An expensive needle in a haystack

▸ Vakil N, Talley N, Veldhuyzen van Zanten S, et al. Cost of detecting malignant lesions by endoscopy in 2741 primary care dyspeptic patients without alarm symptoms. Clin Gastroenterol Hepatol 2009;7:756–61.

The management of uncomplicated dyspepsia, without alarm symptoms, over the last 5–10 years has moved away from prompt upper gastrointestinal (GI) endoscopy for all individuals towards testing and treating for Helicobacter pylori or empirical acid suppression therapy as a result of meta-analyses of large randomised controlled trials that have incorporated cost-effectiveness analyses. However, concern about the potential for a missed diagnosis of upper GI malignancy remains, and national guidelines still recommend that those aged between 50 and 55 years undergo prompt upper GI endoscopy.

This huge multinational study conducted—as part of a randomised controlled trial—in 190 centres provides further evidence that such concern is firstly unjustified, and also unaffordable to a health service with a limited budget. The study included 2471 primary care patients with Rome II dyspepsia, and excluded individuals with probable symptoms of gastro-oesophageal reflux disease, using non-steroidal anti-inflammatory drugs and reporting alarm symptoms. All patients underwent upper GI endoscopy as part of the study, with endoscopic findings collected on a standardised form. The authors report these findings here with the cost of detecting each …