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## Complete 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](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=18028927)

#### 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. \[24
references\]
[PubMed](http://www.ncbi.nlm.nih.gov/pubmed/11726874?dopt=Abstract)

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### 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 EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

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.

#### 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

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.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**Grades of Recommendation\***

  ----------------------------------------------------------------------------
  **Grade of             **Clarity   **Methodologic    **Implications**
  Recommendation**       of          Strength/\        
                         Benefit**   Supporting        
                                     Evidence**        
  ---------------------- ----------- ----------------- -----------------------
  1A                     Clear       Randomized trials Strong recommendation;
                                     without important can be applied to most
                                     limitations       clinical settings

  1B                     Clear       Randomized trials Strong recommendation;
                                     with important    likely to apply to most
                                     limitations       practice settings
                                     (inconsistent     
                                     results, nonfatal 
                                     methodologic      
                                     flaws)            

  1C+                    Clear       Overwhelming      Strong recommendation;
                                     evidence from     can apply to most
                                     observational     practice settings in
                                     studies           most situations

  1C                     Clear       Observational     Intermediate-strength
                                     studies           recommendation; may
                                                       change when stronger
                                                       evidence is available

  2A                     Unclear     Randomized trials Intermediate-strength
                                     without important recommendation; best
                                     limitations       action may differ
                                                       depending on
                                                       circumstances or
                                                       patients\' or societal
                                                       values

  2B                     Unclear     Randomized trials Weak recommendation;
                                     with important    alternative approaches
                                     limitations       may be better under
                                     (inconsistent     some circumstances
                                     results, nonfatal 
                                     methodologic      
                                     flaws)            

  2C                     Unclear     Observational     Very weak
                                     studies           recommendation;
                                                       alternative approaches
                                                       likely to be better
                                                       under some
                                                       circumstances

  3                      Unclear     Expert opinion    Weak recommendation;
                                     only              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]{.underline}**

-   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]{.underline}**:

**Grades of Recommendation\***

  ----------------------------------------------------------------------------
  **Grade of             **Clarity   **Methodologic    **Implications**
  Recommendation**       of          Strength/\        
                         Benefit**   Supporting        
                                     Evidence**        
  ---------------------- ----------- ----------------- -----------------------
  1A                     Clear       Randomized trials Strong recommendation;
                                     without important can be applied to most
                                     limitations       clinical settings

  1B                     Clear       Randomized trials Strong recommendation;
                                     with important    likely to apply to most
                                     limitations       practice settings
                                     (inconsistent     
                                     results, nonfatal 
                                     methodologic      
                                     flaws)            

  1C+                    Clear       Overwhelming      Strong recommendation;
                                     evidence from     can apply to most
                                     observational     practice settings in
                                     studies           most situations

  1C                     Clear       Observational     Intermediate-strength
                                     studies           recommendation; may
                                                       change when stronger
                                                       evidence is available

  2A                     Unclear     Randomized trials Intermediate-strength
                                     without important recommendation; best
                                     limitations       action may differ
                                                       depending on
                                                       circumstances or
                                                       patients\' or societal
                                                       values

  2B                     Unclear     Randomized trials Weak recommendation;
                                     with important    alternative approaches
                                     limitations       may be better under
                                     (inconsistent     some circumstances
                                     results, nonfatal 
                                     methodologic      
                                     flaws)            

  2C                     Unclear     Observational     Very weak
                                     studies           recommendation;
                                                       alternative approaches
                                                       likely to be better
                                                       under some
                                                       circumstances

  3                      Unclear     Expert opinion    Weak recommendation;
                                     only              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](#identifying-information-and-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](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=18028927)

#### ADAPTATION

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

#### DATE RELEASED

2001 Dec (revised 2007 Jan)

#### 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. \[24
references\]
[PubMed](http://www.ncbi.nlm.nih.gov/pubmed/11726874?dopt=Abstract)

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [American Society for
Gastrointestinal Endoscopy Web
site](http://www.asge.org/PublicationsProductsIndex.aspx?id=352).

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.

#### COPYRIGHT STATEMENT

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

### DISCLAIMER

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Date Modified: 11/3/2008