Criteria for adequate versus inadequate endoscopy

To reduce the variability in responses for this section of the root case analysis, we propose the following criteria for adequate and inadequate endoscopy. This is based on expert opinion from the PEUGIC project steering team, as there is no published definition or evidence on what constitutes an adequate endoscopy.

For a diagnostic endoscopy to be adequate, all criteria in the adequate section of the table below must be met with no criteria in the inadequate section of the table below.

Domain	Adequate	Inadequate
Completeness	Examination to D2 with J manoeuvre if possible; photo documentation of D2 and J manoeuvre; photo documentation of suspected malignant, cancer associated (e.g. gastric ulcer) or pre-malignant (e.g. Barrett’s oesophagus) lesions	Unable to intubate the oesophagus and D2
Sampling	When a suspected malignant lesion is found, at least 6 biopsies taken; all gastric ulcers and severe oesophagitis (LA grade D) should be biopsied adequately depending on size or have an adequate plan for repeat endoscopy and biopsy if this not possible on first endoscopy (e.g. due to bleeding)	Less than 6 biopsies from a suspected malignant lesion (exclusion lesions less than 1cm in size)
Equipment factors	Absence of any of the criteria in the inadequate section of this domain	No image capture (with no documented reason for this)
Patient factors	Absence of any of the criteria in the inadequate section of this domain	Food residue preventing adequate mucosal views; bleeding preventing adequate mucosal views; poor patient tolerance including withdrawal of consent
Report writing	Follow-up endoscopy plan in line with BSG guidelines for cancer associated lesions (e.g. gastric ulcers)	Plan not in line with recommended BSG guidelines for follow-up

For surveillance or therapeutic endoscopy, the following modifications apply:

1. The extent of the examination does not need to be to D2, provided there has been a proceeding endoscopy to D2 within the last 12 months.
2. Biopsies for pre-malignant conditions such as Barrett’s and gastric atrophy must be consistent with recommended protocols (Seattle and Syndey protocol respectively).
3. Surveillance or follow-up plan following histology results needs to be in line with BSG guidelines for surveillance of pre-malignant conditions and follow up cancer associated lesions.