What type of endoscopy is recommended for an upper Gastrointestinal (GI) bleed?

Esophagogastroduodenoscopy (EGD) is the Type of Endoscopy for Upper GI Bleeding

For patients with upper gastrointestinal bleeding, esophagogastroduodenoscopy (EGD, also called upper endoscopy) is the first-line diagnostic and therapeutic procedure that should be performed within 24 hours of presentation after hemodynamic stabilization. 1, 2

Why EGD is the Procedure of Choice

• EGD successfully identifies the bleeding source in 95% of cases, making it far superior to other diagnostic modalities 1
• It provides both diagnosis AND treatment capability in a single procedure, allowing immediate therapeutic intervention when high-risk lesions are identified 1, 3, 4
• EGD reduces rebleeding risk, transfusion requirements, need for surgery, hospital length of stay, and mortality when performed appropriately 1, 5

Timing of EGD

• Perform EGD within 24 hours of presentation for all hospitalized patients after achieving hemodynamic stability 1, 2
• Earlier endoscopy (within 12 hours) is recommended for high-risk patients with hemodynamic instability, ongoing bleeding, or shock index >1 2, 6
• Emergency endoscopy is indicated for patients with persistent hemorrhage causing vital sign abnormalities or requiring repeated transfusions 1

Pre-Endoscopic Preparation

• Administer erythromycin infusion before endoscopy to improve visualization by promoting gastric emptying 7
• Ensure hemodynamic resuscitation is complete before proceeding with endoscopy—this means establishing two large-bore IV lines, initiating fluid resuscitation, and correcting coagulopathy if present 2, 6
• For patients with large-volume bleeding, provide airway protection by intubating before performing EGD 1

What EGD Identifies and Treats

EGD allows visualization and treatment of the most common causes of upper GI bleeding:

• Peptic ulcer disease (50-70% of cases) with stigmata of recent hemorrhage including active spurting, oozing, visible vessels, or adherent clots 1, 7
• Mallory-Weiss tears, esophagitis, gastritis, and neoplastic lesions 1
• Rare causes including Dieulafoy lesions, hemobilia, and aortoenteric fistulas 1

Therapeutic Capabilities During EGD

• Combination endoscopic therapy is superior to monotherapy—specifically injection (epinephrine) plus thermal coagulation (heater probe, bipolar electrocoagulation) or mechanical therapy (clips) 1, 6, 3, 7
• Monotherapy reduces rebleeding risk to approximately 20%, while combination therapy reduces it to approximately 10% 3
• Available therapeutic modalities include: injection therapy, thermal ablation (heater probe, bipolar electrocoagulation, argon plasma coagulation), mechanical therapy (endoclips, over-the-scope clips), and hemostatic powder spray 3, 4, 7

When EGD is Contraindicated or Fails

• In postsurgical or traumatic settings where endoscopy is contraindicated, CT angiography (CTA) or catheter-based angiography become the primary diagnostic modalities 1
• If EGD identifies bleeding but cannot control it endoscopically, proceed to catheter-based arteriography with embolization 1
• For hemodynamically unstable patients with shock index >1, consider CT angiography first to localize bleeding before any intervention, then proceed to catheter angiography with embolization within 60 minutes 2, 8

Common Pitfalls to Avoid

• Never delay EGD beyond 24 hours in high-risk patients, as this increases mortality 2
• Do not skip nasogastric lavage in ventilated patients if feasible—blood return is an independent predictor of rebleeding—but avoid in unsedated patients due to aspiration risk 2, 6
• Always consider an upper GI source even in patients presenting with apparent lower GI bleeding (hematochezia) if they are hemodynamically unstable, as 10-15% will have an upper source 1, 2
• Do not perform barium or iodinated oral contrast studies, as these obscure active hemorrhage and interfere with subsequent endoscopic or angiographic procedures 2

Post-EGD Management

• After successful endoscopic hemostasis, administer high-dose IV proton pump inhibitor (80 mg bolus followed by 8 mg/hour continuous infusion) for 72 hours, then transition to oral PPI twice daily for 14 days 6, 7
• Routine second-look endoscopy is not recommended unless there is clinical evidence of rebleeding 1
• Test all patients for Helicobacter pylori and provide eradication therapy if positive 1