Diagnosis and Treatment of Dyspepsia
Diagnosis and Treatment of Dyspepsia
复制标题
消化不良的诊断和治疗
作者：
L. Read;T. Pass;A. Komaroff
消化不良是门诊护理中的常见问题。虽然许多权威人士建议在治疗前进行上胃肠道x线检查（UGI），但有证据表明临床医生经常在没有诊断程序的情况下治疗消化不良。根据已发表文献的概率和结果值进行决策分析以选择最佳管理。评估的选择是对症治疗（低剂量抗酸药或抗胆碱能药），溃疡治疗（高剂量抗酸药或西咪替丁），或UGI之后的进一步测试或治疗。我们的模型表明，如果在选择治疗方法之前进行UGI，并且在x线显示胃溃疡时进行内窥镜检查，则死亡率最低。如果立即开始溃疡治疗，可以减少数周的疼痛，但开始对症治疗可以减少直接的卫生保健费用。根据胃溃疡发现后是否进行内窥镜检查，进行UGI而不是开始进行溃疡治疗所节省的每条额外生命的边际成本为+ 160万至+ 230万。从UGI开始的策略的死亡率优势对有关胃癌发病率的假设和早期诊断的益处敏感。随着这些基本病例值的轻微减少，溃疡治疗策略似乎使除美元成本外的所有结果最小化。
Dyspepsia is a common problem in ambulatory care. While many authorities recommend ordering upper gastrointestinal x-ray series (UGI) before therapy, there is evidence that clinicians frequently treat dyspepsia without diagnostic procedures. Decision analysis was performed to select optimal management based on probabilities and outcome values from the published literature. The choices evaluated were Symptomatic Therapy (low dose antacids or anticholinergics), Ulcer Therapy (high dose antacids or cimetidine), or UGI followed by further tests or therapy. Our model indicates that mortality is minimized if UGI is performed prior to selection of therapy, and if endoscopy is performed when the x ray shows gastric ulcer. Weeks of pain are minimized if Ulcer Therapy is begun immediately, but direct health care costs are minimized by beginning with Symptomatic Therapy. The marginal cost per additional life saved by performing a UGI rather than beginning with Ulcer Therapy was +1.6 million to +2.3 million, depending on whether endoscopy followed the finding of gastric ulcer. Mortality advantages of the strategies beginning with UGI were sensitive to assumptions regarding the incidence of gastric cancer and the benefits of early diagnosis. With slight reductions in these base case values, the Ulcer Therapy strategy appeared to minimize all outcomes except dollar cost.