Abstract
Study objective: To compare two strategies for the evaluation and management of patients who have had acute dyspepsia for four days or more: empiric high-dose antacid therapy combined with patient reassurance (empiric care) versus therapy based on prompt upper gastrointestinal radiography (traditional care).
Design: Prospective, randomized trial. The patients in the empiric care group were reassured that upper gastrointestinal radiography was not necessary and were subsequently treated with high-dose empiric antacid therapy (15–30 ml of high-potency antacid one and three hours after meals and at bedtime). The traditional care group received upper gastrointestinal radiography as part of the initial evaluation. Subsequent treatment was determined by individual physicians based on test results.
Settings: Fee-for-service, hospital-based primary care practice and Veteran’s Administration medical center outpatient clinic.
Patients: All patients were less than 70 years of age and without gastrointestinal bleeding, anemia, significant weight loss, or other specified symptoms of severe acid peptic disease. Fifty patients were randomized to traditional care, and 51 to empiric care. Pre-randomization clinical features were identical with the exception of sex distribution and baseline disability.
Measurements and main results: After six months of follow-up, there were no significant differences in symptom scores, disability, satisfaction, and quality of life measures (as measured by the Sickness Impact Profile scores) between the two groups. Findings were unchanged when adjusted for sex, study site, alcohol consumption, and cigarette smoking. Of the radiographs obtained in the traditional care group, 13 (27%) showed duodenal ulcer disease, gastritis, or duodenitis. There were no serious complications of ulcer disease or therapy noted in either group. The average costs per patient associated with traditional care at one study site were greater, $286 versus $116 (p<0.0001).
Conclusions: Select patients with dyspepsia receiving a combination of reassurance and empiric antacid therapy do as well as patients whose initial management strategy includes upper gastrointestinal radiography, at a substantially lower cost.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
National Center for Health Statistics. The national ambulatory medical care survey, 1977. Hyattsville, MD: National Center for Health Statistics, 1980;28 (no. 69):DHHS no. 80-1975.
Zielske JV, Lohr KN, Goldberg GA, et al. Justification for screening peptic ulcer disease for health insurance study analysis. In: Conceptualization and measurement of physiologic health for adults. Santa Monica, CA: Rand Corporation, 1982.
Gray GM. Peptic ulcer disease. In Scientific American Medicine. Rubenstein E, Federmen DD, eds. New York: Scientific American, Inc., 1985.
Isselbacher KJ, May RJ. Disorders of the alimentary tract. In Principles of Internal Medicine. Brunwald E, Isselbacher KJ, Petersdorf RG, et al. eds. New York: McGraw-Hill, 1987.
Marton KL, Sox HC, Alexander J, Duisenberg CE. Attitudes of patients toward tests. Med Decis Making. 1982;2:439–48.
Goodson JD, Richter JM, Lane RS, et al. Empiric antacids and reassurance for acute dyspepsia. J Gen Intern Med. 1986;1:90–3.
Gudjonsson B, Spiro HM. Response to placebos in ulcer disease. Am J Med. 1978;65:399–402.
Hetzel DJ, Hansky J, Shearman DJC, et al. Cimetidine treatment of duodenal ulceration. Gastroenterology. 1978;74:389–92.
Spiro HM. Moynihan’s disease? The diagnosis of duodenal ulcer. N Engl J Med. 1974;291:567–9.
Read JL, Pass TM, Komoroff TA. Diagnosis and treatment of dyspepsia, a cost effectiveness analysis. Med Decis Making. 1982;2:415–38.
Kohn HI, Fry RJM. Radiation carcinogenesis. N Engl J Med. 1984;310:504–11.
Harrison RM, Clayton CB, Day MJ, et al. A survey of radiation doses to patients in five common diagnostic examinations. Br J Radiol. 1983;56:383–95.
Laws P, Rosenstein M. A somatic dose index for diagnostic radiology. Health Phys 1978;35:629–42.
Leibovic SJ, Caldicott WJH. Gastrointestinal fluoroscopy: patient dose and methods for its reduction. Br J Radiol. 1983;56:715–9.
Marton KL, Sox HC, Wasson J, Duisenberg CE. The clinical value of the upper gastrointestinal tract roentgenogram series. Arch Intern Med. 1980;140:191–5.
Fordtran JS, Collyns JAH. Antacid pharmacology in duodenal ulcer. N Engl J Med. 1966;274;921–7.
Peterson WL, Sturdevant RAL, Frank HD, et al. Healing of duodenal ulcer with an antacid regimen. N Engl J Med. 1977;297:341–5.
Ware JE Jr. Effects of acquiescent response set on patient satisfaction ratings. Med Care. 1978;16:327–36.
Carlsson AM. Assessment of chronic pain. I. Aspects of the reliability and validity of the visual analogue scale. Pain. 1983;16:87–101.
Jorgensen LS, Bonlokke L, Wamberg P. Non-ulcer upper dyspepsia. Scand J Gastroenterol. 1985;20:46–50.
Berger M, Bobbett RA, Pollard WE, et al. The sickness impact profile: validation of a health status measure. Med Care. 1976;14:57–67.
Berger M, Bobbitt RA, Carter WB, Gilson BS. The sickness impact profile: development and final revision of a health status measure. Med Care. 1981;19:787–805.
Deyo RA. Measuring functional outcomes in therapeutic trials for chronic disease. Controlled Clin Trials. 1984;5:223–40.
McCusker J, Stoddard AM. Use of a surrogate for the sickness impact profile. Med Care. 1984;22:789–95.
Ott CR, Sivarajan ES, Newton KM, et al. A controlled randomized study of early cardiac rehabilitation: the sickness impact profile as an assessment tool. Heart Lung. 1983;12:162–70.
Deyo RA, Inui TS, Leininger JD, Overman SS. Measuring functional outcomes in chronic disease: a comparison of traditional scales and a self-administered health status questionnaire in patients with rheumatoid arthritis. Med Care. 1983; 21: 180–92.
Rockey PH, Griep RJ: Behavioral dysfunction in hyperthyroidism. Arch Intern Med. 1980;140:1194–7.
Sullivan DF. Conceptual problems in developing an index of health. National Center for Health Statistics, Washington DC (Public Health Service Pub No 1000, Series 2, no 17), 1966.
Snedecor GW, Cochran WG. Statistical methods. Iowa City, IA: Iowa State University Press, 1980.
Ippoliti AF, Sturdevant RA, Isenberg JI, et al. Cimetidine versus inactive antacid therapy for duodenal ulcer. A multicenter trial. Gastroenterology. 1978;74:393–8.
Hollander D, Harlan J. Antacids versus placebos in peptic ulcer therapy. JAMA. 1973;226:1181–5.
Isenberg JI, Peterson WL, Elashoff JD. Healing of benign gastric ulcer with low dose antacid or cimetidine. N Engl J Med. 1983;322:1319–24.
Scheurer U, Witzel L, Halter F, et al. Gastric and duodenal ulcer healing under placebo treatment. Gastroenterology. 1977;72:838–41.
Fordtran JS. Placebos, antacids and cimetidine for duodenal ulcer. N Engl J Med. 1978;298:1081–3.
Goodson JD, Lehmann JW, Richter JM, et al. The clinical information value of UGI radiography. Clin Res 1986;819A.
Sox HC, Margulies I, Sox CM. Psychologically mediated effects of diagnostic tests. Ann Intern Med. 1981;95:680–5.
Author information
Authors and Affiliations
Additional information
Supported by grants from the Massachusetts Fund for Cooperative Innovation, Massachusetts Hospital Association, and Blue Cross of Massachusetts (60%); the Massachusetts General Hospital (30%); and William H. Rorer, Inc., Fort Washington, Pennsylvania (10%).
Rights and permissions
About this article
Cite this article
Goodson, J.D., Lehmann, J.W., Richter, J.M. et al. Is upper gastrointestinal radiography necessary in the initial management of uncomplicated dyspepsia?. J Gen Intern Med 4, 367–374 (1989). https://doi.org/10.1007/BF02599683
Issue Date:
DOI: https://doi.org/10.1007/BF02599683