Indications for oesophagogastroduodenoscopy

Indications for oesophagogastroduodenoscopy

A full assessment of the role of OGD is outside the scope of this chapter. It will vary with local circumstances and the availability of alternative diagnostic techniques. OGD is usually appropriate when a patient’s symptoms are persistent despite appropriate empirical therapy or are associated with warning signs such as intractable vomiting, anaemia, weight loss, dysphagia or bleeding. It is also part of the diagnostic work-up for patients with anaemia, symptoms of

• Diagnostic procedures +/– biopsy • Biliary or pancreatic stenting • Device-assisted enteroscopy without polypectomy Continue warfarin Warfarin Check INR 1 week before endoscopy • If INR is within therapeutic range continue usual daily dose • If INR is above therapeutic range but <5 reduce daily dose until INR returns to therapeutic range High-risk procedure • Polypectomy • ERCP with sphincterotomy • EMR/ESD • Dilatation of strictures Warfarin Low-risk condition High-risk condition • Prosthetic metal heart valve in mitral or aortic • Xenograft heart valve position • AF without high-risk factors • Prosthetic heart valve and AF (CHADS ≤4) 2 • AF and mitral stenosis • >3 months after VTE • AF with previous stroke/TIA and 3 or more of: • Congestive cardiac failure a • Hypertension • Age >75 years • Diabetes mellitus • AF and stroke/TIA within 3 months • <3 months after VTE • Previous VTE on anticoagulation Stop warfarin for 5 days before Stop warfarin for 5 days before endoscopy • Check INR prior procedure to ensure • Start LMWH 2 days after stopping warfarin INR <5 • Omit LMWH on day of procedure • Restart warfarin evening of the procedure • Restart warfarin evening of the procedure with usual daily dose with usual daily dose • Check INR 1 week later to ensure • Continue LMWH until INR adequate adequate anticoagulation Low-risk condition • Ischaemic heart disease without coronary stent • Cerebrovascular disease • Peripheral vascular disease Stop clopidogrel, prasugrel or ticagrelor 7 days before endoscopy • Continue aspirin if already prescribed • Restart clopidogrel, prasugrel or ticagrelor 1–2 days after procedure Figure 9.2 British Society of Gastroenterology and European Society of Gastrointestinal Endoscopy 2021 guidelines for management of endos copy in patients on antiplatelet or anticoagulant therapy. AF , atrial /f_i brillation; CHADS, score for stroke risk assessment in atrial /f_i brillation; DOAC, direct oral anticoagulant; eGFR, estimated glomerular /f_i ltration rate; EMR, endoscopic mucosal resection; ERCP , endoscopic cholangiopancreatography; ESD, endoscopic submucosal dissection; EUS, endoscopic ultrasound; INR, international normalised ratio; LMWH, low molecular weight heparin; PEG, percutaneous endoscopic gastroenterostomy; TIA, transient ischaemic attack; VTE, venous thrombo a embolism. Blood pressure >140/90 mmHg or on antihypertensive medication. c Depends on haemorrhagic and thrombotic risk; consider extending interval for ESD. (Adapted from Veitch • Oesophageal, enteral or colonic stenting • EUS without sampling or interventional therapy DOAC • Dabigatran Omit DOAC on • Rivaroxaban morning of the • Apixaban procedure • Edoxaban • Therapy of varices • PEG • EUS-guided sampling or with interventional therapy • Oesophageal or gastric radiofrequency ablation DOAC Clopidogrel • Dabigatran • Apixaban Prasugrel • Rivaroxaban • Edoxaban Ticagrelor Take last dose of drug 3 days before endoscopy • For dabigatran with CrCI (eGFR) 30–50 mL/min take last dose 5 days before procedure • In any patients with rapidly deteriorating renal function a haematologist should be consulted • Restart DOAC 2–3 days after c procedure b endoscopy High-risk condition • Coronary artery stents Discuss strategy with consultant interventional cardiologist • Consider temporary cessation of P2Y12 receptor antagonist if: • 6–12 months after insertion of drug-eluting coronary stent • >1 month after insertion of bare metal coronary stent • Continue aspirin

retrograde

b Previous VTE on anticoagulation and target INR now 3.5. et al . 2021.)

malabsorption and chronic diarrhoea. However, increasing ease of access to OGD with the availability of ‘open access’ endoscopy has resulted in a significant number of unnecessary procedures being performed in young patients with dyspepsia or gastro-oesophageal reflux disease (GORD). This has led to a number of international gastroenterology societies proposing guidelines for the management of dyspepsia and GORD, including the empirical use of acid suppression and non-invasive H. pylori tests, such as urease breath tests and stool antigen assay (e.g. the National Institute for Health and Care Excellence guidelines on dyspepsia: https://www .nice.org.uk/ guidance/cg184/chapter/1-recommendations). In addition

(c) Figure 9.3 A normal upper gastrointestinal endoscopy showing the gastro-oesophageal junction the gastric antrum (c) and the second part of the duodenum (a) Figure 9.4 Grade 2 oesophageal varices (a) , which can be treated by the application of bands to ligate the vessel and reduce blood /f_l ow (d) (a) , the gastric fundus in the ‘J’ position (b) , (d) . (b) (b) .

the surveillance of neoplasia development in high-risk patient groups, such as those with genetic conditions such as familial adenomatous polyposis and premalignant conditions such as Barrett’s oesophagus (see Chapter 66 ). Indications for oesophagogastroduodenoscopy

A full assessment of the role of OGD is outside the scope of this chapter. It will vary with local circumstances and the availability of alternative diagnostic techniques. OGD is usually appropriate when a patient’s symptoms are persistent despite appropriate empirical therapy or are associated with warning signs such as intractable vomiting, anaemia, weight loss, dysphagia or bleeding. It is also part of the diagnostic work-up for patients with anaemia, symptoms of

• Diagnostic procedures +/– biopsy • Biliary or pancreatic stenting • Device-assisted enteroscopy without polypectomy Continue warfarin Warfarin Check INR 1 week before endoscopy • If INR is within therapeutic range continue usual daily dose • If INR is above therapeutic range but <5 reduce daily dose until INR returns to therapeutic range High-risk procedure • Polypectomy • ERCP with sphincterotomy • EMR/ESD • Dilatation of strictures Warfarin Low-risk condition High-risk condition • Prosthetic metal heart valve in mitral or aortic • Xenograft heart valve position • AF without high-risk factors • Prosthetic heart valve and AF (CHADS ≤4) 2 • AF and mitral stenosis • >3 months after VTE • AF with previous stroke/TIA and 3 or more of: • Congestive cardiac failure a • Hypertension • Age >75 years • Diabetes mellitus • AF and stroke/TIA within 3 months • <3 months after VTE • Previous VTE on anticoagulation Stop warfarin for 5 days before Stop warfarin for 5 days before endoscopy • Check INR prior procedure to ensure • Start LMWH 2 days after stopping warfarin INR <5 • Omit LMWH on day of procedure • Restart warfarin evening of the procedure • Restart warfarin evening of the procedure with usual daily dose with usual daily dose • Check INR 1 week later to ensure • Continue LMWH until INR adequate adequate anticoagulation Low-risk condition • Ischaemic heart disease without coronary stent • Cerebrovascular disease • Peripheral vascular disease Stop clopidogrel, prasugrel or ticagrelor 7 days before endoscopy • Continue aspirin if already prescribed • Restart clopidogrel, prasugrel or ticagrelor 1–2 days after procedure Figure 9.2 British Society of Gastroenterology and European Society of Gastrointestinal Endoscopy 2021 guidelines for management of endos copy in patients on antiplatelet or anticoagulant therapy. AF , atrial /f_i brillation; CHADS, score for stroke risk assessment in atrial /f_i brillation; DOAC, direct oral anticoagulant; eGFR, estimated glomerular /f_i ltration rate; EMR, endoscopic mucosal resection; ERCP , endoscopic cholangiopancreatography; ESD, endoscopic submucosal dissection; EUS, endoscopic ultrasound; INR, international normalised ratio; LMWH, low molecular weight heparin; PEG, percutaneous endoscopic gastroenterostomy; TIA, transient ischaemic attack; VTE, venous thrombo a embolism. Blood pressure >140/90 mmHg or on antihypertensive medication. c Depends on haemorrhagic and thrombotic risk; consider extending interval for ESD. (Adapted from Veitch • Oesophageal, enteral or colonic stenting • EUS without sampling or interventional therapy DOAC • Dabigatran Omit DOAC on • Rivaroxaban morning of the • Apixaban procedure • Edoxaban • Therapy of varices • PEG • EUS-guided sampling or with interventional therapy • Oesophageal or gastric radiofrequency ablation DOAC Clopidogrel • Dabigatran • Apixaban Prasugrel • Rivaroxaban • Edoxaban Ticagrelor Take last dose of drug 3 days before endoscopy • For dabigatran with CrCI (eGFR) 30–50 mL/min take last dose 5 days before procedure • In any patients with rapidly deteriorating renal function a haematologist should be consulted • Restart DOAC 2–3 days after c procedure b endoscopy High-risk condition • Coronary artery stents Discuss strategy with consultant interventional cardiologist • Consider temporary cessation of P2Y12 receptor antagonist if: • 6–12 months after insertion of drug-eluting coronary stent • >1 month after insertion of bare metal coronary stent • Continue aspirin

retrograde

b Previous VTE on anticoagulation and target INR now 3.5. et al . 2021.)

malabsorption and chronic diarrhoea. However, increasing ease of access to OGD with the availability of ‘open access’ endoscopy has resulted in a significant number of unnecessary procedures being performed in young patients with dyspepsia or gastro-oesophageal reflux disease (GORD). This has led to a number of international gastroenterology societies proposing guidelines for the management of dyspepsia and GORD, including the empirical use of acid suppression and non-invasive H. pylori tests, such as urease breath tests and stool antigen assay (e.g. the National Institute for Health and Care Excellence guidelines on dyspepsia: https://www .nice.org.uk/ guidance/cg184/chapter/1-recommendations). In addition

(c) Figure 9.3 A normal upper gastrointestinal endoscopy showing the gastro-oesophageal junction the gastric antrum (c) and the second part of the duodenum (a) Figure 9.4 Grade 2 oesophageal varices (a) , which can be treated by the application of bands to ligate the vessel and reduce blood /f_l ow (d) (a) , the gastric fundus in the ‘J’ position (b) , (d) . (b) (b) .

the surveillance of neoplasia development in high-risk patient groups, such as those with genetic conditions such as familial adenomatous polyposis and premalignant conditions such as Barrett’s oesophagus (see Chapter 66 ). Indications for oesophagogastroduodenoscopy

A full assessment of the role of OGD is outside the scope of this chapter. It will vary with local circumstances and the availability of alternative diagnostic techniques. OGD is usually appropriate when a patient’s symptoms are persistent despite appropriate empirical therapy or are associated with warning signs such as intractable vomiting, anaemia, weight loss, dysphagia or bleeding. It is also part of the diagnostic work-up for patients with anaemia, symptoms of

• Diagnostic procedures +/– biopsy • Biliary or pancreatic stenting • Device-assisted enteroscopy without polypectomy Continue warfarin Warfarin Check INR 1 week before endoscopy • If INR is within therapeutic range continue usual daily dose • If INR is above therapeutic range but <5 reduce daily dose until INR returns to therapeutic range High-risk procedure • Polypectomy • ERCP with sphincterotomy • EMR/ESD • Dilatation of strictures Warfarin Low-risk condition High-risk condition • Prosthetic metal heart valve in mitral or aortic • Xenograft heart valve position • AF without high-risk factors • Prosthetic heart valve and AF (CHADS ≤4) 2 • AF and mitral stenosis • >3 months after VTE • AF with previous stroke/TIA and 3 or more of: • Congestive cardiac failure a • Hypertension • Age >75 years • Diabetes mellitus • AF and stroke/TIA within 3 months • <3 months after VTE • Previous VTE on anticoagulation Stop warfarin for 5 days before Stop warfarin for 5 days before endoscopy • Check INR prior procedure to ensure • Start LMWH 2 days after stopping warfarin INR <5 • Omit LMWH on day of procedure • Restart warfarin evening of the procedure • Restart warfarin evening of the procedure with usual daily dose with usual daily dose • Check INR 1 week later to ensure • Continue LMWH until INR adequate adequate anticoagulation Low-risk condition • Ischaemic heart disease without coronary stent • Cerebrovascular disease • Peripheral vascular disease Stop clopidogrel, prasugrel or ticagrelor 7 days before endoscopy • Continue aspirin if already prescribed • Restart clopidogrel, prasugrel or ticagrelor 1–2 days after procedure Figure 9.2 British Society of Gastroenterology and European Society of Gastrointestinal Endoscopy 2021 guidelines for management of endos copy in patients on antiplatelet or anticoagulant therapy. AF , atrial /f_i brillation; CHADS, score for stroke risk assessment in atrial /f_i brillation; DOAC, direct oral anticoagulant; eGFR, estimated glomerular /f_i ltration rate; EMR, endoscopic mucosal resection; ERCP , endoscopic cholangiopancreatography; ESD, endoscopic submucosal dissection; EUS, endoscopic ultrasound; INR, international normalised ratio; LMWH, low molecular weight heparin; PEG, percutaneous endoscopic gastroenterostomy; TIA, transient ischaemic attack; VTE, venous thrombo a embolism. Blood pressure >140/90 mmHg or on antihypertensive medication. c Depends on haemorrhagic and thrombotic risk; consider extending interval for ESD. (Adapted from Veitch • Oesophageal, enteral or colonic stenting • EUS without sampling or interventional therapy DOAC • Dabigatran Omit DOAC on • Rivaroxaban morning of the • Apixaban procedure • Edoxaban • Therapy of varices • PEG • EUS-guided sampling or with interventional therapy • Oesophageal or gastric radiofrequency ablation DOAC Clopidogrel • Dabigatran • Apixaban Prasugrel • Rivaroxaban • Edoxaban Ticagrelor Take last dose of drug 3 days before endoscopy • For dabigatran with CrCI (eGFR) 30–50 mL/min take last dose 5 days before procedure • In any patients with rapidly deteriorating renal function a haematologist should be consulted • Restart DOAC 2–3 days after c procedure b endoscopy High-risk condition • Coronary artery stents Discuss strategy with consultant interventional cardiologist • Consider temporary cessation of P2Y12 receptor antagonist if: • 6–12 months after insertion of drug-eluting coronary stent • >1 month after insertion of bare metal coronary stent • Continue aspirin

retrograde

b Previous VTE on anticoagulation and target INR now 3.5. et al . 2021.)

malabsorption and chronic diarrhoea. However, increasing ease of access to OGD with the availability of ‘open access’ endoscopy has resulted in a significant number of unnecessary procedures being performed in young patients with dyspepsia or gastro-oesophageal reflux disease (GORD). This has led to a number of international gastroenterology societies proposing guidelines for the management of dyspepsia and GORD, including the empirical use of acid suppression and non-invasive H. pylori tests, such as urease breath tests and stool antigen assay (e.g. the National Institute for Health and Care Excellence guidelines on dyspepsia: https://www .nice.org.uk/ guidance/cg184/chapter/1-recommendations). In addition

(c) Figure 9.3 A normal upper gastrointestinal endoscopy showing the gastro-oesophageal junction the gastric antrum (c) and the second part of the duodenum (a) Figure 9.4 Grade 2 oesophageal varices (a) , which can be treated by the application of bands to ligate the vessel and reduce blood /f_l ow (d) (a) , the gastric fundus in the ‘J’ position (b) , (d) . (b) (b) .

the surveillance of neoplasia development in high-risk patient groups, such as those with genetic conditions such as familial adenomatous polyposis and premalignant conditions such as Barrett’s oesophagus (see Chapter 66 ).