Dyspepsia is a discomfort that is thought to arise from the upper-gastrointestinal tract. Dyspepsia affects approximately a quarter of the population in Western countries. The American Society for Gastrointestinal Endoscopy (ASGE) has issued guidelines for the role of endoscopy in treating dyspepsia. (An upper endoscopy procedure uses an instrument to assess the inside of the esophagus, stomach and small intestine.) The guidelines were prepared by ASGE's Standards of Practice Committee and appear in the December issue of Gastrointestinal Endoscopy, the monthly peer-reviewed scientific journal of the American Society for Gastrointestinal Endoscopy.

Dyspepsia may include a variety of more precise symptoms, which can include epigastric discomfort, bloating, anorexia and heartburn. These nonspecific symptoms can be indicative of an underlying diagnosis like peptic ulcer disease, GERD, functional disorders (non-ulcer dyspepsia) and malignancy. The appropriate role of endoscopy in the evaluation of dyspepsia is both a realistic concern for the gastroenterologist and an important factor in healthcare costs.

Todd Baron, MD, chair of the ASGE Standards of Practice Committee stated that since dyspepsia affects large numbers of people across a broad spectrum of symptoms, it is not practical to perform endoscopy in all patients with dyspepsia. He said, "in review of the medical data available, we concluded in these guidelines that age and alarm features offer the best guidance for the physician in managing patients and in determining if an endoscopy is appropriate treatment."

Patients With Alarm Features (Symptoms)

Endoscopy offers the chance for early diagnosis of structural disease because dyspepsia is not only a convenient descriptor for upper-gastrointestinal (GI) symptoms, but also a marker for the risk of structural disease: malignancy is present in 1 to 3 percent of patients with dyspepsia, and peptic ulcer disease in another 5 to 15 percent.

Age and alarm features have been used in an attempt to identify those patients with dyspepsia who have structural disease. The alarm features include new onset of symptoms in someone over 50, family history of upper-GI malignancy, unintended weight loss, GI bleeding or iron deficiency anemia, progressive trouble swallowing, pain with swallowing, persistent vomiting, palpable mass or lymphadenopathy, and jaundice.

The guidelines recommend that patients older than 50 years of age with recent onset of dyspepsia or patients of any age with alarm features should undergo an endoscopy. An endoscopy should also be considered for patients in whom there is a clinical suspicion of malignancy even in the absence of alarm features.

Patients with dyspepsia who are younger than age 50 and without alarm features are commonly evaluated by one of three methods: noninvasive testing for Helicobacter pylori (H. pylori), with subsequent treatment if positive (the "test-and-treat" approach), a trial of acid suppression or an initial endoscopy.

In many patients with dyspepsia who have peptic ulcer disease, H. pylori infection will be present. Noninvasive testing options for this infection include a blood test, urea breath testing (UBT), and stool antigen. There is growing evidence that patients who are managed with the test-and-treat approach have similar outcomes when compared with those undergoing initial endoscopy. The test-and-treat approach is more cost effective. Results from a meta-analysis of five randomized studies of test-and-treat versus an initial endoscopy showed a negligible improvement of symptoms in the endoscopy group, but a savings of $389 per patient in the test-and-treat group.

Many investigators and societies advocate acid-suppressive therapy as the initial treatment for patients with dyspepsia. Proton pump inhibitors (PPI) are more effective than H2 blockers in this approach. Initiation of empiric acid suppression will not address underlying H. pylori in those patients with H. pylori-associated peptic ulcer disease, risking recurrent symptoms when acid suppression is withdrawn. This may prompt long-term acid suppression if no further investigation is performed.

One advantage of early endoscopy is the chance of establishing a specific diagnosis, such as peptic ulcer disease or erosive esophagitis. The risk of malignancy is quite low in young patients without alarm features. Many patients, however, with early stage malignancy do not have alarm symptoms. Another advantage of a negative endoscopy in the evaluation of patients with dyspepsia is a reduction in anxiety and an increase in patient satisfaction. However, there is little evidence to suggest significant improvement in outcomes by the initial endoscopy approach. Most studies demonstrate an increased cost with the initial endoscopic approach compared with the test-and-treat method.

In summary, it is recommended that patients with dyspepsia who are 50 years of age or older and/or those with alarm features undergo endoscopic evaluation. Those younger than 50 years of age without alarm features should undergo an initial test-and-treat approach for H. pylori. Younger patients who are H. pylori negative can undergo an initial endoscopy or a short trial of PPI acid suppression, and patients with dyspepsia who do not respond to empiric PPI therapy or have recurrent symptoms after an adequate trial should undergo endoscopy.