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Editor,—There is an ongoing debate regarding the value of endoscopy in younger patients presenting with dyspepsia. One important consideration is the likelihood of detecting an underlying cancer which might be cured by early treatment. The large retrospective study by Breslin and colleagues in the January issue ofGut (
) indicates that underlying cancer will be diagnosed in about 1 in 1000 patients presenting with uncomplicated dyspepsia under 45 years of age. However, the calculated 95% confidence intervals for this are wide (1 in 2963 to 1 in 300).
An important question in considering the significance of this finding is whether the prevalence of cancer in these patients with benign dyspepsia is any different from that in the general population. In our own country, Scotland, the chance of a patient presenting with gastro-oesophageal cancer before the age of 50 is 1 in 909 (ISD Scotland Cancer Surveillance Group Data Request and Analysis Service) and half of those have presented with the cancer within the age band 45–49. Most of these patients will have had the tumour present in their stomach for a considerable time prior to clinical presentation, which would have been detected by screening endoscopy five years earlier. Even allowing for the fact that population based rates of gastro-oesophageal cancer are higher in Scotland than Alberta,1 this suggests that the prevalence of underlying cancer in patients presenting with uncomplicated dyspepsia may not be different from that in the general population. Consequently, offering endoscopy to patients with simple uncomplicated dyspepsia to detect cancer may merely represent screening of the general population.
There has been a general assumption that a tumour growing in the stomach will produce dyspeptic symptoms. However, there is no evidence for this. Tumours developing in the colon or other parts of the gastrointestinal tract rarely, if ever, cause symptoms until they produce complications such as bleeding or obstruction.
A very small proportion of patients presenting with uncomplicated dyspepsia will have underlying cancers but this finding may be unrelated to their symptoms. Unless uncomplicated dyspepsia is confirmed to be a symptom of underlying malignancy, then one would be as well to recommend offering endoscopy to patients presenting with a sprained ankle in order to pick up underlying gastro-oesophageal cancer.
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