Abstract
ObjectivesWe investigated whether using demographic characteristics and alarm symptoms can accurately predict cancer in patients with dyspepsia in Iran, where upper GI cancers and H. pylori infection are common.MethodsAll consecutive patients referred to a tertiary gastroenterology clinic in Tehran, Iran, from 2002 to 2009 were invited to participate in this study. Each patient completed a standard questionnaire and underwent upper gastrointestinal endoscopy. Alarm symptoms included in the questionnaire were weight loss, dysphagia, GI bleeding, and persistent vomiting. We used logistic regression models to estimate the diagnostic value of each variable in combination with other ones, and to develop a risk-prediction model.ResultsA total of 2,847 patients with dyspepsia participated in this study, of whom 87 (3.1%) had upper GI malignancy. Patients reporting at least one of the alarm symptoms constituted 66.7% of cancer patients compared to 38.9% in patients without cancer (p<0.001). Esophageal or gastric cancers in patients with dyspepsia was associated with older age, being male, and symptoms of weight loss and vomiting. Each single predictor had low sensitivity and specificity. Using a combination of age, alarm symptoms, and smoking, we built a risk-prediction model that distinguished between high-risk and low-risk individuals with an area under the ROC curve of 0.85 and acceptable calibration.ConclusionsNone of the predictors demonstrated high diagnostic accuracy. While our risk-prediction model had reasonable accuracy, some cancer cases would have remained undiagnosed. Therefore, where available, low cost endoscopy may be preferable for dyspeptic older patient or those with history of weight loss.
Highlights
H. pylori infection is highly prevalent (.80%) in the Iranian adult population. [39,40,41,42,43,44,45] acid peptic disease is still common in Iran, [44,46] the major indication for upper gastrointestinal (UGI) endoscopy in Iran is ruling out upper GI malignancy as underlying cause
We have conducted a relatively large-scale study to assess the role of alarm symptoms and their diagnostic accuracy in predicting UGI malignancy in patients with dyspepsia in a country with high prevalence of H. pylori infection and upper GI malignancy
Once the variables to be included in the model were defined, we examined the calibration of the model by performing HosmerLemeshow goodness-of-fit test
Summary
A condition defined as recurrent or persistent pain or discomfort centered in the upper abdomen, [1] affects 25%–40% of adults in the general population of the United States, incurring over $12 billion per year in direct annual costs in the United States and nearly £1 billion per year in the United Kingdom. [2,3,4,5,6] Several benign or malignant disorders may underlie dyspepsia, including esophagitis, gastroesophageal reflux disease (GERD), peptic ulcer disease (PUD), erosive duodenitis, [7] and most importantly upper gastrointestinal (UGI) malignancies, which are estimated to be responsible for 1%–3% of all cases of dyspepsia. [7,8,9,10] in over half of the dyspeptic patients no obvious structural abnormality can be found, a condition called ‘‘functional’’ or ‘‘non-ulcer’’ dyspepsia. [1,11,12,13] Recently some experts have argued that GERD should be excluded from the etiologies of dyspepsia and treated as a different entity, [2,14] but this is still in dispute. [15,16]There are several alternative strategies for initial management of dyspepsia including empirical acid suppressive therapy, H. pylori test and treat, and prompt endoscopy, [17,18] and several studies have tried to find the best strategy. [11,12,13,18,19,20] It has been suggested that the most cost-effective initial approach in primary care, in countries with low rates of H. pylori infection is test and treat strategy. [17,21,22,23] it may delay early diagnosis of malignant underlying disease beyond the point where it is still curable and might not be practical in countries with very high rates of H. pylori infection, such as Iran. There are several alternative strategies for initial management of dyspepsia including empirical acid suppressive therapy, H. pylori test and treat, and prompt endoscopy, [17,18] and several studies have tried to find the best strategy. [12,19,25,26,27] In contrast, several studies have shown limited predictive value for either alarm features or age to be able to differentiate low- and high-risk dyspeptic patients for underlying malignancies. We have conducted a relatively large-scale study to assess the role of alarm symptoms and their diagnostic accuracy in predicting UGI malignancy in patients with dyspepsia in a country with high prevalence of H. pylori infection and upper GI malignancy. To the best of our knowledge, no previous study investigated alarm symptoms in Western Asia and Middle East region
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