscopy.

RESULTS

PCPs referred 4262 patients for UGI endoscopy. Oesophageal cancer was diagnosed in 7 and gastric cancer was identified in 27 patients. This represents a diagnostic yield overall of 0.8% for UGI cancers. Barretts oesophagus was identified in 148 (3.5%) and 185 patients (4.34%) were diagnosed with peptic ulcer disease. Interestingly, 3734 patients (87.6%) had a normal UGI endoscopy through our DAE program representing a cost of 2,296,410 Euro. In patients under 40 years of age the diagnostic yield for UGI cancer was 0.14%. More importantly, 92.2% of UGI endoscopies in patients less 40 years of age were normal.

CONCLUSION

It is essential that PCPs adhere to published guidelines prior to referring patients to the DAE program. Furthermore, patients under 40 years of age may represent a subset of patients that may not benefit from immediate UGI endoscopy through a direct access program.

Diagnostic accuracy of age and alarm symptoms for upper GI malignancy in patients with dyspepsia in a GI clinic: a 7-year cross-sectional study

OBJECTIVES

We investigated whether using demographic characteristics and alarm symptoms can accurately predict cancer in patients with dyspepsia in Iran, where upper GI cancers and H. pylori infection are common.

METHODS

All consecutive patients referred to a tertiary gastroenterology clinic in Tehran, Iran, from 2002 to 2009 were invited to participate in this study. Each patient completed a standard questionnaire and underwent upper gastrointestinal endoscopy. Alarm symptoms included in the questionnaire were weight loss, dysphagia, GI bleeding, and persistent vomiting. We used logistic regression models to estimate the diagnostic value of each variable in combination with other ones, and to develop a risk-prediction model.

RESULTS

A total of 2,847 patients with dyspepsia participated in this study, of whom 87 (3.1%) had upper GI malignancy. Patients reporting at least one of the alarm symptoms constituted 66.7% of cancer patients compared to 38.9% in patients without cancer (p<0.001). Esophageal or gastric cancers in patients with dyspepsia was associated with older age, being male, and symptoms of weight loss and vomiting. Each single predictor had low sensitivity and specificity. Using a combination of age, alarm symptoms, and smoking, we built a risk-prediction model that distinguished between high-risk and low-risk individuals with an area under the ROC curve of 0.85 and acceptable calibration.

CONCLUSIONS

None of the predictors demonstrated high diagnostic accuracy. While our risk-prediction model had reasonable accuracy, some cancer cases would have remained undiagnosed. Therefore, where available, low cost endoscopy may be preferable for dyspeptic older patient or those with history of weight loss.

Characteristics of advanced gastric cancer undetected on gastroscopy

BACKGROUND/AIMS

Stomach cancer can be easily diagnosed via endoscopy, but also possible to be missed. The aim of this study was to investigate the clinical and endoscopic characteristics of advanced gastric cancers that were not diagnosed based on endoscopic examination.

METHODS

We evaluated patients who had newly diagnosed advanced gastric cancer that was undetected via endoscopy within the last six months.

RESULTS

Sixteen patients were included in this study. The locations of the cancers were the cardia in six cases, the greater curvature side of the body in eight cases and the antrum in two cases. The histological findings were tubular type adenocarcinoma in 11 cases, with ten cases of moderately to poorly differentiated adenocarcinoma and five cases of signet ring cell type adenocarcinoma.

CONCLUSIONS

Even advanced gastric cancer lesions may not be detected during endoscopy. If a patient continues to complain of upper gastrointestinal symptoms, even though endoscopy does not find abnormal findings, repeated endoscopy and/or additional diagnostic studies should be considered.

Impact of the Rome II paediatric criteria on the appropriateness of the upper and lower gastrointestinal endoscopy in children

BACKGROUND

The demand for paediatric gastrointestinal (GI) endoscopy has increased, resulting in a significant rise of overall costs.

AIM

To assess the clinical impact of the Rome II criteria for functional gastrointestinal disorders when selecting paediatric patients who underwent GI endoscopy.

METHODS

The indications and findings of GI endoscopic procedures performed before and after the publication of the Rome II criteria were evaluated retrospectively.

RESULTS

Upper GI endoscopy was performed in 1124 children, whereas colonoscopy was performed in 500 subjects. A total of 607 (54%) oesophago-gastro-duodenoscopies (OGDs) were positive and 517 (46%) were negative, whereas 306 (61.1%) colonoscopies were positive and 194 (38.9%) were negative. Of the 1624 procedures, 26% were considered inappropriate according to the Rome II criteria. Inappropriate procedures decreased significantly after publication of the Rome II criteria (OR, 3.7; 95% CI, 1.8-7.5). Of 1202 appropriate GI endoscopies, 502 OGD (62.7%) were significantly contributive, compared with only 105 (32.5%) of the 323 inappropriate procedures (OR, 3.5; 95% CI, 2.6-4.6), whereas 265 (65.8%) colonoscopies were significantly contributive, compared with only 41 (42.3%) of the 97 inappropriate procedures (OR, 2.6; 95% CI, 1.6-4.1).

CONCLUSIONS

The use of the criteria for functional gastrointestinal disorders makes a significant positive impact, they should reduce unnecessary paediatric GI endoscopy.

Pattern and validity of clinical diagnosis of upper gastrointestinal diseases in south-west Nigeria

BACKGROUND

Diagnosis of upper gastrointestinal (UGI) diseases is often made on clinical grounds alone in Nigeria due to lack of endoscopic facilities. The validity of using such diagnosis is presently unknown.

OBJECTIVE

The study aimed to determine: age and sex distribution of patients presenting for UGI endoscopy; pattern of clinical and endoscopic diagnoses in patients with UGI diseases; and, the validity of clinic-based diagnosis.

METHODS

Medical records of patients presenting at Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria for UGI endoscopy between September 1999 and August 2003 were reviewed. Data was analysed for sensitivity, specificity, positive predictive value, and negative predictive value of clinical diagnosis using endoscopic diagnosis as "gold" standard.

RESULTS

Males constituted 53.4% of subjects and mean age was 45 years (+/- 1.69 SD). Peptic ulcer disease (PUD) constituted 67.6% of referral diagnosis but 33.9% of endoscopic diagnosis. PUD had the highest sensitivity value (0.72) while gastritis had the least (0.04). Specificity ranged from 0.40 for PUD to 1.00 for corrosive oesophagitis. Positive predictive value ranged from 0.29 (oesophageal cancer) to 0.67 (corrosive oesophagitis) and negative predictive value ranged from 0.66 for gastritis to 0.99 for corrosive oesophagitis.

CONCLUSION

The validity of clinical diagnosis in UGI conditions varied widely, and in general, there is poor agreement between clinical and endoscopic diagnoses.

Age, symptoms and upper gastrointestinal malignancy in primary care endoscopy

OBJECTIVE

Upper gastrointestinal complaints are common in the general population. The aim of this study was to establish whether age and occurrence of alarm symptoms are predictors of malignancy in primary care open-access endoscopy.

MATERIAL AND METHODS

The material comprised 10,061 consecutive patients referred for gastroscopy by general practitioners from 1989 to 2000. The presenting symptoms were recorded; alarm symptoms comprised dysphagia, weight loss, gastrointestinal bleeding, anaemia and vomiting.

RESULTS

In all, 13.0% (1310) of the patients had alarm symptoms. Malignancy was detected in 0.7% (72 patients) in the whole series, in 0.3% (13 patients) aged 55 years or younger and in 1.1% (59 patients) over 55 years of age; the respective percentages in patients with alarm symptoms were 2.5% (33 patients), 1.0% (5 patients) and 3.4% (28 patients). Alarm symptoms (odds ratios 3.98; confidence interval 2.47-6.41), age (1.07/year; 1.05-1.09) and male gender (1.95; 1.22-3.12) were significantly associated with gastrointestinal malignancy.

CONCLUSIONS

The total number of malignancies in the primary care open-access gastroscopy series was low. Alarm symptoms increased the risk 5-6-fold; such patients should therefore undergo endoscopy without delay. At a further one year of age the risk was increased by 7%, but no definite age limit for endoscopy could be asserted.

Effectiveness and costs of implementation strategies to reduce acid suppressive drug prescriptions: a systematic review

Background

Evaluation of evidence for the effectiveness of implementation strategies aimed at reducing prescriptions for the use of acid suppressive drugs (ASD).

Methods

A systematic review of intervention studies with a design according to research quality criteria and outcomes related to the effect of reduction of ASD medication retrieved from Medline, Embase and the Cochrane Library. Outcome measures were the strategy of intervention, quality of methodology and results of treatment to differences of ASD prescriptions and costs.

Results

The intervention varied from a single passive method to multiple active interactions with GPs. Reports of study quality had shortcomings on subjects of data-analysis. Not all outcomes were calculated but if so rction of prescriptions varied from 8% up to 40% and the cost effectiveness was in some cases negative and in others positive. Few studies demonstrated good effects from the interventions to reduce ASD.

Conclusion

Poor quality of some studies is limiting the evidence for effective interventions. Also it is difficult to compare cost-effectiveness between studies. However, RCT studies demonstrate that active interventions are required to reduce ASD volume. Larger multi-intervention studies are necessary to evaluate the most successful intervention instruments.

Appropriateness of upper gastrointestinal endoscopy in children: a retrospective study

BACKGROUND

Upper gastrointestinal endoscopy (UGIE) is appropriate in many situations in adults and children. Recommendations for UGIE use in children were published recently by the French-language Paediatric Hepatology, Gastroenterology, and Nutrition Group (GFHGNP).

PATIENTS AND METHODS

We retrospectively reviewed the 293 UGIE procedures undertaken in 251 children between January 1, 2001 and June 30, 2003 by 2 senior endoscopists. The UGIE procedures were categorized as appropriate or inappropriate based on GFHGNP recommendations, and diagnostic efficiency was compared in the 2 groups with the chi2 test followed by multivariate logistic regression analysis.

RESULTS

Of the 293 UGIE procedures, 52 (17.7%) were considered inappropriate. Diagnostic efficiency was 51% in the appropriate group versus 17.3% in the inappropriate group (odds ratio, 4.2; 95% CI, 2-8.7; P < 10(-3)). The proportion of appropriate UGIE procedures was higher among inpatients than outpatients (odds ratio, 2.51; 95% CI, 1.24-5.08; P = 0.01). Inappropriate reasons for performing UGIE included isolated failure to thrive and follow-up after neonatal esophagogastroduodenitis. Nine inappropriate UGIE procedures contributed useful information: ulcerative esophagitis in 1 patient, hemorrhagic esophagitis in 4 patients, duodenitis in 1 patient, and malabsorption in 3 patients caused in 1 case by cow's milk allergy and in 2 cases to fully documented celiac disease.

CONCLUSIONS

UGIE was usually performed appropriately in our pediatric hospital. Inappropriate UGIE procedures were more common in outpatients than in admitted patients. Awareness of the recommendations for appropriate UGIE use needs to be improved among office-based and hospital-based physicians.

Does endoscopy diagnose early gastrointestinal cancer in patients with uncomplicated dyspepsia?

BACKGROUND

Recent guidelines from NICE have proposed that open access gastroscopy is largely limited to patients with "alarm" symptoms.

AIMS AND METHODS

This study reviewed the outcome of all our patients with verified oesophageal or gastric carcinoma who presented with uncomplicated dyspepsia to see if endoscopic investigation is warranted in this group. All patients with histologically verified upper gastrointestinal (GI) cancers who presented over a period from 1998 to 2002 were identified. Their presenting symptoms, treatment, and outcome were analysed.

RESULTS

228 upper GI cancers (119 oesophageal, 109 gastric; mean age 72 years (29-99 years); 130 male, 82 female) were identified in 11 145 endoscopies performed. Only 14 patients (6.2%) presented without alarm symptoms; three patients were under 55 years of age and all had gastric carcinoma-one of these had chronic diarrhoea only. Eleven had dyspepsia or reflux symptoms only, and two were under surveillance for Barrett's oesophagus. Only five patients had a curative surgical resection and are still alive two-six years from diagnosis. A sixth patient had a curative operation but died of a cerebrovascular accident one year later. The remaining eight patients unfortunately had either metastatic disease or comorbidity, which precluded surgery. All of these died within two years of diagnosis, mean survival 10 months.

CONCLUSION

Only five patients with dyspepsia and no alarm symptoms had resectable upper GI malignancies over a four year period. Limiting open access gastroscopy to those with alarm features only would "miss" a small number of patients who have curable upper GI malignancy.

Applicability and efficacy of qualifying criteria for an appropriate use of diagnostic upper gastrointestinal endoscopy

Appropriate indication for upper gastrointestinal endoscopy (UGE) may be facilitated by referring to qualifying criteria such as those devised by the European Panel (EPAGE) and French Experts (ANAES). This prospective study evaluates the applicability and efficacy of these criteria in clinical practice.

PATIENTS AND METHODS

A total of 522 patients was included (55% inpatients, 57% male, mean age 55 years). Appropriateness of referral was evaluated using EPAGE and ANAES criteria sets by a single independent expert.

RESULTS

EPAGE criteria were applicable in 71% of cases. Indications for UGE were appropriate, inappropriate and uncertain in 62%, 27% and 11% respectively; 74%, 16% and 10% of clinically significant lesions detected by UGE were disclosed in patients having appropriate, inappropriate and uncertain indications respectively. ANAES criteria were applicable in 81% of cases. Indications for UGE were appropriate in 74%, inappropriate in 26%; 76% and 24% of clinically significant lesions detected by UGE were disclosed in patients having appropriate and inappropriate indications respectively. Whatever the criteria set used, all cancers and most of the severe lesions were observed in patients with appropriate indications: those patients were more often in-patients and were significantly older than patients belonging to the inappropriate group.

CONCLUSION

Reference to EPAGE and ANAES qualifying criteria facilitates patient selection for UGE. Final decision must however rely upon practitioner advice. ANAES criteria are significantly more often applicable than EPAGE ones. However EPAGE referential when applicable is more predictive of the UGE findings.

"Test, score and scope": a selection strategy for safe reduction of upper gastrointestinal endoscopies in young dyspeptic patients referred from primary care

OBJECTIVE

To test the ability of pre-endoscopic clinical evaluation to predict clinically relevant findings of upper gastrointestinal endoscopy.

MATERIAL AND METHODS

Patients (341) who had been referred to upper gastrointestinal endoscopy for further evaluation of dyspeptic symptoms were included in this prospective, single-blinded study. Prior to endoscopy, the patients underwent a standardized clinical evaluation consisting of 1) a symptom questionnaire, 2) serological testing for Helicobacter pylori antibody and 3) determination of blood hemoglobin. Based upon this evaluation, patients were assigned to one of three defined risk groups. Group A comprised patients with known risk factors for diseases that would require further therapeutic or diagnostic management. Patients in groups B and C had no such risk factors. Patients in group C had heartburn or regurgitation as a predominant symptom, whereas patients in group B did not. The prevalence of clinically relevant findings upon upper endoscopy was then compared for these three groups.

RESULTS

The prevalence of clinically relevant endoscopic findings in risk groups A, B and C were 20.1, 2.4 and 1.6%, respectively (p<0.01 for both A versus B and A versus C). Furthermore, 89% of those with clinically relevant endoscopic findings belonged to group A, which comprised a total of 45% of the patients studied. In groups B and C, the prevalence of disease was similar to the area-specific prevalence in the general population without dyspeptic symptoms.

CONCLUSIONS

By using a simple standardized questionnaire, H. pylori serology and a hemoglobin reading in the evaluation of dyspeptic patients under 45 years of age, the need for endoscopy can be reduced by 55%.

The European panel on the appropriateness of gastrointestinal endoscopy guidelines colonoscopy in an open-access endoscopy unit: a prospective study

BACKGROUND

The demand for gastrointestinal endoscopy is increasing in most developed countries, resulting in an important rise in overall costs and waiting lists for endoscopic procedures. Therefore, adherence to appropriate indications for these procedures is essential for the rational use of finite resources in an open-access system.

AIM

To assess indications and appropriateness of colonoscopy according to the European Panel on the Appropriateness of Gastrointestinal Endoscopy (EPAGE) criteria.

METHODS

From May to June 2004, all consecutive patients referred to our Unit for open-access colonoscopy were considered for inclusion in this prospective study. Appropriateness of each colonoscopy was established according to the EPAGE criteria. In order to evaluate whether appropriateness of use correlated with the diagnostic yield of colonoscopy, relevant endoscopic findings were also recorded.

RESULTS

A total of 350 consecutive patients were included in the study. In 38 of them, the colonoscopy indication was not listed in the EPAGE guidelines and, consequently, they were not evaluated. In the remaining 312 patients, the indication for the procedure was considered inappropriate in 73 (23%) patients. Both referring doctor characteristics (specialty and health care setting) and patient data (age) correlated with appropriateness of endoscopy. The diagnostic yield was significantly higher for appropriate colonoscopies (42%) than in those judged inappropriate (21%) (P = 0.001).

CONCLUSIONS

A noteworthy proportion of patients referred for colonoscopy to an open-access endoscopy unit are considered inappropriate because of their indication, with significant differences among specialties. These results suggest that implementation of validated guidelines for its appropriate use could improve this situation and, considering the correlation between appropriateness and diagnostic yield, even contribute to improve the prognosis of patients with colorectal diseases.

Long-term follow-up of empirical treatment or prompt endoscopy for patients with persistent dyspeptic symptoms?

BACKGROUND

There are concerns about the safety and possible high costs of ongoing proton pump inhibitor therapy of empirical management strategies for patients with persistent dyspeptic symptoms.

AIM

To compare the long-term results of two treatment strategies: empirical treatment followed by the Helicobacter pylori test and treat strategy (treat and test group) and prompt upper gastrointestinal endoscopy followed by directed medical treatment (endoscopy group).

METHODS

In this study we describe the long-term follow-up data from a previously published randomized clinical trial. At least 6 years after randomization all participating general practitioners and patients were asked to give information about medication use, diagnostic testing, symptoms and quality of life by questionnaire.

RESULTS

Information about a total of 77 out of the 80 patients initially included (96%) was retrieved. Overall, 16 patients from the treat and test group (41%) underwent 18 diagnostic investigations. The 34 patients (100%) from the endoscopy group underwent 38 investigations (P < 0.01). The number of patients of the treat and test group and endoscopy group using acid inhibition therapy was 15 (38%) and 19 (56%), respectively (P = 0.14). There were also no differences in symptom prevalence and quality of life between the groups.

CONCLUSIONS

Treat and test management for patients with dyspeptic symptoms is safe and does not lead to additional diagnostic testing or use of medication when compared to prompt endoscopy.

Appropriateness and diagnostic yield of EGD: a prospective study in a large Asian hospital

BACKGROUND

The appropriateness has become an important issue as the use of EGD becomes more widespread. No study of the appropriateness of EGD has been performed in the Asia-Pacific region. This study examined the appropriateness of EGD in a large Asian hospital by using the American Society for Gastrointestinal Endoscopy 2000 guidelines. A secondary aim was to correlate appropriateness with the presence of positive findings at EGD.

METHODS

A cross-sectional study was conducted of consecutive diagnostic EGDs performed at a university-affiliated, teaching hospital, which has an open-access endoscopy system for doctors who work in the hospital. The main indication(s) for EGD was recorded and assessed as appropriate or inappropriate by using American Society for Gastrointestinal Endoscopy criteria. EGD findings were recorded and classified as positive or negative. Referrals were categorized as being from endoscopists, primary care physicians, and others.

RESULTS

Of 1076 referrals for EGD, 88.3% were deemed appropriate. The group with the highest rate of appropriate referral was endoscopists (90.2%), followed by primary care physicians (89.6%) and "others" (81.9%). The rate of appropriate referrals was significantly higher for endoscopists and primary care physicians compared with "others" (respectively, p=0.001 and p=0.022). The most common appropriate indication was "upper abdominal distress that persists despite an appropriate trial of therapy" (35.4%). The most common inappropriate indication was "dyspepsia in patients aged 45 years or below without adequate empirical medical treatment" (48.4%); 42.2% with an appropriate indication had positive findings compared with only 25.6% of those with inappropriate indications (p=0.006). On multivariate analysis, the following were identified as independent predictive factors for positive findings at EGD: male gender (p=0.005), age over 45 years (p=0.011), smoking (p=0.005), none/primary education (p<0.001), and secondary education (p=0.026).

CONCLUSIONS

The proportion of patients referred for open-access EGD with an appropriate indication(s) was high for all doctor groups in a large university-affiliated medical center in Asia. EGDs performed for appropriate indications had a higher yield of positive findings. Independent predictive factors of positive findings were male gender, age over 45 years, lower education level, and referral by an endoscopist.

Helicobacter pylori test-and-treat intervention compared to usual care in primary care patients with suspected peptic ulcer disease in the United States

OBJECTIVES

[corrected] The Helicobacter pylori (H. pylori) "test-and-treat" strategy in uninvestigated dyspepsia is an effective alternative to prompt endoscopy. Our aims were to determine whether the combination of an educational session and availability of office-based H. pylori testing (test-and-treat intervention [TTI]) increases use of the test-and-treat strategy by primary care practitioners and whether it improves patient outcomes.

METHODS

We conducted a 1-yr prospective trial of patients with suspected peptic ulcer disease in six primary care centers, three with TTI and three designated as usual care controls (UCC).

RESULTS

H. pylori testing was performed in 81% of 54 TTI patients and in 49% of 39 UCC patients (p = 0.004). TTI and UCC patients had similar gastroenterology referral rates (24% vs 33%, p = 0.33), endoscopy or upper GI radiography rates (30% vs 31%, p = 0.91), and primary care visits per patient (3.1 +/- 2.8 vs 3.1 +/- 2.6, p = 0.92). TTI patients were less likely than UCC patients to receive repeated antisecretory medication prescriptions (35% vs 66%, p = 0.003). Symptomatic status at 1 yr and satisfaction with medical care did not differ between groups. Median (and interquartile range) annualized disease-related expenditures per patient were $454 ($162-932) for TTI and $576 ($327-1,435) for UCC patients (p = 0.17).

CONCLUSIONS

The combination of an educational session and availability of office-based H. pylori testing may increase acceptance of the test-and-treat strategy by primary care providers. It remains to be determined whether increased use of the test-and-treat strategy yields significant improvements in clinical and economic outcomes compared to usual care.

Dyspepsia: management guidelines for the millennium

The annual prevalence of dyspepsia in Western countries is approximately 25%, and the condition accounts for 2-5% of all primary care consultations, yet optimal management remains a subject of considerable debate. Some of the outstanding issues and considerations in the management of dyspepsia are discussed, providing an overview of current thinking and recommendations on patient management by primary care physicians and specialists.

Fluctuation in dyspepsia subgroups over time. A three-year follow-up of patients consulting general practice for dyspepsia

BACKGROUND

General practitioners base their treatment and investigation on the symptoms presented by the patients. Subgroups of dyspepsia have been defined in order to guide management.

AIM

To study prospectively changes over time in the presentation of dyspepsia according to different subtypes in a general practitioner population.

SUBJECTS

Patients consulting the general practitioner because of dyspeptic complaints.

METHODS

A random sample of general practitioner patients consulting with different dyspepsia subtypes (ulcer-like, reflux-like, dysmotility-like, uncharacteristic and relapsing dyspepsia) were studied three years after the initial consultation by postal questionnaires to the general practitioners (obtaining information from the patient records) and to the patients (obtaining self-reported symptoms during twelve months). The subtype of dyspepsia at baseline was compared to the subtype in the patient questionnaire.

RESULTS

Between 20 and 34% of the patients reported no dyspepsia after three years, with so significant difference between the subtypes. Changes from one subtype to another were common, ulcer-like and reflux-like often changed into dysmotility-like dyspepsia. Dysmotility-like dyspepsia was significantly more stable over time. Patients with more than one episode of dyspepsia changed subtype significantly less.

CONCLUSIONS

Most patients who presented with dyspepsia to the general practitioner still reported symptoms three years later. Few patients with dysmotility-like dyspepsia changed subtype over time, whereas changes from one subtype to another were common in other subtypes. This implies that dyspeptic patients could end up having dysmotility-like complaints possibly due to the lack of effective treatment for this condition, compared to the other dyspepsia subtypes.

Prospective audit of gastroscopy under the 'three-day rule': a regional initiative in Italy to reduce waiting time for suspected malignancy

BACKGROUND

A regional initiative, called the 'three-day rule', has recently been introduced in Italy to facilitate the earlier diagnosis of malignancy. It requires patients with suspected severe diseases to have a diagnostic procedure performed within three working days of referral by a general practitioner.

AIM

To assess prospectively the effectiveness and compliance with the three-day rule for upper digestive malignancies.

METHODS

We compared patients referred for gastroscopy under the three-day rule initiative with contemporaneous open access referrals over a 12-month period at a single large teaching hospital in west Milan. We compared the prevalence of malignancies and other serious non-neoplastic diseases as well as the waiting times in the two groups. The appropriateness of the indications for each referral was also reviewed by a gastroenterologist blind to the outcome of the test.

RESULTS

One hundred and forty-two patients referred for gastroscopy under the three-day rule scheme and 767 routine referrals were studied. Significantly more oesophageal/gastric cancers (6% vs. 1%) and serious benign gastrointestinal lesions (grade II-III oesophagitis or peptic ulcer) were diagnosed in three-day rule patients in comparison with routine referrals (P < 0.05). The rate of inappropriate referral was significantly lower in the three-day rule group than in the open access group (39% vs. 22%) (P < 0.01). The estimated cost of the three-day rule scheme (in extra list examinations alone) was 10 780 euros, with about 1198 euros per diagnosis of cancer, but only 229.5 euros per 'useful' diagnosis (including peptic ulcer disease and oesophagitis).

CONCLUSIONS

Significantly more upper gastrointestinal cancers and serious benign diseases can be found within a short period to comply with the three-day rule scheme. However, some general practitioners appear to over-interpret alarm symptoms, leading to some inappropriate referrals. Better awareness of appropriate urgent referral criteria is needed in order to ensure that the best use is made of the resources available.

Appropriateness of upper gastrointestinal endoscopy: a hospital-based study

Aims of this study were to evaluate: (1) whether upper gastrointestinal endoscopy (UGE) is used appropriately according to the American Society for Gastrointestinal Endoscopy (ASGE) and British Society of Gastroenterology (BSG) guidelines in a hospital setting and (2) whether there is any relationship between appropriateness of UGE and the presence of lesions detected by endoscopy. Indications and endoscopic findings for 734 consecutive UGE performed in 697 inpatients were retrospectively evaluated using ASGE and BSG guidelines to determine appropriateness of referrals. UGE showing endoscopic findings that had direct therapeutic or prognostic consequences were classified as "positive"; the other UGEs were classified as "negative." In all, 46% of UGEs were "positive," 54% "negative," and 61.7% and 23.2% of UGEs were inappropriate according to ASGE and BSG guidelines, respectively (P < 0.001). The probability of finding a positive endoscopy was significantly higher in UGE rated as appropriate than in those rated as inappropriate on the basis of ASGE guidelines (P < 0.001), but not on the basis of BSG guidelines. Endoscopies rated as inappropriate according to ASGE and BSG criteria showed a positive finding in 37.3% and 42.3% of cases, respectively (not significant difference). Multivariate analysis showed that the positive finding is directly related to age (P < 0.05), male gender (P < 0.001), prior UGE (P < 0.05), hematemesis (P < 0.001), and inversely related with upper abdominal pain (P < 0.01) and dyspepsia (P < 0.05). In hospitalized patients, UGE is frequently used for inappropriate indications, according to both ASGE and BSG guidelines. However, the actual clinical usefulness of appropriateness criteria, such as those proposed by ASGE and BSG, is questionable, as their strict observance could lead to missing a large number of significant endoscopic findings.

Care of the elderly with gastrointestinal problems in family practice

Gastrointestinal problems in older people cause a great amount of anxiety, morbidity and mortality. In general these diseases present for the first time to family practitioners. The management of gastrointestinal problems is more difficult because in an older age group, functional diseases can present in the same way as organic diseases. In addition, family practitioners see a different kind of patient than speciality physicians and may not have immediate access to diagnostic investigations. In this chapter, the role of the family practitioner in screening for gastrointestinal problems in asymptomatic older people is explored. In addition, how they differentiate between organic and non-organic disease and refer appropriately to secondary care is discussed. The role of family practitioners in the on-going maintenance of gastrointestinal diseases and in the management of Helicobacter pylori in community dwelling older people is also considered.

Outcomes of initial noninvasive Helicobacter pylori testing in U.S. primary care patients with uninvestigated dyspepsia

OBJECTIVE

Recent European trials demonstrate that testing and treatment for Helicobacter pylori (H. pylori) is an effective alternative to prompt endoscopy in uninvestigated dyspepsia. The eventual endoscopy rate after H. pylori testing, which is a key determinant of cost-effectiveness, is unknown in the United States. Our aim was to determine the endoscopy rate after H. pylori testing in primary care practice in the United States and to compare outcomes among seropositive and seronegative patients.

METHODS

We performed a retrospective review with mean 13 month follow-up of primary care patients with dyspeptic symptoms tested with office-based H. pylori serology.

RESULTS

Of 268 adults tested (37+/-11 yr, 58% women), 57 (21%) were seropositive and 49/57 (86%) received eradication therapy. Endoscopy or contrast radiography was performed on 19% of seropositive and 19% of seronegative patients (p = 0.97). Annualized median disease-related expenditures were similar among seropositive and seronegative patients ($228 [$93-$654] vs $366 [$107-$1268], p = 0.19). However, aggregate expenditures were substantially lower than the cost of endoscopy alone ($816 [$296-$970]). On follow-up, seropositive and seronegative patients had similar numbers of primary care visits (2.9+/-3.2 vs 3.5+/-3.6, p = 0.23), prolonged antisecretory medication use (25 vs 33%, p = 0.27), and specialist referrals (23 vs 24%, p = 0.83).

CONCLUSION

In a United States center, 81% of primary care patients tested for H. pylori did not undergo endoscopy, and patients incurred significantly lower median expenditures after noninvasive H. pylori testing than the cost of endoscopy alone. Seropositive and seronegative patients experienced comparable outcomes after H. pylori testing.

Randomised controlled trial of Helicobacter pylori testing and endoscopy for dyspepsia in primary care

OBJECTIVE

To determine the cost effectiveness of a strategy of near patient Helicobacter pylori testing and endoscopy for managing dyspepsia.

DESIGN

Randomised controlled trial.

SETTING

31 UK primary care centres.

PARTICIPANTS

478 patients under 50 years old presenting with dyspepsia of longer than four weeks duration.

INTERVENTIONS

Near patient testing for H pylori and open access endoscopy for patients with positive results. Control patients received acid suppressing drugs or specialist referral at general practitioner's discretion.

MAIN OUTCOME MEASURES

Cost effectiveness based on improvement in symptoms and use of resources at 12 months; quality of life.

RESULTS

40% of the study group tested positive for H pylori. 45% of study patients had endoscopy compared with 25% of controls. More peptic ulcers were diagnosed in the study group (7.4% v 2.1%, P=0.011). Paired comparison of symptom scores and quality of life showed that all patients improved over time with no difference between study and control groups. No significant differences were observed in rates of prescribing, consultation, or referral. Costs were higher in the study group ( 367.85 pound sterling v 253.16 pound sterling per patient).

CONCLUSIONS

The test and endoscopy strategy increases endoscopy rates over usual practice in primary care. The additional cost is not offset by benefits in symptom relief or quality of life.

Accuracy of provisional diagnoses of dyspepsia in patients undergoing first endoscopy

BACKGROUND

This study assessed agreement between provisional and endoscopic diagnoses for patients with dyspepsia undergoing initial endoscopy, and examined variation between clinicians at 2 hospitals.

METHODS

This was a retrospective review of 423 consecutive patients.

RESULTS

Crude percentage agreement ranged from 55% to 97%. Kappa scores revealed poor agreement: peptic ulcers (0.11: 95% CI [0.05, 0.17]); gastroesophageal reflux disease (0.29: 95% CI [0.20, 0.38]); benign esophageal stricture (0.33: 95% CI [0.08, 0.58]); and cancer (0.12: 95% CI [-0.12, 0.36]). Positive and negative predictive values for cancer and benign esophageal stricture showed that agreement for a negative diagnosis was almost perfect, whereas agreement for a positive diagnosis was low. Only 17% of patients with cancer were given an accurate provisional diagnosis. Accuracy of diagnosis did not vary substantially between hospitals.

CONCLUSIONS

Crude percentage agreement is misleading. Emphasis should be placed on better prediction of cancer, benign esophageal stricture, and peptic ulcer disease. Accuracy of provisional diagnosis in everyday practice is no worse than that found in prospective studies in which clinicians knew a priori that diagnoses would be scrutinized. The difficulty of predicting diagnoses supports increased reliance on endoscopy.

Helicobacter pylori infection--current treatment practice

Helicobacter pylori infection, which is present in 30 - 60% of the population in developed countries and in more than 60% in developing countries, is established to be a major cause of gastritis, peptic ulcer disease and gastric cancer. Eradication therapy has been incorporated into clinical practice over the past 15 years. Treatment regimens include a 2 week bismuth-based triple therapy (a bismuth compound plus metronidazole, tetracycline or amoxycillin), a 1 week proton-pump inhibitor (PPI)-based triple therapy and a 1 week ranitidine bismuth citrate (RBC)-based triple therapy (a PPI or RBC plus any two of the three antibiotics, metronidazole, amoxycillin and clarithromycin). These regimens achieve eradication rates of >> 80%. H. pylori resistance to metronidazole and clarithromycin decreases the clinical efficacy of most regimens, despite the high eradication rates for resistant strains achieved by the RBC-triple therapy in some recent trials. The dose of antibiotics (especially clarithromycin) and the duration of treatment may also influence the eradication rate. Doctors' beliefs impact on clinical practice and, thus, influence the clinical application of eradication therapy. Whereas peptic ulcer disease and primary gastric low-grade B-cell mucosa-associated lymphoid tissue lymphoma (MALToma) have become established as definite indications for eradication therapy, there remain controversies surrounding non-ulcer dyspepsia, gastro-oesophageal reflux disease, atrophic gastritis, intestinal metaplasia, use of non-steroidal anti-inflammatory drugs (NSAIDs) and H. pylori-related extradigestive diseases.

Cost effectiveness of initial endoscopy for dyspepsia in patients over age 50 years: a randomised controlled trial in primary care

BACKGROUND

Dyspepsia can be managed by initial endoscopy and treatment based on endoscopic findings, or by empirical prescribing. We aimed to determine the cost effectiveness of initial endoscopy compared with usual management in patients with dyspepsia over age 50 years presenting to their primary care physician.

METHODS

422 patients were recruited and randomly assigned to initial endoscopy or usual management. Primary outcomes were effect of treatment on dyspepsia symptoms and cost effectiveness. Secondary outcomes were quality of life and patient satisfaction. Total costs were calculated from individual patient's use of resources with unit costs applied from national data. Statistical analysis of uncertainty on incremental cost-effectiveness ratio (ICER) was done along with a sensitivity analysis on unit costs with cost-effectiveness acceptability curves.

FINDINGS

In the 12 months following recruitment, 213 (84%) patients had an endoscopy compared with 75 (41%) controls. Initial endoscopy resulted in a significant improvement in symptom score (p=0.03), and quality of life pain dimension (p=0.03), and a 48% reduction in the use of proton pump inhibitors (p=0.005). The ICER was Pound Sterling1728 (UK Pound Sterling) per patient symptom-free at 12 months. The ICER was very sensitive to the cost of endoscopy, and could be reduced to Pound Sterling165 if the unit cost of this procedure fell from Pound Sterling246 to Pound Sterling100.

INTERPRETATION

Initial endoscopy in dyspeptic patients over age 50 might be a cost-effective intervention.

Helicobacter pylori test-and-eradicate versus prompt endoscopy for management of dyspeptic patients: a randomised trial

BACKGROUND

Strategies based on screening for Helicobacter pylori to manage dyspeptic patients in primary care have been proposed, but the clinical consequences are unclear. We did a randomised trial to assess the efficacy and safety of a test-and-eradicate strategy compared with prompt endoscopy in the management of patients with dyspepsia.

METHODS

500 patients presenting in primary care with dyspepsia (> or = 2 weeks of epigastric pain, no alarm symptoms) were assigned H. pylori testing plus eradication therapy or endoscopy. Symptoms, quality of life, patients' satisfaction, and use of resources were recorded during 1 year of follow-up.

FINDINGS

250 patients were assigned test-and-eradicate, and 250 prompt endoscopy. The median age was 45 years and 28% were H. pylori infected. 1 year follow-up was completed by 447 patients. We found no differences in symptoms between the two groups (median registered days without dyspeptic symptoms=0.63 [IQR 0.27-0.81] in the test-and-eradicate group vs 0.67 [0.36-0.86] in the prompt endoscopy group; mean difference 0.04 [95% CI -0.01-0.10], p=0.12). Nor did we find any difference in quality of life or numbers of sick-leave days, visits to general practitioners, or hospital admissions. In the test-and-eradicate group, 27 (12%) of the patients were dissatisfied with management, compared with eight (4%) in the endoscopy group (p=0.013). After 1 year, the use of endoscopies in the test-and-eradicate group was 0.40 times (95% CI 0.31-0.51) the use in the endoscopy group, the use of H. pylori tests increased by a factor of 8.1 (5.7-13.1), the use of eradication treatments increased by a factor of 1.5 (0.9-2.7), and the use of proton-pump inhibitors was 0.89 (0.59-1.33) times the use in the endoscopy group. 43 (91% [80-98%]) of 47 peptic-ulcer patients would have been identified by endoscopy or treated by eradication therapy.

INTERPRETATION

A H. pylori test-and-eradicate strategy is as efficient and safe as prompt endoscopy for management of dyspeptic patients in primary care, although fewer patients are satisfied with their treatment.

The ASGE guidelines for the appropriate use of colonoscopy in an open access system

BACKGROUND

Appropriateness of indications is essential to the rational utilization of resources. The aim of this study was to evaluate the appropriate use of colonoscopy in an open access system and to assess whether the American Society for Gastrointestinal Endoscopy (ASGE) guidelines are useful in clinical practice.

METHODS

The indication for colonoscopy was assessed on 3000 consecutive examinations performed at 7 institutions.

RESULTS

The rate of colonoscopies "generally not indicated" according to the ASGE guidelines was 24.5% for outpatients and 15.5% for inpatients; the rates of examinations performed for an indication not listed in the ASGE guidelines were 12% and 20.1%, respectively. Generally not indicated colonoscopies were significantly less frequent for procedures requested by gastroenterologists or family physicians than those requested by other specialists, but were similar. Most generally not indicated examinations requested by gastroenterologists were for routine follow-up of patients with inflammatory bowel disease; when these patients were excluded, the rate of generally not indicated endoscopies requested by gastroenterologists was also lower than the corresponding rate for examinations requested by family physicians.

CONCLUSIONS

In Italy, the rate of colonoscopies performed for generally not indicated reasons is high, particularly among examinations not requested by a gastroenterologist. Many colonoscopies are performed for indications not listed in the ASGE guidelines.

Can helicobacter pylori serology still be applied as a surrogate marker to identify peptic ulcer disease in dyspepsia?

BACKGROUND

Helicobacter pylori infection and associated peptic ulcer disease (PUD) has become less common in some countries.

AIM

To determine if H. pylori serology alone or combined with a history of ingestion of non-steroidal anti-inflammatory drugs (NSAIDs) and an age threshold can be used as an indirect ulcer test.

METHODS

Two hundred and fifty-two consecutive Australian patients (121 males, mean age 52 years) referred for endoscopy were enrolled. Blood was tested by a validated ELISA. At endoscopy, eight biopsies were taken for CLO-testing, culture and histology. NSAID use over the prior 3 months was recorded.

RESULTS

One hundred and six (42%) patients were seropositive for H. pylori, 48 (19%) patients had PUD and 30 (12%) used NSAIDs. Serology alone had a sensitivity of 52% and a specificity of 60% for identifying PUD; the sensitivity and specificity were 60% and 55%, respectively, when combined with a history of NSAID use. Serology, regardless of NSAID use, would have saved 23% in endoscopy workload but would have missed 17% of PUD cases if an age threshold of < 45 years was chosen for omitting endoscopy.

CONCLUSIONS

Serology was a poor ulcer test despite an excellent performance for detecting H. pylori. A strategy combining serology and an age threshold with a history of NSAID use to reduce endoscopy workloads may not always be appropriate.

Detection of upper gastrointestinal cancer in patients taking antisecretory therapy prior to gastroscopy

BACKGROUND

The incidence of early gastric cancer has not increased despite better access to endoscopic facilities for general practitioners. Many patients receive a course of symptomatic treatment while waiting for gastroscopy.

AIMS

To ascertain the effect of antisecretory therapy on the diagnostic process and findings for patients with upper gastrointestinal cancer.

METHODS

A consecutive case study survey of the primary care records of 133 patients who had died of upper gastrointestinal cancer during 1995-97 in the South Tees health district in the north-east of England (population 300 000).

RESULTS

From the 133 patients identified, 116 had died from adenocarcinoma of the oesophagus (31) or stomach (85). Failure to reach the diagnosis of cancer at the index gastroscopy was associated with prior acid suppression therapy. Only one of 54 patients on no treatment or antacids alone was erroneously diagnosed as suffering from benign disease, whereas 22 of 62 patients treated with acid suppression were diagnosed as suffering from benign disease but at varying times later turned out to have adenocarcinoma. Twenty of 45 patients taking a proton pump inhibitor had a delayed diagnosis compared with two of 17 taking an H(2) receptor antagonist. The commonest lesion seen at index gastroscopy in those in whom the diagnosis was initially missed was gastric ulcer. Healing occurred in six patients taking a proton pump inhibitor, despite their later diagnosis of malignancy.

CONCLUSIONS

The treatment of dyspeptic symptoms with acid suppression prior to gastroscopy masks and delays the detection of gastric and oesophageal adenocarcinoma on endoscopy in one third of patients.

Response to open access endoscopy findings by general practitioners guidelines need education for implementation

General practitioners may gain valuable information from the use of open access endoscopy. The benefit to the individual patient depends on the interpretation of the endoscopy findings and the subsequent action. The aim of the study was to determine GPs response to open access endoscopy findings of three conditions with possible malignant complications: Barrett's oesophagus, gastric ulcer and colonic adenomatous polyps. The study took place at Ninewells Hospital, Dundee. Using the endoscopy unit's records for the year, 1 January 1995 to 31 December 1995, all patients having had an open access upper gastro-intestinal endoscopy or sigmoidoscopy were identified. Case-notes were reviewed of patients who had Barrett's oesophagus, gastric ulcer or colonic polyps diagnosed. During the year, 1158 upper gastro-intestinal endoscopies and 293 sigmoidoscopies were performed by the open access service. The referral rates for the conditions were as follows: Barrett's oesophagus 56%; Gastric ulcers 56%; Adenomatous polyps 88%; Non adenomatous polyps 12.5%. The provision of guidelines does not ensure a high referral rate, education is a vital partner.

Gastric cancer in patients under the age of 30

A26-year-old white male presented to surgical outpatients with an 18-month history of epigastric pain relieved by food and oral ranitidine. Gastroscopy showed a chronic gastric ulcer in the mid-body on the lesser curve. Biopsies were of an inflammatory cell infiltration with no evidence of malignancy. Helicobacter culture was negative and the patient was commenced on omeprazole 40 mg once daily. Repeat gastroscopy 6 weeks later showed a persistent non-healed gastric ulcer. Empirically the patient was given a course of quadruple Helicobacter eradication therapy. His symptoms, however, persisted. Two months later, a further endoscopy with biopsies confirmed the diagnosis of a poorly differentiated adenocarcinoma of the stomach. He subsequently underwent total gastrectomy with splenectomy and distal pancreatectomy. Histology showed a 1.5 cm intramucosal signet ring adenocarcinoma with all resected nodes negative. He remains well 5 years following surgery.

High sensitivity and specificity of a laboratory-based serological test, pylori DTect ELISA, for detection of Helicobacter pylori infection

A number of commercial ELISA kits are now available for detection of Helicobacter pylori infection. Generally, whereas the manufacturers have claimed high sensitivity and specificity, independent studies have often failed to confirm the results. The aim of this study was to independently evaluate the pylori DTect ELISA, a commercial kit for detection of H. pylori infection, in Australian patients with dyspepsia and reflux symptoms. Two hundred and nine consecutive patients (102 males and 107 females, mean age 52.8 years) who were referred for endoscopy due to upper gastrointestinal symptoms, but had not received anti-H. pylori therapy were enrolled. A 10 mL blood sample was obtained from each subject and used to evaluate the kit. The absorbance index (AI) was calculated from the mean of two readings of optical density (OD) of each serum sample. Eight biopsies from the gastric antrum (x3), body (x2), fundus (x2), and incisura (x1) were obtained from each patient for CLO-testing (x1), culture (x3), and histological examination (x4) for H. pylori. Overall, 84 (40.2%) patients were infected with H. pylori as determined by the biopsy-based "gold standard." The AIs ranged from 0 to 1.86; 0.12 to 1.86 in H. pylori positive patients and 0 to 1.49 in negative patients. The pylori DTect ELISA obtained an accuracy of 94 to 95% under AI ranges between 0.20 to 0.40, with the highest accuracy being 95% under AIs of 0.25 and 0.35. An AI of 0.25 was recommended as the best cut-off AI, with a sensitivity of 96.4%, specificity of 93.6%, positive predictive value of 91% and negative predictive value of 97.5%. It is concluded that the pylori DTect ELISA is accurate for detecting H. pylori infection in patients with dyspepsia and reflux symptoms in Australia, when an AI of 0.25 is taken as the cut-off value.

[Analysis of indications and diagnosis of the gastroscopies requested by primary care physicians]

OBJECTIVES

To analyse the pathology diagnosed on the basis of the gastroscopies requested from a primary care centre (PCC). Assessment and treatment of Helicobacter pylori (HP) infection.

DESIGN

Retrospective and descriptive.

SETTING

Urban PCC.

PATIENTS

Those over 14 who had a gastroscopy for a diagnostic purpose, requested by their primary care doctor during 1997.

MEASUREMENTS

Review of clinical records and gastroscopy reports analysing: personal data, reasons for request, prior treatment, diagnoses, treatment to eradicate HP, later referral to the digestion specialist and waiting-time for the gastroscopy.

RESULTS

206 gastroscopies were performed, 139 for epigastralgia (67%) and 73 for heartburn (35%). 161 patients (78%) had had previous treatment, with alkalines used in 94 cases (45%). The most common diagnoses were: 54 normal (26%), 60 hiatus hernias (30%), 43 oesophagitis (21%), 18 duodenal ulcers (9%) and 4 gastric ulcers (2%). The Helicobacter pylori study was positive in 67 cases, with triple treatment (amoxycillin, clarithromycin and omeprazole) to eradicate it given for 7 days in 36 cases (54%). Referral to the specialist of 3% of the patients. Waiting-time for the performance of the gastroscopy: 60 days (SD: 35).

CONCLUSIONS

Gastroscopy is a diagnostic method habitually used in our PCC. The pathology diagnosed is mainly treated in primary care. Given the current controversy about actions at determined clinical entities, standardisation of criteria used by professionals at different care levels is very important. This standardisation should affect the indications of the examinations, and the treatment and follow-up of the pathologies. The reduction in waiting-time for a gastroscopy could possibly modify the prescription and duration of the prior treatment.

Diagnostic yield of gastroscopy in a general surgical unit

Gastroscopy is the gold standard for investigating upper gastrointestinal complaints. Open access gastroscopy has advantages, but may not always be feasible in a small unit. Our 2-consultant general surgical unit provides gastroscopy on demand for medical and surgical patients. We audited the 499 gastroscopies carried out in our unit in 1997 to assess yield and diagnostic trends. The overall diagnostic yield of 69 per cent was comparable with published data from centres in Ireland and overseas. Diagnostic yield in our series was significantly lower for medical patients (59 per cent) than for surgical patients (72 per cent) (p < 0.05). Yield also varied considerably according to indication for referral. Patients referred with anaemia had a low yield (41 per cent). The indications associated with high yields were haematemesis (95 per cent), dysphagia (91 per cent), and persistent vomiting (85 per cent).

Decision analysis of histamine H2-receptor antagonist maintenance therapy versus Helicobacter pylori eradication therapy: a randomised controlled trial in patients with continuing pain after duodenal ulcer

BACKGROUND

Much has been published on the efficacy and cost effectiveness of Helicobacter pylori eradication treatment as an alternative to histamine H2-receptor antagonist maintenance treatment in peptic ulcer disease. However, most studies have analysed and emphasised H. pylori eradication rates rather than management/control of symptoms and the associated cost savings. Although H. pylori eradication therapy is very successful in clearing the infection, dyspeptic symptoms may persist and management of these can be expensive.

OBJECTIVE

The aim of this study was to assess the cost implications in controlling symptoms using either H2-receptor antagonist maintenance therapy or H. pylori eradication therapy in patients with duodenal ulcer disease.

DESIGN

This was a non-blind, prospective, randomised, parallel-group study comparing maintenance H2-receptor antagonist treatment using ranitidine with H. pylori eradication therapy, with a 1-year follow-up.

SETTING

This was a study of outpatients from general practices in Dundee, Scotland, or the Ninewells Hospital, Dundee, gastroenterology clinic.

PATIENTS AND PARTICIPANTS

119 patients with confirmed duodenal ulcer, free from active ulceration at study entry but positive for H. pylori infection, who were receiving maintenance H2-receptor antagonist therapy.

INTERVENTIONS

Patients were randomised to receive either continuing maintenance therapy with ranitidine (initially 150 mg daily; 58 patients) or H. pylori eradication therapy using an omeprazole/amoxicillin/metronidazole regimen (or omeprazole/clarithromycin if allergic to penicillin).

MAIN OUTCOME MEASURES AND RESULTS

Overall, H. pylori eradication rates were 100% per protocol and 95.1% intention-to-treat. At completion of 1 year of follow-up, 12 of the 61 (19.7%) patients successfully eradicated of H. pylori were still dependent on acid suppression for symptom relief. H. pylori eradication treatment was the least-cost strategy in managing/controlling symptoms at 1 year (168 Pounds vs 210 Pounds per patient; 1996 values). However, over time, post-eradication treatment costs were greater than H2-receptor antagonist therapy costs. Any potential savings were directly related to the proportion of patients needing further treatment post-eradication, the cost of endoscopy and the urea breath test.

CONCLUSIONS

If dyspepsia persists long term, H. pylori eradication treatment may not be the least-cost option for patients with duodenal ulcer.

Management of uninvestigated and functional dyspepsia: a Working Party report for the World Congresses of Gastroenterology 1998

BACKGROUND

The management of dyspepsia is controversial.

METHODS

An international Working Party was convened in 1998 to review management strategies for dyspepsia and functional dyspepsia, based on a review of the literature and best clinical practice.

RESULTS

Dyspepsia, defined as pain or discomfort centred in the upper abdomen, can be managed with reassurance and over-the-counter therapy if its duration is less than 4 weeks on initial presentation. For patients with chronic symptoms, clinical evaluation depends on alarm features including patient age. The age cut off selected should depend on the age specific incidence when gastric cancer begins to increase, but in Western nations 50 years is generally an acceptable age threshold. In younger patients without alarm features, Helicobacter pylori test and treatment is the approach recommended because of its value in eliminating the peptic ulcer disease diathesis. If, after eradication of H. pylori, symptoms either are not relieved or rapidly recur, then an empirical trial of therapy is recommended. Similarly, in H. pylori-negative patients without alarm features, an empirical trial (with antisecretory or prokinetic therapy depending on the predominant symptom) for up to 8 weeks is recommended. If drugs fail, endoscopy should be considered because of its reassurance value although the yield will be low. In older patients or those with alarm features, prompt endoscopy is recommended. If endoscopy is non-diagnostic, gastric biopsies are recommended to document H. pylori status unless already known. While treatment of H. pylori is unlikely to relieve the symptoms of functional dyspepsia, the long-term benefits probably outweigh the risks and treatment can be considered on a case-by-case basis. In H. pylori-negative patients with documented functional dyspepsia, antisecretory or prokinetic therapy, depending on the predominant symptom, is reasonable, assuming reassurance and explanation are insufficient, unless patients have already failed this approach. Other treatment options include antidepressants, antispasmodics, visceral analgesics such as serotonin type 3 receptor antagonists, and behavioural or psychotherapy although these are all of uncertain efficacy. Long-term drug treatment in functional dyspepsia should be avoided; intermittent short courses of treatment as needed is preferred.

CONCLUSION

The management of dyspepsia recommended is based on current best evidence but must be tailored to local factors such as practice setting, the background prevalence of H. pylori and structural disease, and costs.