Helicobacter pylori Infection Status and Gastric Tumor Incidence According to the Year of Birth

Background/Aims

: The prevalence of Helicobacter pylori-naive status is increasing. Nonetheless, biennial gastroscopy is recommended for all Koreans aged 40 to 75 years. This study aimed to determine whether gastric cancer screening guidelines could be changed according to H. pylori infection status and year of birth.

Methods

: Koreans who underwent serum assays and gastroscopy for gastric cancer screening between 2010 and 2016 were included if screening tests were followed up for ≥3 times. H. pylori infection was confirmed when invasive tests or 13C-urea breath tests were positive. In the case of negative test findings, eradication history, serologically detected atrophy, and intestinal metaplasia/atrophy were checked for past infection. If all were absent, H. pylori-naive status was confirmed.

Results

: Two-thousand and two (256 H. pylori-naive, 743 past-infected, and 1,003 infected) Koreans underwent screening tests for 95.5±28.4 months. The mean year of birth in the naive group (1969±7) differed from those of the past-infected (1957±10, p<0.001) and infected (1958±10, p<0.001) groups. H. pylori-naive status was correlated with recent year of birth (r=0.368, p<0.001). No gastric tumors were observed among the naive participants (p=0.007), whereas 23 adenomas, 18 adenocarcinomas, and two neuroendocrine tumors were detected in 1.9% (14/743) of past-infected and 2.5% (25/1,003) of infected participants, including four infected participants with metachronous tumors.

Conclusions

: The prevalence of H. pylori-naive status is increasing in young Koreans, and gastric tumors are rare in this population. Hence, biennial gastroscopy could be waived after the confirmation of naive status.

Barriers to upper gastrointestinal screening among the general population in high-prevalence areas: a cross-sectional study

BACKGROUND

In China, there are large differences between regions in the use of gastroscopies and public awareness of upper gastrointestinal (UGI) screening.

OBJECTIVE

This study investigated the current context and analyzed the barriers that influence UGI screening behavior among the general population in UGI cancer high-prevalence areas.

METHODS

A total of 320 participants anonymously answered an online questionnaire. The rank sum test was used to analyze the difference in the scores of the UGI screening awareness questionnaire among participants with different socio-demographic characteristics. Using the awareness level of UGI screening and gastroscopy as the dependent variable, and the socio-demographic characteristics as the independent variable, simple linear regression and binary logistic regression analysis were used to determine the factors influencing attitudes toward gastroscopy screening. We used Spearman's correlation analysis to examine the correlation between UGI screening awareness level and willingness to undergo a gastroscopy.

RESULTS

There was a correlation between the willingness to undergo gastroscopy and the awareness level of UGI screening (r = 0.243, p < 0.001). Linear regression analysis found that age, type of residence, education level, employment status, monthly income, history of gastroscopy, dietary habits, physical exercise, and convenience in obtaining information were significantly correlated with the awareness level of UGI screening ( p < 0.05). Binary logistic regression analysis found that factors significantly associated with gastric cancer screening behavior include residence, monthly income, and self-perceived health status ( p  < 0.05).

CONCLUSION

It is necessary to improve education about UGI cancer and screening knowledge, with a focus on populations with lower education and income.

Management of magnetic foreign body ingestion in children

Magnetic foreign bodies ingestion is a special cause for attending emergency department. Here, we aim to analyze the characteristics and treatments of children who ingested magnetic foreign bodies (Buckyballs). Data were collected from children who ingested Buckyballs between February 2017 and October 2019. A retrospective analysis was performed to summarize the experiences of conservative treatment, gastroscopy and surgery when dealing with Buckyballs ingestion.A total of 49 patients with buckyballs ingestion were identified, of whom 11 underwent conservative treatments, 6 underwent gastroscopy, and 32 underwent surgery. Among such individuals, eight patients (72.7%) had a successful conservative treatment (number of Buckyballs [NB]: 3.5[IQR: 2.0-4.0]); four patients (66.7%) had Buckyballs successfully removed by gastroscopy (NB: 3.5[IQR: 3.0-5.5]); 16 asymptomatic (50%) patients (NB: 4.0[IQR: 3.0-8.0]) and 16 symptomatic (50%) patients (NB: 8.5 [IQR: 6.25-11.75]) received emergency surgery. Compared to patients who received conservative treatment, the number of ingested Buckyballs was significantly higher in patients who received surgery or gastroscopy (7.0 [IQR: 3.0-10.75] vs 3.5 [IQR: 2.0-4.0], P < .05). The risk of intestinal perforation was significantly higher in symptomatic patients (P < .05) compared to asymptomatic patients.Gastroscopy is recommended when Buckyballs are in the stomach or esophagus. In asymptomatic patients, conservative treatment can be considered for 4 to 6 days. Patients failing conservative treatment, or those who are symptomatic should undergo emergency surgery.

Salicylate use: a negative predictive factor for finding pathology explanatory for iron deficiency anaemia

PURPOSE

To determine whether the use of salicylates is a predictive factor for detecting explanatory pathology during gastroscopy or colonoscopy procedures in patients with iron deficiency anaemia (IDA).

METHODS

This retrospective study included patients who underwent a gastroscopy and/or a colonoscopyto determine the cause of IDA at Treant Healthcare, hospital location Scheper in Emmen, the Netherlands, between 2010 and 2016. The study compared two groups. The first group consisted of patients who were not taking antithrombotics at the time of, and during the last six months prior to, the endoscopy. The second group consisted of patients who used salicylates at the time of, and during the last six months prior, to the endoscopy. Data were collected on whether and which explanatory pathology was found in the endoscopic evaluation.

RESULTS

In total, 464 patients were included, of whom, 174 were using a salicylate and 290 were not. In 41.2% of the patients, explanatory pathology was found, which was not significantly different between the two groups with univariate analysis (p = 0.207). However, the patients in the group of salicylate users were significantly older and more often male. When correcting for these differences in group characteristics during multivariate analysis, the use of salicylates was found to be a negative predictive factor for finding explanatory pathology (p < 0.001; OR 2.307).

CONCLUSION

When determining the chance of finding explanatory pathology during endoscopic evaluation in patients with IDA, the use of salicylates should be taken into account as a negative predictive factor for finding explanatory pathology during endoscopic evaluation.

Clinicopathological features of early gastric cancers arising in Helicobacter pylori uninfected patients

BACKGROUND

Persistent Helicobacter pylori (H. pylori) infection causes chronic inflammation, atrophy of the gastric mucosa, and a high risk of developing gastric cancer. In recent years, awareness of eradication therapy has increased in Japan. As H. pylori infections decrease, the proportion of gastric cancers arising from H. pylori uninfected gastric mucosa will increase. The emergence of gastric cancer arising in H. pylori uninfected patients though rarely reported, is a concern to be addressed and needs elucidation of its clinicopathological features.

AIM

To evaluate the clinicopathological features of early gastric cancer in H. pylori-uninfected patients.

METHODS

A total of 2462 patients with 3375 instances of early gastric cancers that were treated by endoscopic submucosal dissection were enrolled in our study between May 2000 and September 2019. Of these, 30 lesions in 30 patients were diagnosed as H. pylori-uninfected gastric cancer (HpUIGC). We defined a patient as H. pylori-uninfected using the following three criteria: (1) The patient did not receive treatment for H. pylori, which was determined by investigating medical records and conducting patient interviews; (2) Lack of endoscopic atrophy; and (3) The patient was negative for H. pylori after being tested at least twice using various diagnostic methods, including serum anti-H. pylori-IgG antibody, urease breath test, rapid urease test, and microscopic examination.

RESULTS

The frequency of HpUIGC was 1.2% (30/2462) for the patients in our study. The study included 19 males and 11 females with a mean age of 59 years. The location of the stomach lesions was divided into three sections; upper third (U), middle third (M), lower third (L). Of the 30 lesions, 15 were U, 1 was M, and 14 were L. Morphologically, 17 lesions were protruded and flat elevated type (0-I, 0-IIa, 0-IIa + IIc), and 13 lesions were flat and depressed type (0-IIb, 0-IIc). The median tumor diameter was 8 mm (range 2-98 mm). Histological analysis revealed that 22 lesions (73.3%) were differentiated type.The HpUIGC lesions were classified into fundic gland type adenocarcinoma (7 cases), foveolar type well-differentiated adenocarcinoma (8 cases), intestinal phenotype adenocarcinoma (7 cases), and pure signet-ring cell carcinoma (8 cases). Among 30 HpUIGCs, 24 lesions (80%) were limited to the mucosa; wherein, the remaining 6 lesions showed submucosal invasion. One of the submucosal invasive lesions showed more than 500 μm invasion. The mucin phenotype analysis identified 7 HpUIGC with intestinal phenotype and 23 with gastric phenotype.

CONCLUSION

We elucidated the clinicopathological characteristics of HpUIGC, revealing recognition not only undifferentiated-type but also differentiated-type. In addition, intestinal phenotype tumors were also observed and could be an important tip.

Safety and effectiveness of endoscopic mucosal resection or endoscopic submucosal dissection for gastric neoplasia within 2 days' hospital stay

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) have been well-established methods of treating upper gastrointestinal neoplasia. The aim of this study was to identify the safety and effectiveness of endoscopic treatment for gastric neoplasia within a 2-day hospital stay.Between 2004 and 2015, a total of 914 patients with gastric neoplasia were treated with EMR or ESD within 2 days of hospitalization. The neoplasia sites, en bloc resection rates, pathology, local residual neoplasia rates, and major complications were evaluated retrospectively.The mean age was 63.4 years old, and 636 (69.6%) patients were male. Adenoma was the most common final diagnosis (60.9%), followed by adenocarcinoma (28.9%). The first follow-up endoscopy was performed 4.9 ± 1.1 months after the procedure, and an average of 4.4 endoscopic examinations were performed for 7.16 years (range, 2.1 to 10.2 years). Additional surgery was performed in 11 (1.2%) cases based on post-procedure pathology results. On follow-up endoscopy, a mean of 5.9 months after the procedure, there were 18 residual neoplasia cases (EMR = 13, ESD = 5). Only 4 (0.4%) patients returned to the emergency unit with delayed bleeding, but all 4 cases were successfully controlled with endoscopic treatment. There were no other complications such as delayed perforation or aspiration pneumonia during the 2 days in hospital.EMR and ESD within only 2 days in hospital showed safe and effective outcomes in terms of managing early gastric neoplasia with low complication and local residual rates.

Endoscopic and Histological Findings among Israeli Populations Infected with Helicobacter pylori: Does Ethnicity Matter?

BACKGROUND

The prevalence of Helicobacter pylori varies geographically by age, race, and socioeconomic status (SES). However, the impact of ethnicity on endoscopic outcomes in infected individuals is not well known.

OBJECTIVES

To assess the impact of ethnicity among Israelis with biopsy-proven H. pylori infection.

METHODS

A retrospective study, including patients who underwent gastroscopy and were diagnosed histologically with H. pylori infection, was conducted. Information on demographics, SES, medications, and co-morbidities were extracted from medical records. Univariate (Student's t-test, chi-square test) and multivariate (multinomial and logistic) regression analysis were conducted to examine the predictors of the clinical outcome.

RESULTS

The study included 100 Israeli Jews and 100 Israeli Arabs diagnosed with biopsy-proven H. pylori infection. At univariate analysis, the number of households was higher among Arabs (P < 0.001), whose family income and parental education were lower than among Jews (P < 0.001 for both variables). The response to amoxicillin and clarithromycin differed between the two groups, being higher among Jews (P < 0.001).In clinical outcomes (gastritis severity, gastric and duodenal ulcer, intestinal metaplasia, atrophic gastritis, and MALT), no statistically significant differences could be detected between Jews and Arabs. Concerning intestinal metaplasia, lack of consumption of nonsteroidal anti-inflammatory drugs resulted a statistically significant protective factor (odds ratio 0.128, 95% confidence interval 0.024-0.685, P = 0.016).

CONCLUSIONS

Although in the literature ethnicity seems to be a risk factor for H. pylori colonization, no statistical significance was detected in various endoscopic and histological findings related to H. Pylori infection between Israeli Arabs and Jews.

Earlier tracheostomy and percutaneous endoscopic gastrostomy in patients with hemorrhagic stroke: associated factors and effects on hospitalization

OBJECTIVE

Existing literature supports benefits of early tracheostomy and percutaneous endoscopic gastrostomy (PEG) in certain patient populations. The aim of this study was to review tracheostomy and PEG placement data in patients with hemorrhagic stroke in order to identify factors associated with earlier placement and to evaluate outcomes.

METHODS

The authors performed a retrospective review of consecutive patients treated for hemorrhagic stroke between June 1, 2011, and June 1, 2015. Data were analyzed by logistic and multiple linear regression.

RESULTS

Of 240 patients diagnosed with hemorrhagic stroke, 31.25% underwent tracheostomy and 35.83% underwent PEG tube placement. Factors significantly associated with tracheostomy and PEG included the presence of pneumonia on admission and subarachnoid hemorrhage. Earlier tracheostomy was significantly associated with shorter ICU length of stay; earlier tracheostomy and PEG placement were associated with shorter overall hospitalization. Timing of tracheostomy and PEG was not significantly associated with patient survival or the incidence of complications in this population.

CONCLUSIONS

This study identified patient risk factors associated with increased likelihood of tracheostomy and PEG in patients with hemorrhagic stroke who were critically ill. Additionally, we found that the timing of tracheostomy was associated with length of ICU stay and overall hospital stay, and that the timing of PEG was associated with overall length of hospitalization. Complication rates related to tracheostomy and PEG in this population were minimal. This retrospective data set supports some benefit to earlier tracheostomy and PEG placement in this population and justifies the need for further prospective study.

Peroral endoscopic cardial constriction in gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is a major digestive health problem with a high and increasing incidence worldwide. Peroral endoscopic cardial constriction (PECC) was developed by our group to provide a less invasive treatment for GERD.In this preliminary follow-up study, 16 patients were enrolled and 13 patients with GERD were targeted for analysis according to the Los Angeles classification of reflux esophagitis. The GERD health-related quality of life (GERD-HRQL) scale and esophageal pH monitoring were applied to assess clinical efficiency at 3 and 6 months after PECC treatment, respectively.All GERD patients successively received PECC, and no severe treatment-related complication was reported. Before PECC treatment, the GERD-HRQL scale was 19.92 ± 7.89. At 3 and 6 months after treatment, the GERD-HRQL scale was 4.46 ± 4.31 and 5.69 ± 5.07, respectively. DeMeester score was 125.50 ± 89.64 before PECC treatment, and 16.97 ± 12.76 and 20.32 ± 15.22 at 3 and 6 months after PECC treatment. Furthermore, the fraction time of a pH below 4 significantly decreased at 3 and 6 months after PECC treatment. Fraction time at pH <4 was 35.55 ± 26.20 before PECC treatment and 7.96 ± 13.03 and 4.72 ± 3.78 at 3 and 6 months after PECC treatment, respectively. These results suggest that PECC treatment could significantly reduce the GERD-HRQL scale and DeMeester score (P < .01).PECC is a feasible, safe, and effective method to treatment GERD through narrowing the diameter of the cardia and preventing the reflux of stomach contents.

Is preoperative gastroscopy necessary before sleeve gastrectomy and Roux-en-Y gastric bypass?

BACKGROUND

Consensus on the necessity of esophagogastroduodenoscopy (EGD) before bariatric surgery is lacking. Recommendations and practices vary by country and unit. Several reports have expressed concerns on gastroesophageal reflux disease (GERD) and its consequences after sleeve gastrectomy (SG) and the risk of leaving a premalignant lesion in the excluded stomach after Roux-en-Y gastric bypass (RYGB).

OBJECTIVES

We explored the number and types of clinically significant findings in preoperative EGDs and how they associate with preexisting GERD-symptoms (SG) and premalignant lesions (RYGB). We also studied how many reoperations were performed due to postoperative GERD in SG-patients.

SETTING

University hospital.

METHODS

We investigated preoperative EGD-findings and gastrointestinal symptoms before bariatric surgery in all patients with a primary bariatric operation in our unit between December 2007 and May 2016.

RESULTS

We performed 1474 operations: 1047 (71.0%) RYGB, 407 (27.6%) SG, and 20 (1.4%) others. One thousand two hundred seventy-five (86.5%) preoperative EGD reports were analyzed: 647 (50.7%) EGDs were completely normal. Altogether, 294 patients (23.0% of total) had a clinically significant finding that was relevant for SG (hiatal hernia, esophagitis, Barrett's esophagus, esophageal dysplasia), 144 (49.0%) of whom reported gastrointestinal symptoms. Twenty patients (1.6%) had a significant finding relevant for RYGB (peptic ulcer, atrophic gastritis, gastrointestinal stromal tumor), and 6 (30%) reported gastrointestinal symptoms. Thirteen (3.2%) SGs were converted into RYGB due to GERD.

CONCLUSIONS

Preoperative EGD is indicated before SG but not before RYGB for asymptomatic patients without a risk for gastric pathology.

Histopathological pattern of benign endoscopic gastric biopsies in Western Saudi Arabia: A review of 1236 cases

OBJECTIVE

To determine the histopathological pattern of gastritis and benign gastric diseases in western Saudi Arabia.

METHODS

TThis retrospective histopathology-based study was conducted in a tertiary care hospital in Madinah, Saudi Arabia, and comprised medical records of all patients who were diagnosed to have benign gastric diseases from January 2006 to December 2015.SPSS 19 was used for data analysis.

RESULTS

Of the 1,236 patients, 669(54.1%) were males and 567(45.9%)were females. The overall mean age was 43±10.75 years (range: 10-100 years). Besides, 755(61.1%) patients were in the age group of 20-49 years. Gastritis was diagnosed in 1,105(89.4%) cases, 1,091(88.3%) of which were chronic. Benign polypi was found in 34(2.75%) cases and normal biopsies in 97(7.85%) cases. Helicobacter pylori organisms were detected in 402(32.5%) cases. Helicobacter pylori gastritis was active in 331(82.5%) cases, atrophic in 4(0.9%) and metaplastic in 11(2.7%) cases. The mean age of gastric polypi patients was 50.1±12.52 years (range: 16-90 years). Hyperplastic polypi was seen in 30(88.2%) cases. Fundic gland polypi were found in 4(11.8%) cases.

CONCLUSIONS

Benign gastric diseases appeared to affect the younger individuals. Gastritis was more prevalent and benign polypi was less so.

Endoscopic Resection for Undifferentiated-Type Early Gastric Cancer: Immediate Endoscopic Outcomes and Long-Term Survivals

BACKGROUND

Endoscopic resection (ER) is considered carefully as a curative treatment option for selected cases of undifferentiated-type early gastric cancer (UEGC). This study investigated immediate endoscopic and long-term survival outcomes of patients with UEGC treated with ER.

METHODS

A review of a database of 2483 EGC consecutively enrolled patients who underwent ER between January 2004 and December 2010 identified 101 patients with UEGC who met the expanded indications. Outcomes were investigated in these patients.

RESULTS

The rates of R0 en bloc and curative resection were 86 and 70 %, respectively. Of 30 tumors non-curatively resected, 17 were larger than 20 mm in diameter, 12 had positive resection margins, and 13 had submucosal or lymphovascular invasion on resection pathology. ER-related complications occurred in 12 patients (12 %), with all complications treated endoscopically without surgery. The median ER procedure time was 26 min [interquartile range (IQR) 20-39 min]. Only tumor location in the lower part of the stomach was significantly associated with curative ER (P = 0.038). Tumor recurrence was observed in seven patients at a median 17 months (IQR 12-47 months) after ER. During a median follow-up of 60 months (IQR 48-80 months), the 5-year overall mortality rates were 5 % in the curative and 4 % in the non-curative resection groups (P = 0.927). There were no gastric cancer-related deaths.

CONCLUSIONS

ER shows acceptable immediate endoscopic and long-term survival outcomes in selected patients with UEGC.

Clinical management of patients with gastric neuroendocrine neoplasms associated with chronic atrophic gastritis: a retrospective, multicentre study

To provide data regarding clinical presentation, pathological features, management, and response to different treatments of patients with type I gastric neuroendocrine tumors in stages 0-2A. The study design consist of an Italian multicentre, retrospective analysis of patients with type I gastric neuroendocrine tumors managed with different therapeutic approaches: surgery, endoscopic surveillance, endoscopic resection, or somatostatin analog therapy. Among the 97 patients included, 3 underwent surgery, 45 (46.4%) radical endoscopic resection of the neoplastic lesions, 13 (13.4%) follow-up with upper endoscopy, and 36 (37.1%) somatostatin analog therapy. At the end of the follow-up, all patients were alive and there was no evidence of metastatic disease. Somatostatin analog therapy resulted in a complete response in 76.0% of the patients and stable disease in 24.0%. A prolonged period of therapy, the use of a full dose of somatostatin analogs and higher gastrin levels at diagnosis were related to a complete response to the therapy. The recurrence rate was 26.3% in patients treated with somatostatin analog therapy and 26.2% in patients treated with endoscopic resection, without a statistically significant difference in terms of disease-free survival. Regarding recurrence of the disease, no statistical difference was found according to type of therapy, number of neoplastic lesions, and 2010 WHO classification. The only risk factor for tumor recurrence was a short period of medical treatment. In conclusion, our study suggested that endoscopic surveillance, endoscopic resection and somatostatin analog therapy represent valid options in the management of patients with type I gastric neuroendocrine tumors in stages 0-2A.

Endoscopic Resection Versus Surgical Resection for Early Gastric Cancer: A Systematic Review and Meta-Analysis

Endoscopic resection (ER) has been widely accepted to treat early gastric cancer (EGC) in place of surgical resection (SR). The aim of this meta-analysis was to conduct a comprehensive comparison between the two methods.Four literature databases, including PubMed, Web of Science, the Cochrane Library, and EMBASE, were searched for studies that compared ER with SR to treat EGC. In this meta-analysis, primary and secondary endpoints were compared between the two groups. Primary endpoints included overall survival (OS), disease-specific survival (DSS), disease-free survival (DFS), and recurrence-free survival (RFS). Secondary endpoints included operation-related death, local recurrence, metachronous lesions, procedure-related complication, bleeding, hospital stay, operation time, and cost.Nineteen studies consisting of a total of 6118 patients were identified and selected for evaluation. Meta-analysis showed that long-term outcomes of ER versus SR for EGC were comparable in terms of 5-year OS (risk ratio [RR] 1.00, 95% confidence interval [CI] 0.98-1.02), DSS (RR 0.98, 95% CI 0.89-1.08), DFS (RR 0.95, 95% CI 0.86-1.05), and RFS (RR 0.98, 95% CI 0.94-1.01). However, ER had shorter operation time (standardized mean difference [SMD] -3.39, 95% CI -3.58 to 3.20), hospital stay (SMD -2.86, 95% CI -4.02 to -1.69), lower costs (SMD -5.30, 95% CI -10.37 to -0.22), and fewer procedure-related complications (RR 0.43, 95% CI 0.28-0.65) compared to SR. Nevertheless, ER had higher incidences of local recurrence (risk difference 0.01, 95% CI 0.00-0.02) and metachronous lesions (RR 6.81, 95% CI 3.80-12.19).Endoscopic resection was associated with similar long-term outcomes and considerable advantages concerning operation time, hospital stay, costs, and complications, compared with SR, and was also associated with disadvantages such as higher incidence of local recurrence and metachronous lesions. Further high-quality studies from more countries are required to confirm these results.

Helicobacter pylori Eradication for Prevention of Metachronous Recurrence after Endoscopic Resection of Early Gastric Cancer

Controversies persist regarding the effect of Helicobacter pylori eradication on the development of metachronous gastric cancer after endoscopic resection of early gastric cancer (EGC). The aim of this study was to assess the efficacy of Helicobacter pylori eradication after endoscopic resection of EGC for the prevention of metachronous gastric cancer. A systematic literature review and meta-analysis were conducted using the core databases PubMed, EMBASE, and the Cochrane Library. The rates of development of metachronous gastric cancer between the Helicobacter pylori eradication group vs. the non-eradication group were extracted and analyzed using risk ratios (RRs). A random effect model was applied. The methodological quality of the enrolled studies was assessed by the Risk of Bias table and by the Newcastle-Ottawa Scale. Publication bias was evaluated through the funnel plot with trim and fill method, Egger's test, and by the rank correlation test. Ten studies (2 randomized and 8 non-randomized/5,914 patients with EGC or dysplasia) were identified and analyzed. Overall, the Helicobacter pylori eradication group showed a RR of 0.467 (95% CI: 0.362-0.602, P < 0.001) for the development of metachronous gastric cancer after endoscopic resection of EGC. Subgroup analyses showed consistent results. Publication bias was not detected. Helicobacter pylori eradication after endoscopic resection of EGC reduces the occurrence of metachronous gastric cancer.

Risk factors of developing interval early gastric cancer after negative endoscopy

BACKGROUND

New or missed gastric cancer rates after negative endoscopy are high. However, the clinicopathologic characteristics of missed or interval early gastric cancer (EGC) are not well known. The aim of this study was to evaluate clinicopathologic and endoscopic characteristics of missed or interval EGC after negative endoscopy.

METHODS

We retrospectively analyzed 1,055 patients with EGC confirmed by endoscopic resection or surgery between June 2006 and July 2013. Referred patients with diagnosed or suspected gastric neoplasms were excluded (n = 771). Interval EGC was defined as gastric cancer diagnosed within 2 years of negative endoscopy. Clinicopathologic characteristics of patients with initially detected and interval EGC and risk factors for interval EGC were investigated.

RESULTS

Of 284 patients, 52 had interval EGC (18.3 %; mean age 65.4 years; average interval between diagnosis and previous endoscopy, 12.6 months). Tumors were significantly smaller (1.3 vs. 1.8 cm, P < 0.001), and the incidence of metaplasia was significantly higher (90.4 vs. 65.9 %, P < 0.001) for interval EGC than for initially detected EGC. And no symptoms (50 vs. 17.7 %, P < 0.001) were significantly associated with interval EGC. However, tumor location, differentiation, gross morphology, and Helicobacter pylori infection status did not differ significantly.

CONCLUSIONS

Subtle mucosal lesions with surrounding intestinal metaplasia were associated with interval EGC. Careful endoscopic screening for patients with intestinal metaplasia at short-term interval would be beneficial for decreasing interval EGC rates.

Gastric cancer screening uptake trends in Korea: results for the National Cancer Screening Program from 2002 to 2011: a prospective cross-sectional study

Although the effectiveness of mass screening for gastric cancer remains controversial, several countries with a high prevalence of gastric cancer have implemented nationwide gastric cancer screening programs. This study was conducted to assess trends in the use of either upper gastrointestinal series (UGIS) or endoscopy to screen for gastric cancer, as well as to assess factors strongly associated with changes therein, over a 10-year period. Data were obtained from the National Cancer Screening Program (NCSP) database from 2002 to 2011 in Korea. The NCSP provides biennial gastric cancer screening with either UGIS or endoscopy for men and women aged ≥40 years. Using the NCSP database, overall screening rates for gastric cancer and percentages of endoscopy use among participants were analyzed from 2002 to 2011. To estimate changes in participation rates and endoscopy use over time, we assessed the average annual percentage change (APC) by comparing the rates from 2002 and 2011 as relative rates. Participation rates for gastric cancer screening increased 4.33% annually from 2002 to 2011. In terms of screening method, a substantial increase in endoscopy use was noted among the gastric cancer screening participants over the 10-year period. The percentage of participants who had undergone endoscopy test increased from 31.15% in 2002 to 72.55% in 2011, whereas the percentage of participants who underwent UGIS decreased tremendously. Increased endoscopy test use was greatest among participants aged 40 to 49 (APC = 4.83%) and Medical Aid Program recipients (APC = 5.73%). Overall, men, participants of ages 40 to 49 years, and National Health Insurance beneficiaries of higher socioeconomic status were more likely to undergo screening via endoscopy. This study of nationwide empirical data from 2002 to 2011 showed that endoscopy is increasingly being used for gastric cancer screening in Korea, compared with UGIS. Nevertheless, further study of the impact of endoscopy on gastric cancer mortality is needed, and future evaluations of screening methods should take into account both cost and any associated reduction in gastric cancer mortality.

Laparoscopic-endoscopic cooperative surgery for gastric submucosal tumors

AIM: To assess the feasibility, safety, and advantages of minimally invasive laparoscopic-endoscopic cooperative surgery (LECS) for gastric submucosal tumors (SMT).

METHODS: We retrospectively analyzed 101 consecutive patients, who had undergone partial, proximal, or distal gastrectomy using LECS for gastric SMT at Peking Union Medical College Hospital from June 2006 to April 2013. All patients were followed up by visit or telephone. Clinical data, surgical approach, pathological features such as the size, location, and pathological type of each tumor; and follow-up results were analyzed. The feasibility, safety and effectiveness of LECS for gastric SMT were evaluated, especially for patients with tumors located near the cardia or pylorus.

RESULTS: The 101 patients included 43 (42.6%) men and 58 (57.4%) women, with mean age of 51.2 ± 13.1 years (range, 14-76 years). The most common symptom was belching. Almost all (n = 97) patients underwent surgery with preservation of the cardia and pylorus, with the other four patients undergoing proximal or distal gastrectomy. The mean distance from the lesion to the cardia or pylorus was 3.4 ± 1.3 cm, and the minimum distance from the tumor edge to the cardia was 1.5 cm. Tumor pathology included gastrointestinal stromal tumor in 78 patients, leiomyoma in 13, carcinoid tumors in three, ectopic pancreas in three, lipoma in two, glomus tumor in one, and inflammatory pseudotumor in one. Tumor size ranged from 1 to 8.2 cm, with 65 (64.4%) lesions < 2 cm, 32 (31.7%) > 2 cm, and four > 5 cm. Sixty-six lesions (65.3%) were located in the fundus, 21 (20.8%) in the body, 10 (9.9%) in the antrum, three (3.0%) in the cardia, and one (1.0%) in the pylorus. During a median follow-up of 28 mo (range, 1-69 mo), none of these patients experienced recurrence or metastasis. The three patients who underwent proximal gastrectomy experienced symptoms of regurgitation and belching.

CONCLUSION: Laparoscopic-endoscopic cooperative surgery is feasible and safe for patients with gastric submucosal tumor. Endoscopic intraoperative localization and support can help preserve the cardia and pylorus during surgery.

Improving early detection of gastric cancer: a novel systematic alphanumeric-coded endoscopic approach

Despite extensive worldwide use of standard esophagogastroduodenoscopy (EGD) examinations, gastric cancer (GC) is one of the most common forms of cancer and ranks as the most common malignant tumor in East Asia, Eastern Europe and parts of Latin America. Current limitations of using non systematic examination during standard EGD could be at least partially responsible for the low incidence of early GC diagnosis in countries with a high prevalence of the disease. Originally proposed by Emura et al., systematic alphanumeric-coded endoscopy (SACE) is a novel method that facilitates complete examination of the upper GI tract based on sequential systematic overlapping photo-documentation using an endoluminal alphanumeric-coded nomenclature comprised of eight regions and 28 areas covering the entire surface upper GI surface. For precise localization or normal or abnormal areas, SACE incorporates a simple coordinate system based on the identification of certain natural axes, walls, curvatures and anatomical endoluminal landmarks. Efectiveness of SACE was recently demonstrated in a screening study that diagnosed early GC at a frequency of 0.30% (2/650) in healthy, average-risk volunteer subjects. Such a novel approach, if uniformly implemented worldwide, could significantly change the way we practice upper endoscopy in our lifetimes.

[Upper gastrointestinal endoscopy during Kaposi's sarcoma to the Point G Hospital, Bamako (Mali): case study 20]

INTRODUCTION

Since the advent of HIV, Kaposi's sarcoma has become one of the most common opportunistic infections and the first cancer in patients with HIV. This cancerous disease occurs most often on the skin but also the viscera. Digestive localization was often observed during the search for other locations before the cutaneous form. No studies in Mali has focused on the upper gastrointestinal location.

OBJECTIVES

To describe the epidemiological and clinical aspects of Kaposi's sarcoma in the upper gastrointestinal endoscopy.

METHODS

This was a retrospective descriptive study from June 2005 to February 2009 in the center of endoscopy of the Point G Hospital including all patients seen in upper gastrointestinal endoscopy during the study period.

RESULTS

20 cases were reported from a total of 5068 endoscopy performed during this period a frequency of 0.39% hospital. These 20 cases were identified in all 31 patients with cutaneous localization of Kaposi's sarcoma is a frequency of 64.5%. The sex ratio was equal to 0.81. The average age was 36.8 years ± 8.92 years. The stomach and esophagus were found most locations. All patients were HIV positive. The CD4 count below 200 cells/mm3 was observed in 95% of patients.

[Clinical summary of the first 500 patients in the gastrointestinal soldiers' clinic in Beilinson hospital]

INTRODUCTION

The Soldiers' Clinic for gastrointestinal diseases was established in the Rabin Medical Center in 2006, for better management of these problems.

AIM

To evaluate the diagnosis and treatment in the first 500 soldiers treated in our clinic.

METHODS

Demographic and clinical data were collected for every soldier: age, gender, main reason for referral, background diseases and medical family history. The number of visits was counted and the referrals for laboratory and diagnostic procedures computed. For every procedure, compliance, cost, diagnostic yield and its' proportion in comparison with the other referrals was performed.

RESULTS

The main reasons for referral to our clinic were abdominal pain (46.6%), diarrhea (13.8%) and heartburn (9.4%). Family history of colorectal cancer was found in 20.6% of the soldiers. Out of 608 procedures performed 29.2% were positive. Hydrogen breath test for lactose intolerance was recommended for 9.6% and had the highest diagnostic yield of 52.0%. High yield was also found for 13C-urea breath test for Helicobacter pylori, gastroscopy, abdominal computerized tomography, and colonoscopy: 28.4%, 31.6%, 18.5% and 13.5% respectively. In comparison with abdominal ultrasound, the diagnostic yield was significantly better for gastroscopy and both breath tests. The total cost was NIS 360,244. A significant diagnosis was performed in 317 soldiers (63.4%). The average cost per diagnosis was NIS 1135.4.

CONCLUSION

The Gastrointestinal Clinic for soldiers conducted by a senior experienced gastroenterologist is important for better diagnostic yield and cost-saving in this young population.

Rural surgery in British Columbia: is there anybody out there?

OBJECTIVE

To document surgical procedures performed in British Columbia between 1996 and 2001 at rural hospital sites with no resident specialist surgeons and to define the scope of practice of general practitioner (GP)-surgeons at these small-volume surgical sites.

METHODS

We obtained data from published information available in the medical directories for British Columbia and from the Population Utilization Rates and Referrals For Easy Comparative Tables database (versions 6.0 and 9.0) to conduct a retrospective study of all rural BC hospitals with surgical programs that had no resident specialist surgeon and relied on GP-surgeons for emergency surgical care between 1996 and 2001. We studied surgical programs at the 12 hospitals that met inclusion criteria and interviewed the physician or nurse responsible for the program. Outcomes were measured in terms of the types and volumes of surgical procedures (elective and emergency) from 1996 to 2001, including itinerant surgery.

RESULTS

On average, 2690 surgical procedures were performed annually at the 12 hospitals included in the study. Endoscopy, hand surgery, cesarean section, herniorrhaphy, tonsillectomy and dilation and curettage (D&C) were among the top elective and emergency procedures. For each hospital, between 8 and 26 procedures of hand surgery, cesarean section, herniorrhaphy, D&C and appendectomy were performed each year. In the 12 communities studied, 19% of all surgery was emergency and 81% elective. There was significant overlap in the types of emergency and elective procedures. GP-surgeons carried out most of the emergency procedures, which nonetheless accounted for a small portion of their surgical work.

CONCLUSION

GP-surgeons still perform a significant number of emergency and elective surgical procedures in rural BC hospitals. This study defines useful procedures for GP-surgeons in communities without the population base to sustain a resident specialist surgeon. This information can be used to structure training programs for GP-surgeons that will adequately meet the needs of rural communities.

Factors associated with non-attendance at outpatient endoscopy

OBJECTIVE

Non-attendance at endoscopy procedures leads to wasted resources and increased costs. The purpose of this study was to investigate the factors associated with non-attendance.

MATERIAL AND METHODS

All patients who attended the outpatient clinic for gastroscopy or colonoscopy examinations were included in the study. Patients who missed their appointment were identified and their data were collected prospectively. Patients who kept their appointment in the same period of time served as controls.

RESULTS

Between August 2002 and February 2003, 1051 gastroscopies and 756 colonoscopies were scheduled. A total of 265 patients (14.7%) missed their appointment. No significant differences were found between attendees and non-attendees for mean age, gender, type of examination and day of the week on which the examination was scheduled. The time on the waiting list was longer in patients who did not keep their appointment than in those who did. Fewer appointments were missed in patients with a preferent referral, and among patients referred by their general practitioner a higher percentage failed to keep their appointment compared with those referred by a specialist. In the multivariate analysis, length of time on the waiting list and the source of referral were the only two independent predictive factors for non-attendance.

CONCLUSIONS

A longer time on the waiting list and referral by a general practitioner are factors associated with patients failing to keep their endoscopy appointment.

Pre-endoscopy serological testing for coeliac disease: evaluation of a clinical decision tool

OBJECTIVE

To determine an effective diagnostic method of detecting all cases of coeliac disease in patients referred for gastroscopy without performing routine duodenal biopsy.

DESIGN

An initial retrospective cohort of patients attending for gastroscopy was analysed to derive a clinical decision tool that could increase the detection of coeliac disease without performing routine duodenal biopsy. The tool incorporated serology (measuring antibodies to tissue transglutaminase) and stratifying patients according to their referral symptoms (patients were classified as having a "high risk" or "low risk" of coeliac disease). The decision tool was then tested on a second cohort of patients attending for gastroscopy. In the second cohort all patients had a routine duodenal biopsy and serology performed.

SETTING

Teaching hospital in Sheffield.

PARTICIPANTS

2000 consecutive adult patients referred for gastroscopy recruited prospectively.

MAIN OUTCOME MEASURE

Evaluation of a clinical decision tool using patients' referral symptoms, tissue transglutaminase antibody results, and duodenal biopsy results.

RESULTS

No cases of coeliac disease were missed by the pre-endoscopy testing algorithm. The prevalence of coeliac disease in patients attending for endoscopy was 3.9% (77/2000, 95% confidence interval 3.1% to 4.8%). The prevalence in the high risk and low risk groups was 9.6% (71/739, 7.7% to 12.0%) and 0.5% (6/1261, 0.2% to 1.0%). The prevalence of coeliac disease in patients who were negative for tissue transglutaminase antibody was 0.4% (7/2000). The sensitivity, specificity, positive predictive value, and negative predictive value for a positive antibody result to diagnose coeliac disease was 90.9%, 90.9%, 28.6%, and 99.6%, respectively. Evaluation of the clinical decision tool gave a sensitivity, specificity, positive predictive value, and negative predictive value of 100%, 60.8%, 9.3%, and 100%, respectively.

CONCLUSIONS

Pre-endoscopy serological testing in combination with biopsy of high risk cases detected all cases of coeliac disease. The use of this decision tool may enable the endoscopist to target patients who need a duodenal biopsy.

Influencing referral practice using feedback of adherence to NICE guidelines: a quality improvement report for dyspepsia

PROBLEM

Rising demand and increasing waiting times for upper gastrointestinal endoscopy (gastroscopy).

DESIGN

Quality improvement study with pre- and post-intervention data collection.

SETTING

Three endoscopy units in two hospital trusts (Singleton, Morriston and Baglan Hospitals endoscopy units), UK.

KEY MEASURES FOR IMPROVEMENT

Number of gastroscopy requests from general practitioners (GPs) and hospital doctors; their adherence to dyspepsia referral guidelines and the referral-to-procedure interval for upper gastroscopy. Data collected for six months before and for five months after the intervention.

STRATEGY FOR CHANGE

Referrals were assessed against the National Institute for Health and Clinical Excellence (NICE) guidelines for the management of dyspepsia by two part-time GPs and feedback sent to clinicians where requests did not adhere to the referrals criteria

EFFECTS OF CHANGE

Adherence to guideline criteria increased significantly among GPs after the intervention (from 55% to 75%). There was no similar effect for hospital doctors, although their adherence rate (70%) was at a higher level than that of GPs before the intervention. The number of gastroscopy referrals for dyspepsia declined after the intervention, particularly from hospital doctors where a drop of 31% was observed, from 26.6 to 18.4 referrals per week. With the inclusion of seasonal effects, an estimated drop of 3.2 referrals per week from general practice was not significant (p = 0.065) while an estimated drop of 10.0 referrals per week for hospital doctors was very significant (p<0.001).

LESSONS LEARNT

Referral assessment can be successfully introduced and shows promise as a way of improving the quality of referrals and reducing demand. Hospital clinicians are more resistant than GPs to referral assessment but nevertheless responded to the feedback by reducing their endoscopy gastroscopy requests. Most such referrals are generated in hospitals rather than in primary care: this finding has important implications for demand management.

Difference in accuracy between gastroscopy and colonoscopy for detection of cancer

BACKGROUND/AIMS

There are few reports regarding the accuracy of endoscopy in detecting cancer. We investigated the difference in the false-negative rates for cancer detection between gastroscopy and colonoscopy using the records of a population-based cancer registry, which is the most accurate in Japan.

METHODOLOGY

Between 1990 and 1995, 51,411 gastroscopic and 7756 colonoscopic examinations were carried out in our hospital. These subjects were matched with the cancer registry and the patients whose gastric or colorectal cancers were missed by examinations were identified.

RESULTS

The false-negative rate for the detection with gastroscopy was 25.8 percent at three years but that with colonoscopy was 11.1 percent. This difference was statically significant p = 0.01.

CONCLUSIONS

We concluded that for routine examinations, surveillance after negative endoscopy should be discussed based on the difference in false-negative rates between gastroscopy and colonoscopy.

Impact of feedback and didactic sessions on the reporting behavior of upper endoscopic findings by physicians and nurses

BACKGROUND & AIMS

Guidelines for reporting Barrett's esophagus and hiatal hernia measurements and reflux esophagitis grades have been developed to improve consistency, communication, and, ultimately, patient care. Our aims were to assess the percentage of cases in which findings were reported in accordance with guidelines and to assess the impact of education and feedback on reporting behavior.

METHODS

Prospective cross-sectional study design was used. Chart reviews were performed for all adult patients who underwent esophagogastroduodenoscopy at a tertiary care center during three 2-month time periods during a 12-month interval: Time 1 (March 1, 2004-April 30, 2004), Time 2 (July 1, 2004-August 31, 2004), and Time 3 (March 1, 2005-April 30, 2005). Standardized educational sessions began 2 years before Time 1. No intervention took place between Time 1 and Time 2; data were collected to examine secular change. Between Time 2 and Time 3, individual and group feedback and refresher sessions were given.

RESULTS

Five thousand six hundred nine eligible esophagogastroduodenoscopies were performed, of which 2675 demonstrated Barrett's esophagus, hiatal hernia, and/or reflux esophagitis. At baseline, Barrett's esophagus and hiatal hernia measurements were dictated correctly in a median of 67% and 86% of cases, respectively, improving to 100% (P < .05) and 98% (P < .01) of cases, respectively. The Los Angeles Classification system was used in a median of 100% of cases at baseline and at follow-up.

CONCLUSIONS

Anonymous individual and group feedback, in combination with brief, structured didactic educational sessions, significantly improves compliance with established guidelines for the reporting of Barrett's esophagus and hiatal hernia. Once successfully incorporated into clinical practice, adherence to the esophagitis Los Angeles Classification System is easy to maintain.

Variations in the reporting of endoscopies by different endoscopists

All gastroscopies and colonoscopies performed in two U.K. teaching hospitals over a period of one year were audited to investigate whether endoscopic reporting of gastroscopies and colonoscopies by different endoscopists is consistent. Endoscopic diagnoses were retrieved from the hospitals' endoscopy databases. The results of 1814 colonoscopies and 2127 gastroscopies were analysed using chi2 (Chi squared). The frequency of reporting common diagnoses was variable and the differences between specialist endoscopists were highly significant, including for important conditions such as peptic ulceration (range 2-10%, p = 0.001) and colonic polyps (16-45%, p < 0.001). There is a large variation in the frequency of the diagnoses reported by different endoscopists. This is unlikely to be explained by casemix or chance. This may have major implications for the health of patients. More emphasis must be placed during training on the correct interpretation of endoscopies.

A patient with dementia and cancer: to feed via percutaneous endoscopic gastrostomy tube or not?

Despite the lack of clear benefits of feeding via gastrostomy tube in dementia patients, its use has been increasing. The views of health professionals, patients and their carers differ widely about the perceived benefits, which makes decision-making difficult and stressful. The palliative care approach of facilitating better communication and end-of life care planning can help avoid inappropriate gastrostomy tube placements. A case of an elderly male with dementia and two malignancies is described, and the place of the palliative care approach is explored.

Analysis of risk factors for infection in coplacement of percutaneous endoscopic gastrostomy and ventriculoperitoneal shunt

Patients with severe neurological impairment requiring tube feeding may have concomitant hydrocephalus. Coplacement of percutaneous endoscopic gastrostomy (PEG) and ventriculoperitoneal (VP) shunting is currently standard in such cases. The present study investigated the risk factors for shunt infection in such patients. The medical records of 23 patients with PEG and VP shunting were retrospectively reviewed. Correlations between shunt system infection and potential risk factors were analyzed including order of PEG and VP shunting, position of abdominal shunt catheter, diabetes mellitus, tracheostomy, and activities of daily living. Twelve patients underwent VP shunting after PEG and 11 underwent PEG after VP shunt placement. Four patients experienced shunt infection, and three required shunt revision. Three of these four patients underwent VP shunting after PEG. The period between PEG and VP shunt placement was 18, 19, and 25 days, shorter than the mean period of 29.3 days. VP shunting can be combined with PEG, but a larger study is required to clearly identify the risk factors. Administration of prophylactic antibiotics and a period of at least 1 month between the procedures are recommended, particularly if the shunt is placed after the PEG tube.

Multistate and multifactorial progression of gastric cancer: results from community-based mass screening for gastric cancer

Although multistate progression models for gastric cancer have been proposed, estimation of quantitative parameters of such models is yet to be done. The present study was conducted to elucidate risk factors for gastric cancer and its precursors, and to model the progression rates from superficial gastritis to gastric cancer. Data were derived from a community-based screening programme for gastric cancer in the Matzu region of Taiwan. A total of 2184 residents participated in a two-stage screening project. Subjects testing positive for Helicobacter pylori infection or pepsinogen (PGI or PII/PGII ratio) and immunoglobulin G (IgG), and subjects with a history of peptic ulcer or other upper gastrointestinal disease or with a family history of gastric cancer were referred to endoscopy. We identified 325 biopsy-proven precursors and gastric cancers, including 148 superficial gastritis (SG), 42 atrophic gastritis (AG), 117 intestinal metaplasia (IM) and two gastric cancers. Three further cancers were diagnosed on endoscopy alone and 14 were later diagnosed in those who did not comply with referral to endoscopy. A Markov process model was used to estimate the progression rates from superficial gastritis through to gastric cancer, with exponential regression to assess the effect of covariates on progression rates. The annual progression rate from SG to AG was 0.0670 (95% confidence interval [CI] 0.0446-0.0895). Annual progression rates from AG to IM and from IM to gastric cancer were 0.2775 (0.1665-0.3884) and 0.2265 (0.1315-0.3214), respectively. This gives average dwelling times in AG and IM of 3.60 years and 4.42 years, respectively. Progression from no disease to SG was significantly accelerated in those testing positive for H. pylori, those testing positive for PGI and in subjects with a family history of gastric cancer or a personal history of upper gastrointestinal disease. Further progression to AG and IM was significantly accelerated in those testing positive for PGI and in those with a history of upper gastrointestinal disease.

[Examination of acute disease in the long-term geriatric ward]

We investigated the acute disorder in cases at the long-term geriatric ward. Fifty seven patients were admitted to the hospital during the period of October 2002 to March 2005. In our study, the following items were analyzed: (1) the number of admission, (2) diagnosis, (3) the duration of hospital stay, and (4) the cause of death. The admission of respiratory disease patients, such as pneumonia, bronchitis and pleuritis, were most frequent and had the longest term of hospitalization. We also found that patients with respiratory disease had undergone percutaneous endoscopic gastrostomy (PEG), and their hospitalization was relatively shorter.

Peptic ulcer disease in dyspeptic patients with ischemic heart disease: search and treat?

OBJECTIVE

The aim of this study was to determine the prevalence and risk factors for peptic ulcer disease (PUD) in dyspeptic patients with ischemic heart disease (IHD), and to assess whether the healing of PUD before coronary artery bypass grafting (CABG) could reduce the need for urgent postoperative endoscopy.

PATIENTS AND METHODS

A series of 894 patients referred to Dubrava University Hospital in Zagreb for elective CABG during the period from May 1998 until April 2001 was prospectively analysed. Dyspepsia was assessed by a questionnaire, PUD by upper gastrointestinal endoscopy, and H. pylori status by histology/Giemsa staining and the rapid urease test. The need for urgent postoperative endoscopy (hematemesis and/or melena, sudden onset of anemia or unexplained epigastric pain) was compared between the prospective study group of 894 patients and a series of 463 patients referred for CABG to Dubrava University Hospital during the period from January 1997 until April 1998.

RESULTS

Gastroduodenal dyspepsia predominated in 184 (20.6 %) patients, 142 (77.2 %) of them with Helicobacter (H.) pylori infection and 69 (37.5 %) with verified PUD. Univariate analysis indicated the increased risk of multiple PUD to be related to a previous diagnosis of PUD (OR 3.61, 95 % CI 1.32 - 9.82), H. pylori infection (OR 18.86, 95 % CI 2.31 - 153.98), use of aspirin (OR 5.70; 95 % CI 1.80 - 18.03) and left coronary artery occlusions (3.10, 95 % CI 1.00 - 9.59). Multivariate analysis pointed to H. pylori infection (OR 16.30, 95 % CI 1.57 - 168.53) and left coronary artery occlusions (OR 4.84, 95 % CI 1.05 - 22.30) as independent risk factors for multiple PUD. The OR for urgent postoperative endoscopy due to a major gastrointestinal event was 9.9 (95 % CI 2.2 - 45.1) and the OR for active peptic ulcer with stigmata of recent bleeding was 6.9 (95 % CI 1.4 - 33.1) in the group of patients with IHD who were not submitted to evaluation for dyspepsia prior to elective heart surgery.

CONCLUSIONS

In areas with a high prevalence of H. pylori infection, endoscopy and a "search and treat" strategy for IHD patients with dyspepsia before elective cardiac surgery should significantly reduce the need for urgent postoperative endoscopy due to major gastrointestinal events.

First-time endoscopy and use of antisecretory medication: a population-based cohort study

OBJECTIVE

Endoscopy is the gold standard for diagnostic evaluation of upper gastrointestinal symptoms. The relation between endoscopy and use of antisecretory medication on a population level is unknown. The aim of this study was to describe development in the number of patients undergoing first-time endoscopies and their use of antisecretory medication.

MATERIAL AND METHODS

Data on the use of endoscopies and antisecretory medication (H2 blockers and proton-pump inhibitors) were extracted from five population-based databases and included all citizens in Funen County (population 470,000) who had first-time endoscopies between 1993 and 2002.

RESULTS

A total of 27,829 first-time endoscopy patients were identified. In 2002 the number of first-time endoscopies was 5.6/1000 persons. The proportion that had redeemed prescription(s) on antisecretory medication the last year before endoscopy increased from 33% (1095/3286) in 1993 to 41% (1012/2445) in 2002 (p = 0.000). Following endoscopy, average use of antisecretory medication increased by 90 defined daily doses (DDD)/patient/year (95% CI 84-96) in patients with oesophagitis (N = 4850), by 59 DDD/patient/year (95% CI 54-64) in peptic ulcer patients (N = 4373) and by 18 DDD/patient/year (95% CI 16-20) in patients with normal endoscopies (N = 16,400).

CONCLUSIONS

An increasing proportion of patients are treated with antisecretory medication before endoscopy. Following endoscopy, use of antisecretory medication increases irrespective of the diagnostic findings.

Laparoscopic vs percutaneous endoscopic gastrostomy tube insertion: a new pediatric gold standard?

BACKGROUND/PURPOSE

Gastrostomy tube insertion is frequently performed in children. Percutaneous endoscopic gastrostomy (PEG) insertion, considered by many to be the "gold standard," is unavoidably associated with a risk of intestinal perforation and frequently requires a second anesthetic for its replacement with a low-profile "button." We hypothesized that a laparoscopic technique with low-pressure insufflation would yield comparable outcomes, a lower procedural complication rate, and require fewer anesthetics per patient.

METHODS

A retrospective review of all surgeon-placed gastrostomy tubes (exclusive of those associated with fundoplication or other procedures) between January 2002 and December 2003 was undertaken. Data collected included type of procedure (PEG vs laparoscopic), indication, patient demographics (including neurologic comorbidity), operative time, complications (procedure-specific and nonspecific), and number of procedural anesthetics to "achieve" a low-profile tube. Groups were compared by univariate and multiple logistic regression analyses.

RESULTS

One hundred nineteen gastrostomy tubes (26 laparoscopic = 21.8%) were inserted. The PEG and laparoscopic gastrostomy groups were comparable from the perspectives of age, size, indications for tube placement, and operative time. The complication rate after PEG placement was significantly higher than after LG (14% vs 7.7%; P = .023), and 72 (77.4%) of PEG patients required a second anesthetic for tube change.

CONCLUSIONS

Laparoscopic gastrostomy tube insertion is safe and easy to perform, with outcomes comparable to that of PEG tube insertion. It obviates the need for a second procedural anesthetic and may emerge as the gold standard for gastrostomy tube placement.

[Study of the gastroscopies requested at a health centre]

Objetivos

Determinar los motivos por los que se solicita una gastroscopia y los diagnósticos endoscópicos más frecuentes obtenidos, así como valorar la aceptación de este medio diagnóstico por los médicos de nuestro centro de salud, entendida como la utilización de dicha prueba durante el período de estudio.

Diseño

Estudio descriptivo, retrospectivo.

Emplazamiento

Centro de Atención Primaria de San José de Zaragoza que atiende a una población de edad ≥ 14 años de 34.190 personas.

Población

Todas las gastroscopias solicitadas en el período comprendido entre enero de 1995 y diciembre de 2003.

Medición

La unidad de análisis utilizada es la endoscopia digestiva alta, dado que a un mismo paciente podrían habérsele realizado distintas gastroscopias en momentos diferentes del período de estudio. Se incluyen las gastroscopias solicitadas, tanto con finalidad diagnóstica como de seguimiento de enfermedades ya conocidas.

Las endoscopias se realizan en el centro de especialidadess de referencia, utilizando para esta valoración los registros informatizados de dicho centro de los que se obtienen los siguientes datos: edad y sexo del paciente, médico que realizó la solicitud, motivo de petición de gastroscopia, hallazgos endoscópicos, realización o no de biopsia y hallazgos anatomopatológicos.

Se incluyó a todos los médicos que han trabajado en el centro de salud durante el período de estudio, pero hay que recalcar que no todos han contribuido de igual manera, según la fecha de entrada o abandono del centro de salud. La contribución temporal de cada profesional se ha reflejado en la tabla 1.

Resultados

El total de gastroscopias solicitadas fue de 192. En la tabla 1 se exponen las solicitadas por cada uno de los médicos. Siete médicos no han solicitado ninguna durante el período de estudio (no los incluimos en la tabla) y en los médicos restantes hay grandes diferencias. Del total de gastroscopias solicitadas, 106 (56%) se realizaron en varones frente a 84 (46%) en mujeres. La edad media fue de 52,99 ± 15,54 años y rango de edad de 18-83 años. Los motivos por los que se solicitaron las gastroscopias fueron epigastralgia (54%), seguida de enfermedad por reflujo gastroesofágico (12,1%) y la dispepsia (11,6%). Con menor frecuencia se solicitaron por control, disfagia, estudio o por diagnóstico de sospecha en otra prueba.

Los diagnósticos endoscópicos encontrados con más frecuencia fueron gastritis en 57 casos (30%), seguida de ausencia de enfermedad en 52 casos (28%) y hernia de hiato en 21 casos (11%) y esofagitis por reflujo en 19 casos (5,3%); con menor frecuencia se encontraron: ulcus duodenal en 15 casos (8%), ulcus gástrico (2,7%) y esófago de Barret en 5 casos. Otros diagnósticos fueron pólipo gástrico, acantosis, candidiasis esofágica, engrosamiento de pliegues, no realización por intolerancia, hipotonía de cardias, anillo de Schatzki, divertículo esofágico y varices esofágicas.

Se realizó biopsia en 85 gastroscopias frente a 104 en las que no llegó a realizarse. No aparecía reflejado el diagnóstico anatomopatológico en 9 de los 85 informes. Los hallazgos resultantes de las 76 biopsias informadas ponen de manifiesto el predominio de gastritis crónica en 62 casos (81%) con respecto al resto de los diagnósticos anatomopatológicos, que por orden de frecuencia fueron: normalidad, cambios inflamatorios inespecíficos, gastritis erosiva, esófago de Barret y acantosis glucogénica.

Del total de biopsias realizadas, la presencia de Helicobacter pylori se observó en 52 casos (69%). Aparecía metaplasia en 29 casos (47%) y displasia en 2. La inflamación era severa en 34 casos (58%) y la atrofia estaba presente en 16 casos (26%).

Discusión y conclusiones

Los motives más frecuentes de solicitud de gastroscopia y los diagnósticos endoscópicos encontrados en nuestro estudio coinciden con los resultados obtenidos en otros estudios, con metodología similar a la nuestra1-3.

Según los resultados obtenidos, podemos afirmar que hay gran variabilidad entre los médicos del centro a la hora de solicitar esta prueba, hecho que puede estar justificado por la escasez de guías claras y de protocolos para las enfermedades digestivas, y por el importante porcentaje de población polimedicada y con pluripatología que quizá en otro contexto nos llevaría a realizar dicha solicitud. También observamos que el número de gastroscopias solicitadas parece insuficiente en relación con la elevada prevalencia de enfermedades digestivas susceptibles de ser estudiadas mediante dicha prueba. Algunos autores han intentado comparar el rendimiento de la endoscopia según se acceda a ella desde el médico de familia o mediante consulta previa con el especialista, y podemos observar que se van obteniendo resultados distintos conforme pasan los años4,5. Podemos concluir que este método diagnóstico es una herramienta muy útil para atención primaria, hasta el punto de que sólo en el 7% de los casos se necesita seguimiento por el especialista6 y se ha demostrado que los pacientes tienen un elevado grado de confianza en su medico de familia.

Endoscopy plays an important preoperative role in bariatric surgery

BACKGROUND

The role of upper endoscopy (EGD) in obese patients prior to bariatric surgery is controversial. The aim of this study was to evaluate the diagnostic yield and cost of routine EGD before bariatric surgery.

METHODS

The medical records of consecutive obese patients who underwent EGD prior to bariatric surgery between May 2000 and September 2002 were reviewed. Two experienced endoscopists reviewed all EGD reports, and findings were divided into 4 groups based on predetermined criteria: group 0 (normal study), group 1 (abnormal findings that neither changed the surgical approach nor postponed surgery), group 2 (abnormal findings that changed the surgical approach or postponed surgery), and group 3 (results that were an absolute contraindication to surgery). Clinically important findings included lesions in groups 2 and 3. The cost of EGD (430.72 US dollars) was estimated using the endoscopist fee under Medicare reimbursement.

RESULTS

During the 28-month study period, 195 patients were evaluated by EGD prior to bariatric surgery. One or more lesions were identified in 89.7% of patients, with 61.5% having a clinically important finding. The prevalence of endoscopic findings using the classification system above was as follows: group 0 (10.3%), group 1 (28.2%), group 2 (61.5%), and group 3 (0.0%). Overall, the most common lesions identified were hiatal hernia (40.0%), gastritis (28.7%), esophagitis (9.2%), gastric ulcer (3.6%), Barrett's esophagus (3.1%), and esophageal ulcer (3.1%). The cost of performing routine endoscopy on all patients prior to bariatric surgery was 699.92 US dollars per clinically important lesion detected.

CONCLUSIONS

Routine upper endoscopy before bariatric surgery has a high diagnostic yield and has a low cost per clinically important lesion detected.

Patterns of use of flexible sigmoidoscopy, colonoscopy and gastroscopy: a population-based study in a Canadian province

BACKGROUND & AIMS

Flexible sigmoidoscopy, colonoscopy and gastroscopy are important in the diagnosis and treatment of gastrointestinal (GI) diseases. Pressure on endoscopy resources is expected due to increased screening for GI cancers. The present study examined patterns of use of GI endoscopy in a Canadian province, Alberta, with universal health care insurance.

METHODS

Data on physician payments from January 1, 1994 to March 31, 2002 were used to calculate age-sex adjusted rates and patterns of use.

RESULTS

The gastroscopy rate increased by 17%, from 9.7 (95% CI 9.6 to 9.9) to 10.3 (95% CI 10.1 to 10.5). The colonoscopy rate increased by 105%, from 4.8 (95% CI 4.6 to 5.0) to 9.8 (95% CI 9.6 to 10.1). Flexible sigmoidoscopy rates declined by 10%, from 4.68 (95% CI 4.56 to 4.80) to 4.21 (95% CI 4.11 to 4.32). The increase in colonoscopy rates occurred in all age groups, whereas gastroscopy rates increased only in the older age groups. Regional variation in procedure rates was evident, but rural health regions did not have consistently lower rates than the large urban regions. A polypectomy was performed on 23.7% of male patients and 15.4% of female patients at time of colonoscopy. Rates of polypectomy for individual endoscopists ranged from 0% to 60%.

CONCLUSIONS

There has been a marked increase in gastroscopy and colonoscopy rates, likely due to a broadening of indications rather than just increased use for cancer screening. Modest regional variation in rates exists, but there is no direct evidence of limited rural access to endoscopy. Reasonable polypectomy rates were seen but important variations between endoscopists exist.

Cost-effectiveness and long-term impact of Helicobacter pylori 'test and treat' service in reducing open access endoscopy referrals

INTRODUCTION

We have shown that the introduction of a carbon urea breath test (13C-UBT) service for Helicobacter pylori screening and eradication is effective in reducing the rate of open access endoscopy referrals in patients aged < 40 years in the short term. This has been substantiated by several randomized controlled trials comparing a 'test and treat' strategy with early endoscopy in these patients. However, the long-term impact of such a strategy is not established.

OBJECTIVE

To ascertain the influence of 13C-UBT services on open access endoscopy referral rates in dyspeptic patients under the age of 40 years over a period of 5 years.

METHODS

Retrospective analysis of open access endoscopy referral rates between August 1990 and July 2000. Cost minimization analysis was performed with a Decision Analysis Model using Treeage Data 3.5.

RESULTS

The total number of open access referrals for endoscopy during 1990-1995 was between 765 and 1325 per year. The proportion of endoscopies performed in patients < 40 years ranged between 33.4% and 34.6%. The total number of endoscopy referrals during 1995-2000 after the introduction of the 13C-UBT services was between 1178 and 1321 per year. However, there was a sustained reduction in the proportion of patients aged < 40 years, ranging between 23.2% and 26.2% (Chi2 = 153.9, degrees of freedom = 9, P < 0.0001) during this period.

CONCLUSIONS

The H. pylori screening and treatment strategy using the 13C-UBT service results in a sustained reduction of the number of endoscopy referrals and is cost effective in dyspeptic patients under the age of 40 years, enabling better utilization of available resources.

[Appropriateness in gastroenterology: too many endoscopies or not enough?]

Die Angemessenheit (appropriateness) der Indikationsstellung zu einer medizinischen Untersuchung ist ein Eckpfeiler medizinischer Qualität. Die meisten klinischen Entscheide sind nicht durch randomisierte Studien abgedeckt. Präzise, validierte Angemessenheitskriterien stehen dem praktischen Arzt in dieser Situation zur Verfügung. Am Beispiel der gastrointestinalen Endoskopie werden die EPAGE-Kriterien besprochen (http://www.epage.ch). In prospektiven Studien wurde mit den EPAGE-Kriterien Über- und Untergebrauch der Endoskopie dokumentiert, deren Erkennung zur Qualitätssicherung einen entscheidenden Beitrag liefert.

Diagnostic performance of light-induced fluorescence endoscopy for gastric neoplasms

BACKGROUND AND STUDY AIM

Malignant tumors generate autofluorescent patterns that differ from those of normal tissue. However, whether autofluorescent diagnosis could be genuinely useful in screening for gastric neoplasms has not been well investigated in clinical practice. Accordingly, we retrospectively studied our experience with this diagnostic technique for various gastric lesions and assessed its diagnostic utility.

PATIENTS AND METHODS

Autofluorescence diagnosis of 109 gastric lesions in 79 patients was done, without knowledge of the diagnosis by conventional white light endoscopy, retrospectively and independently by three endoscopists with 6 years', two years' and no experience of the technique. After examination of the interobserver bias in the assessment of autofluorescent pseudocolor in light-induced fluorescence endoscopy (LIFE), the relationship between pseudocolor and characteristics of gastric lesions (including histology, macroscopic type, and depth of invasion) were investigated.

RESULTS

The kappa statistic for agreement in pseudocolor diagnosis between the three endoscopists was 0.71. The assessment of pseudocolor by all of the observers was in agreement in 67 of the total of 109 lesions (61.5 %). Experience with the LIFE technique did not improve the accuracy of pseudocolor determination. All of the cancers, 87.5 % of the adenomas, and 50.9 % of the benign lesions were recognized as having an abnormal autofluorescent image. None of the gastric cancers and 49.1 % of the benign lesions were evaluated as having a normal autofluorescence image. The histopathological and macroscopic types of tumors and their depths of invasion were not reflected in the autofluorescence diagnosis.

CONCLUSIONS

LIFE provided a sensitivity of 96.4 % and specificity of 49.1 %, suggesting that this technique has limited clinical utility, regardless of the merits of acceptable interobserver bias and lack of necessity for experience with this technique.

Yield of endoscopy in children with hematemesis

Upper gastrointestinal (UGI) endoscopy is an important tool in the evaluation of patients presenting with haematemesis. The objective of this study was to report the yield of this procedure in a Saudi Arabian population. We analysed the result UGI endoscopy in children and adolescents of 0-18 years of age who presented with haematemesis over a period of 10 years. From 1993 to 2003, endoscopy was performed on 60 consecutive children presenting with haematemesis. This group represented 12% of the indications during the same period. The majority (98%) were Saudi nationals, with an age range from 4 days to 18 years, and a male to female ratio of 1:1.5. The overall yield of endoscopy was 75%; however, the yield was higher (91%) in children below 12 years of age. Gastritis was the commonest cause of haematemesis (44%), followed by oesophagitis (36%). However, age-related analysis shows that oesophagitis was a more common cause of haematemesis in the younger age group (45%) than gastritis in adolescents (30%). In contrast, gastritis was more common in older children (56%) than oesophagitis (28%). Peptic ulcer disease and oesophageal varices were seen in only 3 (7%) and 2 children (4.3%), respectively. The overall yield of endoscopy in our patients is similar to that in most reports. However, oesophagitis and gastritis were the commonest causes of haematemesis, whereas oesophageal varices and peptic ulcer disease were much less common.

Cost-effectiveness of routine endoscopic biopsies for Helicobacter pylori detection in patients with non-ulcer dyspepsia

BACKGROUND

The role of endoscopic biopsies in the detection of Helicobacter pylori in patients with nonulcer dyspepsia is poorly defined. This study assesses the cost-effectiveness of performing routine biopsies for the detection of H pylori at upper endoscopy in these patients.

METHODS

Clinical decision-making was modeled based on outcomes data from published articles and expert opinion. The target group was adults, less than 45 years of age, with nonulcer dyspepsia as defined by a normal endoscopy. Costs, expressed in Canadian dollars, were tabulated over a 1-year time horizon. The main outcome was relief of symptoms, defined as the absence of symptom persistence or recurrence over the 12 months. A strategy of performing a biopsy for the detection of H pylori with a rapid urease test during gastroscopy was compared with that of not performing a biopsy. In addition, as a secondary analysis, the cost-effectiveness of obtaining a biopsy specimen for histopathologic evaluation in patients after a negative rapid urease test was evaluated.

RESULTS

A strategy of endoscopy with biopsy and rapid urease testing costs 3940 dollars per additional symptom-free patient as compared with endoscopy without biopsy. This result was sensitive to the difference in symptomatic recurrence rate at 1 year between patients in whom H pylori was successfully and unsuccessfully eradicated, which in this analysis, was set at 9.9%. Only when the difference in symptomatic recurrence in patients with successful versus unsuccessful eradication fell to less than 4% was endoscopy with biopsy over 10,000 dollars per cured patient greater than endoscopy without biopsy. The conclusions were otherwise robust when varying the values of other variables across clinically relevant ranges. There was little additional benefit associated with histopathologic assessment of biopsy specimens in patients with a negative rapid urease test and the cost per additional cure was 25,529 dollars.

CONCLUSIONS

In adults with nonulcer dyspepsia under age 45 years undergoing endoscopy, routine procurement of a biopsy specimen for detection of H pylori was more costly yet more effective compared with not obtaining a specimen. The cost-effectiveness of a biopsy is dependent on the benefits of H pylori eradication in this patient population. The less likely a patient with nonulcer dyspepsia is to become asymptomatic after successful H pylori eradication, the more costly a strategy of routinely obtaining a specimen at endoscopy. The additional cost of sending a specimen for histopathologic analysis if the rapid urease test is negative does not appear warranted based on cost-effectiveness considerations.

Results of emergency gastroscopy for acute upper gastrointestinal bleeding outside official hours at King Chulalongkorn Memorial Hospital

This study was to evaluate the epidemiological characteristics, etiology and therapeutic outcome of active upper gastrointestinal bleeding in patients who underwent emergency gastroscopy outside official hours at the Gastroenterology Unit, King Chulalongkorn Memorial Hospital. From January to December 2002, 103 emergency gastroscopies were performed in 99 patients. There were 66 men and 33 women (mean age 55.4 years, range 22-98 years). Causes of bleeding were esophageal varices (29/99; 29.3%), gastric ulcer (25/99; 25.3%), duodenal ulcer (9/99; 9.1%), gastric varices (9/99; 9.1%) and miscellaneous (12/99; 12.1%). Etiology of bleeding was uncertain in 10.1 per cent of the cases. Therapeutic modalities for variceal bleeding were banding (78.6%), sclerotherapy (10.7%) and glue injection (10.7%). Endoscopic therapies for patients with non variceal bleeding were: epinephrine injection with bipolar coaptation (48.1%), epinephrine injection only (11.1%), bipolar coaptation alone (7.4%), heater probe (7.4%), epinephrine injection combined with heater probe (11.1%), epinephrine injection with bipolar coaptation and hemoclipping (7.4%), hemoclipping (3.7%), epinephrine injection with hemoclipping (3.7%). Initial hemostasis was achieved in 91.2 per cent of the patients (91/99). Recurrent bleeding within 72 hours developed in 9.1 per cent of patients (9/99). Of these, eight patients (88.9%) underwent re-endoscopy and bleeding was stopped in 62.5 per cent (5/8). And 2.0 per cent of patients (2/99) had to go for emergency surgery after failed therapeutic endoscopy. Overall mortality was 15.2 per cent (15/99). In conclusion, emergency gastroscopy can offer not only diagnostic but also therapeutic modality for patients with acute upper gastrointestinal bleeding. Endoscopic therapy is effective for both initial hemostasis and recurrent bleeding.

Management delays for early gastric cancer in a country without mass screening

BACKGROUND/AIMS

To examine the symptoms of early gastric cancer and the time scale of management delays in a country without a mass screening program.

METHODOLOGY

Retrospective review of 44 patients with early gastric cancer.

RESULTS

Epigastric pain (63.3%) and gastrointestinal hemorrhage (27.3%) were the main symptoms found. Total delay was made up of patient delay (48.6%), doctor delay (25.5%) and treatment delay (25.9%). Median patient delay (from symptom onset to medical consult) was 30 days (inter-quartile range 2 to 365). Patient delay of more than 6 months was associated with patients aged 50 and younger (P = 0.04) and those presenting with pain (P = 0.05). Median doctor delay (consult to diagnosis) was 21 days (1 to 35) and median treatment delay (diagnosis to surgery) was 8 days (2 to 21). Doctor delay of more than 6 months was associated with a negative gastroscopy or barium meal in the previous 12 months (P = 0.03).

CONCLUSIONS

The detection of early gastric cancer at the symptomatic-detectable stage is possible and this potential window for diagnosis can be more than 1 year for up to one third of cases. Efforts to reduce management delays should be aimed at public education and improving the quality and accessibility of endoscopic evaluation.

Diagnostic investigation rates and use of prescription and non-prescription medications amongst dyspeptics: a population-based study of 2300 Australians

BACKGROUND

: There is limited knowledge of the diagnostic investigation rates and use of prescription and non-prescription drugs amongst dyspeptics.

AIM

: To assess the investigation rates and use of prescription and non-prescription anti-ulcer medications amongst dyspeptics in the population.

METHODS

: A cross-sectional survey was performed of 2300 Australians.

RESULTS

: Of 748 dyspeptics, 422 (56%) had consulted a doctor regarding dyspepsia at some time in their life. Of the consulters, 64% had undergone investigations at some time: 37% an endoscopy, 54% a barium meal and 27% both. A diagnosis of peptic ulcer was reported by 31% of those investigated. The symptom profile of gastroscopy patients differed significantly from that of uninvestigated dyspeptics. Of the consulters, 36% had taken anti-ulcer prescription drugs in the last 3 months: Histamine-2 receptor antagonists (73% of prescriptions), proton pump inhibitors (17%), cytoprotectants (5%) and prokinetic drugs (5%). Antacids were taken by 30% of non-consulting dyspeptics, 44% of consulters not on prescription drugs and 58% of dyspeptics taking prescription drugs. Advancing age, but not gender, was associated with diagnostic investigation and prescription and non-prescription drug usage.

CONCLUSIONS

: There are high rates of diagnostic investigation amongst dyspeptics who consult doctors. Many individuals with dyspepsia decide to self-medicate with antacids regardless of consulting or prescriptions, suggesting that current management is suboptimal.