STAndardization of Reports (the STAR project) Upper gastrointestinal endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative

Abstract

Upper gastrointestinal (UGI) endoscopy is the mainstay for the diagnosis and staging of precancerous and cancerous conditions of the esophagus, stomach, and duodenum. Despite development of several validated classifications for UGI diseases, endoscopy reports differ between endoscopists and endoscopy departments. This document proposes a standardized high quality UGI endoscopy report, including preprocedural, periprocedural, endoscopic findings, and postprocedural information. Preprocedural details should comprise data on the patient, exam, use of antithrombotic drugs, fasting, and premedication. Periprocedural information should report on medications administered, endoscope used, and the mucosal cleanliness assessment. Endoscopic findings should describe the esophagus, stomach, and duodenum, with any observed abnormalities reported using the most commonly employed classification (provided in the document). Postprocedural details should include data on biopsies and vials, pictures taken during the procedure, and the exam duration. A suggestion for a normal findings report is provided. Standardized reporting could enhance the quality of UGI endoscopy.