Which adults with alarm features such as dysphagia, upper gastrointestinal bleeding, iron‑deficiency anemia, unexplained weight loss, persistent vomiting, refractory gastro‑esophageal reflux disease, Barrett’s esophagus, suspected malignancy, persistent gastric ulcer, or age over 55 with new dyspeptic symptoms should be referred for an upper gastrointestinal endoscopy?

Who Should Be Referred for Upper GI Endoscopy

All adults with alarm symptoms—dysphagia, upper GI bleeding, iron-deficiency anemia, unexplained weight loss, or recurrent vomiting—require immediate upper endoscopy regardless of age. 1, 2, 3, 4

Absolute Indications for Urgent Endoscopy

Alarm Symptoms (Any Age)

• Dysphagia warrants immediate endoscopy, as over 50% of patients have clinically significant findings including esophageal stricture or malignancy 3, 5
• Upper GI bleeding (hematemesis, melena, hematochezia) requires urgent endoscopic evaluation for both diagnosis and therapeutic intervention 1, 3
• Iron-deficiency anemia suggests chronic blood loss from erosive disease or malignancy 1, 3
• Unexplained weight loss raises concern for underlying malignancy and mandates endoscopic evaluation 1, 3, 5
• Recurrent vomiting may indicate obstruction, severe esophagitis, or other significant pathology 1, 3

Age-Based Indications

• Adults over age 55 with new-onset dyspepsia should undergo endoscopy, as approximately 70% of early gastric cancers present with uncomplicated dyspepsia without alarm features 1
• The age threshold reflects increased cancer risk; clinical diagnosis is highly inaccurate in distinguishing organic from non-organic disease in this population 1

Refractory GERD

• Typical GERD symptoms persisting despite 4-8 weeks of twice-daily PPI therapy require endoscopy to investigate treatment failure or alternative diagnoses 1, 2, 3, 4
• This represents true refractory disease requiring objective evaluation 2

Severe Erosive Esophagitis

• Follow-up endoscopy after 2 months of PPI therapy is indicated in patients with severe erosive esophagitis (Los Angeles grade C or D) to assess healing and rule out Barrett's esophagus 1, 2, 4
• After healing is confirmed, recurrent endoscopy is not indicated in the absence of Barrett's esophagus, as the risk of developing stricture, Barrett's, or cancer is only 1.9%, 0%, and 0.1% respectively over 7 years 2

Recurrent Stricture

• Patients with history of esophageal stricture who develop recurrent dysphagia require endoscopy for evaluation and potential therapeutic dilation 1, 4

Conditional Indications

Barrett's Esophagus Screening

• Men over age 50 with chronic GERD (>5 years duration) plus multiple risk factors should be considered for screening endoscopy 1, 2, 4
• Risk factors include: nocturnal reflux symptoms, hiatal hernia, elevated BMI, tobacco use, and intra-abdominal fat distribution 1, 2
• Screening should not be routinely performed in women of any age or men under 50, as cancer incidence is very low in these populations 2

Barrett's Esophagus Surveillance

• Patients with known Barrett's esophagus without dysplasia require surveillance endoscopy at intervals of 3-5 years 1, 2, 4
• Patients with Barrett's esophagus and dysplasia require more frequent surveillance (every 6-12 months) due to higher cancer progression risk 2, 4

Clinical Suspicion of Malignancy

• Endoscopy should be considered even in the absence of alarm features when there is clinical suspicion of malignancy 1
• This is critical because approximately 70% of early gastric cancers present without typical alarm symptoms 1

When Endoscopy Is NOT Indicated

• Typical irritable bowel syndrome symptoms (rather than true dyspepsia) do not require endoscopy 3
• Mild or moderate reflux symptoms responding to lifestyle modifications, antacids, or alginates do not warrant endoscopy 3
• Patients under age 45 with dyspepsia and no alarm features who had negative endoscopy within the previous 2 years are unlikely to benefit from repeat examination 3
• Uncomplicated heartburn without alarm features or refractory symptoms does not require endoscopy 3

Critical Clinical Pitfalls to Avoid

Do Not Delay Endoscopy for Alarm Symptoms

• Delaying endoscopy while attempting empirical therapy in patients with alarm symptoms is inappropriate—these patients require immediate evaluation regardless of age 3
• Failure to suspect malignancy and inadequate biopsies are the principal factors associated with missed diagnoses, occurring in 10% of initial endoscopies 1

Optimize Diagnostic Yield

• Endoscopy should be performed when symptoms are present and ideally after at least one month off antisecretory therapy to maximize diagnostic yield 3
• However, for patients with known Barrett's esophagus undergoing surveillance, continuing PPI therapy can decrease inflammation and improve histological assessment 1

Consider Life-Limiting Comorbidities

• Life-limiting comorbidities should factor into screening decisions, particularly for Barrett's surveillance 2
• If initial screening is negative, recurrent periodic endoscopy is not indicated 2

Recognize Low Yield Scenarios

• In patients with symptoms compatible with functional dyspepsia and no alarm features, the diagnostic yield is essentially zero (1 in 10 endoscopies performed in this group show no abnormalities) 6
• Such patients should receive a positive diagnosis of functional dyspepsia without endoscopy 6