Esophagogastroduodenoscopy

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Esophagogastroduodenoscopy (EGD), also referred to as upper endoscopy, is a procedure in which a flexible fiber-optic endoscope is passed through the mouth and oropharynx to visualize the mucosa of the esophagus, stomach, and, sometimes, the duodenum. It is commonly used to diagnose and manage upper gastrointestinal (GI) disorders, monitor precancerous syndromes (e.g., Barrett esophagus), and guide endoscopic percutaneous feeding tube placement. Contraindications include GI perforation and postsurgical upper GI bleeding (UGIB). Complications include bleeding, esophageal perforation, and infection (e.g., bacteremia, aspiration pneumonia).

• Screening for esophageal varices: newly diagnosed cirrhosis or clinically significant portal hypertension ^[2][3]
• Screening for Barrett esophagus: chronic GERD symptoms (weekly for ≥ 5 years) and ≥ 3 additional risk factors for Barrett esophagus ^[4]
• Diagnostic ^[2][3]
  • Active or recent UGIB
  • Persistent dyspepsia and/or heartburn despite adequate treatment
  • Persistent idiopathic nausea and vomiting
  • Esophageal dysphagia or odynophagia
  • Iron deficiency anemia if UGIB is suspected
  • After ingestion of a toxic substance for injury assessment
  • Abnormal imaging findings, e.g., esophageal stricture on esophageal barium swallow
  • Unexplained diarrhea if an upper GI cause is suspected, e.g., celiac disease
  • Unexplained upper abdominal symptoms, especially if associated with anorexia and/or weight loss, or in patients aged > 50 years
• Therapeutic intervention ^[2][3]
  • Endoscopic hemostasis for UGIB, e.g., esophageal variceal bleeding
  • Management of foreign body ingestion or food bolus impaction
  • Endoscopic mucosal resection, submucosal dissection, or ablation of early gastric cancer
  • Dilation or stenting, e.g., for esophageal stricture, achalasia
  • Feeding tube (e.g., gastrostomy tube) placement
• Surveillance ^[2][3]
  • Precancerous syndromes, e.g., Barrett esophagus, hereditary polyposis syndrome
  • Monitoring for progression of known esophageal varices

• Known or suspected GI perforation ^[2]
• Postsurgical UGIB ^[5]

We list the most important contraindications. The selection is not exhaustive.

Always obtain and document informed consent from the patient or their legal guardian.

Aspiration prevention

• Recommended fasting instructions ^[6]
  • No clear liquids for at least 2 hours before endoscopy
  • No solid food for at least 6 hours before endoscopy
• Provide oral and written instructions to improve adherence.

It may not be possible to delay endoscopy for fasting in hemodynamically unstable patients (e.g., those with esophageal variceal bleeding).

Consider intubation before EGD in patients with UGIB who are at risk of aspiration (e.g., patients with altered mental status or severe ongoing hematemesis). ^[7]

Medication management

• Anticoagulant reversal: Consider for selected patients with life-threatening GI bleeding. ^[8][9]
• Antibiotic prophylaxis
  • Give to all patients with esophageal variceal hemorrhage. ^[10]
  • Consider prior to placement of a percutaneous endoscopic gastrostomy or jejunostomy tube. ^[11]
• Vasoactive medications (e.g., octreotide): Give to all patients with esophageal variceal hemorrhage. ^[10]
• Prokinetic agents (e.g., erythromycin): Consider for patients with acute UGIB. ^[12]
• Other medications
  • Consider holding other scheduled medications based on specialist consultation and/or local protocols.
  • Management of antithrombotic agents depends on the procedure-related bleeding risk.
    • Warfarin can usually be continued.
    • Aspirin for ASCVD management can usually be continued.

Preprocedural diagnostic studies ^[13]

• Routine studies are not recommended.
• Consider testing based on patient history, physical examination findings, and procedural risk, e.g.:
  • Pregnancy testing: patients of child-bearing age
  • CBC: known anemia, active significant bleeding, or high procedure-related bleeding risk
  • BMP: known severe renal or hepatic dysfunction (e.g., cirrhosis, renal failure)
  • Coagulation studies: active bleeding
  • Blood typing and crossmatching: active significant bleeding or severe anemia
  • CXR: symptoms of decompensated heart failure or new respiratory symptoms

The following is a general overview and is not intended as a comprehensive guide. ^[14]

• Place the patient in the left lateral decubitus position.
• Initiate continuous cardiac monitoring and pulse oximetry.
• Administer procedural sedation.
• Insert the endoscope into the hypopharynx and pass it through the upper esophageal sphincter under direct visualization.
• Insufflate air as needed to improve visualization.
• Examine the upper, middle, and lower esophagus as the endoscope is gradually advanced toward the gastroesophageal junction.
• Examine the stomach and duodenum.
• Obtain biopsies and/or perform therapeutic interventions if indicated.

Complications from diagnostic EGD are rare. The risk of complications is higher with certain therapeutic interventions, e.g., dilation or management of food bolus impaction. ^[15]

• GI bleeding
• GI perforation, e.g., iatrogenic esophageal perforation
• Complications of procedural sedation
• Aspiration pneumonia or pneumonitis
• Bacteremia
• Complications related to an endoscopic intervention, e.g., stent occlusion or migration

We list the most important complications. The selection is not exhaustive.