The American Society for Gastrointestinal Endoscopy and American College of Gastroenterology Task Force on Quality in Endoscopy recently released updated quality indicators for esophagogastroduodenoscopy, with new priority indicators related to photodocumentation of key landmarks and appropriate documentation metrics for EGD procedures used in an expanding list of disease states and conditions (Am J Gastroenterol 2024;119[9]:1781-1791).
Lead author Rena Yadlapati, MD, the medical director of the Center for Esophageal Diseases at the University of California San Diego Health, told Gastroenterology & Endoscopy News that an update was needed because the care paradigms for EGD performance have evolved since the last iteration of the quality indicators. “EGD procedures are costly, require patients to take a day off of work and often to secure transportation, and carry the potential for risk,” she noted. “It is critical to ensure that EGDs are performed for an appropriate indication and that the optimal steps are taken during endoscopy to optimize diagnostic yield and therapeutic outcomes, all while minimizing risk.”
Dr. Yadlapati and her co-authors noted that while “there is little evidence to support the practice of photodocumentation in EGD, it is intuitive that this practice is a surrogate metric for mucosal cleaning, mucosal inspection including endoscopist blind spots, and a complete endoscopic examination, and serves as a reference in serial examinations and lesions referred for an endoscopic resection.” They added that photodocumentation is “well established” as a key indicator in colonoscopy and has been recommended in EGD by international organizations, including the European Society of Gastrointestinal Endoscopy and the World Endoscopy Organization.
“Endoscopists should be mindful of cleansing and inspecting throughout the entire EGD exam and photodocument the landmark sites,” Dr. Yadlapati said, reflecting a similar evolution in colonoscopy practice.
In addition to photodocumentation, the priority indicators include recommendations specific to common conditions, including erosive esophagitis, Barrett’s esophagus, peptic ulcer disease, upper GI bleeding and gastric premalignant conditions (Table).
| Table. ASGE/ACG Task Force Priority Indicators for EGD | ||
| Quality indicator | Performance target, % | Level of evidence |
|---|---|---|
| Frequency of photodocumentation of the esophagus, gastroesophageal junction, gastric cardia/fundus, corpus, incisura, antrum/pylorus, second portion of duodenum, and detected lesions in patients undergoing EGD | >90 | 3 |
| Frequency of Los Angeles classification documentation when erosive esophagitis is present | >98 | 2C |
| Frequency with which the presence of at least 1 cm of endoscopically evident columnar mucosa is documented while obtaining biopsy samples to evaluate for BE | >95 | 1C |
| Frequency with which the extent of suspected or confirmed BE is documented using the Prague criteria in cases of suspected or confirmed BE | >95 | 1C+ |
| Frequency with which, during EGD examination revealing peptic ulcers, at least 1 of the following stigmata is noted: active bleeding, nonbleeding visible vessels (pigmented protuberance), adherent clot, flat spot, or clean based | >98 | 1A |
| Frequency of endoscopic treatment delivered to ulcers with active spurting or oozing or with nonbleeding visible vessels | >90 | 1A |
| Frequency with which achievement of primary hemostasis in cases of attempted hemostasis of nonvariceal upper GI bleeding lesion is documented | >90 | 2A |
| Frequency of systematic biopsy sampling of the gastric corpus, antrum, and incisura in patients with known GPMCs, patients at high-risk for gastric cancer, or patients with an endoscopic appearance concerning for GPMCs | >90 | 2C |
| Frequency of administering high-dose proton pump inhibitor therapy (continuous or intermittently for 3 d) after successful endoscopic hemostatic therapy of a bleeding ulcer in patients without allergy or contraindication to the medication | >95 | 1A |
| Recommendations are graded from 1A to 3 based on methodologic strength supporting the evidence and clarity of benefit. Grade 1A implies a strong recommendation that can be applied to most clinical settings; grade 1C+ implies a strong recommendation that can apply to most practice settings in most situations; grade 1C implies an intermediate-strength recommendation that may change when stronger evidence is available; grade 2A implies an intermediate-strength recommendation in which the best action may differ depending on circumstances or patients’ or societal values; grade 2C implies a weak recommendation in which alternative approaches are likely to be better under some circumstances; and grade 3 implies a weak recommendation likely to change as data become available. BE, Barrett’s esophagus; EGD, esophagogastroduodenoscopy; GPMCs, gastric premalignant conditions. Based on Am J Gastroenterol 2024;119[9]:1781-1791. | ||
“In particular,” Dr. Yadlapati said, “there is a focus on high-quality screening and surveillance of pre-neoplastic conditions, including inspection with white light and chromoendoscopy, adherence to specific biopsy protocols, and emphasis on designating appropriate surveillance intervals.”
Although it is not a priority indicator, she emphasized the recommendation that EGDs should be performed for an appropriate indication. “Ultimately, endoscopists should consider the goal outcome,” she explained. “For instance, eosinophilic esophagitis should be considered for a patient with dysphagia. For patients with gastric premalignant conditions, it is imperative to risk-stratify in order to guide the need for and timing of surveillance endoscopy, as well as to biopsy thoroughly, as these are associated with gastric cancer. For patients with upper GI bleeding, successful hemostasis is associated with reduced risk of recurrent GI bleeding and mortality.”
Dr. Yadlapati said feedback on the updated quality indicators has been “very positive,” noting that the group has received questions about whether practices should modify their workflows to measure adherence. “In some cases, endoscopy software systems may need to be updated, for instance,” she said.
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The task force considered including new quality indicators focused on procedure and inspection time and neoplasia detection rate, Dr. Yadlapati added, but said the body of evidence was not able to support these. The group anticipates including these topics in future iterations, she said, “as well as … endobariatrics, third space endoscopy and the role of artificial intelligence,” which were beyond the scope of the present updates.
Rajesh Keswani, MD, MS, the director of quality for Northwestern Medicine Digestive Health Center, in Chicago, described the update as “fantastic” and said it will guide clinical practice for years to come. “These indicators are comprehensive and, when possible, supported by high-quality data with references,” Dr. Keswani said. “I am very happy to see this update, as it has been many years since [quality indicators] were last published, and it is important that our indicators reflect the volume of research that has taken place since they were last developed.”
Dr. Keswani praised the updated guidelines’ “strong emphasis” on using a consistent nomenclature when documenting findings, such as for eosinophilic esophagitis, erosive esophagitis and peptic ulcer disease. “This, unfortunately, still does not occur in practice,” he said. “The authors correctly emphasize that using these validated grading systems impacts both treatment and the prediction of future outcomes.”
Dr. Keswani highlighted that the guidelines include “a nice cohort of quality metrics surrounding peptic ulcer bleeding” that run the gamut from pre-procedure management to post-procedure care. “Taken together, these indicators can inform a great quality improvement project,” he said. “For example, the indicators to avoid epinephrine monotherapy for bleeding peptic ulcer disease, ensure Helicobacter pylori testing and adhere to appropriate acid suppression therapy can have both clinical and economic impacts.”
—Ajai Srinivas
Drs. Keswani and Yadlapati reported no relevant financial disclosures.
This article is from the April 2025 print issue.