What are the contraindications to Esophagogastroduodenoscopy (EGD)?

Contraindications to Esophagogastroduodenoscopy (EGD)

EGD has very few absolute contraindications, with suspected perforation or complete bowel obstruction being the primary concerns, while most other clinical scenarios represent relative contraindications that require careful risk-benefit assessment. 1

Absolute Contraindications

• Suspected or known gastrointestinal perforation is an absolute contraindication to EGD, as endoscopic intubation and insufflation can worsen peritoneal contamination and clinical deterioration 1
• Complete esophageal or gastric outlet obstruction that prevents safe passage of the endoscope represents an absolute contraindication
• Uncooperative or combative patients who cannot be adequately sedated pose unacceptable risk for scope-related trauma

Relative Contraindications Requiring Risk Stratification

Cardiovascular Instability

• Recent myocardial infarction within 3 weeks is a relative contraindication, particularly in clinically unstable patients 2
• In a study of 34 EGDs performed within 3 weeks of MI, no complications occurred in 26 clinically stable patients with uncomplicated infarction, but 3 major complications occurred in 8 unstable patients 2
• Hemodynamic instability from any cause increases procedural risk and should prompt stabilization before elective endoscopy 3

Respiratory Compromise

• Severe hypoxemia or acute bronchospasm represents a relative contraindication to EGD 2
• Patients with chronic obstructive pulmonary disease without severe hypoxemia or acute bronchospasm can safely undergo EGD, as demonstrated in 53 patients without complications 2
• Emergency EGD can be performed after endotracheal intubation in patients with severe hypoxemia requiring airway protection 2
• Large pleural effusions causing severe respiratory compromise may require drainage before EGD to ensure adequate respiratory reserve during sedation 3

Coagulation Disorders

• Serious coagulation disorders with INR >1.5 increase bleeding risk, particularly when biopsies or therapeutic interventions are planned 3
• This represents a relative rather than absolute contraindication, as diagnostic EGD without biopsy may still be performed with appropriate precautions

Recent Upper Gastrointestinal Surgery

• Recent esophageal, gastric, or duodenal surgery is a relative contraindication, though EGD can be safely performed when clinically indicated 1, 2
• In 60 patients undergoing EGD within 24 days of upper GI surgery (average 14.7 days), no endoscopic complications occurred, with diagnostic yield of 75% 1
• EGD should ideally be performed more than 7 days after surgery when the benefits outweigh risks 1
• EGD is absolutely contraindicated when wound dehiscence or anastomotic leak is suspected, as insufflation could worsen contamination 1

Pregnancy

• Pregnancy is NOT a contraindication to EGD when clinically indicated, particularly for significant upper gastrointestinal bleeding 2
• Case-controlled studies of 83 pregnant patients undergoing EGD demonstrated safety for both mother and fetus 2
• EGD should be deferred to the second trimester when possible to minimize fetal exposure to sedation 4
• Midazolam, meperidine, fentanyl, and propofol are acceptable sedatives during pregnancy, though prolonged exposure (>3 hours) to midazolam and propofol during the third trimester carries FDA warnings about potential fetal neurocognitive effects 4

Portal Hypertension and Varices

• Active variceal hemorrhage is an INDICATION rather than contraindication for urgent EGD 4
• EGD should be performed within 12 hours of admission in patients with suspected variceal bleeding once hemodynamic stability is achieved 4
• Variceal screening is recommended for all women with cirrhosis within 12 months of conception, with repeat EGD in second trimester if not previously performed 4

Advanced HIV/AIDS

• Advanced HIV infection or AIDS is NOT a contraindication to EGD, sigmoidoscopy, or colonoscopy 2
• AIDS patients should be endoscoped with the same aggressiveness as other patients, though endoscopy may be inappropriate in terminal patients 2

Special Sedation Considerations

• Caution should be exercised when combining intravenous sedation with topical anesthetic throat spray in elderly patients or those at increased risk of aspiration 4
• The combination of sedation and topical anesthesia may increase aspiration risk, though evidence for increased complications in routine practice is limited 4
• Patients taking monoamine oxidase inhibitors (MAOIs) should NOT receive meperidine due to risk of life-threatening excitatory reactions including agitation, hemodynamic instability, rigidity, seizures, and death 4
• Fentanyl and other opioids have not been implicated in MAOI interactions and are safer alternatives 4

Key Clinical Pitfalls to Avoid

• Do not delay EGD for suspected variceal bleeding to correct mild coagulopathy, as early endoscopy (within 12 hours) improves outcomes 4
• Do not assume pregnancy is a contraindication – significant GI bleeding during pregnancy requires prompt endoscopic evaluation 4, 2
• Do not perform EGD when perforation is suspected based on clinical or radiographic findings, as this represents the primary absolute contraindication 1
• Ensure adequate respiratory support is available for high-risk patients, including those with severe COPD, large pleural effusions, or morbid obesity 3, 2, 5