Dyspepsia is the most common gastrointestinal problem in general practice, occurring in 10–50% of the population each year [
The current treatment of FD remains disappointing [
This study was approved by the Siriraj Institutional Review Board. The study site was Siriraj Hospital, a tertiary care university hospital in Bangkok, Thailand. All consecutive patients who presented with dyspepsia and had undergone at least 2 EGDs in our hospital during October 2005 to November 2011 were enrolled.
The endoscopic database was searched systematically to identify all patients with FD who underwent repeat EGD for the evaluation of dyspepsia. Patients with dyspepsia were identified by searching the terms “dyspepsia,” “epigastric pain,” or “abdominal pain” in the “indications” field. Patients who underwent at least 2 EGDs with an indication of dyspepsia were included. The inclusion criteria were as follows: (1) patients with FD, defined by ROME III criteria [
Data were extracted from the medical records, endoscopic and pathological reports. Demographic data included gender, age, comorbid diseases, history of smoking and alcohol drinking, history of gastrointestinal malignancy in first degree relatives, subtype of FD, that is, postprandial distress syndrome (PDS), epigastric pain syndrome (EPS), or mixed subtype, duration of dyspepsia before the first and second EGD, alarm symptoms, night pain/awakening pain, and history of specific drug used within 4 weeks, for example, antiplatelets, aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroid, and proton pump inhibitors (PPI).
Endoscopic data included procedure date, indication of repeat EGD, endoscopic findings, and
Data of patients with positive and negative repeat EGD were compared using univariate and multivariate analyses.
Statistical analysis was done by using SPSS Program version 17.0. Yield and findings were calculated using descriptive statistics and presented with number and percent. The associations between clinical parameters and the results of repeat upper endoscopy used Chi-square test or Fisher-exact test for categorical variables and Student’s
During the study period, a total of 24,905 EGDs were performed in our institute. Of these, 5,278 (21.2%) had dyspepsia or abdominal pain as indications for EGD. There were 1,023 patients (19.4%) who underwent at least 2 EGDs for the evaluation of dyspepsia or abdominal pain, of which 146 (14.3%) had FD at the initial EGDs.
Study population (EGD, esophagogastroduodenoscopy).
The demographic data and procedure-related characteristics of the study patients are summarized in Table
Demographic characteristics of the 146 patients.
Characteristics | Number (%) or mean ± SD |
---|---|
Age (years), mean ± SD | 56.8 ± 11.6 |
Gender (female), |
93 (63.7) |
Time from the first EGD to repeat EGD (months), median (range) | 34 (1–168) |
Indication of repeat EGD, |
|
Dyspepsia with age ≥55 years | 12 (8.2) |
Dyspepsia with alarm features | 30 (20.6) |
Dyspepsia with failed medical therapy | 74 (50.7) |
Patients’ request | 9 (6.2) |
Others | 13 (8.9) |
Not specified | 5 (3.4) |
EGD, esophagogastroduodenoscopy; SD, standard deviation.
The clinical features of dyspepsia during the repeat EGD were EPS (104 patients, 71.2%), PDS (34 patients, 23.3%), and mixed subtype (1 patient, 0.7%) and were not defined in 7 patients (4.8%). Twenty-nine patients (19.9%) had alarm features such as unexplained weight loss (21 patients, 14.4%) and gastrointestinal blood loss (8 patients, 5.5%). Night pain or awakening pain was found in 4 patients (2.7%) and history of aspirin or NSAID used within 4 weeks was found in 34 patients (23.3%).
Repeat EGD was performed at a median of 34.0 months (IQR, 1–168 months) after initial EGD. The indications for repeat EGD are shown in Table
Findings of the repeat EGD are shown in Table
Findings and diagnosis of the repeat EGD in 146 patients.
Findings | Number (%) |
---|---|
Negative | 115 (78.8) |
Positive | 31 (21.2) |
Erosive gastritis | 19 (13.0) |
Peptic ulcer | 11 (7.5) |
Gastric ulcer | 6 (4.1) |
Duodenal ulcer | 5 (3.4) |
Reflux esophagitis | 2 (1.4) |
Barrett’s esophagus | 1 (0.7) |
Data of 115 patients with negative findings and 31 patients who had positive findings on repeat EGD were compared using univariate analyses (Table
Univariate and multivariate analyses of the clinical parameters between patients with positive and negative findings on repeat EGD (data are shown in
Clinical parameters | Univariate analysis | Multivariate analysis | |||
---|---|---|---|---|---|
Negative repeat EGD |
Positive repeat EGD |
|
Hazard ratio (95% CI) |
| |
Age (years), mean ± SD | 56.4 ± 11.8 | 58.3 ± 10.9 | 0.432 | ||
Gender, female | 75 (65.2) | 18 (58.1) | 0.462 | ||
Time to repeat EGD (months), median (range) | 33.5 (1–168) | 36.1 (7–118) | 0.421 | ||
Comorbid illnesses | |||||
Diabetes | 15 (13.0) | 3 (9.7) | 0.765 | ||
Hypertension | 40 (34.8) | 18 (58.1) | 0.019 | 2.96 (1.38–6.36) | 0.050 |
Dyslipidemia | 32 (27.8) | 11 (35.5) | 0.406 | ||
Coronary artery disease | 7 (6.1) | 5 (16.1) | 0.071 | ||
Kidney diseases | 1 (0.9) | 0 | 1.000 | ||
Liver diseases | 0 | 0 | 1.000 | ||
Malignancies | 3 (2.6) | 4 (12.9) | 0.037 | 3.65 (1.16–11.46) | 0.027 |
Family history of GI malignancies | 6 (5.2) | 1 (3.2) | 1.000 | ||
Smoking | 8 (6.9) | 5 (16.1) | 0.015 | 3.88 (1.31–11.51) | 0.015 |
Alcohol drinking | 11 (9.5) | 1 (3.2) | 0.462 | ||
Use of NSAIDs or antiplatelets | 23 (20.0) | 11 (35.5) | 0.007 | 4.10 (1.13–14.90) | 0.032 |
Night pain/awakening pain | 3 (2.6) | 1 (3.2) | 1.000 | ||
Indications of repeat EGD | |||||
Dyspepsia with age ≥55 years | 11 (9.5) | 1 (3.2) | 0.462 | ||
Dyspepsia with alarm features | 24 (20.9) | 6 (19.4) | 0.853 | ||
Dyspepsia with failed medical therapy | 56 (48.7) | 18 (58.1) | 0.354 | ||
Patients’ request | 6 (5.2) | 3 (9.7) | 0.401 | ||
Others | 10 (8.7) | 3 (9.7) | 1.000 | ||
Not specified | 4 (3.5) | 1 (3.2) | 1.000 | ||
Alarm features | |||||
Dysphagia | 0 | 0 | — | ||
Unexplained weight loss | 17 (14.8) | 4 (12.9) | 1.000 | ||
Persistent vomiting | 0 | 0 | — | ||
Evidence of GI blood loss | 7 (6.1) | 1 (3.2) | 1.000 | ||
Use of PPI within 8 wk | 89 (77.4) | 23 (74.2) | 0.709 | ||
|
6 (5.2) | 3 (9.7) | 0.400 |
EGD, esophagogastroduodenoscopy; GI, gastrointestinal; NSAIDs, non-steroidal anti-inflammatory drugs; PPI, proton pump inhibitor; SD, standard deviation.
Multivariate analysis was performed (Table
Details of the positive repeat EGD in patients with the 4 factors for positive repeat EGD.
Presence of predictors |
|
Positive repeat EGD | Negative repeat EGD | |||
---|---|---|---|---|---|---|
Peptic ulcer | Erosive gastritis | Reflux esophagitis | Others | |||
Hypertension | 58 | 8 | 9 | 2 | 40 | |
History of malignancies | 7 | 1 | 3 | 3 | ||
Smoking | 13 | 1 | 1 | 1 | 1 | 8 |
Use of NSAIDs or antiplatelets | 34 | 4 | 9 | 1 | 23 |
FD is a chronic functional gastroduodenal disorder characterized by its remitting and exacerbating nature. This may lead patients to the repeat EGD due to the fear of serious diseases, by either the patients or the physicians. Currently, there is no recommendation on the optimal indications and timing for repeating EGD.
In the present study, the authors demonstrated that 14% of the patients who had FD underwent repeat EGD. It has been estimated from the randomized trials on the management strategies for dyspepsia that the rates of repeat EGD were 5–25% in 1 year [
Yield of positive significant lesions on the repeat EGD in the present study was 21%. All of the findings were acid-related disorders and no malignancy was found during the median of 34 months. Data in the literature is limited regarding the yield of repeat EGD in FD. Result of the present study showing 21% positive significant findings is close to the results of the previous studies by Ladabaum and Dinh (18%) [
The present study is the first study to evaluate the predictors for positive findings on repeat EGD. The results might help physicians select patients who will likely derive benefit from repeat EGD. The present study demonstrated 4 factors that independently associated with positive findings on repeat EGD, that is, smoking, hypertension, malignancies, and history of antiplatelets/NSAIDs used within 4 weeks. On the other hand, the presence of alarm features, failure to respond to medical therapy, or the
Cigarette smoking, antiplatelets, and NSAIDs are the well-known risk factors for peptic ulcer diseases [
The present study found that the presence of alarm features, failure to respond to medical therapy of FD, and
There are some limitations of the present study. First, because it was a single-center retrospective study, some repeat EGD at other hospitals might be missed and not included. Second, the decision to repeat EGD was on-demand and depended on the attending physicians, not to every patient in a certain interval. Thus, the frequency of positive repeat EGD in the present study might not represent the real frequency in FD. However, even in these highly selected patients, the yield of repeat EGD remained low. Third, we used “dyspepsia” and “abdominal pain” for the indication to perform EGD as the searching keywords; thus we might miss some patients with FD that might use other words. However, we believe that these words are proper enough for indicating dyspepsia.
The yield and findings of repeat EGD in Thai patients with FD were substantially low; most findings were minor acid-related disorders and no malignancy was found during the median 3-year follow-up. Cigarette smoking, hypertension, history of malignancies, and history of antiplatelets or NSAIDs used within 4 weeks were associated with positive findings on repeat EGD.
The authors declare that there is no conflict of interests regarding the publication of this paper.