Indications for upper gastrointestinal endoscopy

What it is

Upper endoscopy is both the diagnostic and the therapeutic tool of the upper gastrointestinal tract, and the question is when it is needed and when it is not. Three settings carry their own rules: chronic dyspepsia, suspected esophageal cancer, and upper gastrointestinal bleeding.

How it is diagnosed

Chronic dyspepsia. For patients aged under 50 years with chronic dyspepsia and no alarm symptoms, that is no anemia, dysphagia, persistent vomiting or weight loss, use the test and treat approach for H pylori without initially performing EGD. Obtain EGD with H pylori testing for patients with chronic dyspepsia who are 50 years or older, or who are under 50 years with persistent symptoms or alarm features. In a patient with reflux and without alarm features, symptom relief with PPI therapy confirms the diagnosis of GERD. Two indications for upper endoscopy in GERD are named alongside it. GERD symptoms refractory to empiric therapy with PPIs call for upper endoscopy; if that endoscopy is normal, then choose ambulatory esophageal pH monitoring or impedance pH testing while taking a PPI for symptom-reflux correlation. Dysphagia, odynophagia, and weight loss call for upper endoscopy to rule out cancer. In patients undergoing EGD for suspected PUD, biopsy and histologic assessment for H pylori, or rapid urease testing, should be performed.

Suspected esophageal cancer. The order of tests is: 1) upper endoscopy with a biopsy of suspicious lesions, which is the recommended initial evaluation for symptoms of esophageal cancer; 2) esophagography, appropriate in patients unable to undergo endoscopy but not the preferred test; 3) CT of the abdomen, which is not indicated in the initial evaluation and belongs with a PET scan for staging; 4) esophageal manometry, reserved for patients with dysphagia if upper endoscopy does not establish a diagnosis and a motility disorder is suspected. Increasing the dosage of the proton pump inhibitor is not appropriate treatment here and may delay diagnosis if the patient is not referred promptly for upper endoscopy.