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The Rational Clinical Examination | Clinician's Corner

Can the Clinical History Distinguish Between Organic and Functional Dyspepsia?

Paul Moayyedi, MD; Nicholas J. Talley, MD, PhD; M. Brian Fennerty, MD; Nimish Vakil, MD
JAMA. 2006;295(13):1566-1576. doi:10.1001/jama.295.13.1566.
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Published online

Context Upper gastrointestinal symptoms occur in 40% of the population. An accurate diagnosis would help rationalize investigation and treatment.

Objective To systematically review the literature of the accuracy of primary care physicians, gastroenterologists, or computer models in diagnosing organic dyspepsia.

Data Sources A search of Cochrane Controlled Trials Register (December 2003), MEDLINE (1966-December 2003), EMBASE (1988-December 2003), and CINAHL (1982-December 2003) for studies that reported on cohorts of patients attending for endoscopy that had symptoms, clinical opinion, or both recorded before investigation.

Study Selection Studies that prospectively compared the diagnosis reached by a clinician, computer model, or both with results of upper gastrointestinal endoscopy in adult patients with upper gastrointestinal symptoms.

Data Extraction Two authors independently assessed studies (n = 79) for eligibility and abstracted data for estimating likelihood ratios (LRs) of clinical opinion, computer models, or both in diagnosing an organic cause for dyspepsia.

Data Synthesis Fifteen studies were identified that evaluated 11 366 patients, with 4817 patients (42%) classified as having organic dyspepsia. The computer models performed similarly to the clinician; therefore, the 2 approaches were combined. The diagnosis reached by the clinician or computer model suggesting organic dyspepsia had an LR of 1.6 (95% confidence interval [CI], 1.4-1.8), and a negative result decreased the likelihood of organic dyspepsia (LR, 0.46; 95% CI, 0.38-0.55). A diagnosis of peptic ulcer disease performed similarly with an LR of 2.2 (95% CI, 1.9-2.6), but an evaluation that suggested the absence of peptic ulcer disease had an LR of 0.45 (95% CI, 0.38-0.53). A clinical history suggesting esophagitis had an LR of 2.4 (95% CI, 1.9-3.0) vs a negative history that had an LR of 0.50 (95% CI, 0.42-0.60).

Conclusion Neither clinical impression nor computer models that incorporated patient demographics, risk factors, history items, and symptoms adequately distinguished between organic and functional disease in patients referred for endoscopic evaluation of dyspepsia.

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Figure 1. Flow Diagram of the Studies Identified in the Systematic Review
Graphic Jump Location
Figure 2. Positive and Negative Likelihood Ratios of Different Approaches to Diagnosing an Organic Cause of Dyspepsia
Graphic Jump Location

CI indicates confidence interval; DDSG, Danish Dyspepsia Study Group. Each square represents an individual study. The size of the square is a measure of the size of the study and the horizontal line through the square indicates a graphical representation of the 95% CI of that study. For the combined analysis, the diamond and vertical dashed line indicate the pooled positive or negative likelihood ratio, with the left and right ends of the diamond indicating the pooled 95% CI.

Figure 3. Positive and Negative Likelihood Ratios of Different Approaches to Diagnosing Peptic Ulcer Disease
Graphic Jump Location

CI indicates confidence interval; DDSG, Danish Dyspepsia Study Group. Each square represents an individual study. The size of the square is a measure of the size of the study and the horizontal line through the square indicates a graphical representation of the 95% CI of that study. For the combined analysis, the diamond and vertical dashed line indicate the pooled positive or negative likelihood ratio, with the left and right ends of the diamond indicating the pooled 95% CI.

Figure 4. Positive and Negative Likelihood Ratios of Different Approaches to Diagnosing Esophagitis
Graphic Jump Location

CI indicates confidence interval; DDSG, Danish Dyspepsia Study Group. Each square represents an individual study. The size of the square is a measure of the size of the study and the horizontal line through the square indicates a graphical representation of the 95% CI of that study. For the combined analysis, the diamond and vertical dashed line indicate the pooled positive or negative likelihood ratio, with the left and right ends of the diamond indicating the pooled 95% CI.

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