Endoscopy: When Is It Appropriate for a Patient With Dyspepsia?

Under what circumstances is endoscopy advisable for a patient with dyspepsia?

As many as 4 to 7 out of 10 primary care visits include the complaint of dyspepsia.¹ Empiric acid suppression therapy is often prescribed. In fact, the percentage of persons in the general population who use this therapy may be as high as 5%.² Is there cause for concern here? What if empiric therapy is masking serious underlying disease like cancer? What is the best way to determine whether endoscopy-urgent (within 2 weeks) or otherwise-is necessary?

The American Gastroenterological Association and the Canadian Dyspepsia Working Group have recommended age cutpoints for endoscopy in patients with dyspepsia (45 and 50 years, respectively). The United Kingdom National Institute does not have such a cutpoint.^1,3 If the experts disagree, how should the primary care physician proceed?

One way to stratify risk is to determine whether VBAD (vomiting, bleeding or anemia, abdominal mass or weight loss, and dysphagia) symptoms are present. However, few studies have looked at the accuracy of these "alarming" symptoms in predicting serious disease. Recently, Kapoor and colleagues⁴ performed endoscopies on 1852 patients who had at least one of these symptoms. The most common symptoms were dysphagia (34%), weight loss (29%), and vomiting (28%).

Three factors seemed to predict cancer:

• Age over 55 years.
• Weight loss.
• Dysphagia.

The authors developed a "2-week endoscopy rule": Any patient with dyspepsia who experiences dysphagia or weight loss, or any patient older than 55 years with any alarm symptom, should undergo endoscopy sooner rather than later. They then applied these criteria to 1785 patients and found that about 3% of them had malignancies and about 12% had significant benign disease.

What lessons does this study offer primary care doctors? Patients with dyspepsia who are older than 55 years and who have any VBAD symptoms-dysphagia and weight loss especially-need immediate endoscopy. The absence of the VBAD symptoms appears to predict which patients can be given acid suppression therapy with or without elective endoscopy at a later date.