Predictive Determinants for Gastro-oesophageal Malignancy in Dyspeptic patients with Alarm features.

Chandra Mohan, S (2009) Predictive Determinants for Gastro-oesophageal Malignancy in Dyspeptic patients with Alarm features. Masters thesis, Stanley Medical College, Chennai.


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INTRODUCTION : Dyspepsia is a nonspecific term to denote upper abdominal discomfort that is thought to arise from the upper-GI tract. Dyspepsia may encompass a variety of more specific symptoms, including epigastric discomfort,bloating, anorexia, early satiety, belching or regurgitation, nausea, and heartburn. Symptoms of dyspepsia most commonly result from 1 of 4 underlying disorders: peptic ulcer disease, GERD, functional disorders (nonulcer dyspepsia),and malignancy: malignancy is present in 1% to 3% of patients with dyspepsia and peptic ulcer disease in another 5% to 15%. The estimated annual prevalence in western countries is approximately 25% to 40% accounting 2-5% of all primary care consultations. In India almost one-third of the population has symptoms. Endoscopy is the procedure of choice for the diagnostic evaluation of this common, longterm, symptom shifting, expensive disorder.It offers the potential for early diagnosis of structural disease.Yet, given the large numbers of patients with dyspepsia, it is not practical to perform endoscopy in all patients with dyspepsia. Age and alarm features have been used in an attempt to identify those patients with dyspepsia who harbor structural disease. Patients with a new onset of dyspepsia after 45 to 55 years of age and those with symptoms or signs (unintended weight loss, Upper Gastrointestinal bleeding or iron deficiency anemia, progressive dysphagia, persistent vomiting, palpable mass, lymphadenopathy, jaundice) that suggest structural disease are advised to undergo initial endoscopy. Patients with alarm features and dyspepsia have significantly worse outcomes than the population at large. In a prospective questionnaire study, patients with alarm symptoms and dyspepsia had a significant increase in both GI cancer and mortality over a 3-year period. Even though alarm features predict relatively poor patient outcomes, they have a low predictive value for GI cancer. In a meta-analysis of 15 studies that evaluated more than 57,000 patients with dyspepsia, alarm symptoms showed a positive predictive value for GI cancer of <11% in all but 1 of these studies. The negative predictive value of alarm symptoms was much higher, at > 97%, because of the low prevalence of GI cancer in that population. A second meta-analysis of 26 studies that totaled more than 16,000 patients with dyspepsia showed similar results: the positive predictive value of alarm symptoms for upper-GI cancer was only 5.9% and the negative predictive value was >99%. Unfortunately, clinical impression, demographics,risk factors, history items, and symptoms also do not adequately distinguish structural disease from functional disease in patients with dyspepsia who are referred for endoscopy. It is worth noting that one fourth of patients with malignancy and dyspepsia have no alarm symptoms. AIM OF THE STUDY : 1.To determine the predictive factors of gastroesophageal malignancy in dyspeptic patients presenting with alarm features. 2.To arrive at or to refine indications for Upper Gastrointestinal Endoscopy in patients with dyspepsia. CONCLUSIONS : The alarm features like dysphagia(p=0.003), persistent vomiting(p=0.02), anemia(p=0.01), age>45 years(p = 0.02) and weight loss(p = 0.008) were identified as significant predictors for Gastroesophageal malignancy in dyspeptic patients. No gender difference observed to influence the malignant outcome(p = 0.3). The duration of alarm inversely correlates with malignant outcome(p<0.0001). Presence of alarm combination do not significantly increase the chances of malignancy (p=0.3) Alarm features in age > 45 years predict more significantly(p=0.008) the malignant outcomes than younger age group with alarm. Alarm features like Upper GI bleed(p=0.8), early satiety(p=0.2), anorexia(p=0.1), easy fatiguability(p=0.13), mass abdomen(p=0.6) do not predict significantly Gastroesophageal malignancy. Based on the results of the present study,we recommend the following guidelines that can be followed in our set up: 1.Irrespective of age group, any dyspeptic patient with alarm should be subjected to Upper GI endoscopy to rule out malignancy as per the recommendation.But the urgency of endoscopy can be prioritised. (a) In Age > 45 years presenting with alarm,Upper GI endoscopy should be done urgently/at the earliest without even waiting for the baseline investigations. (b) In Age > 45 years without alarm & younger patients with alarm,Upper GI scopy can be done in an elective basis or after undergoing baseline investigations. 2.Patients presenting with dysphagia,vomiting ,weight loss,anemia should be done endoscopy in an urgent basisThe above indications may minimize the workload to the endoscopist and at the same time identifies the malignancy at the earliest.

Item Type: Thesis (Masters)
Uncontrolled Keywords: Predictive Determinants ; Gastro-oesophageal Malignancy ; Dyspeptic patients ; Alarm features.
Subjects: MEDICAL > Gastroenterology
Depositing User: Kambaraman B
Date Deposited: 13 Jul 2017 04:17
Last Modified: 13 Jul 2017 04:17

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