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Kumari P, Machhan P, Sharma B, Sharma R, Bodh V, Kumar R. Dyspepsia with alarm symptoms in patients aged less than 60 years: Is upper gastrointestinal endoscopy justified in Indian scenario? Indian J Gastroenterol 2022; 41:430-439. [PMID: 36308702 DOI: 10.1007/s12664-022-01275-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 06/26/2022] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Priya Kumari
- Department of Medicine, Indira Gandhi Medical College and Hospital, Shimla, 171 001, India
| | - Prem Machhan
- Department of Medicine, Indira Gandhi Medical College and Hospital, Shimla, 171 001, India
| | - Brij Sharma
- Department of Gastroenterology, Indira Gandhi Medical College and Hospital, Shimla, 171 001, India
| | - Rajesh Sharma
- Department of Gastroenterology, Indira Gandhi Medical College and Hospital, Shimla, 171 001, India
| | - Vishal Bodh
- Department of Gastroenterology, Indira Gandhi Medical College and Hospital, Shimla, 171 001, India.
| | - Rajesh Kumar
- Department of Gastroenterology, Indira Gandhi Medical College and Hospital, Shimla, 171 001, India
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Dutta AK, Rebekah G, Chowdhury SD, Gangadharan SK, Subramani Y, Sahu MK, Kurien RT, David D, Simon EG, Joseph AJ, Donapati VR, Chacko A. A Simple Pre-endoscopy Score for Predicting Risk of Malignancy in Patients with Dyspepsia: A 5-Year Prospective Study. Dig Dis Sci 2018; 63:3442-7. [PMID: 30109577 DOI: 10.1007/s10620-018-5245-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Accepted: 08/07/2018] [Indexed: 12/16/2022]
Abstract
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.
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Lee SW, Chang CS, Yeh HJ, Lien HC, Lee TY, Peng YC. The Diagnostic Value of Alarm Features for Identifying Types and Stages of Upper Gastrointestinal Malignancies. Gastroenterology Res 2017; 10:120-125. [PMID: 28496533 PMCID: PMC5412545 DOI: 10.14740/gr826w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/03/2017] [Indexed: 12/26/2022] Open
Abstract
Background Upper gastrointestinal (GI) malignancies are an uncommon cause of dyspepsia but of great concern. The aim of this study was to determine the association between alarm features and each type and stage of upper GI malignancies. Methods Patients who underwent endoscopy for symptoms of dyspepsia between January 2008 and December 2009 were retrospectively collected. Alarm features studied in this study were dysplasia, body weight loss and GI bleeding. Patients were classified according to the findings of endoscopy and histological reports. Results A total of 3,926 patients were included in the study, with 82 (2.1%) cases with GI malignancies. The specificity and negative predictive value of alarm features ranged from 93.8% to 99.8%, but the sensitivity and positive predictive value ranged from 11.6% to 29.3%. The only variable with a positive predictive value was dysphagia (66.7%). The patients with esophageal cancers and upper gastric cancers had the highest ratio of alarm features, most body weight loss and dysphagia. There was a positive correlation between alarm features and advanced stages of gastric cancers, with the exception of GI bleeding sign. Conclusion Although alarm features had a low sensitivity in identifying patients with upper GI malignancies, the presence of alarm features did help diagnose esophageal or upper gastric cancer and the sign of GI bleeding for early gastric cancer. In addition, dysphagia and weight loss are associated with higher stages of gastric cancer.
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Affiliation(s)
- Shou-Wu Lee
- Division of Gastroenterology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China.,Department of Internal Medicine, Chung Shan Medical University, Taichung, Taiwan, Republic of China
| | - Chi-Sen Chang
- Division of Gastroenterology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China.,Department of Internal Medicine, Chung Shan Medical University, Taichung, Taiwan, Republic of China
| | - Hong-Jeh Yeh
- Division of Gastroenterology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China.,Department of Internal Medicine, Yang-Ming University, Taipei, Taiwan, Republic of China
| | - Han-Chung Lien
- Division of Gastroenterology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China.,Department of Internal Medicine, Yang-Ming University, Taipei, Taiwan, Republic of China
| | - Teng-Yu Lee
- Division of Gastroenterology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China.,Department of Internal Medicine, Chung Shan Medical University, Taichung, Taiwan, Republic of China
| | - Yen-Chun Peng
- Division of Gastroenterology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China.,Department of Internal Medicine, Yang-Ming University, Taipei, Taiwan, Republic of China
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Fiorenza JP, Tinianow AM, Chan WW. The Initial Management and Endoscopic Outcomes of Dyspepsia in a Low-Risk Patient Population. Dig Dis Sci 2016; 61:2942-2948. [PMID: 26846116 DOI: 10.1007/s10620-016-4051-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 01/21/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIMS Dyspepsia is frequently encountered by primary care providers (PCP) and gastroenterologists (GI). While esophagogastroduodenoscopy (EGD) may be useful, current guidelines suggest a proton pump inhibitor (PPI) trial and H. pylori (HP) test-and-treat before EGD for low-risk patients. This study aimed to evaluate pre-EGD management and endoscopic outcomes in this population. METHODS This was a retrospective cohort study of low-risk dyspepsia patients (age ≤55, no alarm features) undergoing EGD at an ambulatory endoscopy center from January 2011 to March 2012. Adherences to initial management guidelines (PPI trial and HP test-and-treat strategy before EGD) were compared between PCP and GI. Endoscopic and pathologic outcomes were assessed for all patients. Statistical analyses were performed using Chi-squared test (categorical variables) and Student's t test (continuous variables). This study received IRB approval (2011P001715). RESULTS A total of 309 low-risk patients underwent EGD for dyspepsia. Only 202 (65.4 %) had HP testing, and 220 (71.2 %) were trialed on any dose/length PPI pre-EGD, with no differences between PCP and GI. PPI exposure was similar between groups for all dose/duration except for trials ≥8 weeks of any dose (46.9 % GI vs 34.3 % PCP, p = 0.03) and high dose (32 % GI vs 18.7 % PCP, p = 0.01). Overall, only 178 (57.6 %) patients had both HP testing and any PPI exposure pre-EGD (56.6 % GI vs 59 % PCP, p = 0.73). Significant pathology was rare, with gastritis (46.6 %) and HP (17.2 %) being most common. No malignancy was found. CONCLUSIONS A significant proportion of low-risk dyspepsia patients did not receive any PPI trial or HP testing before EGD. Within this population, significant finding on EGD was rare, supporting the current noninvasive initial management guidelines for dyspepsia.
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Affiliation(s)
- Jeffrey P Fiorenza
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.,Harvard Medical School, Boston, MA, USA
| | | | - Walter W Chan
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA. .,Harvard Medical School, Boston, MA, USA.
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Almario CV, Chey WD, Iriana S, Dailey F, Robbins K, Patel AV, Reid M, Whitman C, Fuller G, Bolus R, Dennis B, Encarnacion R, Martinez B, Soares J, Modi R, Agarwal N, Lee A, Kubomoto S, Sharma G, Bolus S, Chang L, Spiegel BMR. Computer versus physician identification of gastrointestinal alarm features. Int J Med Inform 2015; 84:1111-7. [PMID: 26254875 DOI: 10.1016/j.ijmedinf.2015.07.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 07/14/2015] [Accepted: 07/14/2015] [Indexed: 12/27/2022]
Abstract
OBJECTIVE It is important for clinicians to inquire about "alarm features" as it may identify those at risk for organic disease and who require additional diagnostic workup. We developed a computer algorithm called Automated Evaluation of Gastrointestinal Symptoms (AEGIS) that systematically collects patient gastrointestinal (GI) symptoms and alarm features, and then "translates" the information into a history of present illness (HPI). Our study's objective was to compare the number of alarms documented by physicians during usual care vs. that collected by AEGIS. METHODS We performed a cross-sectional study with a paired sample design among patients visiting adult GI clinics. Participants first received usual care by their physicians and then completed AEGIS. Each individual thus contributed both a physician-documented and computer-generated HPI. Blinded physician reviewers enumerated the positive alarm features (hematochezia, melena, hematemesis, unintentional weight loss, decreased appetite, and fevers) mentioned in each HPI. We compared the number of documented alarms within patient using the Wilcoxon signed-rank test. RESULTS Seventy-five patients had both physician and AEGIS HPIs. AEGIS identified more patients with positive alarm features compared to physicians (53% vs. 27%; p<.001). AEGIS also documented more positive alarms (median 1, interquartile range [IQR] 0-2) vs. physicians (median 0, IQR 0-1; p<.001). Moreover, clinicians documented only 30% of the positive alarms self-reported by patients through AEGIS. CONCLUSIONS Physicians documented less than one-third of red flags reported by patients through a computer algorithm. These data indicate that physicians may under report alarm features and that computerized "checklists" could complement standard HPIs to bolster clinical care.
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Affiliation(s)
- Christopher V Almario
- Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Division of Gastroenterology, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA; Division of Digestive Diseases, UCLA, Los Angeles, CA, USA; Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA, USA
| | - William D Chey
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - Sentia Iriana
- Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Francis Dailey
- Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Karen Robbins
- Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Anish V Patel
- Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Mark Reid
- Division of Gastroenterology, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA; Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA, USA
| | - Cynthia Whitman
- Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA, USA
| | - Garth Fuller
- Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA, USA
| | - Roger Bolus
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA, USA
| | - Buddy Dennis
- UCLA Computing Technology Research Laboratory (CTRL), Los Angeles, CA, USA
| | - Rey Encarnacion
- UCLA Computing Technology Research Laboratory (CTRL), Los Angeles, CA, USA
| | - Bibiana Martinez
- Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Division of Gastroenterology, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA; Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA, USA
| | - Jennifer Soares
- Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Division of Gastroenterology, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA; Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA, USA
| | - Rushaba Modi
- Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Division of Gastroenterology, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA; Division of Digestive Diseases, UCLA, Los Angeles, CA, USA
| | - Nikhil Agarwal
- Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Division of Gastroenterology, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA; Division of Digestive Diseases, UCLA, Los Angeles, CA, USA
| | - Aaron Lee
- Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Scott Kubomoto
- Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Gobind Sharma
- Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Sally Bolus
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA, USA
| | - Lin Chang
- Division of Digestive Diseases, UCLA, Los Angeles, CA, USA
| | - Brennan M R Spiegel
- Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Division of Gastroenterology, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA; Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA, USA.
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