Overuse of upper gastrointestinal endoscopy among young dyspeptic patients

A retrospective analysis in Karachi

Abstract

Background: 

Dyspepsia, one of the most commonly encountered complaints across the world, can manifest as epigastric pain, burning sensations, bloating, or nausea. The primary aim of this study was to explore the prevalence of endoscopic findings in younger dyspeptic patients and compare these findings with those observed in aged people. Additionally, the research also aimed to assess the overuse of endoscopic procedures in these patients and to probably redefine standards for this invasive procedure in our setting.

Materials and Methods: 

The study was a retrospective analysis of patients who had endoscopy for dyspepsia. The patients were categorized into low risk and high risk based on the age and the presence or absence of alarming features. The chi-square test was used to analyze the data.

Results: 

The sample for this study includes 183 individuals with a mean age of 39.4 (±12.4); out of which 89 (%) were males and 94 (%) were females. Patients aged 45 years or older were at higher risk of having significant findings on endoscopy (18/51 patients, 35.3%) compared to patients younger than 45 years (20/132 patients, 15.1%; P = 0.003).

Conclusions: 

Endoscopy in younger dyspeptic patients was found to have a low yield. Consequently, in these patients, approaches other than endoscopic that are less invasive or noninvasive should be considered for diagnosis and treatment before resorting to endoscopy.

INTRODUCTION

Dyspepsia remains the clinic’s most frequently encountered gastrointestinal complaint.[¹] It is prevalent in 10%–20% of the population in the Asia-Pacific region. Dyspepsia can arise from multiple etiologies, including functional or organic disorders and benign or malignant disorders.[²] It includes symptoms such as pain and burning sensation in the stomach, early satiety, bloating, epigastric fullness, or nausea.[³] Patients manifesting recurrent symptoms of dyspepsia from previous months, with initial symptoms showing about 6 months earlier than the diagnosis, without any anatomic abnormality at endoscopy of the upper gastrointestinal tract are considered to have functional dyspepsia.[⁴]

About 50% of all oesophagogastroduodenoscopies are carried out in patients manifesting dyspepsia.[⁵] Combining endoscopy with histology can substantially give a high yield and accurate diagnosis.[⁶]

However, upon evaluating a larger number of cases, the diagnosis does not present any inherent organic lesion,[⁵] specifically for the younger dyspeptic population and for those patients who do not have any alarming symptoms, such as sudden weight loss, hematemesis, black tarry stools, dysphagia, anemia, and continual vomiting.[⁷] In third-world countries, health sector budgets are constrained, implying that incorrect referral of dyspeptic patients for endoscopy leads to increased workload, objectionable utilization of healthcare resources, and substantially increased waiting time for clinically serious patients. All these factors may be inimical to a patient’s health.[⁵] Additionally, the investigation may cause discomfort and potential complications to the patient, even when performed by a senior gastroenterologist.[⁸] Therefore, assessing the significance of endoscopic findings in young patients with dyspepsia, as well as its feasibility as a diagnostic/investigative tool, is essential to improve the management of this common complaint and, concurrently, to reduce the negative consequences associated with it.

In this study, the primary aims were to explore the prevalence of significant endoscopic diagnosis in dyspeptic patients aged 45 years or less and compared them with patients aged 45 years or more with dyspepsia, to determine the characteristics of such patients, to redefine indications for endoscopic procedures in dyspeptic young adults, and to access potential overuse of endoscopy in young dyspeptic patients, in a large tertiary hospital in Karachi. This research will add to the efficacy of diagnosis and management of dyspeptic patients and improve outcomes for patients.

MATERIALS AND METHODS

This retrospective study used the endoscopic procedure database at Jinnah Postgraduate Medical Centre (JPMC), Karachi, Pakistan. This database, in anticipation, routinely collects selective information concerning all the endoscopies carried out at the gastroenterology wards, including the type of procedure, patient’s code number, age, gender, date of procedure, endoscopy referral, drugs used in sedation, indications, intervention, and diagnosis. Required information for the research was compiled via an electronic performa. Patient and medical professional identifiers were omitted from the data file before transmission from the database into performa, to maintain confidentiality. The study was reviewed and approved by the Institutional Review Board of JPMC and Jinnah Sindh Medical University. For this study, all male and female patients aged 15–75 years with dyspepsia as their primary indication for endoscopic evaluation between January 2020 and April 2021 were included. Dyspepsia was defined as pain and burning sensation in the stomach, early satiety, bloating, epigastric fullness, or nausea. Some patients had secondary indications along with dyspepsia, including, but not limited to weight loss, dysphagia, and abdominal pain. Exclusion criteria for this research consisted patients enrolled for endoscopy who did not have dyspepsia as the initial complaint and patients who were less than 15 or more than 75 years of age. A total of 183 patients were identified for analysis. All statistical analyses were performed using SPSS Statistics 26.0 software. Selected patients were further categorized into two groups: high-risk and low-risk patients, and their correlation with the significant endoscopic diagnosis was explored. High-risk patients were identified based on their age being more than 45 years. Low-risk patients had aged less than 45 years. Also, a critical diagnosis consisted of erosive esophagitis, gastric or duodenal ulcer, stricture, fissures, or gastroesophageal malignancy.[⁹] Descriptive statistics were used to measure demographic values. The data were found to be normally distributed. Continuous variables were presented as means and standard deviation, and categorical variables were presented using numbers and percentages. The chi-squared test of goodness of fit was run to analyze the link between significant endoscopic findings with age.[³] Differences in key outcomes were considered to be statistically significant at P value < 0.05.

RESULTS

During the study period, 183 endoscopies of patients with a primary complaint of dyspepsia fell under our inclusion criteria. The mean age was 39.4 (standard deviation, ±12.4); 89 (48.6%) were males and 94 (51.4%) were females. As shown in Table 1, the most common age group referred for endoscopies for dyspepsia complaints was younger than 45 years (132 patients, 72.1%).

Table 1: Demographics of the patients that underwent upper endoscopy for dyspepsia

Out of 183 patients, 38 had some alarming features other than the primary complaint of dyspepsia for endoscopy as shown in Table 2; the most common alarming feature among dyspeptic patients was epigastric pain (14/38 patients or 36.8%). Persistent vomiting, hematemesis, and weight loss were always associated with abnormal endoscopic findings. In this study, chronic hepatitis B and C were always associated with normal endoscopic findings. Overall, it was found that patients with alarming features had more significant findings as compared to patients with no associated indication (P < 0.05), this is expected, as the associated features considered in this study correspond to the ALARM features pertaining to dyspepsia (which are generally accompanied by presence of organic lesions). In this study, female patients were found to be at higher risk of having significant findings (26/94 patients, 26.6%), as compared to male patients (12/89 patients, 13.5%; P < 0.05). At the same time, it was observed that patients aged ≥ 45 years are at higher risk of having significant findings on endoscopy (18/51 patients, 35.3%) as compared to patients younger than 45 years (20/132 patients, 15.1%; P < 0.05).

Table 2: Comparison between patients with significant and insignificant endoscopic findings regarding patient characteristics

As seen in Table 3, among patients with significant endoscopic findings, 26/38 (68.4%) significant findings were seen in the stomach, including gastric ulcers, gastric mass, and other relevant findings. The stomach was followed by the esophagus and duodenum, each having significant findings of 6/38 (15.8%). In the duodenum, ulcers and strictures were seen, whereas in the esophagus, erosive esophagitis was seen.

Table 3: Endoscopic findings in patients with significant findings

DISCUSSION

Dyspepsia is an extremely common issue among the general public, with roughly 50% of the global population being estimated to have experienced symptoms of dyspepsia at some point in their life.[¹⁰] In recent years, clinical cases of dyspepsia without any structural or organic abnormality—commonly referred to as functional dyspepsia[¹¹¹²]—have become quite common. Despite the growing popularity of functional—as opposed to organic or structural—dyspepsia in the clinic, gastroduodenal endoscopy remains one of the mainstays of diagnosis.[⁷] The “overuse” of endoscopy as a diagnostic modality for dyspepsia, particularly in younger patients, has been subject to scrutiny in recent years because of the low prevalence of significant lesions, the possible predictive role of age and alarm features, and a lack of adherence with guidelines.[¹³] An under-studied issue in the Pakistani clinical setting and the appropriateness of endoscopic evaluation of dyspeptic patients remains critical for the improvement of healthcare outcomes, as well as the cost-effectiveness of the overall approach toward the diagnosis and management of dyspepsia.

At the outset, our results indicate that only 20.8% of endoscopies provide evidence of significant lesions or organic causes of dyspepsia. This implies that four in five endoscopies do not possess any diagnostic value in cases of dyspepsia, posing serious questions regarding their usefulness in the diagnosis and management of dyspepsia in the first place. Although this finding is in contrast with the recommendations provided by Shaukat et al.,[¹⁴] where endoscopic evaluation has been identified as one of the approaches toward the diagnosis and management of dyspepsia, the results obtained here are in line with those of Abdeljawad et al.,[³] who show that only 10.6% of dyspeptic patients have significant results or evidence of organic lesions upon endoscopic evaluation. Furthermore, Gupta et al.’s results[⁷] also show that only 21.3% of endoscopies in dyspeptic patients provided evidence of significant findings or organic lesions, reinforcing the idea that the overall diagnostic yield of endoscopies in dyspeptic patients is limited.

Extending this notion further, the results of this study show that the prevalence of significant findings varies by the age of dyspeptic patients. As noted in Table 2, only 15.2% of endoscopic reports from dyspeptic patients aged less than 45 years contain significant findings. The proportion of reports with significant findings increases to 35.3% in patients aged 45 or above, clearly supporting the notion that the presence/absence of significant findings on endoscopy depends on the age of dyspeptic patients being evaluated. These results are comparable with those of Mahadeva and Goh,[¹⁵] who report that the prevalence of clinically significant findings on endoscopic evaluation of dyspeptic patients is 30.9% in patients aged greater than or equal to 45, as compared to 19% in patients younger than 45 years of age. Apart from that, Abdeljawad et al.[³] also provide similar findings, albeit with a slightly different age group—aged greater than or equal to 55 years. Regardless of said differences in age, the said research shows that the prevalence of significant findings on endoscopy is tied with the age of patients. Overall, this indicates that the usefulness of endoscopies for the diagnosis and management of dyspepsia is particularly low in younger patients, with the age of 45 being a suitable cutoff point as evident from the current study’s findings, as well as those of Mahadeva and Goh.[¹⁵]

Interestingly, the idea that gastroduodenal endoscopy loses its diagnostic value in young dyspeptic patients is supported by studies on best practices in the management of chronic dyspepsia. Azzam et al.,[¹³] Gado et al.,[¹⁶] and Bai et al.[¹⁷] all point out that other strategies for management—such as tests and treatment for Helicobacter pylori—are more useful than endoscopic evaluation in young patient’s dyspepsia. Such studies recommend that the conduction of endoscopic evaluation for dyspeptic patients younger than 45 years of age lacks diagnostic value. Although these studies show that it is best practice to limit the use of endoscopies in younger dyspeptic patients, in this study, 72.1% of endoscopy referrals were for patients aged younger than 45 years. This is an unusual finding. The clinical setting explored by Mahadeva and Goh[¹⁵] had nearly twice as many endoscopy referrals for patients aged 45 or more than for patients younger than 45 years of age. Similarly, in other studies,[³¹⁶] the mean age of the sample was 48.4 ± 12.6 years and 43 ± 15 years, respectively, as compared to the mean age of 39.4 ± 12.4 years seen in this study. Overall, it is clear that when compared with other similar studies conducted in different clinical settings, the prevalence of endoscopic referrals for younger patients in this research is higher. This is quite concerning because endoscopic evaluation is not recommended as a diagnostic modality in young patients with dyspepsia.

CONCLUSIONS

Gastroduodenal endoscopy is considered to be a valuable tool for the diagnosis and management of chronic dyspepsia (a frequently encountered complaint in the clinic). In recent years, however, concerns have been raised regarding its usefulness in younger patients with dyspepsia, as well as the potential for clinicians to overuse endoscopies. These concerns have been observed to be quite valid in our clinical setting, with most endoscopic reports in younger patients being devoid of significant findings and the overprescription of endoscopic evaluation being observed too. Considering the discomfort, risks of infection, and high cost of the endoscopic evaluation, it is recommended that prompt endoscopic evaluation be limited to patients aged equal to or above 45 only, with other treatment and manage treatment modalities—such as test and treat—being preferred for younger dyspeptic patients.

Further research on the topic is essential, with the use of cross-sectional design as well as an emphasis on the presence/absence of alarm features or past medical history relevant to dyspepsia being critical to a better understanding of the overuse of endoscopies and their diagnostic value in a younger dyspeptic patient.

It is important, however, to note here that the current study has a few limitations. The most significant of this is that a retrospective research design (as opposed to a cross-sectional one) has been used, which limits access to subjective (often important) details regarding patients. Second, complete reliance on endoscopy reports implies that the proficiency, as well as opinions of professionals preparing, said reports might decrease the reliability and accuracy of collected data. Third, the research’s emphasis on prior diseases, symptoms, or treatment of patients is negligible; these factors can influence endoscopic findings, and neglecting them weakens our study’s design. Fourth, biopsy findings have not been included in the research, implying that microscopic lesions and histopathologic evidence of organic dyspepsia have been excluded. Finally, the presence or absence of clinical factors that merit the conduction of endoscopies in younger patients—such as ALARM features[¹³]—has not been considered, marking another limitation of the current research.

Authors’ contributions

FN, KU, MA, and RN developed the study, were involved in data collection process, analyzed the data, and wrote the article. All authors were involved in the review and writing of the final article. KU is the guarantor of this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Patient consent for publication

Not required.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Data availability statement

Data are available upon reasonable request.

Acknowledgment

The authors would like to thank the staff of the Endoscopy Department at Jinnah Postgraduate Medical Center (JPMC) for their support during the data collection process.