Assessing Visualization During Upper Endoscopy

Assessing Visualization During Upper Endoscopy

Prateek Sharma, MD, FASGE, reviewing Khan R, et al. Endoscopy 2023 Feb.

Esophagogastroduodenoscopy (EGD) requires clear visualization of the upper gastrointestinal (UGI) mucosa, but there is no standardized method to assess mucosal visualization. Lesions are often missed due to the presence of mucus, foam, bubbles, and other materials, despite preprocedure preparation.

In this study, an international group of endoscopy experts developed the Toronto Upper Gastrointestinal Cleaning System (TUGCS) using Delphi methodology to rate their agreement with proposed items on a Likert scale. The TUGCS was refined using an 80% agreement threshold for consensus. 

The TUGCS includes four anatomical areas (fundus, body, antrum, and duodenum), each scored from 0 (solid food, blood or blood clots, or other content that could not be suctioned or washed, or an obstruction that prevented adequate visualization of the majority of the area) to 3 (entire mucosa could be seen without need for suctioning or washing). The aggregate scores were then categorized into four categories of mucosal visualization: inadequate, fair, good, and excellent.

For procedures, the study found that the TUGCS achieved high inter-rater (0.79; 95% confidence interval [CI], 0.64-0.88) and test-retest reliability (0.83; 95% CI, 0.77-0.87) and good internal consistency. There was a positive correlation between TUGCS ratings and a global rating of visualization (r=0.41, P=.002), and TUGCS ratings for EGDs with excellent global ratings were significantly higher than those for fair global ratings.

Prateek Sharma, MD, FASGE


Achieving excellent visualization of the UGI mucosa is critical for a high-quality upper endoscopy. The use of a standardized scoring system is a meaningful step to operationalize mucosal visualization as a quality metric for EGD.



Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.


Khan R, Gimpaya N, Vargas JI, et al. The Toronto Upper Gastrointestinal Cleaning Score: a prospective validation study. Endoscopy 2023;55:121-128. (


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