Does concern about missing malignancy justify endoscopy in uncomplicated dyspepsia in patients aged less than 55?

There is increasing interest in using noninvasive H. pylori testing rather than endoscopy in determining the management of younger patients presenting with dyspepsia. However, there is concern that this approach may result in missing potentially curable malignancy. The aim of the study was therefore to assess whether concern over occult malignancy is valid in patients aged <55 yr presenting with uncomplicated dyspepsia.

A predetermined questionnaire was used to review the case notes of patients aged <55 yr who had presented with esophageal or gastric cancer between 1989 and 1993 within the Greater Glasgow Health Board population of 940,000.

A total of 169 patients aged <55 yr were diagnosed to have gastroesophageal malignancy over the 5-yr period, representing an incidence of about 1 per 28,000 total population/yr. There were only five patients who were found to have upper GI malignancy when undergoing upper GI investigation in the absence of sinister symptoms. This represents an incidence of underlying malignancy in patients of <55 yr with uncomplicated dyspepsia of 1.06 per million total population/yr. Of these five patients, all had lymph node metastases at diagnosis and four had died between 2 months and 3 yr of follow-up.

Upper GI malignancy is extremely rare in patients <55 yr presenting with uncomplicated dyspepsia and, when found, is usually incurable. Consequently, concern about missing underlying curable malignancy is not a valid indication for endoscoping patients <55 yr presenting with uncomplicated dyspepsia.