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

A Simple Pre-endoscopy Score for Predicting Risk of Malignancy in Patients with Dyspepsia: A 5-Year Prospective Study

BACKGROUND

The guidelines for performing endoscopy in dyspeptic patients based on clinical parameters alone have shown variable performance, and there is a need for better prediction tools.

AIM

We aimed to prospectively develop and validate a simple clinical-cum-laboratory test-based scoring model to identify dyspeptic patients with high risk of upper gastrointestinal malignancy (UGIM).

METHODS

Adult patients with dyspeptic symptoms were prospectively recruited over 5 years. Clinical details including alarm features were recorded, and blood tests for hemoglobin and albumin were done before endoscopy. The presence of UGIM was the primary outcome. Risk factors for UGIM were assessed, and based on the OR of significant factors, a predictive scoring model was constructed. ROC curve was plotted to identify optimal cutoff score. The model was validated using bootstrapping technique.

RESULTS

The study included 2324 patients (41.9 ± 12.8 years; 33.4% females). UGIM was noted in 6.8% patients. The final model had following five positive predictors for UGIM-age > 40 years (OR 3.3, score 1); albumin ≤ 3.5 g% (OR 3.4, score 1); Hb ≤ 11 g% (OR 3.3, score 1); alarm features (OR 5.98, score 2); recent onset of symptoms (OR 8.7, score 3). ROC curve had an impressive AUC of 0.9 (0.88-0.93), and a score of 2 had 92.5% sensitivity in predicting UGIM. Validation by bootstrapping showed zero bias, which further strengthened our model.

CONCLUSION

This simple clinical-cum-laboratory test-based model performed very well in identifying dyspeptic patients at risk of UGIM. This can serve as a useful decision-making tool for referral for endoscopy.

MARK's Quadrant scoring system: a symptom-based targeted screening tool for gastric cancer

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.

Helicobacter Pylori "Test-and-Treat" Strategy for Management of Dyspepsia: A Comprehensive Review

OBJECTIVES:

Deciding on whether the Helicobacter pylori test-and-treat strategy is an appropriate diagnostic–therapeutic approach for patients with dyspepsia invites a series of questions. The aim present article addresses the test-and-treat strategy and attempts to provide practical conclusions for the clinician who diagnoses and treats patients with dyspepsia.

METHODS:

Bibliographical searches were performed in MEDLINE using the keywords Helicobacter pylori, test-and-treat, and dyspepsia. We focused mainly on data from randomized controlled trials (RCTs), systematic reviews, meta-analyses, cost-effectiveness analyses, and decision analyses.

RESULTS:

Several prospective studies and decision analyses support the use of the test-and-treat strategy, although we must be cautious when extrapolating the results from one geographical area to another. Many factors determine whether this strategy is appropriate in each particular area. The test-and-treat strategy will cure most cases of underlying peptic ulcer disease, prevent most potential cases of gastroduodenal disease, and yield symptomatic benefit in a minority of patients with functional dyspepsia. Future studies should be able to stratify dyspeptic patients according to their likelihood of improving after treatment of infection by H. pylori.

CONCLUSIONS:

The test-and-treat strategy will cure most cases of underlying peptic ulcer disease and prevent most potential cases of gastroduodenal disease. In addition, a minority of infected patients with functional dyspepsia will gain symptomatic benefit. Several prospective studies and decision analyses support the use of the test-and-treat strategy. The test-and-treat strategy is being reinforced by the accumulating data that support the increasingly accepted idea that “the only good H. pylori is a dead H. pylori”.

[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/).

Association of an NFKB1 intron SNP (rs4648068) with gastric cancer patients in the Han Chinese population

Background

Hyperactivation of nuclear factor-κB (NF-κB) is associated with various types of tumors. This study investigated the susceptibility of the rs4648068 A/G genotype in the intron region of NFKB1 to gastric cancer and the association of this polymorphism with clinicopathologic variables in gastric cancer patients.

Methods

A hospital-based case–control study of 248 gastric cancer patients and 192 control individuals was conducted in Fudan University Shanghai Cancer Center (Shanghai, China). Single nucleotide polymorphism (SNP) rs4648068 genotype in NFKB1 from blood samples of a total of 440 people was analyzed by polymerase chain reaction-based genotyping.

Results

The frequencies of the AA, AG, and GG genotypes of the rs4648068 polymorphism were 31.5%, 47.2%, and 21.3% in the gastric cancer patients and 29.7%, 59.9%, and 10.4% in the control individuals, respectively. We found that the GG genotype was associated with a significantly increased risk of gastric cancer (P = 0.042). Furthermore, among the gastric cancer cases, the rs4648068 GG genotype was associated with high clinical stage (AOR = 2.27, 95% CI: 1.11- 4.66), lymph node involvement (AOR = 2.90, 95% CI = 1.40- 6.03) and serosa invasion (AOR = 2.78, 95% CI = 1.34- 5.75). However, rs4648068 genotypes were not associated with tumor differentiation in gastric cancer patients.

Conclusions

Homozygous rs4648068 GG was associated with an increased risk of gastric cancer, especially for the lymph node status and serosa invasion in Han Chinese population.

Upper gastrointestinal cancer in its early stages is predominantly asymptomatic

BACKGROUND

Current guidelines for urgent endoscopic investigation of dyspepsia are based on alarm features and age criteria. However, there is concern that this type of guideline may delay the diagnosis of upper gastrointestinal (GI) cancer.

OBJECTIVE

To evaluate the timescale of symptoms in upper GI cancer, determining whether patients experience dyspepsia before developing alarm features, and hence whether the current guidelines may delay diagnosis.

METHOD

A prospective study of patients diagnosed with upper GI cancer between May 2004 and January 2007. A structured interview was performed directly after endoscopic diagnosis regarding the nature and duration of symptoms.

RESULTS

Alarm features were present in 56 of the 60 patients interviewed. Only eight patients reported dyspepsia before developing their alarm feature; three of these had complained of dyspepsia for >10 years, one reported dyspepsia preceding the alarm feature by 18 months and in four patients dyspepsia preceded the alarm feature by ≤8 weeks. Preceding dyspepsia did not cause significant delay in referral for endoscopy (p=0.670), or affect tumour stage at diagnosis (p=0.436) or length of survival (p=0.325).

CONCLUSION

It is rare for patients with upper GI cancer to experience significant dyspepsia before the onset of their alarm symptoms, therefore limiting the prospect of an earlier diagnosis. Early upper GI cancer is largely asymptomatic, and guidelines should limit the availability of open-access gastroscopy in simple dyspepsia. Increased awareness of the need to urgently investigate patients with concurrent anaemia or weight loss is required.

Positive selection on a bacterial oncoprotein associated with gastric cancer

Background

Helicobacter pylori is a vertically inherited gut commensal that is carcinogenic if it possesses the cag pathogenicity island (cag PaI); infection with H.pylori is the major risk factor for gastric cancer, the second leading cause of death from cancer worldwide (WHO). The cag PaI locus encodes the cagA gene, whose protein product is injected into stomach epithelial cells via a Type IV secretion system, also encoded by the cag PaI. Once there, the cagA protein binds to various cellular proteins, resulting in dysregulation of cell division and carcinogenesis. For this reason, cagA may be described as an oncoprotein. A clear understanding of the mechanism of action of cagA and its benefit to the bacteria is lacking.

Presentation and survival of operable esophageal cancer in patients 55 years of age and below

BACKGROUND

The increased incidence of esophageal cancer, especially in the younger age group, should encourage early diagnosis. The perceived rarity and poor prognostic outcome of esophageal cancer in this group is based on retrospective studies. The goal of this study was to review the presentation and survival of young patients with esophageal cancer.

METHODS

This study was conducted from 2000 to 2007 in a specialized esophagogastric center. All patients who had esophageal cancer operations were included. Variables collected included ages, duration of symptoms, presenting symptoms, tumor characteristics, and follow-up data.

RESULTS

In total, 365 esophagectomies were performed for cancer, of which 76 patients were younger than aged 55 years (20.8%) and 289 were older than aged 55 years. In patients younger than aged 55 years, 15 patients had symptoms for 6 months or more, 54 had dysphagia, 35 had weight loss compared with 220 and 175 respectively of patients older than aged 55 years. On histopathology, 48 had T3 tumors (63.2%), 17 had T2 (22.4%), and 10 had T1 (13.2%) for patients younger than aged 55 years compared with 141 had T3 (48.7%), 85 had T2 (29.4%), and 55 had T1 (19%) for patients older than aged 55 years. These differences in tumor stage at presentation between groups were significant (p < 0.05 with 3DF). In-hospital mortality was 0 for the group younger than aged 55 years and 5 for those older than aged 55 years. Average follow-up was 35 (minimum, 15) months. Thirty patients had locoregional recurrence in the first group and 110 in the latter group. Survival at 1 year after surgery was 79.6%, at 2 years 65.1%, and at 5 years 42.3% compared with 78.4, 60.6, and 45.9%, respectively, for the group older than aged 55 years, but this was not significant using log-rank (p = 0.99).

CONCLUSIONS

A significant proportion (20.8%) of patients presenting with operable esophageal cancer was younger than aged 55 years. Almost two-thirds of those presenting younger than aged 55 years had T3 stage tumors, which was significantly different than those older than aged 55 years. Despite more advanced tumor stage at presentation, the prognosis of esophageal cancer for patients younger than aged 55 years is similar to those older than aged 55 years (log-rank = 0.99).

Comparative outcome of oesophagogastric cancer in younger patients

INTRODUCTION

The incidence of oesophageal and gastric cardia adenocarcinoma has increased rapidly over the previous two decades. There has been a rise in the number of younger patients affected, and the disease may be more aggressive and have a worse prognosis in these individuals. Current UK guidelines for urgent cancer referral focus on patients who are over 55 years. This study prospectively compares the referral times and outcome in a cohort of patients diagnosed with oesophagogastric cancer under the age of 55 years with a matched cohort over 55 of age.

PATIENTS AND METHODS

Every patient diagnosed with oesophageal, junctional or gastric cancer under the age of 55 years and every subsequent patient over the age of 55 years was accepted into this study. In all, 17 hospitals participated over a 12-month period. The following data were recorded: duration of symptoms, number of fast-track referrals, duration from GP referral to first hospital visit and stage at presentation. A survival analysis between the two groups was conducted at 2 years after the end of recruitment.

RESULTS

In total, 102 patients under the age of 55 years were diagnosed with oesophagogastric cancer during the study period. There were fewer fast-track referrals from GPs in this group compared to the over 55-year matched cases (29.4% vs 40.2%). Duration of time from GP referral to first hospital visit was significantly longer in the under 55-year group (median 14 days vs 11 days; P = 0.045 Mann-Whitney). Stage at presentation was similar between groups, but a higher proportion of patients under 55 years were offered a curative treatment plan compared to those over 55 years (P < 0.01). Survival analysis conducted at 2 years after the end of recruitment demonstrated a longer median survival in the under 55-year group (348 days vs 248 days; P = 0.03 log rank).

CONCLUSIONS

Although there was a longer referral time in patients under the age of 55 years, this had no effect on disease stage at presentation. Patients under the age of 55 years diagnosed with oesophageal or gastric cancer appear to have a better prognosis than those aged over 55 years.

Serum macrophage migration-inhibitory factor as a diagnostic and prognostic biomarker for gastric cancer

BACKGROUND

This study aimed to determine the potential diagnostic value of migration-inhibitory factor (MIF) for gastric cancer in patients presenting with dyspepsia and its prognostic value for gastric cancer.

METHODS

A cohort of 97 patients with histologically confirmed gastric adenocarcinoma and 222 patients with dyspepsia were recruited. Enzyme-linked immunosorbent assay was used to measure serum MIF and carcinoembryonic antigen (CEA).

RESULTS

The serum MIF concentrations were 6554.0 +/- 204.1 pg/mL and 1453.7 +/- 79.9 pg/mL, respectively, in gastric cancer patients and dyspeptic patients (P < .001). Serum MIF levels increased with the advancing gastric pathologies (P < .001). With the cutoff value of 3230 pg/mL, serum MIF had sensitivity, specificity, and accuracy of 83.5%, 92.3%, and 89.7%, respectively, in diagnosing gastric cancer, whereas the rates were 60.8%, 83.3%, and 76.5%, respectively, for serum CEA. Gastric cancer patients with serum MIF levels above 6600 pg/mL had a lower 5-year survival rate than those with serum MIF level below that level (P = .012). Higher serum CEA levels were also associated with poor survival. The prediction for 5-year survival was even better (P = .0001), using a combination of serum MIF and CEA.

CONCLUSIONS

Serum MIF level, which correlates with gastric MIF expression, is a better molecular marker than CEA in diagnosing gastric cancer in patients presenting with dyspepsia. A combination of serum MIF and CEA predicts 5-year survival better than the individual test.

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.

[Evaluation of endoscopic visualisation for identifying premalignant gastric lesions in a Columbian population using histopathology as a reference]

AIM

To evaluate the performance of endoscopic visualization in the identification of premalignant gastric lesions, with histopathological examination of biopsy samples as a reference test, in Bucaramanga, Colombia.

LOCATION

League for the Fight Against Cancer, Bucaramanga, Colombia.

DESIGN

Diagnostic technology evaluation with cross-sectional sampling.

MEASUREMENTS

We calculate the sensitivity, specificity, positive predictive value, negative predictive value, likelihood ratio (+), likelihood ratio (-), kappa index and the prevalence rate kappa.

RESULTS

A total of 155 patients were studied, with a mean age of 45.43 (14.15) years and an approximate male:female ratio of 2:1. The endoscopic visualization had a sensitivity of 87.84%, a specificity of 55.56%, a positive predictive value of 64.36%, a negative predictive value of 83.33%, a likelihood ratio+of 1.98, a likelihood ratio-de 0.22 and a kappa index of 0.4272, in the identification of preneoplastic lesions of the stomach in a population with a disease prevalence of 47.74%.

CONCLUSIONS

The endoscopic visualization of the gastrointestinal mucosa, allows a moderate and fast identification of early preneoplastic lesions, providing an opportunity of its early histopathological diagnosis.

Simple uninvestigated dyspepsia: age threshold for early endoscopy in Bosnia and Herzegovina

OBJECTIVE

To establish an optimal age threshold for endoscopy referral in patients with simple uninvestigated dyspepsia in the setting of European developing country (Bosnia and Herzegovina) with low availability and high workload of endoscopy units.

METHODS

We reviewed patient information on all upper endoscopies performed during a 6-year period (2000-2005). Different age thresholds were evaluated in terms of their predictive power for absence of malignancy.

RESULTS

A total of 82 of 4403 (1.86%) dyspeptic patients had upper gastrointestinal (GI) malignancy. Age cutoffs of 40 years for men and 45 years for women had the best predictive power, without any cases of upper GI malignancies below those thresholds. Age cutoffs of 45 years for men and 50 years for women also had excellent negative predictive values (99.7 and 99.9%, respectively) with 1.45 and 0.98 cases of missed upper GI malignancies per 1000 endoscopies, respectively. A total of 1709 of 4403 (38.8%) of endoscopies might have been avoided in men of less than 45 and women of less than 50 with uninvestigated dyspepsia.

CONCLUSION

(i) Age thresholds for endoscopy referral are lower than in Western countries and should be different for men and women. (ii) Cutoff values of 40 and 45 years for men and women, respectively, are completely safe to use. (iii) Thresholds of 45 years for males and 50 years for females have a small level of risk of missing upper GI malignancy, but are acceptable to use in areas of low availability of endoscopy.

Current guidelines for dyspepsia management

BACKGROUND

Dyspepsia is a global problem and the management of the condition remains a considerable burden on health care resources. Many countries have adopted evidence-based guidelines for the management of the condition, in an attempt to reduce health care expenditure. This article compares and contrasts dyspepsia management guidelines from several geographical regions.

METHODS

We obtained current guidelines from five regions and examined composition of guideline development groups, methodology involved, definition of dyspepsia utilized, and recommendations in terms of first-line approach, age cutoff for prompt upper gastrointestinal (GI) endoscopy, and subsequent role of endoscopy.

RESULTS

All guidelines carried out extensive reviews of the literature to inform their recommendations. The majority used a definition of dyspepsia in line with the Rome criteria. All agreed that alarm symptoms at any age warranted prompt endoscopy, and most recommended an age cutoff of between 50 and 55 years for endoscopy as an initial management strategy. In young patients without alarm symptoms, either 'test and treat' or empirical acid suppression were the initial management strategies of choice in all cases, with only one guideline recommending mandatory endoscopy in those whose symptoms failed to settle after this approach.

CONCLUSIONS

Despite varying composition of guideline development groups and the different geographical regions, the recommendation of all the guidelines were remarkably similar, reflecting the quality of research conducted by the GI community as a whole.

Gastric cancer patients treated by a general or gastric cancer surgical team: a comparative study

BACKGROUND

Although gastric cancer has been decreasing in incidence in many countries, it is still the second most common cause of cancer deaths worldwide. Its prognosis is poor and depends, among other factors, on early diagnosis as well as on surgeon expertise.

AIM

To compare the outcomes of gastric cancer patients treated at a university hospital by a general surgical team and later on by a gastric cancer surgical team.

METHODS

Gastric cancer patients were separated into two groups according to whether they were treated by a general surgical team (group 1, n = 136; 1984 to 1993) or by gastric cancer team (group 2, n = 149; 1994 to 2003). Clinical and pathologic features and survival rates were assessed.

RESULTS

During a 20-year period, a decreased number of patients underwent surgical resection in the second period (94% vs 86%), a greater number of upper gastrointestinal endoscopies were performed resulting in an increased number of tumors diagnosed as stage I (5% vs 22%). Also, D2 gastrectomies were more frequently performed instead of D0 gastrectomies and negative surgical margins were adequate. Mortality decreased from 9% to 6% in group 1 and 2, respectively and adjuvant therapy has been considered.

CONCLUSION

Surgical specialized units for gastric cancer are necessary if better results are to be expected since this approach definitely provides better patient care.

Early diagnosis of early gastric cancer

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.

Does endoscopy diagnose early gastrointestinal cancer in patients with uncomplicated dyspepsia?

BACKGROUND

Recent guidelines from NICE have proposed that open access gastroscopy is largely limited to patients with "alarm" symptoms.

AIMS AND METHODS

This study reviewed the outcome of all our patients with verified oesophageal or gastric carcinoma who presented with uncomplicated dyspepsia to see if endoscopic investigation is warranted in this group. All patients with histologically verified upper gastrointestinal (GI) cancers who presented over a period from 1998 to 2002 were identified. Their presenting symptoms, treatment, and outcome were analysed.

RESULTS

228 upper GI cancers (119 oesophageal, 109 gastric; mean age 72 years (29-99 years); 130 male, 82 female) were identified in 11 145 endoscopies performed. Only 14 patients (6.2%) presented without alarm symptoms; three patients were under 55 years of age and all had gastric carcinoma-one of these had chronic diarrhoea only. Eleven had dyspepsia or reflux symptoms only, and two were under surveillance for Barrett's oesophagus. Only five patients had a curative surgical resection and are still alive two-six years from diagnosis. A sixth patient had a curative operation but died of a cerebrovascular accident one year later. The remaining eight patients unfortunately had either metastatic disease or comorbidity, which precluded surgery. All of these died within two years of diagnosis, mean survival 10 months.

CONCLUSION

Only five patients with dyspepsia and no alarm symptoms had resectable upper GI malignancies over a four year period. Limiting open access gastroscopy to those with alarm features only would "miss" a small number of patients who have curable upper GI malignancy.

Endoscopy has minimal impact on mortality from upper gastrointestinal cancer in patients older than 55 years with uncomplicated dyspepsia

INTRODUCTION

The objective of the study was to determine the effectiveness of endoscopy to detect curable upper gastrointestinal malignancy in patients older than 55 years presenting with uncomplicated dyspepsia.

METHODS

A cohort study was performed in North Glasgow Health Trust. One hundred and thirty-one patients older than 55 years of age, diagnosed to have upper gastrointestinal cancer within the North Glasgow Trust between January 1995 and December 1997, identified by the West of Scotland Cancer Registry were included. The main outcome measures were the proportion of upper gastrointestinal cancers that present in patients older than 55 years with uncomplicated dyspepsia, and the proportion of patients that presented with uncomplicated dyspepsia who have curable upper gastrointestinal cancer.

RESULTS

Of the 131 cancer cases identified, only 30 (23%) had dyspepsia (complicated or uncomplicated) as their predominant symptom and only eight (6%) patients presented with uncomplicated dyspepsia. Of those eight patients presenting with uncomplicated dyspepsia and found to have upper gastrointestinal cancer, six were found to have lymph node metastases and/or extensive metastases at the time of diagnosis. Each of these six patients died from their cancer within 39 months of diagnosis. Of the two patients presenting with uncomplicated dyspepsia without evidence of lymph node spread, one died 55 days after diagnosis. Only one patient presenting with uncomplicated dyspepsia and found to have cancer remains alive at 5-year follow-up.

CONCLUSIONS

Of the 131 patients diagnosed with upper gastrointestinal cancer, only eight presented with uncomplicated dyspepsia and only one of these was cured. Consequently a policy of endoscoping patients older than 55 years with uncomplicated dyspepsia will reduce death from upper gastrointestinal cancers by less than 1% in our population.

Limited impact on endoscopy demand from a primary care based 'test and treat' dyspepsia management strategy: the results of a randomised controlled trial

BACKGROUND

Helicobacter pylori testing has been suggested as an alternative to endoscopy for young patients with dyspepsia. Secondary care studies have suggested that demand for endoscopy among this group could be reduced by up to 74%. However, the effect of H. pylori testing in the primary care setting, where the majority of dyspepsia is managed, is unclear.

AIM

To determine the effects of providing a H. pylori serology service for GPs upon demand for open access endoscopy.

DESIGN OF STUDY

A prospective randomised controlled trial.

SETTING

Forty-seven general practices in Gloucestershire.

METHOD

General practices were stratified by endoscopy referral rate and randomised into two groups. The intervention group was provided with access to H. pylori serology testing and encouraged to use it in place of endoscopy for patients aged under 55 years with dyspepsia. Endpoints were referral for endoscopy and serology use.

RESULTS

There was a significant reduction in referrals for endoscopy in the intervention group compared to the control group: 18.8% (95% confidence interval = 5.0 to 30.6%; P = 0.009).

CONCLUSIONS

Providing GPs with H. pylori serology testing reduced demand for open access endoscopy, but by less than previous studies had predicted.

Age threshold for endoscopy and risk of missing upper gastrointestinal malignancy--data from the Scottish audit of gastric and oesophageal cancer

BACKGROUND

Urgent endoscopy is indicated for suspected upper gastrointestinal malignancy. However, there is limited evidence on the age threshold for performing urgent endoscopy in uncomplicated dyspepsia (that is, without alarm features).

AIM

To quantify the risk of missing upper gastrointestinal malignancy within Scotland, if the age threshold for urgent endoscopy in uncomplicated dyspepsia was increased from 45 to 55 years.

METHODS

Analysis of data collected prospectively by the Scottish Audit of Gastric and Oesophageal Cancer. 'Alarm' features at presentation were defined as dysphagia, weight loss, gastrointestinal bleeding, anaemia, vomiting, history of gastric surgery and history of peptic ulcer disease.

RESULTS

Of the 3293 patients diagnosed with upper gastrointestinal malignancy, 290 (8.8%) patients were <55 years of age. Twenty-one of the patients aged <55 years had no alarm features (0.64% of all patients); 12 were aged 45-55 years and nine were aged <45 years. Only two patients (one aged <45 years) underwent potentially curative surgery.

CONCLUSION

Upper gastrointestinal malignancy is uncommon under 55 years of age and most of the patients present with alarm features. Raising the age threshold for endoscopy for new-onset uncomplicated dyspepsia from 45 to 55 years would not impact adversely on the diagnosis or outcome of upper gastrointestinal malignancy.

Evaluation of the diagnostic accuracy of gastroscopy to detect gastric tumours: clinicopathological features and prognosis of patients with gastric cancer missed on endoscopy

OBJECTIVES

Some gastric cancers are missed during diagnostic gastroscopy, but data are sparse on the clinical characteristics of patients with missed gastric cancers and on the accuracy of gastroscopy for detecting these tumours. We evaluated the number, clinicopathological characteristics, and survival of patients with missed gastric cancers, and the sensitivity and specificity of gastroscopy to detect these tumours.

METHODS

Data on gastric cancers detected in 1996-2001 in a single hospital referral area were obtained from the National Cancer Registry. Patient files were examined to identify those who underwent gastroscopy less than 3.5 years before a cancer diagnosis.

RESULTS

Of the 284 gastric cancer patients, 13 (4.6%) had undergone gastroscopy in the previous 3.5 years; their mean age was 72.4 years at the time of the first gastroscopy. The median delay in cancer diagnosis was 11.5 months. Histologically, all patients had gastric carcinoma. The sensitivity and specificity of gastroscopy for diagnosing gastric cancer were 0.93 and 1.00, respectively. Among the deceased patients, no difference was observed in the survival of cases with non-missed (n = 191) and missed (n = 10) carcinoma: 9.4 versus 7.3 months (P = 0.15).

CONCLUSION

A small proportion of gastric carcinomas are missed on gastroscopy, causing a significant delay in diagnosis. However, the prognoses of patients with missed and non-missed gastric carcinoma were equally poor.

The risk of missed gastroesophageal cancer diagnoses in users and nonusers of antisecretory medication

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.

Prognostic significance of alarm symptoms in patients with gastric cancer

BACKGROUND

The aim of this study was to determine the incidence and spectrum of alarm symptoms in patients with newly diagnosed gastric cancer, and to examine the relationship between symptoms and outcome.

METHODS

Three hundred consecutive patients with gastric adenocarcinoma were studied prospectively. The outcomes of 40 patients (13.3 per cent) without alarm symptoms (21 men; median age 69 years) were compared with those of the 260 patients (86.7 per cent) with alarm symptoms (175 men; median age 72 years).

RESULTS

It was possible to perform an R0 gastrectomy more often in patients without alarm symptoms (21 patients; 52 per cent) than in those with alarm symptoms (71 patients; 27.3 per cent) (chi(2) = 10.35, 1 d.f., P = 0.001). The cumulative survival rate at 5 years was 38 per cent for patients without alarm symptoms versus 15.0 per cent for those with alarm symptoms (chi(2) = 10.18, 1 d.f., P = 0.001). In a multivariate analysis, distant metastasis (hazard ratio (HR) 2.73 (95 per cent confidence interval (c.i.) 2.04 to 3.66); P < 0.001), overall stage of cancer (HR 1.83 (95 per cent c.i. 1.53 to 2.19); P < 0.001) and persistent vomiting at diagnosis (HR 1.66 (95 per cent c.i. 1.26 to 2.18); P < 0.001) were independently associated with length of survival.

CONCLUSION

Alarm symptoms are absent in a significant minority of patients with gastric cancer at diagnosis; these patients stand a better chance of curative surgery and long-term survival than those with alarm symptoms.

Is it possible to reduce endoscopy workload using age, alarm symptoms and H. pylori as predictors of peptic ulcer and oesophagogastric cancers?

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.

Missing gastric cancer in dyspepsia

BACKGROUND

Dyspepsia is common in gastric cancer, but also in many benign conditions. European Helicobacter pylori Study Group and American Gastroenterological Association guidelines recommend endoscopy in dyspepsia for patients with alarm symptoms or at age >45 years. However, recommendations are controversial.

AIM

To investigate whether criteria for endoscopy in patients with dyspepsia are adequate to detect gastric cancer.

METHODS

In 215 patients at initial diagnosis of gastric adenocarcinoma, symptoms were classified as alarm and non-alarm. Cases were staged according to the TNM system. Stages T(1)-T(3)N(x)M(0) were defined as potentially curable.

RESULTS

Dyspepsia was present in 128 patients. Among patients with dyspepsia, 15 were < or =45 years and 41 denied alarm symptoms. The combination of both criteria excluded only three (2.3%) patients from endoscopy, but increasing the threshold to >50 and >55 years would have raised the rate of excluded patients to seven (5.5%) and 11 (8.6%). Only 53 potentially curable stages and 18 early gastric cancers occurred, but the tumour stage was not associated with dyspepsia duration, age threshold of 45 years, or alarm symptoms.

CONCLUSIONS

Our results support current European Helicobacter Study Group and American Gastroenterological Association criteria for endoscopy in patients with dyspepsia to detect gastric cancer. Regardless, most cancers are advanced at detection.

Combination of age and sex improves the ability to predict upper gastrointestinal malignancy in patients with uncomplicated dyspepsia: a prospective multicentre database study

BACKGROUND AND AIMS

Current guidelines recommend endoscopy for dyspeptic patients >45 yr of age and/or with "alarm" symptoms. The management of younger patients with uncomplicated dyspepsia is controversial. The objective of the study was to identify any risk factors predictive of upper gastrointestinal malignancy in patients with uncomplicated dyspepsia and validate their ability in refining indications for endoscopy.

METHODS

Prospective database study of consecutive uninvestigated dyspeptic outpatients undergoing endoscopy was performed. A questionnaire including multiple possible prognostic variables was systematically submitted to patients prior to endoscopic examination. Risk factors for upper gastrointestinal malignancy identified were used to derive a prediction rule subsequently validated on an independent population.

RESULTS

A total of 5,224 patients with uncomplicated dyspepsia were considered (training sample). Twenty-two (16 males) had malignancy at endoscopy. These patients were about 20 yr older than patients with no malignancy (p < 0.001). The mean age of females with cancer was almost 10 yr higher compared to males (p= 0.08). Such differences in age were confirmed in a split sample of 3,684 patients (p < 0.001 and p < 0.05, respectively). The age cut-offs identified were 35 yr for males and 56 yr for females.

CONCLUSIONS

The age threshold for endoscopy should be lowered in males to decrease the risk of missing cancers, and can be safely increased in females without affecting outcomes. In patients with uncomplicated dyspepsia, the combination of age and gender provides a better discriminant power than age alone.

Predictive value of alarm features in a rapid access upper gastrointestinal cancer service

AIMS

(i) To determine the value of individual alarm features for predicting cancer in subjects referred to a rapid access upper gastrointestinal cancer service; and (ii) to develop a clinical prediction model for cancer and to prospectively validate this model in a further patient cohort.

METHODS

Patient demographics, referral indications, and subsequent diagnosis were recorded prospectively. Logistic regression analyses were employed to determine the predictive value of individual alarm features in an evaluation cohort of 1852 consecutive cases. The potential impact of applying a modified set of referral criteria was then examined in a validation cohort of 1785 patients.

RESULTS

Evaluation cohort: mean age was 59 years; cancer prevalence 3.8%; and serious benign pathology 12.8%. Dysphagia (odds ratio (OR) 3.1), weight loss (OR 2.6), and age >55 years (OR 9.5) were found to be significant predictive factors for cancer but the value of other accepted alarm features was more limited. In particular, uncomplicated dyspepsia in those over 55 years was a negative predictive factor for cancer within this high risk cohort (OR 0.1). Validation cohort: the clinical prediction model would have selected 92% of cancer patients for fast track investigation while reducing the "two week rule" workload by 572 cases (31%).

CONCLUSIONS

Fast track endoscopy in subjects fulfilling current criteria for suspected upper gastrointestinal malignancy results in a significant yield of cancer ( approximately 4%) and serious benign diseases such as peptic ulceration, strictures, and severe oesophagitis (13%). However, the predictive value of individual features for cancer varies widely. Uncomplicated dyspepsia in older subjects was a poor predictor of cancer. Application of narrower referral criteria for accessing fast track services may reduce pressures while retaining high sensitivity for cancer.

Meta-analysis: the diagnostic value of alarm symptoms for upper gastrointestinal malignancy

BACKGROUND

With the advent of empirical treatment strategies for patients with dyspeptic symptoms, it becomes increasingly important to select patients with a high risk of having cancer for immediate endoscopy. Usually alarming symptoms are used for this matter, but their diagnostic value is by no means clear.

AIM

To investigate the diagnostic value of alarm symptoms for upper gastrointestinal malignancy.

METHODS

Meta-analysis of studies describing prevalence of alarm symptoms in patients with and without endoscopically verified upper gastrointestinal malignancy were identified through a Medline search. The prevalence, pooled sensitivity, specificity, positive and negative predictive values were calculated.

RESULTS

About 17 case studies and nine cohort studies were selected. The mean prevalence of gastrointestinal malignancies in the cohort studies was 2.8% of 16,161 patients. Five cohort studies indicated that 25% of the patients diagnosed with upper gastrointestinal malignancy had no alarm symptoms. The pooled sensitivities of individual alarm symptoms varied from 9 to 41%, the pooled positive predictive value ranged from 4.6 to 7.9%, and was 5.9% for 'having any alarm symptom'. The pooled negative predictive value was 99.4% for 'having any alarm symptom'.

CONCLUSION

The risk of upper gastrointestinal malignancy in any individual without alarm symptoms is very low, but approximately one in four patients with upper gastrointestinal cancer have no alarm symptoms at the time of diagnosis.

Cost-effectiveness and long-term impact of Helicobacter pylori 'test and treat' service in reducing open access endoscopy referrals

INTRODUCTION

We have shown that the introduction of a carbon urea breath test (13C-UBT) service for Helicobacter pylori screening and eradication is effective in reducing the rate of open access endoscopy referrals in patients aged < 40 years in the short term. This has been substantiated by several randomized controlled trials comparing a 'test and treat' strategy with early endoscopy in these patients. However, the long-term impact of such a strategy is not established.

OBJECTIVE

To ascertain the influence of 13C-UBT services on open access endoscopy referral rates in dyspeptic patients under the age of 40 years over a period of 5 years.

METHODS

Retrospective analysis of open access endoscopy referral rates between August 1990 and July 2000. Cost minimization analysis was performed with a Decision Analysis Model using Treeage Data 3.5.

RESULTS

The total number of open access referrals for endoscopy during 1990-1995 was between 765 and 1325 per year. The proportion of endoscopies performed in patients < 40 years ranged between 33.4% and 34.6%. The total number of endoscopy referrals during 1995-2000 after the introduction of the 13C-UBT services was between 1178 and 1321 per year. However, there was a sustained reduction in the proportion of patients aged < 40 years, ranging between 23.2% and 26.2% (Chi2 = 153.9, degrees of freedom = 9, P < 0.0001) during this period.

CONCLUSIONS

The H. pylori screening and treatment strategy using the 13C-UBT service results in a sustained reduction of the number of endoscopy referrals and is cost effective in dyspeptic patients under the age of 40 years, enabling better utilization of available resources.

Diagnostic approach to dyspepsia

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.

Urgent cancer referral guidelines: a retrospective cohort study of referrals for upper gastrointestinal adenocarcinoma

Dyspepsia in primary care is common and guidelines indicate that patients with alarm symptoms, as defined by the urgent cancer referral guidelines, should be investigated by gastroscopy. The specificity and sensitivity of alarm symptoms is poor and only a small percentage of patients will turn out to have malignant disease. This primary care study shows that employing current guidelines will identify only 72% of patients at their initial visit to a general practitioner, but this figure could be increased to 86% if the guidelines included patients with weight loss or anaemia in the absence of dyspepsia. Past performance indicates that the majority of patients with the commonest symptom complex were not referred quickly and less than half were seen within 4 weeks.

What the physician needs to know for correct management of gastro-oesophageal reflux disease and dyspepsia

Upper gastrointestinal symptoms are highly prevalent; usually those consulting have multiple symptoms, confounding management. Here, common clinically relevant management issues are considered based on the best available evidence. Regardless of the presenting symptoms, determine if there are any alarm features; these have a low positive predictive value for malignancy but all patients with them should be referred for prompt upper gastrointestinal endoscopy. Ask about medications; of most importance are the non-steroidal anti-inflammatory drugs (NSAIDs), both non-selective and COX-2 selective. Try to ascertain if the symptom pattern suggests gastro-oesophageal reflux disease (GERD) or not. Dominant heartburn, however, may be of limited value; if the background prevalence of GERD is 25% and the patient complains of dominant heartburn, then the likelihood that such a patient has GERD as identified by 24-h oesophageal pH testing is only just over 50%. If reflux disease is strongly suspected and there are no alarm features, give an empirical trial of a proton pump inhibitor (PPI). Symptoms cannot separate adequately functional from organic dyspepsia. Endoscopy in dyspepsia with no alarm features is more costly than an empirical management approach. H. pylori testing and treatment remains in most settings the preferable initial choice for managing dyspepsia without obvious GERD. However, a PPI trial may offer a similar outcome and may be preferable in low H. pylori prevalence areas; head-to-head management trials in primary care are lacking.

Diagnostic yield of alarm features in irritable bowel syndrome and functional dyspepsia

OBJECTIVE

The diagnostic value of the addition of alarm symptoms in distinguishing functional from organic gastrointestinal disease remains uncertain. We aimed to establish the value of alarm features in differentiating between organic disease and irritable bowel syndrome (IBS) and functional dyspepsia (FD).

METHODS

A total of 568 consecutive patients (63% female; mean age 44.7 years) completed a detailed symptom questionnaire and then received a complete diagnostic workup, as required. Questionnaire data were collected prospectively and audited retrospectively; the treating physician was blinded to the results of the questionnaires. Patients were coded and allocated to the following diagnostic groups: IBS, FD, organic diseases of the upper gastrointestinal tract, or organic diseases of the lower gastrointestinal tract. Logistic regression was used to identify the best subset of symptoms that discriminated organic disease from functional illness. Separate models compared IBS (n = 214) with diseases of the lower gastrointestinal tract (n = 66), and FD (n = 70) with diseases of the upper gastrointestinal tract (n = 250).

RESULTS

Age (50 years at symptom onset: odds ratio (OR) 2.65 (95% confidence interval 1.4-5.0); p = 0.002) and blood on the toilet paper (OR 2.7 (1.4-5.1);p = 0.002) emerged as alarm features that discriminated IBS from lower gastrointestinal illness. A diagnosis of IBS was typically associated with female sex (OR2.5 (1.3-4.6); p = 0.004), pain on six or more occasions in the previous year (OR 5.0 (2.2-11.1); p<0.001), pain that radiated outside of the abdomen (OR 2.9 (1.4-6.3); p = 0.006), and pain associated with looser bowel motions (OR 2.1 (1.1-4.2); p = 0.03). A model incorporating three Manning criteria and alarm features yielded a correct diagnosis of IBS in 96% and a correct diagnosis of organic disease in 52% of cases. Alarm features did not discriminate FD from upper gastrointestinal disease. Patients with FD were significantly more likely to report upper abdominal pain (OR 3.7 (1.7-8.3); p = 0.002) and significantly less likely to report aspirin use (OR 0.26 (0.1-0.6); p = 0.001). The predictive value of symptoms in diagnosing FD was only 17%.

CONCLUSIONS

Symptoms plus alarm features have a high predictive value for diagnosing IBS but the predictive value for a diagnosis of FD remains poor. Current criteria for the diagnosis of IBS should incorporate relevant alarm features to improve the diagnostic yield.

Delta (13)C-urea breath test value is a useful indicator for Helicobacter pylori eradication in patients with functional dyspepsia

BACKGROUND

Eradication of Helicobacter pylori is not routinely recommended for the symptomatic relief and the prevention of gastric cancer in patients with functional dyspepsia. The present study investigated a useful indicator of H. pylori eradication in such patients by determining the optimal cutoff value of a 13C-urea breath test (UBT).

METHODS

One hundred dyspeptic patients participated in the study. Dyspepsia was scored, and a 13C-UBT administered. A level of delta 13C-UBT of>4 per thousand was diagnosed as H. pylori-positive. After the stomach was endoscopically sprayed with phenol red, biopsy specimens were taken from the antrum, body and cardia of the stomach for the assessment of H. pylori density, and activity (neutrophil infiltration) and degree (lymphocyte infiltration) of gastritis.

RESULTS

Correlation between delta 13C-UBT and dyspepsia score was not found. Delta 13C-UBT significantly correlated with H. pylori density score in the total stomach (r = 0.53, P < 0.0001), neutrophil (r = 0.34, P = 0.0005) and lymphocyte score (r = 0.69, P < 0.0001). Twenty-six of the 100 subjects had a neutrophil score of >or=4, lymphocyte score of >or=4, and H. pylori score of >or=4. Their 95% confidence interval of mean was 58.2 per thousand, which reflects moderate to marked acute and chronic gastritis, and dense H. pylori colonization.

CONCLUSIONS

The 13C-UBT is a reliable semiquantitative test to assess H. pylori density and the activity and degree of gastritis. It is proposed that H. pylori eradication therapy might be beneficial for patients with functional dyspepsia with a delta 13C-UBT of >58.2 per thousand.

Contribution of artificial neural networks to the classification and treatment of patients with uninvestigated dyspepsia

OBJECTIVES

To verify whether symptoms reported by patients with uninvestigated dyspepsia might be helpful in either classifying functional from organic dyspepsia (1st experiment), or recognising which Helicobacter pylori infected patients may benefit from eradication therapy (2nd experiment).

METHODS

We compared the performance of artificial neural networks and linear discriminant analysis in two experiments on a database including socio-demographic features, past medical history, alarming symptoms, and symptoms at presentation of 860 patients with uninvestigated dyspepsia enrolled in a large observational multi-centre Italian study.

RESULTS

In the 1st experiment, the best prediction for organic disease was given by the Sine Net model (specificity of 87.6% with 13 patients misclassified) and the best prediction for functional dyspepsia by the FF Bp model (sensitivity of 83.4% with 56 patients misclassified). The highest global accuracy of linear discriminant analysis was 65.1%, with 150 patients misclassified. In the 2nd experiment, the highest predictive performance was provided by the SelfDASn model: all infected patients who became symptom-free after successful eradicating treatment were correctly classified, whereas nine errors were made in forecasting patients who did not benefit from such a therapy. The highest global performance of linear discriminant analysis was 53.2%, with 37 patients misclassified.

CONCLUSIONS

In patients with uninvestigated dyspepsia, artificial neural networks might have potential for categorising those affected by either organic or functional dyspepsia, as well as for identifying all Helicobacter pylori infected dyspeptic patients who will benefit from eradication.

Can a non-invasive strategy for managing young dyspeptics be safely implemented in Asia?

Dyspepsia is a common problem in the Asia-Pacific region, with a prevalence rate ranging from 10-20%. It constitutes 2-5% of consultations with primary-care physicians and forms a major part of the gastroenterologists' workload. Although upper gastrointestinal endoscopy (UGIE) is the investigation of choice, no serious disease is present in the majority of patients and various other ways have been suggested, mainly in the West, to reduce the demand on the finite resources of UGIE services. The alternative methods to UGIE have been based on non-invasive detection of Helicobacter pylori in patients with dyspepsia, as the organism has been shown to be associated with most peptic ulcers and even gastric cancer. A positive H. pylori test in a patient with dyspepsia may not necessarily indicate serious disease, but H. pylori eradication eliminates the propensity for developing peptic ulcers and perhaps even cancer (not proven). In high-risk populations, non-invasive screening for H. pylori can even be considered a 'cancer test', as it can help target investigations in a selected group of patients.

A rational approach to uninvestigated dyspepsia in primary care: review of the literature

In this paper the rationale and limitations of the four most important approach strategies to dyspepsia in primary care (empiric treatment, prompt endoscopy, "test-and-scope", and "test-and-treat") are analysed. It is concluded that in the absence of alarm symptoms, a "test-and-treat" approach is currently the most rational approach provided that three conditions are met: (1) a highly accurate test should be used, (2) the prevalence of Helicobacter pylori in the population should not be too low, and (3) an effective anti-H pylori regimen should be prescribed taking sufficient time to instruct and motivate the patient.

Review article: dyspepsia: how to manage and how to treat?

Recent guidelines for dyspepsia, defined as pain or discomfort centred in the upper abdomen, emphasize that in younger patients with no alarm features and not taking nonsteroidal anti-inflammatory drugs, testing for Helicobacter pylori and treatment of the infection if present is a standard of care. If H. pylori is not present, empirical management (e.g. acid suppression) is often prescribed. It is further recommended that if patients relapse or fail to respond to treatment then upper endoscopy be undertaken. However, these guidelines have become controversial for a number of reasons. Firstly, the prevalence of H. pylori infection is falling as is the incidence of peptic ulcer disease due to the infection. Idiopathic peptic ulcer disease is also being increasingly recognized. Furthermore, the cost-effectiveness of endoscoping treatment failures has been questioned, as the yield is low and patient management is usually not altered. Finally, it remains controversial whether the treatment of H. pylori infection in functional dyspepsia is of value, and two recent high quality meta-analyses have reached diametrically opposite conclusions. Alternative strategies, such as initially treating with acid suppression and then considering H. pylori infection in those who fail have been suggested, as has in low H. pylori prevalent regions the abandonment of a test-and-treat strategy. However, appropriate management trials of these alternative strategies in primary care are lacking. The management of patients with functional dyspepsia who fail initial antisecretory therapy is now difficult; prokinetics have fallen into some disrepute. Tricyclic antidepressants (at a low dose) may be useful in a subset, but adequate trials are lacking.