Introduction
A range of criteria have been created to evaluate the appropriateness of gastrointestinal (GI) endoscopy. The most widely recognized were set by the American Society for Gastrointestinal Endoscopy and the European Panel of Appropriateness of Gastrointestinal Endoscopy (EPAGE), updated EPAGE-II criteria. Nevertheless, the application of general rules is not sufficient, especially in hospitalized patients. The complexity, singularity, and dynamic clinical evolution demands the proactive involvement of an experienced endoscopist to make the decision whether or not to perform the exam.
Aims & Methods
Our aim was to analyze the appropriateness of endoscopic exam requests in hospitalized patients over the course of one year.
A prospective observational study was conducted in an endoscopic unit of a tertiary hospital center. The requested exams were triaged by a gastroenterologist after reviewing the patient’s medical record, assessing clinical status and complementary diagnostic tests. In cases of unclear indication, and no absolute contraindication, the decision to proceed was discussed with the referring physician.
Results
A total of 184 requests for inpatient endoscopy and/or colonoscopy were received during 1 year (table 1). 154 (84%) of the requests were thought to be appropriate. 12 (6%) were cancelled during triage: 2 were patients on best supportive care, 1 died, 3 had other diagnosis which plausibly justified the clinical situation, 2 had recent endoscopic exams, and 4 presented no clinical/analytical evidence of GI bleeding). 18 (10%) requests were initially postponed (8 were awaiting imaging results; 5 had poor clinical status and 5 respiratory distress) and ended up being cancelled (8 had another diagnosis in imaging tests, 8 maintained clinical deterioration contraindicating exam and 3 died). In total 30 (16%) of the requests were cancelled.
The most frequent exam requested was endoscopy, and the most common indication was suspected GI neoplasia. From a total of 58 suspected GI neoplasms, 11 were confirmed as gastric neoplasia, which was the most common finding.
None of the patients with a cancelled exam was diagnosed with a GI disease during follow up.
Mortality rate was considerably higher in the group with cancelled exams (33% vs 11% during hospitalization, 50% vs 32% during follow up, 15% vs 1.8% within 30 days after discharge). Mean age was similar between groups. This findings reveal a frail group of patients, with little likelihood of benefiting from an invasive exam.
| Total, n=184 | GI endoscopy performed | GI endoscopy deferred and/or cancelled |
| N, % | 154 (84) | 30 (16) |
| Sex, male (%) | 89 (58) | 16 (53) |
| Age (years), mean (±SD) | 72 (12.8) | 71 (14) |
Type of exam
Endoscopy, n (%)
Colonoscopy, n (%)
Endoscopy + Colonoscopy, n (%)
Flexible sigmoidoscopy, n (%) |
68 (44)
28 (18)
55 (36)
3 (19) |
13 (42)
6 (19)
10 (33)
1 (33) |
Indication, n
Anemia
Diarrhea
Dysphagia
Epigastric pain
Chronic liver disease
Suspected GI neoplasia¥
Suspected upper GI neoplasia
Suspected colorectal neoplasia
Suspected GI bleeding |
42
5
8
3
7
44
14
15
4 |
5
-
-
1
-
20
-
-
4 |
Relevant endoscopy findings, n
Hypopharyngeal neoplasm
Grade C, D esophagitis
Esophageal neoplasia
Esophagogastric varices
Gastric angiodysplasia
Gastric neoplasia
Neoplastic infiltration of duodenum
Colorectal neoplasia
Inconclusive (poor bowel preparation) |
2
2
2
6
3
11
2
7
3 | - |
Motive to defer and/or cancel, n
Awaiting imaging results
Clinical deterioration
Respiratory distress
End-of-life care
Evidence of myeloma
Evidence of ovarian cancer
Recent endoscopic evaluation
Without analytical or clinical evidence of bleeding
Death | - |
8
5
5
2
1
2
2
4
1 |
| Death during hospitalization, n (%) |
17 (11) |
10 (33) |
| Death within 30 days after discharge, n (%) |
2 (1.8) |
3 (15) |
¥ Suspected GI neoplasia includes constitutional syndrome, evidence of metastases without a known primary source, ascites and/or pleural effusion.
Table 1. Patient’s characteristics and exam indications and findings.
Conclusion
16% of the requests were considered inappropriate, which allowed to avoid 30 unnecessary exams.
Developing standardized indications for endoscopic exams in inpatient care is difficult, and an individualized approach is critical in order to reach an equilibrium between overusage and overlooking, while considering the principle of primum non nocere.
References
- American Society for Gastrointestinal Endoscopy. Appropriate use of gastrointestinal endoscopy. Gastrointest Endosc 2000;52:831-7
- Juillerat P, Peytremann-Bridevaux I, Vader JP, et al. Appropriateness of colonoscopy in Europe (EPAGE II). Presentation of methodology, general results, and analysis of complications. Endoscopy 2009;41:240-6
- Gimeno García AZ, González Y, Quintero E, et al. Clinical validation of the European Panel on the Appropriateness of Gastrointestinal Endoscopy (EPAGE) II criteria in an open-access unit: a prospective study. Endoscopy. 2012 Jan;44(1):32-7.
- Shaheen NJ, Fennerty MB, Bergman JJ. Less Is More: A Minimalist Approach to Endoscopy. Gastroenterology. 2018 May;154(7):1993-2003.
- Leal C, Almeida N, Silva M, et al. Appropriateness of Endoscopic Procedures: A Prospective, Multicenter Study. GE Port J Gastroenterol. 2021 May 25;29(1):5-12.
