Red flags in dyspepsia

When should dyspepsia become a clinical concern? What are the high-risk groups or red flags that should never be ignored in patients with dyspepsia?

Paul Moayyedi: Our data would suggest red flags are not as important as the textbooks would suggest. Most patients with the so-called red flags—that should be things like weight loss, anemia, dysphagia, vomiting—do not have organic pathology. Most still have a functional dyspepsia.

The message is alarm features should not prompt you to automatically do an endoscopy, particularly in a young person, someone who is 20 and very unlikely to have cancer, very unlikely to have ulcer disease, and even if they do, a Helicobacter pylori test-and-treat strategy should treat that. I would not get concerned by alarm features.

What does concern me, the one I would highlight, is dysphagia. That is the highest risk. Still, in a 20-year-old it is hard to imagine. But if there is progressive dysphagia, especially combined with weight loss, it would prompt me even in a young person to do an endoscopy. And I would have a lower threshold if they were at the age of 50 years, let’s say, even though the guidelines are now saying 60. It is not a hard-and-fast rule. Together with alarm features, sure, you should be scoping.