Assessing Visualization During Upper Endoscopy

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.