Letters

RAPID RESPONSES FROM BMJ.COM

As of April 13th, three e-letters had been posted on bmj.com in response to the paper by Delaney. They are reproduced below in abbreviated form.Editor

What about dysphagia as an "alarm symptom"?

Don't forget about lactose intolerance

Dyspepsia: a missed opportunity in detecting early-stage cancer

What about dysphagia as an "alarm symptom"?

This article originally appeared in BMJ USA

EDITORI think the "10-minute consultation" series is an excellent addition to the BMJ. Why was dysphagia not included in the list of "alarm symptoms"?

Ross Upshur, assistant professor. 
Sunnybrook and Women's College Health Sciences Centre,Toronto, Canada rupshur{at}idirect.com

Don't forget about lactose intolerance

EDITORLactose intolerance is one of the most common etiologies within all communities. In a selected population presenting with gastrointestinal problems or to gastroenterologists for endoscopy/consultation, about two in five patients will have coexistent lactose intolerance.

Biopsies taken for small bowel histology and enzymes/disacharridases in all patients with non-ulcer dyspepsia will identify concomitant lactose intolerance and, occasionally, gluten sensitivity. Lactase levels will identify mild, moderate, or severe degrees of lactose in- tolerance and will generally correlate with symptom severity.

Ric Reiner, gastroenterologist. 
Mackay Hospital, Queensland 4740, Australia rereiner{at}ozemail.com.au

Dyspepsia: a missed opportunity in detecting early-stage cancer

EDITORWhat a shame that Delaney missed an opportunity to educate primary health care physicians about common misconceptions concerning dyspepsia.

The greatest pitfall for any doctor seeing patients with this common symptom is to incorrectly diagnose a benign, if troublesome, condition when, in fact, the patient has esophagogastric cancer. Clearly, not all patients need further investigation. The great difficulty is deciding who should be referred for endoscopy, and it is on this point that Delaney's article lacks clarity.

Age has to be the most important factor. Gastric cancer in patients younger than 50 years of age is very uncommon in many countries, such as the United Kingdom. Delaney mentions age once in the third paragraph and does not refer to it again. In addition, he should have stressed that it is impossible to distinguish between the symptoms of a peptic ulcer and an early gastric cancer. Few doctors appreciate this. A course of acid-suppressing medication will reduce the symptoms from an ulcerating gastric tumor in the first few weeks of treatment just as it will for a peptic ulcer. By the time patients with gastric cancer develop so-called "alarm symptoms," such as weight loss or vomiting, the majority are incurable. Only by increasing the proportion of tumors that are diagnosed at an early stage will we improve the currently dismal survival rates for these cancers.

The statement "Endoscopy may reassure patients and their doctor that serious disease is not being missed, but it is expensive and may not help management" is too simplistic and sends the wrong message. Patients aged 50 and older with new-onset dyspeptic symptoms should all be referred for endoscopy. Younger patients should be referred if symptoms recur or persist despite appropriate treatment.

Of course, all patients with "alarm symptoms" should be referred for urgent investigation regardless of age. We must get this message across to primary care physicians if there is to be any chance of curing more patients with gastric cancer.

IN REPLYAs a follow-up to the note by Dr Hardwick, readers might be interested in knowing about the following study: Christie J, Shepherd NA, Codling BW, Valori RM. Gastric cancer below the age of 55: implications for screening patients with uncomplicated dyspepsia. Gut 1997;41:513-7. It showed that 24 (96%) of 25 cases of gastric cancer in patients under the age of 55 had at least one suspicious symptom or signmost commonly weight loss14, dysphagia8, or anemia7.

Dr Cheryl Flynn has prepared a "POEM" (patient-oriented evidence that matters) review of this study, which is available at www.infopoems.com/POEMS/JC029808.htm.

Richard H Hardwick, consultant surgeon. 
Cambridge Upper Gastro-Intestinal Unit, Addenbrookes NHS Trust, United Kingdom rhh{at}hardwick1.fsworld.co.uk

Ronald M Davis, editor. 
BMJ USA