American Gastroenterological AssociationAGA technical review: Evaluation of dyspepsia☆,☆☆
Section snippets
Definitions and epidemiology
Upper abdominal pain or discomfort is remarkably common in the general population. The annual prevalence of recurrent upper abdominal pain or discomfort in the United States and other Western countries is approximately 25%; if frequent heartburn (defined as retrosternal burning pain or discomfort once a week or more often) is also considered, the prevalence approaches 40%.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 When classic heartburn or acid regurgitation are the dominant symptoms, objective evidence
The problem: What is the optimal management of dyspepsia?
For many persons, the symptoms of dyspepsia are of short duration or mild severity21 and are therefore self-managed. Less than half of dyspepsia sufferers seek medical care for their complaints in the United States and Europe.7, 9, 10, 22, 23 Despite this, the management of dyspepsia represents a major issue in clinical practice; 2%–5% of all family practice consultations are accounted for by dyspepsia.24 The factors that determine whether a patient consults a physician are poorly defined, but
Differential diagnosis of dyspepsia
In patients with dyspepsia who are investigated, four major causes can be identified for their complaints: chronic peptic ulcer disease, gastroesophageal reflux (with or without esophagitis), malignancy, and functional (or non-ulcer) dyspepsia (Table 1, Table 2).17, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65
Diagnostic tests
The yield from upper endoscopy in patients being investigated for dyspepsia increases with advancing age.49, 96, 97 Once a single adequate endoscopy has been performed, the value of most additional tests is at best marginal based on the data available.51, 58, 84, 106, 107, 108 Gastric emptying testing may detect delayed solid or liquid emptying in 25%–50% of patients with functional dyspepsia, but this usually does not alter management.89, 92 Ultrasonography of the gallbladder in dyspepsia has
Endoscopy versus barium meal to exclude ulcer and cancer
In family practice, upper gastrointestinal radiographs are still commonly used to exclude peptic ulcer and other diseases in patients with dyspepsia. However, endoscopy has consistently been shown to provide superior diagnostic accuracy in detecting structural causes of dyspepsia than radiography (Table 3).38, 112, 113, 114
Empty Cell Empty Cell Barium meal Upper endoscopy Study, yr (no. of patients) Diagnosis Sensitivity Specificity Sensitivity Empty Cell
Stratifying for patients at high and low risk of structural disease
Because resources are always limited in relation to needs, directing diagnostic tests only to those with a high probability of benefiting from having their diagnosis definitely established (e.g., those with peptic ulcer, gastric cancer) is valuable. One predictive factor is age49, 106, 123; Williams et al.49 noted that abnormal findings were made much more often in older people compared with younger people. The frequency of abnormal findings in older people was 69% by endoscopy and 58% by
Natural history of dyspepsia
Patients with functional dyspepsia typically have a relapsing condition.8, 11, 21, 22, 136, 137, 138, 139 In one report,139 65% of those with dyspepsia at study entry reported the same symptom 3 years later. A U.S. study8 found that 86% still reported dyspepsia after 12–20 months, and a British study22 found dyspepsia was present in 74% of the cases after 2 years. Chronic peptic ulcer is also a relapsing disease unless H. pylori is eradicated or maintenance therapy is given; symptomatic relapse
Decision analyses on management of dyspepsia
Many investigators have used decision analysis to evaluate alternate strategies for the diagnosis or management of patients with dyspepsia. A systematic review of all published decision analysis was undertaken.109, 144, 145, 146, 147, 148, 149, 150, 151, 152, 153, 154, 155 These decision analyses differ in the clinical problem addressed (peptic ulcer disease or dyspepsia), the perspective of the analysis, the time frame considered, the underlying causes considered in the analysis, the patients
Trials of management strategies
There is some, albeit limited, empiric evidence that the frequently recommended conservative strategy of an initial trial of empiric therapy in younger patients before investigation is nearly as costly as a strategy of initial investigation and may be less satisfying to the patient.60, 156 In a randomized study in a family physician setting, Goulston et al.157 compared an “Australian strategy,” which required a positive diagnosis of an ulcer or ulcerative esophagitis at endoscopy or radiography
Treat or investigate: A close call
Based on the literature review and review of the available decision analyses and trials, noninvasive testing and empiric H. pylori treatment seems to represent an acceptable strategy and may be the least expensive approach. How much will be saved in the long term over a strategy of endoscoping all cases on presentation largely depends on the costs of endoscopy, the cost of physician visits, and the symptom recurrence rate.
Recommendations to manage patients with dyspepsia by empiric H. pylori
Conclusions
While management must be individualized, based on the available evidence the following is concluded regarding strategies for management of new adult patients with chronic or recurrent dyspepsia in Western nations. Endoscopy remains the gold standard approach because it is still the optimal means of establishing a firm diagnosis, targeting therapy, and providing adequate reassurance. Prompt endoscopy is always indicated in older patients or in those with alarm features such as weight loss. This
Acknowledgements
The Clinical Practice and Practice Economics Committee acknowledges the following individuals whose critiques of this review paper provided valuable guidance to the authors: Naoki Chiba, M.D., F.R.C.P.C., Andrew H. Soll, M.D., Vincent A. DeLuca, M.D., and Mark Feldman, M.D.
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Address requests for reprints to: Chair, Clinical Practice and Practice Economics Committee, AGA National Office, 7910 Woodmont Avenue, 7th Floor, Bethesda, Maryland 20814. Fax: (301) 654-5920.
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Supported by the American Gastroenterological Association.