Introduction Straight to Test (STT) Oesophagogastroduodenoscopy (OGD) is a referral pathway for General Practitioners (GP) for suspected cancer (red flag) symptoms of the Upper Gastrointestinal (UGI) tract. Pathways vary between organisations, many of which discharge patients following a normal OGD. Here we report the outcome of further investigation of patients with a normal upper endoscopy.
Method Data were gathered retrospectively from STT referrals over a 3 month period (January – March 2012) at Leeds Teaching Hospitals NHS Trust, UK. Patients with simple dyspepsia and a normal OGD were discharged; those with weight loss underwent CT scan and clinic review. Electronic records were reviewed for further investigations and outcomes. Data were compared to a similar audit in 2009 in the same hospital.
Results Of 298 STT endoscopy referrals 16 were excluded, due to failure to attend for OGD (8) or incomplete or inappropriate procedure (8). 282 patients underwent STT OGD; age range: 20 to 91 yrs, mean: 66 yrs, 44% males. In comparison, in the previous audit 200 patients were referred over a 6 month period. Presenting symptoms included: dysphagia 114 (40%), dyspepsia 98 (34%) and unintentional weight loss 91 (32%). UGI and non-UGI cancer was identified in 17 (6.02%) and 16 (5.67%) of patients, respectively; the corresponding figures from the 2009 audit were 13 (6.5%) and 7 (4.0%). Of the 17 identified UGI cancers, 9 (52.9%) were oesophageal, 7 (41.2%) gastric and 1 (5.9%) gastro-oesophageal junction. Other findings included peptic ulcer 20 (7.1%) and oesophagitis 10 (3.5%). Patients with a normal OGD and alarm symptoms (84) underwent further investigation, usually CT (65). The 16 cancers identified outside the UGI tract were pancreatic (3), lung (3), lymphoma (2), CLL (1), renal (2), ampullary (1), liver- HCC (1), parathyroid (1), colorectal (1) and ovarian (1). The positive predictive value (PPV) of individual symptoms is shown in the table; the PPV of dysphagia plus weight loss for UGI cancer was 23.07%.
Conclusion Since 2009, suspected UGI cancer referrals have tripled, yet detection of UGI and non-UGI malignancy combined remains over 10%. UGI malignancy was identified in 1 in 4 patients presenting with the combination of dysphagia and weight loss. For patients referred with suspected UGI cancer and no significant finding on endoscopy, further targeted investigation is recommended.
Disclosure of interest None Declared.