EUS in the management of uninvestigated dyspepsia

doi:10.1016/S0016-5107(02)70357-X

Gastrointestinal Endoscopy

Volume 56, Issue 6, December 2002, Pages 842-848

Presented at the 12th International Symposium on Endoscopic Ultrasonography, February 11-13, 2000, Monte-Carlo, Monaco (Endoscopy 2000;32:A5).

https://doi.org/10.1016/S0016-5107(02)70357-X Get rights and content

Abstract

Background: Management of dyspepsia often involves multiple diagnostic tests. By virtue of luminal and extraluminal imaging, EUS may be a satisfactory single test for the evaluation of patients with dyspepsia. Methods: Patients with uninvestigated dyspepsia of more than 4 weeks duration were recruited. All underwent transabdominal US followed by EUS and EGD to look for both luminal and extraluminal lesions that could account for the dyspeptic symptoms. Each of these studies was performed by an independent operator blinded to the results of the other examinations. Patients were followed for 1 year to monitor clinical outcome. Results: Two hundred patients were recruited. Compared with EGD, EUS had accuracies of 92% to 100% for the diagnosis of different luminal lesions. All gastric ulcers and cancers were detected by EUS, but 3 duodenal ulcers were missed. EUS also identified 48 pancreaticobiliary lesions, 23 of which were detected by US, that could account for the dyspeptic symptoms. Other extraintestinal lesions including mediastinal malignant lymphadenopathy and a dissecting aortic aneurysm were also diagnosed by EUS. Through the identification of extraluminal lesions, staging of tumors, and exclusion of pancreaticobiliary diseases, EUS altered clinical management in 50 patients (25%). Conclusion: EUS is a useful one-step investigation in patients with dyspepsia. (Gastrointest Endosc 2002;56:842-8.)

Section snippets

Patients and methods

The study was carried out in the gastroenterology clinic of our hospital to which patients are referred by primary care physicians. Patients over 18 years of age with dyspepsia, defined as pain or discomfort centered in the upper abdomen,¹ of more than 4 weeks' duration despite initial treatment were prospectively recruited for the study. The Rome II criteria for diagnosis of dyspepsia were not used because these have not been validated in a Chinese population. Exclusion criteria were

Results

A total of 200 patients (134 women, 66 men; median age 51 years, range 19-84 years) were recruited from June 1998 to June 2000. The self-reported median duration of dyspepsia was 36 months (range 1-480 months). Twenty-five (12.5%) patients claimed significant weight loss at presentation and 6 (3%) had biliary-type pain in addition to the dyspeptic symptom. Initial treatments included antacid (55%), H2 receptor antagonist (27%), proton pump inhibitor (10%), and cisapride (7%). Before

Discussion

Dyspepsia is associated with a heterogeneous group of disorders, including functional disorders without identifiable pathologic cause, benign diseases such as peptic ulcer, and malignancy such as carcinomas of the stomach and pancreas.4, 6 Patients with dyspepsia typically have relapsing symptoms.19, 20 Because the symptom of dyspepsia may not correlate with the underlying pathologic disorder, if present, there is always a concern that recurring symptoms signify occult but significant disease.

References (31)

NJ Talley et al.
AGA technical review: evaluation of dyspepsia. American Gastroenterological Association
Gastroenterology
(1998)
AT Lassen et al.
Helicobacter pylori test-and-eradicate versus prompt endoscopy for management of dyspeptic patients: a randomised trial
Lancet
(2000)
JJ Sung et al.
Incidence of gastroesophageal malignancy in patients with dyspepsia in Hong Kong: implications for screening strategies
Gastrointest Endosc
(2001)
A Chak et al.
Prospective comparative evaluation of video US endoscope
Gastrointest Endosc
(1999)
AV Sahai et al.
Prospective assessment of the ability of endoscopic ultrasound to diagnose, exclude, or establish the severity of chronic pancreatitis found by endoscopic retrograde cholangiopancreatography
Gastrointest Endosc
(1998)
L Agreus et al.
Irritable bowel syndrome and dyspepsia in the general population: overlap and lack of stability over time
Gastroenterology
(1995)
I Wiklund et al.
Does endoscopy have a positive impact on quality of life in dyspepsia?
Gastrointest Endosc
(1998)
F Gress et al.
Role of EUS in the preoperative staging of pancreatic cancer: a large single-center experience
Gastrointest Endosc
(1999)
CE. Forsmark
The diagnosis of chronic pancreatitis
Gastrointest Endosc
(2000)
L Laine et al.
Interobserver agreement and predictive value of endoscopic findings for H. pylori and gastritis in normal volunteers
Gastrointest Endosc
(1995)

PW Moorman et al.

Descriptive features of gastric ulcers: do endoscopists agree on what they see?

Gastrointest Endosc

(1995)

NJ Talley et al.

Functional dyspepsia: a classification with guidelines for diagnosis and management

Gastroenterol Int

(1991)

R Jones et al.

Prevalence of symptoms of dyspepsia in the community

BMJ

(1989)

JE. Richter

Dyspepsia: organic causes and differential characteristics from functional dyspepsia

Scan J Gastroenterol

(1991)

AG Klauser et al.

What is behind dyspepsia

Dig Dis Sci

(1993)

Cited by (23)

Morphological and functional changes of chronic pancreatitis in patients with dyspepsia: A prospective, observational, cross-sectional study
2018, Pancreatology
Whether chronic pancreatitis (CP) may present with dyspepsia is controversial. We aimed at evaluating the frequency and risk factors of changes of CP in patients presenting with epigastric pain syndrome (EPS)-like symptoms.
A prospective, observational, cross-sectional study was carried out in patients with EPS-like symptoms. Patients underwent endoscopic ultrasound (EUS) evaluation of the pancreas, and changes of CP were defined as the presence of five or more EUS criteria of the disease. In patients with 3 or 4 EUS criteria, magnetic resonance dynamic evaluation of the pancreas (MRI/sMRCP) and endoscopic pancreatic function test (ePFT) were carried out to confirm or exclude the presence of changes of CP. A multivariate logistic regression analysis was performed to evaluate factors associated with CP findings, and results are shown as odds ratio (OR) and 95% confidence interval (CI).
213 patients were included. Changes of CP were confirmed by EUS (≥5 criteria) in 18 patients (8.4%). Thirty-four patients had 3-4 EUS criteria, and changes of CP were confirmed in 27 of them by MRI/sMRCP and ePFT (12.7%). Morphological and functional findings of CP were then present in 45 patients (21.1%). Male gender (OR 2.97; 95%CI 1.39–6.37) and alcohol and tobacco consumption (OR 6.56; 95%CI 1.97–21.85) were associated with the presence of changes of CP.
Morphological and functional changes of CP are frequent in patients with EPS-like symptoms. Whether these pancreatic changes explain EPS-like symptoms requires further investigation.
Recurrent and chronic pancreatitis
2012, Medicine
La pancreatitis aguda recurrente (PAR) y la pancreatitis crónica (PC) constituyen síndromes complejos que comparten vías fisiopatológicas comunes. Identificando la causa de la PAR a través de varios estudios evitaremos el desarrollo de la PC. Entre las causas que desencadenan la PAR y PC se encuentran las toxicometabólicas (alcohol y tabaco principalmente), las genéticas, las obstructivas y las autoinmunes, con un porcentaje de casos en los que no es posible determinarla. Hoy en día se considera a la PC como una enfermedad claramente infradiagnosticada. Sus síntomas principales son el dolor abdominal, la esteatorrea con malnutrición y el desarrollo de una diabetes. Para su diagnóstico en los últimos años se emplean fundamentalmente la ecoendoscopia (USE) y la colangiopancreatorresonancia con secretina (S-CPRM), quedando relegada la colangiopancreatografía retrógrada endoscópica (CPRE) para fines terapéuticos. El pilar fundamental del tratamiento lo constituye el manejo del dolor (mediante fármacos, vía endoscópica o quirúrgica) y el tratamiento enzimático sustitutivo.
Recurrent acute pancreatitis (RAP) and chronic pancreatitis (CP) are complex syndromes with converging pathologic pathways. Identifying the cause of RAP towards some procedures will avoid the development of CP. The conditions that can cause a PAR and CP are toxic-metabolic (mainly tobacco and alcohol), genetics, autoimmune and obstructive, with a percentage of cases in which is not possible to find anyone. Nowadays, CP is considered as an infra-diagnosed disease. Most common symptoms are abdominal pain, steatorrhea with malnutrition and the development of diabetes. Many procedures have been used for the diagnosis of CP. In the last years, the most important are Endoscopic Ultrasound (EUS) and Magnetic Resonance Cholangiopancreatography with Secretin infusion (S-MRCP), which are able to identify CP in early stages, playing the Endoscopic Retrograde Cholangiopancreatography (ERCP) a therapeutic role. Treatment goals are the management of pain (with drugs, endoscopic procedures and surgery) and enzymatic replacement therapy.
The role of endoscopic ultrasound in the evaluation of chronic mesenteric ischaemia
2011, Digestive and Liver Disease
Citation Excerpt :
However, its ability to obtain Doppler waveforms can be limited by bowel gas, artefacts or obesity [5–8]. Some evidence suggests that endoscopic ultrasound (EUS) might be an adequate, cost-effective, single test to evaluate chronic upper abdominal pain [9–11]. EUS is the most sensitive test to diagnose small gallstones, bile duct stones and pancreatic diseases [12].
Doppler transabdominal ultrasound is a validated screening test for chronic mesenteric ischaemia, but gas and obesity are limitations. Endoscopic ultrasound has been proposed as a comprehensive test to evaluate chronic upper abdominal pain and is capable of Doppler measurement. We aim to evaluate the accuracy of Doppler endoscopic ultrasound (D-EUS) as a single screening test to rule out chronic mesenteric ischaemia in patients with abdominal pain and compare it with Doppler transabdominal ultrasound (D-TUS).
We enrolled all patients ≥50 years with chronic upper abdominal pain and vascular risk referred for endoscopic ultrasound. All were scheduled for D-EUS and D-TUS plus a confirmatory test if one of the previous resulted positive. We estimated the accuracy of both techniques comparing them using McNemar test.
68 patients completed the study. Fifty-three (78%) underwent D-EUS, D-TUS, and a confirmatory test. Fifteen (38%) underwent follow-up after negative results. Three (4%) in the D-EUS group and 14 in the D-TUS (21%) were excluded due to artefacts. D-EUS presented a sensitivity of 63%, specificity of 84%, whilst D-TUS presented a sensitivity of 80% and a specificity of 78%. Specificity of D-EUS was not significantly different to D-TUS.
These results support the role of Doppler endoscopic ultrasound to exclude chronic mesenteric ischaemia as cause of chronic abdominal pain.
EUS in the initial assessment of upper abdominal pain: Time for a paradigm shift?
2010, Gastrointestinal Endoscopy
EUS compared with endoscopy plus transabdominal US in the initial diagnostic evaluation of patients with upper abdominal pain
2010, Gastrointestinal Endoscopy
Citation Excerpt :
Therefore, our primary objective was to determine whether the combination of oEGD plus EUS, using a dual function instrument, was diagnostically equivalent to EGD plus TUS in the primary evaluation of UAP patients referred to gastroenterologists. A recent Hong Kong study39 reported the results of performing EGD, TUS, and EUS all on the same day. Some of these patients, however, had previous imaging tests.
Primary upper endoscopy (EGD) and transabdominal US (TUS) are often performed in patients with upper abdominal pain.
Primary: Determine whether the combination of EGD and EUS was equivalent to EGD plus TUS in the diagnostic evaluation of upper abdominal pain. Secondary: Compare EUS versus TUS in detecting abdominal lesions, and compare EGD by using an oblique-viewing echoendoscope versus the standard, forward-viewing endoscope in detecting mucosal lesions.
Prospective, paired design.
Six academic endoscopy centers.
This study involved patients with upper abdominal pain referred for endoscopy.
All patients had EGD, EUS, and TUS. The EGD was done using both an oblique-viewing echoendoscope and the standard, forward-viewing endoscope (randomized order) by two separate endoscopists in a blinded fashion, followed by EUS. TUS was performed within 4 weeks of EGD/EUS, also in a blinded fashion. Follow-up: telephone interviews and chart reviews.
Diagnose possible etiology of upper abdominal pain and detect clinically significant lesions.
A diagnosis of the etiology of upper abdominal pain was made in 66 of 172 patients (38%). The diagnostic rate was 42 of 66 patients (64%) for EGD plus EUS versus 41 of 66 patients (62%) for EGD plus TUS, which was statistically equivalent (McNemar test; P = .27). One hundred ninety-eight lesions were diagnosed with either EUS or TUS. EUS was superior to TUS for visualizing the pancreas (P < .0001) and for diagnosing chronic pancreatitis (P = .03). Two biliary stones were detected only by EUS. Two hundred fifty-one mucosal lesions were similarly diagnosed with EGD with either the standard, forward-viewing endoscope or the oblique-viewing echoendoscope (kappa = 0.48 [95% CI, .43-.54]). EGD with the standard, forward-viewing endoscope was preferred for biopsies.
No cost analysis.
The combination of EGD with EUS is equivalent to EGD plus TUS for diagnosing a potential etiology of upper abdominal pain. EUS is superior to TUS for detecting chronic pancreatitis. EGD combined with EUS should be considered in the first-line diagnostic evaluation of patients with upper abdominal pain.
The role of endoscopy in dyspepsia
2007, ASGE Clinical Update
Citation Excerpt :
Occasionally, patients with pancreatic or biliary pathology will present with dyspepsia, (typically epigastric pain), but a diagnosis may be delayed in this setting.1 In a study of 200 patients from Hong Kong, the EUS identified pancreatic or biliary lesions in 48 patients and led to a change in management in 25% of cases.18 In a study from the United States, pancreatic disease was also found to be an atypical presentation of dyspepsia.19
In practice, dyspepsia is commonly used as an indication for endoscopy to exclude upper-gut mucosal abnormalities. However, in this review, Dr Nicholas J. Talley offers a much more pragmatic approach for the diagnosis and management of dyspepsia. By using several systematic reviews, meta-analyses, and recently proposed practice guidelines for dyspepsia, Dr Talley provides a convincing argument that upper endoscopy in subjects younger than 55 years with dyspepsia but without alarm symptoms is a low-yield diagnostic strategy. In contrast, subjects with dyspepsia and who are older than 55 years and/or with alarm symptoms would benefit from upper endoscopy as the initial evaluative strategy. An easy-to-follow (and remember) diagnostic algorithm for uninvestigated dyspepsia is offered at the end of the monograph.
– Ronnie Fass, MD, Editor

View all citing articles on Scopus

^☆: Reprint requests: Yuk Tong Lee, MD, Department of Medicine and Therapeutics, Prince of Wales Hospital, Shatin, N. T., Hong Kong SAR, China.

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Original ArticlesEUS in the management of uninvestigated dyspepsia☆

Abstract

Section snippets

Patients and methods

Results

Discussion

Gastroenterology

Lancet

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastroenterology

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Functional dyspepsia: a classification with guidelines for diagnosis and management

Gastroenterol Int

Prevalence of symptoms of dyspepsia in the community

BMJ

Dyspepsia: organic causes and differential characteristics from functional dyspepsia

Scan J Gastroenterol

What is behind dyspepsia

Dig Dis Sci

Original Articles
EUS in the management of uninvestigated dyspepsia☆