Effectiveness of management strategies for uninvestigated dyspepsia: systematic review and network meta-analysis

Abstract

ObjectiveTo determine the effectiveness of management strategies for uninvestigated dyspepsia.DesignSystematic review and network meta-analysis.Data sourcesMedline, Embase, Embase Classic, the Cochrane Central Register of Controlled Trials, and clinicaltrials.gov from inception to September 2019, with no language restrictions. Conference proceedings between 2001 and 2019.Eligibility criteria for selecting studiesRandomised controlled trials that assessed the effectiveness of management strategies for uninvestigated dyspepsia in adult participants (age ≥18 years). Strategies of interest were prompt endoscopy; test for Helicobacter pylori and perform endoscopy in participants who test positive; test for H pylori and eradication treatment in those who test positive (“test and treat”); empirical acid suppression; or symptom based management. Trials reported dichotomous assessment of symptom status at final follow-up (≥12 months).ResultsThe review identified 15 eligible randomised controlled trials that comprised 6162 adult participants. Data were pooled using a random effects model. Strategies were ranked according to P score, which is the mean extent of certainty that one management strategy is better than another, averaged over all competing strategies. “Test and treat” ranked first (relative risk of remaining symptomatic 0.89, 95% confidence interval 0.78 to 1.02, P score 0.79) and prompt endoscopy ranked second, but performed similarly (0.90, 0.80 to 1.02, P score 0.71). However, no strategy was significantly less effective than “test and treat.” Participants assigned to “test and treat” were significantly less likely to receive endoscopy (relative risk v prompt endoscopy 0.23, 95% confidence interval 0.17 to 0.31, P score 0.98) than all other strategies, except symptom based management (relative risk v symptom based management 0.60, 0.30 to 1.18). Dissatisfaction with management was significantly lower with prompt endoscopy (P score 0.95) than with “test and treat” (relative risk v “test and treat” 0.67, 0.46 to 0.98), and empirical acid suppression (relative risk v empirical acid suppression 0.58, 0.37 to 0.91). Upper gastrointestinal cancer rates were low in all trials. Results remained stable in sensitivity analyses, with minimal inconsistencies between direct and indirect results. Risk of bias of individual trials was high; blinding was not possible because of the pragmatic trial design.Conclusions“Test and treat” was ranked first, although it performed similarly to prompt endoscopy and was not superior to any of the other strategies. “Test and treat” led to fewer endoscopies than all other approaches, except symptom based management. However, participants showed a preference for prompt endoscopy as a management strategy for their symptoms.Systematic review registrationPROSPERO registration number CRD42019132528.

The yield of upper gastrointestinal endoscopy in patients below 60 years and without alarm symptoms presenting with dyspepsia

“…Our study supports withholding upper GI endoscopy in patients deemed 'low-risk' as only a limited number of patients included in our study had an upper GI malignancy detected (0.3%, n ¼ 47 out of n ¼ 13,978). This result is in line with the pooled prevalence of a recently published network metaanalysis that compared management strategies for noninvestigated dyspepsia in the absence of alarm symptoms (0.4%, 20 of 5028 patients) [22].…”

Dyspepsia: when to endoscope?

“…44 In addition, the research carried out in 2016 with 184 individuals seen in a family doctor's office showed that the use of canned food in patients of older age or "fast food" intake was also related to a worse prognosis (p<0.002), 33 while, in addition, a crosssectional analytical study carried out in 2018 with 1241 students from 4 medical schools in Latin America, showed that the intake of caffeine was clearly related to the worsening of dyspeptic symptoms . 45,46 Psychologic aspects: In relation to other symptoms, the presence of depression is associated with the worsening of dyspeptic symptoms, as shown in the same study mentioned above conducted with medical students in 4 schools in Latin America, which also states that the difficulty to sleep is related to the worsening dyspepsia. This is also in line with the study carried out with fast food workers in a shopping center in Peru, in which those who had more difficulty falling asleep or suffered nighttime awakenings had a higher frequency of functional dyspepsia (p<0.045) 35 .…”

Systematic review and network meta‐analysis: efficacy of drugs for functional dyspepsia

“…Uninvestigated dyspepsia is highly prevalent in this setting, and 80% of patients with dyspepsia will have a normal endoscopy, 105 and therefore be labelled as having FD. Non‐invasive management strategies for uninvestigated dyspepsia include testing for, and treating, H. pylori , or empirical PPI 106 . Given that most patients with uninvestigated dyspepsia in primary care will have FD, pragmatic trials of a TCA vs one or other of these management strategies may also be warranted.…”