Yield of alarm features in predicting significant endoscopic findings among hospitalized patients with dyspepsia

doi:10.3748/wjg.v30.i26.3210

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Jul 14, 2024 (publication date) through Jul 10, 2024

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World Journal of Gastroenterology

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1007-9327

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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA

Retrospective Cohort Study

World J Gastroenterol. Jul 14, 2024; 30(26): 3210-3220
Published online Jul 14, 2024. doi: 10.3748/wjg.v30.i26.3210

Table 1 Basic demographics of the study population

Features	n of 605	%
Age, mean ± SD (58.2 ± 19), median = 60
< 60 years	294	48.6
≥ 60 years	311	51.4
Sex
Female	297	49.2
Male	307	50.8
Duration of symptoms
< 30 days	330	62.6
30-59 days	75	13.2
60-89 days	11	7.3
≥ 90 days	14	9.3
Control without alarm features	92	15.2
Patients with alarm features	513	84.8
Alarm features
Upper GI bleeding	144	23.8
Unexplained weight loss	137	22.6
Persistent vomiting	124	20.5
Iron deficiency anemia	50	8.3
Dysphagia	37	6.1
Odynophagia	5	0.8
Epigastric mass or lymphadenopathy	1	0.2
Endoscopic finding
Patients without endoscopic finding	431	71.2
Patients with any endoscopic finding	174	28.8
Peptic ulcer disease	92	15.2
Erosive esophagitis class B or higher	34	5.6
Malignancy	42	6.9
Stricture	1	0.2
Finding requiring specific therapy	15	2.5
Medications
PPIs	173	29
Statins	191	32.3
Aspirin	111	18.8
Anticoagulant	39	6.6
Anti-aggregate	30	5.1
NSAIDs	23	3.9

GI: Gastrointestinal; NSAIDs: Non-steroidal anti-inflammatory drugs; PPI: Proton pump inhibitors; SD: Standard deviation.

Table 2 Patients’ clinical and demographics characteristics at presentation in both groups with and without significant endoscopic findings, n (%)

Patients’ clinical characteristics	Total, n = 605	SEFs, n = 174	No SEFs, n = 431	P value
Sex				0.08¹
Female	297 (49.2)	94 (54)	203 (47.2)
Male	307 (50.8)	80 (46)	227 (52.8)
Duration of symptoms				0.01²
< 30 days	330 (62.2)	106 (70.2)	224 (59.6)
30-59 days	75 (14.2)	20 (13.2)	55 (14.6)
60-89 days	39 (7.4)	11 (7.3)	28 (7.4)
≥ 90 days	83 (15.7)	14 (9.3)	69 (18.4)
Pulse				0.001²
Bradycardia	51 (8.5)	10 (5.8)	41 (9.5)
Normal pulse	524 (86.9)	146 (84.4)	378 (87.9)
Tachycardia	28 (4.6)	17 (9.8)	11 (2.6)
Blood pressure				0.08²
Hypotension	61 (10.1)	24 (13.9)	37 (8.6)
Normal BP	417 (69.3)	116 (67.1)	301 (70.2)
Hypertension	124 (20.6)	33 (19.1)	91 (21.2)

¹Pearson χ² test.

²Mann-Whitney test.

BP: Blood pressure; SEFs: Significant endoscopic findings.

Table 3 Patients’ blood test, n (%)

CBC	Total (%), n = 605	SEFs, n = 174	No SEFs, n = 431	P value
Normal CBC	234 (38.7)	39 (22.4)	195 (45.2)	< 0.001¹
Abnormal CBC	371 (61.3)	135 (77.6)	236 (54.8)
Normocytic anemia	194 (32.1)	83 (47.7)	111 (25.8)	< 0.001¹
Microcytic anemia	87 (14.4)	28 (16.1)	59 (13.7)	0.52¹
Macrocytic anemia	3 (0.5)	1 (0.6)	2 (0.5)	1.0³
Leukocytosis	134 (22.1)	52 (29.9)	82 (19)	0.005¹
Leukopenia	8 (1.3)	2 (1.1)	6 (1.4)	1.0³
Thrombocytosis	18 (3.0)	7 (4.0)	11 (2.6)	0.427¹
Thrombocytopenia	14 (2.3)	6 (3.4)	8 (1.9)	0.24³
CRP
CRP normal, < 5	289 (47.9)	83 (47.7)	206 (48.0)	1.00¹
CRP abnormal	314 (52.1)	91 (52.3)	223 (52.0)
Albumin
Hypoalbuminemia	102 (17.2)	47 (28.0)	55(12.9)	< 0.001²
Normal albumin	489 (82.3)	118 (70.2)	371 (87.1)
Hyperalbuminemia	3 (0.5)	3 (1.8)	0 (0)
Liver function test
Normal	554 (91.7)	157 (90.2)	397 (92.3)	0.416¹
Hepatocellular enzymes elevated	39 (6.5)	13 (7.5)	26 (6.0)	0.58¹
Cholestatic enzymes elevated	22 (3.6)	9 (5.2)	13 (3.0)	0.231¹

¹Pearson χ² test.

²Mann-Whitney test.

³Fisher exact test.

CBC: Complete blood count; CRP: C reactive protein; SEFs: Significant endoscopic findings.

Table 4 Correlation between regular medication use during dyspeptic symptom period, n (%)

Drug	Total (%), n = 605	SEFs, n = 174	No SEFs, n = 431	P value
PPI	173 (29)	48 (28.2)	125 (29.6)	0.77¹
NSAIDs	23 (3.9)	9 (5.3)	14 (3.3)	0.35¹
Aspirin	111 (18.8)	27 (15.9)	84 (19.9)	0.29¹
Statin	191 (32.3)	54 (31.8)	137 (32.4)	0.92¹
Anticoagulant	39 (6.6)	10 (5.9)	29(6.9)	0.72¹
Anti-aggregate	30 (5.1)	13 (7.6)	17 (4)	0.05¹

¹Pearson χ² test.

NSAIDs: Non-steroidal anti-inflammatory drugs; PPI: Proton pump inhibitors; SEFs: Significant endoscopic findings.

Table 5 Association of alarm features with significant endoscopic findings, n (%)

Alarm features	Total (%), n = 605	SEFs, n = 174	No SEFs, n = 431	P value
Unexplained weight loss	137 (22.6)	35 (20.1)	102 (23.7)	0.391¹
Dysphagia	37 (6.1)	13 (7.5)	24 (5.6)	0.453¹
Persistent vomiting	124 (20.5)	40 (23.0)	84 (19.5)	0.373¹
Odynophagia	5 (0.8)	2 (1.1)	3 (0.7)	0.629³
Upper GI bleeding	145 (24)	67 (38.5)	78 (18.1)	< 0.001¹
IDA	50 (8.3)	12 (6.9)	38 (8.8)	0.516¹
Epigastric mass or lymphadenopathy	1 (0.2)	0	1 (0.2)	1.000³

¹Pearson χ² test.

³Fisher’s exact test.

GI: Gastrointestinal; IDA: Iron deficiency anemia.

Table 6 Correlation between radiologic findings during hospitalization and endoscopic findings, n (%)

Imaging modality	Total (%), n = 605	SEFs, n = 174	No SEFs, n = 431	OR	95%CI	P value
Imaging modality not performed	188 (31.2)	64 (37)	124 (28.8)	1.45	0.99-2.1	0.051
Imaging modality performed	415 (68.8)	109 (63)	306 (71.2)	1.45	0.99-2.1	0.051
CT	345 (57)	n = 100	n = 245
Normal abdominal CT	214(62)	31 (31)	183 (74.7)	6.57	3.94-11	< 0.001
CT shows suspected PUD	5 (0.8)	2 (2.0)	3 (1.2)	1.65	0.27-100	0.59
CT shows suspected SOL	35 (10.1)	26 (26.0)	9 (3.7)	9.21	4.13-20.54	< 0.001
CT shows bowel wall thickening	60 (17.4)	25 (25.0)	35 (14.3)	2	1.12-3.56	0.02
CT shows stricture	5 (0.8)	2 (2.0)	3 (1.2)	1.65	0.27-10	0.59
CT shows metastatic disease	12 (2.0)	9 (9.0)	3 (1.2)	8	2.11-30.13	0.002
CT shows distended stomach	9 (1.5)	5 (5.6)	4 (1.6)	3.17	0.83-12.1	0.09
CT shows lymphadenopathy	8 (1.3)	3(3.0)	5 (2.0)	1.48	0.35-6.33	0.59
US	113 (18.7)	n = 19	n = 94
Normal abdominal US	110 (97.3)	19 (100)	91 (96.8)	0		1
US shows cholecystitis	3 (2.7)	0 (0.0)	3 (3.2)	0		1

CI: Confidence interval (calculated on the basis of univariate logistic regression); CT: Computerized tomography; OR: Odds ratio; SEFs: Significant endoscopic findings; SOL: Space-occupying lesion; US: Ultrasound.

Table 7 Five models presenting the correlation between alarm features and other variables found significant in our univariate analysis and significant endoscopic findings

Model	Variables	P value	OR	95%CI for OR
1	Dependent variable: Significant endoscopic finding
	Persistent vomiting	0.09	1.59	0.93	2.73
	Odynophagia	0.08	12.65	0.72	222.1¹
	UGIB	< 0.001	3.48	2.07	5.86
	Normocytic anemia	0.003	2.06	1.28	3.29
	Leukocytosis	0.02	1.83	1.11	3.04
	Low albumin	0.05	1.78	1.01	3.15
	Duration of symptoms	0.04	0.99	0.99	1.00
	Abnormal CT²	< 0.001	7.83	4.21	14.54
2	Dependent variable: Significant endoscopic finding (duration of symptoms not included)
	Persistent vomiting	0.03	1.75	1.05	2.91
	Odynophagia	0.07	7.81	0.85	72.07
	UGIB	< 0.001	3.22	1.97	5.27
	Normocytic anemia	< 0.001	2.36	1.51	3.69
	Leukocytosis	0.01	1.83	1.13	2.98
	Hypoalbuminemia	0.04	1.77	1.04	3.01
	Abnormal CT²	< 0.001	8.64	4.82	15.49
	Tachycardia	0.01	3.11	1.26	7.69
3	Dependent variable: Peptic ulcer disease
	Unexplained weight loss	0.009	0.31	0.13	0.75
	Persistent vomiting	0.04	1.92	1.05	3.75
	UGIB	< 0.001	3.81	2.22	6.52
	Normocytic anemia	< 0.001	3.12	1.77	5.48
	Leukocytosis	0.03	1.92	1.06	3.48
	Abnormal CT²	0.04	2.29	1.03	5.10
	tachycardia	0.03	2.85	1.14	7.17
4	Dependent variable: Erosive esophagitis class B or higher
	Odynophagia	0.004	21.03	2.69	164.3¹
	Anti-aggregate medications	0.01	3.94	1.37	11.33
	Leukocytosis	0.003	2.99	1.45	6.17
5	Dependent variable: Malignancy as an endoscopic finding
	Unexplained weight loss	0.07	2.05	0.95	4.41
	Abnormal CT²	< 0.001	39.68	11.81	133.33

¹We suggest that upper limit of 95% confidence interval for odds ratio of odynophagia is high unproportionate due to the small number of patients with odynophagia in comparison to the sample size. The rest of the models’ main dependent factor is each significant endoscopic finding with the above-mentioned variables.

²Abnormal contrast tomography is a variable we created which consists of contrast tomography showing suspected space-occupying lesion, lymphadenopathy or a metastatic disease.

The first model solely includes duration of symptoms as one of the variables. CI: Confidence interval; CT: Computed tomography; OR: Odds ratio; UGIB: Upper gastrointestinal bleeding.

Citation: Ibrahim L, Basheer M, Khoury T, Sbeit W. Yield of alarm features in predicting significant endoscopic findings among hospitalized patients with dyspepsia. World J Gastroenterol 2024; 30(26): 3210-3220
URL: https://www.wjgnet.com/1007-9327/full/v30/i26/3210.htm
DOI: https://dx.doi.org/10.3748/wjg.v30.i26.3210