UM Guidelines

	Deleted Clinical Indications for the following diagnoses:
	Milliman Care Guidelines Clinical Indications were deleted.

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	Added to: Clinical Indications
	Esophagogastroduodenoscopy (EGD) is generally indicated in the following circumstances Upper gastrointestinal bleeding: Acute active or recent bleeding Chronic bleeding of presumed upper gastrointestinal origin Chronic bleeding of unknown origin when a colon source has been excluded Suspected portal hypertension Treatment may include electrocoagulation, heater probe, laser or injection therapy, sclerotherapy, or banding of varices. Upper gastrointestinal foreign body Dysphagia or odynophagia: Treatment may include dilation of stenotic lesions, ablation of stenosing neoplasms, or stent placement. Caustic ingestion A radiographic study has suggested a neoplasm, obstruction, or gastric ulcer. Tri-annual surveillance of patients with familial adenomatous polyposis with or without soft tissue manifestations Obstruction, delayed gastric emptying, or persistent vomiting without radiographic explanation Weight loss of more than 10% of original body weight of unknown cause Persistent upper gastrointestinal symptoms suggestive of ulcer, gastritis, esophagitis, or reflux despite one month of maximum medical management including diet, positioning, antacids, with two weeks of histamine blockers, or proton pump inhibitors Sampling of gastric, duodenal, or jejunal tissue or fluid Placement of feeding or drainage tubes Surveillance of Barrett’s esophagus: After Index exam with biopsies One year follow-up exam with biopsies (if both biopsies are negative, then the next exam should be in 3 years) Barrett’s esophagus (low-grade dysplasia) Follow-up exam at 6 month intervals times two (if stable or clear) follow-up is annually Barrett’s esophagus (high-grade dysplasia) Follow-up every three months with biopsies to determine persistence or progression of the high-grade dysplasia (if the disease is multifocal HGD or the HGD persist), intervention is generally recommended SOURCES American College of Gastroenterology. (2005). Practice Guidelines: Guidelines for the management of dyspepsia. Retrieved March 1, 2006 from http://www.acg.gi.org/physicians/guidelines/dyspepsia.pdf. BlueCross BlueShield of Tennessee network physicians. April - June 2008. Jacobson, B. C., Hirota, W., Baron, T. H., Leighton, J. A., & Faigel, D. O. (2003). The role of endoscopy in the assessment and treatment of esophageal cancer. Gastrointestinal Endoscopy, 57 (7), 817-822. John Hopkins Pathology. (2000-2004). Barrett’s esophagus: Dysplasia. Retrieved November 24, 2003 from http://www.pathology2.jhu.edu/beweb/Dysplasia.cfm. National Cancer Institute. (2003, December). Screening for esophageal cancer. Retrieved November 24, 2003 from http://www.nci.nih.gov/cancerinfo/pdq/screening/esophageal/healthprofessional/. Sampliner, R. E., & The Practice Parameters Committee of the American College of Gastroenterology. (2002). The American Journal of Gastroenterology, 97 (8), 1888-1895. Talley, N. J., Vakil, N., & the Practice Parameters Committee of the American College of Gastroenterology. (2005). Practice Guidelines: Guidelines for the management of dyspepsia. American Journal of Gastroenterology, 100 (10), 2324-2337. * These guideline(s) have been revised from the Milliman USA Milliman Care Guidelines.  The portions of the guideline(s) which have been revised are identified through the use of [insert: italic, boldface, underlined, etc. as appropriate] text, and Milliman USA has neither reviewed nor approved the modified material.  Any statement to the contrary or association of the modified material with Milliman USA is strictly prohibited. This document has been classified as public information. The above information only contains the modified portion of the Milliman Care Guideline. If you wish to view the complete Milliman Care Guideline, please contact Milliman USA.