Utility of esophagogastroduodenoscopy in positive FOBT with negative colonoscopy: Yield of upper gastrointestinal malignancy and clinically significant findings

The role of esophagogastroduodenoscopy (EGD) in evaluating patients with a positive fecal occult blood testing (FOBT) or fecal immunochemical testing (FIT) and normal colonoscopy findings remains uncertain, with current recommendations based on limited and low-quality evidence. This retrospective cohort study (2012-2022) included consecutive patients with positive FOBT or fecal FIT and normal colonoscopy, alongside asymptomatic controls referred for routine EGD prior to bariatric surgery. Demographic, clinical, and endoscopic data were collected and analyzed. Predictors of upper gastrointestinal malignancy and clinically significant findings (CSFs) were examined. Among 858 patients with positive FOBT/FIT and 2010 controls, significant differences in age and sex distribution were observed (<i>p</i> < 0.001). Hiatus hernia and reflux esophagitis were more common in controls (<i>p</i> < 0.01). CSFs were more frequent in the FOBT-positive group (11.3% vs 8.3%, <i>p</i> < 0.01). On multivariate analysis, male sex, older age, and endoscopist experience (>3 years) were independent predictors of CSFs, while positive FOBT was not independently associated with their presence. The diagnostic yield of EGD in patients with positive FOBT/FIT but normal colonoscopy is modest and comparable to that of asymptomatic controls. These findings suggest that universal EGD may not be routinely warranted in this setting, supporting instead a selective, risk-based approach. Prospective studies are warranted to confirm these findings and assess the cost-effectiveness of universal versus selective EGD in this population.