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Am Fam Physician. 2001;64(1):160

Physicians remain undecided on the optimal management strategy for dyspepsia. Some authors recommend empiric therapy that targets acid suppression or eradication of Helicobacter pylori, or both. Conversely, other experts recommend initial endoscopy with the subsequent treatment strategy determined by the endoscopic findings. Delaney and colleagues compared these two strategies in a large trial of the management of dyspepsia in primary care patients older than 50 years.

Thirty-one general practices in England agreed to refer patients older than 50 years who had symptoms of epigastric pain or heartburn with or without nausea and bloating. Patients who had undergone positive barium studies or endoscopy within the previous three years were excluded from the study. More than 400 patients were randomly assigned to prompt endoscopy or usual management. Usual management could include referral to a gastroenterologist but excluded immediate endoscopy. Urgent referral was also allowed if warranted by the clinical situation. Patients were followed for up to 18 months, and outcomes were assessed using a dyspepsia symptom score, questionnaires concerning quality of life and social functioning, and assessments of cost.

The patients assigned to each treatment strategy were comparable in all significant respects. More than 200 (84 percent) of the patients assigned to prompt endoscopy underwent the procedure. During the first year, 75 (41 percent) of the control patients also underwent endoscopy. In all patients who had endoscopy, 26 percent had esophagitis, 8.7 percent had a peptic ulcer and 2.4 percent had malignant disease. Eradication therapy was provided to 19 (76 percent) of the patients diagnosed with peptic ulcer disease at endoscopy.

Both groups showed improvement in dyspepsia symptom scores and quality of life assessments at 18 months. These improvements were greater in the patients assigned to prompt endoscopy, even after adjustment for age and smoking status. The groups did not differ in measures of emotional or social functioning or in patient satisfaction. Primary care consultation rates for dyspepsia were similar in the two groups, but patients in the usual treatment group were more likely to attend outpatient facilities. Consumption of antacids, prokinetic drugs and histamine H2-receptor antagonists was similar in each treatment group, but patients in the initial endoscopy group were prescribed proton-pump inhibitors 48 percent less often. The total costs were higher for patients assigned to prompt endoscopy, but 75 (40 percent) of these patients were symptom free compared with 47 (35 percent) of the usual treatment group. This result made calculation of cost-effectiveness highly sensitive to the cost of endoscopy and the value placed on being symptom free.

The authors conclude that in dyspeptic patients older than 50 years, initial endoscopy could be an effective strategy if the cost of the procedure could be lowered.

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