Is Endoscopy Really Necessary in My Case? A Four Year Retrospective Study

About 40% of the general population report dyspepsia at some time in their life making it a fairly common disease [1,2].

Dyspepsia is defined as “an upper gastrointestinal symptom complex characterized by epigastric pain or discomfort and may include heartburn, acid regurgitation, excessive burping/belching, abdominal bloating, feeling of abnormal or slow digestion, early satiety or nausea” [3,4]. Currently anti-secretory treatment is started for dyspepsia and endoscopy is reserved for dyspepsia with danger signs [5].

Uncomplicated dyspepsia refers to patients whose dyspepsia is not accompanied by alarm features or associated with NSAIDS usage [5]. Alarm features for dyspepsia are anaemia, dysphagia, bleeding, recurrent vomiting, weight loss [6].

This study was conducted at KR Hospital Mysore where the patient load is high and facilities are limited. Economic and time constraints frequently raise the question whether it is justified to recommend a time consuming, expensive and invasive investigation such as UGI endoscopy for uncomplicated dyspepsia, and hence, it becomes important to scrutinize the screening process adopted for the same.

To assess the need for UGI Endoscopy in patients presenting with uncomplicated untreated dyspepsia and to study the patterns of endoscopic presentations in uncomplicated dyspepsia.

This is a retrospective endoscopic study of 1450 patients presenting with dyspepsia in KR Hospital Mysore from March 2011 to Febraury 2014 (4 years review). The inclusion criteria contain patients older than 13 years of age with uninvestigated, uncomplicated, untreated dyspepsia for more than 4 weeks presenting to the surgical OPD at KR Hospital, Mysore, India. The exclusion criteria contain pregnant and lactating women, patients with hepato-biliary-pancreatic disease and patients who received PPI drugs/treatment for H.Pylori. Patients selected for the study had undergone USG abdomen to rule out hepato-biliary-pancreatic disease, and then subjected to UGI endoscopy, biopsy taken from the pathological site. Biopsy specimens were subjected to histo-pathological examination. These findings entered in the KRH endoscopy register, were analysed.

The results of our study showed that the most common presenting complaints in our population is Epigastric discomfort> Heart Burns [Table/Fig-1]. The highest prevalence of dyspepsia is seen in 40-50 year old patients. Dyspepsia is more common in Males (65.11%) than Female (34.90%) patients [Table/Fig-1,2,3]. Most common

endoscopic finding is Non ulcer dyspepsia > Esophagitis > Gastritis > Cancer > Hiatus hernia [Table/Fig-1,4]. Malignancy was diagnosed in 2.5% of the patients [Table/Fig-1].

In our study the most common age presenting with dyspepsia was 40-50 years and the most common presentation on Endoscopy and HPE was Non Ulcer Dyspepsia [7] (36%) [8] [Table/Fig-1]. This is consistent with the presentations among the various studies conducted prior to our study [9-13]. The CADET –PE [9] study showed 42% of the study group presented with no findings on endoscopy. Sarvar et al., showed 51.7 % presented with non ulcer dyspepsia [12] [Table/Fig-5].

However, a significant 64% of the patients presenting with uncomplicated dyspepsia are found to have findings on endoscopy [Table/Fig-1]. This is significantly raised as compared to the other studies in reference, perhaps because:

Patients in this study had not been administered treatment in the form of PPI/Anti- Helicobacter pylori.

The next most common finding on endoscopy was esophagitis (33.95%) in our study [Table/Fig-1,6]. It’s consistent with Sarvar et al., khan et al., and Cadet P study as the second most common finding [9,12,13]. But, Ziauddin et al., have found gastritis to be the second most common finding [10]. Gastritis, however, was the third most common finding on UGI endoscopy in our study with agreeable results with Sarvar et al., and Khan et al., [12,13] [Table/Fig-1,5,7].

Thompson ABR et al., (CADET-PE), Choomsri P et al., Sarvar et al., showed Malignancy in 2%, 1% and 3% of the cases [9,11,12]. Malignancy was detected in 2.5% of the cases in our study [Table/Fig-1,5,8,9].

[Table/Fig-2]:

Endoscopic findings with relative gender distribution in study population

[Table/Fig-3]:

Gender specific percentage distribution of findings in study population

[Table/Fig-4]:

Percentage distribution in study population

[Table/Fig-6]:

Esophagitis

[Table/Fig-7]:

Gastritis

[Table/Fig-8]:

Esophageal CA

[Table/Fig-9]:

Gastric CA

It is justified to carry out upper GI endoscopy in patients presenting with uncomplicated dyspepsia for patients above 40 years of age in our hospital as the rates of malignancy is concurrent with the findings of previous studies as mentioned above [Table/Fig-1,5].

[1]. G Tougas, Y Chen, P Hwang, MM Liu, A Eggleston, Prevalence and impact of upper gastrointestinal symptoms in the Canadian population: findings from the DIGEST study Am J Gastroenterol 1999 94:2845-54.  [Google Scholar]

[2]. RH Jones, SE Lydeard, FD Hobbs, JE Kenkre, EI Williams, SJ Jones, Dyspepsia in England and Scotland Gut. 1990 31:401-05.  [Google Scholar]

[3]. SJ Veldhuyzen van Zanten, N Flook, N Chiba, D Armstrong, A Barkun, M Bradette, An evidence-based approach to the management of patients with uninvestigated dyspepsia in the era of Helicobacter pylori, Canadian Dyspepsia Working Group Can Med Assoc J. 2000 162(12):S3-23.  [Google Scholar]

[4]. N Chiba, Definitions of dyspepsia: time for a reappraisal. Eur J Surg 1998 583:14-23.  [Google Scholar]

[5]. . Williams, Bailey and Love's Short Practice of Surgery 2013 20th EditionLondonCRC Press:200  [Google Scholar]

[6]. Sign.ac.uk. Guideline 68: Dyspepsia [Internet]. 2015 [cited 25 February 2015]. Available fromhttp://www.sign.ac.uk/guidelines/fulltext/68/section3.html   [Google Scholar]

[7]. . Brunicardi,, F. Schwartz's Principles of Surgery 2015 10th EditionNew yorkMcGraw Hill:1050.  [Google Scholar]

[8]. A Arora, Nonulcer dyspepsia: From the Editors: Mayo Clinic Health Letter [8][Internet]. Healthletter.mayoclinic.com. 2015 [cited 25 February 2015]. Available from. http://www.healthletter.mayoclinic.com/editorial/editorial.cfm/i/497/t/nonulcer%20dyspepsia.   [Google Scholar]

[9]. ABR Thomson, AN Barkun, D Armstrong, N Chiba, RJ White, S Daniels, The prevalence of clinically significant endoscopic findings in primary care patients with uninvestigated dyspepsia, the Canadian Adult Dyspepsia Empirical Treatment-Prompt Endoscopy (CADET-PE) study. Aliment Pharmacol Ther. 2003 17:1481-91.  [Google Scholar]

[10]. . Ziauddin, Endoscopic findings in Dyspepsia a prospective study of 200 cases J Post Grad Med Inst 2003 17(2):235-9.  [Google Scholar]

[11]. P Choomsri, W Bumpenboon, Y Wasuthit, C Euanorasetr, P Sumritpradit, W Suwanthunma, Upper gastrointestinal Endoscopic findings in patient presenting with dyspepsia. The Thai journal of surgery 2010 31:7-12.  [Google Scholar]

[12]. M Sarwar, A Waheed, K Aziz, T Alam, Endoscopic assessment of Dyspepsia Pak Armed Forces Med J. 2004 54:48-50.  [Google Scholar]

[13]. N Khan, G Shabbir, M Zarif, MI Khattak, Upper Gastrointestinal Endoscopic assessment of patients presenting with Dyspepsia Journal of Post Graduate Medical Institute. 2007 21(3):212-6.  [Google Scholar]