DIAGNOSTIC YIELD OF UPPER GI ENDOSCOPY AND ULTRASONOGRAPHY IN PATIENTS OF DYSPEPSIA

JK-Practitioner volume 17 No. October- December 2012 original article DIAGNOSTIC YIELD OF UPPER GI ENDOSCOPY AND ULTRASONOGRAPHY IN PATIENTS OF DYSPEPSIA Mohd Mubarik, Farooq Ahmad Bhat, G.M.Malik, Feroze Ahmad. MohdMubarik MD; Assistant Prof. Internal Medicine,SKIMS Medical College, G.M.Malik MD; FACG. Ex Professor and Head Department of General Medicine, Govt. Medical College and Associated Hospitals. Farooq Ahmad Bhat MD; Feroze Ahmad MD; Consultant Physicians, Jammu and Kashmir Health Services Srinagar, Kashmir,India Received December 2011 Accepted June 2012 Correspondence:-Dr. Mohd. Mubarik Naqash, Assistant Professor, Department of Internal Medicine SKIMS Medical College-Hospital, Bemina, Srinagar-190017 (J&K-India) Abstract The Study was carried out in a teaching cum referral Medical College Hospital of Kashmir to ascertain the diagnostic yield of upper gastrointestinal (UGI) endoscopy and ultrasonography (USG) in detecting various causes of dyspepsia in Kashmiri population. Two hundred patients, presenting with the symptoms related to dyspepsia were included in the study and were subjected to UGI endoscopy and USG. Functional dyspepsia (Normal UGI endoscopy and USG) was found in 108 (5%) in and organic dyspepsia in 92 (6%) of patients. In the organic dyspepsia group inflammatory lesions (including gastritis, gastroduodenitis, duodenitis and esophagitis) was observed in 36 (39.13%) patients while as duodenal ulcer (including channel ulcers in 3 (36.5%), cholelithiasis in 10 (10.86%), gastric ulcer in 06 (6.25%), carcinoma stomach in, carcinoma esophagus in 02(2.17%) and hiatus hernia in patients. The combined use of UGI endoscopy and USG provided a higher diagnostic yield in patients with symptoms related to dyspepsia.functional dyspepsia predominated in females (7%), while as organic dyspepsia predominated in males (62%).Smokers comprised 5(27%) of the dyspepsia patients, out of which 2(.%) had organic dyspepsia and 30(55.56%) had functional dyspepsia. Further, out of 160(80%) patients, who gave history of some psychiatric disorder, 102(51%) belonged to functional dyspepsia group. JK-Practitioner 2012;17(): 15-19 Key Words: Dyspepsia (functional, organic), upper gastrointestinal (UGI) endoscopy, ultrasonography (USG), duodenal ulcer, gastric ulcer, inflammatory lesions, gastric cancer, cholelithiasis, hiatus hernia. 15

INTRODUCTION: 6) Patients with any systemic disease. The clinical observation has revealed that dyspeptic RESULTS: symptoms are quite commonly observed in the A Total of two hundred patients (96 males and 10 Kashmiri population as in other parts of the world. females) in the age group of 37 ± 12.8 years, with Dyspepsia is a very common complaint of patients duration of symptoms ranging from one month to three 1 presenting in both hospital and general practice. It is months were included in the study. 5(27%) dyspeptic very difficult to define dyspepsia and as per Dr.WG patients were smokers, out of which 2(.%) had 2 Thompson dyspepsia defies definition. Dyspepsia may organic dyspepsia. be early symptom of various disease conditions like Ninety percent of all the patients presented with pain peptic ulcer disease, cholelethiasisc and gastric upper abdomen, 8% had epigastric and / or retrosternal carcinoma, denoted as organic dyspepsiabut sometimes discomfort, 0-70% complained of nausea, flatulence, no lesion has been found, denoted as functional belching, vomiting, post prandial discomfort/distension 3, dyspepsia. According to 2006 Rome III criteria, and 30-35% had water brash, weight loss and anorexia. functional dyspepsia must include one or more of In110(55%) patients, food relieved symptoms, while as following symptoms; bothersome postprandial fullness, in 80(0%) patients had aggrevation of symptoms, and early satiation, epigastric pain, epigastric burning with 10(5%) patients had no effect. Besides, 160(80%) no evidence of structural disease including the use of patients gave history of psychiatric disorder ranging upper endoscopy. Criteria should be fulfilled for at least from mild anxiety to depression,out of which 102(51%) 3 months with symptom onset at least 6 months patients belonged to functional dyspepsia group. previously. Since the patients of dyspepsia form a large All the patients were subjected to UGI endoscopy and group of our Medical out patients department, it was a ultrasonography. Functional dyspepsia was observed in relevant and genuine proposition to evaluate these 108(5%) patients and organic dyspepsia in 92(6%) patients, with an aim to study the causes of dyspepsia patients. In functional dyspepsia group, females and to know the diagnostic yield of UGI endoscopy and predominated (7:3), while as in organic dyspepsia USG in detecting the conditions causing dyspepsia. group, males predominated (62:30).Out of 96 males MATERIAL AND METHODS: 3(35.1%) had functional dyspepsia,while as out of Two hundred patients who attended the outpatient 108 females,7(71.51%) had functional dyspepsia and department or were admitted in our hospital with only 30 (28.8%) had organic dyspepsia(table -1). symptoms suggestive of dyspepsia were considered for In the organic dyspepsia group comprising 92 patients, inclusion in the study. The criteria for inclusion in the UGI endoscopy revealed inflammatory lesions study was pain abdomen, discomfort restricted to upper (gastritis, duodenitis, esophagitis and gastroduodenitis) abdomen or heart burn for more than one month in 36(39.13%) patients, duodenal ulcer (including associated with other symptoms like nausea, vomiting, channel ulcers) 3(36.95%) gastric ulcer in 06(6.52%) belching, flatulence, anorexia, dysphagia, water while as gastric carcinoma, esophageal carcinoma and brushes, post-prandial discomfort, distension and hiatus hernia was found in 02(2.17%) patients each. weight loss. History of diet, smoking and drugs Further, ultrasonography revealed gallbladder disease (especially non-steroidal anti-inflammatory drugs) was including cholelithiasis in 10(10.86%) in the organic also enquired from the patients. Each patient underwent dyspepsia group (Table-2). In the organic dyspepsia thorough clinical assessment and routine investigations group, duodenal ulcer predominated in males (25:9) and were performed. All the patients were subjected to UGI so was true of inflammatory lesions, (26:10) while as endoscopy and ultrasonography for ascertaining the females predominated in gallbladder disease (7:3) and investigative diagnosis of dyspepsia either as organic or gastric ulcer (:2) Table 3. functional. The diagnosis of functional dyspepsia was Table -1 : Showing sex distribution of functional and established as per Rome III criteria. The following organic dyspepsia. patients were not included in the study: 1) Previously documented upper gastrointestinal Dyspepsia type Males Females lesions including peptic ulcer disease. Functional 3 (35.1%) 7 (71.15%) 2)Significant abdominal findings like hepatosplenomegaly or any mass in the Organic 62 (6.58%) 30 (28.8%) abdomen. 3) The findings of ova or cysts in the abdomen. Note: Functional dyspepsia predominated in females; ) History of upper gastrointestinal bleeding. while as organic dyspepsia predominated in males. 5) Patients on regular intake of anti-inflammatory drugs or steroids. 16

Table -2 : Endoscopic and USG findings in patients of organic dyspepsia ( No :92) Type of findings 1. Inflammatory Lesions (I) Gastritis (ii) Duodenitis (III) Esophagitis (iv) Gastro duodenitis 2. Duodenal ulcer (including channel ulcer) 3. Gastric Ulcer. Carcinoma stomach 5. Carcinoma esophagus 6. Gallbladder diseases(cholelithiasis) 7. Hiatus hernia No of cases (with %) 36 (39.13%) 26 (28.26%) 06 (6.52%) 3 (36.95%) 06 (6.25%) 10(10.86%) 02(2.17%) original article 12 definite cause is never established. Thus, this study was carried out to establish the investigative diagnosis and ruling out functional dyspepsia by subjecting the patients to UGI endoscopy and ultrasonography. We observed that peptic ulcer disease (combined duodenal and gastric) predominated (3.7%), followed closely by inflammatory lesions (39.13%), gallbladder disease (cholelithiasis) 10.86%, while as other lesions accounted for less percentage of patients in our organic dyspepsia group, in conformity 13, 1 with some other studies as well. Further, an earlier study in the Kashmir Valley has shown the point prevalence of peptic Ulcer disease as.72% and life 15 time prevalence as 11.22%. Reflux esophagitis has been observed to be the second important cause of organic dyspepsia after peptic ulcer disease with gallbladder disease as rare findings some 13, 1, 16 earlier studies. The same was not in conformity with our observation of about 11% of patients having DISCUSSION: gallbladder disease (cholelithiasis) and insignificant Dyspepsia is upper abdominal pain or discomfort that is percentage having esophagitis in our organic dyspepsia episodic or persistent and often associated with group. Earlier study from Kashmir has also revealed the belching, bloating, heart burning, nausea or vomiting prevalence of gall stones as 6.12 %( 3.07% for men and and is reported to occur in approximately 25% of the 17 9.6% for women) amongst the general population. in population each year, but mostly the affected persons conformity with our observation. A significant don't seek medical care 5-7. The present study was percentage of esophagitis in our organic dyspepsia carried out to look for the diagnostic yield of UGI group can be explained on the basis of less number of endoscopy and ultrasonography together in ascertaining patients. Further, the selection of patients was not the etiology in 200 patients with symptoms related to random but was done after ruling out any definite related dyspepsia. cause clinically or on the basis of previous investigative In about 50 60% of patients, a specific etiology is not diagnosis. identified (functional or non-ulcer dyspepsia) and in rest Inflammatory lesions especially gastritis was observed is caused by structural or biochemical disease, denoted in a sizable number of our patients of organic dyspepsia. 2,,8,9 as organic dyspepsia,. In our study group, 108(5%) The clinical experience has revealed that most of the patients had functional dyspepsia as per Rome III Kashmiri population are habituated to the use of over the criteria ( referred by Brun R ) with UGI endoscopy and counter medications especially the pain killers 11 ultrasonography showing no abnormality, while as including NSAIDS. Also, the food habits of most 92(6%) had organic dyspepsia in conformity with Kashmiri population include the consumption of hot above studies. However, some authors have reported salted alkaline tea, pickles, smoked fish, Kashmiri Hak higher percentage of functional dyspepsia and some (brassica olerecea), spice cakes etc. These foods have 2, 10, 11 have shown even lesser percentage. The same can be earlier been reported to be related to the increased explained on the basis of differences in selection of 18 incidence of gastric cancer in Kashmir. Thus, excess patients in various studies. So far as our study group was use of pain killers and peculiar dietary habits might also concerned, we did not include those patients who had a be responsible for more of inflammatory lesions and definite correlation with some cause like already peptic disease in our valley. diagnosed peptic ulcer disease, history of upper A high prevalence of psychiatric disorders among gastrointestinal bleed or intake of non-steroidal anti- patients with functional dyspepsia has been reported in inflammatory drugs (NSAIDS), already diagnosed, gall 19, 20 earlier studies. We also observed that the patients of bladder disease etc. Also, the number of patients in our dyspepsia especially functional dyspepsia had study group was less as compared to other studies. underlying psychiatric disorders ranging from mild Pain abdomen has been reported to be a predominant anxiety to frank depression. Besides other factors, the symptom, followed by other symptoms like nausea, same might be also related to the prevailing turmoil in vomiting, flatulence often referred as secondary the Kashmir valley since 1990, causing lot of mental symptoms 10, 11 in conformity with frequency of stress to most of the Kashmiris because of many reasons symptoms in our study group. The initial evaluation of including loss of life (close relatives).we observed that patients with dyspepsia includes a thorough history and the females predominated in the functional dyspepsia physical examination with special attention given to the 21, group in conformity with some earlier studies as well. 23 findings suggestive of some serious disease. However, Gender related differences have been observed in some symptoms of possible causes often overlap, making the studies of the prevalence of individual clinical diagnosis difficult and in most of the patients a dyspepsiasymptoms as also in gastric emptying and 17

proximal gastric motor function. Gender differences in technical review; evaluation of dyspepsia. the psychosocial realm have also been observed, with Gastroenterology. 1998; 339; 376-81. dyspeptic women experiencing a lesser sense of well- 9. Richter JE. Dyspepsia: organic causes and differential 2 being than dyspeptic men. The significant proportion characteristics from functional dyspepsia. Scand J. of females in our functional dyspepsia group can also be Gastroenterol(Suppl). 1991; 182-11-6. explained on the basis our observation that females 10. Gautam R, Konar A. Diagnostic problems of non- reacted to psychosocial aftermaths of the prevailing ulcer dyspepsia Ind J of Gastroenterol. 1988: Vol. 8, turmoil more so than the male counterparts. Suppl. F A10. We observed that 5(27%) of all dyspepsia patients 11. Toukan AU. Upper gastrointestinal tract findings were smokers, out of which 2(.%) had organic with patients of dyspepsia. 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