Young Dyspeptic Patients Research Articles

Overuse of upper gastrointestinal endoscopy among young dyspeptic patients: A retrospective analysis in Karachi

Overuse of upper gastrointestinal endoscopy among young dyspeptic patients: A retrospective analysis in Karachi

Are Histopathological Changes of H. pylori Infection in Young Dyspeptic Patients Necessitate Endoscopy?

BACKGROUND:Helicobacter pylori is an important gastrointestinal infective bacteria with many serious complications including gastric erosions and ulceration, duodenal ulcer, gastric carcinoma and MALT gastric lymphoma. The gastric biopsy is commonly performed in H. pylori-positive dyspeptic individuals, and many previous researchers studied the histopathological features of infected gastric biopsies however little previous studies focused on the histopathological findings in young population in comparison to the older one.AIM:To make a focus on the histopathological effects of H. pylori infection in young patients compared with the older one and predicts the need for endoscopy in this population, also to estimates the prevalence of infection in Iraqi patients.MATERIAL AND METHODS:the sample for this study is 180 patients in total, they attended Marjan medical city in Iraq for dyspepsia of more than 3 months and prepared for OGD. Patients asked for their permission to do immunological tests for H. pylori. Both serology for H. pylori antibodies and stool for antigen tests are used, and the case is included in the study only if both tests were positive, after OGD, the gastric biopsies are processed and examined histopathologically.RESULTS:Normal gastric biopsy is the most common histopathological finding in young (< 25 years) patients (75%) while chronic atrophic gastritis is the most common one in patients > 25 years age (57%). The prevalence of Helicobacter pylori infection in dyspeptic patients was 73.3%, the correlation between infection and sex was insignificant (p-value 0.06), and no significant correlation between infection and age (p-value 0.07) was concluded.CONCLUSION:H. pylori-related histopathological changes of gastric mucosa in young (< 25 years) are commonly mild and does not necessitate endoscopy at this age unless there are alarming signs.

Managing dyspepsia in the young adult patient: effects of different tests for Helicobacter pylori in a “test-and-scope” approach

Aim. To evaluate how different methods for the detection of Helicobacter pylori influence on a “test, score and scope” decision approach in young dyspeptic patients. Results. Complete data from 341 patients (52.2% males) were analyzed. One hundred and ten (32%) were H. pylori-positive by definition. The rapid serology test was true-positive in 64 patients, false-positive in 8, and false-negative in 46. For the EIA IgG serology test, the corresponding results were 99 true-positive, 7 false-positive, and 11 false-negative. If the H. pylori fecal test or urea breath test had been applied, 108 (98%) and 107 (97%) positives would have been correctly detected, respectively, as well as 14 and 7 false positives. Models using test data in a setting of decreasing H. pylori prevalence show that test properties have increasing significance. Conclusions. In a selection strategy for young dyspeptics based on the detection of H. pylori, the choice of test should be made with caution. H. pylori fecal test would probably give the best basis for such selection.

OC-029 Dyspepsia management in Malawi: a prospective audit

IntroductionDyspepsia is a very common symptom world wide. Unless managed effectively it can burden endoscopy services and create high treatment costs. Management algorithms are widely used in developed countries but...

Lansoprazole was not effective in young dyspeptic patients without Helicobacter pylori

Source Citation Leung WK, Wu JC, Chan FK, et al. Initial treatment with lansoprazole in young dyspeptic patients with negative urea breath test result: a randomized controlled trial with 12-month f...

Clinical trial: evaluation of a clinical decision‐support model for upper abdominal complaints in primary‐care practice

Gastro-oesophageal reflux disease (GERD) and dyspepsia affect 25-40% of the general population. In the absence of alarm symptoms, the current recommended policy in young dyspeptic patients is a 'test and treat' strategy for Helicobacter pylori; in GERD patients, a therapeutic trial with proton pump inhibitors is the treatment of choice. To create a short and simple clinical algorithm, for the diagnosis and treatment of patients with upper gastrointestinal complaints. The clinical usefulness and cost-effectiveness of the new algorithm were evaluated in a controlled clinical trial, held in primary-care clinics in Israel. Clinical and economical treatment outcomes were evaluated after 1, 3 and 6 months comparing doctors who used the algorithm (cases) vs. those who did not (controls). 78 cases and 54 controls completed the 6 months of follow up. The improvement in symptom severity and quality of life was greater in the cases than in the controls (P < 0.05). General practitioner clinics visits (P = 0.04), gastroenterology clinics visits (P = 0.02) and medication costs (P = 0.004) were all significantly reduced among cases. Controls underwent also more imaging tests (computerized tomography, ultrasound and X-ray) and endoscopies. The average cost for 6 months' treatment and follow-up was $US 199 for cases compared with an average of $US 336 in the control group. The use of a clinical decision-support tool can facilitate and promote the implementation of management guidelines by general practitioners. The short algorithm presented in the study was found to be useful and easy to apply in clinical practice. Its effectiveness can be further increased by implementing it in computerized medical systems.

Initial Treatment With Lansoprazole in Young Dyspeptic Patients With Negative Urea Breath Test Result: A Randomized Controlled Trial With 12-Month Follow-Up

Although empirical antisecretory drug therapy is recommended to young dyspeptic patients without alarming features, the effectiveness of this approach remains undetermined. We evaluated the long-term effects of an initial 12-wk course of lansoprazole in young dyspeptic patients without Helicobacter pylori (H. pylori) infection. Patients who were less than 45 yr and presented with at least 3 months of dyspepsia in the absence of alarming features were eligible. They were offered (13)C-urea breath test (UBT) to determine H. pylori status and all symptomatic patients with negative UBT were randomized to receive lansoprazole 30 mg daily or placebo for 12 wk. Those who had previous endoscopy or positive UBT were excluded. Primary end point was the proportion of patients with treatment failure, defined as worsening of global dyspeptic symptom, while on study medication. Patients were followed up for 26 wk for global dyspeptic symptom as determined by 7-point Likert scale. Quality-of-life assessment (SF-36), need of endoscopy, and utilization of other health-care services were monitored for 52 wk. A total of 157 dyspeptic patients were randomized. At the end of 12-wk treatment, the proportion of patients with treatment failure was similar in the lansoprazole (33.3%) and placebo (30.3%) groups (P= 0.74). Patients' global assessment of their dyspeptic symptom was comparable at all time points measured. There was also no significant difference in the SF-36 mental and physical summary scales. At the end of 52 wk, there was no difference in the proportion of patients who underwent endoscopy, had additional medical consultations, or used other nonstudy medications between the two groups. Lansoprazole is not effective in the initial management of young dyspeptic patients without H. pylori infection.

“Test, score and scope”: A selection strategy for safe reduction of upper gastrointestinal endoscopies in young dyspeptic patients referred from primary care

Objective. To test the ability of pre-endoscopic clinical evaluation to predict clinically relevant findings of upper gastrointestinal endoscopy. Material and methods. Patients (341) who had been referred to upper gastrointestinal endoscopy for further evaluation of dyspeptic symptoms were included in this prospective, single-blinded study. Prior to endoscopy, the patients underwent a standardized clinical evaluation consisting of 1) a symptom questionnaire, 2) serological testing for Helicobacter pylori antibody and 3) determination of blood hemoglobin. Based upon this evaluation, patients were assigned to one of three defined risk groups. Group A comprised patients with known risk factors for diseases that would require further therapeutic or diagnostic management. Patients in groups B and C had no such risk factors. Patients in group C had heartburn or regurgitation as a predominant symptom, whereas patients in group B did not. The prevalence of clinically relevant findings upon upper endoscopy was then compared for these three groups. Results. The prevalence of clinically relevant endoscopic findings in risk groups A, B and C were 20.1, 2.4 and 1.6%, respectively (p<0.01 for both A versus B and A versus C). Furthermore, 89% of those with clinically relevant endoscopic findings belonged to group A, which comprised a total of 45% of the patients studied. In groups B and C, the prevalence of disease was similar to the area-specific prevalence in the general population without dyspeptic symptoms. Conclusions. By using a simple standardized questionnaire, H. pylori serology and a hemoglobin reading in the evaluation of dyspeptic patients under 45 years of age, the need for endoscopy can be reduced by 55%.

Helicobacter pylori “Test and Treat” or Endoscopy for Managing Dyspepsia: An Individual Patient Data Meta-analysis

Helicobacter pylori "test and treat" has been recommended for the management of young dyspeptic patients without alarm symptoms, and trials have suggested that it is as effective as endoscopy. However, none of these trials have had sufficient sample size to confirm that "test and treat" costs less or to detect small differences in effect. A collaborative group has prospectively registered trials comparing prompt endoscopy with a "test and treat" approach, with the aim of performing an individual patient data meta-analysis of both effect and resource utilization data. Researchers provided data for meta-analysis, pooling effects of interventions on individual dyspepsia symptoms. Standardized unit costs were applied to resource utilization, and net benefit was calculated at patient level. Effects, costs, and net benefit were then pooled at study level. Five trials were identified, containing 1924 patients (946 endoscopy [mean age, 40 years], 978 "test and treat" [mean age, 41 years]). The relative risk (RR) of remaining symptomatic after 1 year was reduced with endoscopy compared with "test and treat" (RR = 0.95; 95% confidence interval [CI]: 0.92-0.99). "Test and treat" cost 389 dollars less per patient (95% CI: 275-502 dollars). Using the net benefit approach, at no realistic level of willingness to pay per patient symptom-free did prompt endoscopy become cost-effective. Prompt endoscopy confers a small benefit in terms of cure of dyspepsia but costs more than "test and treat" and is not a cost-effective strategy for the initial management of dyspepsia.

Sequential therapy; a new treatment for Helicobacter pylori infectionBut is it ready for general use?

According to the WHO, Helicobacter pylori is a class I carcinogen and therefore leaving a diagnosed infection untreated is generally considered to be unethical. Thus, a physician ordering a diagnostic Helicobacter test needs to be prepared to treat all the individuals who test positive, and if not, then he should not order the test. Furthermore, once it is established that a patient is infected, evidence suggests that its eradication is cheaper and is associated with better long-term improvement than the empiric proton pump inhibitor (PPI) therapy [1,2]. A “test for Helicobacter & treat the positives”-strategy for young dyspeptic patients has been shown to be a cost-effective alternative for endoscopy in primary care patients with dyspepsia [3,4]. It is now recommended in several national and international guidelines, including the European consensus report [5]. With infection rates of H. pylori infection still being high, the implementation of these guidelines would not only result in an increasing number of the diagnostic tests, but would also lead to an increasing number of patients who would be in need of eradication therapy.

Sequential therapy; a new treatment for Helicobacter pylori infection : But is it ready for general use?

According to the WHO, Helicobacter pylori is a class I carcinogen and therefore leaving a diagnosed infection untreated is generally considered to be unethical. Thus, a physician ordering a diagnostic Helicobacter test needs to be prepared to treat all the individuals who test positive, and if not, then he should not order the test. Furthermore, once it is established that a patient is infected, evidence suggests that its eradication is cheaper and is associated with better long-term improvement than the empiric proton pump inhibitor (PPI) therapy [1,2]. A “test for Helicobacter & treat the positives”-strategy for young dyspeptic patients has been shown to be a cost-effective alternative for endoscopy in primary care patients with dyspepsia [3,4]. It is now recommended in several national and international guidelines, including the European consensus report [5]. With infection rates of H. pylori infection still being high, the implementation of these guidelines would not only result in an increasing number of the diagnostic tests, but would also lead to an increasing number of patients who would be in need of eradication therapy.

Screening for gastric cancer by Helicobacter pylori serology: a retrospective study

Screening by serology for Helicobacter pylori in young dyspeptic patients has been shown to be effective in reducing demand for endoscopy. H. pylori has been implicated in the causation of gastric cancer and the reported seropositivity rate in patients with gastric cancer ranges from 69 to 94 per cent. The aim of this study was to assess the potential value of Helicobacter antibodies as a method of selecting dyspeptic patients over the age of 45 years for endoscopy. A retrospective comparison of the antibody status to H. pylori was made between 154 patients with gastric cancer and a sex- and date of birth-matched dyspeptic control group. Results from the former group were correlated with demographic data and tumour characteristics. Significantly more patients with gastric cancer were seropositive than controls (77 versus 66 per cent). H. pylori was not related to the Laurén classification of the tumour. Tumour site was significant: body and antrum tumours were associated with Helicobacter whereas cardial tumours appeared to be unrelated. Screening by antibody assays to H. pylori would miss more than 30 per cent of current gastric cancers. The increasing incidence of cardial cancer would cause this percentage to rise in the future.

Open access endoscopy in an epidemiological situation of high prevalence of Helicobacter pylori infection: applicability of the guidelines of the European Society for Primary Care Gastroenterology.

Dyspepsia is a common syndrome and provides primary care physicians with a significant workload. To optimize the management of dyspepsia, several guidelines have been developed. The aim of this study was to determine the incidence of upper gastrointestinal diseases and their relationship to Helicobacter pylori infection in dyspeptic patients referred for upper endoscopy by family physicians, as well as to assess the applicability of the guidelines of the European Society for Primary Care Gastroenterology (ESPCG). A total of 168 unselected dyspeptic out-patients (mean age 38 years, range 18-75), 88 male and 80 female, were included. Two biopsies from the antrum and two from the corpus were taken for histological assessment, and one from the antrum and one from the corpus were taken for culture. Half of the patients had clinically significant findings at endoscopy: peptic ulcer which occurred in 35% of the patients under the age of 30 years, in 45% of the patients in the age group 30-44 years and in 36% of the patients over 45 years of age. The prevalence of H. pylori infection in these age groups was 67, 87 and 89%, respectively. Duodenal ulcer was 12 times more common than gastric ulcer. The overall incidence of upper gastrointestinal disease, especially among young dyspeptic patients, was high compared with that observed in Western countries. The characteristics of dyspeptic patients, consulted in primary care, should be used for adaptation of the ESPCG guidelines to local needs.

Helicobacter pylori test and treat strategy for young dyspeptic patients: new data.

Decision analysis models have given different conclusions on the value of the Helicobacter pylori "test and treat" strategy for the management of dyspepsia. This uncertainty relates to the lack of primary data on this strategy. Four randomised controlled trials have compared the H pylori "test and treat" strategy with prompt endoscopy and have allowed a more accurate decision analysis model to be constructed. The model indicates that the H pylori test and treat strategy is more cost effective than prompt endoscopy, and should be the new "gold standard" against which other strategies are compared.

Young dyspeptic patients: with a test-and-treat policy, are the benefits of decreased symptom severity and oesophago-gastric-duodenoscopy workload sustained?

To examine the symptom severity and requirement for oesophago-gastro-duodenoscopy (OGD) in young dyspeptic patients 2 years after serological testing for Helicobacter pylori, and to compare the outcomes of seronegative patients with those of seropositive patients. Long-term follow-up study of 232 participants from our previous trial. Telephone assessment of patients' symptom severity, scored using a previously validated questionnaire; return of patients for OGD determined using local patient administration system (PAS); and review of medical case notes. Dyspepsia symptom severity of both seronegative and seropositive patients remained reduced compared with initial scores at time of trial recruitment. Symptom severity of seropositive patients was significantly lower than that of seronegative patients (P< 0.001). Seventeen additional patients returned for OGD between six months and two years after the start of the serological study. As 61 of the original 232 study patients returned for OGD within the first six month follow-up period, a total of 78 individuals (34%) had OGD during the two years following the study. Thus, 66% of the original participants avoided OGD. This study of non-invasive testing for H. pylori in young dyspeptic patients has demonstrated an improvement in symptom severity and a substantial reduction in OGD workload over a 2-year period.

Diagnostic work-up and management of young patients with ulcer-like dyspepsia: A cost-minimisation study

Objective: We initiated a cost-minimisation modelling study to compare the costs of strategies based on initial endoscopy or initial non-invasive tests for the detection of Helicobacter (C13 UBT or serology) from the perspective of the Italian National Health Service. The secondary outcomes were the number of patients undergoing unnecessary Helicobacter pylori (HP) eradication treatment and the number of endoscopic examinations spared.Methods: The study was based on a decision analysis model referring to patients aged less than 45 years with ulcer-like dyspepsia and no alarming symptoms. The probabilities entered in the model were weighted means from published studies, and the costs were derived from the Italian NHS reimbursement schedule. Sensitivity analyses were conducted over a wide range of probability and cost estimates in order to test the robustness of the model.Results: Non-invasive tests (such as the preliminary work-up of patients with ulcer-like dyspepsia aged less than 45 years) were cheaper than the use of prompt endoscopy. Among the non-invasive strategies, initial serology led to a small cost saving in comparison with initial C13, but this was offset by an increase in the number of endoscopies and the number of patients unnecessarily undergoing eradication treatment. Finally, the use of CI3 UBT was cheaper than endoscopy in verifying the effect of eradication in HP-positive patients.Conclusion: The results of this study show that, from the perspective of the Italian NHS, non-invasive testing would lead to cost savings in the work-up of young dyspeptic patients with ulcer-like symptoms.

From bench to bedside to bug: an update of clinically relevant advances in the care of persons with Helicobacter pylori- associated diseases.

In-depth meetings of the XIth International Workshop on Gastroduodenal Pathology and Helicobacter pylori led to the presentation and discussion of extensive new data on H. pylori and its diseases. The mode of transmission of H. pylori remains unclear, and it remains unknown why only a small proportion of infected individuals develop duodenal or gastric ulcer disease and even fewer develop gastric cancer. The role of H. pylori eradication in persons with uninvestigated dyspepsia remains controversial. New clinical trials of H. pylori treatment show symptom relief and improvement in the quality of life of persons with functional dyspepsia, especially in those with ulcer-like or reflux-like dyspepsia. Clearly the move is toward symptom-based management of persons with dyspepsia, with fewer endoscopies being needed in the otherwise healthy young dyspeptic patients. It remains controversial whether eradicating H. pylori in duodenal ulcer or functional dyspepsia increases the risk of subsequent development of gastroesophageal reflux disease. The one-week proton pump inhibitor-based triple regimens remain the gold standard of H. pylori therapy, but some of the ranitidine bismuth citrate plus two antibiotic regimens also achieve an 80% H. pylori eradication rate on an intention-to-treat basis. While the urea breath test remains the noninvasive test of choice, interesting new data are available on the use of stool antigen testing to diagnose H. pylori infection. The number of H pylori-associated gastroduodenal diseases grows to include possible liver, vascular, immune and skin conditions.

Gastric cancer and other endoscopic diagnoses in patients with benign dyspepsia

BACKGROUNDIt has been suggested that endoscopy could be replaced with non-invasive assessment of helicobacter status in the initial work up of young dyspeptic patients without sinister symptoms.AIMSTo determine the incidence...

The effectiveness of screening and treating Helicobacter pylori in the management of dyspepsia.

(1) To investigate the effects of a Helicobacter pylori screening and treatment strategy on open access endoscopy referral rates in dyspeptic patients aged < 40 years. (2) To determine the effectiveness of an H. pylori screening and treatment strategy, compared with endoscopy, in reducing dyspeptic symptoms, and in the utilization of dyspepsia related health care in general practice. Subjects were dyspeptic patients aged < 40 years, who were not taking NSAIDs and were without sinister symptoms. Patients were referred by their general practitioners. The proportion of endoscopies carried out in patients aged < 40 years during the 5 years before the introduction of a screening and treatment strategy was compared with the proportion 2 years afterwards, as determined in a retrospective audit. Dyspepsia scores were obtained from unselected endoscopy patients and those who received a 13C-urea breath test (13C-UBT) at their initial visit and 6 months later. The number of visits made by patients with dyspepsia to their GPs, as well as the number of prescriptions given for antisecretory drugs, during the 6 months before attending for investigation were compared, in the same patient groups, with the same variables during the 6 months after the investigation. There was a 37% reduction in open access endoscopies performed in patients aged < 40 years (95% CI, 34-40%) following the introduction of the 13C-UBT service. Six months after attending the 13C-UBT service there was a significant fall in dyspepsia score (15.5 +/- 7.4 to 7.2 +/- 7.0, P < 0.0001), general practice dyspepsia consultations (2.0 +/- 1.3 to 1.0 +/- 1.7, P < 0.0001), H2 receptor antagonist prescription (14.2 +/- 32.6 tablets to 6.7 +/- 25.6 tablets, P = 0.006) but not proton pump inhibitor prescription (6.9 +/- 21.9 tablets to 7.2 +/- 27.6 tablets, P = 0.90). These changes were not significantly different from those found in the open access endoscopy control patients. An H. pylori screening and treatment strategy reduces the endoscopy workload in young dyspeptic patients. This strategy appears to be as effective as endoscopy in reducing dyspepsia symptoms, dyspepsia consultation rates and the prescribing of anti-secretory drugs.

Serologic detection of CagA positive Helicobacter pylori strains predicts the presence of peptic ulcer in young dyspeptic patients

Background: Helicobacter Pylori infection has been strongly associated with upper gastrointestinal (GI) disease, especially duodenal ulcer. Endoscopy or contrast radiography is needed to diagnose and appropriately manage peptic ulcer disease. These diagnostic procedures, however, are time consuming and expensive; endoscopy is invasive and contrast radiography cannot help in the diagnosis of H pylori infection. Our aim was to examine in a prospective study the relation between serologic detection of cytotoxic associated gene (CagA) H pylori strains and endoscopic findings among young dyspeptic patients to determine whether this noninvasive test can help differentiate patients with from those without ulcers. Methods: One hundred patients younger than 45 years with dyspepsia referred for upper GI endoscopy were included in the study. During endoscopy antral biopsy specimens were obtained for the rapid urease test and histologic examination. At histologic examination gastritis was graded from 0 (normal histologic features) to 3 (severe gastritis). After endoscopy blood was obtained for serologic determination of CagA status. Results: Among the 100 patients 56 were H pylori positive and 44 were H pylori negative. In the group of 56 H pylori –positive patients 36 (64.3%) had peptic ulcers and 20 (35.7%) did not. Among patients with peptic ulcer 34 of 36 (94.4%) were CagA positive and 2 (5.6%) were CagA negative. The respective values for the group of patients without ulcers were 9 of 20 (45%) and 11 of 20 (55%). The difference in the proportion of CagA-positive subjects between the group with and that without peptic ulcer was highly significant ( p < 0.0001). Conclusions: Among young patients with dyspepsia, CagA seropositivity is highly associated with duodenal ulcer at endoscopy. (Gastrointest Endosc 1999;50:511-5.)