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Guideline Summary
Guideline Title
The role of endoscopy in dyspepsia.
Bibliographic Source(s)
ASGE Standards of Practice Committee, Ikenberry SO, Harrison ME, Lichtenstein D, Dominitz JA, Anderson MA, Jagannath SB, Banerjee S, Cash BD, Fanelli RD, Gan SI, Shen B, Van Guilder T, Lee KK, Baron TH. The role of endoscopy in dyspepsia. Gastrointest Endosc. 2007 Dec;66(6):1071-5. [40 references] PubMed External Web Site Policy
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Eisen GM, Dominitz JA, Faigel DO, Goldstein JA, Kalloo AN, Petersen BT, Raddawi HM, Ryan ME, Vargo JJ 3rd, Young HS, Fanelli RD, Hyman NH, Wheeler-Harbaugh J. The role of endoscopy in dyspepsia. Gastrointest Endosc 2001 Dec;54(6):815-7. [24 references]

The American Society for Gastrointestinal Endoscopy (ASGE) reaffirmed the currency of the guideline in 2011.

Scope

Disease/Condition(s)

Dyspepsia

Note: The Rome III Committee defined dyspepsia as one or more of the following three symptoms:

  • Postprandial fullness
  • Early satiety
  • Epigastric pain or burning
Guideline Category
Diagnosis
Evaluation
Management
Risk Assessment
Clinical Specialty
Family Practice
Gastroenterology
Internal Medicine
Intended Users
Physicians
Guideline Objective(s)

To define the role of upper endoscopy in the diagnostic evaluation and management of patients with dyspepsia

Target Population

Patients with dyspepsia

Note: Patients with heartburn are excluded from this guideline.

Interventions and Practices Considered
  1. "Test-and-treat" approach including noninvasive testing for Helicobacter pylori (H pylori) such as serology, urea breath testing (UBT), and stool antigen and subsequent treatment of H pylori
  2. Endoscopy
  3. Acid suppressive agents (proton pump inhibitors)
Major Outcomes Considered
  • Sensitivity, specificity, and negative and positive predictive values of diagnostic tests
  • Signs and symptoms

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

2007 Guideline

In preparing this guideline, a search of the medical literature was performed by using PubMed, supplemented by accessing the "related articles" feature of PubMed. Additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When little or no data exist from well-designed prospective trials, emphasis is given to results from large series and reports from recognized experts.

2011 Reaffirmation

A search of medical databases (PubMed, MEDLINE) and annual meeting proceedings from 1990 to 2011 was conducted by one to two Standards of Practice Committee members.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus
Rating Scheme for the Strength of the Evidence

Not applicable

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

2007 Guideline

Guidelines for appropriate utilization of endoscopy are based on a critical review of the available data and expert consensus at the time the guidelines are drafted.

2011 Reaffirmation

A search of medical databases and annual meeting proceedings was conducted by one to two Standards of Practice Committee members with discussion and voting regarding novelty and informative value of new publications since the previous version of the guideline.

Rating Scheme for the Strength of the Recommendations

Grades of Recommendation*

Grade of Recommendation Clarity of Benefit Methodologic Strength/
Supporting Evidence
Implications
1A Clear Randomized trials without important limitations Strong recommendation; can be applied to most clinical settings
1B Clear Randomized trials with important limitations (inconsistent results, nonfatal methodologic flaws) Strong recommendation; likely to apply to most practice settings
1C+ Clear Overwhelming evidence from observational studies Strong recommendation; can apply to most practice settings in most situations
1C Clear Observational studies Intermediate-strength recommendation; may change when stronger evidence is available
2A Unclear Randomized trials without important limitations Intermediate-strength recommendation; best action may differ depending on circumstances or patients' or societal values
2B Unclear Randomized trials with important limitations (inconsistent results, nonfatal methodologic flaws) Weak recommendation; alternative approaches may be better under some circumstances
2C Unclear Observational studies Very weak recommendation; alternative approaches likely to be better under some circumstances
3 Unclear Expert opinion only Weak recommendation; likely to change as data become available

*Adapted from Guyatt G, Sinclair J, Cook D, Jaeschke R, Schunemann H, Pauker S. Moving from evidence to action: grading recommendations—a qualitative approach. In: Guyatt G, Rennie D, eds. Users' guides to the medical literature. Chicago: AMA Press; 2002. p. 599-608.

Cost Analysis

Published cost analyses were reviewed.

The test-and-treat approach is more cost effective than the initial endoscopy approach. Results from a meta-analysis of 5 randomized studies of test-and-treat versus an initial endoscopy showed a negligible improvement of symptoms in the endoscopy group but a savings of $389 per patient in the test-and-treat group. Results from a large, randomized study that compared test-and-treat with initial endoscopy found no significant difference in dyspeptic symptoms at 1 year but with a 60% reduction in endoscopy utilization in the test-and-treat group.

A decision analysis of one study showed that cost-effectiveness of the test-and-treat approach versus empiric acid suppression depends on the prevalence of Helicobacter pylori (H pylori). If the incidence of H pylori is <20%, then empiric acid-suppression therapy is more cost effective.

Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation

This document was reviewed and approved by the Governing Board of the American Society for Gastrointestinal Endoscopy.

Recommendations

Major Recommendations

Recommendations were graded on the strength of the supporting evidence (Grades 1A--3). Definitions of the recommendation grades are presented at the end of the "Major Recommendations" field.

Summary

  • Patients with dyspepsia who are older than 50 years of age and/or those with alarm features should undergo endoscopic evaluation. (1C)
  • Patients with dyspepsia who are younger than 50 years of age and without alarm features may undergo an initial test-and-treat approach for Helicobacter pylori (H pylori). (1B)
  • Patients who are younger than 50 years of age and are H pylori negative can be offered an initial endoscopy or a short trial of proton-pump inhibitors (PPI) acid suppression. (2B)
  • Patients with dyspepsia who do not respond to empiric PPI therapy or have recurrent symptoms after an adequate trial should undergo endoscopy. (3)

Definitions:

Grades of Recommendation*

Grade of Recommendation Clarity of Benefit Methodologic Strength/
Supporting Evidence
Implications
1A Clear Randomized trials without important limitations Strong recommendation; can be applied to most clinical settings
1B Clear Randomized trials with important limitations (inconsistent results, nonfatal methodologic flaws) Strong recommendation; likely to apply to most practice settings
1C+ Clear Overwhelming evidence from observational studies Strong recommendation; can apply to most practice settings in most situations
1C Clear Observational studies Intermediate-strength recommendation; may change when stronger evidence is available
2A Unclear Randomized trials without important limitations Intermediate-strength recommendation; best action may differ depending on circumstances or patients' or societal values
2B Unclear Randomized trials with important limitations (inconsistent results, nonfatal methodologic flaws) Weak recommendation; alternative approaches may be better under some circumstances
2C Unclear Observational studies Very weak recommendation; alternative approaches likely to be better under some circumstances
3 Unclear Expert opinion only Weak recommendation; likely to change as data become available

*Adapted from Guyatt G, Sinclair J, Cook D, Jaeschke R, Schunemann H, Pauker S. Moving from evidence to action: grading recommendations—a qualitative approach. In: Guyatt G, Rennie D, eds. Users' guides to the medical literature. Chicago: AMA Press; 2002. p. 599-608.

Clinical Algorithm(s)

A clinical algorithm is provided in the original guideline document for evaluation of dyspepsia.

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified for each recommendation (see "Major Recommendations").

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate diagnostic evaluation and management of dyspepsia

Potential Harms

Drawbacks to the test-and-treat approach include the risk of Clostridium difficile-associated colitis and induction of antibiotic resistance.

Qualifying Statements

Qualifying Statements
  • Further controlled clinical studies may be needed to clarify aspects of this guideline. This guideline may be revised as necessary to account for changes in technology, new data, or other aspects of clinical practice.
  • This guideline is intended to be an educational device to provide information that may assist endoscopists in providing care to patients. This guideline is not a rule and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment. Clinical decisions in any particular case involve complex analysis of the patient's condition and available courses of action. Therefore, clinical considerations may lead an endoscopist to take a course of action that varies from these guidelines.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Clinical Algorithm
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness

Identifying Information and Availability

Bibliographic Source(s)
ASGE Standards of Practice Committee, Ikenberry SO, Harrison ME, Lichtenstein D, Dominitz JA, Anderson MA, Jagannath SB, Banerjee S, Cash BD, Fanelli RD, Gan SI, Shen B, Van Guilder T, Lee KK, Baron TH. The role of endoscopy in dyspepsia. Gastrointest Endosc. 2007 Dec;66(6):1071-5. [40 references] PubMed External Web Site Policy
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2001 Dec (revised 2007 Jan; reaffirmed 2011)
Guideline Developer(s)
American Society for Gastrointestinal Endoscopy - Medical Specialty Society
Source(s) of Funding

American Society for Gastrointestinal Endoscopy

Guideline Committee

Standards of Practice Committee

Composition of Group That Authored the Guideline

Committee Members: Steven O. Ikenberry, MD; M. Edwyn Harrison, MD; David Lichtenstein, MD; Jason A. Dominitz, MD, MHS; Michelle A. Anderson, MD; Sanjay B. Jagannath, MD; Subhas Banerjee, MD; Brooks D. Cash, MD; Robert D. Fanelli, MD, SAGES Representative; Seng-Ian Gan, MD; Bo Shen, MD; Trina Van Guilder, RN, SGNA Representative; Kenneth K. Lee, MD, NAPSGHAN Representative; Todd H. Baron, MD, Chair

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Eisen GM, Dominitz JA, Faigel DO, Goldstein JA, Kalloo AN, Petersen BT, Raddawi HM, Ryan ME, Vargo JJ 3rd, Young HS, Fanelli RD, Hyman NH, Wheeler-Harbaugh J. The role of endoscopy in dyspepsia. Gastrointest Endosc 2001 Dec;54(6):815-7. [24 references]

The American Society for Gastrointestinal Endoscopy (ASGE) reaffirmed the currency of the guideline in 2011.

Guideline Availability

Electronic copies: Available from the American Society for Gastrointestinal Endoscopy Web site External Web Site Policy.

Print copies: Available from the American Society for Gastrointestinal Endoscopy, 1520 Kensington Road, Suite 202, Oak Brook, IL 60523

Availability of Companion Documents

None available

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI on March 23, 2005. The information was verified by the guideline developer on March 31, 2005. This NGC summary was updated by ECRI Institute on March 4, 2008. This summary was updated by ECRI Institute on July 26, 2010 following the U.S. Food and Drug Administration (FDA) advisory on Proton Pump Inhibitors (PPI). The currency of the guideline was reaffirmed by the developer in 2011 and this summary was updated by ECRI Institute on October 16, 2012.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

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