美国胃肠内镜学会（American Society for Gastrointestinal Endoscopy, ASGE）颁布了内镜治疗消化不良的指南。消化不良是指上消化道不适，1/4的西方人罹患此病。该指南由ASGE实践标准委员会发表在十二月出版的《胃肠道内镜》杂志上（Gastrointestinal Endoscopy），后者为美国胃肠内镜学会的同行评议科学月刊。
消化不良涵盖了很多具体症状，包括上腹部不适、腹胀、厌食、胃灼热等。这些症状能够提示隐性诊断，如消化性溃疡病、胃食管返流性疾病（GERD）、功能性病变（非溃疡性消化不良）和恶性肿瘤等。在评价消化不良时内窥镜的作用既是胃肠病专家所关注的对象，也是医疗成本的决定因素。
ASGE实践标准委员会主席Todd Baron博士说：“消化不良通过多种不同的症状影响着大量的人群，因此，想要对所有消化不良患者都实施内镜检查是行不通的。在回顾了现有的医疗数据之后，我们在本指南中得出结论，年龄和预警症状为医生怎样管理患者以及是否该为患者进行内窥镜检查提供了最好的征兆。”
有预警特征（症状）的患者
消化不良所描述的不仅仅是上消化道不适等症状，同时也标志着出现器质性疾病的风险。恶性肿瘤见于1-3％的消化不良患者，而消化性溃疡则见于另外的5-15%消化不良患者。此时，内镜检查便提供了早期诊断器质性疾病的可能。
年龄和预警症状被用来确定有器质性疾病风险的消化不良患者。预警症状包括50岁以上患者出现新症状、上消化道恶性肿瘤家族史、体重减轻、消化道出血或缺铁性贫血、进行性吞咽困难、吞咽疼痛、持续性呕吐、可触及的肿块或淋巴结病、黄疸等。
本指南推荐最近出现消化不良的50岁以上的患者，或出现任何预警症状的任何年龄段的患者，都应该进行内窥镜检查。针对没有预警症状但怀疑有临床肿瘤风险的患者，也应该考虑进行内窥镜检查。
无预警症状的患者
对于年龄不超过50岁且没有出现预警症状的消化不良患者，通常需要通过以下三种方法中的一种来进行评估：幽门螺旋杆菌(H. pylori)的无创性检查；如为阳性则给予后续治疗（检测--治疗方法，"test-and-treat" approach）；抑酸试验或早期内窥镜检查。
许多有消化性溃疡疾病的消化不良患者会存在H. pylori感染。该感染的无创性检查包括验血、尿素呼吸试验（UBT）和粪便抗原检测。越来越多的证据表明，使用检测--方法的患者与接受早期内窥镜检查的患者疗效相似。而且，检测--治疗方法性价比更高。研究人员对检测--治疗方法vs.内窥镜检查进行的五项随机试验进行Meta分析，结果显示，内窥镜组仅有轻微的症状改善，但是检测--治疗组的每位患者比内窥镜组节省了$389。
许多学者和科学家提倡将抑酸治疗作为消化不良患者的初始治疗策略。在该方法中，质子泵抑制剂（PPI）比H2阻滞剂更有效。凭经验进行抑酸治疗并不能说明与H. pylori有关的消化性溃疡疾病患者体内潜伏着H. pylori，当撤消抑酸治疗后有症状复发的风险。如果没有进行进一步的调查就可以长期使用抑酸疗法。
早期内窥镜检查的优点是有可能建立一个特异性诊断，例如消化性溃疡疾病或腐蚀性食管炎。没有预警症状的年轻患者发生恶性肿瘤的风险是很低的。但是，很多早期恶性肿瘤患者并没有出现预警症状。在对消化不良患者进行评估时，内窥镜检查结果阴性的另一个优点就是能够减少焦虑，同时增加患者的满意度。到目前为止，还缺乏能够证明早期内窥镜检查可以明显改善疗效的证据。大部分研究证明的都是早期内窥镜检查比检测--治疗方法的费用更高。
ASGE推荐
--50岁以上和/或出现预警症状的消化不良患者，应该进行内窥镜评估。
--50岁以下且没有预警症状的消化不良患者，应该进行针对幽门螺旋杆菌（H. pylori）的早期检测--治疗。
--50岁以下且H. pylori阴性的消化不良患者，可以给与早期内窥镜检查或短期PPI抑酸疗法。
--对经验性PPI疗法无效，或经过有效治疗后症状再次复发的消化不良患者，应该进行内窥镜检查。
ASGE Offers Guidelines on Endoscopic Treatment of Dyspepsia
The American Society for Gastrointestinal Endoscopy (ASGE) has issued guidelines for the role of endoscopy in treating dyspepsia, discomfort thought to arise from the upper-gastrointestinal tract, which affects a fourth of the population in Western countries.
The guidelines, prepared by ASGE's Standards of Practice Committee, appear in the December issue of Gastrointestinal Endoscopy, the monthly peer-reviewed scientific journal of the American Society for Gastrointestinal Endoscopy.
Dyspepsia may encompass a variety of more specific symptoms, including epigastric discomfort, bloating, anorexia, and heartburn. These nonspecific symptoms can be indicative of an underlying diagnosis such as peptic ulcer disease, GERD, functional disorders (nonulcer dyspepsia), and malignancy. The appropriate role of endoscopy in the evaluation of dyspepsia is both a pragmatic concern for the gastroenterologist and an important determinant in healthcare costs.
"Since dyspepsia affects large numbers of people across a broad spectrum of symptoms, it is not practical to perform endoscopy in all patients with dyspepsia," said Todd Baron, MD, chair of the ASGE Standards of Practice Committee. "In review of the medical data available, we concluded in these guidelines that age and alarm features offer the best guidance for the physician in managing patients and in determining if an endoscopy is appropriate treatment."
Patients With Alarm Features (Symptoms)
Dyspepsia is not only a convenient descriptor for upper-gastrointestinal (GI) symptoms, but also a marker for the risk of structural disease: malignancy is present in 1 to 3% of patients with dyspepsia, and peptic ulcer disease in another 5 to 15%. Endoscopy offers the potential for early diagnosis of structural disease.
Age and alarm features have been used in an attempt to identify those patients with dyspepsia who harbor structural disease. Alarm features include new onset of symptoms in someone over 50, family history of upper-GI malignancy, unintended weight loss, GI bleeding or iron deficiency anemia, progressive trouble swallowing, pain with swallowing, persistent vomiting, palpable mass or lymphadenopathy, and jaundice.
The guidelines recommend that patients older than 50 years of age with recent onset of dyspepsia or patients of any age with alarm features should undergo an endoscopy. An endoscopy should also be considered for patients in whom there is a clinical suspicion of malignancy even in the absence of alarm features.
Patients Without Alarm Features
Patients with dyspepsia who are younger than age 50 and without alarm features are commonly evaluated by one of three methods: noninvasive testing for Helicobacter pylori (H. pylori), with subsequent treatment if positive (the "test-and-treat" approach), a trial of acid suppression or an initial endoscopy.
In many patients with dyspepsia who have peptic ulcer disease, H. pylori infection will be present. Noninvasive testing options for this infection include a blood test, urea breath testing (UBT), and stool antigen. There is growing evidence that patients who are managed with the test-and-treat approach have similar outcomes when compared with those undergoing initial endoscopy. In addition, the test-and-treat approach is more cost effective. Results from a meta-analysis of five 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.
Many investigators and societies advocate acid-suppressive therapy as the initial strategy for patients with dyspepsia. Proton pump inhibitors (PPI) are more effective than H2 blockers in this approach. Initiation of empiric acid suppression will not address underlying H. pylori in those patients with H. pylori -- associated peptic ulcer disease, risking recurrent symptoms when acid suppression is withdrawn. This may prompt long-term acid suppression if no further investigation is performed.
One advantage of early endoscopy is the possibility of establishing a specific diagnosis, such as peptic ulcer disease or erosive esophagitis. The risk of malignancy is quite low in young patients without alarm features. Many patients, however, with early stage malignancy do not have alarm symptoms. Another advantage of a negative endoscopy in the evaluation of patients with dyspepsia is a reduction in anxiety and an increase in patient satisfaction. Yet, there is little evidence to suggest significant improvement in outcomes by the initial endoscopy approach. Most studies demonstrate an increased cost with the initial endoscopic approach compared with the test-and-treat method.
Recommendations
--Patients with dyspepsia who are older than 50 years of age and/or those with alarm features should undergo endoscopic evaluation
--Patients with dyspepsia who are younger than 50 years of age and without alarm features may undergo an initial test-and-treat approach for H. pylori
--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 PPI acid suppression
--Patients with dyspepsia who do not respond to empiric PPI therapy or have recurrent symptoms after an adequate trial should undergo endoscopy.
[责任编辑:刘聪]
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