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Non ulcer dyspepsia is associated with helicobacter pylori infection in patients with Parkinson's disease
Results: Up to age 60 in males, and 70 in females, test and eradicate saved more lives than early endoscopy, by preventing the later development of distal gastric cancer. Above these ages endoscopy saved more life, but at additional cost. At no point in the analysis was endoscopy cheaper than test and treat. The table shows the effectiveness of the most effective (dominant) strategy and the ICER (cost per life additional life year saved) for endoscopy with age cut-off and sex.
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Non Ulcer Dyspepsia Is Associated with Helicobacter Pylori Infection in Patients with Parkinson' s Disease Antonio Pietroiusti, Carla Fontana, Andrea Magrini, Cartesio Favallr Antonio Bergamaschi, PaoIo Stanzione, Alberto Gatante Background: Dyspepsia is common in Parkinson' s disease (PD), due to basic PD pathology, chronic drug administration or both. It is not presently known if H. pylori infection may be a cofactor in the development of dyspeptic symptoms in these patients. Aim : to evaluate the efficacy of eradication therapy in relieving dyspeptic symptoms in H. pylari positive PD patients. Patients and Methods: 247 consecutive patients with PD and 202 age and sex matched seemingly healthy controls were evaluated for H. pylon status (lgG antibody titer Pyloryset, ORION Diagnostica, Espoo, Finland; analysis of stool samples, HpSA EI.A), and prevalence and degree of dyspepsia (according to a validated four point scale derived by diary cards). Upper G] endoscopy was performed in dyspeptic H. pylon positive subjects (IgG titer >300 plus positive stool test): those with nonulcer dyspepsia (absence of lesions at endoscopy) were randomized to eradication therapy (one week treatment with omeprazole 20 mg bid, amoxicillin 1 gr bid and clarithromycin 500 mg bid) or identical appearing placebo tablets, and re-evalnated for the prevalence and degree of dyspepsia two months after the end of therapy. Results: H. Pylori prevalence was significantly higher in symptomatic PD patients than in asymptomatic ones (87 out of 115-75.7%- vs 62 out of 132 -47%P<0.0001, Chi-square test), whereas it was similar in symptomatic and asymptomatic controls ( 24 out of 41 -58.5%- vs 89 of 161-55.3%- P=NS). "/'he difference in H. priori prevalence between symptomatic and asymptomatic PD patients was still present after multivariate analysis taking into account age, sex,smoking, l-dopa therapy and socio-economic status (OR 3.41, CI 194 to 5.99, P< 0.0001). H. pylori positive PD patients with endoscopic diagnosis of non ulcer dyspepsia, were randomized to eradication therapy (24 patients), or placebo (24 patients) Of those taking the active drug, 5 became asymptomatic and the mean score for dyspepsia dropped from 2.35 to 1.06 (P< 0.0001, Friedman ANOVA), wheras among placebo-treated patients, no patients became asymptomatic, and the mean score for dyspepsia was only slightly changed ( from 2.27 to 2.09, p = 0.78). The dyspepsia score was unchanged after eradication therapy or placebo in 17 controls with non ulcer dyspepsia. Conclusions: These data suggest that H. pylori infection has a role in the development of symptoms in dyspeptic PD patients. Eradication of the organism is beneficial in these subjects
Conclusions: Below age 60 in males and age 70 in females, 'test and treat' is likely to save more years of life than endoscopy. Only above age 70 does endoscopy appear cost-effective to detect and treat early cancer. Decisions about appropriate age cut-oils for endoscopy should take into account the effectiveness of alternative strategies. Colt I~r Ilfe.y~" reed of e~lcol~y v. H.pylorl lett and b'eat' alone by ige cut off md ~ End~co~ 40yrs f~ym 60yts ?Oyrs above age: NNT 63 71 86 47 ICER dominated dominated 385 000 20 000 Females NNT 154 150 198 151 ICER dominated dominated dominated 42 000 NNT= numb~ neededto treatto save c~e year of lifefor mosteffe~ve s~'alegy.ICER = I~cr~ mentalcost.effec~venessr~o endoscopycompared~th testand treat [$ per LY saved],'domina~l' = whCe testand treatsavesrnomlife,
S1247 Predictive Value of Alarm Features in Patients Referred to a Rapid Access Upper Gastrointestinal Cancer Service (RAUGICS) Nell Kapoor, Asish Bassi, Richard Sturgess, Keith Bodger BACKGROUND A variety of so-called "alarm features" are recognised as raising clinical suspicion for upper gastrointestinal cancer (UGIC). These have been incorporated into recent UK cancer guidelines recommending fast-track evaluation (within 2 weeks, the "two week rule") of all patients having any of the designated alarm features. The evidence-base for such recommendations is limited. The aim of the present study was to assess the predictive value of individual alarm features for UG1C among subjects referred to a new fast-track cancer service (RAUGICS). SETTING A University teaching hospital serving a population of 330,000 and providing approximately 2,000 Open Access Gastroseopies per year. METHODS Referrals to the service were made using a standard referral form indicating the presence of one or more pre-determined alarm features Referral criteria and subsequent endoscopic diagnosis were recorded prospectively. Single and multiple logistic regression analyses were employed to determine the predictive value of individual alarm features and to construct a clinical prediction model aimed at limiting demand for the service whilst maimaining diagnostic sensitivity for cancer. The impact of the new service on total direct access endoscopy workload was also evaluated. RESULTS 1,852 patients were referred to the RAUGICS in 18 months (mean age: 59 yrs; 63% over 55 years of age; prevalence of cancer: 38%, 70 cases). Introduction of the RAUGICS led to a 33% increase in total direct access endoscopy activity (over half of all referrals meeting criteria for rapid assessment). Dysphagia (OR 3.1), weight loss (OR 2.6) and age >55 years (OR 9.5) were found to be significant predictive factors for cancer, but the value of other accepted alarm features was limited. Applying narrower referral criteria, 545 patients could have been re-allocated to less urgent investigation (eg. routme open access endoscopy) whilst retaniing 99% sensitivity for cancer. CONCLUSIONS The UK "two week rule" demands fast-track investigation for dyspeptic patients with traditional alarm features yet the yield of malignancy among such patients ks low. The benefits of rapidly evaluating all patients who meet current referral criteria is questionable as some of the proposed alarm features are poor predictors of cancer. In health care systems where endoscopy capacity is limited, the use of narrower referral criteria may improve the efficient use of fast-track cancer diagnostic services.
S1250 selecting The Dyspeptic Patients W h o Are Most Likely to Benefit from Helicobacter Pylori Eradication Therapy: THE Bristol Helicobacter Project Richard F. Harvey, Athene Lane, Dam Murray, fan Harvey, Jenny Donovan, Pmkash Nair The outcome of treatment of patients with Helicobacter pylon infection and epigastrlc pain is often disappointing. Lack of improvement in symptoms usually means that the pain was not due to H.pylori-related peptic ulcer disease (PUD). We have inveatlgated the relationship of three common dyspeptic symptoms, epigastric pain, heartburn and gastro-esophageal reflux, with each other before and after treatment with H.pylori eradication therapy, to see whether the outcome can be predicted. Methods The Bristol Helicobacter Project is a large community-based prospecuve randomised controlled trial of the effects of H.pylori infection and its eradication. 10,537 people gave informed consent to take part in the study, had a 13C-urea breath test and completed a detailed symptom questionnaire. Participants with a positive 13C-urea breath test were treated with clarithromycin 500rag twice daily and ranitidine bismuth citrate 400rag twice daffy for two weeks, or matching placebo. A further questionnaire was completed two years later. All analyses were made on an intention-totreat basis. Results Heartburn (26.1%), epigasttic pain (25.6%) and reflux (178%) were all common in the study population, and often coexisted. From the pre-treatment data, it could be estimated that at least 80% of all epigastric pain was not due to PUD, but probably mostly due to GERD Two years after H. pylori eradication therapy, subjects with epigastric pain who also had at least moderately severe heartburn at baseline showed no significant improvement in their epigastric pain: OR for pain 1.05 (0.70,1.59), compared with those who had epigastric pain but no heartbum, who got significant benefit: OR for epigastric pain 0.71 (0.50,0.98). Conclusion When using a "test and treat" policy for patients with epigastric pain and H.pylori infection, select for treatment those patients who do not have heartburn
S1248 Development of Dyspepsia in Asymptomaric Subjects Treated for H. pylori Infection: a Challeng~ for Screen-and-Treat Strategies Augusto E Llosa, Maria L. Sanchez-Figueroa, Alejandro Mohar, Jeannete Guamer, Roberto Herrera-Goepfert, David HaIperln*, Julie Parsonnet Background Some studies report that Helicobacterpylori treatment improves dyspepsia while others find treatment to have deleterlons effects, particularly on reflux-like symptoms. Few data are available from developing countries or from initially asymptomatic subjects. Methods Healthy adults older than 40 years were recruited as part of a randomized clinical trial of H. pylori eradication and regression of preneoplastic lesions in Chiapas, Mexico. Subjects completed a validated Spanish language dyspepsia questionnaire (SLDQ) to assess symptoms prior to treatment and one year later Outcomes included changes in total SLDQ scores, as well as in subscales of: lower gastrointestinal pain and discomfort, upper gastrointestinal pain and discomfort, reflux, use of medications and quality of life. Resulm 126 subjects completed an SLDQ at baseline and one year after randomization. Among 57 subjects who were considered to have dyspepsia at baseline, 11 (33%) of 33 in the active treatment arm showed marked improvement in symptoms at one year compared to 7 (29%) of 24 in the placebo arm. (relative risk (RR) = 1.1; 95% confidence intervals (CI) = 0.5 - 2.5). Among the 69 subjects considered to be without dyspepsia at baseline, 6 (21%) of 28 in the active treatment arm had worsening of symptoms at one year compared to 2 (5%) of 41 in the placebo arm (RR = 4.4; 95% CI = 1.0 - 20.2). This worsening was largely attributable to increased reflux symptoms in the active treatment arm compared to placebo (RR = 11.7; 95% CI = 1.6 - 88.5). A deleterious effect of treatment was also noted in "use of medications and quality of life" subscale with 8 (29%) of 28 subjects in active treatment showing worsening at one year compared to 3 (7%) of 41 in placebo arm, (RR = 3.9; 95% CI = 1.1 - 13.5). Conclusions In Chiapas, Mexico, treatment of H. pylon infection does not improve symptoms o[ dyspepsia compared to placebo. In subjects with little or no dyspepsia, however, treatment of H pylori may be associated with an increase in reflux symptoms and deleterious effects on quality of life
s1251 Age and Other Risk Factors In Determining Serious Upper Gastrintestinal Pathology In a Multi-racial Asian Population with Dyspepsia Muthukarapan C Raman, Sanjiv Mahadeva, Khean-Lee Goh BACKGROUND Dyspepsia is a common problem worldwide Screening of young patients with dyspepsia using non-mvasive methods has been proposed in the West as a means of reducing the over burdening endoscopic workload. It is uncertain if such a policy can be implemented in South East Asia due to its d/verse population. AIM To determine the proportion and risk factors for serious pathology in patients with dyspepsia in a South East Asian population. METHODS All patients undergoing routine outpatient upper gastrointestinal endoscopy (UGIE) for investigation of dyspepsia were interviewed using a detailed questionnaire and subjected to a cross-sectional study. Serious pathology was defined as either peptic ulcer disease and/or gastrointestinal malignancy. RESULTS From January to August 2002, 720 patients with dyspepsia underwent routine UGIE at this institution and 693 patients were included in the final analysts. 268 (39%) were aged < 45 years and 425(61%) were 45 years and above. 272 (39%)of them were males and 421 (61%) were females. 305(44%) of them were Chinese, 220 (32%) were Indians and 168 (24%) were Malays. Serious pathology was evident in 52 (12 %) patients in those > 45 years old compared to 9 (3%) patients in the < 45 year group (p < 0.001, OR 4.01, 95% CI = 1.87, 8.90). All 8 cases of GI cancer (predominantly gastric) of which 5 were in males, were found m patients > 45 years mainly of Chinese ethnicity (6 patients), the youngest being 51 years
A-181
AGA
Abstracts
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Non Ulcer Dyspepsia Is Associated with Helicobacter Pylori Infection in Patients with Parkinson' s Disease Antonio Pietroiusti, Carla Fontana, Andrea Magrini, Cartesio Favallr Antonio Bergamaschi, PaoIo Stanzione, Alberto Gatante Background: Dyspepsia is common in Parkinson' s disease (PD), due to basic PD pathology, chronic drug administration or both. It is not presently known if H. pylori infection may be a cofactor in the development of dyspeptic symptoms in these patients. Aim : to evaluate the efficacy of eradication therapy in relieving dyspeptic symptoms in H. pylari positive PD patients. Patients and Methods: 247 consecutive patients with PD and 202 age and sex matched seemingly healthy controls were evaluated for H. pylon status (lgG antibody titer Pyloryset, ORION Diagnostica, Espoo, Finland; analysis of stool samples, HpSA EI.A), and prevalence and degree of dyspepsia (according to a validated four point scale derived by diary cards). Upper G] endoscopy was performed in dyspeptic H. pylon positive subjects (IgG titer >300 plus positive stool test): those with nonulcer dyspepsia (absence of lesions at endoscopy) were randomized to eradication therapy (one week treatment with omeprazole 20 mg bid, amoxicillin 1 gr bid and clarithromycin 500 mg bid) or identical appearing placebo tablets, and re-evalnated for the prevalence and degree of dyspepsia two months after the end of therapy. Results: H. Pylori prevalence was significantly higher in symptomatic PD patients than in asymptomatic ones (87 out of 115-75.7%- vs 62 out of 132 -47%P<0.0001, Chi-square test), whereas it was similar in symptomatic and asymptomatic controls ( 24 out of 41 -58.5%- vs 89 of 161-55.3%- P=NS). "/'he difference in H. priori prevalence between symptomatic and asymptomatic PD patients was still present after multivariate analysis taking into account age, sex,smoking, l-dopa therapy and socio-economic status (OR 3.41, CI 194 to 5.99, P< 0.0001). H. pylori positive PD patients with endoscopic diagnosis of non ulcer dyspepsia, were randomized to eradication therapy (24 patients), or placebo (24 patients) Of those taking the active drug, 5 became asymptomatic and the mean score for dyspepsia dropped from 2.35 to 1.06 (P< 0.0001, Friedman ANOVA), wheras among placebo-treated patients, no patients became asymptomatic, and the mean score for dyspepsia was only slightly changed ( from 2.27 to 2.09, p = 0.78). The dyspepsia score was unchanged after eradication therapy or placebo in 17 controls with non ulcer dyspepsia. Conclusions: These data suggest that H. pylori infection has a role in the development of symptoms in dyspeptic PD patients. Eradication of the organism is beneficial in these subjects
Conclusions: Below age 60 in males and age 70 in females, 'test and treat' is likely to save more years of life than endoscopy. Only above age 70 does endoscopy appear cost-effective to detect and treat early cancer. Decisions about appropriate age cut-oils for endoscopy should take into account the effectiveness of alternative strategies. Colt I~r Ilfe.y~" reed of e~lcol~y v. H.pylorl lett and b'eat' alone by ige cut off md ~ End~co~ 40yrs f~ym 60yts ?Oyrs above age: NNT 63 71 86 47 ICER dominated dominated 385 000 20 000 Females NNT 154 150 198 151 ICER dominated dominated dominated 42 000 NNT= numb~ neededto treatto save c~e year of lifefor mosteffe~ve s~'alegy.ICER = I~cr~ mentalcost.effec~venessr~o endoscopycompared~th testand treat [$ per LY saved],'domina~l' = whCe testand treatsavesrnomlife,
S1247 Predictive Value of Alarm Features in Patients Referred to a Rapid Access Upper Gastrointestinal Cancer Service (RAUGICS) Nell Kapoor, Asish Bassi, Richard Sturgess, Keith Bodger BACKGROUND A variety of so-called "alarm features" are recognised as raising clinical suspicion for upper gastrointestinal cancer (UGIC). These have been incorporated into recent UK cancer guidelines recommending fast-track evaluation (within 2 weeks, the "two week rule") of all patients having any of the designated alarm features. The evidence-base for such recommendations is limited. The aim of the present study was to assess the predictive value of individual alarm features for UG1C among subjects referred to a new fast-track cancer service (RAUGICS). SETTING A University teaching hospital serving a population of 330,000 and providing approximately 2,000 Open Access Gastroseopies per year. METHODS Referrals to the service were made using a standard referral form indicating the presence of one or more pre-determined alarm features Referral criteria and subsequent endoscopic diagnosis were recorded prospectively. Single and multiple logistic regression analyses were employed to determine the predictive value of individual alarm features and to construct a clinical prediction model aimed at limiting demand for the service whilst maimaining diagnostic sensitivity for cancer. The impact of the new service on total direct access endoscopy workload was also evaluated. RESULTS 1,852 patients were referred to the RAUGICS in 18 months (mean age: 59 yrs; 63% over 55 years of age; prevalence of cancer: 38%, 70 cases). Introduction of the RAUGICS led to a 33% increase in total direct access endoscopy activity (over half of all referrals meeting criteria for rapid assessment). Dysphagia (OR 3.1), weight loss (OR 2.6) and age >55 years (OR 9.5) were found to be significant predictive factors for cancer, but the value of other accepted alarm features was limited. Applying narrower referral criteria, 545 patients could have been re-allocated to less urgent investigation (eg. routme open access endoscopy) whilst retaniing 99% sensitivity for cancer. CONCLUSIONS The UK "two week rule" demands fast-track investigation for dyspeptic patients with traditional alarm features yet the yield of malignancy among such patients ks low. The benefits of rapidly evaluating all patients who meet current referral criteria is questionable as some of the proposed alarm features are poor predictors of cancer. In health care systems where endoscopy capacity is limited, the use of narrower referral criteria may improve the efficient use of fast-track cancer diagnostic services.
S1250 selecting The Dyspeptic Patients W h o Are Most Likely to Benefit from Helicobacter Pylori Eradication Therapy: THE Bristol Helicobacter Project Richard F. Harvey, Athene Lane, Dam Murray, fan Harvey, Jenny Donovan, Pmkash Nair The outcome of treatment of patients with Helicobacter pylon infection and epigastrlc pain is often disappointing. Lack of improvement in symptoms usually means that the pain was not due to H.pylori-related peptic ulcer disease (PUD). We have inveatlgated the relationship of three common dyspeptic symptoms, epigastric pain, heartburn and gastro-esophageal reflux, with each other before and after treatment with H.pylori eradication therapy, to see whether the outcome can be predicted. Methods The Bristol Helicobacter Project is a large community-based prospecuve randomised controlled trial of the effects of H.pylori infection and its eradication. 10,537 people gave informed consent to take part in the study, had a 13C-urea breath test and completed a detailed symptom questionnaire. Participants with a positive 13C-urea breath test were treated with clarithromycin 500rag twice daily and ranitidine bismuth citrate 400rag twice daffy for two weeks, or matching placebo. A further questionnaire was completed two years later. All analyses were made on an intention-totreat basis. Results Heartburn (26.1%), epigasttic pain (25.6%) and reflux (178%) were all common in the study population, and often coexisted. From the pre-treatment data, it could be estimated that at least 80% of all epigastric pain was not due to PUD, but probably mostly due to GERD Two years after H. pylori eradication therapy, subjects with epigastric pain who also had at least moderately severe heartburn at baseline showed no significant improvement in their epigastric pain: OR for pain 1.05 (0.70,1.59), compared with those who had epigastric pain but no heartbum, who got significant benefit: OR for epigastric pain 0.71 (0.50,0.98). Conclusion When using a "test and treat" policy for patients with epigastric pain and H.pylori infection, select for treatment those patients who do not have heartburn
S1248 Development of Dyspepsia in Asymptomaric Subjects Treated for H. pylori Infection: a Challeng~ for Screen-and-Treat Strategies Augusto E Llosa, Maria L. Sanchez-Figueroa, Alejandro Mohar, Jeannete Guamer, Roberto Herrera-Goepfert, David HaIperln*, Julie Parsonnet Background Some studies report that Helicobacterpylori treatment improves dyspepsia while others find treatment to have deleterlons effects, particularly on reflux-like symptoms. Few data are available from developing countries or from initially asymptomatic subjects. Methods Healthy adults older than 40 years were recruited as part of a randomized clinical trial of H. pylori eradication and regression of preneoplastic lesions in Chiapas, Mexico. Subjects completed a validated Spanish language dyspepsia questionnaire (SLDQ) to assess symptoms prior to treatment and one year later Outcomes included changes in total SLDQ scores, as well as in subscales of: lower gastrointestinal pain and discomfort, upper gastrointestinal pain and discomfort, reflux, use of medications and quality of life. Resulm 126 subjects completed an SLDQ at baseline and one year after randomization. Among 57 subjects who were considered to have dyspepsia at baseline, 11 (33%) of 33 in the active treatment arm showed marked improvement in symptoms at one year compared to 7 (29%) of 24 in the placebo arm. (relative risk (RR) = 1.1; 95% confidence intervals (CI) = 0.5 - 2.5). Among the 69 subjects considered to be without dyspepsia at baseline, 6 (21%) of 28 in the active treatment arm had worsening of symptoms at one year compared to 2 (5%) of 41 in the placebo arm (RR = 4.4; 95% CI = 1.0 - 20.2). This worsening was largely attributable to increased reflux symptoms in the active treatment arm compared to placebo (RR = 11.7; 95% CI = 1.6 - 88.5). A deleterious effect of treatment was also noted in "use of medications and quality of life" subscale with 8 (29%) of 28 subjects in active treatment showing worsening at one year compared to 3 (7%) of 41 in placebo arm, (RR = 3.9; 95% CI = 1.1 - 13.5). Conclusions In Chiapas, Mexico, treatment of H. pylon infection does not improve symptoms o[ dyspepsia compared to placebo. In subjects with little or no dyspepsia, however, treatment of H pylori may be associated with an increase in reflux symptoms and deleterious effects on quality of life
s1251 Age and Other Risk Factors In Determining Serious Upper Gastrintestinal Pathology In a Multi-racial Asian Population with Dyspepsia Muthukarapan C Raman, Sanjiv Mahadeva, Khean-Lee Goh BACKGROUND Dyspepsia is a common problem worldwide Screening of young patients with dyspepsia using non-mvasive methods has been proposed in the West as a means of reducing the over burdening endoscopic workload. It is uncertain if such a policy can be implemented in South East Asia due to its d/verse population. AIM To determine the proportion and risk factors for serious pathology in patients with dyspepsia in a South East Asian population. METHODS All patients undergoing routine outpatient upper gastrointestinal endoscopy (UGIE) for investigation of dyspepsia were interviewed using a detailed questionnaire and subjected to a cross-sectional study. Serious pathology was defined as either peptic ulcer disease and/or gastrointestinal malignancy. RESULTS From January to August 2002, 720 patients with dyspepsia underwent routine UGIE at this institution and 693 patients were included in the final analysts. 268 (39%) were aged < 45 years and 425(61%) were 45 years and above. 272 (39%)of them were males and 421 (61%) were females. 305(44%) of them were Chinese, 220 (32%) were Indians and 168 (24%) were Malays. Serious pathology was evident in 52 (12 %) patients in those > 45 years old compared to 9 (3%) patients in the < 45 year group (p < 0.001, OR 4.01, 95% CI = 1.87, 8.90). All 8 cases of GI cancer (predominantly gastric) of which 5 were in males, were found m patients > 45 years mainly of Chinese ethnicity (6 patients), the youngest being 51 years
A-181
AGA
Abstracts