When is an endoscopy recommended for patients with gastritis?

When to Perform Endoscopy for Gastritis

Endoscopy should be performed immediately in patients with alarm symptoms (weight loss, bleeding, anemia, dysphagia, recurrent vomiting) at any age, and in patients over 55 years with new-onset or persistent dyspeptic symptoms, even without alarm features. 1

Age-Based Indications

Patients Over 55 Years

• All patients over 55 years with new-onset or persistent dyspeptic symptoms warrant endoscopy, regardless of whether alarm symptoms are present 1
• This threshold exists because approximately 70% of patients with early gastric cancer present with uncomplicated dyspepsia without alarm features like anemia, dysphagia, or weight loss 1
• Clinical diagnosis is highly inaccurate in distinguishing organic from non-organic disease, making endoscopy essential in this age group 1
• In Western countries, an age cutoff of 50 years may be appropriate, while lower thresholds (45 years or less) should be used in regions with higher gastric cancer incidence, such as Asia-Pacific countries 1

Younger Patients

• Endoscopy is indicated at any age when alarm symptoms are present 1
• For patients under 55 without alarm symptoms, empirical therapy with proton pump inhibitors is appropriate initially 1

Alarm Symptoms Requiring Immediate Endoscopy

The following symptoms mandate urgent endoscopy regardless of patient age 1:

• Weight loss (unexplained)
• Bleeding (overt or occult)
• Anemia (iron deficiency)
• Dysphagia (difficulty swallowing)
• Recurrent vomiting
• Jaundice
• Palpable abdominal mass
• Odynophagia (painful swallowing)

NSAID Users

• Patients taking traditional NSAIDs regularly who develop dyspeptic symptoms require endoscopy due to the risk of life-threatening ulcer complications 1
• This recommendation does not apply to COX-2 selective NSAIDs 1
• Risk is particularly elevated in patients over 60 years, those with prior peptic ulcer disease, or those taking concurrent glucocorticosteroids or anticoagulants 1

Failed Empirical Therapy

• If 4-8 weeks of twice-daily PPI therapy fails to control symptoms, endoscopy is indicated 1
• Initial therapy should begin with once-daily PPI for typical GERD symptoms (heartburn, regurgitation), escalating to twice-daily if unsuccessful 1
• Endoscopy should be performed while symptoms are present and after at least one month off antisecretory therapy when possible 1

Severe Erosive Esophagitis

• Patients with documented severe erosive esophagitis (grade B or worse) require follow-up endoscopy after 8 weeks of PPI therapy to ensure healing and exclude Barrett's esophagus 1
• If this examination is normal, further routine endoscopy is not indicated 1

Special Considerations

Patient Anxiety

• Endoscopy may be indicated to address significant patient concerns about serious underlying disease, as the procedure provides reassurance and improves psychological well-being 1

Atrophic Gastritis Screening

• Patients with unexplained iron or vitamin B-12 deficiency should be evaluated for atrophic gastritis with endoscopy and biopsy 2
• Iron deficiency occurs in up to 50% of patients with corpus-predominant atrophic gastritis and presents earlier than B-12 deficiency 2

Critical Pitfalls to Avoid

• Do not rely on alarm symptoms alone to select patients for endoscopy in those over 55 years, as this approach causes patients with localized disease to be overlooked 1
• Ensure adequate biopsies are obtained (5-8 samples) during endoscopy, as failure to take sufficient biopsies is a principal factor in missed diagnoses, with 10% of upper GI malignancies missed at first endoscopy 1
• Stop PPIs before the first diagnostic endoscopy when malignancy is suspected, as PPIs can mask endoscopic findings and alter the appearance of malignant ulcers 1