What are the indications and contraindications for Esophagogastroduodenoscopy (EGD) in adults, particularly those with a history of smoking or alcohol use, and what are the considerations for patients with severe respiratory or cardiac disease, bleeding disorders, or those taking anticoagulant medications like warfarin (Coumadin) or aspirin?

Indications and Contraindications for Esophagogastroduodenoscopy (EGD)

Absolute Indications for EGD

Perform EGD immediately in any patient presenting with alarm symptoms, regardless of age, gender, or smoking/alcohol history. 1, 2

Alarm Symptoms Requiring Urgent Endoscopy:

• Dysphagia (difficulty swallowing) 1, 2
• Gastrointestinal bleeding (hematemesis, melena) 1, 2
• Anemia (unexplained iron deficiency) 1, 2
• Unintentional weight loss 1, 2
• Recurrent vomiting 1, 2

Treatment-Refractory GERD:

EGD is indicated when typical GERD symptoms persist despite 4-8 weeks of twice-daily proton pump inhibitor (PPI) therapy taken 30-60 minutes before meals. 1, 2, 3 This represents true refractory disease requiring objective evaluation rather than treatment failure from inadequate dosing. 4

Severe Erosive Esophagitis:

After diagnosing severe erosive esophagitis (Los Angeles grade C or D), perform follow-up EGD after 2 months of PPI therapy to assess healing and rule out Barrett's esophagus. 1, 5, 2 Approximately 6% of patients with severe erosive esophagitis may have underlying Barrett's esophagus unmasked after healing. 5 However, recurrent endoscopy after this single follow-up examination is not indicated in the absence of Barrett's esophagus or new symptoms. 1, 5

Recurrent Dysphagia with Known Stricture:

Patients with a history of esophageal stricture who develop recurrent dysphagia require EGD for evaluation and potential therapeutic dilation. 1

Conditional Indications for EGD

Barrett's Esophagus Screening:

Consider screening EGD in men over 50 years old with chronic GERD symptoms (>5 years duration) who have multiple additional risk factors. 1, 2, 3

Risk factors include:

• Nocturnal reflux symptoms 1, 2
• Hiatal hernia 1, 2
• Elevated body mass index 1, 2
• Tobacco use 1, 2
• Intra-abdominal fat distribution 1, 2

Do not routinely screen women of any age or men under 50 years, as esophageal adenocarcinoma incidence is very low in these populations. 2 Life-limiting comorbidities should factor into the screening decision, as the benefit of detecting early cancer diminishes with reduced life expectancy. 2

Barrett's Esophagus Surveillance:

For patients with known Barrett's esophagus without dysplasia, perform surveillance EGD at intervals of 3-5 years. 1, 2 More frequent surveillance (every 6-12 months) is indicated for patients with dysplasia due to higher cancer progression risk. 1, 2

When EGD is NOT Indicated

Do not perform routine upper endoscopy in patients with chronic GERD symptoms to diminish the risk of death from esophageal cancer. 1 The evidence supporting screening endoscopy for Barrett's esophagus to reduce mortality from esophageal adenocarcinoma is insufficient. 1

Do not perform EGD as the initial diagnostic test for uncomplicated GERD or upper gastric pain. 6, 3 Instead, begin with H. pylori testing, which is non-invasive and has higher sensitivity and specificity for detecting infection. 6 Empirical PPI therapy is appropriate for typical GERD symptoms without alarm features. 3, 7

Do not routinely perform EGD solely for the assessment of extraesophageal GERD symptoms (such as chronic cough or laryngitis). 3

Do not obtain tissue samples from endoscopically normal esophageal mucosa to diagnose GERD or exclude Barrett's esophagus in adults. 3

Contraindications and Special Considerations

Anticoagulation and Bleeding Disorders:

EGD is a low-risk procedure for bleeding, and most patients on anticoagulants can safely undergo diagnostic endoscopy without interrupting therapy. 1 However, the decision to continue or hold anticoagulation (warfarin, aspirin, or other agents) should balance the thrombotic risk against bleeding risk, particularly if therapeutic interventions (biopsies, dilations) are planned. 1

For patients with known bleeding disorders, assess the severity and consider correction of coagulopathy before elective procedures, though diagnostic EGD alone carries minimal bleeding risk. 1

Severe Cardiopulmonary Disease:

Patients with severe respiratory or cardiac disease require careful risk-benefit assessment before EGD. 1 The procedural risks include:

• Hypoxemia during sedation in patients with compromised respiratory reserve
• Cardiac arrhythmias or ischemia in patients with unstable coronary disease
• Aspiration risk in patients with impaired airway protection

The benefits of performing endoscopy—regardless of indication—must be balanced against potential harms, including procedural risks, sedation complications, and financial burdens. 1 Informed consent outlining risks, benefits, alternatives, and potential complications must be obtained and documented before the procedure. 1

Smoking and Alcohol History:

Smoking and alcohol use are risk factors for esophageal adenocarcinoma and should be considered when determining the appropriateness of Barrett's esophagus screening in men over 50 with chronic GERD. 1, 2 However, these factors alone do not constitute absolute indications for EGD in the absence of other criteria. 1

Quality Measures During EGD

When performing EGD, endoscopists should spend sufficient time carefully inspecting the foregut mucosa in both anterograde and retroflexed views to improve detection of abnormalities. 1 Suspicious areas should be clearly described, photodocumented, and biopsied separately using standardized biopsy protocols. 1

Document any abnormalities using established classifications and standard terminology. 1 Provide patients with management recommendations based on endoscopic findings, and document whether subsequent surveillance endoscopy is indicated with appropriate intervals. 1