Diagnostic Upper GI Endoscopy Requesto Gastroscopy
Indication A: Symptoms and Investigations
(tick all that apply and provide copy of relevant results)
Bleeding:
o Haematemesis o Melaena
o Iron deficiency anaemia (attach Hb and Ferritin level)
o Abnormal blood test (please check): o low Hb / o low ferritin /
o microcytosis / o hypochromasia / o raised platelets
Suspected malignancy:
o Age ≥ 55 years o Dysphagia
o Suspected malignancy on imaging (attach report)
o Nausea / vomiting, persistent (≥ 6 weeks)
o Loss of appetite o Early satiety
o Unexplained weight loss (≥10% of body weight)
o Known: o Barrett’s oesophagus / o gastric intestinal metaplasia /
o gastric dysplasia / o atrophic gastritis / (check all that apply)
o Family history of upper GI cancer in 1st degree relative
Other symptoms:
o GORD o Not responsive to PPI o Recent onset
o Dyspepsia o Not responsive to PPI and/or H. pylori treatment (please circle)
o Upper abdominal pain
o Suspected coeliac disease (with positive serology – attach results
o Other: