GPs' ability to diagnose dyspepsia based only on physical examination and patient history

History-taking, Clinical Signs, Tests and Scores for Detection of Non-organic Dyspepsia (NOD) Among Patients With Acute Abdominal Pain (AAP)

BACKGROUND/AIM

The diagnostic accuracy of history-taking, clinical signs and tests and diagnostic scores (DSs) for patients with non-organic dyspepsia (NOD) have been rarely evaluated.

PATIENTS AND METHODS

A cohort of 1333 patients presenting with acute abdominal pain (AAP) were studied, including 50 patients with confirmed NOD. The most significant diagnostic variables (in multivariate logistic regression analysis) were used to construct six different DS models and their diagnostic accuracy was compared with clinical symptoms and signs and tests. Meta-analytical techniques were used to detect the summary sensitivity (Se) and specificity (Sp) estimates for each data set (symptoms, signs and tests as well as DS models).

RESULTS

In hierarchical summary receiver operating characteristic (HSROC) analysis, the area under curve (AUC) values for i) symptoms ii) signs and tests iii) DS were as follows: i) AUC=0.608 [95% confidence interval (CI)=0.550-0.666]; ii) AUC=0.621 (95% CI=0.570-0.672) and iii) AUC=0.877 (95% CI=0.835-0.919). The differences between these AUC values (roccomp analysis) are as follows: between i) and ii) p=0.715; between i) and iii) p<0.0001; between ii) and iii) p<0.0001.

CONCLUSION

The present study is the first to provide evidence that the DS could be used in diagnosis of NOD. The major advantage of our DS is that this model does not need radiology or endoscopy to reach high diagnostic accuracy.

Gastroesophageal Reflux Disease-Functional Dyspepsia Overlap: Do Birds of a Feather Flock Together?

INTRODUCTION

Gastroesophageal reflux disease (GERD) and functional dyspepsia (FD) are 2 of the most prevalent upper gastrointestinal (GI) disorders in the Western world. Previous Rome definitions excluded patients with predominant heartburn from the definition of FD because they were considered to have GERD. However, more recent studies showed that heartburn and acid regurgitation are also common symptoms in patients with FD. The aim of this study is to provide an overview of the prevalence of overlap between GERD and FD, the underlying pathophysiology and implications for treatment.

METHODS

A review of the literature was performed using the PubMed database, and a meta-analysis with random effects model was completed.

RESULTS

This review showed considerable overlap between GERD and FD. A meta-analysis on the data included in this review showed 7.41% (confidence interval [CI]: 4.55%-11.84%) GERD/FD overlap in the general population, 41.15% (CI: 29.46%-53.93%) GERD with FD symptoms, and 31.32% (CI: 19.43%-46.29%) FD with GERD symptoms. Although numerous committees and consensus groups attempted to develop uniform definitions for the diagnosis of GERD and FD, various diagnostic criteria are used across studies and clinical trials (frequency, severity, and location of symptoms). Several studies showed that the overlap between GERD and FD can be explained by a shared pathophysiology, including delayed gastric emptying and disturbed gastric accommodation.

DISCUSSION

For diagnoses of GERD and FD, uniform definitions that are easy to implement in population studies, easy to interpret for physicians, and that need to be well explained to patients to avoid overestimation or underestimation of true prevalence are needed. Both GERD and FD coexist more frequently than expected, based on coincidence, suggesting a potential pathophysiological link. More research is needed to explore the common GERD/FD overlap population to identify the underlying pathophysiological mechanisms, which may lead to a more effective therapeutic approach.

An Approach to the Patient With Chronic Undiagnosed Abdominal Pain

Abdominal pain is a common reason for referral to a gastroenterologist. The workup of patients with chronic abdominal pain can be extremely challenging as clinicians are responsible for determining whether the patient can be observed or treated symptomatically or this abdominal pain heralds a more systemic disease. The differential is typically wide and given the innervation of the abdomen, localization of abdominal pain does not always provide clear insight into the etiology. This review attempts to help the gastroenterologist narrow down that broad differential and focus on key elements of the patient visit. We emphasize the importance of a detailed history from the patient, along with review-specific details of their history and physical examination that can clue one in about the etiology of the abdominal pain. We review the causes of diffuse abdominal pain that may not first be considered along with uncommon causes of localized abdominal pain. We also review the functional causes of abdominal pain and the importance of identifying these disorders, to avoid unnecessary testing that commonly occurs with these patients.

How accurate is diagnosis of congenital anomalies made by family physicians?

BACKGROUND

Although family physicians have a key role in clinical management of many diseases and in community health, the accuracy of the diagnosis for congenital anomalies by family physicians still needs more investigations. The aim of this study was to assess the accuracy of family physicians in case detection and diagnosis of congenital anomalies in rural areas, northwest of Iran.

METHODS

In a community-based study of 22500 children born between 2004 and 2012, all 172 cases of congenital anomalies diagnosed by family physicians were assessed by a qualified pediatrician in 47 health houses in rural areas of Tabriz District, northwest Iran. A group of 531 children was compared as control subjects.

RESULTS

The overall sensitivity and specificity of family physicians‟ diagnosis for congenital anomalies were estimated 98% (95% Confidence Interval (CI): 95.9 to 100) and 100% (95% CI: 99.3 to 100), respectively. Sensitivity for diagnosis of congenital heart diseases was 97% (95% CI: 93 to 100), and for genitourinary tract, it was 86% (95% CI: 59 to 100). Specificity was estimated 100% for both groups of heart and genitourinary tract anomalies.

CONCLUSION

The performance of family physicians was found accurate enough in the diagnosis of congenital anomalies. Health care system may consider family physician program as an effective approach to detect and clinical management of congenital anomalies.

[Clinical practice guideline on the management of patients with dyspepsia. Update 2012]

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/).

[Clinical practice guideline on the management of patients with dyspepsia. Update 2012]

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/).

Dyspepsia: organic versus functional

Dyspepsia is the medical term for difficult digestion. It consists of various symptoms in the upper abdomen, such as fullness, discomfort, early satiation, bloating, heartburn, belching, nausea, vomiting, or pain. The prevalence of dyspepsia in the western world is approximately 20% to 25%. Dyspepsia can be divided into 2 main categories: "organic" and "functional dyspepsia" (FD). Organic causes of dyspepsia are peptic ulcer, gastroesophageal reflux disease, gastric or esophageal cancer, pancreatic or biliary disorders, intolerance to food or drugs, and other infectious or systemic diseases. Pathophysiological mechanisms underlying FD are delayed gastric emptying, impaired gastric accommodation to a meal, hypersensitivity to gastric distension, altered duodenal sensitivity to lipids or acids, altered antroduodenojenunal motility and gastric electrical rhythm, unsuppressed postprandial phasic contractility in the proximal stomach, and autonomic nervous system-central nervous system dysregulation. Pathogenetic factors in FD are genetic predisposition, infection from Helicobacter pylori or other organisms, inflammation, and psychosocial factors. Diagnostic evaluation of dyspepsia includes upper gastrointestinal endoscopy, abdominal ultrasonography, gastric emptying testing (scintigraphy, breath test, ultrasonography, or magnetic resonance imaging), and gastric accommodation evaluation (magnetic resonance imaging, ultrasound, single-photon emission computed tomography, and barostat). Antroduodenal manometry can be used for the assessment of the myoelectrical activity of the stomach, whereas sensory function can be evaluated with the barostat, tensostat, and satiety test. Management of FD includes general measures, acid-suppressive drugs, eradication of H. pylori, prokinetic agents, fundus-relaxing drugs, antidepressants, and psychological interventions. This review presents an update on the diagnosis of patients presenting with dyspepsia, with an emphasis on the pathophysiological and pathogenetic mechanisms of FD and the differential diagnosis with organic causes of dyspepsia. The management of uninvestigated and FD, as well as the established and new pharmaceutical agents, is also discussed.

Prevalence of undiagnosed advanced atrophic corpus gastritis in Finland: an observational study among 4,256 volunteers without specific complaints

OBJECTIVE

The objective of this observational study was to estimate the prevalence of advanced atrophic corpus gastritis (ACG) among Finnish adult volunteers without specific complaints using a biomarker blood test. The objective also was to assess the feasibility and acceptance of the biomarker test among the volunteers.

MATERIALS AND METHODS

GastroView biomarker test (Biohit Oyj, Helsinki, Finland) was performed on mostly fingerprick blood samples from 4,256 volunteers (average age 56 years, range 18-92 years), independent of symptoms. GastroView biomarker test was offered to citizens at public events during 2007-2009. The test consisted of the measurement of pepsinogen I and II levels (and ratio) and H. pylori IgG antibody level in plasma by ELISA.

RESULTS

Altogether 3.5% (150 individuals) of all 4,256 volunteers had ACG. In the age group of 70 or over, the prevalence of ACG increased to 8% (62 individuals). Altogether 19% (819 individuals) of all volunteers and 37% (56 individuals) of those with ACG had an ongoing H. pylori infection. In volunteers with ACG, the diagnosis was new in 95% (142 individuals), 5% (7 individuals) had received vitamin B12 supplementation and 13% (20 individuals) had received PPI medication according to a self-administered questionnaire; and 26% (39 individuals) reported gastrointestinal reflux like symptoms.

CONCLUSIONS

This study shows that advanced ACG is a common disease among Finnish adults, and remains to be undiagnosed in most under the current healthcare practice. The biomarker test shows high feasibility and acceptance among the general public, and is simple to perform even in "field" conditions.

Sensitivity of ultrasonography for gastric cancer diagnosis in symptomatic patients

Endoscopy with biopsy sampling is the gold standard used in gastric cancer diagnosis. However, the positive predictive value of signs and symptoms for the diagnosis of carcinomas is quite limited, and, therefore, many patients are subjected to non-diagnostic endoscopies, especially when symptoms are not so specific. This study shows that ultrasonography is sensitive enough for the diagnosis of gastric cancer, and, therefore, use of this technique would further ensure a better selection of patients for endoscopy. The study included 143 patients (86 men and 57 women, with an average age of 68.6 years) who were suspected of having gastric cancer. The diagnostic accuracy of ultrasonography was evaluated in a blind study. The conventional technique was used in all cases. Demographic parameters and a series of other clinical-analytical variables were studied to look for possible gastric cancer predictive factors, which when present would make ultrasonographic results irrelevant. Statistical analysis was done using SPSS 12.0, wherein a value of P < 0.05 was considered to be statistically significant. Of the 143 patients studied, 40 were diagnosed to have gastric cancer. Sonography was able to diagnose 37 cases correctly, while there were three false negative findings and eight false positive findings. This results in 92.5% sensitivity, 92.2% specificity, 82.2% positive predictive value, 96.9% negative predictive value, and a global accuracy of 92.3%. Univariate analysis showed that persistent vomiting (P = 0.021), hemoglobin level of less than 8 g/dl (P = 0.045) and a positive ultrasonography result (P < 0.0001) were associated with a higher frequency of gastric cancer. Multivariate analysis showed that persistent vomiting, with an odds ratio for gastric cancer of 3.68 (95% confidence interval 1.15-11.79; P = 0.039), and a positive ultrasonography result, with an odds ratio for gastric cancer of 117.78 (95% confidence interval 32.45-427.49; P < 0.0001), could be considered as independent predictive factors for gastric cancer. It was concluded that ultrasonography is a very sensitive and specific technique for diagnosing gastric cancer. Gastric cancer was found to be present in just 28% of the patients studied, and their condition was suspect because of the clinical manifestations. Only vomiting and a positive ultrasonography result can be considered as independent predictive factors of gastric cancer.

Age, symptoms and upper gastrointestinal malignancy in primary care endoscopy

OBJECTIVE

Upper gastrointestinal complaints are common in the general population. The aim of this study was to establish whether age and occurrence of alarm symptoms are predictors of malignancy in primary care open-access endoscopy.

MATERIAL AND METHODS

The material comprised 10,061 consecutive patients referred for gastroscopy by general practitioners from 1989 to 2000. The presenting symptoms were recorded; alarm symptoms comprised dysphagia, weight loss, gastrointestinal bleeding, anaemia and vomiting.

RESULTS

In all, 13.0% (1310) of the patients had alarm symptoms. Malignancy was detected in 0.7% (72 patients) in the whole series, in 0.3% (13 patients) aged 55 years or younger and in 1.1% (59 patients) over 55 years of age; the respective percentages in patients with alarm symptoms were 2.5% (33 patients), 1.0% (5 patients) and 3.4% (28 patients). Alarm symptoms (odds ratios 3.98; confidence interval 2.47-6.41), age (1.07/year; 1.05-1.09) and male gender (1.95; 1.22-3.12) were significantly associated with gastrointestinal malignancy.

CONCLUSIONS

The total number of malignancies in the primary care open-access gastroscopy series was low. Alarm symptoms increased the risk 5-6-fold; such patients should therefore undergo endoscopy without delay. At a further one year of age the risk was increased by 7%, but no definite age limit for endoscopy could be asserted.

Diagnostic value of the proton pump inhibitor test for gastro-oesophageal reflux disease in primary care

AIM

To assess the diagnostic accuracy of the proton pump inhibitor test in a primary care population as well as its additional value over reflux history, using the symptom association probability outcome during 24-h oesophageal pH recording as reference test for gastro-oesophageal reflux disease.

METHODS

Subjects with symptoms suggestive of gastro-oesophageal reflux disease were recruited from primary care. After a 24-h pH recording with calculation of the symptom association probability, subjects started using 40 mg esomeprazole once daily for 13 days. The proton pump inhibitor test was considered positive when the subjects reported adequate symptom suppression. Data are presented as means with 95% confidence intervals.

RESULTS

Successful 24-h pH recording was accomplished in 84 of the 90 subjects, while the symptom association probability was calculable in 74. The symptom association probability was positive in 70% of the subjects. The sensitivity of the proton pump inhibitor test was 0.91 (CI 0.78-0.96) and the specificity was 0.26 (CI 0.10-0.49). The mean likelihood ratio was 1.2 (CI 0.9-1.6) with little variation over the 13 consecutive proton pump inhibitor test days. The likelihood ratios of gastro-oesophageal reflux disease symptoms were comparable, ranging around 1.

CONCLUSIONS

In primary care patients with reflux symptoms gastro-oesophageal reflux disease is highly prevalent. Under these conditions the additional value of short-term treatment with a proton pump inhibitor for diagnosing gastro-oesophageal reflux disease is limited.

A prospective 1-year follow-up study in patients with functional or organic dyspepsia: changes in gastrointestinal symptoms, mental distress and fear of serious illness

BACKGROUND

Psychosocial factors are common among patients with functional gastrointestinal disorders (FGIDs). Whether they affect the course of the disease remains unresolved.

AIM

To evaluate whether reassuring investigations of primary care patients with functional dyspepsia (FD) and organic dyspepsia (OD) influence gastrointestinal (GI) symptoms and psychological factors, and to assess whether these changes are correlated.

METHODS

Four hundred consecutive patients with dyspepsia were referred for thorough examinations. Patients completed questionnaires screening symptoms at baseline and on 1-year follow-up.

RESULTS

At baseline, there was no difference in GI symptoms, prevalence of mental distress or fear of serious illness between patients with FD or OD. On follow-up, the patients with FD had more GI symptoms, but there was no difference in mental distress or fear of serious illness. Relevant GI symptom reduction related to alleviation of mental distress (53.4% vs. 20.5%, P < 0.001) and fear of serious illness (56.5% vs. 23.7%, P = 0.002), but reached statistical significance only in patients with OD.

CONCLUSIONS

Gastrointestinal symptoms in FD patients are long lasting compared with those with organic diseases. Reassuring investigations could lower mental distress and fear of serious illness in these patients. Psychological factor change correlates with the change in GI symptom severity and is not specific to FGIDs.

Limited value of alarm features in the diagnosis of upper gastrointestinal malignancy: systematic review and meta-analysis

BACKGROUND & AIMS

Alarm features such as dysphagia, weight loss, or anemia raise concern of an upper gastrointestinal malignancy in patients with dyspepsia. The aim of this study was to determine the diagnostic accuracy of alarm features in predicting malignancy by performing a metaanalysis based on the published literature.

METHODS

English-language studies were identified by searching MEDLINE, EMBASE, Cochrane Controlled Trials Register, and CINAHL. Cohort studies that measured alarm features and compared them with the endoscopic findings were included. Studies were screened for inclusion by 2 authors who independently extracted the data. Sensitivity, specificity, and likelihood ratios were calculated by comparing the alarm feature with the endoscopic diagnosis. The summary receiver operating characteristic curve method was used to summarize test characteristics across studies. Individual alarm features were also assessed when the study report permitted.

RESULTS

Eighty-three of 2600 studies met the initial screening criteria; 15 met inclusion criteria after detailed review. These 15 studies evaluated a total of 57,363 patients, of whom 458 (.8%) had cancer. The sensitivity of alarm symptoms varied from 0% to 83% with considerable heterogeneity between studies. The specificity also varied significantly from 40% to 98%. A clinical diagnosis made by a physician was very specific (range, 97%-98%) but not very sensitive (range, 11%-53%).

CONCLUSIONS

Alarm features have limited predictive value for an underlying malignancy. Their use in dyspepsia management strategies needs further refinement and study.

How useful are the Rome II criteria for identification of upper gastrointestinal disorders in general practice?

OBJECTIVE

The Rome II criteria are a classification of functional gastrointestinal disorders. It is not known whether they can be used as a diagnostic tool. This study evaluates the agreement between GPs and the Rome II criteria on the diagnosis of upper gastrointestinal disorders.

MATERIAL AND METHODS

Consecutive patients with abdominal complaints were included in this pragmatic cross-sectional study. All patients answered a questionnaire based on the Rome II criteria. The diagnoses based on these criteria were compared with the GPs' diagnoses.

RESULTS

A total of 549 consecutively selected patients were included in the study. The agreement between GPs and the Rome II criteria was 65%, kappa 0.34 (CI 0.27-0.41). The agreement was lower when dyspepsia and gastroesophageal reflux/functional heartburn were evaluated separately. The positive and negative predictive values of the Rome II criteria varied between 29-58% and 82-90%, respectively, in various groups of patients with confirmed diagnoses.

CONCLUSIONS

The GPs' diagnoses differed from those based entirely on the Rome II criteria. Strict adherence to the criteria will result in other diseases being disregarded. The diagnoses of upper gastrointestinal disorders should be based on all available information and the Rome II criteria used only as an additional aid to improve the precise classification of functional disorders.

Measuring the quality of referral letters about patients with upper gastrointestinal symptoms

BACKGROUND

General practitioners state the reason for referring patients in referral letters. The paucity of information in these letters has been the source of criticism from specialist colleagues.

OBJECTIVE

To invite general practitioners to set standards for referral letters to gastroenterologists and to apply these standards to actual referral letters to one specialist gastroenterology unit.

METHODS

A scoring schedule was designed based on the responses to a questionnaire survey of a large sample of all general practitioners in one locality. Altogether 350 consecutive letters to a district general hospital about patients referred for an upper gastrointestinal specialist opinion were subsequently scored using the schedule.

RESULTS

102 practitioners responded to the survey. Their responses imply that colleagues assess and record findings on 18 potential features of upper bowel disease. In practice most referral letters address fewer than six features of upper bowel disease. The mean number of positive features of upper gastrointestinal disease reported in each letter was one.

CONCLUSIONS

This study reported a failure to meet "peer defined" standards for the content of referral letters set by colleagues in one locality. Referral letters serve many purposes, however, encouraging full documentation of specific clinical findings may serve to increase the pre-referral assessments performed in practice.

Review article: how valuable are proton-pump inhibitors in establishing a diagnosis of gastro-oesophageal reflux disease?

Diagnostic studies for gastro-oesophageal reflux disease (endoscopy, pH testing) have significant limitations. A short trial of acid suppression with a proton-pump inhibitor is often used in clinical practice as a diagnostic test for gastro-oesophageal reflux disease. If there is a significant improvement in symptoms, the patient is considered to have gastro-oesophageal reflux disease. Several studies have evaluated the administration of proton-pump inhibitors as a diagnostic test for gastro-oesophageal reflux disease. A recent meta-analysis found that response to a proton-pump inhibitor had limited value as a diagnostic test. Likelihood ratios for a positive test ranged from 0.45 to 1.86. The positive predictive value of the test ranged from 0.17 to 0.90 and the negative predictive value from 0.17 to 1, depending on the gold standard against which comparisons were made. These results may be explained by the inadequacy of the gold standard against which the proton-pump inhibitor test is compared or by the inability of acid suppression to differentiate between gastro-oesophageal reflux disease, peptic ulcer disease or dyspepsia. Although a trial of acid suppression may have pragmatic value in clinical practice, the proton-pump inhibitor test is not an accurate test for the diagnosis of gastro-oesophageal reflux disease.

Mental distress in patients with functional or organic dyspepsia: a comparative study with a sample of the general population

BACKGROUND

It has been argued that patients with functional gastrointestinal disorders have mental disorders more often than healthy controls and patients with organic disease. Most studies surveying psychological factors at the population level have relied on symptom questionnaires to diagnose functional dyspepsia. However, the symptom patterns alone are unable to adequately discriminate organic from functional dyspepsia.

AIM

To evaluate the frequency of mental distress in primary care patients with organic or functional dyspepsia and compare the findings with a sample of the Finnish general population.

METHODS

Four-hundred consecutive, unselected dyspeptic patients were referred for upper gastrointestinal endoscopy and other diagnostic examinations. All patients compiled a self-administered questionnaire including the 12-item General Health Questionnaire to detect cases of recent mental disorders.

RESULTS

The prevalence of mental distress among patients with functional and organic dyspepsia was 38 and 36.4% respectively. The sex- and age-adjusted risk of having mental distress was nearly fourfold higher among patients with dyspepsia than in the general population.

CONCLUSION

Mental distress is common among patients with functional or organic dyspepsia. Nevertheless, there is no difference between patients with functional or organic dyspepsia in the prevalence or risk of mental distress.

Can symptoms predict endoscopic findings in GERD?

BACKGROUND

It is difficult to decide which patients with reflux symptoms require endoscopy. The aim of this study was to develop a scoring system to predict esophageal findings at endoscopy.

METHODS

A consecutive sample of 1011 adult patients scheduled for upper endoscopy were asked to complete a validated symptom questionnaire. The endoscopy reports were abstracted. Individual logistic regression models were developed to predict esophagitis, Barrett's esophagus (long and short segment) and esophageal stricture, including Schatzki's ring.

RESULTS

Reflux esophagitis was independently associated with heartburn frequency (p<0.0001) but not severity or duration (p>0.05). Barrett's esophagus was associated with the duration of acid regurgitation (p<0.005) but not with frequency or severity (p>0.05). Strictures were associated with dysphagia severity (p<0.0001) and duration (p<0.0001) but not frequency (p>0.05). At a sensitivity of 80%, the models had a specificity of 49% for esophagitis, 57% for Barrett's esophagus, and 68% for strictures. At a specificity of 80%, the sensitivities were 51% for esophagitis, 62% for Barrett's esophagus and 71% for strictures.

CONCLUSIONS

Endoscopic findings were associated with distinct attributes of reflux symptoms. Symptoms are only modestly predictive of findings at endoscopy.

What is the long-term outcome of the different subgroups of functional dyspepsia?

BACKGROUND

Functional dyspepsia is often a long-lasting disorder that accounts for substantial healthcare costs. It has been classified into subgroups assuming that it can guide management of dyspepsia.

AIM

To evaluate the clinical significance of subgrouping functional dyspepsia in a long-term perspective study.

METHODS

Consecutive patients with dyspepsia identified by general practitioners were investigated. Those patients with functional dyspepsia (n=201) were enrolled in this study. Initially, patients were divided into five subgroups (ulcer-like, dysmotility-like, reflux-like, unspecified, and irritable bowel syndrome-like). Patients' medical histories were reviewed after 6-7 years, and the number and outcome of repeated investigations were analysed. At the end of follow-up, patients filled in a questionnaire similar to that at baseline, and were invited for gastroscopy.

RESULTS

Only 2% of patients developed peptic ulcer during follow-up, none of them were in the ulcer-like subgroup. When referrals to hospital and examinations during follow-up were registered, no statistically significant differences existed between subgroups. Patients with reflux-like dyspepsia made fewer revisits than others (P=0.02), but had used antidyspepsia drugs during the previous year more often (P=0.036). Stability of the subgroups over time was poor.

CONCLUSIONS

Functional dyspepsia is a long-lasting disorder with a very good prognosis. Subgroups of functional dyspepsia play only a minor role in prediction of the long-term outcome, and their usefulness in clinical practice is also hampered by subgroup instability over time.