Abbreviations
EREFS:
edema, rings, exudate, furrows, strictures
ESGE:
European Society of Gastrointestinal Endoscopy
GRACE:
G astroscopy RA te of C leanliness E valuation (scale)
PEACE:
P olprep: E ffective A ssessment of C leanliness in E sophagogastroduodenoscopy (scale)
QIC:
Quality Improvement Committee
UGI:
upper gastrointestinal
Introduction
Upper gastrointestinal (UGI) endoscopy is essential for diagnosing gastrointestinal
diseases of the esophagus, stomach, and duodenum. Performance measures for UGI endoscopy
were published by the European Society of Gastrointestinal Endoscopy (ESGE) in 2016
[1 ], and have been updated in 2025 [2 ]. A high quality UGI endoscopy entails appropriate documentation of good performance.
ESGE aims to improve the quality of endoscopy with eventual standardization of high
quality endoscopy for the GI tract [3 ]
[4 ]. In this document, the ESGE Quality Improvement Committee (QIC) proposes information
that should be included in all UGI endoscopy reports.
Methods
An initial proposal was advanced in 2022 from the project leader (G.E.) to the Chair
of the QIC (M.F.), and the ESGE Governing Board approved the proposal.
The project leader developed a list of possible statements as discussed between four
of the authors of this Position Statement (M.F., R.B., M.A., G.E.); this was then
shared and approved by the members of the UGI working group of the QIC. No evidence-based
statements were developed for the Position Statement because of the lack of available
data on standardizing endoscopic reports, and the most frequently used classifications
for endoscopic findings, based on the working group’s expertise, were proposed.
The statements were then submitted to 37 ESGE members, including the UGI working group
and the Reporting Taskforce of the QIC (listed as authors) and the Executive of the
ESGE Governing Board (listed as External voting panel). The ESGE members evaluated
all the statements through an online Delphi consensus process, using a five-point
Likert scale (1, strongly disagree; 2, disagree; 3, neither agree nor disagree; 4,
agree; 5, strongly agree), and with the possibility to comment on every individual
statement. Consensus on each statement was defined as a sum of “agree” and “strongly
agree” voting of at least 80 %. After the first Delphi round, the project leader deleted
or reformulated statements based on the comments from the ESGE members who voted in
the first round. After two voting rounds, the final statements and manuscript were
discussed and approved by all the authors.
During the development of the present document, ESGE performance measures for UGI
endoscopy were being updated and through the Delphi process for that update a cleanliness
evaluation scale was added as a new performance measure. For this reason, during the
present authors’ approval process for this document, they decided to include the reporting
of a cleanliness evaluation scale.
The first draft was sent for external peer review and modifications, and the subsequent
version was sent for revision and approval by the ESGE Governing Board; that version
was sent to all ESGE individual members for comments.
This document was developed according to the ESGE Publications Policy [5 ].
Results
After two rounds of the Delphi process, 55 statements reached an agreement of at least
80 % (Table 1 s , available online-only in Supplementary Material). These related to preprocedure
information (10 statements), periprocedure information (2 statements), endoscopic
findings (38 statements: 4 regarding the report structure, 14 for the esophagus, 11
for the stomach, and 9 for the duodenum), and postprocedure information (5 statements).
A total of 8 statements did not show agreement after voting rounds. They related to
the presence of a phone number in the preprocedure information, the description of
gastric juice and peristalsis, the use of the Siewert classification for esophagogastric
junction tumors [6 ], the use of the vessel plus surface (VS) classification system for gastric lesions
[7 ], and the use of the Haraldsson classification for the Vater papilla [8 ].
Preprocedure information
The report should include:
the date of the exam
the name of the patient
the date of birth of the patient
the indication for the exam
whether the patient is on antithrombotic drugs (antiplatelets, anticoagulants, heparins)
the fasting time for solids
the fasting time for liquids
the use of premedication.
The preprocedure report information should include the date of the exam, information
about the patient (name and date of birth), and the indication for the procedure.
During the preprocedure assessment, it is crucial to know whether the patient is taking
any antithrombotic drugs and whether the antithrombotic medication was interrupted.
In fact, considering diagnostic UGI procedures, biopsies could be performed with continuation
of antiplatelets but omission of direct oral anticoagulants on the morning of the
procedure [9 ]. In many departments, this information could be contained in a checklist [10 ].
Following the quality measures for UGI endoscopy [1 ], fasting for solids and liquids should be reported, and premedication (simethicone,
N-acetylcysteine, other) administered before the UGI endoscopy should be reported.
Periprocedure information
Periprocedure information
The report should include:
For several reasons, but especially for side effects after UGI endoscopy, it is important
to report drugs administered during endoscopy (xylocaine spray, midazolam, propofol,
simethicone, atropine, reversal agents, and others). The type of endoscope used could
give helpful information about the technology used during the exam (high definition
endoscope, type of virtual chromoendoscopy) and for traceability purposes [11 ]
[12 ]
[13 ].
Mucosal cleanliness assessment
Mucosal cleanliness assessment
A scale for the evaluation of the cleanliness of the mucosa should be used to assess
the visibility of the esophagus, stomach, and duodenum, after the use of water or
simethicone and suction to improve the cleanliness of the mucosa. Recently, three
scales, the GRACE scale [14 ], the PEACE scale [15 ], and the Barcelona scale [16 ], have been proposed and validated ([Table 1 ]). The GRACE and the PEACE scales are structured similarly, evaluating 3 segments
(esophagus, stomach, and duodenum). A score of 0 to 3 (0 poor visibility; 3 excellent
visibility) should be assigned to each segment for a total score ranging from 0 to
9. The Barcelona scale scores 5 segments (esophagus, gastric fundus, corpus and antrum,
and duodenum) with 3 grades ranging from 0 to 2 (0, poor visibility; 2, excellent
visibility), with a total ranging from 0 to 10.
Table 1
Mucosal cleanliness evaluation scales.
Scale
Segments evaluated
Score definitions
Total score range
GRACE [14 ]
Esophagus, stomach, duodenum
0 = presence of solid food
0–9
1 = severe presence of mucus, bubbles, biliary fluid, and/or foam, covering more than
50 % of surface
2 = moderate presence of mucus, bubbles, biliary fluid, and/or foam, covering between
5 % and 50 % of surface
3 = no or minimal presence of mucus, bubbles, biliary fluid, and/or foam, covering
less than 5 % of surface
PEACE [15 ]
Esophagus, stomach, duodenum
0 = substantial amount of fluid/foamy/solid content completely preventing evaluation
of the mucosa
0–9
1 = substantial amount of opaque fluid/foamy/solid content that does not allow evaluation
of some parts of the mucosa
2 = small amount of hazy fluid/foamy/solid content, but allowing inspection of most
of the mucosa
3 = clean mucosa or minor amounts of transparent fluid not impeding mucosal inspection
Barcelona [16 ]
Esophagus, gastric corpus, fundus and antrum, duodenum
0 = nonaspirable solids or semisolids, presence of bile or foam, which does not allow
visualization of most of the mucosa
1 = small amount of semisolids, bile or foam, allowing visualization of most of the
mucosa
2 = absence of any residues, so visualization of the mucosa is nearly 100 %
0–10
GRACE, G astroscopy RA te of C leanliness E valuation; PEACE, P olprep: E ffective A ssessment of C leanliness in E sophagogastroduodenoscopy
Endoscopic findings
The report should be divided into esophagus, stomach, and duodenum.
The description of the stomach should include cardia, corpus/fundus, and antrum (including
incisura).
The description of the duodenum should include the bulb and the second portion (descending
part).
In the case of previous surgery, the type of surgery/reconstruction should be described.
The QIC strongly recommends the use of a standardized structured report, which includes
all major anatomical portions of the UGI tract, even if they are all normal.
UGI endoscopy report: Normal findings
UGI endoscopy report: Normal findings
All the statements regarding normal findings for each portion of the tract are provided
in [Table 2 ].
Table 2
Reporting normal findings in upper gastrointestinal (UGI) endoscopy: statements with
at least 80 % agreement.
Description of normal UGI findings
Esophagus
17 The mucosa should be described as endoscopically normal if no alterations are found.
20 The esophagogastric junction should be measured from incisors.
21 The hiatus should be measured from incisors.
23 The squamocolumnar junction should be measured from incisors.
Stomach
31,33,38 The mucosa should be described as endoscopically normal if no alterations
are found.
37,41 If chromoendoscopy has been used, it should be stated in the report.
Duodenum
42,46 The mucosa should be described as endoscopically normal if no alterations are
found.
43,47 Villi could be described as normal or atrophic.
50 If visible, the papilla should be described as normal if no alterations are found.
The mucosa of esophagus, stomach (cardia, corpus/fundus, and antrum), and duodenum
(bulb and second portion, including the villi and the papilla) should be described
as endoscopically normal if no alterations are observed. If an alteration in the submucosal
layer is observed, it should be described as an abnormality.
A proper description of the esophagogastric junction, hiatus, and squamocolumnar junction
is fundamental for exams with normal findings.
Furthermore, if chromoendoscopy (dye-based or virtual) has been used, it should be
stated in the report.
In [Fig. 1 ], a proposal for a UGI endoscopy report for normal findings is provided.
Fig. 1 Proposal for an upper gastrointestinal endoscopy report of normal findings.
UGI endoscopy report: Abnormal findings
UGI endoscopy report: Abnormal findings
All statements regarding abnormal findings for each part of the UGI tract are provided
in [Table 3 ].
Table 3
Reporting abnormal findings in upper gastrointestinal (UGI) endoscopy: statements
with at least 80 % agreement.
Description of abnormal UGI findings
Esophagus
18 The presence of proximal ectopic mucosa (inlet patch) should be described.
19 The presence of Zenker diverticulum (or any diverticulum) should be described.
22 If the esophagogastric junction is not coincident with the hiatus, the hiatal hernia
should be measured.
24 In the case of Barrett’s esophagus, Prague classification should be used [18 ].
25 In the case of Barrett’s esophagus, if acetic acid or virtual chromoendoscopy is
used, it should be stated in the report.
26 Polyps or suspected lesions should be described using the Paris classification
[22 ].
27 Esophagitis should be described using the Los Angeles classification [17 ].
28 Varices should be described using the Baveno classification [19 ].
29 The suspected eosinophilia esophagitis should be described using the EREFS classification
(edema, rings, exudate, furrows, strictures) [20 ].
30 Caustic esophagitis should be described using the Zargar classification [21 ].
Stomach
32,36,40 Polyps or suspicious lesions should be described using the Paris classification
[22 ].
34,39 Ulcers should be described using the Forrest classification [23 ].
35 Varices should be described using the Sarin classification [24 ].
Duodenum
44 Ulcers should be described using the Forrest classification [23 ].
45,48 Polyps or suspicious lesions should be described using the Paris classification
[22 ].
49 The presence of diverticula should be described.
50 If the papilla presents a suspicion of adenoma, this should be described.
All findings should be described using validated classifications when available in
cases of abnormalities. The most common classifications for the most common alterations
seen during UGI endoscopy are described in detail below.
Hiatal hernia
In the presence of a hiatal hernia, the report should contain the following information:
“The esophagogastric and squamocolumnar junctions are located (X cm) from the incisors,
and the hiatus is located (X cm) from the incisors. A hiatal hernia of (X cm in length)
is present.”
Esophagitis
In the presence of esophagitis, the report should state grades of esophagitis, according
to the Los Angeles classification [17 ]:
Grade A: One or more mucosal break ≤ 5 mm that does not extend between the tops of
two mucosal folds.
Grade B: One or more mucosal break > 5 mm that does not extend between the tops of
two mucosal folds.
Grade C: One or more mucosal break that is continuous between the tops of two or more
mucosal folds but that involves < 75 % of the circumference.
Grade D: One or more mucosal break that involves ≥ 75 % of the esophageal circumference.
In this case, the report should contain the following sentence:
“The esophagogastric and squamocolumnar junctions are located (X cm) from the incisors,
coincident with the hiatus where there is the presence of one or more mucosal break
… (esophagitis grade X by Los Angeles classification).”
Barrett’s esophagus
In the case of Barrett’s esophagus, the Prague classification should be used.
In the case of Barrett’s esophagus, if acetic acid or virtual chromoendoscopy is used,
this should be stated in the report.
In the presence of Barrett’s esophagus as tongue-like areas or circumferential mucosa
proximal to the esophagogastric junction, the extent in centimeters and the Prague
classification [18 ] should be reported:
The C value represents the extent of totally circumferential columnar-lined mucosa
above the esophagogastric junction.
The M value represents the total maximum extent of the entire Barrett’s area, including
the circumferential extent and any tongue-like protrusions, above the gastro-esophageal
junction.
Therefore, the following is always applicable: M ≥ C.
In this case the report should contain, for example, the following sentence:
“The esophagogastric junction is located (X cm) from the incisors, and the suspected/known
Barrett’s esophagus has a circumferential extent up to XX cm and a maximum extent
up to XX cm from the incisors (CxMx by Prague classification). Acetic acid/virtual
chromoendoscopy was used, and areas of suspected dysplasia were/were not identified.”
Esophageal varices
If esophageal varices are present during the UGI endoscopy, they should be described
following the Baveno classification [19 ]:
If varices are observed during UGI endoscopy, they should be described as follows:
“Presence of XX esophageal varices of less/more than 5 mm in diameter (small/large
following Baveno classification).”
Eosinophilic esophagitis
Suspected eosinophilic esophagitis should be described using the EREFS classification
(edema, rings, exudate, furrows, strictures).
In the presence of eosinophilic esophagitis, some characteristics of the esophagus
should be described following the EREFS classification [20 ]:
Edema (also referred to as decreased vascular markings, mucosal pallor):
Grade 0: Absent (distinct vascularity present)
Grade 1: Loss of clarity, or absence of vascular markings
Rings (also referred to as concentric rings, corrugated esophagus, corrugated rings,
ringed esophagus, trachealization):
Grade 0: None
Grade 1: Mild (subtle circumferential ridges)
Grade 2: Moderate (distinct rings that do not impair passage of a standard adult endoscope
[outer diameter 8–9.5 mm])
Grade 3: Severe (distinct rings)
Exudate (also referred to as white spots, plaques):
Furrows (also referred to as vertical lines, longitudinal furrows):
Grade 0: Absent
Grade 1: Present
Stricture:
Grade 0: Absent
Grade 1: Present.
In this case, the report should contain the following sentence:
“The esophagus presented edema (grade 0/1), rings (grade 0/1/2/3), exudate (grade
0/1/2), furrows (grade 0/1/), and stricture (grade 0/1), according to the EREFS classification.”
Caustic esophagitis
If the UGI endoscopy is performed after caustic ingestion, the Zargar classification
[21 ] should be used:
Grade 0: Normal esophagus
Grade 1: Esophageal hyperemia
Grade 2a: Superficial ulceration, noncircumferential
Grade 2b: Deep, discrete, or circumferential ulceration
Grade 3a: Black, brown necrosis is noted with areas of ulceration
Grade 3b: Extensive necrosis
Grade 4: Perforation.
In this case, the report should contain the following sentence:
“The esophagus presented … (grade X according to Zargar classification).”
Esophagus: Other alterations
In the proximal esophagus, the presence of ectopic mucosa (inlet patch) and/or the
presence of Zenker diverticulum should be reported, as well as their location from
the incisors and estimated size.
Esophagus, stomach, and duodenum: Polyps or suspected lesions
If a polyp or a suspected lesion (a flat elevated or a flat area of the mucosa with
or without depression) is identified during UGI endoscopy, it should be described
in location, size (mm), and shape following the Paris classification [22 ]:
Protruded lesions
Flat elevated lesions
Flat lesions
0-IIb: flat mucosal change
0-IIc: mucosal depression
0-IIc/IIa: mucosal depression with raised edge.
In this case, the report should contain the following sentence:
“At (location) a XX mm polyp/suspected lesion is identified and appears as a X polyp
(X according to Paris classification).”
Stomach and duodenum: Ulcers
In the presence of an ulcer during UGI endoscopy, it should be described in location,
size (mm), and bleeding stigmata using the Forrest classification [23 ]:
In this case, the report should contain the following sentence:
“At (location) a XX mm ulcer with (description) (type X according to the Forrest classification)
was found.”
Gastric varices
If gastric varices are present during the UGI endoscopy, they should be described
following the Sarin classification [24 ]:
GOV 1: Appear as continuations of esophageal varices and extend for 2 to 5 cm below
the gastroesophageal junction, along the lesser curve of the stomach
GOV 2: Extend beyond the gastroesophageal junction into the fundus of the stomach
IGV 1: Are located in the fundus of the stomach and fall short of the cardia by a
few centimeters
IGV 2: include isolated ectopic varices and can appear anywhere in the stomach, such
as in the body, antrum, or pylorus.
In this case, the report should contain the following sentence:
“Presence of gastric varices located at (location) (X according to Sarin classification).”
Duodenum (bulb and second portion/descending part): Other alterations
In cases of alteration of villi, they could be described as atrophic.
The presence of diverticula should be reported, and if the papilla presents a suspicion
of adenoma, it should be described.
Postprocedure information
Postprocedure information
The type of biopsies should be described: random or targeted.
The location of biopsies should be reported.
The number of biopsies for each area and the number of vials, specifying the specimens
inserted in each vial, should be reported.
Photographic images obtained during UGI endoscopy (complying with performance measures
in UGI endoscopy guidelines) should be inserted in the report according to the capabilities
of the reporting system.
The duration of the exam should be reported from intubation to extubation (total time).
At the end of the report, the endoscopists should clearly state the location of biopsies,
the number of biopsies for each area, whether the biopsies were random or targeted,
and the number of vials sent for the histopathological examination, specifying the
specimens inserted in each vial.
Photodocumentation of all normal anatomical landmarks and all abnormal findings is
also required. During the UGI endoscopy, images should be taken following the ESGE
updated Performance measures for upper gastrointestinal endoscopy , in terms of number and locations [2 ], and inserted in the report as far as the reporting system allows, bearing in mind
that photographic images are a fundamental part of the report. A proposed systematic
sequence for the recording of the 10 suggested pictures, regarding all relevant normal
landmarks, would be: proximal esophagus (1), distal esophagus (2), Z-line and diaphragmatic
indentation (3), duodenal bulb (4), second part of duodenum (5), antrum (6), cardia
and fundus in full inversion (7), lesser curvature of corpus in partial inversion
(8), incisura in partial inversion (9), greater curvature of corpus in forward view
(10). When withdrawing from the esophagus, a repeated final picture of the upper esophagus
just below the sphincter allows a precise calculation of the examination time (from
picture 1 to picture 11 in a normal diagnostic endoscopy). Any abnormality should
have at least one picture to complement the information written in the report.
The report should state the exam duration, considering the total time from intubation
to extubation, namely from the insertion of the scope in the patient’s esophagus to
the retrieval of the scope from the patient’s esophagus.
The endoscopic report should be concluded with the names of all staff involved and
their roles.
Conclusions
To the best of our knowledge, this is the first document aiming to provide a standardized
report for UGI endoscopy.
There are some limitations in this document. Most of the authors and co-authors who
participated in the manuscript and the Delphi processes are from European countries,
and this could affect the terminology used and the classifications of every pathology
of the UGI tract. However, most are expert endoscopists whose practice is dedicated
to the UGI tract. Due to the lack of rigorous studies, many of the reporting proposals
are expert opinions and not evidence-based.
Nevertheless, this document provides the most important classifications that should
be used during the writing of a UGI endoscopy report, aiming to counter vague and
useless descriptions that are liable to varying interpretations, misunderstanding,
and error. Uniform and essential information describing the UGI tract promotes consistency
among endoscopy providers, diminishes information errors, and might even speed up
the writing of the report, saving more time for performance of the endoscopic procedure,
where it is clinically more useful.
In conclusion, standardization of reporting could enhance the quality of endoscopy
and shape endoscopist performance towards uniformly high quality UGI endoscopy.
Disclaimer
The legal disclaimer for ESGE guidelines [5 ] applies to this Position Statement.
