Clinical Question: What is the best cutoff age for endoscopic evaluation in patients with uncomplicated dyspepsia?

Setting: Outpatient (specialty)

Study Design: Cohort (prospective)

Synopsis: Current guidelines recommend upper endoscopy for any patient with onset of symptoms after 45 years of age or with alarm symptoms such as unexplained weight loss, recurrent vomiting, dysphagia, hematemesis or melena, anemia, or palpable mass. The authors decided to look more carefully at patients with uncomplicated dyspepsia at any age, defined as an absence of alarm symptoms and no history of chronic nonsteroidal anti-inflammatory drug (NSAID) use. Patients referred by their primary care physicians with uncomplicated dyspepsia underwent a structured clinical evaluation and upper endoscopy.

The authors included 6,135 consecutive patients; the mean age was 49 years, 57 percent were men, and an upper gastrointestinal (GI) cancer was detected in 58 patients (0.9 percent). Of this group, 911 had an alarm symptom and/or were using NSAIDs chronically, leaving 5,224 patients with uncomplicated dyspepsia, of whom 22 (0.4 percent) had an upper GI cancer. Of these 22, only four were younger than 45 years, all of whom were men. The mean age of patients with uncomplicated dyspepsia and an upper GI cancer was much higher than those without malignancy (66 versus 47 years; P < .001). This was particularly true of women: those with upper GI cancer had a mean age of 73 years compared with a mean age of 64 years for men with upper GI cancer. Fifteen of 16 upper GI cancers occurred in men older than 35 years, whereas six of six occurred in women older than 56 years. A second similar group of 3,684 patients was used to evaluate these cutoff ages. Of 16 cancers, seven of eight were found in men older than 35 years, and six of eight were detected in women older than 56 years. In the training and testing groups, the majority of cancers were resectable.

Bottom Line: A cutoff age older than 35 years for men and 56 years for women would detect more upper GI cancers among patients with uncomplicated dyspepsia than a single cutoff age of 45 years for both sexes. Presumably the cost of more endoscopies in younger men would be balanced by the need to perform fewer in women 45 to 56 years of age. However, whether this sort of differential sex-based diagnostic strategy is politically possible is another matter. (Level of Evidence: 1b)