Guideline sources The following summarized guidelines for the evaluation and management of upper gastrointestinal endoscopy are prepared by our editorial team based on guidelines from the American College of Gastroenterology (ACG/CAG 2022), the European Society of Gastrointestinal Endoscopy (ESGE 2021), the European Society of Gastrointestinal Endoscopy (ESGE/BSG 2021), and the American Society for Gastrointestinal Endoscopy (ASGE 2020; 2018; 2016). 1 2 3 4 5 6 Guidelines 1. Diagnostic procedures Tissue sampling (technical considerations): consider placing mucosal biopsy specimens into labeled containers containing adequate amounts of tissue fixation fluid (10% buffered formalin). C Show 4 more Tissue sampling (dyspepsia and GERD): take 2 biopsies from the antrum and 2 from the corpus in patients with suspected H. pylori infection and for gastritis staging. B Show 2 more Tissue sampling (Barrett's esophagus): perform biopsy from all visible mucosal abnormalities in patients with endoscopic evidence of Barrett's esophagus of > 1 cm. Perform additional random 4-quadrant biopsies every 2 cm within the Barrett's segment, starting from the upper end of the gastric folds. Place biopsies from each level in a separate container. A https://web.pathway.md/diseases/recwGWfulUFHKwaTB 1/5 6/29/23, 3:47 AM Upper gastrointestinal endoscopy Pathway Tissue sampling (premalignant and malignant lesions): take at least 6 biopsies in patients with suspected advanced esophageal cancer. B Show 8 more Tissue sampling (celiac disease): take at least 6 biopsies from different locations in the duodenum, including 2 samples from the duodenal bulb, in patients with suspected celiac disease. Consider placing biopsies in the same container. A Tissue sampling (eosinophilic esophagitis): take at least 6 biopsies, 2-4 biopsies from the distal esophagus and 2-4 biopsies from the proximal esophagus, targeting areas with endoscopic mucosal abnormalities in patients with suspected eosinophilic esophagitis. Place distal and proximal biopsies in separate containers. B Show 2 more Tissue sampling (infectious esophagitis): Consider performing biopsies in patients with suspected candida esophagitis only if results are expected to have therapeutic consequences. Obtain histologic and mycologic analysis of esophageal biopsies targeted at white plaque-like lesions, if there is treatment resistance. C Take 6 biopsies, including from the base and edge of the esophageal ulcers, for histologic analysis in patients with suspected viral esophagitis. B 2. Medical management Management of antiplatelet therapy, preprocedural: As per CAG/ACG 2022 guidelines, insufficient to recommend for or against temporary interruption of the P2Y12 inhibitor in patients on single antiplatelet therapy with P2Y12 inhibitor agents undergoing elective endoscopic gastrointestinal procedures. E Show 2 more As per ESGE/BSG 2021 guidelines, counsel all patients on the thrombotic risks of discontinuing antiplatelets, as well as the hemorrhagic risks of continuing therapy. B Show 4 more As per ASGE 2016 guidelines, consider continuing low doses of aspirin and NSAIDs in the periendoscopic period. C Show 4 more Management of antiplatelet therapy, postprocedural: As per CAG/ACG 2022 guidelines, insufficient evidence to recommend for or against resuming P2Y12 inhibitor on the same day of the procedure versus 1-7 days after the procedure in patients interrupted the P2Y12 inhibitor in the periprocedural period for elective endoscopic gastrointestinal procedures. I As per ESGE/BSG 2021 guidelines: Resume antiplatelet therapy, if discontinued preprocedurally, up to 2-3 days after the procedure depending on the perceived hemorrhagic and thrombotic risks. B Counsel all patients on antiplatelets about the increased risk of postprocedural hemorrhage. B Management of antiplatelet therapy, acute GI bleeding: https://web.pathway.md/diseases/recwGWfulUFHKwaTB 2/5 6/29/23, 3:47 AM Upper gastrointestinal endoscopy Pathway As per ESGE/BSG 2021 guidelines, consider discontinuing aspirin permanently for primary prophylaxis. C Show 2 more As per ASGE 2016 guidelines: Consult with the prescribing specialist (or their colleague) before stopping antiplatelets in situations of significant gastrointestinal bleeding in patients with recently (< 1 year) placed drug-eluting intracoronary stents, within 30 days after insertion of a bare metal intracoronary stent, or within 90 days of acute coronary syndrome. Recognize that the risk of an adverse cardiac event associated with cessation of the antiplatelet therapy likely exceeds the benefit of decreasing postendoscopic bleeding. B Keep antiplatelet agents in patients on antiplatelet therapy with life-threatening or serious gastrointestinal bleeding after discussion with their cardiologist. B Management of anticoagulant therapy, preprocedural: As per CAG/ACG 2022 guidelines, consider continuing warfarin rather than temporarily interrupting (1-7 days) in patients on warfarin undergoing elective/planned endoscopic gastrointestinal procedures. C Show 2 more As per ESGE/BSG 2021 guidelines, counsel all patients on the thrombotic risks of discontinuing anticoagulants, as well as the hemorrhagic risks of continuing therapy. B Show 5 more As per ASGE 2016 guidelines, defer elective endoscopic procedures until short-term anticoagulation therapy (such as warfarin for VTE) is completed. B Show 3 more Management of anticoagulant therapy, postprocedural: As per CAG/ACG 2022 guidelines: Insufficient evidence to recommend for or against resuming warfarin on the same day of the procedure versus 1-7 days after the procedure in patients interrupted warfarin in the periprocedural period for elective endoscopic gastrointestinal procedures. I Insufficient evidence to recommend for or against resuming the direct OAC on the same day of the procedure versus 1-7 days after the procedure in patients interrupted the direct OAC in the periprocedural period for elective endoscopic gastrointestinal procedures. I As per ESGE/BSG 2021 guidelines: Resume anticoagulant therapy, if discontinued preprocedurally, up to 2-3 days after the procedure depending on the perceived hemorrhagic and thrombotic risks. B Counsel all patients on anticoagulants about the increased risk of postprocedural hemorrhage. B As per ASGE 2016 guidelines: Consider resuming warfarin on the same day as the procedure in all patients not having ongoing bleeding. C Consider delaying reinitiation of direct acting anticoagulants after high-risk endoscopic procedures until adequate hemostasis is ensured, given their rapid onset of action and lack of reversal agents. Consider administering thromboprophylaxis (UFH, bridge) if therapeutic doses of direct acting anticoagulants cannot be restarted within 12-24 hours after a high- https://web.pathway.md/diseases/recwGWfulUFHKwaTB 3/5 6/29/23, 3:47 AM Upper gastrointestinal endoscopy Pathway risk endoscopic procedure, to decrease the risk of thromboembolism, given the short half- life of the direct acting anticoagulant agent, in patients with a high risk for thromboembolism. C Management of anticoagulant therapy, acute GI bleeding: As per ESGE/BSG 2021 guidelines, withhold OAC and correct coagulopathy according to the severity of hemorrhage and the patient's thrombotic risk in coordination with a consultant cardiologist/hematologist. Ensure that the correction of coagulopathy does not delay endoscopy or radiological intervention. B Show 3 more As per ASGE 2016 guidelines, keep anticoagulant agents in patients with acute gastrointestinal bleeding on anticoagulation therapy to facilitate achievement of hemostasis. B Show 3 more 3. Quality improvement Requirements for staffing members: consider ensuring a minimum staffing of 1 endoscopy staff member (unlicensed assistive personnel or registered nurse) in the room for routine procedures without sedation. E Show 5 more Requirements for infection control: recognize that transmission of infection as a result of gastrointestinal endoscopes is extremely rare, and most reported cases are attributable to lapses in currently accepted endoscope reprocessing protocols or to defective equipment. Show 8 more References 1. Roos E Pouw, Maximilien Barret, Katharina Biermann et al. Endoscopic tissue sampling Part 1 Upper gastrointestinal and hepatopancreatobiliary tracts. European Society of Gastrointestinal Endoscopy ESGE Guideline. Endoscopy. 2021 Nov;53 11 1174 1188. Open 2. ASGE Standards of Practice Committee, Ruben D Acosta, Neena S Abraham et al. The management of antithrombotic agents for patients undergoing GI endoscopy. Gastrointest Endosc. 2016 Jan;83 1 3 16. Open 3. ASGE Quality Assurance in Endoscopy Committee, Audrey H Calderwood, Lukejohn W Day et al. Infection control during GI endoscopy. Gastrointest Endosc. 2018 May;87 5 1167 1179. Open 4. Andrew M Veitch, Franco Radaelli, Raza Alikhan et al. Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology BSG and European Society of Gastrointestinal Endoscopy ESGE guideline update. Gut. 2021 Sep;70 9 1611 1628. Open 5. Laith H Jamil, Mariam Naveed, Deepak Agrawal et al. ASGE guideline on minimum staffing requirements for the performance of GI endoscopy. Gastrointest Endosc. 2020 Apr;91 4 723 729.e17. Open 6. Neena S Abraham, Alan N Barkun, Bryan G Sauer et al. American College of Gastroenterology- Canadian Association of Gastroenterology Clinical Practice Guideline: Management of Anticoagulants https://web.pathway.md/diseases/recwGWfulUFHKwaTB 4/5 6/29/23, 3:47 AM Upper gastrointestinal endoscopy Pathway and Antiplatelets During Acute Gastrointestinal Bleeding and the Periendoscopic Period. Am J Gastroenterol. 2022 Mar 17. Open 7. Calderwood AH, Chapman FJ, Cohen J et al. Guidelines for safety in the gastrointestinal endoscopy unit. Gastrointest Endosc. 2014 Mar;79 3 363 72. Open 8. ASGE Standards of Practice Committee, Ashley L Faulx, Jenifer R Lightdale et al. Guidelines for privileging, credentialing, and proctoring to perform GI endoscopy. Gastrointest Endosc. 2017 Feb;85 2 273 281. Open 9. Jean-Marc Dumonceau, Pierre H Deprez, Christian Jenssen et al. Indications, results, and clinical impact of endoscopic ultrasound EUS)-guided sampling in gastroenterology: European Society of Gastrointestinal Endoscopy ESGE Clinical Guideline Updated January 2017. Endoscopy. 2017 Jul;49 7 695 714. Open 10. ASGE Standards of Practice Committee, Mouen A Khashab, Krishnavel V Chithadi et al. Antibiotic prophylaxis for GI endoscopy. Gastrointest Endosc. 2015 Jan;81 1 81 9. Open https://web.pathway.md/diseases/recwGWfulUFHKwaTB 5/5