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Information

Editors

PerttuArkkila
JukkaKoffert

Gastroscopy

Essentials

  • The significance of gastroscopy in the investigation of upper abdominal complaints has diminished as the occurrence of recurrent peptic ulcers caused by Helicobacter pylori infection as well as the incidence of gastric cancer have decreased.
  • Before referring the patient to gastroscopy, find out about the histological findings of the previous gastroscopies. If the histology of the stomach and of the descending duodenum have been normal, Helicobacter pylori infection, peptic ulcer, gastric cancer and coeliac disease are improbable.
  • Gastroscopy is indicated if the patient has dyspepsia with onset at the age of over 55-60 years, or if he/she has alarming symptoms or signs.

Indications for gastroscopy

Gastroscopy as a diagnostic investigation

  • Dyspepsia with onset at the age of over 55-60 years
  • Alarming symptoms or patient history
  • Dyspepsia in a patient 55-60 years of age or younger
    • If the Helicobacter test is negative, the patient is treated with a proton pump inhibitor for 4 weeks. If the patient develops alarming symptoms or needs repeated PPI courses (at least 3 courses/year), he/she should be referred for a gastroscopy.
  • Suspicion of coeliac disease Coeliac Disease
    • When suspecting coeliac disease only if antibody testing has not lead to diagnosis or if one wants to exclude other, concurrent diseases.
  • Before bariatric surgery Bariatric Surgery (Obesity Surgery)
    • Helicobacter testing is sufficient except when surgery with the sleeve technique is planned or there is a strong suspicion of diaphragmatic hernia.

As a follow-up examination

  • Follow-up of Barrett's oesophagus
  • Follow-up of the healing of an oesophageal or ventricle ulcer
  • Follow-up of the healing of severe oesophagitis (LA classification: grades C and D)
  • Follow-up of atrophic gastritis and dysplastic changes
  • Follow-up of adenomatous polyp or carcinoid of the ventricle
  • Examining a person with coeliac disease if they have symptoms despite correct gluten-free dietary managementCoeliac Disease
  • Diagnosis and follow-up of oesophageal varices

Procedures

  • Ligations and other treatments for varicose veins
  • Ablation of Barrett's changes
  • Treatment of bleeding and prevention of re-bleeding
  • Dilatation of strictures
  • Polypectomy
  • Stenting
  • Percutaneous endoscopic gastrostomy (PEG tube installation)

Gastroscopy usually not indicated

  • The following conditions do not fulfil the criteria for gastroscopy:
    • mild symptoms suggesting gastro-oesophageal reflux that responds to changes in life style or mild medication
    • dyspepsia in a patient 55-60 years of age or younger that cures with eradication treatment for Helicobacter pylori or during a 4-week PPI treatment, provided that the patient has no alarming symptoms and does not use NSAIDs
      • The recommended age threshold varies between guidelines.
    • dyspepsia when the patient has already undergone gastroscopy with normal findings
    • symptoms suggesting lactose intolerance before a trial with milk-free diet
    • long-standing symptoms of irritable bowel syndrome, such as abdominal pain, distention, diarrhoea and/or constipation.

Biopsies

  • Biopsies support the diagnostics: gastritis, Helicobacter infection, atrophy, possible malignancy of a peptic ulcer, coeliac disease and giardiasis can be diagnosed or ruled out.
    • Routine biopsies are taken from the lesser and greater curvature of the stomach, from the area of both the corpus and the antrum, and from the descending part of the duodenum. If the person has difficulties swallowing, biopsies should also be taken from the middle and lower thirds of the oesophagus (to exclude e.g. oesinophilic oesophagitis).

Preparation for the investigation and care after it

  • The patient must not take food after 8 o'clock on the preceding evening, or for a minimum of 5 hours before the examination.
  • Sucralfate, antacids (which adsorb on the gastric mucosa) and drugs that delay gastric emptying should be stopped (1-)2 days before the investigation. Other drugs can the taken as usual.
  • After the investigation the patient should eat cool, soft food. If a local anaesthetic has been used the patient should not drink or eat during the first 1-2 hours after the examination (risk of aspiration).
  • Antimicrobial prophylaxis is not needed before gastroscopy Prevention of Bacterial Endocarditis.
  • Interrupting anticoagulant therapy
    • Normally there is no need to interrupt aspirin or warfarin therapy, if only regular biopsies are taken during the gastroscopy. Clopidogrel should be paused for 5 days except in patients who initially started using it because of a cardiological indication (consult a cardiologist about interrupting the medication).
    • Interrupting direct anticoagulant therapy is carried out according to local guidelines.
  • Premedication: anaesthetization of the throat by lidocaine spray or gel. No other routine medication is required, but 1-2 mg of intravenous midazolam may be given before the endoscopy, if needed.

Significant gastroscopic findings

Oesophagus

  • Erosive striae (Los Angeles classification is recommended)
  • Strictures, ulcers, tumours
  • Pale plaques or coatings (e.g. Candida esophagitis, may be a sign of immunosuppressive disease or medication)
  • Barrett's oesophagus (squamous cell epithelium is replaced by metaplastic columnar epithelium, intestinal metaplasia): endoscopic follow-up may be needed because of an increased risk of cancer)

Ventricle

  • Retention
  • Ulcer (large size, undefined borders, nodular base suggest malignancy); control gastroscopy and biopsies required after treatment
  • Tumour, adenoma
  • Bleeding lesion (coagulation at endoscopy often possible)
  • Clear atrophy
    • Atrophic corpus gastritis may lead to vitamin B12 deficiency; determine the serum concentration of the transcobalamin II-bound vitamin B12.
    • Atrophic gastritis increases the risk of cancer to some degree. Gastroscopic follow-up of symptomless patients with atrophic gastritis is not indicated, but in symptomatic patients gastroscopy should be repeated quite readily.

Duodenum

  • Ulcer
  • Erosive or deformed bulbus (suggests a risk of duodenal ulcer)
  • Histological bulbitis (suggests a risk of duodenal ulcer)
  • Histological villus atrophy (confirms the diagnosis of coeliac disease)
  • Giardiasis

Findings of uncertain or marginal clinical significance

  • See table T2.

Gastroscopy findings and histological changes in a dyspepsia patient with uncertain or marginal clinical significance

FindingPossible clinical significance
Oesophagus
Gastric heterotopia in the upper thirdInnocent congenital anomaly
Redness, reddish patches, ill-defined striaeUnspecific for oesophagitis
Hiatus herniaNot always associated with the symptoms
Histological oesophagitis without erosionMay be a normal finding in the distal end; sensitivity and specificity are poor.
Ventricle
Bile refluxNo clear correlation with the symptoms
Redness, erosionsNo correlation with gastritis or symptoms
Prepyloric deformed folds (+ erosions)Correlation with symptoms unclear
Intestinal metaplasiaAssociated with atrophy, does not require follow-up
Duodenum
Redness and swellingNo correlation with histological duodenitis

Contraindications to and complications

  • Decompensated heart failure and severe pulmonary disease are contraindications to gastroscopy.
  • Recent myocardial infarction is a relative contraindication, although endoscopy seldom causes ischaemia in haemodynamically stable patient.
  • Pregnancy is not a contraindication.

    References

    • Beaton DR, Sharp L, Lu L, ym. Diagnostic yield from symptomatic gastroscopy in the UK: British Society of Gastroenterology analysis using data from the National Endoscopy Database. Gut 2024;73(9):1421-1430.[PubMed]
    • Yang YX, Brill J, Krishnan P, et al. American Gastroenterological Association Institute Guideline on the Role of Upper Gastrointestinal Biopsy to Evaluate Dyspepsia in the Adult Patient in the Absence of Visible Mucosal Lesions. Gastroenterology 2015;149(4):1082-7. [PubMed]
    • Boustière C, Veitch A, Vanbiervliet G, et al. Endoscopy and antiplatelet agents. European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2011;43(5):445-61. [PubMed]
    • Talley NJ, Vakil N. Practice Parameters Committee of the American College of Gastroenterology. Guidelines for the management of dyspepsia. Am J Gastroenterol 2005;100(10):2324-37. [PubMed]