The role of fibreoptic upper gastrointestinal endoscopy as the primary investigation in Malaysians presenting with dyspepsia was studied in 1119 patients. Five hundred and sixty-two of the examinations (50 percent) were normal. Females below 40 years of age were very likely to have normal endoscopies. Peptic ulcer was seen in 21 percent of patients while visual evidence of gastric or duodenal mucosal disease (gastritis or non-erosive duodenitis) was reported in 20 percent. With increasing age, the prevalence of (1) peptic ulcer steadily increased and (2) nonulcer dyspepsia decreased. Key words: Non-ulcer dyspepsia, peptic ulcer, endoscopy, gastric carcinoma

M. V. Kudva

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Med. J. Malaysia Vol. 43 No. 4 December 1988
Upper gastrointestinal endoscopy as
an initial investigation in dyspepsia
- A Malaysian experience
M.V. Kudva, MBBS(Malaya), MRCP(UK), MRCP(lre)
Thein-Htut, MBBS(Rangoon), FRCP(Edin)
DepartmentofMedicine, Faculty ofMedicine
Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
Summary
The role of fibreoptic upper gastrointestinal endoscopy as the primary investigation in Malay-
sians presenting with dyspepsia was studied in 1119 patients. Five hundred and sixty-two of the
examinations (50 percent) were normal. Females below 40 years of age were very likely to
have normal endoscopies. Peptic ulcer was seen in 21 percent of patients while visual evidence
of gastric or duodenal mucosal disease (gastritis or non-erosive duodenitis) was reported in 20
percent. With increasing age, the prevalence of (1) peptic ulcer steadily increased and (2) non-
ulcer dyspepsia decreased.
Key words: Non-ulcer dyspepsia, peptic ulcer, endoscopy, gastric carcinoma.
Introduction
Dyspepsia is a very common complaint in hospital and in general practice. It may be defined
as upper abdominal or retrosternal pain or discomfort, heartburn, nausea, vomiting or other
symptoms considered to be referable to the proximal alimentary tract.'
Management involves identifying those with an organic illness and treating them appropriately.
Endoscopically diagnosed 'organic' dyspepsia includes the presence of specific lesions - such as
peptic ulcer, erosive duodenitis, esophagitis, esophageal ulcers, and gastric and esophageal carci-
noma. Non-ulcer dyspepsia indicates the absence of these specific lesions. It is difficult to diffe-
rentiate between these two groups by symptoms alone? Hence, patients are investigated, either
by upper gastrointestinal endoscopy or barium meal X-ray. It has been established that endo-
scopy is more sensitive than radiology in picking up lesions."
This study was done to evaluate the role of upper gastrointestinal endoscopy in Malaysian
patients presenting with dyspepsia.
Materials and methods
Data from all upper gastrointestinal endoscopies performed at the Endoscopy Unit, Department
of Medicine, National University of Malaysia (NUM), Kuala Lumpur, over a 33-month period
(April 1985 to December 1987), was fed into a mainframe computer at the Computer Centre,
Medical Faculty, NUM and analysed using an SAS software package." The majority of endo-.
scopies were performed by the two authors, the remainder were done by trainees supervised
by the authors.
311On 1697 patients, 2158 endoscopies were performed. To rule out any bias, all endoscopies that
were repeated were excluded. Of these, 1119 (66%) presented with dyspepsia as the main symp-
tom and formed the population studied. This population of 1119 patients was called the 'All
Endoscopies' group. This was subdivided into two main groups:-
1) Endoscopically diagnosed 'organic' dyspepsia (EOD) - with definite evidence of specific
lesions - peptic ulcer, erosive duodenitis, esophagitis, esophageal ulcers and malignancies
in the esophagus and stomach. Peptic ulcer consisted of gastric ulcer (GU), duodenal ulcer
(DU) or both. Erosive duodenitis was diagnosed on the finding of visible erosions, and was
included in 'organic' dyspepsia as some evidence indicates that erosive duodenitis is a variant
ofpeptic ulcer disease.
2) Non-ulcer dyspepsia (NUD) _. where the endoscopy was normal or there was only visual
evidence of gastric or duodenal mucosal lesions (gastritis or non-erosive duodenitis) and
others (e.g. polyps). Gastritis was defined as visual evidence of erythema, petechiae or
erosions. Non-erosive duodenitis was visual evidence oferythema in the absence oferosions.
The groups were then compared according to sex, age and race. The main Malaysian ethnic
groups of Malays, Chinese and Indians were studied. Other ethnic groups comprised only 22
patients and were excluded from the racial comparison. Chisquare, with Yates correction when
necessary, was used to compare the racial composition of the peptic ulcer and non-ulcer
dyspepsia groups, as well as the frequency of normal endoscopies between males and females.
Results
Endoscopic findings are summarised in Table I and Fig. I
Of the 1119 endoscopies, the findings were normal in 562 (50%). Of the remainder, peptic ulcer
(21 %) was the commonest finding followed by gastritis or non-erosive duodenitis (20%).
FINDINGS IN 1119 ENDOSCOPIES FOR DYSPEPSIA
,- t.fJCOSAL DISEASE 19.9%
223
ESOPHAGfllS 3.8"
~
EROSIVE DUODENrns t9%
21
CARCNOMA STOMAOit."
16
ESOPHAGUS: 01HERS0••"
5
NORMAL ENDOSCOPY 50.2"
552
Fig. 1
ESOPHIoGUS 01HER= CARCNQIM ESOPIW;USIESOPHAGEAL UlCER
312The EOD group numbered 318 (28%) whilst the NUD group totalled 801 (72%). Normal endo-
scopies were commoner in female patients than in males (62% versus 40%) (p <0.001). Males
had an almost twice higher prevalence of EOD than females (37% versus 19%). The gastric ulcer
(GU) to duodenal ulcer (DU) ratio was 0.9. The male to female ratio of GU and DU was 1.5 and
2.9 respectively.
Gastric carcinoma was found in 16 patients (1.4%). Their mean age was 60.3 years (range:
38 to 81 years). All but two, of the patients were males. The racial breakdown was 10 Chinese,
four Malays and two Indians.
Table I
in 1119 for
Males Females
= 588)
No. % No. %
Gastric ulcer (GU)
61 } 41 }
Duodenal ulcer (DU) 83 (27) 2: ( 140)
GU + OU 15
Erosive duodenitis 16 ( 3) 5 ( 1)
Carcinoma stomach 14 ( 2) 2 ( <1)
Carcinoma esophagus 0 ( 0) 1 ( <1)
Esophagitis 29 ( 5) 14 ( 3)
Esophageal ulcer 2 « 10) 2 ( <1)
TOTAL FOR ENDOSCOPICALLY
DIAGNOSED 'ORGANIC' DYSPEPSIA 220 (37) 98 (19)
Normal endoscopy 233 ( 40) 329 ( 62)
Visual evidence of gastric or duodenal 126 ( 21) 97 ( 18)
mucosal disease
Others 9 ( 2) 7 ( 1)
TOTAL FOR NON-ULCER DYSPEPSIA
TOTAL ENDOSCOPIES
368 (63)
588 (100)
433 (81)
531 (100)
Percentages have been rounded to the nearest 1%.
313Non ulcer dyspepsia and peptic ulcer diseaseby age and sex
In both sexes, with increasing age, there was a steady decrease in the frequency of NUD. Whereas
90 percent of males below the age of 19 had NUD, this decreased to 39 percent in those aged
70 and above. Similarly 96 percent of females below 29 years had NUD, and this decreased to
46 percent in those aged 70 and above. Females had a higher frequency of NUD in every age
group. (Figs. 2 and 3)
In contrast, the frequency of peptic ulcer in both sexes increased with age until a peak was
reached in the age group 60 - 69 (males) and 50 - 69 (females). For peptic ulcer, males had
a higher frequency at every age group, except for those aged 70 and above.
NON-ULCER DYSPEPSIA (NUD) AND PEPTIC ULCER (PU)
INMALES BY AGE
Nu:> PU
150,..NO.;...;.O;..F;..PA_J~IE_NJ;..S ....
100
50
/ .
: -'. . ~
if .
· ~ · ~ · ~ · '. · '.
--------------- "",---
,;,;
c<19 20-29 30-39 40-49 50-59 50-59 c>70
Fig. 2
AGE tiEARS)
All=All ENDOSCOPIES
NON-ULCER DYSPEPSIA (NUD) AND PEPTIC ULCER (PU)
INFEMALES BY AGE
NUD PU ALL
100
". .....
....'.".
".'.". '. ...................
'. '. '.-.
'" '.".
'"
-----~~~~-----~~~ --- =<19 20-29 30-39 40-49 50-59 50-59 c>70
Fig 3
AGE tiEARS)
All=ALL ENDOSCOPIES
314Table n
Racial composition of non-ulcer dyspepsia and peptic ulcer patients
Race
All
Endoscopies
No. %
NUD
No. %
GU
No. %
DU
No. %
Male
Chinese 187 ( 32) 103 ( 28) 32 ( 42) 38 ( 40)
Indians 156 ( 27) 102 ( 28) 17 ( 22) 27 ( 28)
Malays 234 ( 41) 161 ( 44) 27 ( 36) 31 ( 32)
---------------------------------------------------------
TOTAL 577 (100) 366 (lOO) 76 (lOO) 96 (100)
Female
Chinese 211 ( 41) 158 ( 37) 24 ( 57) 21 ( 66)
Indians 104 ( 20) 93 ( 22) 3 ( 7) 6 ( 19)
Malays 205 ( 39) 179 ( 41) 15 ( 36) 5 (15)
---------------------------------------------------------
TOTAL 520 (lOO) 430 (lOO) 42 (100) 32 (100)
Other ethnic groups comprising 22 patients are excluded. Nineteen patients had both GU and
DU.
NUD : Non-ulcer dyspepsia, GU : Gastric ulcer, DU : Duodenal ulcer
NUD vs GU : P<0.05 (males); P<0.01 (females)
NUD vsDU: P<0.05 (males); P< 0.003 (females)
Non ulcer dyspepsia and peptic ulcer disease by race
There was a significant difference in the racial composition of non-ulcer dyspepsia patients
compared to both gastric and duodenal ulcer patients. Of the three races, more Chinese males
and females had GU and DU as compared to NUD. Chinese males comprised 42, 40 and 28 per-
cent of GU, DU and NUD patients respectively. Similarly Chinese females comprised 57,66 and
37 percent of GU, DU and NUD patients respectively. (Table II)
Discussion
There is as yet no agreement on the definition or classification of dyspepsia.' We define
dyspepsia in the broadest way to encompass the whole range of symptomatic upper gastro-
intestinal disease. We proceeded then to divide dyspepsia into endoscopically diagnosed 'organic'
dyspepsia and non-ulcer dyspepsia. The former is due to lesions which have been well defmed
and for which definitive modalities of therapy are available. Hence these lesions should be
detected early and treated accordingly. Failure to treat patients with organic dyspepsia might
result in progression of the disease with complications. On the other hand, there is as yet no
agreement on the classification and management of non-ulcer dyspepsia. This entity is usually
taken to include gastritis and duodenitis. Prevalence rates of gastritis among dyspeptics has been
reported to be similar to that in the general population.f ." There is disagreement as to whether
duodenitis is a component of duodenal ulcer disease although there are some suggestions that
it might be, especially in the presence of erosions." Therefore we decided to include erosive
315duodenitis as a separate category within 'organic' dyspepsia, and not as part of peptic ulcer
disease.
It must be emphasised that there are many organic diseases which present with dyspepsia but
cannot be diagnosed by upper gastrointestinal endoscopy. These would be considered as non-
ulcer dyspepsia in our classification. These organic diseases include gallbladder, liver, pancreatic,
small intestinal or even colonic disease. Hence in any patient with depending on their
symptoms, appropriate investigations like ultrasonography, endoscopic retrograde cholangio-
pancreaticogram, colonoscopy and small bowel series, should be carried out to exclude these
organic lesions. Thus, it must be reiterated that endoscopy is only the first line ofinvestigation
in NUD. The causes of NUD in patients without organic disease remains poorly understood.
Several mechanisms have been postulated including antral hypomotility," Campylobacter pylori
Infection." duodeno-gastric reflux, food allergy10 and psychological factors.l !
In our study the percentage of patients having no abnormalities on endoscopy was 50 percent.
This is in agreement with other studies. The proportion of patients with no abnormalities has
remained between 30 percent and 55 percent, even with the advent of endoscopies which can
detect muccsal lesions."? One in five patients had peptic ulcer, the frequency ofwhich increased
with age. Males and Chinese in particular, seem to have a higher frequency ofpeptic ulcer. Visual
evidence of gastric or duodenal disease (excluding erosive duodenitis) was noted in a fifth ofour
patients (20 percent). It must be pointed out that the diagnosis of gastritis and non-erosive
duodenitis is dependent on the endoscopists perception of "redness" and is subject to inter as
well as intra-observer variations. To reduce this observer variations, almost all the endoscopies
were performed or supervised by the two authors. Similar rates of gastritis and duodenitis have
been reported by several others. Gear and Barnes reported mucosal lesions in 19.4%,
1
3 Saunders
et al in 18%14 and Holdstock in 20%/5 of dyspeptic patients. However it should be noted that
endoscopic gastritis does not correlate with histological gastritis, and our findings only refer
to the former.
Females had a higher frequency of normal endoscopies and non-ulcer dyspepsia. Gear et al
noted similar findings. 1 6 Less than 12 percent of females below the age of 40 had evidence of
organic dyspepsia. The younger the patient the lower the prevalence of organic dyspepsia.i"
The increase in the frequency of endoscopically diagnosed organic dyspepsia with age is
accounted for by both peptic ulcer and carcinoma.
Chinese have been reported to have a higher prevalence of peptic ulcer.1 8 This was also noted
in our study. Of the three races (Malays, Chinese and Indians), the Chinese (ofboth sexes) were
found to have a higher prevalence of peptic ulcer than non-ulcer dyspepsia. This was true for
both gastric as well as duodenal ulcers. There are no ethnic differences in gastric acid secretion
in both normals and ulcer patients.i" Mucosal resistance and"environmental factors may play
a role.
Our study shows that upper gastrointestinal endoscopy is useful as an initial diagnostic tool in
dyspepsia. Based on our findings, the chances of detecting organic lesions on endoscopy in
younger patients, particularly females below 40 years of age, is low. Further studies need to be
done to better delineate the different diagnostic categories ofnon-ulcer dyspepsia.
The authors wish to thank Ms Poh Siew Kuan for secretarial assistance and Dr. SyarifLubis,
Department ofCommunity Medicine for statistical analysis.
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