What are the indications for Upper Gastrointestinal (UGI) endoscopy?

Indications for Upper Gastrointestinal Endoscopy

Upper gastrointestinal (UGI) endoscopy is strongly indicated for patients with hematemesis, progressive dysphagia, or persistent dyspepsia despite H2 antagonist treatment, as these symptoms may indicate serious underlying conditions requiring immediate diagnosis and intervention. 1

Urgent Indications (High Priority)

• Active bleeding manifestations:

  • Hematemesis (99% agreement among physicians) 1
  • Melena when upper GI source is suspected 2
  • Acute UGIH (upper gastrointestinal hemorrhage) - should be performed early (≤24 hours) following hemodynamic resuscitation 3

• Progressive dysphagia (97.6% agreement) 1

  • Particularly important to rule out malignancy or strictures

• Persistent symptoms despite treatment:

  • Dyspepsia continuing despite H2 antagonists (96.8% agreement) 1
  • Patients requiring continuous long-term treatment with acid-suppressing medications 1

• Concerning symptoms in older patients:

  • Patients over 60 years with anorexia, early satiety, or weight loss, even with normal barium studies (87.2% agreement) 1
  • Any patient over 45 years with new-onset dyspeptic symptoms or change in dyspeptic pattern 1

Risk-Based Indications

• Younger patients with specific risk factors:

  • Under 45 years with dyspepsia who are H. pylori positive on non-invasive testing 1
  • Under 45 years taking NSAIDs with dyspeptic symptoms 1
  • Under 45 years with severe and persistent symptoms not responding to treatment 1

• Pre-treatment assessment:

  • Before planning continuous long-term treatment with H2 receptor antagonists, acid pump inhibitors, or prokinetic drugs 1

Inappropriate Indications (Low Value)

• Asymptomatic conditions:

  • Asymptomatic sliding hiatus hernia seen on barium meal (only 4.5% agreement) 1
  • Follow-up endoscopy after gastrectomy in patients without symptoms (28.6% agreement) 1

• Responding to treatment:

  • Uncomplicated heartburn responding to treatment (5% agreement) 1
  • Uncomplicated duodenal ulcer shown on barium study responding to H2 receptor antagonists (7.9% agreement) 1

• Recent negative findings:

  • Patients under 40 years with dyspepsia who had negative endoscopy results in the past two years (22% agreement) 1

• Functional disorders:

  • Patients with typical symptoms of irritable bowel syndrome rather than dyspepsia 1
  • Patients with mild or moderate reflux symptoms responding to simple measures like lifestyle changes, antacids, and alginates 1

Special Considerations

Risk Stratification

• For acute upper GI bleeding, the Glasgow-Blatchford Score (GBS) is recommended for pre-endoscopy risk stratification 3
• Patients with GBS ≤1 can be safely managed as outpatients with outpatient endoscopy 3

Timing of Endoscopy

• Early endoscopy (≤24 hours) is recommended for acute upper GI bleeding 3
• Urgent endoscopy (≤12 hours) is not recommended as it does not improve outcomes compared to early endoscopy 3

Post-Bariatric Surgery

• Endoscopy is valuable for evaluating UGI symptoms after Roux-en-Y gastric bypass 4
• Patients presenting with symptoms less than 3 months after surgery are more likely to have abnormal findings requiring intervention 4

Common Findings and Diagnostic Value

• Most common indications in practice include dyspepsia (63.5%) and hematemesis (12.7%) 5
• Common findings include gastritis (26.6%), esophageal and gastric varices (in patients with portal hypertension), and ulcerative disease 5, 2
• Endoscopy detects gastric (4.4%) and esophageal tumors (3.2%) more accurately than clinical assessment, especially in elderly patients with troublesome symptoms 5

Pitfalls and Caveats

• Endoscopy for cancer screening (e.g., in pernicious anemia) or routine surveillance after gastric surgery is controversial and generally not recommended 1
• H. pylori testing should be considered before endoscopy in younger patients with dyspepsia, as those who are negative and not taking NSAIDs have a low likelihood of serious organic disease 1
• Avoid unnecessary endoscopy in patients with a single episode of dyspepsia who are now asymptomatic and not receiving treatment 1