'Alarm symptoms' in patients with dyspepsia: a three-year prospective study from general practice

Ten percent of patients consulting a general practitioner (GP) because of dyspepsia report one or more alarm symptom(s): anemia, black stools, blood in stools, dysphagia, jaundice, weight loss. We observed the consequence of such symptoms prospectively over 3 years.

Postal questionnaires were sent to GPs to obtain recorded information from patients who had consulted the GP because of dyspepsia. Mortality and gastrointestinal morbidity per 1000 person years were studied in two cohorts of patients, one presenting with, the other without, alarm symptoms and compared to expected rates from the general population. The incidence of ulcers was compared between the two cohorts. The predictive value of alarm symptoms for the development of cancer and ulcer was calculated.

Compared to the general population, dyspeptic patients without alarm symptoms had an insignificant increase in mortality (OR = 1.5 (0.9-2.4)) and a significant increase in gastrointestinal (GI) cancers (OR = 2.4 (1.1-7.1)), whereas in patients with alarm symptoms both mortality (OR = 2.3 (1.7-3.2)) and GI cancers (OR = 6.3 (3.6-11.0)) were significantly raised. In dyspeptic patients, the presence of alarm symptoms increased the risk of developing peptic ulcers significantly (OR = 5.3 (3.1-9.1)) and gastrointestinal cancer insignificantly (OR = 1.9 (0.9-4.1)). Positive predictive values for development of cancer and ulcer were 4% and 14%, respectively. During 3 years of observation, patients with alarm symptoms were diagnosed with a malignancy in 4%, ulcers in 11% and minor gastrointestinal diseases in 25% of cases.

Although the presence of alarm symptoms predicts a bad prognosis, the positive predictive values were low and negative predicted values high, reflecting low incidences of the diseases in the population at risk. The majority of patients who developed cancer or ulcer did not present with alarm symptom(s) at the initial consultation.