Digestive and Liver Disease 44 (2012) 218–223 Contents lists available at SciVerse ScienceDirect Digestive and Liver Disease jou rn al h om epage: www.elsevier.com/locate/dld Alimentary Tract Can clinical features stratify use of endoscopy for dyspeptic patients with high background prevalence of upper gastrointestinal cancer?  Yao-Chun Hsu a , Tzeng-Huey Yang b , Jyh-Ming Liou c , Wei-Lun Hsu b , Hwai-Jeng Lin d , Huei-Tang Wu b , Jaw-Town Lin a,c , Hsiu-Po Wang c , Ming-Shiang Wu c,∗ a Department of Internal Medicine, E-Da Hospital/I-Shou University, Kaohsiung, Taiwan b Department of Internal Medicine, Lotung Poh-Ai Hospital, Ilan, Taiwan c Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei City, Taiwan d Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan a r t i c l e i n f o Article history: Received 10 May 2011 Accepted 17 October 2011 Available online 23 November 2011 Keywords: Alarm symptoms Cost-effectiveness Dyspepsia Endoscopy Malignancy a b s t r a c t Background: Whether clinical features can stratify priority of endoscopy remains controversial for dys- peptic patients with high background prevalence of upper gastrointestinal cancer. Aim: To examine the predictive performance of clinical features for cancerous lesions in dyspeptic patients in Taiwan. Methods: Between April 2008 and July 2009, 2530 consecutive dyspeptic outpatients underwent prospec- tive evaluation with standardized questionnaire and then upper gastrointestinal endoscopy. Performance of using age thresholds and alarm symptoms to predict malignancy was determined. Independent risk factors associated with malignancy and those with negative endoscopic findings were identified. Results: Malignant lesions were found in 31 patients (1.2%) and were independently associated with age, male gender, gastrointestinal bleeding, weight loss, and alcohol consumption. Any symptom of weight loss, bleeding and dysphagia, or simply age >45 years predicted 97% of cancer cases, with the sensitivity, specificity, positive and negative predictive values being 96.8%, 29.3%, 1.7%, and 99.9%, respectively. This strategy achieved a low negative likelihood ratio (0.11) and a high diagnostic odds ratio (12.45). Negative endoscopic finding (n = 1377, 54.4%) was independently associated with younger age, female gender, no use of non-steroidal anti-inflammatory drug, and no tobacco or alcohol consumption. Conclusions: Absence of weight loss, dysphagia, and gastrointestinal bleeding predicts low likelihood of malignancy in dyspeptic Taiwanese patients aged <45 years. © 2011 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved. 1. Introduction Dyspepsia, defined as various upper abdominal symptoms thought to originate from the gastroduodenal region [1,2], is a common chief complaint for either primary care visit or gas- troenterology referral [3,4]. Because structural diseases at upper gastrointestinal (UGI) tract such as peptic ulcer, erosive esophagi- tis, luminal stricture, and malignancy may manifest with dyspepsia [5–9], esophagogastroduodenoscopy (EGD) is the diagnostic pro- cedure of choice to distinguish patients with organic from those with functional dyspepsia [2]. Nevertheless, a prompt endoscopy for every dyspeptic patient cannot be a practical approach because  This study is orally presented at the United European Gastroenterology Week (UEGW) 2011 on October 25 2011 in Stockholm, Sweden. ∗ Corresponding author at: Department of Internal Medicine, National Taiwan University Hospital, 7, Chung-Shan S. Rd., Taipei 100, Taiwan. Tel.: +886 2 23123456x65410. E-mail address: mingshiang@ntu.edu.tw (M.-S. Wu). the high prevalence (10–20%) will render the required cost and workload unaffordable to any healthcare systems [10–12]. Diag- nostic yield and cost effectiveness will also be low on account of a large portion of investigated dyspepsia being functional [13–15]. How to utilise EGD in the management of uninvestigated dyspepsia remains controversial around the world. Risk stratification based on simple clinical parameters is con- venient, inexpensive and non-invasive, and hence an attractive strategy to direct the priority of further investigation. Practice guidelines from international academic associations have endorsed using alarm symptoms with or without age thresholds, usually set at 50–55 years, to select dyspeptic patients for endoscopy [16–20]. The predictive performance of using alarm features to predict UGI pathology has been extensively studied, but the results were incon- sistent [5,21,22]. Moreover, the majority of previous research was conducted in Europe or North America. For example, only one out of the 15 studies included in the systemic review and meta- analysis performed by Vakil et al. came from Asia (Hong Kong) [5]. Conclusions from Western studies may not be applicable in Asian countries where prevalence of UGI diseases remarkably differs. 1590-8658/$36.00 © 2011 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.dld.2011.10.012