From the Guidelines
Elderly patients should undergo an Esophagogastroduodenoscopy (EGD) when they present with alarm symptoms such as dysphagia, bleeding, anemia, weight loss, and recurrent vomiting, or when they have typical GERD symptoms that persist despite a therapeutic trial of proton-pump inhibitor therapy, as recommended by the American College of Physicians 1. When considering an EGD in elderly patients, it's essential to weigh the benefits of diagnostic clarity against the potential risks of sedation and procedural complications. The procedure is generally safe, but elderly patients may be more susceptible to complications due to comorbidities and frailty. Some key indications for EGD in elderly patients include:
- Persistent upper gastrointestinal symptoms that don't respond to initial therapy
- Unexplained iron deficiency anemia
- Unintentional weight loss
- Persistent vomiting
- Progressive difficulty swallowing (dysphagia)
- Gastrointestinal bleeding
- Screening and surveillance of Barrett's esophagus in patients with long-standing gastroesophageal reflux disease (GERD)
- Evaluation of abnormal imaging findings
- Assessment before bariatric surgery The American Gastroenterological Association Institute guideline on the role of upper gastrointestinal biopsy to evaluate dyspepsia in the adult patient in the absence of visible mucosal lesions provides additional guidance on the use of EGD in patients with dyspepsia, but it does not specifically address the elderly population 1. However, the guideline emphasizes the importance of considering the risks and benefits of EGD and biopsy in individual patients, which is particularly relevant in elderly patients with comorbidities and frailty. In terms of sedation, medications like midazolam (1-5mg IV) or propofol are commonly used, and patients are typically required to fast for at least 6-8 hours beforehand. Special consideration should be given to the elderly patient's comorbidities, medication use (especially anticoagulants which may need temporary discontinuation), and overall frailty status when determining the appropriateness of the procedure. Ultimately, the decision to perform an EGD in an elderly patient should be made on a case-by-case basis, taking into account the individual patient's symptoms, medical history, and potential risks and benefits of the procedure.
From the Research
Indications for EGD in Elderly Patients
- EGD is recommended for elderly patients with symptoms such as dyspepsia and dysphagia, as it is a high-yield procedure with no significant increase in adverse events in patients over 80 years 2.
- The procedure is also indicated for patients with non-variceal upper gastrointestinal bleeding (NVGIB), although the ideal timing is unclear 3.
- EGD can be performed for palliative indications in elderly patients, but this is relatively rare, with only 7% of patients undergoing procedures for palliative care in one study 4.
Safety and Efficacy of EGD in Elderly Patients
- Gastrointestinal endoscopy, including EGD, is extremely safe and well tolerated in extremely elderly patients, with no procedure-related mortality reported in one study 4.
- The incidence of complications such as cardiopulmonary complications, colonic perforation, and post-ERCP pancreatitis is relatively low in elderly patients 4, 2.
- Advanced age should not be regarded as an absolute contraindication to any gastrointestinal endoscopy procedure, including EGD 2.
Considerations for EGD in Elderly Patients
- The anticipated benefits of EGD should be weighed against the increased risks associated with procedural sedation and some endoscopic procedures in elderly patients 5.
- Elderly patients undergoing EGD may have a higher risk of mortality and inter-hospital transfer, especially if the procedure is performed early (within 24 hours) 3.
- The yield of EGD in elderly patients is high, especially for those with symptoms such as bleeding or iron-deficiency anemia 2.