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Gastroscopy in younger patients: an analysis of referrals and pathologies. BACKGROUND AND AIM: Diagnostic guidelines for the investigation of dyspepsia for patients <50 years have been implemented. However, it is unsure whether these guidelines are used appropriately. We aimed to investigate the adherence to the national guidelines of uninvestigated dyspepsia and to examine the prevalence of upper gastrointestinal pathology in patients 18-50 years. We also aimed to detect any possible risk factors for pathology in esophagogastroduodenoscopy referrals and to evaluate differences between referrals from the hospital and primary health care. METHOD: This is a retrospective review of medical records including patients who underwent esophagogastroduodenoscopy between January 2019 and April 2020 (n = 1809). Odds ratios (OR), positive predictive values (PPV), negative predictive values (NPV), chi-square and Mann-Whitney U-tests were applied. RESULTS: In total 1708 patients were included, of whom 43.6% (n = 744) had a pathologic finding. Age group 41-50 years showed the highest prevalence with an OR 1.34 [95% confidence interval (CI), 1.07-1.69]. Helicobacter pylori testing was performed in 21.1% (n = 167) of patients with dyspepsia lacking alarm symptoms (n = 791). PPV and OR were generally low for a pathologic esophagogastroduodenoscopy. The absence of alarm symptoms showed a high NPV for significant pathology (98.7-99.6%). Significant pathology was almost exclusively found in hospital-based referrals. CONCLUSIONS: Esophagogastroduodenoscopy is widely performed in young adults, often without significant findings. Adherence to the national guidelines was poor. No referral factors were associated with a significant risk for a pathologic finding. Esophagogastroduodenoscopy based on primary healthcare referrals demonstrated almost exclusively benign pathology. Significant pathology was only found via hospital-based referrals.