Gastroenterology

Gastroenterology

Volume 131, Issue 2, August 2006, Pages 390-401
Gastroenterology

Clinical–alimentary tract
Limited Value of Alarm Features in the Diagnosis of Upper Gastrointestinal Malignancy: Systematic Review and Meta-analysis

https://doi.org/10.1053/j.gastro.2006.04.029Get rights and content

Background & Aims: Alarm features such as dysphagia, weight loss, or anemia raise concern of an upper gastrointestinal malignancy in patients with dyspepsia. The aim of this study was to determine the diagnostic accuracy of alarm features in predicting malignancy by performing a metaanalysis based on the published literature. Methods: English-language studies were identified by searching MEDLINE, EMBASE, Cochrane Controlled Trials Register, and CINAHL. Cohort studies that measured alarm features and compared them with the endoscopic findings were included. Studies were screened for inclusion by 2 authors who independently extracted the data. Sensitivity, specificity, and likelihood ratios were calculated by comparing the alarm feature with the endoscopic diagnosis. The summary receiver operating characteristic curve method was used to summarize test characteristics across studies. Individual alarm features were also assessed when the study report permitted. Results: Eighty-three of 2600 studies met the initial screening criteria; 15 met inclusion criteria after detailed review. These 15 studies evaluated a total of 57,363 patients, of whom 458 (.8%) had cancer. The sensitivity of alarm symptoms varied from 0% to 83% with considerable heterogeneity between studies. The specificity also varied significantly from 40% to 98%. A clinical diagnosis made by a physician was very specific (range, 97%–98%) but not very sensitive (range, 11%–53%). Conclusions: Alarm features have limited predictive value for an underlying malignancy. Their use in dyspepsia management strategies needs further refinement and study.

Section snippets

Searches

Two authors (N.V., P.M.) performed independent electronic database searches of MEDLINE (1966-December 2003), EMBASE (1988- January 2005), Cochrane Controlled Trials Register (January 2005), and CINAHL (1982-January 2005). Papers on upper gastrointestinal neoplasia were identified with the following terms: stomach neoplasms, esophageal neoplasms (all mesh heading and free text terms), gastric adj5 cancer, gastric adj5 adenocarcinoma, (o)esophageal adj5 adenocarcinoma, (o)esophageal adj5 cancer,

Results

After the initial screening of 2635 papers detected by the general search strategy, we identified 85 citations on alarm features that were evaluated in more detail (Figure 1). Of these, 15 studies met the inclusion criteria for a prospective evaluation of alarm features8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22 with excellent agreement between reviewers (κ = .90; 95% confidence intervals [CI]: .76–.96). A total of 57,363 dyspeptic patients were evaluated in the eligible papers, of

Discussion

The results of this analysis suggest that alarm features, clinical diagnoses, and computer models are relatively inaccurate predictors of an underlying malignancy. When present, alarm features have low positive predictive values for an underlying upper GI malignancy. The likelihood is that an upper GI malignancy increases slightly if an alarm feature is present, but the absolute increase in detected cases was small. The negative predictive value was high for all individual alarm features and

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