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Therapeutics
Review: Initial endoscopy is not effective for management of dyspepsia
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http://dx.doi.org/10.1136/ebm.4.6.173

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    Ofman JJ, Rabeneck L. The effectiveness of endoscopy in the management of dyspepsia: a qualitative systematic review. Am J Med. 1999 Mar;106: 335-46.

    Question

    Does initial endoscopy improve patient outcomes and medical decision making and reduce subsequent use of medical resources in patients with dyspepsia?

    Data sources

    English-language studies were identified by searching MEDLINE, HEALTH-STAR, and EMBASE/Excerpta Medica for articles from January 1985 to July 1998. Bibliographies of relevant arti- cles were reviewed, and experts were contacted.

    Study selection

    Clinical studies were selected if they assessed the effectiveness of endoscopy for patient outcomes, clinical decision making, resource utilization, or cost- effectiveness. Decision analyses were included if they considered initial endoscopy as a management strategy. Review articles, editorials, letters, case series, and studies of children were excluded.

    Data extraction

    Data were extracted on study design, patients, interventions, outcome measures, main findings, and conclusions. Individual studies were assessed for methodologic quality (i.e., inclusion and exclusion criteria, randomized design, concealment of allocation, blinding, accounting for dropouts, and description of analysis methods).

    Main results

    21 studies met the inclusion criteria. The findings from randomized controlled trials and cost-effectiveness or utility analyses are briefly described below. Initial endoscopy did not improve patient outcomes (symptoms, lost wages, or quality of life) when compared with initial antisecretory therapy (H2>-receptor antagonists) (2 studies) or upper gastrointestinal radiography (1 study), although patients were more satisfied with care and had fewer sick days with initial endoscopy than with ranitidine (1 study). Endoscopy resulted in fewer physician or office visits and lower costs than radiography (1 study) and ranitidine (1 study); medication use did not differ for initial endoscopy compared with initial H2-receptor antag- onists (1 study). 1 randomized controlled trial comparing initial endoscopy with radiography reported that endoscopy did not affect medical decision making. Of 4 cost-effectiveness analyses, 2 found that initial Helicobacter pylori serologic testing followed by treatment was more cost-effective than endoscopy, 1 found that initial anti­ H. pylori therapy was more cost-effective, and 1 found no difference in medical costs at 1 year for antisecretory therapy compared with endoscopy. 1 cost-utility analysis found that initial H. pylori testing and follow-up treatment and initial anti­H. pylori therapy each resulted in higher quality-adjusted life-years at a lower cost than endoscopy.

    Conclusion

    In patients with dyspepsia, initial en-doscopy does not improve most patient outcomes and is not more cost-effective than initial empiric therapies, such as antisecretory agents.

    Source of funding: Department of Veterans Affairs Health Services Research and Development.

    For correspondence: Dr. J. Ofman, 200 North Robertson Boulevard, Suite #205, Beverly Hills, CA 90211, USA. FAX 310-274-0746.

    Abstract and Commentary also published in ACP Journal Club. 1999;131:65.

    Commentary

    Dyspepsia is a symptom complex characterized by upper abdominal pain or discomfort. The prevalence of dyspepsia in adults is 15% to 40%, and dyspepsia is the main symptom in 2% to 5% of primary care visits. Organic causes of dyspepsia, such as gastroesophageal reflux disease, gastro-duodenal ulcer, and gastric cancer, are found in approximately 40% of patients. Most patients with no structural or biochemical cause are considered to have functional dyspepsia. Although upper gastrointestinal endoscopy is the most sensitive test to detect organic disease in patients with dyspepsia, the role of endoscopy is controversial because of the frequent occurrence of functional disease.

    Ofman and Rabeneck did a qualitative systematic review of the medical literature to evaluate the effectiveness of endoscopy in the management of dyspepsia. Although the search strategy identified 855 citations, only 21 articles met the inclusion criteria. Even in these studies, the definitions of dyspepsia were not uniform, and symptoms or health-related quality of life and patient outcomes were seldom assessed by using standardized, reliable, and valid instruments. Overall, the authors conclude that the available data do not support the effectiveness of endoscopy in the management of dyspepsia.

    I believe that a reasonable strategy is to perform upper endoscopy in patients with dyspepsia who are older than 45 years of age or have alarm symptoms of weight loss, dysphagia, or positive results on fecal occult blood test. In younger patients with dyspepsia but no alarm symptoms, initial testing for H. pylori may be done with appropriate follow-up treatment. Patients without H. pylori may be treated on the basis of predominant symptoms with a gastric acid­suppressing agent or a prokinetic agent. The role of endoscopy in dyspepsia will need to be re-evaluated because the costs for endoscopy are decreasing. The future of endoscopy may involve the use of ultra-thin endoscopes without intravenous sedation, which could further reduce costs and potentially improve patient satisfaction.

    John R. Saltzman, MD

    Brigham and Women's Hospital

    Harvard Medical School

    Boston, Massachusetts, USA