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• Probably even less effective than claimed
  Ian L. P. Beales
  Published on: 17 December 2017

• Published on: 17 December 2017

  Probably even less effective than claimed

  • Ian L. P. Beales, Consultant Gastroenterologist University or East Anglia

  The authors rightly point out the low yield of gastroscopy in the management of, even complicated, dyspepsia. In fact it looks like gastroscopy is even less useful than the authors claim. There are several important points in the paper that deserve wider discussion. Firstly the authors state that they studied patients over 55 undergoing gastroscopy for dyspepsia, yet the mean age in the cohort was 58 with a standard deviation of 16 years: this implies that actually a substantial proportion of the subjects were in fact well under 55. The data on which the current 2-week wait pathways were based showed that the positive predictive value of all dyspeptic type symptoms, or symptom-combinations, in those under 55 was less than 1%, [1]. Hence by including these patients, the authors have not only confused the reading of their paper but also altered the potential perception of the utility of gastroscopy in relation to the 2-week wait criteria.
  Additionally the claimed usefulness of gastroscopy in 16% of cases seems rather high. Of the cancers in the cohort 3 out of 4 would have has a gastroscopy for indications over and above simple dyspepsia, at least 5 of the "positive" cases seemed to have been having the gastroscopy to obtain histology for a previously suspected condition (hence not simple dyspepsia), 12 benign ulcers would have been managed with acid suppression whether or not a gastroscopy was performed, presumably the oesophageal strictures significant enou...

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  The authors rightly point out the low yield of gastroscopy in the management of, even complicated, dyspepsia. In fact it looks like gastroscopy is even less useful than the authors claim. There are several important points in the paper that deserve wider discussion. Firstly the authors state that they studied patients over 55 undergoing gastroscopy for dyspepsia, yet the mean age in the cohort was 58 with a standard deviation of 16 years: this implies that actually a substantial proportion of the subjects were in fact well under 55. The data on which the current 2-week wait pathways were based showed that the positive predictive value of all dyspeptic type symptoms, or symptom-combinations, in those under 55 was less than 1%, [1]. Hence by including these patients, the authors have not only confused the reading of their paper but also altered the potential perception of the utility of gastroscopy in relation to the 2-week wait criteria.
  Additionally the claimed usefulness of gastroscopy in 16% of cases seems rather high. Of the cancers in the cohort 3 out of 4 would have has a gastroscopy for indications over and above simple dyspepsia, at least 5 of the "positive" cases seemed to have been having the gastroscopy to obtain histology for a previously suspected condition (hence not simple dyspepsia), 12 benign ulcers would have been managed with acid suppression whether or not a gastroscopy was performed, presumably the oesophageal strictures significant enough to cause dysphagia and were not purely incidental findings? These exclusions drop the yield in those with dyspepsia significantly. The inclusion of oesophageal candidiasis is also controversial, if this was significant candida in a predisposed patient causing dysphagia or odynophagia, or minor candida unrelated to dyspepsia symptoms, these also should probably be removed from the "positives." This leaves yield of only 9.7%. Whilst these issues may not alter the message from the authors, it is important that these important debates over the use of expensive and relatively limited resources are fully and accurately informed.
  1. Stapley S, Peters TJ, Neal RD, Rose PW, Walter FM, Hamilton W. The risk of oesophago-gastric cancer in symptomatic patients in primary care: a large case-control study using electronic records. Br J Cancer. 2013 Jan 15;108(1):25-31. doi: 10.1038/bjc.2012.551.

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  Conflict of Interest:
  None declared.

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