What are the reporting standards for abnormal findings in ... · Grade Description Prognosis I Oedema, hyperaemia No sequel IIa Superficial ulceration, erosions, friability, blisters,

What are the reporting standards for abnormal findings in upper GI endoscopy?

Portuguese Oncology Institute, Coimbra Center for Health Technology and Services Research, Faculty of Medicine, Porto Portugal

Miguel Areia

Learning Objectives

1. To understand the importance of standardizing endoscopic reports;

2. To know consensus classifications on upper endoscopic diseases to report, if applicable.

• Abnormal findings can vary substantially in upper GI:

– Organ location

– Disease: • Anatomical distortions

• Congenital lesions

• Acute lesions

• Chronic lesions

• Pathologies situated outside gastrointestinal tract

– Emergency situations.

Standards for abnormal findings


• Standardization of reporting of lesions is fundamental:

– Comparability, reproducibility, data aggregation

Rey JF, et al. ESGE recommendations for quality control in gastrointestinal endoscopy: guidelines for image documentation in upper and lower GI endoscopy. Endoscopy 2001; 33: 901-3

Cohen J, et al. Quality indicators for esophagogastroduodenoscopy. Am J Gastroenterol 2006; 101: 886-91 Landis JR, Koch GG. Biometrics. 1977;33:159

• Location

• Size or length

• Number

• Morphology

• Homogeneity

• Clinical suspicion

• Picture documentation

• If applicable: – Signs of haemorrhage

– Previous surgery: type

– Stenosis: traversable or not

– Technique performed

• Haemostasis was achieved


Park WG, et al. Quality indicators for EGD. Gastrointest Endosc. 2015;81:17 Minimal Standard Terminology for Gastrointestinal Endoscopy: World Endoscopy Organisation (WEO), 2009:1

• Protruding lesions (lump):

– Stenosis, compression or ring

– Nodule, polyp, tumor, varix, fold, ectopic pancreas.

• Excavated lesions:

– Diverticulum

– Erosion, ulcer, scar, fistula, perforation or Mallory-Weiss tear.

• Mucosa:

– Erythematous, oedematous, granular, nodular, atrophic.


Cohen J, et al. Quality indicators for esophagogastroduodenoscopy. Am J Gastroenterol 2006; 101: 886-91 Minimal Standard Terminology for Gastrointestinal Endoscopy: World Endoscopy Organisation (WEO), 2009:1-45

Validated or consensus

classifications

• Barrett oesophagus (Prague C & M classification)

Validated or consensus classifications

Armstrong D. Aliment Pharmacol Ther. 2004;20 Suppl 5:40 Sharma P, et al. Gastroenterology 2006;131:1392

Tytgat GNJ, Tytgat HAJ. Grading and Staging in Gastroenterology. Thieme Verlag, 2009:81 Minimal Standard Terminology for Gastrointestinal Endoscopy: World Endoscopy Organisation (WEO), 2009:1

• 18 gastroenterology trainees

• Agreement: C extent 0.94 (0.89-0.98), M extent 0.96 (0.94-0.98)

• 8 Barrett’s experts and 9 community hospital endoscopists

• Agreement: C extent 0.95 (0.94-0.96), M extent 0.96 (0.95-0.97)

• Reflux oesophagitis (Los Angeles classification)


Armstrong D, et al. Gastroenterology 1996;111:85 Lundell LR, et al. Gut 1999;45:172

Tytgat GNJ, Tytgat HAJ. Grading and Staging in Gastroenterology. Thieme Verlag, 2009:81 Minimal Standard Terminology for Gastrointestinal Endoscopy: World Endoscopy Organisation (WEO), 2009:1

• 46 endoscopists, experts and trainees, Europe, USA, Japan, Australia

• LA agreement: 0.40 (0.22–0.51); all other < 0.10

• 4 experts, 5 trainees

• Los Angeles and Hetzel-Dent classifications

• Experts: κ = 0.55 vs. 0.55, Trainees: κ = 0.44 vs. 0.39

• Caustic injury (Zargar scale)


Zargar SA, et al. Gastroenterology. 1989;97:702 Zargar SA et al. Gastrointest Endosc 1991;37:165

Tytgat GNJ, Tytgat HAJ. Grading and Staging in Gastroenterology. Thieme Verlag, 2009:1-80

Grade Description Prognosis

I Oedema, hyperaemia

No sequel IIa Superficial ulceration, erosions,

friability, blisters, exudates, hemorrhages, whitish membranes

IIb Grade 2a plus deep discrete or circumferential ulcerations

Scar

IIIa Multiple small ulceration and areas of necrosis with brown-black or grayish discoloration

IIIb

Multiple and deep ulcerations Extensive necrosis

• Oesophageal varices: Northern Italian Endoscopy Club and Conn scales


NIEC. N Engl J Med 1988;319:983-9 Conn HO, et al. Gastroenterology. 1967;52:810-8

De Francis R, Baveno V Faculty. J Hepatol 2010;53:762

NIEC Conn Size/Grade Baveno

3 Sizes Classification

2 Sizes Classification

Small and straight

Flat Small Small

Medium, less than one-third

Permanently visible

Medium

Medium- -Large

Large and tortuous, more than one-third

Extremely prominent

Large

• Agreement for size (kappa = 0.59) and red signs (kappa = 0.60)

• Agreement grades 0 to 1 vs. 2 to 3 (kappa = 0.52)

J Pediatr Gastroenterol Nutr. 2015;61:176

• 3-degree vs. 2-degree scales: kappa = 0.34 vs. 0.38

• Red signs: kappa = 0.49

• Gastric varices (Sarin and Kumar scale)


Sarin SK, Kumar A. Am J Gastroenterol. 1989;84:1244 Tytgat GNJ, Tytgat HAJ. Grading and Staging in Gastroenterology. Thieme Verlag, 2009:81

Gastroesophageal varices (GEV)

• Portal hypertensive gastropathy (Baveno classification)


Parameter Score

1-Mucosal mosaic pattern

Mild 1

Severe 2

2-Red markings

Isolated 1

Confluent 2

3-Gastric antral vascular ectasia

Absent 0

Present 2

Gastropathy Scoring System Score

Mild <4

Severe ≥4

de Franchis R. J Hepatol. 1996;25:390 Tytgat GNJ, Tytgat HAJ. Grading and Staging in Gastroenterology. Thieme Verlag, 2009:81

• Peptic bleeding (Forrest classification)


Forrest JA, et al. Lancet. 1974;2:394 de Groot NL, et al. Endoscopy. 2014;46:46

Gralnek Ian M et al. Nonvariceal upper gastrointestinal hemorrhage: ESGE Guideline. Endoscopy 2015;47:1

Class IA IB IIA IIB IIC III

Lesion Arterial bleeding

Arterial oozing bleeding

Visible vessel Sentinel clot Hematin covered

flat spot No stigmata

Risk of re-bleeding (%)

100 55 43 22 10 5

Treatment

Endoscopic haemostasis Clot removal;

If Ia or Ib or IIa Haemostasis

No haemostasis

• 47 endoscopists, kappa = 0.60

Negative predictive value Re-bleeding Death

Forrest classification 91% 97%

Rockall risk scoring system 91% 100%

Blatchford scoring system 50% 100%


• Duodenal polyposis in FAP (Spigelman classification)

Spigelman AD, et al. Lancet 1989;2:783 Saurin JC, et al. J Clin Oncol 2004;22:493

Syngal S, et al. ACG guideline. Am J Gastroenterol 2015;110:223

• Superficial neoplastic lesion (Paris classification)

• Endoscopic appearance has predictive value for submucosa invasion – Critical for the risk of nodal metastases


Update on the Paris endoscopic classification of superficial neoplastic lesions in the digestive tract. Endoscopy 2005;37:570-8

Type 0-Is

Oesophagus Stomach

Frequency of submucosal invasion:

79% 57%


Type 0-IIa

Oesophagus Stomach


48% 29%


Type 0-IIb

Oesophagus Stomach


15% 20%


Yao K, The endoscopic diagnosis of early gastric cancer. Ann Gastroenterol 2013;26:11

Type 0-IIc

Oesophagus Stomach


27% 37%


Type 0-III

Oesophagus Stomach


84%


40%

• 7 Experts, 85 videos, colonic polyps: kappa 0.42

• 42 Polyps were type Is or IIa: kappa 0.55 if combined

Conclusion

1. Use standardized language in endoscopic reports “Minimal Standard Terminology for Gastrointestinal Endoscopy”

2. If a lesion is detected Describe all you would like others to tell you

3. Use validated/consensus classifications Interobserver agreement

Related to prognosis and/or treatment options

Consensus recommended

Coimbra, Portugal

Thanks for your attention!

Documents

What are the reporting standards for abnormal findings in ... · Grade Description Prognosis I Oedema, hyperaemia No sequel IIa Superficial ulceration, erosions, friability, blisters,