At what point do you order an Esophagogastroduodenoscopy (EGD) for a patient with persistent epigastric pain, particularly those with a history of Non-Steroidal Anti-Inflammatory Drug (NSAID) use, smoking, or a family history of gastrointestinal cancer?

When to Order EGD for Persistent Epigastric Pain

Order urgent (2-week wait) EGD immediately for patients ≥55 years with persistent epigastric pain, or at any age if accompanied by alarm features including weight loss, dysphagia, recurrent vomiting, gastrointestinal bleeding (melena or hematemesis), or anemia. 1, 2

Age-Based Thresholds for Endoscopy

For patients ≥55 years:

• Urgent endoscopy is indicated for dyspepsia with weight loss at age ≥55 years 1
• The age threshold should be adjusted based on local gastric cancer incidence—in Western countries, 50-55 years is appropriate, while lower thresholds (40-45 years) apply in high-risk populations (Asian descent, family history of gastroesophageal malignancy) 1

For patients <55 years without alarm features:

• Consider non-urgent endoscopy for treatment-resistant dyspepsia at age ≥55 years 1
• Initial management with H. pylori testing and empiric PPI therapy is appropriate before proceeding to endoscopy 1

Alarm Features Requiring Urgent EGD (Any Age)

Immediate endoscopy is mandatory when any of these are present: 1, 2, 3

• Gastrointestinal bleeding: melena (dark stools) or hematemesis
• Unintentional weight loss
• Dysphagia or odynophagia
• Recurrent/persistent vomiting
• Unexplained iron deficiency anemia (check complete blood count)
• Palpable abdominal mass
• Jaundice

These alarm features indicate potential peptic ulcer complications (bleeding occurs in 2-10% of cases with 8.6% 30-day mortality), perforation (30% mortality if delayed), or gastric malignancy (32% 5-year survival). 1, 2, 4

Special Populations Requiring Lower Threshold for EGD

NSAID users with persistent epigastric pain:

• Endoscopy is recommended due to risk of life-threatening ulcer complications, even without alarm symptoms 1
• This does not apply to COX-2 selective NSAIDs 1

High-risk ethnic/family history:

• Patients from areas with increased gastric cancer risk or with family history of gastroesophageal malignancy warrant urgent endoscopy at age >40 years 1

Initial Management Before Endoscopy (Low-Risk Patients)

For patients <55 years without alarm features: 1, 2

• Test for H. pylori using 13C urea breath test or stool antigen test (≥90% sensitivity/specificity required)
• Start high-dose PPI therapy (omeprazole 20-40 mg once daily) with 80-90% healing rates for ulcers
• If symptoms persist despite 4-8 weeks of appropriate therapy, proceed to endoscopy

Critical Pitfalls to Avoid

Do not delay endoscopy when: 1, 2, 3

• Cardiac causes have not been excluded—obtain ECG within 10 minutes and serial troponins at 0 and 6 hours, as acute coronary syndrome presents with epigastric pain in up to 20% of cases with 10-20% mortality if missed
• Peritoneal signs develop (fever ≥38°C, tachycardia ≥110 bpm, abdominal rigidity)—this suggests perforation requiring immediate surgical consultation
• Serum lipase is ≥2x normal—this indicates acute pancreatitis (30-40% mortality in necrotizing forms)

Recognize that: 5

• 6.7% of upper GI cancers had a negative endoscopy 12-36 months prior to diagnosis
• If initial endoscopy is negative but symptoms persist, repeat endoscopy is warranted, particularly in higher-risk patients

Diagnostic Capabilities of EGD

Endoscopy provides: 2, 4

• Direct visualization of ulcers, erosions, and malignancy
• Tissue sampling for histopathology (minimum 2 biopsies from antrum and body)
• H. pylori testing from biopsy specimens
• Therapeutic intervention (hemostasis for bleeding lesions)