What symptoms, such as gastrointestinal (GI) bleeding, difficulty swallowing, severe abdominal pain, or persistent vomiting, prompt an endoscopy in patients with a history of ulcers, cancer, or other digestive tract conditions?

Symptoms That Prompt Endoscopy

Immediate endoscopy is indicated for any patient presenting with alarm symptoms—including dysphagia, gastrointestinal bleeding (hematemesis or melena), anemia, unintentional weight loss, or recurrent vomiting—regardless of age. 1, 2

Absolute Indications for Immediate Endoscopy

Alarm Symptoms (Any Age)

• Progressive dysphagia warrants urgent endoscopy, with over 50% of patients having clinically significant findings such as esophageal stricture or malignancy 3, 2
• Gastrointestinal bleeding (hematemesis, melena, or hematochezia) requires immediate endoscopic evaluation for diagnosis and potential therapeutic intervention 3, 1, 4
• Anemia (particularly iron deficiency) suggests chronic blood loss from erosive disease or malignancy 1, 2
• Unintentional weight loss raises concern for underlying malignancy and necessitates endoscopic evaluation 3, 1, 2
• Recurrent vomiting may indicate obstruction, severe esophagitis, or other significant pathology 1, 2

Age-Based Criteria

• Any patient over age 45 (or 55 in some guidelines) with new-onset dyspepsia or change in dyspeptic symptoms should undergo endoscopy due to increased risk of gastric cancer 3
• The age threshold should be adjusted based on local gastric cancer incidence—lower thresholds (age 40-45) are appropriate in high-risk populations such as Asia-Pacific regions 3

NSAID Users

• Patients taking traditional NSAIDs who present with dyspeptic symptoms require endoscopy due to risk of life-threatening ulcer complications, though this does not apply to COX-2 selective inhibitors 3

Conditional Indications for Endoscopy

Treatment-Refractory Symptoms

• Persistent typical GERD symptoms despite 4-8 weeks of twice-daily PPI therapy warrant endoscopy to investigate treatment failure or alternative diagnoses 3, 1, 2
• Severe and persistent dyspeptic symptoms in patients under age 45 that do not respond to treatment may require endoscopy 3

Helicobacter pylori Positive Patients

• Patients under age 45 with dyspepsia who test positive for H. pylori on non-invasive testing should undergo endoscopy, as infection is responsible for over 95% of duodenal ulcers 3

Long-Term Treatment Planning

• Patients requiring continuous long-term treatment with H2 receptor antagonists, PPIs, or prokinetic drugs should undergo endoscopy before committing to indefinite therapy 3

Severe Erosive Esophagitis

• Patients with documented severe erosive esophagitis (Los Angeles grade C or D) require follow-up endoscopy after 8 weeks of PPI therapy to assess healing and rule out Barrett's esophagus, as approximately 6% may have underlying Barrett's 1, 5, 2

High-Risk Screening

• Men over 50 years with chronic GERD (>5 years) and multiple risk factors (nocturnal reflux, hiatal hernia, elevated BMI, tobacco use, intra-abdominal fat distribution) may benefit from screening endoscopy for Barrett's esophagus 1, 2

Recurrent Stricture

• Patients with history of esophageal stricture who develop recurrent dysphagia require endoscopy for evaluation and potential therapeutic dilation 1, 2

Situations Where Endoscopy Is NOT Indicated

• Typical irritable bowel syndrome symptoms rather than true dyspepsia 3
• Mild or moderate reflux symptoms responding to lifestyle modifications, antacids, or alginates 3
• Known duodenal ulcer responding to treatment 3
• Single episode of dyspepsia in asymptomatic patients not receiving treatment 3
• Uncomplicated heartburn responding to treatment 3

Critical Clinical Pitfalls

• Do not delay endoscopy in patients with alarm symptoms while attempting empirical therapy—these patients require immediate evaluation regardless of age 1, 2
• Endoscopy should be performed when symptoms are present and after a minimum of one month off antisecretory therapy to maximize diagnostic yield 3
• Do not repeat endoscopy in young patients with persistent non-alarm dyspeptic symptoms after failed empirical therapy without first reassessing the diagnosis—the yield is extremely low and may not be cost-effective 3
• Symptom subgroups (ulcer-like, reflux-like, dysmotility-like) have no discriminant value in predicting underlying structural disease and should not guide decisions about endoscopy 3