Why is endoscopy (endoscopic procedure) recommended?

Indications for Endoscopic Procedures

Endoscopy is strongly recommended for patients with alarm symptoms, those over age 45-50 with new-onset dyspepsia, patients on traditional NSAIDs with dyspeptic symptoms, and in cases of acute gastrointestinal bleeding to diagnose and potentially treat the underlying cause. 1

Primary Indications for Endoscopy

Urgent/Emergency Indications

• Active gastrointestinal bleeding - Endoscopy is the gold standard for diagnosis and treatment of upper GI bleeding 1
• Patients with sinister or "alarm" symptoms 1:
  • Weight loss
  • Recurrent vomiting
  • Bleeding or anemia
  • Dysphagia
  • Jaundice
  • Palpable abdominal mass
• Progressive dysphagia (97.6% agreement among experts) 1
• Hematemesis (99% agreement among experts) 1

Age-Related Indications

• Older patients with new-onset dyspeptic symptoms - Traditionally age 45 years, but may be adjusted to 50 years in Western countries with lower gastric cancer rates 1
• Any patient over 45 with recent onset of dyspeptic symptoms or change in dyspeptic symptoms 1
• Patients over 60 years with anorexia, early satiety or weight loss even with normal barium meal results (87.2% agreement) 1

Medication-Related Indications

• Patients taking traditional NSAIDs with dyspeptic symptoms due to risk of potentially life-threatening ulcer complications 1
  • Not applicable to COX-2 specific NSAIDs
  • Risk increases with age over 60 years, history of peptic ulcer disease, concurrent glucocorticosteroids or anticoagulants

Treatment Response Indications

• Patients with dyspepsia who continue to have symptoms despite H2 antagonists (96.8% agreement) 1
• Patients under 45 with severe and persistent symptoms that do not respond to treatment 1
• Patients in whom continuous long-term treatment with H2 receptor antagonists, acid pump inhibitors, or prokinetic drugs is planned 1

Diagnostic Value of Endoscopy

Endoscopy provides three key benefits:

1. Identifying the cause of bleeding or symptoms 1
2. Assessing prognosis by identifying high-risk stigmata 1
3. Administering therapeutic interventions when indicated 1

For patients with uninvestigated dyspepsia, endoscopy remains the gold standard initial approach compared to barium studies 1. It enables targeted therapy for conditions like peptic ulcer disease, esophagitis, and gastric cancer when present, and provides a definitive diagnosis of functional dyspepsia 1.

Special Considerations

Cancer Screening

The American College of Gastroenterology recommends screening endoscopy for patients with long-standing GERD symptoms, particularly those over 50 years, to assess for Barrett's esophagus 1. However, there are no randomized controlled trials demonstrating prevention of cancer or increased life expectancy with this approach 1.

Patient Reassurance

Endoscopy may provide psychological reassurance to patients with concerns about serious underlying disease 1. The psychological general well-being score has been shown to improve in the week following endoscopy in patients with untreated functional dyspepsia 1.

Inflammatory Bowel Disease

In patients with inflammatory bowel disease, endoscopy is recommended for first diagnosis and for acute severe ulcerative colitis 1. For moderate to severe Crohn's disease flares, alternative tests like fecal calprotectin, MRI, or ultrasonography may be considered 1.

Inappropriate Indications for Endoscopy

Endoscopy is generally not indicated in:

• Patients with typical symptoms of irritable bowel syndrome 1
• Patients with mild or moderate reflux symptoms responding to simple measures (lifestyle changes, antacids) 1
• Known duodenal ulcer patients responding to treatment 1
• Patients who had a single episode of dyspepsia and are now asymptomatic 1
• Asymptomatic sliding hiatus hernia seen on barium meal 1
• Uncomplicated heartburn responding to treatment 1

Procedural Considerations

When performing endoscopy:

• Ensure adequate resuscitation before endoscopy in actively bleeding patients 1
• Consider endotracheal intubation in severely bleeding patients to prevent pulmonary aspiration 1
• Ensure experienced endoscopists who can perform therapeutic procedures are available 1
• For patients on anticoagulants or antiplatelets, follow specific guidelines for management before and after procedures 1
• Resume anticoagulation 24-72 hours after endoscopy depending on bleeding and thrombotic risks 2

Safety Considerations

Endoscopy is generally safe with a major complication rate of approximately 1 in 1,000 (including perforation, cardiopulmonary events, and aspiration or bleeding requiring hospitalization) 1. However, mass screening of millions of patients could result in thousands of major complications 1.

Studies show that endoscopy is well-tolerated even in elderly patients aged 80 years or more, with only 10% of first endoscopies being normal in this population 3.

By following appropriate indications and taking necessary precautions, endoscopy serves as an invaluable tool for diagnosis, prognosis, and treatment of gastrointestinal conditions, ultimately improving patient outcomes in terms of morbidity, mortality, and quality of life.