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Clin Gastroenterol Hepatol. 2009 Jul;7(7):756-61. doi: 10.1016/j.cgh.2009.03.031. Epub 2009 Apr 10.

Cost of detecting malignant lesions by endoscopy in 2741 primary care dyspeptic patients without alarm symptoms.

Collaborators (188)

Bai JC, Segal E, Di Risio C, Pedrana R, Rainoldi J, Milutin M, Palazzo F, Macken E, Baetens P, D'Haens G, Cabooter M, Martinet JP, Delwaide J, Piessevaux H, Buset M, Janssens J, Vergauwe P, Pollet S, Quilici F, Rodriguez TN, da Silva EP, Nader F, Luiz Jorge J, Achilles P, Corrêa BL, Guedes J, Clark D, Plourde, Desai M, Morgan EP, Gray J, Cohen A, Reddy S, Jobin G, Sadowski D, Kelly A, Morgan D, Ing G, Liang W, Tytus R, Teitelbaum I, Lasko B, Kassner R, Carlson B, O'Keefe D, Somani R, Greenspoon A, Faiers A, Banks M, Jardine F, Woodland R, Luces K, Cox R, Rolfe A, Fay D, Akhras D, Mazza G, Kiilerich S, Bytzer P, Hendel L, Eriksen J, Thordal C, Vadstrup S, Fly G, Goldfain D, Coulanjon G, Leothaud G, Delette O, Mathoniere O, Zrihen D, Lemaitre JP, Peignot JF, Barberis A, Tordjman G, Gompel M, Grandguillaume J, Marciano P, Le Texier A, Boye A, Tondut A, Scheer J, Schmidt W, Kölling W, Regling S, Alasmar D, Becker-Tesch A, Lehmann R, Schirrmeister G, Speetzen G, Stahl HD, Roitenberg A, Kitis GE, Karamanolis D, Triantafillou G, Tzivras M, Avgerinos A, Björnsson Orvar K, Kristjánsdóttir, Birgisson, Valdimarsson, Björnsson S, Stanghellini V, Spisni R, Scarpulla G, Minoli G, Della Bianca G, Bianco MA, Pistoia MA, Vaira D, Longhini A, Cestari R, Jomaas H, Johansen Y, Lier J, Løland O, Skjegstad E, Jørum IM, Fonneløp H, Wangestad M, Tomassen ST, Nordstrand A, Hertzenberg AB, Saebø L, Mansilla-Tinoco R, Norheim PD, Solnør L, Lundby B, Tomala T, Sanaker H, Fauske J, Oshaug M, Lindstrøm M, Rudneva E, Hansen AN, Skag A, Werner EL, Ahlqvist JO, Bø PE, Kjørlaug K, Eikeland T, Hatlebrekke T, Olsen K, Tudor N, Dobru D, Redis R, Coman F, Baladas H, Fock KW, Ho LK, Lim CC, Grobler S, Ally R, Aboo N, van Rensburg C, Mohame H, Schneider H, Prins M, Moola S, Bekker J, Abad A, Mearin Manrique F, Dominguez E, HerrerIas Gutiérrez JM, Diaz Rubio M, Wedén M, Edin R, Ung KA, Toth E, Johnsson F, Stubberöd A, Tour R, Falk A, Hultber C, Larnefeldt H, Lönneborg L, Ericsson M, Knutsson AC, Fröberg L, Larsson A, Tracz S, Hollenberg S, Wide S, Polhem B, Paulsson L, Grimfors S, Roos H, Skalenu JO, Weber KB.

Author information

University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin 53233, USA.



Current guidelines recommend empirical, noninvasive approaches to manage dyspeptic patients without alarm symptoms, but concerns about missed lesions persist; the cost savings afforded by noninvasive approaches must be weighed against treatment delays. We investigated the prevalence of malignancies and other serious abnormalities in patients with dyspepsia and the cost of detecting these by endoscopy.


We studied 2741 primary-care outpatients, 18-70 years in age, who met Rome II criteria for dyspepsia. Patients with alarm features (dysphagia, bleeding, weight loss, etc) were excluded. All patients underwent endoscopy. The cost and diagnostic yield of an early endoscopy strategy in all patients were compared with those of endoscopy limited to age-defined cohorts. Costs were calculated for a low, intermediate, and high cost environment.


Endoscopies detected abnormalities in 635 patients (23%). The most common findings were reflux esophagitis with erosions (15%), gastric ulcers (2.7%), and duodenal ulcers (2.3%). The prevalence of upper gastrointestinal malignancy was 0.22%. If all dyspeptic patients 50 years or older underwent endoscopy, 1 esophageal cancer and no gastric cancers would have been missed. If the age threshold for endoscopy were set at 50 years, at a cost of $500/endoscopy, it would cost $82,900 (95% CI, $35,714-$250,000) to detect each case of cancer.


Primary care dyspeptic patients without alarm symptoms rarely have serious underlying conditions at endoscopy. The costs associated with diagnosing an occult malignancy are large, but an age cut-off of 50 years for early endoscopy provides the best assurance that an occult malignancy will not be missed.

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