When is a referral for Esophagogastroduodenoscopy (EGD) recommended?

Indications for Esophagogastroduodenoscopy (EGD) Referral

Upper endoscopy is indicated in patients with heartburn and alarm symptoms (dysphagia, bleeding, anemia, weight loss, and recurrent vomiting), in patients with GERD symptoms that persist despite adequate PPI therapy, and in men over 50 with chronic GERD symptoms and additional risk factors. 1

Primary Indications for EGD

Alarm Symptoms

• Upper endoscopy is strongly indicated in both men and women who present with heartburn plus any of the following alarm symptoms: dysphagia, bleeding, anemia, weight loss, or recurrent vomiting 1
• Immediate referral for endoscopy is recommended for patients with these sinister or "alarm" symptoms due to the risk of underlying malignancy 1
• Food bolus obstruction requires urgent referral to gastroenterology for endoscopic intervention, as EoE is the most common cause of food bolus obstruction presenting to emergency departments 1

Persistent GERD Symptoms

• Upper endoscopy is indicated in patients with typical GERD symptoms that persist despite a therapeutic trial of 4 to 8 weeks of twice-daily proton-pump inhibitor therapy 1
• This recommendation applies to both men and women, as persistent symptoms may indicate underlying pathology requiring direct visualization 1

Post-Treatment Assessment

• Patients with severe erosive esophagitis should undergo EGD after a 2-month course of PPI therapy to assess healing and rule out Barrett esophagus 1
• Patients with a history of esophageal stricture who have recurrent symptoms of dysphagia should be referred for endoscopy 1

Age-Related Considerations

Older Patients

• Upper endoscopy may be indicated in men older than 50 years with chronic GERD symptoms (symptoms for more than 5 years) and additional risk factors (nocturnal reflux symptoms, hiatal hernia, elevated body mass index, tobacco use, and intra-abdominal distribution of fat) 1
• The age threshold for immediate endoscopy has traditionally been 45 years but may be adjusted to 50 years in Western countries based on the local incidence of gastric cancer 1
• In regions with higher gastric cancer incidence, a lower age threshold may be advisable 1

Younger Patients

• Patients under 45 years with dyspepsia who are positive for Helicobacter pylori on non-invasive testing or who have other risk factors such as treatment with non-steroidal anti-inflammatory drugs should be considered for endoscopy 1
• Younger patients with severe and persistent symptoms that do not respond to treatment should also be considered for endoscopy 1

Special Populations

NSAID Users

• Endoscopy is recommended in patients presenting with dyspeptic symptoms who are taking NSAIDs regularly due to the risk of potentially life-threatening ulcer complications 1
• This recommendation does not apply to patients taking COX-2 specific NSAIDs 1

Barrett's Esophagus Surveillance

• Upper endoscopy is indicated for surveillance evaluation in men and women with a history of Barrett esophagus 1
• In patients with Barrett esophagus and no dysplasia, surveillance examinations should occur at intervals no more frequently than 3 to 5 years 1
• More frequent intervals are indicated in patients with Barrett esophagus and dysplasia 1

Situations Where EGD is Not Indicated

• Endoscopy is not indicated in patients with mild or moderate reflux symptoms that respond to simple measures such as lifestyle changes, antacids, and alginates 1
• Patients with typical GORD symptoms refractory to PPIs do not require endoscopy to exclude eosinophilic esophagitis unless they have clinical features suggestive of EoE such as dysphagia and atopy 1
• Recurrent endoscopy after follow-up examination is not indicated in the absence of Barrett esophagus 1
• Patients known to have duodenal ulcer who are responding to treatment do not require endoscopy 1

Risks and Benefits Considerations

• Upper endoscopy is a low-risk procedure but carries a 1-in-1000 to 1-in-10,000 risk for complications, including perforation, cardiovascular events, or death 1
• Other rare risks include aspiration pneumonia, respiratory failure, hypotension, dysrhythmia, or reactions to anesthetic agents 1
• The incidence of perforation associated with EGD is approximately 0.033%, with similar rates whether an interventional procedure is performed or not 2
• EGD is highly effective for diagnosing pathology in patients with dysphagia, with abnormal findings in 70% of cases and major pathology in 54% 3

Common Pitfalls to Avoid

• Overuse of upper endoscopy contributes to higher healthcare costs without improving patient outcomes 1
• Inappropriate referrals may expose patients to unnecessary risks 1
• When referring patients to a gastroenterologist, it should be clear that a cognitive service to aid in medical management, not simply a "referral for upper endoscopy," is the goal 1
• The presence of duodenitis on endoscopy does not confirm GERD as a cause of extraesophageal symptoms, and additional testing may be needed 4

By following these evidence-based guidelines for EGD referral, clinicians can ensure appropriate use of this valuable diagnostic tool while minimizing unnecessary procedures, reducing healthcare costs, and avoiding potential complications.