What is the step-wise diagnosis for oesophageal gastroscopy?

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Last updated: October 26, 2025 • View editorial policy

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Step-wise Diagnostic Approach for Oesophageal Gastroscopy

For patients undergoing oesophageal gastroscopy, biopsies should be taken in all adults with dysphagia or food bolus obstruction regardless of endoscopic appearance, and in all children with upper gastrointestinal symptoms to ensure proper diagnosis. 1

Initial Assessment and Indications

  • Oesophageal gastroscopy is indicated in adults with symptoms of dysphagia, food bolus obstruction, or reflux symptoms refractory to treatment 1
  • In children, indications include feeding difficulties, failure to thrive, vomiting, abdominal pain, dysphagia, or food impaction depending on age 1
  • Alarm symptoms requiring urgent endoscopy include weight loss, vomiting, anaemia, and food impaction 1
  • Antisecretory therapy (PPIs) should ideally be withheld for at least 3 weeks prior to endoscopy to avoid misdiagnosis 1

Endoscopic Examination Protocol

Step 1: Visual Inspection

  • Systematically examine the entire oesophagus for endoscopic signs including:
    • Furrows, rings, white plaques, mucosal oedema, fragile mucosa, narrow calibre oesophagus, and strictures 1
    • In children, look for mucosal granularity (42.8%), furrows (25%), rings (22.6%), and exudates (10.7%) 1
    • Note that 7-17% of patients with eosinophilic oesophagitis (EoE) may have normal endoscopic appearance 1

Step 2: Biopsy Protocol

  • For adults with dysphagia or food bolus obstruction:

    • Take multiple biopsies regardless of endoscopic appearance 1
    • Obtain samples from at least two different oesophageal levels 1
    • Target areas of apparent inflammation when present 1

  • For children with upper GI symptoms:

    • Always take oesophageal biopsies regardless of endoscopic appearance 1
    • This is crucial as 21% of children with EoE have macroscopically normal oesophagus 1

  • For suspected malignancy:

    • Take multiple four-quadrant biopsies at 2 cm intervals along the entire length of suspicious areas 1
    • Follow up gastric ulcers to healing with repeat biopsy 1

Step 3: Additional Sampling

  • Obtain gastric and duodenal biopsies when clinically indicated by symptoms or endoscopic findings 1
  • In children, routine gastric and duodenal biopsies are recommended even without visible abnormalities 1

Diagnostic Criteria and Interpretation

For Eosinophilic Oesophagitis (EoE)

  • Diagnosis requires ≥15 eosinophils per high-power field (or ~60 eos/mm²) on biopsy 1
  • Clinical symptoms must correlate with histological findings 1
  • Consider age-specific presentation:
    • Young children: feeding difficulties, failure to thrive, vomiting 1
    • Older children: abdominal pain, dysphagia, food impaction 1
    • Adults: dysphagia, food impaction, heartburn, chest pain 1

For Oesophageal/Gastric Cancer

  • Look for high-grade dysplasia in Barrett's oesophagus or stomach 1
  • Diagnosis should be confirmed by an experienced histopathologist 1
  • For oesophagogastric junctional tumours, classify as:
    • Type I (distal oesophageal)
    • Type II (cardia)
    • Type III (proximal stomach) 1

Follow-up Recommendations

  • For patients with food bolus obstruction:

    • Schedule follow-up endoscopy and outpatient review even after spontaneous resolution 1
    • Consider maintenance therapy with topical steroids to reduce recurrence risk 1

  • For patients with high-grade dysplasia:

    • Perform urgent repeat endoscopy and biopsy due to risk of intramucosal cancer 1

  • For gastric ulcers:

    • Follow up to healing with repeat biopsy 1

Common Pitfalls to Avoid

  • Failing to take biopsies in patients with normal-appearing mucosa, especially in children or adults with dysphagia 1
  • Continuing PPI therapy before diagnostic endoscopy, which may mask endoscopic findings 1
  • Assuming symptoms are due to benign stricture or simple oesophagitis without biopsy confirmation 1
  • Inadequate number of biopsies, leading to missed diagnoses 1
  • Dilating obstructed oesophagus for diagnostic purposes, which carries high risk of perforation 1

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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