5. Appropriateness of Gastroscopy: Bleeding and Dysphagia [1]

Introduction

Within the framework of a European Union concerted action, we convened a European expert panel to consider the appropriateness of gastrointestinal endoscopy in a wide variety of clinical situations [1]. One of the areas where the appropriateness of endoscopy was examined was an array of symptoms often evoking suspicion of serious disease. Under the heading of alarm symptoms, the following situations were considered by the expert panel: upper GI bleeding, dysphagia, odynophagia and unexplained weight loss.

Upper gastrointestinal endoscopy (UGE) is an accurate means of determining the presence and site of bleeding, and should be considered for use as a diagnostic and therapeutic solution in patients with active hemorrhage. Although endoscopic therapy for upper GI bleeding is still evolving, several effective methods have been described in the literature, which greatly increase the value of upper GI endoscopy in patients with upper GI hemorrhage.

Dysphagia is a common symptom and a detailed history-taking will suggest its etiology in a large percentage of cases. Patients with dysphagia should be thoroughly investigated because the treatment eventually chosen will depend on the underlying cause. If a mechanical origin is suspected in the clinical history, UGE with biopsy is the procedure of choice.

Odynophagia usually reflects the presence of severe inflammation involving the esophagus. Odynophagia, especially in immuno-compromised or diabetic patients, may merit endoscopy because biopsy and brush cytology may well reveal the underlying cause.

In November 1998, a multidisciplinary European expert panel convened in Lausanne, Switzerland, to discuss and develop criteria for the appropriate use of gastrointestinal endoscopy, a widely-used procedure, regarded as highly accurate and safe. The RAND appropriateness method was chosen for this purpose, because it allows the development of appropriateness criteria based on published evidence and supplemented by explicit expert opinion. A detailed description of the RAND appropriateness method, including the literature search process [1], and of the whole process, as well as the global results of the panel [2], are published as separate articles in this issue of the Journal. The literature review was based on a systematic search of Medline, Embase and the Cochrane Library conducted up to the end of 1997 and completed with some key articles published in 1998. Updating and revision of the literature review is currently ongoing.

This article is divided into three parts: 1. A review of the literature related to the specific alarm symptoms that were considered by the panel of experts and the role of endoscopy in presence of each of those symptoms. This review was made available to the panelists as a background document to support their assessment of the appropriateness of use of UGE in the presence of alarm symptoms. 2. An overview of the main panel results. 3. A summary of the published evidence and of the panel-based appropriateness criteria.

1 The European Panel on Appropriateness of Gastrointestinal Endoscopy (EPAGE, Lausanne, Switzerland)

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1 The European Panel on Appropriateness of Gastrointestinal Endoscopy (EPAGE, Lausanne, Switzerland)