Clinical Question: What is the predictive value of alarm symptoms in patients with dyspepsia?

Setting: Outpatient (primary care)

Study Design: Cohort (prospective)

Synopsis: Most guidelines for the management of dyspepsia emphasize that patients with alarm symptoms (e.g., anemia, black stools, bloody stools, dysphagia, jaundice, weight loss) should undergo endoscopic evaluation. But, what is the predictive value of these symptoms in primary care? In this study, 93 general practitioners in Denmark systematically collected data for three years on more than 7,000 patients presenting with dyspepsia. At the end of the study period, the general practitioners returned a survey that reported what had happened to these patients. One limitation of the study is the possibility that patients were treated empirically for an ulcer that was never formally diagnosed endoscopically, because not all patients underwent endoscopy. The data for cancer as a diagnosis are probably more reliable. A random sample of 988 patients from different diagnostic groups with and without alarm symptoms was used to determine the predictive value of alarm symptoms. Overall, 11 percent (105) of the patients in this group had one or more alarm symptoms; the most common were weight loss (46), dysphagia (35), black stools (24), and bloody stools (14). The positive predictive value of any alarm symptom for cancer was 3 percent and for ulcer was 10 percent; negative predictive values were 99 and 97 percent, respectively. The risk of cancer during the follow-up period was increased in persons with dyspepsia and alarm symptoms as compared with the general population (odds ratio: 6.3; 95 percent confidence interval: 3.6 to 11.0).

Bottom Line: Alarm symptoms for dyspepsia, such as anemia, evidence of gastrointestinal bleeding, jaundice, weight loss, and dysphagia, are associated with an increased risk of cancer. This finding supports current recommendations for more aggressive evaluation of these patients. (Level of Evidence: 2b)