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Zullo A, De Francesco V, Amato A, Bergna I, Bendia E, Giorgini G, Buscarini E, Manfredi G, Cadoni S, Cannizzaro R, Realdon S, Ciuffi M, Ignomirelli O, Da Massa Carrara P, Finucci G, Di Somma A, Frandina C, Loria M, Galeazzi F, Ferrara F, Gemme C, Bertetti NS, Gentili F, Lotito A, Germanà B, Russo N, Grande G, Conigliaro R, Cravero F, Venezia G, Marmo R, Senneca P, Milano A, Efthymakis K, Monica F, Montalto P, Lombardi M, Morelli O, Castellani D, Nigro D, Festa R, Peralta S, Grasso M, Privitera A, Di Stefano ME, Scaccianoce G, Loiacono M, Segato S, Balzarini M, Satta PU, Lai M, Fortunato F, Manta R. Upper endoscopy in elderly patients: a multicentre, cross-sectional study. Ir J Med Sci 2024:10.1007/s11845-024-03774-7. [PMID: 39186194 DOI: 10.1007/s11845-024-03774-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2024] [Accepted: 07/31/2024] [Indexed: 08/27/2024]
Abstract
BACKGROUND Both macroscopic and histological lesions are frequently detected at upper endoscopy in elderly patients. We assessed the prevalence of main endoscopic and histological alterations in elderly (> 65 years old) patients. METHODS In this study, clinical, endoscopic and histological features of patients referred for upper endoscopy in clinical practice were retrieved. Both univariate and multivariate analyses were executed. Comparisons with previous data were performed. RESULTS A total of 1336 underwent upper endoscopy in the 28 participating centres. At endoscopy, at least one macroscopic lesion was present in overall 420 (31.4%) patients. Erosive gastritis (13.3%) and erosive oesophagitis (9.8%) were the most prevalent lesions, whilst Barrett's oesophagus, gastric ulcer, duodenal ulcer and erosive duodenitis were observed in 1.8%, 2%, 1.4% and 3.1% patients, respectively. Nine (0.6%) cases of oesophageal, 25 (1.8%) gastric and 2 (0.1%) duodenal neoplasia were detected. At histology, Helicobacter pylori infection was diagnosed in 99 (15.9%) patients, and extensive precancerous lesions on gastric mucosa were detected in 80 (14.5%) patients. Endoscopic lesions were more frequent in males, at first endoscopy and in those with alarm symptoms and lower during PPI therapy. At multivariate analysis, PPI therapy significantly reduced the probability of finding endoscopic lesions (OR: 0.68, 95% CI: 0.46-0.99; P = 0.04), whilst neoplastic lesions were associated with presence of alarm symptoms (OR: 1.5, 95% CI: 1.1-2.1; P = 0.005). CONCLUSIONS We found that the frequency of erosive and neoplastic lesions remained high in elderly patients, whilst the prevalence of both H. pylori infection and peptic ulcer was decreased.
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Affiliation(s)
- Angelo Zullo
- Gastroenterology and Endoscopy Unit, Nuovo Regina Margherita' Hospital, Rome, Italy
| | - Vincenzo De Francesco
- Gastroenterology and Endoscopy Unit, Department of Medical and Surgical Sciences, Policlinico 'Riuniti Hospitals', University of Foggia, Viale L. Pinto, 71100, Foggia, Italy.
| | - Arnaldo Amato
- Gastroenterology Unit, 'A. Manzoni' Hospital, Lecco, Italy
| | - Irene Bergna
- Gastroenterology Unit, 'A. Manzoni' Hospital, Lecco, Italy
| | | | | | | | - Guido Manfredi
- Gastroenterology and Endoscopy Unit, 'Maggiore' Hospital, Crema, CR, Italy
| | - Sergio Cadoni
- Gastroenterology Unit, 'CTO' Hospital, Iglesias, Italy
| | - Renato Cannizzaro
- Experimental Oncological Gastroenterology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, PN, Italy
| | - Stefano Realdon
- Experimental Oncological Gastroenterology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, PN, Italy
| | - Mario Ciuffi
- Endoscopy Unit, IRCCS CROB' Hospital, Rionero in Vulture, PZ, Italy
| | | | | | - Giovanni Finucci
- Gastroenterology Unit, ASL Toscana Nord-Ovest, 'San Luca' Hospital, Lucca, Italy
| | | | - Chiara Frandina
- Gastroenterology Unit, 'S. Giovanni di Dio' Hospital, Crotone, Italy
| | | | | | | | - Carlo Gemme
- Gastroenterology Unit, 'SS. Antonio, Biagio e Cesare Arrigo' Hospital, Alessandria, Italy
| | - Noemi Sara Bertetti
- Gastroenterology Unit, 'SS. Antonio, Biagio e Cesare Arrigo' Hospital, Alessandria, Italy
| | | | - Antonio Lotito
- Gastroenterology Unit, Santa Maria' Hospital, Terni, Italy
| | | | - Nunzia Russo
- Gastroenterology and Endoscopy Unit, San Martino' Hospital, Belluno, Italy
| | - Giuseppe Grande
- Gastroenterology Unit, Civile Baggiovara' Hospital, Modena, Italy
| | - Rita Conigliaro
- Gastroenterology Unit, Civile Baggiovara' Hospital, Modena, Italy
| | - Federico Cravero
- Gastroenterology Unit, Santa Croce e Carle' Hospital, Cuneo, Italy
| | - Giovanna Venezia
- Gastroenterology Unit, Santa Croce e Carle' Hospital, Cuneo, Italy
| | - Riccardo Marmo
- Gastroenterology Unit, 'L. Curto' Hospital, Polla, SA, Italy
| | - Piera Senneca
- Gastroenterology Unit, 'L. Curto' Hospital, Polla, SA, Italy
| | - Angelo Milano
- Gastroenterology and Endoscopy Unit, 'SS. Annunziata' Hospital, Chieti, Italy
| | | | - Fabio Monica
- Gastroenterology Unit, 'San Giovanni di Dio' Hospital, Gorizia, Italy
- Gastroenterology and Endoscopy Unit, 'Cattinara' Hospital, Trieste, Italy
| | - Paolo Montalto
- Gastroenterology Unit, ASL Toscana Centro, Pistoia, Italy
| | - Mario Lombardi
- Gastroenterology Unit, ASL Toscana Centro, Pistoia, Italy
| | - Olivia Morelli
- Gastroenterology Unit, Santa Maria della Misericordia' Hospital, Perugia, Italy
| | - Danilo Castellani
- Gastroenterology Unit, Santa Maria della Misericordia' Hospital, Perugia, Italy
| | - Daniela Nigro
- Gastroenterology Unit, San Carlo' Hospital, Melfi, PZ, Italy
| | - Roberto Festa
- Gastroenterology Unit, San Carlo' Hospital, Melfi, PZ, Italy
| | - Sergio Peralta
- Gastroenterology Unit, 'AOU Policlinico' Hospital, Palermo, Italy
| | - Maria Grasso
- Gastroenterology Unit, 'AOU Policlinico' Hospital, Palermo, Italy
| | | | | | | | | | - Sergio Segato
- Gastroenterology Unit, ASST dei Sette Laghi' Hospital, Varese, Italy
| | - Marco Balzarini
- Gastroenterology Unit, ASST dei Sette Laghi' Hospital, Varese, Italy
| | | | | | - Francesca Fortunato
- Hygiene Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Raffaele Manta
- Gastroenterology Unit, ASL Toscana Nord-Ovest, 'San Luca' Hospital, Lucca, Italy
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Vales A, Coyle C, Plehhova K, Hobson A, Woodland P. Randomised clinical trial: the use of alginates during preinvestigation proton pump inhibitor wash-out and their impact on compliance and symptom burden. BMJ Open Gastroenterol 2023; 10:bmjgast-2022-001026. [PMID: 36627148 PMCID: PMC9835863 DOI: 10.1136/bmjgast-2022-001026] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 11/18/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND/AIMS Investigation of gastro-oesophageal reflux disease is usually performed off proton pump inhibitors (PPIs). This can exacerbate symptoms, potentially impacting investigation accuracy if patients circumvent the preinvestigation instructions. There are no standard recommendations on how to manage PPI withdrawal. We aimed to assess the impact of structured alginate use on symptom burden. METHODS Participants were already established on ≥4 weeks of PPI therapy and being referred for manometry and 24-hour pH/impedance testing. Preinvestigation instructions involved stopping PPIs and H2 receptor antagonists for 1 week, but antacids and alginates were allowed until the night before. Participants were randomised to follow these standard instructions (control group), or the same instructions with the provision of Gaviscon Advance to be taken four times daily (treatment group). The primary outcome assessed change in Gastro-Oesophageal Reflux Disease Health-Related Quality of Life Score. KEY RESULTS Data for 48 patients were available for primary outcome assessment. While patients in the control group had a significant increase in symptoms (median difference 6.5, 95% CI (1 to 7), p=0.04), no change occurred in the treatment arm (median difference -1.5, 95% CI (-2, 3.5), p=0.54). There were no serious adverse events. CONCLUSIONS Structured alginate use prevents symptom exacerbation during preinvestigation PPI wash-out. These findings are limited to the 1-week wash-out period but can benefit thousands of patients undergoing investigation for gastro-oesophageal reflux each year. Further research is required to assess this effect in other settings, such as sustained PPI deprescription. The trial was funded by Reckitt Benckiser. TRIAL REGISTRATION NUMBER EudraCT registration 2019-004561-41.
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Castaño-Llano R, Piñeres A, Jaramillo R, Molina S, Aristizábal F, Puerta JE. Interval gastric cancer: A call to attentiveness and action. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2022; 88:91-99. [PMID: 35659441 DOI: 10.1016/j.rgmxen.2022.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 05/25/2021] [Indexed: 10/18/2022]
Abstract
INTRODUCTION AND AIMS Endoscopy is the most effective method for identifying gastric adenocarcinoma (GAC). Interval gastric cancer (IGC) is GAC that is diagnosed 2-3 years after a normal endoscopy. Its characteristics are unknown in the Colombian environment. The clinical, histopathologic, and endoscopic characteristics were evaluated, along with the presentation rate, proton pump inhibitor (PPI) use, and IGC survival rate, and compared with other types of GAC. METHODS A retrospective, analytic study was conducted on a prospective cohort. It evaluated 513 patients with GAC treated at our institution, within the time frame of January 2012 and June 2018. The patients had endoscopic diagnosis of GAC and endoscopy within the past three years that was negative for tumor. RESULTS A total of 513 patients diagnosed with GAC were evaluated. Forty-two of the patients had IGC (8.2%): 9 early lesions and 33 advanced lesions (79%). The IGCs were smaller (31 vs. 41 mm; P < .01), as well as flatter and more depressed (P < .01). There was no association with PPI use, but there was an association with a history of gastrectomy and anastomosis (P = .02), as well as the absence of red flags (P < .003). The most frequent locations were the gastric body (52%) and the antrum (26%). Overall two-year survival was similar between IGC and GAC (37.1 vs. 39.3%, P = .72). CONCLUSION A total of 8.2% of recently diagnosed GAC were cases of IGC. The presence of anastomosis and the absence of red flags were related to IGC. Overall survival was poor and there were no differences from the other types of GAC detected.
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Affiliation(s)
- R Castaño-Llano
- Cirugía Gastrointestinal y Endoscopia Clínica las Américas, Medellín, Antioquía, Colombia; Grupo de Gastro-Hepatología, Universidad de Antioquia, Medellín, Antioquía, Colombia; Instituto de Cancerología, Clínica las Américas, Medellín, Antioquía, Colombia.
| | - A Piñeres
- Cirugía Gastrointestinal y Endoscopia Clínica las Américas, Medellín, Antioquía, Colombia; Instituto de Cancerología, Clínica las Américas, Medellín, Antioquía, Colombia
| | - R Jaramillo
- Instituto de Cancerología, Clínica las Américas, Medellín, Antioquía, Colombia; Clínica las Américas, Medellín, Antioquía, Colombia
| | - S Molina
- Instituto de Cancerología, Clínica las Américas, Medellín, Antioquía, Colombia; Clínica las Américas, Medellín, Antioquía, Colombia
| | - F Aristizábal
- Instituto de Cancerología, Clínica las Américas, Medellín, Antioquía, Colombia; Clínica las Américas, Medellín, Antioquía, Colombia
| | - J E Puerta
- Universidad CES, Medellín, Antioquía, Colombia
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Socioeconomic and administrative factors associated with treatment delay of esophageal and gastric carcinoma: Prospective study from a tertiary care centre in a developing country. Cancer Epidemiol 2020; 67:101770. [PMID: 32593160 DOI: 10.1016/j.canep.2020.101770] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 06/08/2020] [Accepted: 06/13/2020] [Indexed: 12/24/2022]
Abstract
This study was aimed to analyze the spectrum of time intervals, from the onset of symptoms to the commencement of treatment in esophagogastric cancers. Factors influencing these time delays and correlation between these time points with variables including socioeconomic strata, educational level, histopathology, location of tumor and the initial modality of treatment were assessed. STUDY SETTING AND METHODS A prospective analysis of patients with esophagogastric cancer presenting to a single tertiary care unit over a period of 12 months was performed. Histopathology other than adenocarcinoma and squamous cell were excluded. RESULTS 202 patients were enrolled in the study. Most patients presented with advanced disease, i.e. 91.5 % of esophageal and 90 % of gastric malignancies belonged to either stage 3 or stage 4 as per American Joint Committee on Cancer (AJCC) tumor-node-metastasis (TNM) staging system. The median delay from the appearance of the first symptoms to initiation of treatment was 15 weeks (range 4-64). Patient related factors contributed to a significant delay [median of 5 weeks (range 1-24)]. Administrative factors were responsible for median delay of 3 weeks (range 0.5-20). Curative multimodality treatment was administered in 62.5 % of patients. Significant longer delay was influenced by socioeconomic strata, educational level, evaluation by non-specialist (p < 0.05). No relationship was noted between histopathology, location of tumor or initial modality of treatment. CONCLUSIONS Delays in our setting is much more than that is seen in Western and even some Asian countries. An important component of delay is administrative related factors. These may be intervened at the hospital level compared to other factors which may need long term community oriented approaches.
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Zullo A, Fiorini G, Bassotti G, Bachetti F, Monica F, Macor D, Paoluzi OA, Scaccianoce G, Portincasa P, De Francesco V, Lorenzetti R, Saracino IM, Pavoni M, Vaira D. Upper Endoscopy in Patients with Extra-Oesophageal Reflux Symptoms: A Multicentre Study. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2020; 27:312-317. [PMID: 32999903 DOI: 10.1159/000505581] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 12/09/2019] [Indexed: 01/10/2023]
Abstract
Background There are no evidence-based recommendations for performing upper gastrointestinal endoscopy (UGIE) in patients with extra-oesophageal symptoms of gastro-oesophageal reflux disease (GORD). However, UGIEs are often performed in clinical practice in these patients. We aimed to assess the prevalence of gastro-oesophageal lesions in patients with atypical GORD symptoms. Methods Patients complaining of at least one extra-oesophageal GORD symptom and undergoing UGIE in seven centres were prospectively enrolled. Clinically relevant lesions (Barrett's oesophagus, erosive oesophagitis, gastric precancerous conditions, peptic ulcer, cancer, and H. pylori infection) were statistically compared between groups regarding GORD symptoms (atypical vs. both typical and atypical), type of atypical symptoms, age, and presence of hiatal hernia. Results Two hundred eleven patients were enrolled (male/female: 74/137; mean age: 55.5 ± 14.7 years). Barrett's oesophagus was detected in 4 (1.9%), erosive oesophagitis in 12 (5.7%), gastric precancerous conditions in 22 (10.4%), and H. pylori infection in 38 (18%) patients. Prevalence of clinically relevant lesions was lower in patients with only atypical GORD symptoms (28.6 vs. 42.5%; p = 0.046; χ<sup>2</sup> test), in patients ≤50 years (20 vs. 44.8%; p = 0.004; χ<sup>2</sup> test), and in those in ongoing proton pump inhibitor (PPI) therapy (21.1 vs. 40.2%; p = 0.01; χ<sup>2</sup> test). No clinically relevant lesions were detected in patients ≤50 years, without alarm symptoms, and receiving PPI therapy. Hiatal hernia was diagnosed in only 6 patients with cardiologic and in 41 patients with ear-nose-throat symptoms (11.3 vs. 35.1%; p = 0.03; χ<sup>2</sup> test). Conclusions Clinically relevant lesions are uncommon among young (≤50 years) patients with extra-oesophageal GORD symptoms. Hiatal hernia is not more prevalent in patients with cardiologic symptoms and suspicion of GORD. The usefulness of UGIE in these patients is questionable.
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Affiliation(s)
- Angelo Zullo
- Gastroenterology and Digestive Endoscopy, Nuovo Regina Margherita Hospital, Rome, Italy
| | - Giulia Fiorini
- Department of Medical and Surgical Sciences, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Gabrio Bassotti
- Gastroenterology and Hepatology Section, Department of Medicine, University of Perugia Medical School, Perugia, Italy
| | - Francesco Bachetti
- Gastroenterology and Hepatology Section, Department of Medicine, University of Perugia Medical School, Perugia, Italy
| | - Fabio Monica
- Gastroenterology and Digestive Endoscopy, Academic Hospital Cattinara, Trieste, Italy
| | - Daniele Macor
- Gastroenterology and Digestive Endoscopy, Academic Hospital Cattinara, Trieste, Italy
| | - Omero Alessandro Paoluzi
- Gastroenterology Unit, Department of Systems Medicine, Tor Vergata University of Rome, Rome, Italy
| | - Giuseppe Scaccianoce
- Internal Medicine A. Murri, Department of Biomedical Sciences and Human Oncology, University of Bari, Bari, Italy
| | - Piero Portincasa
- Internal Medicine A. Murri, Department of Biomedical Sciences and Human Oncology, University of Bari, Bari, Italy
| | - Vincenzo De Francesco
- Section of Gastroenterology, Department of Medical Sciences, University of Foggia, Foggia, Italy
| | - Roberto Lorenzetti
- Gastroenterology and Digestive Endoscopy, Nuovo Regina Margherita Hospital, Rome, Italy
| | - Ilaria Maria Saracino
- Department of Medical and Surgical Sciences, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Matteo Pavoni
- Department of Medical and Surgical Sciences, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Dino Vaira
- Department of Medical and Surgical Sciences, S. Orsola Hospital, University of Bologna, Bologna, Italy
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Delgado Guillena PG, Morales Alvarado VJ, Jimeno Ramiro M, Rigau Cañardo J, Ramírez Salazar C, García Rodríguez A, Córdova Guevara H, Fernández Esparrach G. Gastric cancer missed at esophagogastroduodenoscopy in a well-defined Spanish population. Dig Liver Dis 2019; 51:1123-1129. [PMID: 30967337 DOI: 10.1016/j.dld.2019.03.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Revised: 03/07/2019] [Accepted: 03/12/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Although esophagogastroduodenoscopy (EGD) is the standard procedure for the diagnosis of gastric cancer (GC), some GCs are missed. There are no published data on the missed rate of GC in Spain. AIMS To determine the frequency and characteristics of missed GCs and assess the quality of the EGD in a specific population with GC. METHODS Records of all patients diagnosed with gastric adenocarcinoma between 2012 and 2016 in a defined geographic area were reviewed. Missed GC was defined as a case with a prior negative EGD for cancer. Quality indicators from the prior EGDs were measured. RESULTS From 212 cases of GC, 25 cases were excluded. Seventeen out of 187 patients had a prior EGD (9.1%). Twelve of those 17 missed GC had a prior EGD with some abnormal findings. In 6 of them, biopsies were taken. Survival was no different between patients with missed and non-missed GC. Quality indicators that failed to meet standards were recording time, image documentation, and a protocol of biopsies. CONCLUSIONS Missed GC in an EGD in a defined population in Spain is not uncommon (9.1%). The endoscopist is an important factor in missed GC due to lack of adequate detection and sampling error. Compliance with performance of quality indicators could reduce missed GC.
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Affiliation(s)
- Pedro Genaro Delgado Guillena
- Department of Gastroenterology, Hospital General de Granollers, Barcelona, Spain; Scientia Clinical and Epidemiological Research Institute, Trujillo, Peru.
| | | | | | | | | | | | - Henry Córdova Guevara
- Department of Gastroenterology, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Gloria Fernández Esparrach
- Department of Gastroenterology, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
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Hernanz N, Rodríguez de Santiago E, Marcos Prieto HM, Jorge Turrión MÁ, Barreiro Alonso E, Rodríguez Escaja C, Jiménez Jurado A, Sierra M, Pérez Valle I, Volpato N, García Prada M, Nuñez-Gómez L, Ríos-León R, Castaño García A, García de Paredes AG, Aicart M, Caminoa A, Peñas Parcía B, Vázquez-Sequeiros E, Albillos A. Characteristics and consequences of missed gastric cancer: A multicentric cohort study. Dig Liver Dis 2019; 51:894-900. [PMID: 30898522 DOI: 10.1016/j.dld.2019.02.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 02/09/2019] [Accepted: 02/11/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Missed gastric cancer (MGC) is poorly documented in Mediterranean populations. AIMS (1) To assess the rate, predictors and survival of MGC. (2) To compare MGC and non-MGC tumors. METHODS This is a retrospective-cohort study conducted at four centers. MGC was defined as cancer detected within three years after negative esophagogastroduodenoscopy. Gastric adenocarcinomas diagnosed between 2008-2015 were included. Patients with no follow-up were excluded. RESULTS During the study period 123,395 esophagogastroduodenoscopies were performed, with 1374 gastric cancers being diagnosed (1.1%). A total of 1289 gastric cancers were finally included. The overall rate of MGC was 4.7% (61/1289, 3.7-6%). A negative esophagogastroduodenoscopy in MGC patients was independently associated with PPI therapy (p < 0.001), previous Billroth II anastomosis (p = 0.002), and lack of alarm symptoms (p < 0.001). The most frequent location for MGC was the gastric body(52.4%). MGCs were smaller than non-MGCs (31 vs 41 mm, p = 0.047), more often flat or depressed (p = 0.003) and less likely to be encountered as advanced disease. Overall 2-year survival was similar between MGC (34.1%) and Non-MGC (35.3 %) (p = 0.59). CONCLUSION MGC accounted for nearly five percent of newly-diagnosed gastric adenocarcinomas. Overall survival was poor and not different between MGC and non-MGC.
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Affiliation(s)
- Nerea Hernanz
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, University of Alcala, Spain
| | - Enrique Rodríguez de Santiago
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, University of Alcala, Spain; Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS),Spain.
| | | | | | | | - Carlos Rodríguez Escaja
- Department of Gastroenterology and Hepatology, Hospital Universitario Central de Asturias, Spain
| | - Andrea Jiménez Jurado
- Gastroenterology department, Hospital Universitario de Salamanca, University of Salamanca, IBSAL, Spain
| | - María Sierra
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, University of Alcala, Spain
| | | | - Nadja Volpato
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, University of Alcala, Spain
| | - María García Prada
- Gastroenterology department, Hospital Universitario de Salamanca, University of Salamanca, IBSAL, Spain
| | - Laura Nuñez-Gómez
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, University of Alcala, Spain
| | - Raquel Ríos-León
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, University of Alcala, Spain
| | - Andrés Castaño García
- Gastroenterology department, Hospital Universitario de Salamanca, University of Salamanca, IBSAL, Spain
| | - Ana García García de Paredes
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, University of Alcala, Spain
| | - Marta Aicart
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, University of Alcala, Spain
| | - Alejandra Caminoa
- Department of Pathology, Hospital Universitario Ramón y Cajal, University of Alcala, Spain
| | - Beatriz Peñas Parcía
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, University of Alcala, Spain; Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS),Spain
| | - Enrique Vázquez-Sequeiros
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, University of Alcala, Spain; Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS),Spain
| | - Agustín Albillos
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, University of Alcala, Spain; Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS),Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Spain
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White JR, Sami SS, Reddiar D, Mannath J, Ortiz-Fernández-Sordo J, Beg S, Scott R, Thiagarajan P, Ahmad S, Parra-Blanco A, Kasi M, Telakis E, Sultan AA, Davis J, Figgins A, Kaye P, Robinson K, Atherton JC, Ragunath K. Narrow band imaging and serology in the assessment of premalignant gastric pathology. Scand J Gastroenterol 2018; 53:1611-1618. [PMID: 30600732 DOI: 10.1080/00365521.2018.1542455] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Patient outcomes in gastric adenocarcinoma are poor due to late diagnosis. Detecting and treating at the premalignant stage has the potential to improve this. Helicobacter pylori is also a strong risk factor for this disease. AIMS Primary aims were to assess the diagnostic accuracy of magnified narrow band imaging (NBI-Z) endoscopy and serology in detecting normal mucosa, H. pylori gastritis and gastric atrophy. Secondary aims were to compare the diagnostic accuracies of two classification systems using both NBI-Z and white light endoscopy with magnification (WLE-Z) and evaluate the inter-observer agreement. METHODS Patients were prospectively recruited. Images of gastric mucosa were stored with histology and serum for IgG H. pylori and Pepsinogen (PG) I/II ELISAs. Blinded expert endoscopists agreed on mucosal pattern. Mucosal images and serological markers were compared with histology. Kappa statistics determined inter-observer variability for randomly allocated images among four experts and four non-experts. RESULTS 116 patients were prospectively recruited. Diagnostic accuracy of NBI-Z for determining normal gastric mucosa was 0.87(95%CI 0.82-0.92), H. pylori gastritis 0.65(95%CI 0.55-0.75) and gastric atrophy 0.88(95%CI 0.81-0.94). NBI-Z was superior to serology at detecting gastric atrophy: NBI-Z gastric atrophy 0.88(95%CI 0.81-0.94) vs PGI/II ratio < 3 0.74(95%CI 0.62-0.85) p<.0001. Overall NBI-Z was superior to WLE-Z in detecting disease using two validated classifications. Inter-observer agreement was 0.63(95%CI 0.51-0.73). CONCLUSIONS NBI-Z accurately detects changes in the GI mucosa which currently depend on histology. NBI-Z is useful in the detection of precancerous conditions, potentially improving patient outcomes with early intervention to prevent gastric cancer.
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Affiliation(s)
- Jonathan R White
- a 1 NIHR Nottingham Biomedical Research Centre , Nottingham University Hospitals NHS Trust and The University of Nottingham , Nottingham , UK.,b 2 Nottingham Digestive Diseases Centre , The University of Nottingham , Nottingham , UK
| | - Sarmed S Sami
- c 3 Mayo Clinic Division of Gastroenterology and Hepatology , Rochester , MN, USA
| | - Dona Reddiar
- a 1 NIHR Nottingham Biomedical Research Centre , Nottingham University Hospitals NHS Trust and The University of Nottingham , Nottingham , UK.,b 2 Nottingham Digestive Diseases Centre , The University of Nottingham , Nottingham , UK
| | - Jayan Mannath
- d 4 Department of Gastroenterology , University Hospitals Coventry and Warwickshire NHS Trust , Coventry , UK
| | - Jacobo Ortiz-Fernández-Sordo
- a 1 NIHR Nottingham Biomedical Research Centre , Nottingham University Hospitals NHS Trust and The University of Nottingham , Nottingham , UK.,b 2 Nottingham Digestive Diseases Centre , The University of Nottingham , Nottingham , UK
| | - Sabina Beg
- a 1 NIHR Nottingham Biomedical Research Centre , Nottingham University Hospitals NHS Trust and The University of Nottingham , Nottingham , UK.,b 2 Nottingham Digestive Diseases Centre , The University of Nottingham , Nottingham , UK
| | - Robert Scott
- a 1 NIHR Nottingham Biomedical Research Centre , Nottingham University Hospitals NHS Trust and The University of Nottingham , Nottingham , UK.,b 2 Nottingham Digestive Diseases Centre , The University of Nottingham , Nottingham , UK
| | - Prarthana Thiagarajan
- a 1 NIHR Nottingham Biomedical Research Centre , Nottingham University Hospitals NHS Trust and The University of Nottingham , Nottingham , UK.,b 2 Nottingham Digestive Diseases Centre , The University of Nottingham , Nottingham , UK
| | - Saqib Ahmad
- e 5 Sherwood Forest Hospitals NHS Foundation Trust, Kings Mill Hospital , Nottinghamshire , UK
| | - Adolfo Parra-Blanco
- a 1 NIHR Nottingham Biomedical Research Centre , Nottingham University Hospitals NHS Trust and The University of Nottingham , Nottingham , UK.,b 2 Nottingham Digestive Diseases Centre , The University of Nottingham , Nottingham , UK
| | - Madhavi Kasi
- a 1 NIHR Nottingham Biomedical Research Centre , Nottingham University Hospitals NHS Trust and The University of Nottingham , Nottingham , UK.,b 2 Nottingham Digestive Diseases Centre , The University of Nottingham , Nottingham , UK
| | - Emmanouil Telakis
- f 6 Department of Gastroenterology , Hellenic Red Cross Hospital , Athens , Greece
| | - Alyshah A Sultan
- g 7 Research Institute for Primary Care and Health Sciences, Primary Care Sciences , Keele University , Staffordshire , UK
| | - Jillian Davis
- h 8 Department of Pathology , Nottingham University Hospitals NHS Trust, Queen's Medical Centre Campus , Nottingham , UK
| | - Adam Figgins
- h 8 Department of Pathology , Nottingham University Hospitals NHS Trust, Queen's Medical Centre Campus , Nottingham , UK
| | - Philip Kaye
- h 8 Department of Pathology , Nottingham University Hospitals NHS Trust, Queen's Medical Centre Campus , Nottingham , UK
| | - Karen Robinson
- a 1 NIHR Nottingham Biomedical Research Centre , Nottingham University Hospitals NHS Trust and The University of Nottingham , Nottingham , UK.,b 2 Nottingham Digestive Diseases Centre , The University of Nottingham , Nottingham , UK
| | - John C Atherton
- a 1 NIHR Nottingham Biomedical Research Centre , Nottingham University Hospitals NHS Trust and The University of Nottingham , Nottingham , UK.,b 2 Nottingham Digestive Diseases Centre , The University of Nottingham , Nottingham , UK
| | - Krish Ragunath
- a 1 NIHR Nottingham Biomedical Research Centre , Nottingham University Hospitals NHS Trust and The University of Nottingham , Nottingham , UK.,b 2 Nottingham Digestive Diseases Centre , The University of Nottingham , Nottingham , UK
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9
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Rodríguez de Santiago E, Hernanz N, Marcos-Prieto HM, De-Jorge-Turrión MÁ, Barreiro-Alonso E, Rodríguez-Escaja C, Jiménez-Jurado A, Sierra-Morales M, Pérez-Valle I, Machado-Volpato N, García-Prada M, Núñez-Gómez L, Castaño-García A, García García de Paredes A, Peñas B, Vázquez-Sequeiros E, Albillos A. Rate of missed oesophageal cancer at routine endoscopy and survival outcomes: A multicentric cohort study. United European Gastroenterol J 2018; 7:189-198. [PMID: 31080603 DOI: 10.1177/2050640618811477] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 10/15/2018] [Indexed: 02/06/2023] Open
Abstract
Background Missed oesophageal cancer (MEC) at upper gastrointestinal endoscopy (UGE) is poorly documented. Objective The objectives of this study were: (1) to assess the rate, predictors and survival of MEC; (2) to compare MEC and non-MEC tumours. Methods This was a retrospective cohort study conducted at four tertiary centres. Oesophageal cancers (ECs) diagnosed between 2008 and 2015 were included. Patients with a premalignant condition (Barrett, achalasia), prior diagnosis of EC or oesophagogastric junction tumour of gastric origin were excluded. MEC was defined as EC detected within 36 months after negative UGE. Results 123,395 UGEs were performed during the study period, with 502 ECs being diagnosed (0.4%). A total of 391 ECs were finally included. Overall MEC rate was 6.4% (95% confidence intervals (CI): 4.4-9.3%). The interval between negative and diagnostic UGE was less than 2 years in 84% of the cases. Multivariate analysis showed that a negative endoscopy was associated with proton pump inhibitor (PPI) therapy and less experienced endoscopists. MEC was smaller than non-MEC at diagnosis (25 versus 40 mm, p = 0.021), more often flat or depressed (p = 0.013) and less frequently diagnosed as metastatic disease (p = 0.013). Overall 2-year survival rate was similar for MEC (20%) and non-MEC (24.1%) (p = 0.95). Conclusions MEC accounted for 6.4% of all ECs and was associated with poor survival. High-quality UGE and awareness of MEC may help to reduce its incidence.
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Affiliation(s)
- Enrique Rodríguez de Santiago
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, University of Alcala, Madrid, Spain.,Instituto Ramón y Cajal de Investigación Biosanitaria (IRYCIS), Madrid, Spain
| | - Nerea Hernanz
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, University of Alcala, Madrid, Spain
| | - Héctor Miguel Marcos-Prieto
- Gastroenterology Department, Hospital Universitario de Salamanca, University of Salamanca, IBSAL (Instituto de Investigación Biomédica de Salamanca), Salamanca, Spain
| | | | | | - Carlos Rodríguez-Escaja
- Department of Gastroenterology and Hepatology, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Andrea Jiménez-Jurado
- Gastroenterology Department, Hospital Universitario de Salamanca, University of Salamanca, IBSAL (Instituto de Investigación Biomédica de Salamanca), Salamanca, Spain
| | - María Sierra-Morales
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, University of Alcala, Madrid, Spain
| | | | - Nadja Machado-Volpato
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, University of Alcala, Madrid, Spain
| | - María García-Prada
- Gastroenterology Department, Hospital Universitario de Salamanca, University of Salamanca, IBSAL (Instituto de Investigación Biomédica de Salamanca), Salamanca, Spain
| | - Laura Núñez-Gómez
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, University of Alcala, Madrid, Spain
| | - Andrés Castaño-García
- Gastroenterology Department, Hospital Universitario de Salamanca, University of Salamanca, IBSAL (Instituto de Investigación Biomédica de Salamanca), Salamanca, Spain
| | - Ana García García de Paredes
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, University of Alcala, Madrid, Spain
| | - Beatriz Peñas
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, University of Alcala, Madrid, Spain.,Instituto Ramón y Cajal de Investigación Biosanitaria (IRYCIS), Madrid, Spain
| | - Enrique Vázquez-Sequeiros
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, University of Alcala, Madrid, Spain.,Instituto Ramón y Cajal de Investigación Biosanitaria (IRYCIS), Madrid, Spain
| | - Agustín Albillos
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, University of Alcala, Madrid, Spain.,Instituto Ramón y Cajal de Investigación Biosanitaria (IRYCIS), Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
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10
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Liu LWC, Andrews CN, Armstrong D, Diamant N, Jaffer N, Lazarescu A, Li M, Martino R, Paterson W, Leontiadis GI, Tse F. Clinical Practice Guidelines for the Assessment of Uninvestigated Esophageal Dysphagia. J Can Assoc Gastroenterol 2018; 1:5-19. [PMID: 31294391 PMCID: PMC6487990 DOI: 10.1093/jcag/gwx008] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND AND AIMS Our aim is to review the literature and provide guidelines for the assessment of uninvestigated dysphagia. METHODS A systematic literature search identified studies on dysphagia. The quality of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development, and Evaluation (GRADE) approach. Statements were discussed and revised via small group meetings, teleconferences, and a web-based platform until consensus was reached by the full group. RESULTS The consensus includes 13 statements focused on the role of strategies for the assessment of esophageal dysphagia. In patients presenting with dysphagia, oropharyngeal dysphagia should be identified promptly because of the risk of aspiration. For patients with esophageal dysphagia, history can be used to help differentiate structural from motility disorders and to elicit alarm features. An empiric trial of proton pump inhibitor therapy should be limited to four weeks in patients with esophageal dysphagia who have reflux symptoms and no additional alarm features. For patients with persistent dysphagia, endoscopy, including esophageal biopsy, was recommended over barium esophagram for the assessment of structural and mucosal esophageal disease. Barium esophagram may be useful when the availability of endoscopy is limited. Esophageal manometry was recommended for diagnosis of esophageal motility disorders, and high-resolution was recommended over conventional manometry. CONCLUSIONS Once oropharyngeal dysphagia is ruled out, patients with symptoms of esophageal dysphagia should be assessed by history and physical examination, followed by endoscopy to identify structural and inflammatory lesions. If these are ruled out, then manometry is recommended for the diagnosis of esophageal dysmotility.
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Affiliation(s)
- Louis W C Liu
- Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, ON
| | - Christopher N Andrews
- Division of Gastroenterology, Department of Medicine, University of Calgary, Calgary, AB
| | | | - Nicholas Diamant
- Division of Gastroenterology, Department of Medicine, Queen’s University, Kingston, ON
| | - Nasir Jaffer
- Department of Medical Imaging, Mount Sinai Hospital, Toronto, ON
| | | | - Marilyn Li
- Division of Gastroenterology, Department of Medicine, Queen’s University, Kingston, ON
| | - Rosemary Martino
- Department of Speech-Language Pathology, University of Toronto, Toronto, ON
| | - William Paterson
- Division of Gastroenterology, Department of Medicine, Queen’s University, Kingston, ON
| | | | - Frances Tse
- Department of Medicine, McMaster University, Hamilton, ON
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11
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Missing rate for gastric cancer during upper gastrointestinal endoscopy: a systematic review and meta-analysis. Eur J Gastroenterol Hepatol 2016; 28:1041-9. [PMID: 27148773 DOI: 10.1097/meg.0000000000000657] [Citation(s) in RCA: 134] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Esophagogastroduodenoscopy (EGD) is considered a very effective method to identify gastric cancer (GC). However, the existence of missed lesions has been frequently discussed. This systematic review and meta-analysis aimed at assessing the magnitude of missing GC diagnosis with EGD and its predictive factors. METHODS MEDLINE was searched to identify all studies assessing and reporting the proportion of missed GC diagnosis with EGD. Pooled proportion and negative predictive values were computed using the random-effects model and heterogeneity was assessed using the Cochrane Q-test and I. RESULTS The studies included (n=22) were grouped by study design. The pooled negative predictive value was 99.7% (95% confidence interval 99.6-99.9%). Missed GCs proportion was 9.4% (95% confidence interval 5.7-13.1%), being 10.0% in studies including patients with negative EGD followed over time, 8.3% in studies including patients with GC, and 23.3% in studies evaluating the proportion of missed synchronous lesions. Mainly, missed cancers were located in the gastric body both in Eastern and in Western studies (39 and 47%, respectively). The majority of missed GCs were adenocarcinomas. Younger age (<55 years), female sex, marked gastric atrophy, gastric adenoma or ulcer, and inadequate number of biopsy fragments were reported as predictive factors for diagnostic failure. CONCLUSION EGD is a very effective method to rule out GC. However, missing GC with EGD is not uncommon, with one out of 10 cancers being potentially missed. Interestingly, lesions were more often missed in the body and therefore a more rigorous protocol for endoscopy and biopsy should be implemented worldwide.
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12
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Gastric Cancers Missed During Endoscopy in England. Clin Gastroenterol Hepatol 2015; 13:1264-1270.e1. [PMID: 25645877 DOI: 10.1016/j.cgh.2015.01.025] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Revised: 01/13/2015] [Accepted: 01/23/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Single-center studies have estimated that 4.6% to 25.8% of gastric cancers are missed at endoscopy. We performed a population-based study to make a more precise estimate of factors associated with missed lesions in England. METHODS We performed a retrospective population-based observational cohort study of 2727 patients diagnosed with gastric cancer from April 2011 through March 2012 in England, using linked records from 3 national data sets. The primary outcome was the proportion of patients who had undergone endoscopy in the 3 to 36 months before a diagnosis of gastric cancer. We determined this proportion for the entire cohort and for subgroups. RESULTS Of the 2727 patients in the cohort, 8.3% (95% confidence interval, 7.2%-9.3%) underwent endoscopic evaluation in the 3 to 36 months before their diagnosis of gastric cancer. An endoscopy within 3 to 36 months of diagnosis was associated with a diagnosis of early stage cancer (stages 0 or 1, 11.5%; stage 2, 7.9%; stages 3 or 4, 6.9%; P = .01 for stage 0 or 1 vs stage 2 or greater), younger age at diagnosis (<55 y, 13.3% vs ≥55 y, 7.8%; P = .03), and female sex (10% of women vs 7.3% of men; P = .01). Gastric ulcers were detected in 15% of endoscopies performed at any time in the 3 years before cancer diagnosis, and in 64% of endoscopies performed 3 to 6 months before a diagnosis of gastric cancer. CONCLUSIONS Based on a retrospective analysis of medical records in England, in 8.3% of patients with gastric cancer, their cancer was missed at endoscopy within the 3 previous years. A previous endoscopy detected benign gastric ulcers more frequently than any other lesion in patients who later were diagnosed with gastric cancer.
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13
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Zullo A, Esposito G, Ridola L, Hassan C, Lahner E, Perri F, Bianco MA, De Francesco V, Buscarini E, Di Giulio E, Annibale B. Prevalence of lesions detected at upper endoscopy: an Italian survey. Eur J Intern Med 2014; 25:772-6. [PMID: 25245606 DOI: 10.1016/j.ejim.2014.08.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 08/27/2014] [Accepted: 08/28/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Prevalence of gastroduodenal lesions is changing in the last decades. Prevalence of Helicobacter pylori infection, non-steroidal anti-inflammatory drugs (NSAIDs), and proton pump inhibitor (PPI) therapy may be involved in such a phenomenon. We assessed gastroduodenal lesions prevalence in a nationwide study. MATERIALS AND METHODS Consecutive patients who underwent upper endoscopy for the first time in 24 Italian centres between January 2012 and 31 March 2012 were enrolled. Prevalence of gastric ulcer (GU), duodenal ulcer (DU), gastric erosions (GE), duodenal erosions (DE), gastric polyp (GP), Barrett's oesophagus (BE), and neoplasia was assessed. RESULTS Overall, 1054 (M/F: 388/666; Mean age: 57.5 ± 5 years) patients were enrolled. H. pylori infection was detected in 356 (33.9%) patients, 358 (34%) were taking NSAIDs, and 532 (50.5%) PPIs. PPI therapy was associated with a significantly lower H. pylori detection rate (27.8% vs 39.8%; OR: 0.6, 95% CI 0.45-0.77; P<0.001). GU, DU, GE, DE, GP and BE were detected in 17 (1.6%), 13 (1.2%), 150 (14.2%), 50 (4.7%), 51 (4.8%) and 17 (1.6%), respectively. Moreover, 3 (0.3%) distal gastric cancers were observed. H. pylori infection remained the most prevalent factor for all gastroduodenal lesions, but gastric polyp. One third of patients with GU and GE were taking only NSAIDs therapy. CONCLUSIONS The prevalence of peptic ulcer was very low (<3%), with a similar rate between DU and GU. As many as half patients were on ongoing PPI therapy. Such a therapy could affect both the detection rate of H. pylori infection and the real prevalence of gastroduodenal lesions.
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Affiliation(s)
- Angelo Zullo
- Gastroenterology and Digestive Endoscopy, 'Nuovo Regina Margherita' Hospital, Rome, Italy.
| | - Gianluca Esposito
- Department of Digestive and Liver Disease, Sant'Andrea Hospital, University Sapienza of Rome, Rome, Italy
| | - Lorenzo Ridola
- Gastroenterology and Digestive Endoscopy, 'Nuovo Regina Margherita' Hospital, Rome, Italy
| | - Cesare Hassan
- Gastroenterology and Digestive Endoscopy, 'Nuovo Regina Margherita' Hospital, Rome, Italy
| | - Edith Lahner
- Department of Digestive and Liver Disease, Sant'Andrea Hospital, University Sapienza of Rome, Rome, Italy
| | - Francesco Perri
- Department of Gastroenterology and Digestive Endoscopy, "Casa Sollievo della Sofferenza" Hospital, IRCCS, San Giovanni Rotondo, Foggia, Italy
| | | | | | | | - Emilio Di Giulio
- Department of Digestive and Liver Disease, Sant'Andrea Hospital, University Sapienza of Rome, Rome, Italy
| | - Bruno Annibale
- Department of Digestive and Liver Disease, Sant'Andrea Hospital, University Sapienza of Rome, Rome, Italy
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14
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Gikas A, Triantafillidis JK. The role of primary care physicians in early diagnosis and treatment of chronic gastrointestinal diseases. Int J Gen Med 2014; 7:159-73. [PMID: 24648750 PMCID: PMC3958525 DOI: 10.2147/ijgm.s58888] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Chronic gastrointestinal disorders are a source of substantial morbidity, mortality, and cost. They are common in general practice, and the primary care physician (PCP) has a central role in the early detection and management of these problems. The need to make cost-effective diagnostic and treatment decisions, avoid unnecessary investigation and referral, provide long-term effective control of symptoms, and minimize the risk of complications constitute the main challenges that PCPs face. The literature review shows that, although best practice standards are available, a considerable number of PCPs do not routinely follow them. Low rates of colorectal cancer screening, suboptimal testing and treatment of Helicobacter pylori infection, inappropriate use of proton pump inhibitors, and the fact that most PCPs are still approaching the irritable bowel disease as a diagnosis of exclusion represent the main gaps between evidence-based guidelines and clinical practice. This manuscript points out that updating of knowledge and skills of PCPs via continuing medical education is the only way for better adherence with standards and improving quality of care for patients with gastrointestinal diseases.
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Corleto VD, Festa S, Di Giulio E, Annibale B. Proton pump inhibitor therapy and potential long-term harm. Curr Opin Endocrinol Diabetes Obes 2014; 21:3-8. [PMID: 24310148 DOI: 10.1097/med.0000000000000031] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE OF REVIEW This review summarizes the recent literature on the potential side-effects of proton pump inhibitors (PPIs) and known interactions with the metabolism/absorption of other drugs. RECENT FINDINGS Data confirm that PPIs are a very well tolerated drug class. Their high safety, efficacy and wide distribution lead to overuse, inappropriate dosage or excessive duration of treatment. Despite the absorption of micronutrients or other plausible effects on the development of bacterial infections linked to PPI-induced hypochlorhydria, it is difficult to demonstrate an association between PPI and specific symptoms. A possible negative effect of PPIs on bone integrity appears weak, but hypomagnesemia is likely a PPI drug class effect. A higher risk of Clostridium difficile infection and other infectious diseases such as small intestinal bacterial overgrowth and spontaneous bacterial peritonitis remain controversial in PPI users. However, the careful use of PPIs in cirrhotic or otherwise fragile patients is mandatory. Short-term or long-term PPI use may trigger microscopic colitis, and the management of this condition may include PPI withdrawal. The effect of PPIs on stimulating exocrine or endocrine gastric cell proliferation is poorly understood. A diagnostic delay or masking of diseases such as gastrinoma is difficult to evaluate. SUMMARY Short-term standard dose PPI treatment is low risk. Long-term PPI use may complicate health conditions by various mechanisms linked to PPIs and/or to hypochlorhydria.
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Affiliation(s)
- Vito Domenico Corleto
- aDepartment of Gastroenterology and Digestive Endoscopy, School of Medicine and Psychology, Sapienza University of Rome, Sant'Andrea Hospital bCentro Ricerche S. Pietro, Ospedale S. Pietro, Rome, Italy
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16
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MARK's Quadrant scoring system: a symptom-based targeted screening tool for gastric cancer. Ann Gastroenterol 2014; 27:34-41. [PMID: 24714557 PMCID: PMC3959528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2013] [Accepted: 07/01/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Gastric cancer is notably one of the leading causes of cancer-related death in the world. In Malaysia, these patients present in the advanced stage, thus narrowing the treatment options and making the surgery nearly impossible for successful curative resection. Failure to identify high-risk patients and delay in diagnostic endoscope procedure contributed to the delay in diagnosis. The aim of the study was to develop and validate a scoring system (MARK's Quadrant) which can identify symptomatic patients who are at risk for gastric cancer. METHODS A 3-phase approach was undertaken: Phase 1: development of the weighted scoring system; Phase 2: estimating positive predicting value of MARK's Quadrant; and Phase 3: a) testing the validity of MARK's Quadrant in an open-access endoscope system; and b) comparing its usefulness compared to conventional referral system. RESULTS In phases 1 and 2, MARK's Quadrant with weighted symptoms was developed. The sensitivity of MARK's Quadrant is 88% and the specificity is 45.5% to detect cancerous and precancerous lesions of gastric. This was confirmed by the prospective data from phase 3 of this study where the diagnostic yield of MARK's Quadrant to detect any pathological lesion was 95.2%. This score has a high accuracy efficiency of 75%, hence comparing to routine referral system it has an odds ratio (95%CI) of 10.98 (4.63-26.00), 6.71 (4.46-10.09) and 0.95 (0.06-0.15) (P<0.001 respectively) for cancer, precancerous lesion and benign lesion diagnosis respectively. CONCLUSION MARK's Quadrant is a useful tool to detect early gastric cancer among symptomatic patients in a low incidence region.
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Hamzat H, Sun H, Ford JC, Macleod J, Soiza RL, Mangoni AA. Inappropriate prescribing of proton pump inhibitors in older patients: effects of an educational strategy. Drugs Aging 2013; 29:681-90. [PMID: 22775478 DOI: 10.1007/bf03262283] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND An increasing number of older patients are prescribed proton pump inhibitors (PPIs). However, the extent of inappropriate PPI prescribing in this group is largely unknown. OBJECTIVE We sought to identify clinical and demographic factors associated with inappropriate PPI prescribing in older patients and to assess the effects of a targeted educational strategy in a controlled hospital environment. METHODS Clinical and demographic characteristics and full medication exposure on admission were recorded in 440 consecutive older patients (mean ± SD age 84 ± 7 years) admitted to a teaching hospital between 1 February 2011 and 30 June 2011. A 4-week educational strategy to reduce inappropriate PPI prescribing during hospital stay, either by stopping or reducing PPI doses, was conducted within the study period. The main outcome measures of the study were the incidence of inappropriate PPI prescribing and the effects of interventions to reduce it. RESULTS On admission, PPIs were established therapy in 164 patients (37%). This was considered inappropriate in 100 patients (61%). Lower Charlson Comorbidity Index score (odds ratio [OR] 0.76; 95% CI 0.57, 0.94; p = 0.006) and history of dementia (OR 1.65; 95% CI 1.28, 1.83; p = 0.005) were independently associated with inappropriate PPI prescribing. Interventions to reduce inappropriate PPI prescribing occurred more frequently during and after the education phase (frequency of interventions in patients with inappropriate PPI prescribing: pre-education phase 9%, during education phase 43%, and post-education phase 46%, p = 0.006). Prescribing interventions were not associated with acid rebound symptoms. CONCLUSIONS Inappropriate PPI prescribing in older patients is frequent and independently associated with co-morbidities and dementia. A targeted in-hospital educational strategy can significantly and safely reduce inappropriate PPI prescribing in the short term.
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Affiliation(s)
- Hanifat Hamzat
- Division of Applied Medicine, University of Aberdeen, Aberdeen, UK
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Gisbert JP, Calvet X, Ferrándiz J, Mascort J, Alonso-Coello P, Marzo M. [Clinical practice guideline on the management of patients with dyspepsia. Update 2012]. Aten Primaria 2012; 44:727.e1-727.e38. [PMID: 23036729 PMCID: PMC7025630 DOI: 10.1016/j.aprim.2012.05.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Accepted: 05/30/2012] [Indexed: 12/13/2022] Open
Abstract
The aim of the Clinical Practice Guideline (CPG) on the Management of Patients with Dyspepsia is to generate recommendations on the optimal approach to dyspepsia in the primary care and specialized outpatient setting. The main objective of this CPG is to help to optimize the diagnostic process, identifying patients with a low risk of a serious organic disease (mainly tumoral), who could be safely managed without the need for invasive diagnostic tests and/or referral to a specialist. The importance of this aim lies in the need to accurately diagnose patients with esophagogastric cancer and correctly treat peptic ulcer while, at the same time, reduce negative endoscopies in order to appropriately use the available healthcare resources. This CPG reviews the initial strategies that can be used in patients with uninvestigated dyspepsia and evaluates the possible decision to begin empirical therapy or to investigate the existence of a lesion that could explain the symptoms. This CPG also discusses functional dyspepsia, which encompasses all patients with dyspepsia with no demonstrable cause on endoscopy. Recommendations for the diagnosis and treatment of peptic ulcer and Helicobacter pylori infection are also made. To classify the scientific evidence and strengthen the recommendations, the GRADE (Grading of Recommendations Assessment, Development and Evaluation Working Group) system has been used (http://www.gradeworkinggroup.org/).
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Affiliation(s)
- Javier P. Gisbert
- Servicio de Aparato Digestivo, Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria Princesa (IP), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, España
| | - Xavier Calvet
- Corporació Universitària Parc Taulí, Departament de Medicina, Universitat Autònoma de Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, España
| | - Juan Ferrándiz
- Subdireccion de Calidad, Dirección General de Atención al Paciente, Servicio Madrileño de Salud, Madrid, España
| | - Juan Mascort
- CAP Florida Sud, Institut Català de la Salut, Departament de Ciències Clíniques, Campus Bellvitge, Facultat de Medicina, Universitat de Barcelona, L’Hospitalet de Llobregat, Barcelona, España
| | - Pablo Alonso-Coello
- Centro Cochrane Iberoamericano, Instituto de Investigaciones Biomédicas (IIB Sant Pau) Barcelona, España
| | - Mercè Marzo
- Unitat de suport a la recerca – IDIAP Jordi Gol, Direcció d’Atenció Primària Costa De Ponent, Institut Català de la Salut, Barcelona, España
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[Clinical practice guideline on the management of patients with dyspepsia. Update 2012]. GASTROENTEROLOGIA Y HEPATOLOGIA 2012. [PMID: 23186826 DOI: 10.1016/j.gastrohep.2012.05.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The aim of the Clinical Practice Guideline (CPG) on the Management of Patients with Dyspepsia is to generate recommendations on the optimal approach to dyspepsia in the primary care and specialized outpatient setting. The main objective of this CPG is to help to optimize the diagnostic process, identifying patients with a low risk of a serious organic disease (mainly tumoral), who could be safely managed without the need for invasive diagnostic tests and/or referral to a specialist. The importance of this aim lies in the need to accurately diagnose patients with esophagogastric cancer and correctly treat peptic ulcer while, at the same time, reduce negative endoscopies in order to appropriately use the available healthcare resources.This CPG reviews the initial strategies that can be used in patients with uninvestigated dyspepsia and evaluates the possible decision to begin empirical therapy or to investigate the existence of a lesion that could explain the symptoms. This CPG also discusses functional dyspepsia, which encompasses all patients with dyspepsia with no demonstrable cause on endoscopy. Recommendations for the diagnosis and treatment of peptic ulcer and Helicobacter pylori infection are also made. To classify the scientific evidence and strengthen the recommendations, the GRADE (Grading of Recommendations Assessment, Development and Evaluation Working Group) system has been used (http://www.gradeworkinggroup.org/).
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Khademi H, Radmard AR, Malekzadeh F, Kamangar F, Nasseri-Moghaddam S, Johansson M, Byrnes G, Brennan P, Malekzadeh R. Diagnostic accuracy of age and alarm symptoms for upper GI malignancy in patients with dyspepsia in a GI clinic: a 7-year cross-sectional study. PLoS One 2012; 7:e39173. [PMID: 22720064 PMCID: PMC3374763 DOI: 10.1371/journal.pone.0039173] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Accepted: 05/16/2012] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES We investigated whether using demographic characteristics and alarm symptoms can accurately predict cancer in patients with dyspepsia in Iran, where upper GI cancers and H. pylori infection are common. METHODS All consecutive patients referred to a tertiary gastroenterology clinic in Tehran, Iran, from 2002 to 2009 were invited to participate in this study. Each patient completed a standard questionnaire and underwent upper gastrointestinal endoscopy. Alarm symptoms included in the questionnaire were weight loss, dysphagia, GI bleeding, and persistent vomiting. We used logistic regression models to estimate the diagnostic value of each variable in combination with other ones, and to develop a risk-prediction model. RESULTS A total of 2,847 patients with dyspepsia participated in this study, of whom 87 (3.1%) had upper GI malignancy. Patients reporting at least one of the alarm symptoms constituted 66.7% of cancer patients compared to 38.9% in patients without cancer (p<0.001). Esophageal or gastric cancers in patients with dyspepsia was associated with older age, being male, and symptoms of weight loss and vomiting. Each single predictor had low sensitivity and specificity. Using a combination of age, alarm symptoms, and smoking, we built a risk-prediction model that distinguished between high-risk and low-risk individuals with an area under the ROC curve of 0.85 and acceptable calibration. CONCLUSIONS None of the predictors demonstrated high diagnostic accuracy. While our risk-prediction model had reasonable accuracy, some cancer cases would have remained undiagnosed. Therefore, where available, low cost endoscopy may be preferable for dyspeptic older patient or those with history of weight loss.
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Affiliation(s)
- Hooman Khademi
- Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
- International Agency for Research on Cancer, Lyon, France
| | - Amir-Reza Radmard
- Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Malekzadeh
- Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Farin Kamangar
- Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
- Department of Public Health Analysis, School of Community Health and Policy, Morgan State University, Baltimore, Maryland, United States of America
| | - Siavosh Nasseri-Moghaddam
- Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Graham Byrnes
- International Agency for Research on Cancer, Lyon, France
| | - Paul Brennan
- International Agency for Research on Cancer, Lyon, France
| | - Reza Malekzadeh
- Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Hegedus I, Csizmadia C, Lomb Z, Cseke L, Enkh-Amar Y, Pajor L, Bogner B. [Massive fundic gland polyposis caused by chronic proton pump inhibitor therapy]. Orv Hetil 2012; 153:351-6. [PMID: 22348851 DOI: 10.1556/oh.2012.29313] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
We report two cases of a massive fundic gland polyposis associated with protracted proton pump inhibitor (PPI) therapy. Both patients were females aged 51. On repeated endoscopy, the number of fundic gland polyps was increasing steeply, and they resulted in a passage disorder. In the first case, the enormous number of polyps made endoscopic removal impossible, so the patient was treated by total gastrectomy. Although our case is the second one reported in the world, we would like to draw the attention to this rare complication of long lasting PPI therapy.
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Affiliation(s)
- Ivett Hegedus
- Pécsi Tudományegyetem, Általános Orvostudományi Kar Patológia Intézet.
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Ahn HS, Shin YS, Park PJ, Kang KN, Kim Y, Lee HJ, Yang HK, Kim CW. Serum biomarker panels for the diagnosis of gastric adenocarcinoma. Br J Cancer 2012; 106:733-9. [PMID: 22240791 PMCID: PMC3322950 DOI: 10.1038/bjc.2011.592] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background: Currently, serum biomarkers, which are sufficiently sensitive and specific for early detection and risk classification of gastric adenocarcinoma do not exist. Therefore, this study identified a panel of serum biomarkers for the diagnosis of gastric adenocarcinoma. Methods: A 29-plex array platform with 29 biomarkers, consisting of 11 proteins discovered through proteomics and 18 previously known to be cancer-associated, was constructed. A test/training set consisting of 120 gastric adenocarcinoma and 120 control samples were examined. After 13 proteins were selected as candidate biomarkers, multivariate classification analyses were used to identify algorithms for diagnostic biomarker combinations. These algorithms were independently validated using a set of 95 gastric adenocarcinoma and 51 control samples. Results: Epidermal growth factor receptor (EGFR), pro-apolipoprotein A1 (proApoA1), apolipoprotein A1, transthyretin (TTR), regulated upon activation, normally T-expressed and presumably secreted (RANTES), D-dimer, vitronectin (VN), interleukin-6, α-2 macroglobulin, C-reactive protein and plasminogen activator inhibitor-1 were selected as classifiers in the two algorithms. These algorithms differentiated between the majority of gastric adenocarcinoma and control serum samples in the training/test set with high accuracy (>88%). These algorithms also accurately classified in the validation set (>85%). Conclusion: Two panels of combinatorial biomarkers, including EGFR, TTR, RANTES, and VN, are developed, which are less invasive method for the diagnosis of gastric adenocarcinoma. They could supplement clinical gastroscopic evaluation of symptomatic patients to enhance diagnostic accuracy.
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Affiliation(s)
- H S Ahn
- Department of Surgery, Seoul National University-Boramae hospital, Seoul, Korea
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Kam SY, Hennessy T, Chua SC, Gan CS, Philp R, Hon KK, Lai L, Chan WH, Ong HS, Wong WK, Lim KH, Ling KL, Tan HS, Tan MM, Ho M, Kon OL. Characterization of the human gastric fluid proteome reveals distinct pH-dependent protein profiles: implications for biomarker studies. J Proteome Res 2011; 10:4535-46. [PMID: 21842849 DOI: 10.1021/pr200349z] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Gastric fluid is a source of gastric cancer biomarkers. However, very little is known about the normal gastric fluid proteome and its biological variations. In this study, we performed a comprehensive analysis of the human gastric fluid proteome using samples obtained from individuals with benign gastric conditions. Gastric fluid proteins were prefractionated using ultracentrifuge filters (3 kDa cutoff) and analyzed by two-dimensional gel electrophoresis (2-DE) and multidimensional LC-MS/MS. Our 2-DE analysis of 170 gastric fluid samples revealed distinct protein profiles for acidic and neutral samples, highlighting pH effects on protein composition. By 2D LC-MS/MS analysis of pooled samples, we identified 284 and 347 proteins in acidic and neutral samples respectively (FDR ≤1%), of which 265 proteins (72.4%) overlapped. However, unlike neutral samples, most proteins in acidic samples were identified from peptides in the filtrate (i.e., <3 kDa). Consistent with this finding, immunoblot analysis of six potential gastric cancer biomarkers rarely detected full-length proteins in acidic samples. These findings have important implications for biomarker studies because a majority of gastric cancer patients have neutral gastric fluid compared to noncancer controls. Consequently, sample stratification, choice of proteomic approaches, and validation strategy can profoundly affect the interpretation of biomarker findings. These observations should help to refine gastric fluid biomarker studies.
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Affiliation(s)
- Siok Yuen Kam
- Division of Medical Sciences, Humphrey Oei Institute of Cancer Research, National Cancer Centre , Singapore
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Simone A, Casadei A, De Vergori E, Morgagni P, Saragoni L, Ricci E. Rescue endoscopy to identify site of gastric dysplasia or carcinoma found at random biopsies. Dig Liver Dis 2011; 43:721-5. [PMID: 21596632 DOI: 10.1016/j.dld.2011.04.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Revised: 03/22/2011] [Accepted: 04/10/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUND Incidental findings of high-grade dysplasia or gastric cancer at random biopsies with endoscopic diagnosis of chronic gastritis constitute a serious problem to clinical management of patients and sometimes requires blind gastrectomy. AIM To evaluate diagnostic value of second-look endoscopy, called "rescue endoscopy", in order to identify focal lesions containing neoplastic changes. METHODS Over a three-year period, 20 patients underwent rescue endoscopy using advanced endoscopy and mapping technique. All mucosal irregularities were identified and the locations of these areas were mapped onto a schematic diagram of gastric anatomy. Each area was biopsied and samples included in individually marked specimen containers, to evaluate the correlation between macroscopic and microscopic diagnosis. RESULTS Rescue endoscopy identified a total of 68 focal lesions, 18 of which were focal areas of high-grade dysplasia (13 patients) or gastric cancer (5 patients). Two patients had no dysplastic change identified by our targeted biopsies. A second pathologist's opinion confirmed absence of dysplasia on random and targeted biopsies. All patients underwent a median follow-up of 15.2 months (2.6-43.5), and no residual or metachronous lesions were identified. CONCLUSIONS In our experience, rescue endoscopy is highly effective in localizing undetermined areas of high-grade dysplasia or carcinoma.
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Affiliation(s)
- Adriana Simone
- Gastroenterology and Endoscopy Unit, Morgagni-Pierantoni Hospital, Forli, Italy.
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Prompt upper endoscopy is an appropriate initial management in uninvestigated chinese patients with typical reflux symptoms. Am J Gastroenterol 2010; 105:1947-52. [PMID: 20354508 DOI: 10.1038/ajg.2010.121] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES We sought to investigate the prevalence of clinically significant endoscopic findings (CSEFs) in Chinese patients presenting with uninvestigated typical reflux symptoms in the absence of alarm symptoms, and to evaluate whether prompt endoscopy is an appropriate initial management in these patients. METHODS Consecutive patients presenting with uninvestigated typical reflux symptoms (i.e., heartburn or acid regurgitation) as chief complaints were recruited for symptom evaluation and upper endoscopy, followed by a 2-week proton pump inhibitor (PPI) therapy. RESULTS Of 469 patients recruited, CSEFs were observed in 180 (38.4%): 154 (32.8%) with erosive esophagitis (EE), 18 (3.8%) with Barrett's esophagus (BE), 24 (5.1%) with peptic ulcer disease (PUD), and 4 (0.9%) with carcinomas (1 esophageal carcinoma and 3 gastric adenocarcinomas). Multivariate analysis identified that an age >50 years (odds ratio (OR)=1.94, P=0.008), male gender (OR=4.11, P<0.001), being overweight or obese (OR=2.99, P<0.001), and alcohol use (OR=9.96, P<0.001) were independent risk factors for EE; an age >50 years (OR=4.61, P=0.003) and alcohol use (OR=5.50, P=0.003) were independent risk factors for BE; and Helicobacter pylori infection (OR=8.52, P<0.001) and alcohol use (OR=4.08, P=0.004) were independent risk factors for PUD. Symptom evaluation and response to PPI treatment were not correlated with EE, BE, and PUD in these patients. CONCLUSIONS CSEFs other than gastroesophageal reflux disease are present in a considerable proportion of Chinese patients with uninvestigated typical reflux symptoms but without alarm features. Symptom evaluation is of limited practical value, and thus prompt endoscopy seems to be an appropriate initial management option in these patients.
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Telford JJ, Enns RA. Endoscopic missed rates of upper gastrointestinal cancers: parallels with colonoscopy. Am J Gastroenterol 2010; 105:1298-300. [PMID: 20523313 DOI: 10.1038/ajg.2009.739] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Recent publications assessing colonoscopy missed rates of colorectal cancer have generated efforts toward colonoscopy quality improvement. To date, esophagogastroduodenoscopy (EGD) has escaped similar scrutiny in Western populations. Raftopoulos et al. (1) report an upper gastrointestinal cancer missed rate of up to 6.7% in a cohort of 28,000 patients who underwent EGD at a hospital-based endoscopy unit in Perth, Western Australia. Of the missed esophageal and gastric cancers, approximately 80% of patients had alarm symptoms and 73% had abnormalities reported at the time of EGD. The missed cancers may not have been visualized, or were visualized and either not biopsied or biopsied inadequately, or interpreted incorrectly by pathologists. There was no difference in survival between the missed cancers and those detected at the index EGD.
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Kokkola A, Sipponen P, Arkkila P, Danielson H, Puolakkainen P. Does the eradication of Helicobacter pylori delay the diagnosis of gastric cancer? Scand J Gastroenterol 2009; 43:1456-60. [PMID: 18663664 DOI: 10.1080/00365520802273041] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To assess the frequency of gastric cancer patients having received eradication treatment of Helicobacter pylori, and whether this treatment has any influence on the delay in the diagnosis or the stage of the tumours at the time of the operation. MATERIAL AND METHODS A total of 119 consecutive patients with gastric cancer were interviewed preoperatively between 2001 and 2003 at the Department of Surgery, Helsinki University Central Hospital. Abdominal symptoms, previous endoscopies, previous H. pylori testing and eradication therapies were recorded. RESULTS. Of these patients, 112 (94%) had abdominal symptoms before the cancer diagnosis, and in 110 patients (92%) these symptoms were alarming or had changed before the cancer diagnosis. Thirty-five patients (29%) had received H. pylori eradication therapy prior to the diagnosis of gastric cancer (15 after onset or change in symptoms, 10 more than 5 years prior to the cancer diagnosis). The median duration of alarm, new or changed symptoms was longer among patients with H. pylori eradication therapy after the onset or change in their symptoms as compared to other patients (12.0 versus 4.5 months, p=0.001). However, there was no difference in the tumour stages at time of the operation between the eradication and no eradication groups. A previous gastroscopy within 2 years prior to the cancer diagnosis was performed in 17 (14%) patients. Diffuse-type cancers were missed significantly more often in endoscopies than cancers of intestinal type. CONCLUSION Previous H. pylori eradication may delay the detection of gastric cancer if it is given during symptoms caused by tumour.
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Affiliation(s)
- Arto Kokkola
- Department of Surgery, Helsinki University Central Hospital, Helsinki, Finland.
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Im JP, Kim SG, Kim JS, Jung HC, Song IS. Time-dependent morphologic change in depressed-type early gastric cancer. Surg Endosc 2009; 23:2509-14. [PMID: 19296170 DOI: 10.1007/s00464-009-0434-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2008] [Revised: 02/13/2009] [Accepted: 02/27/2009] [Indexed: 12/29/2022]
Abstract
BACKGROUND Depressed-type early gastric cancer (EGC) is known to repeat improvement and exacerbation of ulceration during its natural course, forming a "malignant cycle." However, it is difficult to observe the malignant cycle of EGC in clinical practice, and little is known about the clinicopathologic factors associated with this cycle. This study aimed to evaluate the malignant cycle of EGC and to determine the clinicopathologic factors associated with the time-dependent morphologic change of EGC. METHODS The medical records of EGC patients treated at the Seoul National University Hospital were retrospectively reviewed with two or more comparable endoscopic photos taken between March 1999 and December 2005. The ulcer stages in EGC were classified by the gastric ulcer stage system and evaluated for time-dependent morphologic changes according to the relevant factors. RESULTS In this study, 231 cases of depressed-type EGC were evaluated. At the follow-up endoscopy after a median interval of 23 days, a change in ulcer stage was observed in 66 patients (29%), with improvement in 45 patients (20%) and exacerbation in 21 patients (9%). Of the 177 patients who demonstrated an active or healing stage, 45 (25%) showed improvement and 10 (6%) exhibited exacerbation. The multivariate analysis showed that the usage of antisecretory medications, mucosal cancer, and a longer interval between the two endoscopic examinations were the factors that had a significant association with improvement of the ulcer stage. CONCLUSIONS The malignant cycle was frequently observed in depressed-type EGC. The improvement of ulceration in EGC was time dependent and associated with the usage of antisecretory medication and the depth of invasion.
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Affiliation(s)
- Jong Pil Im
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, 28 Yongon-dong, Chongno-gu, Seoul, 110-799, Korea
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Amorena Muro E, Borda Celaya F, Martínez-Peñuela Virseda JM, Borobio Aguilar E, Oquiñena Legaz S, Jiménez Pérez FJ. [Analysis of the clinical benefits and cost-effectiveness of performing a systematic second-look gastroscopy in benign gastric ulcer]. GASTROENTEROLOGIA Y HEPATOLOGIA 2008; 32:2-8. [PMID: 19174093 DOI: 10.1016/j.gastrohep.2008.07.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2008] [Accepted: 07/30/2008] [Indexed: 01/14/2023]
Abstract
INTRODUCTION We analyzed the need to routinely perform a second gastroscopy after an initial diagnosis of benign gastric ulcer. METHOD A total of 226 consecutive cases of gastric ulcer were reviewed. Sensitivity (S), specificity (Sp), positive and negative predictive value (PPV and NPV) and the accuracy of the initial gastroscopy plus biopsy were analyzed, both overall and according to the initial endoscopist's experience (attending or resident physician). The diagnostic accuracy of the initial and second-look gastroscopies was compared. The number of second endoscopies required to diagnose a new case of malignant gastric ulcer and their cost was calculated, both overall and according to the endoscopist's experience. RESULTS There were 178 benign ulcers (79%) and 48 malignant ulcers (21%). The initial gastroscopy (S: 87.2%; Sp: 100%; PPV: 100%; PNV: 96.7%; accuracy: 96.7%) was performed by an attending physician in 74% of the patients and by a resident physician in the remaining 26%. Diagnostic accuracy was higher for attending physicians than for residents (98.2% vs. 94.8%; p=0.18). The accuracy of second-look endoscopy was 100%, with a significant improvement when compared with the initial procedure (p=0.035). Three new cases of MALT lymphoma and three new cases of gastric adenocarcinoma were diagnosed and could be treated with curative intent. The number of second gastroscopies required to diagnose a new case of malignant gastric ulcer and their economic cost was: 37.3 (4,675 Euros) for the whole group, 55.2 (6,845 Euros) for attending physicians and 19.3 (2,393 Euros) for residents. CONCLUSIONS Initial gastroscopy showed high diagnostic accuracy, which was slightly lower when performed by resident physicians. Second-look gastroscopy significantly improved the results, confirming the clinical benefit of this procedure in diagnosing potentially curable malignant lesions. The mean cost of each new diagnosis of malignancy was 4,675 Euros, which was three times lower if the initial gastroscopy was performed by a less experienced endoscopist.
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Kon OL, Yip TT, Ho MF, Chan WH, Wong WK, Tan SY, Ng WH, Kam SY, Eng AK, Ho P, Viner R, Ong HS, Kumarasinghe MP. The distinctive gastric fluid proteome in gastric cancer reveals a multi-biomarker diagnostic profile. BMC Med Genomics 2008; 1:54. [PMID: 18950519 PMCID: PMC2584050 DOI: 10.1186/1755-8794-1-54] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2007] [Accepted: 10/25/2008] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Overall gastric cancer survival remains poor mainly because there are no reliable methods for identifying highly curable early stage disease. Multi-protein profiling of gastric fluids, obtained from the anatomic site of pathology, could reveal diagnostic proteomic fingerprints. METHODS Protein profiles were generated from gastric fluid samples of 19 gastric cancer and 36 benign gastritides patients undergoing elective, clinically-indicated gastroscopy using surface-enhanced laser desorption/ionization time-of-flight mass spectrometry on multiple ProteinChip arrays. Proteomic features were compared by significance analysis of microarray algorithm and two-way hierarchical clustering. A second blinded sample set (24 gastric cancers and 29 clinically benign gastritides) was used for validation. RESULTS By significance analysyis of microarray, 60 proteomic features were up-regulated and 46 were down-regulated in gastric cancer samples (p < 0.01). Multimarker clustering showed two distinctive proteomic profiles independent of age and ethnicity. Eighteen of 19 cancer samples clustered together (sensitivity 95%) while 27/36 of non-cancer samples clustered in a second group. Nine non-cancer samples that clustered with cancer samples included 5 pre-malignant lesions (1 adenomatous polyp and 4 intestinal metaplasia). Validation using a second sample set showed the sensitivity and specificity to be 88% and 93%, respectively. Positive predictive value of the combined data was 0.80. Selected peptide sequencing identified pepsinogen C and pepsin A activation peptide as significantly down-regulated and alpha-defensin as significantly up-regulated. CONCLUSION This simple and reproducible multimarker proteomic assay could supplement clinical gastroscopic evaluation of symptomatic patients to enhance diagnostic accuracy for gastric cancer and pre-malignant lesions.
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Affiliation(s)
- Oi Lian Kon
- Division of Medical Sciences, Humphrey Oei Institute of Cancer Research, National Cancer Centre, Singapore, Republic of Singapore.
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Axon A. Is diagnostic and therapeutic endoscopy currently appropriate?: suggestions for improvement. Best Pract Res Clin Gastroenterol 2008; 22:959-70. [PMID: 18790441 DOI: 10.1016/j.bpg.2008.07.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Endoscopy is the driving force in gastroenterology today, and recent exciting advances in technology have extended its frontiers at an unprecedented rate. We have a wider range of diagnostic and therapeutic possibilities at our disposal with more detailed methods available to analyse what we see on our video screens. We can access the small bowel lumen with consistency and intra-abdominal operations have been performed through the mouth and anus so where are the current limitations of the procedure? In spite of these remarkable advances many challenges remain for both the endoscopist and for industry, they are mainly ones associated with human weakness. Endoscopy is an art, performed by individuals who require training and continued education and it is done to patients who are vulnerable, afraid and often seriously unwell. It is human aspects of endoscopy that require improvement. This chapter addresses the areas where endoscopy is falling short and suggests what can be done to improve practice. Changes are needed in management, information technology, education, team working, quality, patient comfort and safety. There also remain a number of areas where improved technology may be able to reduce human error.
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Affiliation(s)
- Anthony Axon
- Department of Gastroenterology, Room 234 D Floor Clarendon Wing, The General Infirmary at Leeds, Great George Street, Leeds, LS1 3EX, UK.
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Van Vliet EPM, Kuipers EJ, Steyerberg EW, Siersema PD. Users and utilization patterns of over-the-counter acid inhibitors and antacids in The Netherlands. Scand J Gastroenterol 2008; 43:662-8. [PMID: 18569982 DOI: 10.1080/00365520701885499] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE General practitioners (GPs) are the first-line physicians who are consulted for upper digestive symptoms. Persons with symptoms may, however, prefer to buy acid inhibitors or antacids in drugstores or pharmacies and bypass a GP. The aim of this work was to study users, reasons for use, and utilization patterns of over-the-counter (OTC) acid inhibitors and antacids in The Netherlands. We also studied factors that were associated with the substitution of OTC acid inhibitors or antacid use for consultation with a GP. MATERIAL AND METHODS From July 2005 to January 2006, persons buying OTC acid inhibitors or antacids in 12 pharmacies and 4 drugstores were asked to complete a questionnaire. A total of 82/160 (51%) questionnaires were returned. RESULTS Heartburn was the main symptom for buying an acid inhibitor or antacid. Seventy-one (87%) participants substituted OTC drug use for a GP consultation. The most commonly reported reason was the belief that symptoms were not serious enough to seek medical care. Exploratory analyses showed that substitution was less common in participants with comorbidity, a history of upper gastrointestinal disorder, use of an acid inhibitor or antacid previously prescribed by a physician, alarm symptoms (such as pain and nausea), and with being symptomatic for >4 days/week. CONCLUSIONS Although the reasons for substitution of OTC acid inhibitor or antacid use for a GP consultation in The Netherlands do not suggest an a priori increased risk of an underlying serious disorder, it may be advisable for staff in drugstores and pharmacies to provide users with information on appropriate use and when to consult a GP.
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Prognostic significance of gastrin expression in patients undergoing R0 gastrectomy for adenocarcinoma. Gastric Cancer 2008; 10:159-66. [PMID: 17922093 DOI: 10.1007/s10120-007-0429-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2007] [Accepted: 05/19/2007] [Indexed: 02/07/2023]
Abstract
BACKGROUND Gastrointestinal (GI) hormones regulate several GI functions, including the proliferation and repair of normal mucosa, and hormone receptors may therefore be implicated in the growth, invasion, and metastasis of cancers of the GI tract. The aim of this study was to determine the cellular distribution of gastrin in intestinal-type gastric cancers, and to determine its relationship to outcomes after R0 gastrectomy. METHODS Eighty-six consecutive patients undergoing R0 gastrectomy for adenocarcinoma were studied. Normal gastric mucosa and tumor were stained for gastrin and their specific cellular distribution was determined. RESULTS The duration of survival of patients whose tumors exhibited well-differentiated gastrin-positive tumor (GPT) cells (n = 12) was significantly poorer than that of patients whose tumors were GPT-negative (5-year survival, 30% vs 54%; P = 0.037). Patients with GPT-positive intestinal-type gastric cancer (5 of 47 patients) had the poorest survival of all (median, 14 months; 5-year survival, 0%; P = 0.006). In a multivariate analysis, only lymph node metastases (hazard ratio [HR], 2.13; 95% confidence interval [CI], 1.2 to 3.79; P = 0.01) and the presence of GPT cells (HR, 6.61; 95% CI, 1.74 to 25.09; P = 0.01) were independently and significantly associated with durations of survival in patients with intestinal-type gastric cancer. CONCLUSION The presence of GPT cells in patients with gastric adenocarcinoma is a significant and independent prognostic indicator.
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Affiliation(s)
- Riza Tady Conroy
- Department of Family Medicine, The Ohio State University, OSU Family Practice-Gahanna, 504 Havens Corners Road, Gahanna, OH 43230, USA
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Abstract
Proton pump inhibitors (PPIs) are very effective in maintaining symptomatic and endoscopic remission of acid peptic disorders, such as gastro-oesophageal reflux disease. Side effects with respect to function and morphology of the gastric mucosa are common. Helicobacter pylori eradication can partially prevent and reverse these effects without impairing PPI therapy for gastro-oesophageal reflux disease. This makes long term PPI treatment a safe therapy for patients with acid peptic disorders. The potential side effects of such therapy are discussed here.
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Affiliation(s)
- E J Kuipers
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, PO Box 2040, 3000 CA Rotterdam, the Netherlands.
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Abstract
The prognosis of gastric cancer is closely related to the stage of disease at diagnosis. Early gastric cancer, whereby disease is limited to mucosa and submucosa, confers a survival rate of greater than 90% in 5 years in many centres. Gastric cancer is still a major cause of cancer mortality worldwide. In high incidence areas such as Japan, screening of asymptomatic population has been advocated. However, in Western countries, mass screening is not cost-effective. Hence, strategy has been directed to screen symptomatic individuals who are at higher risk of gastric cancer. Most patients with early gastric cancer present with symptoms indistinguishable from benign peptic ulcer disease. Screening for this group of patients improves detection rate of early gastric cancer and therefore its prognosis. Endoscopy for surveillance of premalignant lesions has been explored with this objective in mind. Serology testing for biomarkers such as pepsinogen, anti-Helicobacter pylori antibody and gastrin has been studied as an alternative to endoscopy. There is compelling evidence for the role of H. pylori in the initiation of Correa's cascade (stepwise progression from chronic active gastritis, atrophic gastritis, intestinal metaplasia, dysplasia and finally adenocarcinoma). Regression of premalignant lesions has been demonstrated with H. pylori eradication. However, it is not known whether this might effectively prevent gastric cancer in either low or high-risk population.
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Affiliation(s)
- Yih K Tan
- Department of Surgery, Queen Elizabeth Hospital, Edgbaston, Birmingham, UK
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Macdonald S, Macleod U, Campbell NC, Weller D, Mitchell E. Systematic review of factors influencing patient and practitioner delay in diagnosis of upper gastrointestinal cancer. Br J Cancer 2006; 94:1272-80. [PMID: 16622459 PMCID: PMC2361411 DOI: 10.1038/sj.bjc.6603089] [Citation(s) in RCA: 112] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
As knowledge on the causation of cancers advances and new treatments are developed, early recognition and accurate diagnosis becomes increasingly important. This review focused on identifying factors influencing patient and primary care practitioner delay for upper gastrointestinal cancer. A systematic methodology was applied, including extensive searches of the literature published from 1970 to 2003, systematic data extraction, quality assessment and narrative data synthesis. Included studies were those evaluating factors associated with the time interval between a patient first noticing a cancer symptom and presenting to primary care, between a patient first presenting to primary care and being referred to secondary care, or describing an intervention designed to reduce those intervals. Twenty-five studies were included in the review. Studies reporting delay intervals demonstrated that the patient phase of delay was greater than the practitioner phase, whilst patient-related research suggests that recognition of symptom seriousness is more important than recognition of the presence of the symptom. The main factors related to practitioner delay were misdiagnosis, application and interpretation of tests, and the confounding effect of existing disease. Greater understanding of patient factors is required, along with evaluation of interventions to ensure appropriate diagnosis, examination and investigation.
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Affiliation(s)
- S Macdonald
- General Practice and Primary Care, Division of Community Based Sciences, University of Glasgow, 1 Horselethill Road, Glasgow G12 9LX, UK
| | - U Macleod
- General Practice and Primary Care, Division of Community Based Sciences, University of Glasgow, 1 Horselethill Road, Glasgow G12 9LX, UK
| | - N C Campbell
- General Practice and Primary Care, University of Aberdeen, Foresterhill Health Centre, Westburn Road, Aberdeen AB25 2AY, UK
| | - D Weller
- Community Health Sciences (General Practice), University of Edinburgh, 20 West Richmond Street, Edinburgh EH8 9DX, UK
| | - E Mitchell
- School of Health and Social Care, Glasgow Caledonian University, City Campus, Cowcaddens Road, Glasgow G4 0BA, UK
- School of Health and Social Care, Glasgow Caledonian University, City Campus, Cowcaddens Road, Glasgow G4 0BA, UK. E-mail:
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Abstract
Five-year survival of gastric cancer is 10% in Western countries compared with over 50% in Japan. This is because the disease is not identified in the West until later in its evolution. T1 cancer has an excellent prognosis, but most of the patients either have no symptoms or complain of long-standing, non-specific dyspepsia; alarm symptoms, when identified, usually indicate that the cancer is already inoperable. Early gastric cancer is infrequently diagnosed in the West because the low prevalence of gastric cancer means that endoscopists do not search with the same diligence as they do in Japan. A further barrier is the widespread prescription of proton pump inhibitors that heal malignant ulcers and diminish symptoms, thus rendering them more difficult to identify clinically and endoscopically. An improvement in diagnosis may be achieved by newer endoscopy technology which enables cancers to be identified more easily, or by an inexpensive screening test to select patients with extensive gastric atrophy, thereby identifying those at risk who can then be screened endoscopically.
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Affiliation(s)
- Anthony Axon
- Department of Gastroenterology, The General Infirmary at Leeds, Leeds, UK.
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39
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Affiliation(s)
- Peter C Belafsky
- Center for Voice and Swallowing, UC Davis Medical Center, Department of Otolaryngology/Head and Neck Surgery, 2521 Stockton Boulevard, Suite 7200 Sacramento, California 95817, USA.
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40
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Lassen A, Hallas J, de Muckadell OBS. The risk of missed gastroesophageal cancer diagnoses in users and nonusers of antisecretory medication. Gastroenterology 2005; 129:1179-86. [PMID: 16230072 DOI: 10.1053/j.gastro.2005.07.028] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2005] [Accepted: 06/30/2005] [Indexed: 12/25/2022]
Abstract
BACKGROUND & AIMS Some patients with early gastroesophageal cancer may appear to "heal" because of antisecretory medication, but the risk of a missed diagnosis is unknown. The aim of the study was to estimate the incidence of gastroesophageal cancer with or without pre-endoscopic treatment with antisecretory medication. METHODS We extracted data on use of endoscopies, gastroesophageal cancer diagnoses, death, migration, and use of antisecretory medication (H(2) blockers and proton pump inhibitors) from 5 population-based registries covering 1974-2002. We included all citizens in Funen County (population, 470,000) who between 1993 and 2002 were investigated by endoscopy for the first time. The patients were followed up until death, emigration, or the end of the study period. RESULTS Among 27,829 patients with a first endoscopy (mean age, 56 years; 48% male, 115,804 person-years of follow-up), 461 had gastroesophageal cancer diagnosed at the first endoscopy and 52 were diagnosed during a median follow-up of 2.7 years after the first endoscopy. The incidence during follow-up was similar to the background population (standardized incidence ratio, 1.24; 95% confidence interval, 0.81-1.91), increased with age, and was higher in male patients. The incidence of gastroesophageal cancer during follow-up was 46 per 100,000 person-years in users of antisecretory medication the last 180 days before the first endoscopy compared with 44 per 100,000 person-years in nonusers (age and sex standardized difference, 4 per 100,000 person-years; 95% confidence interval, -14 to 22). CONCLUSIONS Very few cancers are missed at endoscopy. The risk seems similar in users and nonusers of antisecretory medication before endoscopy.
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Affiliation(s)
- Annmarie Lassen
- Department of Medical Gastroenterology, Odense University Hospital, Denmark.
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Abstract
Dyspepsia is a chronic or recurrent pain or discomfort centered in the upper abdomen; patients with predominant or frequent (more than once a week) heartburn or acid regurgitation, should be considered to have gastroesophageal reflux disease (GERD) until proven otherwise. Dyspeptic patients over 55 yr of age, or those with alarm features should undergo prompt esophagogastroduodenoscopy (EGD). In all other patients, there are two approximately equivalent options: (i) test and treat for Helicobacter pylori (H. pylori) using a validated noninvasive test and a trial of acid suppression if eradication is successful but symptoms do not resolve or (ii) an empiric trial of acid suppression with a proton pump inhibitor (PPI) for 4-8 wk. The test-and-treat option is preferable in populations with a moderate to high prevalence of H. pylori infection (> or =10%); empirical PPI is an initial option in low prevalence situations. If initial acid suppression fails after 2-4 wk, it is reasonable to consider changing drug class or dosing. If the patient fails to respond or relapses rapidly on stopping antisecretory therapy, then the test-and-treat strategy is best applied before consideration of referral for EGD. Prokinetics are not currently recommended as first-line therapy for uninvestigated dyspepsia. EGD is not mandatory in those who remain symptomatic as the yield is low; the decision to endoscope or not must be based on clinical judgement. In patients who do respond to initial therapy, stop treatment after 4-8 wk; if symptoms recur, another course of the same treatment is justified. The management of functional dyspepsia is challenging when initial antisecretory therapy and H. pylori eradication fails. There are very limited data to support the use of low-dose tricyclic antidepressants or psychological treatments in functional dyspepsia.
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Affiliation(s)
- Nicholas J Talley
- Division of Gastroenterology and Hepatology, Mayo Clinic, Clinical Enteric Neuroscience Translational and Epidemiological Research Program, Mayo Clinic, Rochester, Minnesota 55905, USA
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Voutilainen M, Mäntynen T, Mauranen K, Kunnamo I, Juhola M. Is it possible to reduce endoscopy workload using age, alarm symptoms and H. pylori as predictors of peptic ulcer and oesophagogastric cancers? Dig Liver Dis 2005; 37:526-32. [PMID: 15975541 DOI: 10.1016/j.dld.2005.01.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2004] [Accepted: 01/24/2005] [Indexed: 12/11/2022]
Abstract
OBJECTIVES We examined referrals to oesophagogastroduodenoscopy and the impact of demographic and clinical variables to predict major findings (peptic ulcer, cancer) on oesophagogastroduodenoscopy. METHODS We collected data on 3669 consecutive patients referred for oesophagogastroduodenoscopy. RESULTS Dyspeptic and reflux symptoms constituted 80% of oesophagogastroduodenoscopy referrals. A major finding was observed in 419 patients (11.4%). The mean age of cancer patients was 72.7 years (95% confidence interval (CI) 70.0-76.5 years) and that of peptic ulcer patients 62.0 years (95% CI 60.5-63.5 years). Independent risk factors for a major finding were age >50 years (odds ratio (OR) 1.62, 95% CI 1.24-2.10), male sex (OR 1.38, 95% CI 1.11-1.72), ulcer-type pain (OR 2.33, 95% CI 1.80-3.02), weight loss (OR 1.70, 95% CI 1.14-2.53), anaemia (OR 1.82, 95% CI 1.38-2.40), bleeding symptoms (OR 3.27, 95% CI 2.26-4.75) and Helicobacter pylori (OR 2.49, 95% CI 2.00-3.11), whereas reflux symptoms were protective (OR 0.73, 95% CI 0.53-1.00). The area under receiver operating characteristic curve of age over 50 years with alarm symptoms to predict major finding was 0.68 (95% CI 0.65-0.71), which positive H. pylori status increased to 0.71 (95% CI 0.69-0.74). Of the major findings, 87.2% were detected in patients with risk factors. Major findings were detected in 15.1% patients with and 8.1% (p < 0.001) without alarm symptoms. CONCLUSIONS Dyspeptic and reflux symptoms constitute the majority of oesophagogastroduodenoscopy workload. Discriminative power of alarm symptoms even with positive H. pylori status to detect peptic ulcer or cancer was low. Because of their low cancer risk, reflux and dyspeptic patients younger than 50 years can be treated without oesophagogastroduodenoscopy.
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Affiliation(s)
- M Voutilainen
- Department of Internal Medicine, Jyväskylä Central Hospital, Finland.
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Mat Saad AZ, Collins N, Lobo MM, O'Connor HJ. Proton pump inhibitors: a survey of prescribing in an Irish general hospital. Int J Clin Pract 2005; 59:31-4. [PMID: 15707461 DOI: 10.1111/j.1742-1241.2004.00298.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Prescription rates and attendant costs of proton pump inhibitors (PPIs) continue to rise. The aim of this study was to assess the extent and appropriateness of PPI prescribing in an Irish general hospital. Using a structured pro forma, we conducted a 1-day comprehensive survey of the prescription charts of all inpatients. Of the 157 inpatients, 48 (30.6%) were on PPI therapy and omeprazole was the most widely prescribed PPI. Rabeprazole, the least expensive PPI, was the least prescribed. Prescription of PPI therapy was for an approved indication in 32 patients (66.6%) but was for an unapproved or unknown indication in 16 (33.3%). Prescribing had been initiated in hospital in 34 patients (70.8%) but only one-third of the patients on PPI therapy had undergone endoscopy. Over 90% of patients were on additional, often multiple, prescribed medications. Our results suggest that PPIs are overprescribed in hospital practice, and there is scope to improve the quality and cost-effectiveness of PPI prescribing.
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Affiliation(s)
- A Z Mat Saad
- Department of Medicine, Midland Regional Hospital, Tullamore, County Offaly, Ireland
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Abstract
PURPOSE OF REVIEW This review reports and attempts to place in some context current key observations in the literature, as they relate to peptic ulcer disease. RECENT FINDINGS Focus areas in this review are general, the usefulness of symptom-based triage in management decision making and critical review of current practice as it relates to foregut malignancy; Helicobacter pylori, important observations regarding gastric cancer prevention are presented, the role of the organism in "acid rebound" is discussed, and further evidence to support the role of H. pylori eradication in peptic ulcer disease is provided; medication, a number of studies comparing steady state and onset of action efficacy of current proton pump inhibitors at a gastric pH level are reviewed and a new agent is introduced. Problems with and strategies for the safe use of antithrombotic agents are reviewed, and exciting data with regard to a new class of nonsteroidal antiinflammatory drug are provided, now at the "proof of concept" stage. SUMMARY The review period's main "new" information relates to the nonsteroidal antiinflammatory drugs in which a number of exciting agents are being developed. Although inconclusive, the observations with regard to the effect of H. pylori eradication on gastric carcinogenesis is likely to lead to more work in this field.
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Affiliation(s)
- Japie A Louw
- Gastroenterology Division, Department of Medicine, Queen's University, Kingston, Ontario, Canada.
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Abstract
The optimal diagnostic approach to the dyspeptic patient in primary care is still debated. Early endoscopy continues to be the diagnostic gold standard but competing non-invasive strategies challenge this. The most important approaches are empiric antisecretory treatment reserving endoscopy for unresponsive patients and patients with an early symptomatic relapse and helicobacter-based strategies reserving endoscopy for infected patients (test-and-scope) or for failures after eradication therapy (test-and-treat). Early endoscopy is recommended in patients with alarm features and should be considered in patients with new onset dyspepsia after age 50. In the remaining patients, early investigation can only be recommended in areas providing endoscopy at a low cost and with a short waiting list. The test-and-scope strategy may lead to a rise in the referral rates for endoscopy and cannot be recommended. The test-and-treat strategy is well documented in clinical trials as a safe and cost-effective approach. Helicobacter-based strategies are challenged by a decreasing prevalence of peptic ulcer disease and of the infection. In the near future, the empirical acid inhibition strategy will probably be cost-effective as gastro-oesophageal reflux becomes the predominant disorder in dyspeptic patients.
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Affiliation(s)
- Peter Bytzer
- Department of Medical Gastroenterology and Endoscopy, Glostrup University Hospital, DK-2600 Glostrup, Denmark.
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46
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Sebastian SS, Kernan N, Qasim A, O'Morain CA, Buckley M. Appropriateness of gastric antisecretory therapy in hospital practice. Ir J Med Sci 2004; 172:115-7. [PMID: 14700112 DOI: 10.1007/bf02914494] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Recent data indicate an exponential increase in proton pump inhibitor (PPI) prescribing, and concerns are raised regarding the appropriateness of these prescriptions and the financial implications. AIM To survey the appropriateness of PPI prescription in a cohort of patients in a tertiary referral hospital. METHODS Prescription records of all inpatients on a randomly selected day were reviewed. The appropriateness of prescription and relevant investigations were identified by interview of patients, review of patient records and of a computerised endoscopy records system. RESULTS Thirty-two per cent (87 of 272) of all patients were on PPIs. A valid indication for therapy was not apparent in 63% of the patients on PPIs with the only predictive factor for inappropriate prescription being increasing age. Only 36 of the 87 patients on PPIs had undergone appropriate investigations for their gastrointestinal symptoms. Gender, age, speciality of admission or duration of hospital stay did not influence the appropriateness of prescription or performance of relevant investigations. CONCLUSION There appears to be a widespread and inappropriate use of PPIs in hospital practice.
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Affiliation(s)
- S S Sebastian
- Department of Gastroenterology, Adelaide Hospital, Tallaght, Dublin, Ireland
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Abstract
Gastro-oesophageal reflux disease (GORD) in older patients presents particular problems for the clinician. Older patients may present with complications rather than with symptoms, which may be less marked than in younger patients. Extraoesophageal symptoms are also more common in this group, and this may lead to confusion over the exact diagnosis. The increased likelihood of co-pathologies and concomitant medication complicate diagnosis and management further. GORD tends to be more severe for any level of symptom severity in the older patient. Erosive oesophagitis is more common among older people with GORD, meaning that this group is more likely to require aggressive therapy for both symptom relief and oesophagitis healing - full or high doses of acid suppression therapy may be necessary.
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Affiliation(s)
- A Pali S Hungin
- Centre for Integrated Health Care Research, Wolfson Research Institute, University of Durham, UK.
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Panter SJ, O'Flanagan H, Bramble MG, Hungin APS. Empirical use of antisecretory drug therapy delays diagnosis of upper gastrointestinal adenocarcinoma but does not effect outcome. Aliment Pharmacol Ther 2004; 19:981-8. [PMID: 15113364 DOI: 10.1111/j.1365-2036.2004.01924.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Upper gastrointestinal cancer carries a poor prognosis. Although the incidence of gastric adenocarcinoma is falling, oesophageal adenocarcinoma is increasing. This has been attributed to an increasing prevalence of gastro-oesophageal reflux disease, commonly treated empirically in primary care with antisecretory drugs. Treatment has been associated with delayed diagnosis but it is unclear if this influences prognosis. AIMS To ascertain the effect of antisecretory drugs on time to diagnosis, symptoms, tumour stage and outcome. METHODS A retrospective cohort study of primary care records for 747 patients diagnosed with upper gastrointestinal adenocarcinoma at South Tees NHS Trust between 1991 and 2001. RESULTS Mean time from the onset of symptoms to diagnosis was 30 weeks. Mean and median times at the primary care stage were longer than at the hospital stage for both oesophageal and gastric cancer (P < 0.0001). Patients with benign symptoms prescribed antisecretory drugs were referred later than those not on antisecretory drugs (P < 0.0001), as were patients with alarm symptoms (P = 0.0008). Prior use of antisecretory drugs delayed diagnosis by 17.6 weeks (mean) but had no effect on tumour stage at diagnosis or survival. CONCLUSION Prior antisecretory drug therapy was associated with delayed diagnosis of upper gastrointestinal adenocarcinoma irrespective of presenting symptoms. Concerns that delays might adversely affect tumour stage or long-term survival were not substantiated.
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Affiliation(s)
- S J Panter
- Department of Gastroenterology, James Cook University Hospital, Middlesbrough, UK.
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Bessa Caserras X. [Possible mistakes in the diagnosis of functional dyspepsia]. GASTROENTEROLOGIA Y HEPATOLOGIA 2004; 27:156-60. [PMID: 14998468 DOI: 10.1016/s0210-5705(03)79116-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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50
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Talley NJ. Yield of endoscopy in dyspepsia and concurrent treatment with proton pump inhibitors: the blind leading the blind? Gastrointest Endosc 2003; 58:89-92. [PMID: 12838227 DOI: 10.1067/mge.2003.302] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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