[Analysis of the clinical benefits and cost-effectiveness of performing a systematic second-look gastroscopy in benign gastric ulcer]. / Estudio del beneficio clínico y de coste-efectividad tras efectuar sistemáticamente una segunda gastroscopia en la úlcera gástrica benigna.

INTRODUCTION: We analyzed the need to routinely perform a second gastroscopy after an initial diagnosis of benign gastric ulcer. METHOD: A total of 226 consecutive cases of gastric ulcer were reviewed. Sensitivity (S), specificity (Sp), positive and negative predictive value (PPV and NPV) and the accuracy of the initial gastroscopy plus biopsy were analyzed, both overall and according to the initial endoscopist's experience (attending or resident physician). The diagnostic accuracy of the initial and second-look gastroscopies was compared. The number of second endoscopies required to diagnose a new case of malignant gastric ulcer and their cost was calculated, both overall and according to the endoscopist's experience. RESULTS: There were 178 benign ulcers (79%) and 48 malignant ulcers (21%). The initial gastroscopy (S: 87.2%; Sp: 100%; PPV: 100%; PNV: 96.7%; accuracy: 96.7%) was performed by an attending physician in 74% of the patients and by a resident physician in the remaining 26%. Diagnostic accuracy was higher for attending physicians than for residents (98.2% vs. 94.8%; p=0.18). The accuracy of second-look endoscopy was 100%, with a significant improvement when compared with the initial procedure (p=0.035). Three new cases of MALT lymphoma and three new cases of gastric adenocarcinoma were diagnosed and could be treated with curative intent. The number of second gastroscopies required to diagnose a new case of malignant gastric ulcer and their economic cost was: 37.3 (4,675 Euros) for the whole group, 55.2 (6,845 Euros) for attending physicians and 19.3 (2,393 Euros) for residents. CONCLUSIONS: Initial gastroscopy showed high diagnostic accuracy, which was slightly lower when performed by resident physicians. Second-look gastroscopy significantly improved the results, confirming the clinical benefit of this procedure in diagnosing potentially curable malignant lesions. The mean cost of each new diagnosis of malignancy was 4,675 Euros, which was three times lower if the initial gastroscopy was performed by a less experienced endoscopist.

Estudio del beneficio clínico y de coste-efectividad tras efectuar sistemáticamente una segunda gastroscopia en la úlcera gástrica benigna / Analysis of the clinical benefits and cost-effectiveness of performing a systematic second-look gastroscopy in benign gastric ulcer

Introducción: se discute la necesidad de efectuar sistemáticamente una segunda gastroscopia de control tras el diagnóstico inicial de una úlcera gástrica benigna. Método: revisamos 226 casos consecutivos de úlcera gástrica. Analizamos la sensibilidad (S), la especificidad (E), el valor predictivo positivo y negativo (VPP, VPN) y la precisión de la primera exploración: gastroscopia con biopsias, de modo global y según la experiencia del primer explorador (médico de plantilla o MIR). Comparamos la precisión diagnóstica entre la primera y la segunda endoscopia. Calculamos el número necesario de segundas exploraciones (NNE) para diagnosticar un nuevo caso de úlcera maligna y su coste, tanto global como según la experiencia del explorador. Resultados: registramos 178 (79%) úlceras benignas y 48 (21%) malignas. La primera exploración fue efectuada por un médico de plantilla (74%) y MIR (26%): S 87,2%, E 100%, VPP 100%, VPN 96,7% y precisión 96,7%. La precisión del médico de plantilla fue superior (98,2%) a la del MIR (94,8%) (p=0,18). La segunda exploración de control tuvo una precisión del 100%, mejorando significativamente a la primera (p=0,035) y diagnosticando 3 nuevos linfomas MALT y 3 carcinomas tratados con intención curativa. El NNE y el coste de un nuevo diagnóstico de lesión maligna fueron los siguientes: global, 37,3 (4.675 euros); médico de plantilla, 55,2 (6.845 euros), y MIR, 19,3 (2.393 euros). Conclusiones: la primera exploración obtuvo una elevada precisión diagnóstica, ligeramente menor para los MIR. La segunda endoscopia de control mejora significativamente los resultados, confirmando su beneficio clínico al diagnosticar lesiones malignas potencialmente curables. El coste medio de cada nuevo diagnóstico de malignidad ascendió a 4.675 euros, siendo 3 veces inferior si la primera exploración la efectúa un médico con menos experiencia(AU)

Introduction: We analyzed the need to routinely perform a second gastroscopy after an initial diagnosis of benign gastric ulcer. Method: A total of 226 consecutive cases of gastric ulcer were reviewed. Sensitivity (S), specificity (Sp), positive and negative predictive value (PPV and NPV) and the accuracy of the initial gastroscopy plus biopsy were analyzed, both overall and according to the initial endoscopist's experience (attending or resident physician). The diagnostic accuracy of the initial and second-look gastroscopies was compared. The number of second endoscopies required to diagnose a new case of malignant gastric ulcer and their cost was calculated, both overall and according to the endoscopist's experience. Results: There were 178 benign ulcers (79%) and 48 malignant ulcers (21%). The initial gastroscopy (S: 87.2%; Sp: 100%; PPV: 100%; PNV: 96.7%; accuracy: 96.7%) was performed by an attending physician in 74% of the patients and by a resident physician in the remaining 26%. Diagnostic accuracy was higher for attending physicians than for residents (98.2% vs. 94.8%; p=0.18). The accuracy of second-look endoscopy was 100%, with a significant improvement when compared with the initial procedure (p=0.035). Three new cases of MALT lymphoma and three new cases of gastric adenocarcinoma were diagnosed and could be treated with curative intent. The number of second gastroscopies required to diagnose a new case of malignant gastric ulcer and their economic cost was: 37.3 (4,675 Euros) for the whole group, 55.2 (6,845 Euros) for attending physicians and 19.3 (2,393 Euros) for residents(AU)

Conclusions: Initial gastroscopy showed high diagnostic accuracy, which was slightly lower when performed by resident physicians. Second-look gastroscopy significantly improved the results, confirming the clinical benefit of this procedure in diagnosing potentially curable malignant lesions. The mean cost of each new diagnosis of malignancy was 4,675 Euros, which was three times lower if the initial gastroscopy was performed by a less experienced endoscopist(AU)

[Upper gastrointestinal bleeding secondary to Dieulafoy's lesion: differential features]. / Presenta características diferenciales la hemorragia digestiva alta por lesión de Dieulafoy?

OBJECTIVE: To analyze the possible differential features of upper gastrointestinal (GI) bleeding due to Dieulafoy's lesion (DL) compared with bleeding due to gastroduodenal ulcer. MATERIAL AND METHODS: We evaluated variables associated with patient characteristics, hemorrhagic characteristics and clinical severity in 31 cases of bleeding secondary to DL and 31 cases of gastroduodenal ulcer bleeding. Univariate and multivariate statistical analysis were performed. RESULTS: The comorbidity rate was 80% in the DL group and 42% in the ulcer group (OR = 5.54; 95%CI, 1.5-20.7; p < 0.0004). Lesion location was gastric in 87% of DL versus 39% of ulcers (OR = 10.7; 95%CI, 2.6-47.6; p < 0.0003). More than one gastroscopy was required for diagnosis in 30% of DL vs. 3.2% of ulcers (OR = 12.9; 95%CI, 1.4-291; p < 0.01). Endoscopic treatment was required in 97% of DL and 39% of ulcers (OR = 47.5; 95%CI, 5.5-106.1; p < 0.0001). Active bleeding during endoscopy was registered in 81% of DL and in 29% of ulcers (OR = 10.2; 95%CI, 2.7-40.3; p < 0.0005). The remaining variables analyzed showed no significant differences. The mortality rate was 9.7% in the DL group and 3.2% in the ulcer group (p = NS). Multivariate analysis showed that gastric location (p < 0.01), active bleeding (p < 0.01), and comorbidity (p < 0.02) were more frequent in DL. CONCLUSIONS: Active bleeding and gastric location of the lesion were more frequent in the DL group than in the ulcer group. Diagnosis of DL is difficult, requiring a greater number of gastroscopies. Initial hemorrhage severity and the success rate of endoscopic treatment were similar in the two groups. The higher mortality found in DL can be explained by the greater comorbidity in these patients, with a worse bleeding tolerance.

¿Presenta características diferenciales la hemorragia digestiva alta por lesión de Dieulafoy? / Upper gastrointestinal bleeding secondary to Dieulafoy’s lesion: differential features

Objetivo: Analizar la presencia de posibles rasgos diferenciales de la hemorragia digestiva alta (HDA) por lesión de Dieulafoy (LD), comparándola con el sangrado por úlcera gastroduodenal. Material y métodos: Evaluamos los parámetros referentes a las características de los pacientes, de la hemorragia y de la gravedad clínica en 31 casos de hemorragia por LD y 31 por úlcera gastroduodenal. Se efectuó un análisis comparativo univarinate y multivariante entre ambos grupos. Resultados: El índice de comorbilidad fue del 80% en LD y del 42% en la úlcera (odds ratio [OR] = 5,54; intervalo de confianza del 95%, 1,5-20,7; p < 0,0004). La localización de la lesión fue gástrica en el 87% de las LD y en el 39% de las úlceras (OR = 10,7; IC del 95%, 2,6-47,6; p < 0,0003). Se precisó más de una gastroscopia para llegar al diagnóstico en el 30% de LD frente al 3,2% de las úlceras (OR = 12,9; IC del 95%, 1,4-291; p < 0,01). Fue necesario aplicar tratamiento endoscópico en el 97% de las LD frente al 39% de las úlceras (OR = 47,5; IC del 95%, 5,5-106,1; p < 0,0001). Se registró un sangrado activo durante la endoscopia en el 81% de las LD frente al 29% de las úlceras (OR = 10,2; IC del 95%, 2,7-40,3; p < 0,0005). El resto de los parámetros analizados no mostró diferencias significativas. La tasa de mortalidad fue del 9,7% en las LD frente al 3,2% en las úlceras (p = no significativo). En el análisis multivariante, la localización gástrica de la lesión (p < 0,01), el sangrado activo (p < 0,01) y la comorbilidad (p < 0,02) fueron superiores en la LD. Conclusiones: En la LD, la localización gástrica y el sangrado activo son hallazgos más frecuentes que en el grupo ulceroso. El diagnóstico de LD es más difícil, ya que requiere un mayor número de gastroscopias. La gravedad inicial de la hemorragia y el éxito del tratamiento endoscópico son similares en ambos grupos. La mayor mortalidad encontrada en las LD podría explicarse por la mayor comorbilidad de estos pacientes, con una peor tolerancia al sangrado

Objective: To analyze the possible differential features of upper gastrointestinal (GI) bleeding due to Dieulafoy’s lesion (DL) compared with bleeding due to gastroduodenal ulcer. Material and methods: We evaluated variables associated with patient characteristics, hemorrhagic characteristics and clinical severity in 31 cases of bleeding secondary to DL and 31 cases of gastroduodenal ulcer bleeding. Univariate and multivariate statistical analysis were performed. Results: The comorbidity rate was 80% in the DL group and 42% in the ulcer group (OR = 5.54; 95%CI, 1.5-20.7; p < 0.0004). Lesion location was gastric in 87% of DL versus 39% of ulcers (OR = 10.7; 95%CI, 2.6-47.6; p < 0.0003). More than one gastroscopy was required for diagnosis in 30% of DL vs. 3.2% of ulcers (OR = 12.9; 95%CI, 1.4-291; p < 0.01). Endoscopic treatment was required in 97% of DL and 39% of ulcers (OR = 47.5; 95%CI, 5.5-106.1; p < 0.0001). Active bleeding during endoscopy was registered in 81% of DL and in 29% of ulcers (OR = 10.2; 95%CI, 2.7-40.3; p < 0.0005). The remaining variables analyzed showed no significant differences. The mortality rate was 9.7% in the DL group and 3.2% in the ulcer group (p = NS). Multivariate analysis showed that gastric location (p < 0.01), active bleeding (p < 0.01), and comorbidity (p < 0.02) were more frequent in DL. Conclusions: Active bleeding and gastric location of the lesion were more frequent in the DL group than in the ulcer group. Diagnosis of DL is difficult, requiring a greater number of gastroscopies. Initial hemorrhage severity and the success rate of endoscopic treatment were similar in the two groups. The higher mortality found in DL can be explained by the greater comorbidity in these patients, with a worse bleeding tolerance