Benbassat Jochanan
Department of Medicine, Hebrew University - Hadassah Medical Center, Jerusalem, Israel.
Front Med (Lausanne). 2021 Sep 16;8:681587. doi: 10.3389/fmed.2021.681587. eCollection 2021.
The management of patients with dyspepsia is uncertain. Some authors advocate endoscopy for all; others restrict endoscopy only to patients at high risk of gastric cancer, namely to those above an age threshold, or with a family history, dysphagia, loss of weight, anemia, or a childhood in Asian countries. Still others recommend various combinations between test-and-treat for Helicobacter pylori, anti-secretory treatment, and/or endoscopy. To highlight the uncertainties in the choice between the various strategies and argue that these uncertainties should be shared with the patient. An overview of reported life expectancy, patient satisfaction, gastric cancer detection rates, symptom relief, and cost effectiveness of the management strategies for dyspepsia. There are no randomized controlled trials of the effect of screening by endoscopy on mortality of patients with gastric cancer. Lower grades of evidence suggest that early diagnosis reduces this mortality. Analyses, which assume a survival benefit of early diagnosis, indicate that mass screening in countries of high incidence gastric cancer (> 10 cases per 100,000) and targeted screening of high-risk persons in countries of low-intermediate incidence (<10 cases per 100,000) is cost-effective at a willingness to pay of $20,000-50,000 per QALY. Prompt endoscopy appears to be best for patient satisfaction and gastric cancer detection, and test-and-treat for H pylori-for symptom relief and avoiding endoscopies. The gain in is the main source of uncertainty in the choice between management strategies. This choice should be shared with the patients after explaining uncertainties and eliciting their preferences.
消化不良患者的管理尚无定论。一些作者主张对所有患者进行内镜检查；另一些人则将内镜检查仅限于胃癌高危患者，即年龄超过阈值、有家族史、吞咽困难、体重减轻、贫血或在亚洲国家度过童年的患者。还有一些人推荐了针对幽门螺杆菌的检测与治疗、抗分泌治疗和/或内镜检查的各种组合。强调各种策略选择中的不确定性，并认为应与患者分享这些不确定性。概述消化不良管理策略的报告预期寿命、患者满意度、胃癌检出率、症状缓解情况及成本效益。目前尚无关于内镜筛查对胃癌患者死亡率影响的随机对照试验。较低等级的证据表明早期诊断可降低这种死亡率。假设早期诊断有生存益处的分析表明，在胃癌高发国家（每10万人中>10例）进行大规模筛查，以及在中低发国家（每10万人中<10例）对高危人群进行针对性筛查，在每质量调整生命年愿意支付20,000 - 50,000美元的情况下具有成本效益。及时进行内镜检查似乎对患者满意度和胃癌检测最有利，而对幽门螺杆菌进行检测与治疗则有利于症状缓解并避免内镜检查。获益情况是管理策略选择中不确定性的主要来源。在向患者解释不确定性并了解他们的偏好后，应与患者共同做出这种选择。
