Gastric cancer below the age of 55: implications for screening patients with uncomplicated dyspepsia

Combined analysis of the ORCHID and OCAY studies: does eradication of Helicobacter pylori lead to sustained improvement in functional dyspepsia symptoms?

Currently, one of the most important unresolved questions concerning Helicobacter pylori is whether eradication of the organism leads to a sustained improvement in symptoms in patients diagnosed with functional (non-ulcer) dyspepsia. Recently, two very similar studies, the ORCHID and OCAY studies, have been completed and the combined results of these two multicentre, multinational, randomised, double blind, controlled clinical trials are reviewed.

Dyspepsia: management guidelines for the millennium

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

Randomised trial of endoscopy with testing for Helicobacter pylori compared with non-invasive H pylori testing alone in the management of dyspepsia

OBJECTIVE

To compare the efficacy of non-invasive testing for Helicobacter pylori with that of endoscopy (plus H pylori testing) in the management of patients referred for endoscopic investigation of upper gastrointestinal symptoms.

DESIGN

Randomised controlled trial with follow up at 12 months.

SETTING

Hospital gastroenterology unit.

PARTICIPANTS

708 patients aged under 55 referred for endoscopic investigation of dyspepsia, randomised to non-invasive breath test for H pylori or endoscopy plus H pylori testing.

MAIN OUTCOME MEASURE

Glasgow dyspepsia severity score at one year. Use of medical resources, patient oriented outcomes, and safety were also assessed.

RESULTS

In 586 patients followed up at 12 months the mean change in dyspepsia score was 4.8 in the non-invasive H pylori test group and 4.6 in the endoscopy group (95% confidence interval for difference -0.7 to 0.5, P=0.69). Only 8.2% of patients followed up who were randomised to breath test alone were referred for subsequent endoscopy. The use of non-endoscopic resources was similar in the two groups. Reassurance value, concern about missed pathology, overall patient satisfaction, and quality of life were similar in the two groups. The patients found the non-invasive breath test procedure less uncomfortable and distressing than endoscopy with or without sedation. No potentially serious pathology requiring treatment other than eradication of H pylori was missed.

CONCLUSION

In this patient group, non-invasive testing for H pylori is as effective and safe as endoscopy and less uncomfortable and distressing for the patient. Non-invasive H pylori testing should be the preferred mode of investigation.

Upper GI malignancy, uncomplicated dyspepsia, and the age threshold for early endoscopy

OBJECTIVES

We sought to determine the frequency with which patients with upper GI malignancies present with uncomplicated dyspepsia and to determine the impact of changing the threshold for early endoscopy from 45 to 55 yr, as has recently been recommended in European studies.

METHODS

Three hundred forty-one patients with upper GI malignancies at two Milwaukee teaching hospitals were identified from electronic databases. Trained physician-investigators reviewed the charts using a specifically designed questionnaire. Staging of GI cancers was performed using the TNM classification to determine operability. Uncomplicated dyspepsia was defined as dyspepsia without alarm symptoms/signs (dysphagia, vomiting, weight loss, early satiety, GI bleeding, or anemia).

RESULTS

There were 341 patients with upper GI malignancies with a mean age of 68 yr (range = 22-94). Twenty-one patients were younger than 45 and 65 were under 55. Uncomplicated dyspepsia was the presenting symptom in five of 65 (7.7%) patients younger than 55 and one of 21 (4.8%) patients under 45 (p = 0.99). Five patients 55 or younger presented with uncomplicated dyspepsia. All had advanced, inoperable disease (stage III or higher).

CONCLUSIONS

1) In a racially diverse United States population, upper GI malignancy presenting without alarm symptoms is uncommon. 2) Raising the threshold for immediate endoscopy in uncomplicated dyspepsia from age 45 to 55 increases the risk of missing an underlying malignancy but may not affect outcome, as incurable disease was present at diagnosis within a few weeks of the onset of symptoms.

How do younger patients view long-term treatment with proton pump inhibitors?

Dyspepsia (also called indigestion or heartburn) is a common reason for consulting a general practitioner (GP). One of the medicines available for treating dyspepsia is a type of acid suppressant called a proton pump inhibitor or PPI. There is a growing concern over the rapid increase in prescribing PPI drugs and the escalating costs associated with this trend. There has been an effort to reduce prescribing of PPIs. Most patients who are prescribed these drugs are aged over 45 years. Younger patients (those under 45) are a minority but, in absolute terms, a sizeable number who could potentially be taking PPIs for many years and therefore be expensive. This is a group for whom the appropriateness of prescribing PPIs is often questioned because of the everyday and non-life threatening nature of gastric disorders. A widespread association between dyspeptic symptoms and features of adverse lifestyle that are, at least in principle, easily avoidable has led to the suggestion that PPIs might be used to support unhealthy lifestyles. The perspective of younger patients taking PPIs in the long term has been neglected. In this paper the accounts of ten younger respondents, from a large qualitative investigation of patient and GP perspectives on long-term PPI prescribing, are examined to gain insight into how younger patients viewed their stomach problem, the effectiveness of PPIs and long-term PPI taking. The findings showed a gap between patient experience and medical perception. The perspectives of younger patients need to be recognised in order to deal adequately with their concerns about illness and treat their gastrointestinal conditions effectively.

Reducing community dyspepsia drug costs: a controlled trial

BACKGROUND

Dyspepsia drug costs account for nearly 0.5% of the National Health Service budget. We hypothesised that improved management of dyspepsia would lead to reduced drug costs.

AIM

To determine whether a multifaceted educational strategy for general practitioners aimed at improving quality of dyspepsia management can control dyspepsia costs without increasing demand for endoscopy.

METHODS

A multifaceted educational intervention was delivered to general practitioners in West Gloucestershire but not to those in the east of the county. Dyspepsia drug costs, the primary outcome measure, were obtained from the Prescription Pricing Authority and compared between the two sides of the county. Referral rates for endoscopy, admission to the gastrointestinal bleed unit, and delayed diagnosis of gastric cancer were secondary measures recorded in West Gloucestershire only.

RESULTS

Following the intervention, drug costs declined and then stabilised in West Gloucestershire. Drug costs peaked in the control group 15 months after those in the intervention group. Using an autoregressive integrated moving average model it was estimated the overall costs in the intervention group reduced by 57.9 pence per head of population per half year (95% confidence interval 45.8-69.9 pence/half year; p<0.0001) in comparison with the control group. This difference was maintained for three consecutive years resulting in a cumulative saving of pound1.13 million. Referral rates for upper gastrointestinal endoscopy remained stable during the study period.

CONCLUSION

A multifaceted educational intervention for general practitioners designed to improve the quality of care of patients with dyspepsia is an effective means of controlling dyspepsia drug costs without increasing demand for endoscopy.

Age and alarm symptoms do not predict endoscopic findings among patients with dyspepsia: a multicentre database study

INTRODUCTION

Symptoms of dyspepsia are common but most patients do not have major upper gastrointestinal pathology. Endoscopy is recommended for dyspeptic patients over the age of 45, or those with certain "alarm" symptoms. We have evaluated the effectiveness of age and "alarm" symptoms for predicting major endoscopic findings in six practising endoscopy centres.

METHODS

Clinical variables of consecutive patients with dyspepsia symptoms undergoing upper endoscopy examinations were recorded using a common endoscopy database. Patients who had no previous upper endoscopy or barium radiography were included. Stepwise multivariate logistic regression was used to identify predictors of endoscopic findings. The accuracy of these for predicting endoscopic findings was evaluated with receiver operating characteristic analysis. The sensitivity and specificity of age thresholds from 30 to 70 years were evaluated.

RESULTS

Major pathology (tumour, ulcer, or stricture) was found at endoscopy in 787/3815 (21%) patients with dyspepsia. Age, male sex, bleeding, and anaemia were found to be significant but weak independent predictors of endoscopic findings. A multivariate prediction rule based on these factors had poor predictive accuracy (c statistic=0.62). Using a simplified prediction rule of age > or =45 years or the presence of any "alarm" symptom, sensitivity was 87% and specificity was 26%. Increasing or decreasing the age cut off did not significantly improve the predictive accuracy.

CONCLUSIONS

Age and the presence of "alarm" symptoms are not effective predictors of endoscopic findings among patients with dyspepsia. Better clinical prediction strategies are needed to identify patients with significant upper gastrointestinal pathology.

Gastric cancer: diagnosis, risk factors, treatment and life issues

Gastric cancer is the sixth most common malignancy in the UK. It is responsible for over 9000 deaths annually in the UK. Distal gastric cancer has a decreasing incidence, but proximal gastric cancer continues to increase. Gastroscopy remains the gold standards for accurate diagnosis. Early diagnosis is essential, but symptoms and signs are often mistaken for other less serious diseases. Major surgery is the only proven treatment, but 5-year survival rates postoperatively are only 34%, and many people will continue to suffer side-effects of the surgery. Open access gastroscopy and health promotion may be the best chance of detecting this disease early enough so that it is treated successfully.

Should non-invasive Helicobacter pylori testing replace endoscopy in investigation of dyspepsia?

Our knowledge of Helicobacter pylori infection is now changing the way in which we investigate patients presenting with dyspepsia, with noninvasive H. pylori testing replacing endoscopy. Non-invasive H. pylori testing has been shown to be useful in predicting the underlying diagnosis in patients presenting with dyspepsia. Several studies have shown that 20-50% of dyspeptic patients with a positive H. pylori test will have evidence of underlying ulcer disease or duodenitis. In contrast, less than 5% of dyspeptic patients with a negative H. pylori test will have evidence of ulcer disease and in these subjects, the likeliest diagnosis is gastroesophageal reflux disease. This has led to many groups recommending that noninvasive H. pylori testing should be used in place of endoscopy, with all those testing positive being given anti-H. pylori therapy and those testing negative being treated symptomatically. One concern about nonendoscopic management of dyspeptic patients is the possibility of missing underlying malignancy but studies have shown that in western countries this is rare in patients less than 55 years of age presenting with dyspepsia in the absence of sinister symptoms. There is increasing evidence supporting eradication of H. pylori infection in dyspeptic patients without ulcer disease. Meta-analysis of four prospective randomized trials indicates that such treatment is superior to placebo in about 10% of subjects. H. pylori-positive dyspeptic patients are also recognized to have an increased risk of developing ulcer disease in the future which will be removed by treating the infection. Another justification for eradicating the infection in the absence of ulcer disease is the fact that H. pylori infection is now proven to be a risk factor for gastric cancer. Prospective randomized studies comparing endoscopy with noninvasive H. pylori testing in the management of dyspeptic patients indicate that managing dyspepsia by noninvasive H. pylori testing is at least as effective as endoscopic-based management in producing symptomatic resolution and saves a substantial number of endoscopic procedures. There is therefore now substantial evidence indicating that noninvasive H. pylori testing should be used in place of endoscopy to determine the management of younger dyspeptic patients without sinister symptoms and who are not taking nonsteroidal anti-inflammatory drugs.

Gastric cancer in patients under the age of 30

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

Gastric cancer and other endoscopic diagnoses in patients with benign dyspepsia

BACKGROUND

It has been suggested that endoscopy could be replaced with non-invasive assessment of helicobacter status in the initial work up of young dyspeptic patients without sinister symptoms.

AIMS

To determine the incidence of gastro-oesophageal malignancy in young dyspeptic patients.

METHODS

The Alberta Endoscopy Project captured clinical and demographic data on all endoscopies performed from April 1993 to February 1996 at four major adult hospitals in Alberta. The endoscopic and histological diagnosis in a subgroup of patients under 45 years of age without alarm symptoms that had undergone gastroscopy was reviewed. In addition, a random list of 200 patients was generated and their medical records reviewed in order to assess the proportion with symptoms suitable for a non-invasive management strategy.

RESULTS

Gastroscopy was performed in 7004 patients under 45 years. In 3634 patients (56% female) alarm type symptoms were absent; 78.9% of patients had symptoms amenable to a non-invasive initial approach, giving a corrected sample size of 2867 patients (correction factor 0.789). Three gastric cancers, one case of moderate dysplasia, 10 biopsy proved cases of Barrett's oesophagus, and 19 oesophageal strictures/rings were detected within this sample. The corrected prevalence of gastric cancer in this select population was 1.05 per thousand patients.

DISCUSSION

Endoscopy yielded three gastric cancers in this sample of under 45 year old dyspeptic patients without sinister symptoms. While initial non-invasive screening with one-week triple therapy for helicobacter positive individuals is unlikely to have a detrimental outcome the physician is advised to consider endoscopy in patients with persisting, recurrent, or sinister symptoms.

Disease management in ulcer disease

BACKGROUND

Our knowledge of Helicobacter pylori infection indicates that it is possible to eliminate ulcer disease and improve quality of life for ulcer patients. Treatment is evidence-based and cost-effective. However, though we now have the tools, we have not yet been able to eliminate ulcer disease from society. Dissemination of knowledge and treatment implementation have been problematic. In primary care, there is diagnostic and therapeutic chaos regarding this infection. Disagreement exists on indications for treatment. Expenditure on acid-reducing drugs has greatly increased. Clearly we are not treating all ulcer patients properly (undertreatment); instead we have incorporated H. pylori therapy ('test and treat') into our approach to dyspepsia (overtreatment). Anti-H. pylori therapy in patients with non-ulcer dyspepsia may increase costs because most patients still suffer from symptoms after antibiotic therapy, and therefore require further diagnostic procedures and prescription of new drugs. In order to redeem the great promise of H. pylori, we must focus less on new ulcer patients, because the incidence is rapidly decreasing in Western Europe. Prevalence of ulcer disease, however, is still high. Thus we need to focus more on prevalent cases. We ought to seek and treat those persons already known to have ulcer disease. Systematic 'case-finding' strategies must be performed using standard protocols. Only such 'disease management' programmes performed at the primary care level will suffice to eliminate ulcer disease while also being cost-effective.

Serologic screening before endoscopy: the value of Helicobacter pylori serology, serum recognition of the CagA and VacA proteins, and serum pepsinogen I

BACKGROUND

We wanted to assess the diagnostic value of pre-endoscopy screening by Helicobacter pylori serology, serum recognition of the CagA and VacA proteins, and serum pepsinogen I levels (sPGI) in patients up to 55 years of age with uncomplicated simple dyspepsia.

METHODS

Consecutive dyspeptic patients referred for open-access endoscopy, excluding patients with alarm symptoms, recent intake of acid suppressants, or ingestion of non-steroidal anti-inflammatory drugs. H. pylori status was determined by histology and urease testing. H. pylori serologic status was determined with the enzyme-linked immunosorbent assay (ELISA) and Western blotting, serum recognition of CagA and VacA with Western blot, and sPGI levels by radioimmunoassay.

RESULTS

One hundred and fifteen patients were studied (mean age, 40 years: range, 20-55 years), of whom 58 were H. pylori-positive in biopsy-based tests. Twenty-one patients (18%) had significant gastroduodenal lesions (erosions, ulcers, or cancer). The sensitivity (specificity) of the ELISA (optimized) and Western blot in determining H. pylori status was 94.8% (89.5%) and 100% (96.4%), respectively. Screening strategies based on the ELISA or Western blot for determining H. pylori serologic status would have detected 95% or 100% of significant lesions, respectively, and each 'saved' 47% of endoscopies for simple dyspepsia. Serum recognition of the CagA protein would have detected 95% of significant lesions and 'saved' 55% of endoscopies, whereas recognition of the VacA protein would have detected only 81% of the lesions. Screening by H. pylori serology plus a 'low' (<55 ng/ml) or 'high' sPGI (>125 ng/ml) would detect only 57% of significant lesions, although the only case of cancer was included in the hypopepsinogenaemic subgroup of just 11 patients.

CONCLUSIONS

In patients with uncomplicated, simple dyspepsia up to 55 years of age, screening by H. pylori serology identified 95%-100% of patients with significant gastroduodenal lesions while potentially saving 46.9% of endoscopies. Serum recognition of the CagA protein identified 95% of lesions and would have saved an additional number of endoscopies (7.9%) compared with basic serology. Measurement of sPGI was of limited diagnostic value.

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

BACKGROUND

The management of dyspepsia is controversial.

METHODS

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

RESULTS

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

CONCLUSION

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

How should Helicobacter pylori positive dyspeptic patients be managed?

Dyspepsia, according to the internationally accepted Rome criteria, refers to pain or discomfort centred in the upper abdomen; patients with predominant heartburn are excluded from this group, although minor or infrequent heartburn is commonly associated with dyspepsia. It is an important condition not only because it is common and costly, but because it may indicate the presence of serious disease such as peptic ulcer or gastric cancer. However, the most frequent causes of dyspepsia are functional dyspepsia and gastro-oesophageal reflux disease. The discovery of Helicobacter pylori has resulted in important advances in the management of dyspepsia. The clinician faced with a patient who has persistent or recurrent dyspepsia needs to differentiate clearly those patients who have not been previously investigated from patients documented to have functional dyspepsia after investigation (fig 1). Here, the management of H pylori positive dyspeptic patients who have and have not been fully investigated will be reviewed.

Treatment of functional dyspepsia

Many functional dyspepsia treatment trials have until recently suffered from important weaknesses in study design. A major problem has been the low number of studies that have used validated outcome measures. Fortunately, progress has been made in this area. The evidence for the efficacy of antacids, H2-receptor antagonists, omeprazole, domperidone, cisapride and anti-Helicobacter therapy is reviewed. Although several of these have shown benefit, it is unclear whether this may be a result of the inclusion of patients with unrecognized gastro-oesophageal reflux disease. The data on anti-Helicobacter therapy are conflicting.

Organic causes of dyspepsia, and discriminating functional from organic dyspepsia

A wide variety of disorders affecting the upper gastrointestinal tract, as well as systemic disorders, are associated with symptoms of dyspepsia. The more important of these conditions are considered in this chapter, with particular reference to their symptom patterns on presentation. The differentiation, on clinical grounds, between these organic causes of dyspepsia and functional dyspepsia remains an important area of research. Those aspects of the history and physical examination most relevant to this distinction are also considered.