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Indication for upper Gastrointestinal endoscopy: a mini-review
Professor Dr.Mohamed Alshekhani
Kurdistan center for GEH, College of Medicine, department of
Medicine,Sulaimaniyah University,Iraqi Kurdistan,Iraq.
Indications of upper and lower GIT endoscopy have been expanded to include various
new fields covering diagnostic,therapeutic & screening indications.The main
objectives of upper both types of endoscopies, are to detect early cancers for a better
survival & find significant upper pathologies explaining the patient's symptoms
presenting with dyspepsia & other upper –lower abdominal discomforts.
Indications of upper GI endoscopy:
Include diagnostic,therapeutic & screening indications as follows:
1. The most indication is for dyspepsia & the obgective is to detect serious diseases
early specially gastric cancer for a better outcome.Dyspepsia is epigastric pain or
discomfort with postprandial heaviness, early satiety & nausea ( heart burn incating
GERD is now not included in the definition of dyspepsia). Dyspepsia is common
affecting large number of the general population, so it is not cost-effective to do upper
GI endoscopy to all of these patients & the yield is not high because more half of
endoscopies done in dyspeptic patients are normal. For this reason guideliness suggest
doing endoscopy for dyspepstic patients if their age is 50 years or more or if they have
red flags inluding anorexia,weight loss, dysphagia, vomiting,iron deficiency anemia,
hematemesis, melena or family history of colorectal cancer. Those dyspeptic patients
who are youger or with no red flags are managed either with emprical PPI or test and
treat strategy, while keeping endoscopy for those not responding to this approach.
2. Upper GI Bleeding: the second most common indication after dyspepsia.Upper GI
endoscopy plays a pivotal role in acute upper GIT Bleeding & in the search of
potential upper GIT source in patients with iron deficiency anemia. Endoscopy
usually is carried out within 12-24 hours after acute upper GI Bleeding & it has
diagnostic & therapeutic role to ensure endoscopic hemostasis by dual therapy
included adrenaline-saline endoscopic injection.
3. Dysphagia:endoscopy is indicated in patients with dysphagia specially for
esophageal dysphgia to detect the structural cause of dysphagia such as cancer,benign
or malignat strictures or external compressions, webs or diverticuli or errosive GERD
4. Foreign body injestions: upper endoscopy is indicated in patients with susspected
FB& caustic-acid injestion after proper stabilization to confirm the diagnosis &
remove the FB in a timely fasion & assess for the degree of the injury & complication
in caustic-acid injestion.
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5. Gastroesophageal reflux disaese: upper endoscopy is indicated in patients with
heart burn not reponding to two months of proton pump inhibitors twice daily to
confirm the diagnosis if there is errosive GERD, consider other diagnosis such as
eosinophilic esophagitis, achalasia & exclude peptic ulcer disease or gastric outlet
obstruction and the presence or absence of complications like ulcers ,strictures,
bleeding & Barret's.
6. Diagnosis of esophageal varices in established chronic liver disaese or support the
diagnosis of chronic liver disease by confirm the presence of portal hypertension & its
features including esophgeal varives,fundal varices, other ectopic upper GI varives,
portal hypertensive gastropathy, portal hypertensive polyps & gastric antral vascular
7. Diagnosis of celiac disease by duodenal biopsies in patients with intestinal typical
features or those with atypical presentations.
B. Therapeutic indications:
1. Upper GI Bleeding: is the most common therapeutic indication for upper GI
endoscopy.It usually done after patient stabilization within 12-24 hours.The aim of
upper GI endoscopy to find the cause of upper GI bleeding whether non-variceal or
variceal or due to other causes.Commonly missed lesions during initial endoscopy for
upper GI bleeding are dialafoey lesions, Cameron lesions & angiodysplasia which
frequently lead to multiple admisions & endoscopies untill the final diagnosis is done.
Another aim of endoscopy is to stratify bleeding peptic ulcers according to Forrest
classification so that dual endoscopic intervention ios carried out for spurting vessels,
ozzing lesions,adherent clot & visible vessel in the ulcer base, while ulcers with clean
base or few pigmentary lesions are managed without endoscopic interventions.Second
trial of endoscopic intervention is indicated for rebleeding lesion after first endoscopic
intervention and if still recurrence occurs, interventional radiology methods are used
to control the bleeding before resorting to surgery.
2. Assessment and removal of foreign bodies injestion: upper GI endoscopy is
indicated in cases of foreign body ingestions to confirm the diagnosis and remove
sharp ones which poses risk of perforation and long ones which can not pass the
duodenal bend and also assess the magnitute of injury in acoustic –acid ingestion.
3. Dilatation of strictures:benign esophageal strictures like peptic strictures or surgical
anastomotic strictures are amenable to endoscopic balloon or sivary bouge dilation &
sometimes needle knife endoscopic incisional dilation or on the contrary endoscopic
narrowing of bariatric wide mouth gastrojejunostomies by vvarious endoscopic
4. Endoscopic interventions for Achalasia: usually in the form of through the scope
Balloon dilation or botulinium toxin endoscopic ingections or recently performing per
oral endoscopic myomotmy(POEM) instead of the more invarive laproscopic heller's
5. Stenting for strictures & fistulas:patients with malignant gastric outlet obstruction
and esophageal strictures are managed with endoscopic insertion of self expandable
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metalic stents either for paliation if advanced or as a bridge for more definitive
surgery after radiochemotehrapy.Benign esophageal stricture like those due to GERD
or eosinophilic esophagitis or caustic ingestion are manged with endoscopic dilation
or temporary plastic steting. Tracheoesophageal fistulas can be closed by applying
endoscopic fully covered self expandable metalic stents.
6. Endoscopic interventions for GERD: patients with GERD refractory to therapy or
patients don’t willing to take chronic PPIs, can be maneged with a variet of
endoscopic GERD intervention ,the most commonly studied is the endoscopic
radiofrequency ablation of the lower esophageal sphicter to augment it & decrease or
prevent acid reflux.
7. Endoscopic erradication of Barret's: patients with chronic GERD & Barret's with
high grade dysplasia or low grade dysplasia with nodules, are managed with a variety
of endoscopic methods to erradicate the Barret's, most commonly with radiofrequency
ablation or endoscopic mucosal resection in case of localized nodular Barret's.
8. Endoscopic insertion of perendoscopic gastrostmy (PEG) tube:indicated in patients
who can have adequate nutrition or require prolonged nasogastric feeding , like those
with debilitating neurological diseases as dementia or cerebrovascular accidents or
severe muscular dystrophies.
9. Endoscopic bariatric interventioms such as intragastric baloons for managing
appetite & hence obsity, gastric botox injections or gastric plication by applying a
sewing devices attached to the scope head.New intragastric Balloons are invented that
does not require endoscopy for insertion but only for removal usually after six
10. Endospic removal of polyps & early gastric cancer by EMR or ESD.
C. Screening indications:
1. Screening for Barrets in patients with chronic GERD symptoms.
2. Screening for features of portal hypertension in patients with chronic liver disease.
3. Screening for cancer in those with high risk of esophageal Sqamous cell cancer and
gastric cancer such as chronic smokers and alcoholic, family history or those with
chronic atrophic gastritis or those with familial polyposis syndromes known to affect
the upper GIT.