Performance of American Society for Gastrointestinal Endoscopy guidelines for dyspepsia in Saudi population: Prospective observational study

Yield of alarm features in predicting significant endoscopic findings among hospitalized patients with dyspepsia

BACKGROUND

Dyspepsia is a very prevalent upper gastrointestinal tract symptoms complex. Some of these symptoms might arise from serious underlying diseases, so the promotion of evidence-based guidelines could potentially better align evaluation and treatment.

AIM

To determine the value of alarm features as a predictive factor for significant endoscopic findings (SEFs) among hospitalized patients presenting with dyspepsia.

METHODS

We conducted a retrospective case-control study including information about 6208 endoscopic procedures performed for hospitalized patients. Patients were divided into two groups, with and without SEFs, and compared to elucidate the ability of the different alarm features to predict SEFs.

RESULTS

During the study, 605 patients fulfilled the inclusion criteria. When the demographics and clinical characteristics of the two groups were compared, tachycardia (P < 0.05), normocytic anemia, (P < 0.05), leukocytosis (P < 0.05), and hypoalbuminemia (P < 0.05) documented on admission prior to endoscopy were strong predictors of SEFs. Among the alarm features, upper gastrointestinal bleeding, persistent vomiting, odynophagia [odds ratio (OR) = 3.81, P < 0.05; OR = 1.75, P = 0.03; and OR = 7.81, P = 0.07, respectively] were associated with SEFs. Unexplained weight loss was strongly associated with malignancy as an endoscopic finding (OR = 2.05; P < 0.05). In addition, long-term use of anti-aggregate medications other than aspirin (P < 0.05) was correlated to SEFs.

CONCLUSION

Novel predictors of SEFs were elucidated in this study. These parameters could be used as an adjunctive in decision making regarding performing upper endoscopy in hospitalized patients with dyspepsia.

Appropriateness and diagnostic yield of open access gastroscopy in two tertiary centers in South-western Nigeria

Background

There is need for the appropriate use of gastroscopy.

Objective

To determine the appropriateness of upper gastrointestinal endoscopy, and its association with significant endoscopy findings in our environment.

Methods

This was a prospective study of subjects who underwent gastroscopy at two centers in south-western Nigeria between August 2020 and August 2021. Indications were classified as either appropriate or inappropriate according to the ASGE guidelines, gastroscopic findings as either significant or not significant, patients as either elderly (≥ 60 years) or not, inpatients or outpatients, and referrals as either gastroenterologist referral, or not.

Results

There were 227 subjects, 131 (57.7%) females, mean age 45 ± 13.7 years. Fifteen percent were elderly, 65.6% were gastroenterologist referrals, 14.1% were inpatients, while 45.8% had co-morbidities. Endoscopy was appropriately indicated in 81.9%, and significant endoscopy findings were detected in 95.6%. Appropriateness was not associated with significant endoscopy findings. The sensitivity, specificity and AUROC of the ASGE guidelines were 10%, 82%, and 0.46 respectively.

Conclusion

According to our study, most procedures are appropriately indicated. However, appropriateness did not determine endoscopy yield. Larger studies are needed to determine the utility of the ASGE guidelines in our environment.

Dyspepsia with alarm symptoms in patients aged less than 60 years: Is upper gastrointestinal endoscopy justified in Indian scenario?

BACKGROUND

Newer American College of Gastroenterology (ACG) and Canadian Association of Gastroenterology (CAG) guidelines do not suggest endoscopy to investigate alarm features for dyspepsia patients under the age of 60 to exclude upper gastrointestinal (GI) neoplasia. The validity of this recommendation has not been evaluated in our population. So, this study was conducted to assess the utility of upper GI endoscopy to investigate alarm features in dyspepsia patients less than 60 years of age to exclude upper GI neoplasia.

METHODS

This prospective observational study evaluated consecutive patients of dyspepsia between 18 and 60 years of age, with at least one or more of the alarm symptoms (unintentional weight loss; loss of appetite; GI bleeding; anemia; recurrent or persistent vomiting; dysphagia with predominant epigastric pain; and family history of upper GI cancer) with upper GI endoscopy to exclude any organic lesion and malignancy.

RESULTS

Of total 294 patients evaluated with endoscopy, 34.7% (n=102) had normal endoscopy (functional dyspepsia [FD]) while 65.3% (n=192) had abnormal endoscopic findings (organic dyspepsia [OD]). Of 192 patients with OD, 146 patients (49.6% of the total study population) had benign abnormality (benign OD) while 46 patients (15.6% of the total study population) had malignancy of the upper GI tract (malignant OD).

CONCLUSION

The investigation of alarm features in dyspepsia patients less than 60 years of age with upper GI endoscopy leads to detection of organic lesion (65.3%) including malignancy (15.6%) in a significant percentage of patients.

Single-Center Review of Appropriateness and Utilization of Upper Endoscopy in Dyspepsia in the United States

Background

We compared real-world practice of dyspepsia management to the new American College of Gastroenterology (ACG)/Canadian Association of Gastroenterology (CAG) guidelines 2017.

Methods

We conducted a retrospective, observational study using administrative data to include patients undergoing esophagogastroduodenoscopy (EGD) for dyspepsia.

Results

Out of 122 EGDs, only 30 (24.5%) were deemed appropriate per guidelines. Only 13 (14.1%) patients had undergone both Helicobacter pylori (H. pylori) test and treat and adequate proton pump inhibitor (PPI) before undergoing endoscopy. Nineteen (15.5%) patients had alarm symptoms (weight loss, melena and early satiety). Positivity rate of H. pylori was 36.3%, but only half completed treatment. Twenty-six patients (21.3%) had abnormalities on endoscopy, most commonly gastritis. There were no cases of gastric/esophageal cancer.

Conclusions

The rate of inappropriate upper gastrointestinal endoscopy is higher than the existing literature, likely because of the stricter use of EGD in patients < 60 years. Only one in eight patients underwent the recommended workup before undergoing endoscopy.

Upper gastrointestinal bleeding: Causes and patient outcomes

BACKGROUND

Upper gastrointestinal bleeding (UGIB) remains a healthcare burden and is associated with considerable morbidity and mortality. We aim to describe the presentation, clinical, and laboratory characteristics of patients presenting with UGIB as well as important patient outcomes.

METHODS

This is a retrospective study performed at a tertiary care university hospital in Riyadh. Electronic endoscopic reports of patients undergoing gastroscopies for the indication of UGIB from January 2006 to January 2015 were included. Demographic data, past medical conditions, medications used, symptoms on presentation, as well as the patients' hemodynamic status, laboratory investigations on presentations, the need for blood products, the need for admission to an intensive care unit, rebleeding, and in-hospital mortality rates were retrieved from medical records.

RESULTS

Two hundred fifty-nine patients were included with a mean age of 57.1 years and males constituted 66.8% of the study cohort. At least one comorbidity was present in 88.2%, while 20.7% had a history of prior UGIB, 12.6% had a history of peptic ulcer disease, and 9.2% had known esophageal varices. A nonvariceal source represented 80.1% of the causes (95% CI: 75.4 to 85.3%), 15.5% required admission to the intensive care unit (ICU), the rebleeding rate was 8.9% (95% CI; 5.7% to 12.2%) while the in-hospital mortality was 4.4% (95% CI; 2.4% to 6.9%). The mean pre-endoscopic Rockall score was 2.6 (range: 0 to 5), while the total Rockall score was 4.4 (range: 1 to 9). There was no association between the pre-endoscopic Rockall score and rebleeding (3.0 vs. 2.5, P = 0.27) or need for ICU admission (3.2 vs. 2.4, P = 0.08), the total Rockall score and rebleeding (5.0 vs. 4.4, P = 0.58) or need for ICU admission (5.0 vs. 4.3, P = 0.36).

CONCLUSION

Causes of UGIB in this patient population were predominantly nonvariceal and the rebleeding and mortality rates resembled those of other studies.

Use of alarm features in predicting significant endoscopic findings in Nigerian patients with dyspepsia

Introduction

Dyspepsia is prevalent in the community. Guidelines recommend early endoscopy in dyspeptic patients who are older than 55 years, or have alarm features. There is a lack of data on endoscopy in patients with alarm features in Nigeria.

Methods

A retrospective study of the endoscopic findings in adults with dyspepsia and alarm features, between August 1^st 2017 and July 31^st 2018 in Lagos, Nigeria. Data were analysed using Statistical Package for Social Sciences, version 23.0. The sensitivity, specificity, positive predictive value, and negative predictive value of the alarm features were calculated.

Results

One hundred and fifty-nine gastroscopies were performed during this period, mean age was 47.8 (±14.4) years, 49.1% were male. Dyspepsia was the commonest indication for endoscopy (80.5%), 60.2% of the dyspeptics had at least one alarm feature. The most frequent dyspeptic symptom was epigastric pain/burning sensation (75%), while the commonest alarm features were recent onset dyspepsia in a patient over 45 years (79%) and unexplained weight loss (28.6%). Endoscopy was normal in 26%. The most frequent significant endoscopic findings were gastritis (49%) and gastric ulcer (17%) and they were not associated with alarm features. Upper gastrointestinal bleeding, persistent vomiting and odynophagia were specific for significant endoscopic findings. The pooled sensitivity, specificity, positive predictive value, and negative predictive value of the alarm features were 65%, 49%, 71% and 41% respectively.

Conclusion

Patients with dyspepsia and upper gastrointestinal bleeding, persistent vomiting or odynophagia, should be referred for prompt upper GI endoscopy.

Appropriateness of American Society for Gastrointestinal Endoscopy Guidelines for Upper Gastrointestinal Endoscopy: A Prospective Analytical Study

Introduction

Extensive use of upper gastrointestinal endoscopy (UGE) with the advent of open access centers has resulted in inappropriate endoscopies. Our study aimed to evaluate the appropriateness of American Society for Gastrointestinal Endoscopy (ASGE) guidelines for UGE and to assess the diagnostic yield of endoscopy in a tertiary care center in South India.

Methods

The study was conducted as a prospective analytical study. Indications for endoscopy were classified as “ASGE appropriate” and “ASGE inappropriate”. The significance of association of ASGE guidelines and other categorical variables with endoscopic findings were assessed.

Results

ASGE appropriate indications and inappropriate indications accounted for 85.9% and 14.1% of endoscopies, respectively. The most common appropriate indication was persistent dyspepsia despite adequate proton-pump inhibitor (PPI) therapy (28.1%) and the only inappropriate indication for endoscopy was isolated dyspepsia without adequate PPI therapy (14.1%). The diagnostic yield of endoscopy for appropriate indications was 69.5% and for inappropriate indications was 55.1%, the difference was statistically significant (P= 0.003; OR-1.857). The sensitivity and specificity of ASGE guidelines was 88.5% and 19.5%, respectively.

Conclusion

According to our study, ASGE guidelines may be considered as appropriate guidelines for UGE in our population and these guidelines were followed 85.9% of the times in referring patients for the same. However, the high diagnostic yield even in inappropriate endoscopies indicates the necessity of further studies that might identify other relevant indications for endoscopy, thus avoiding misutilization of resources without missing out on relevant cases.

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.

Overtesting and undertesting in primary care: a systematic review and meta-analysis

BACKGROUND

Health systems are currently subject to unprecedented financial strains. Inappropriate test use wastes finite health resources (overuse) and delays diagnoses and treatment (underuse). As most patient care is provided in primary care, it represents an ideal setting to mitigate waste.

OBJECTIVE

To identify overuse and underuse of diagnostic tests in primary care.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES AND ELIGIBILITY CRITERIA

We searched MEDLINE and Embase from January 1999 to October 2017 for studies that measured the inappropriateness of any diagnostic test (measured against a national or international guideline) ordered for adult patients in primary care.

RESULTS

We included 357 171 patients from 63 studies in 15 countries. We extracted 103 measures of inappropriateness (41 underuse and 62 overuse) from included studies for 47 different diagnostic tests.The overall rate of inappropriate diagnostic test ordering varied substantially (0.2%-100%)%).17 tests were underused >50% of the time. Of these, echocardiography (n=4 measures) was consistently underused (between 54% and 89%, n=4). There was large variation in the rate of inappropriate underuse of pulmonary function tests (38%-78%, n=8).Eleven tests were inappropriately overused >50% of the time. Echocardiography was consistently overused (77%-92%), whereas inappropriate overuse of urinary cultures, upper endoscopy and colonoscopy varied widely, from 36% to 77% (n=3), 10%-54% (n=10) and 8%-52% (n=2), respectively.

CONCLUSIONS

There is marked variation in the appropriate use of diagnostic tests in primary care. Specifically, the use of echocardiography (both underuse and overuse) is consistently poor. There is substantial variation in the rate of inappropriate underuse of pulmonary function tests and the overuse of upper endoscopy, urinary cultures and colonoscopy.

PROSPERO REGISTRATION NUMBER

CRD42016048832.

A comparison of propofol and midazolam/meperidine sedation in upper gastrointestinal endoscopy

INTRODUCTION

There is increasing interest in sedation for upper gastrointestinal endoscopy (UGE). Prospective randomized studies comparing sedation properties and complications of propofol and midazolam/meperidine in upper gastrointestinal endoscopy (UGE) are few.

AIM

To compare propofol and midazolam/meperidine sedation for UGE in terms of cardiopulmonary side effects, patient and endoscopist satisfaction and procedure-related times.

MATERIAL AND METHODS

This was a prospective, randomized, double-blind study of propofol versus midazolam and meperidine in 100 patients scheduled for diagnostic upper gastrointestinal endoscopy. The patients were divided into propofol and midazolam/meperidine groups. Randomization was generated by a computer. Cardiopulmonary side effects (hypotension, bradycardia, hypoxemia), procedure-related times (endoscopy time, awake time, time to hospital discharge), and patient and endoscopist satisfaction were compared between groups.

RESULTS

There was no significant difference between the groups with respect to the cost, endoscopy time, or demographic and clinical characteristics of the patients. Awake time and time to hospital discharge were significantly shorter in the propofol group (6.58 ±4.72 vs. 9.32 ±4.26 min, p = 0.030 and 27.60 ±7.88 vs. 32.00 ±10.54 min, p = 0.019). Hypotension incidence was significantly higher in the propofol group (12% vs. 0%, p = 0.027). The patient and endoscopist satisfaction was better with propofol.

CONCLUSIONS

Propofol may be preferred to midazolam/meperidine sedation, with a shorter awake and hospital discharge time and better patient and endoscopist satisfaction. However, hypotension risk should be considered with propofol, and careful evaluation is needed, particularly in cardiopulmonary disorders.

Functional dyspepsia

PURPOSE OF REVIEW

Structural causes are absent in more than 50% of patients with symptoms referred to the gastroduodenal region when routine diagnostic tests are applied. New knowledge holds the prospect that targeted therapy may more optimally manage subsets of these patients with functional dyspepsia.

RECENT FINDINGS

An understanding of gut-to-brain and brain-to-gut pathways in functional dyspepsia is expanding. Minimal mucosal inflammation with eosinophils (and in some cases mast cells) characterized by ultrastructural changes in the duodenum appears to be present in a substantial subgroup of functional dyspepsia patients as identified now by investigators globally. Although antibiotic therapy targeting Helicobacter pylori appears to be effective in a small proportion of functional dyspepsia patients, eradication therapy may be more effective in functional dyspepsia patients with microscopic duodenal inflammation, a potentially important finding needing to be confirmed. This may suggest that the effects of antibiotics for functional dyspepsia are not simply mediated by the eradication of gastric H. pylori, but have other antibacterial effects (e.g., on the duodenal microbiome). Abnormal visceral sensory function plays a key role not only in the manifestations of functional dyspepsia but also in peptic ulcer disease.

SUMMARY

The pathophysiologic concepts underlying functional dyspepsia and related treatment approaches are shifting from a focus on H. pylori, acid suppression or modulation of motility toward new models. New evidence suggests that minimal duodenal inflammation plays a role in symptom generation in at least a proportion of patients with otherwise unexplained symptoms. This is a paradigm shift and ultimately may change the treatment of many patients with functional gastrointestinal disorders.