Dyspepsia: who and when to endoscope?
Introduction: One quarter of the population in the Western countries suffer from dyspepsia. Thus, if every patient with dyspepsia were to be endoscoped, then the cost to community and the individual would be substantial and the work load of the endoscopist would be large. In this article, I hope to address the evidence for and against endoscopy as first line investigation for dyspepsia vis-à-vis other modalities of treatment such as trial PPI (proton pump inhibitor) therapy and H.Pylori eradication.
Definition: The Rome III committee defined dyspepsia as one or more of the fol- lowing :a) postprandial fullness, b) early satiety, or c) epigastric pain or burning. Dyspeptic symptoms are most commonly caused by non-ulcer dyspepsia, peptic ulcer, reflux oesophagitis or rarely malignancy. However, the same symptoms can be caused by medication side effects, biliary or pancreatic disorder and motility disorder.
Evidence for and against endoscopy: Endoscopy, in patients with uninvesti- gated dyspepsia shows erosive oesophagitis in 43%, peptic ulcer in 5-10%, and can- cer in 1-3% cases. The remaining , approximately 50%, have a normal endoscopy. Again there is good data to indicate that pre-endoscopy PPI or H2RA (H2 receptor antagonist) reduces endoscopy findings to normal in 50% of cases due to prior healing of oesophagitis and peptic ulcer. The data, that supported the contention that endoscopy serves to improve patient satisfaction, reduce anxiety and thus improve symptoms, has not been universally corroborated by other studies. While first up endoscopy may reveal a finding in 50% cases , one should not necessarily expect reassurance and improvement of symptoms in the other 50% with- out endoscopic findings.
Role of alarm symptoms and controversies: In U.S cancer incidence rises rapidly after the age of 55. Some experts recommend that patients with alarm symp- toms e.g., wt loss , anaemia , progressive dysphagia, family history of upper gastrointestinal cancer, vomiting or new-onset dyspepsia in patients older than 50 should have endoscopy first. However, they also recommend that H.Pylori eradication and or short trial of PPI therapy for patients with dyspepsia without alarm symptoms. A number of studies have called into question the validity and reliance on alarm symptoms.Two meta-analysis totaling 41 studies involving 73,000 patients concluded that alarm symptoms have a positive predictive value of 6-10% and a negative predictive value of 97-98% for gastrointestinal cancers. This implies that absence of alarm symptoms is a good predictor of lack of cancer but presence of alarm symptoms is a poor predictor for the presence of cancer in 6-10% cases only. A large Hong Kong study has demonstrated that alarm symptoms can be absent in young (45 yr or less) Hong Kong Chinese with gastroesophageal cancers. While presence or absence of alarm symptoms, by and large, can be relied upon to initiate an endoscopy in the Caucasian patient, the same paradigm may not apply for the Asian patients.
The younger (less than 50) dyspeptic patient without alarm symptoms: In cost-effectiveness analysis, endoscopy as the first line investigation does not rate compared to urea breath test followed by H.Pylori eradication or short trial of PPI therapy if the H.Pylori test is negative. If H.Pylori eradication and subsequent PPI therapy fails to relieve the symptoms, then endoscopy should be performed in these patients. Failing all, do not forget the pancreas, the biliary tree, and the colon since pathology in these organs can also cause dyspeptic symptoms. A Hong Kong study has demonstrated the usefulness of endoscopic ultrasound in some cases of dyspepsia when all else fail. Likewise standard ultrasound of the gall bladder, liver and colonoscopy may be required as a last re- sort. Studies have indicated that ultra-thin (5-6 mm) gastroscopy without sedation is acceptable to 70% patients cutting out the anaesthetic cost.
Summary:
- New onset dyspepsia in patients who are 50 or older and those with alarm symptoms (any age) should have endoscopy as the first investigation.
- Dyspeptic patients younger than 50 and without alarm symptoms should have urea breath test and if positive , H.Pylori eradicated .
- Dyspeptic patients younger than 50 and without alarm symptoms and nega- tive for H.Pylori ,should have a short trial of PPI.
- Patients who fail H.Pylori eradication and or trial PPI should proceed en- doscopy, ultrasound, ,CT, endoscopic ultrasound and colonoscopy dictated by patients’ symptoms and at the discretion of the clinician.Further Reading:
- Ikenberry S.O. et al, Role of endoscopy in dyspepsia, Gastrointest Endosc 2007,66,1071
- Tally N.J.Role of endoscopy in dyspepsia,Clinical Update 2007,15.1-4.
- Tally N.Yield of endoscopy in dyspepsia,Gastrointest Endosc.2003,58,89
- Smith T et al, Low yield of endoscopy,Gastrointest Endosc,2003,58,9.
- Sung J et al,Incidence of gastroesophageal malignancy, Gastrointest Endosc2001,54,454.
Suggested algo- rithm for the evaluation of dyspepsia: Cour- tesy,Ikenberry S O,Gastrointest. Endosc,2007, 66,1071-1075. EGD:esophago- gastroduodenos- copy.
Editorial: Patient expectations and realities of post-anaesthetic cognition in the discharge lounge following endoscopy.
I would like to address the issue of how much useful discussion could or should take place in the discharge lounge soon after an- aesthetics following endoscopy. Although I have always seen every patient post procedure and had a brief discussion as to their diagnosis and management, from the perspective of a very small minority of patients, the discussion is never enough. Problem, however, is that there would always be post-anaesthetic impaired memory and cognition. Some patients do not remember seeing their doctor at all in the discharge lounge. Others ask the same question 3 times in a span of 2 minutes. In recognition of patients’ temporary congnitive impairment in the post-anaesthetic situation, we keep discussions brief, provide all patients with an envelope containing the report to be taken to the referring doctor, written instruction regarding follow up with the referring doctor, medication intake, literature on the specific diagnosis of the patient and follow up with the gastroenterologist ,if required , at a later date when anaesthetic influence would not be a hindrance. In recognition of these facts, we, at Southcoast Digestive Diseases Centre , are in the process of introducing a standard information sheet , outlining the reasons for the briefness of discussion in the discharge lounge when patients are still under the influence of anaesthetic agents, to be given to every patient at the time of booking for an endoscopic procedure. Indeed this is the very reason why the Anaesthetic College has always recommended patients be driven home and elderly patients be supervised at home after day procedures requiring intravenous anaesthetics. I hope the information sheet would improve patient understanding of the procedure in the discharge lounge.
Bhaskar Chakravarty