Upper and lower GI endoscopies have diagnostic, therapeutic, and screening indications. For upper endoscopy, common diagnostic indications include dyspepsia in patients over age 60 or with red flags, upper GI bleeding, and dysphagia. Therapeutic uses include treatment of bleeding, removal of foreign bodies, dilation of strictures, and stenting. Screening is done for portal hypertension, Barrett's esophagus, eosinophilic esophagitis, and cancers. Lower endoscopy indications involve diagnostic evaluation of bleeding, abdominal pain, diarrhea, and screening of average-risk adults over 50 and high-risk groups. Therapeutic colonoscopy is used for polypectomy, bleeding treatment, and stricture dilation

1. Indications for upper & lower GI endoscopies
2020
by Professor Dr. Mohamed Alshekhani.

2. OGD Indications:
 Diagnostic.
 Therapeutic
 Screening

3.  1. Dyspepsia: The most indication, to detect serious diseases early
especially gastric cancer for a better outcome.
OGD:Diagnostic indications

4.  Dyspepsia is epigastric pain or discomfort, postprandial heaviness, early
satiety , nausea &occasional vomiting ( heart burn incating GERD is now
not included in the definition of dyspepsia).
 Dyspepsia is common affecting large number (25%)of the population
 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.
 Guidelines suggest doing endoscopy for dyspepstic patients if :
 A. Age is >60ys(west) & 45( in areas with high GC incidence like ours) or
 If they have red flags ; anorexia,weight loss, dysphagia,reapeted vomiting,
IDA, hematemesis, melena or family history of gastric cancer.
 Those dyspeptics who are youger &no red flags are managed either with
empIrical PPI or HP test & treat strategy, while keeping endoscopy for
those not responding to these 2 approach.
Diagnostic indications:dyspepsia

5.  Common > 50% of dyspeptic patients.
 Clue to diagnosis is the presence of other functional GIT( functional heart
burn,IBS, Functional abdominal pain, functional constipation, etc) or
functional non-GI disorders(irritable urinary bladder ,migraine tension
headache,fibromyalgias, functional pelic pain syndrome).
 Management:
 Explanation & reassurance.
 PPI.
 Prokinetics.
 Antidepressants.
 Psychotherapy.
Diagnostic indications:functional dyspepsia

6.  2. Upper GI Bleeding:. 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 include adrenaline-saline
endoscopic injection. & another endoscopic interventionmodality.
 3. 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 or achalasia.
 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.
 5. GERD: OGD is indicated in patients with heart burn not reponding to
two months of PPI 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 & the presence
or absence of complications like ulcers ,strictures, bleeding & Barret's.
Diagnostic indications:

7.  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 features including esophgeal varives,fundal varices,
other ectopic upper GI varives, portal hypertensive gastropathy, portal
hypertensive polyps & gastric antral vascular ectasia(GAVE).
 7. Diagnosis of celiac disease by duodenal biopsies in patients with
intestinal typical features or those with atypical presentations.
 8.Diagnostic evaluation of menopausal women and men with IDA.
 9. Evaluation of fresh bleeding per rectum with hemdynamic instability
should start with OGD before colonoscopy because of high possibility of
upper GI source.
 10.Gastroscopic or NGT application of stool in the procedure of fecal
microbiotal trsnsplantstion for recurrent clostridium difficilli infection.
Diagnostic indications:

8.  1. Upper GI Bleeding: is the most common therapeutic indication for
upper GI endoscopy.
 It is usually done after patient stabilization within 12-24 hours for
suspected NV UGIB & within 12 hours for suspected V UGIB.
 The aim of upper OGD is to find the cause of upper whether non-variceal
or variceal or other causes & do therapeutic endoscopic interventions.
 Commonly missed lesions during initial endoscopy for upper GI bleeding
are dialafoey lesions, Cameron lesions & angiodysplasia which frequently
lead to multiple admisions & endoscopies until the final diagnosis is done.
 Another aim is to stratify bleeding peptic ulcers according to Forrest
classification so that dual endoscopic intervention is carried out for
spurting vessels, ozzing lesions,adherent clot & visible vessel in the ulcer
base, while clean base ulcers or pigmentary lesions are managed conserv.
 2nd trial of endoscopic intervention is indicated for rebleeding lesion after
failure of first endoscopic intervention, interventional radiology are used
to control the bleeding before resorting to surgery.
OGD:Therapeutic indications

9.  2. Assessment&removal of FBs: to confirm the diagnosis& remove sharp
ones with risk of perforation & long ones with obstruction risk &assess the
magnitude of injury in acoustic–acid ingestion.
 3. Dilatation of strictures:benign eso strictures like peptic strictures or
surgical anastomotic strictures are amenable to endoscopic balloon or
savary bouge dilation & needle knife endoscopic incisional dilation or
narrowing of bariatric wide mouth gastrojejunostomies.
 4. Achalasia: Balloon dilation or botox ingections or per oral endoscopic
myomotmy(POEM) instead of more invasive laproscopic heller mymotmy.
 5. Stenting for strictures & fistulas:for malignant gastric outlet obstruction
or esophageal strictures ,endoscopic insertion of self expandable metalic
stents either for paliation if advanced or as a bridge for more definitive
surgery after radiochemotehrapy. Benign eso stricture due to GERD or
eosinophilic esophagitis or caustic ingestion with endoscopic dilation or
temporary plastic stenting. TE fistulas can be closed by fully covered self
expandable metalic stents.
Therapeutic indications:

10.  6. Endoscopic interventions for GERD: refractory to therapy or don’t
willing to take chronic PPIs, can be maneged with; endoscopic
radiofrequency ablation of the lower esophageal or endo funduplication.
 7. Endoscopic eradication 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. Perendoscopic gastrostmy (PEG):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, gastric botox injections or endoscopic gastrostomy .
 10. Endospic removal of polyps & early gastric cancer by EMR or ESD.
Therapeutic indications:

11.  6. Screening for features of portal hypertension in those with known or
suspected chronic liver disease or vascular liver diseases.
 7. Screening of those with severe GERD for complications specially for
Barret’s and EAC.
 8. Screening of those with EoE for response to therapy.
 9. Screening of celiac disease patients to GFD.
 10. Screening of those with high risk for esophageal and gastric cancer like
chronic smoker and alcoholic or aclasia or those with chronic atrophic
gastric from chronic H Pylori or autoimmune gastritis or family history of
these cancers or Gastric cancer removed with curative intent.
OGD: Screening &surveillance indications:

12.  1. Hematochesia or fresh bleeding per rectum.
 Melena with normal OGD raised the possibility of slowly bleeding
proximal colonic lesions.
 Abdominal pain or discomfort with with red flags as anorexia, weight loss,
sudden changes in bowel habits, night pains awakening from sleep,IDA,
Family H/O CRC,IBD & Celiac.
 Chronic diarrhea with red falgs,family H/O IBD,risk factors for
Clostridium difficili infection,microscopic colitis after excluding celiac
disease and thyrotoxicosis by appropriate lab testing.
 Peri-anal diseases as hemorrhoids, fissure and fistulas to exclude
underlying colonic diseases.
Colonoscopy indications: diagnostic

13.  Colonic intervention for sources of lower GI Bleeding.
 Removal of polyps; peduculated and flat; adenomatous or serrated, small
or large to prevent their progress to CRC by hot snare or cold snare
polypectomies, EMR or ESD.
 ESD removal of early CRC.
 Colonoscopic interventions of perianal diseases as endoscopic band ligation
for hemmorroids or botox ingection for anal fissure.
 Clonoscopy delooping for sigmoid volvulus.
 Colonoscopic self-expandable metallic stents for malignant obstruction as
paliation or bridge for definitive surgery.
 Colonoscopy before closing colostomies.
 Colonoscopic application of stool in the procedure of fecal microbiotal
trsnsplantstion for recurrent clostridium difficilli infection.
 Colonoscopic dilation of Crohn’s strictures.
Colonoscopy indications: Therapeutic

14.  Screening of every adult with average risk for CRC; 50 years and above(
45 years and above in certain races and ethnics).
 Screening earlier in those with family history of CRC( 10 years earlier
than the age of the affected 1st-dgree relative) or those with family history
of hereditary CRC syndrome as FAP or Lynch syndrome.
 Screening of IBD patients, 8 years after active colitis.
 Screening of those with cured CRC.
 Screening of those with removed colonic polyps, the interval depending on
their number,location, size and histopatholgy.
Colonoscopy indications: screening