When is an upper endoscopy recommended?

When is Upper Endoscopy Recommended?

Upper endoscopy should be performed in patients with alarm symptoms (dysphagia, bleeding, anemia, weight loss, recurrent vomiting), anyone over age 45 with new or changed dyspeptic symptoms, and patients with persistent symptoms despite appropriate medical therapy. 1

Urgent/Emergent Indications

Upper endoscopy requires immediate performance in the following scenarios:

• Hematemesis or gastrointestinal bleeding - Nearly 99% of physicians would perform endoscopy for this indication, as it allows both diagnosis and potential therapeutic intervention 2, 1
• Progressive dysphagia - Requires urgent evaluation to rule out obstructive lesions including malignancy, with 97.6% of physicians endorsing this indication 2, 1
• Significant unexplained weight loss, anorexia, or early satiety - These alarm symptoms raise concern for malignancy and warrant prompt endoscopic evaluation 1, 3

Age-Based Indications

The age threshold is critical for detecting gastric cancer, which accounts for over 10,000 deaths annually in England and Wales:

• Any patient over age 45 with recent onset or change in dyspeptic symptoms should undergo endoscopy to avoid missing gastric cancer 2, 1
• Men over age 50 with chronic GERD and additional risk factors (nocturnal reflux, hiatal hernia, elevated BMI, tobacco use) should undergo screening endoscopy for esophageal adenocarcinoma and Barrett's esophagus 1, 3

Dyspepsia Management Algorithm

For patients under age 45 with dyspepsia:

• H. pylori positive on non-invasive testing - Endoscopy is appropriate, as H. pylori causes over 95% of duodenal ulcers and most gastric ulcers 2
• NSAID use or other risk factors - These patients warrant endoscopy due to increased risk of peptic ulcer disease 2
• Severe and persistent symptoms not responding to treatment - Endoscopy is indicated after failed empiric therapy 2
• H. pylori negative without risk factors - Can be managed with empiric therapy for 4-6 weeks before considering endoscopy 4

GERD-Specific Indications

• Typical GERD symptoms persisting despite 4-8 weeks of twice-daily PPI therapy warrant endoscopic evaluation 1, 3, 5
• Documented severe erosive esophagitis requires repeat endoscopy after 2 months of PPI therapy to assess healing and rule out Barrett's esophagus 1, 3
• Recurrent dysphagia in patients with prior esophageal stricture necessitates repeat endoscopy with possible dilation 1, 3

Pre-Treatment Planning

• Patients requiring continuous long-term treatment with H2 receptor antagonists, acid pump inhibitors, or prokinetic drugs should undergo endoscopy before committing to indefinite therapy 2

Inappropriate Indications (Do NOT Perform Endoscopy)

Avoid endoscopy in these scenarios to prevent unnecessary procedures:

• Typical irritable bowel syndrome symptoms rather than true dyspepsia 2, 1
• Mild or moderate reflux symptoms responding to lifestyle modifications, antacids, or alginates 2, 1
• Known duodenal ulcer responding to treatment - Only 7.9% of physicians would perform endoscopy in this scenario 2
• Single episode of dyspepsia, now asymptomatic and not on treatment 2
• Uncomplicated heartburn responding to treatment - Only 5% of physicians would perform endoscopy 2
• Asymptomatic sliding hiatus hernia found on barium study - Only 4.5% of physicians would perform endoscopy 2

Surveillance Considerations

• Barrett's esophagus without dysplasia - Surveillance every 3-5 years; more frequent intervals with dysplasia 1
• Routine surveillance after gastrectomy in asymptomatic patients is not recommended, with only 28.6% of physicians endorsing this practice 2
• Screening for gastric cancer in pernicious anemia or post-surgical stomachs is controversial and probably not merited 2

Common Pitfalls

Failing to recognize alarm symptoms can lead to delayed diagnosis of malignancy - this is the most critical error to avoid 1, 3. However, be aware that age and alarm symptoms alone have limited predictive accuracy (sensitivity 87%, specificity only 26%), so clinical judgment remains essential 6. The key is not missing cancer while avoiding unnecessary procedures in low-risk patients with functional dyspepsia, who represent approximately 10% of endoscopy referrals and have essentially zero diagnostic yield when lacking alarm features 7.