Age threshold and symptoms are useful for scheduling upper endoscopy in clinical practice.

Upper gastrointestinal symptoms, including dyspepsia, gastro-oesophageal reflux disease (GERD), and alarm symptoms, frequently prompt referral for upper gastrointestinal endoscopy (UGIE). However, inappropriate endoscopic prescriptions contribute to increased healthcare costs, prolonged waiting lists, and environmental burden. We aimed to evaluate the diagnostic yield of UGIE according to the age threshold and presenting symptoms in routine clinical practice. In this nationwide, multicentre, cross-sectional study, consecutive adult patients undergoing their first UGIE for upper gastrointestinal symptoms were enrolled across 18 Italian centres. During pre-endoscopy patients' interview, the main symptom was captured and accordingly used to categorize symptomatology as dyspepsia, reflux symptoms, or alarm symptoms. Endoscopic and histological findings, including Helicobacter pylori infection status, were prospectively collected. The association between clinical variables and endoscopic lesions was assessed using univariate and multivariate analyses. Overall, 762 patients were included (mean age 55.5 ± 15.4 years; 42.1% males). Dyspepsia was the indication for UGIE in 42.4% of cases, reflux symptoms in 35.4%, and alarm symptoms in 22.2%. At least one endoscopic lesion was detected in 33.5% of patients, with erosive oesophagitis being the most frequent finding (16.5%). Histologically confirmed neoplastic lesions were identified in 1% of cases. Patients aged ≥ 50 years showed a significantly higher prevalence of mucosal lesions compared with younger individuals (51% vs 29%; OR 2.54, 95% CI 1.84-3.53). At multivariate analysis, Helicobacter pylori infection and smoking habit were independently associated with all endoscopic lesions, whilst male sex and reflux symptoms with oesophageal lesions, and alarm symptoms with gastric and duodenal lesions. The diagnostic yield of UGIE is significantly higher in patients aged ≥ 50 years and in those presenting with alarm symptoms or additional risk factors. Conversely, younger patients with uncomplicated dyspepsia showed a low prevalence of clinically relevant lesions. Integrating age threshold, symptom profile, and selected risk factors into referral strategies may improve the appropriateness of UGIE prescriptions and support more sustainable use of endoscopic resources.