AGA Clinical Practice Update on High-Quality Upper Endoscopy: Expert Review

DescriptionThe purpose of this Clinical Practice Update (CPU) Expert Review is to provide clinicians with guidance on best practices for performing a high-quality upper endoscopic exam.MethodsThe best practice advice statements presented herein were developed from a combination of available evidence from published literature, guidelines, and consensus-based expert opinion. No formal rating of the strength or quality of the evidence was carried out, which aligns with standard processes for American Gastroenterological Association (AGA) Institute CPUs. These statements are meant to provide practical, timely advice to clinicians practicing in the United States. This Expert Review was commissioned and approved by the American Gastroenterological Association (AGA) Institute Clinical Practice Updates (CPU) Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the CPU Committee and external peer review through standard procedures of Clinical Gastroenterology & Hepatology.Best Practice Advice 1Endoscopists should ensure that upper endoscopy is being performed for an appropriate indication and that informed consent clearly explaining the risks, benefits, alternatives, sedation plan, and potential diagnostic and therapeutic interventions is obtained. These elements should be documented by the endoscopist before the procedure.Best Practice Advice 2Endoscopists should ensure that adequate visualization of the upper gastrointestinal mucosa, using mucosal cleansing and insufflation as necessary, is achieved and documented.Best Practice Advice 3A high-definition white-light endoscopy system should be used for upper endoscopy instead of a standard-definition white-light endoscopy system whenever possible. The endoscope used for the procedure should be documented in the procedure note.Best Practice Advice 4Image enhancement technologies should be used during the upper endoscopic examination to improve the diagnostic yield for preneoplasia and neoplasia. Suspicious areas should be clearly described, photodocumented, and biopsied separately.Best Practice Advice 5Endoscopists should spend sufficient time carefully inspecting the foregut mucosa in an anterograde and retroflexed view to improve the detection and characterization of abnormalities.Best Practice Advice 6Endoscopists should document any abnormalities noted on upper endoscopy using established classifications and standard terminology whenever possible.Best Practice Advice 7Endoscopists should perform biopsies for the evaluation and management of foregut conditions using standardized biopsy protocols.Best Practice Advice 8Endoscopists should provide patients with management recommendations based on the specific endoscopic findings (eg, peptic ulcer disease, erosive esophagitis), and this should be documented in the medical record. If recommendations are contingent upon histopathology results (eg, H pylori infection, Barrett's esophagus), then endoscopists should document that appropriate guidance will be provided after results are available.Best Practice Advice 9Endoscopists should document whether subsequent surveillance endoscopy is indicated and, if so, provide appropriate surveillance intervals. If the determination of surveillance is contingent on histopathology results, then endoscopists should document that surveillance intervals will be suggested after results are available. The purpose of this Clinical Practice Update (CPU) Expert Review is to provide clinicians with guidance on best practices for performing a high-quality upper endoscopic exam. The best practice advice statements presented herein were developed from a combination of available evidence from published literature, guidelines, and consensus-based expert opinion. No formal rating of the strength or quality of the evidence was carried out, which aligns with standard processes for American Gastroenterological Association (AGA) Institute CPUs. These statements are meant to provide practical, timely advice to clinicians practicing in the United States. This Expert Review was commissioned and approved by the American Gastroenterological Association (AGA) Institute Clinical Practice Updates (CPU) Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the CPU Committee and external peer review through standard procedures of Clinical Gastroenterology & Hepatology. Endoscopists should ensure that upper endoscopy is being performed for an appropriate indication and that informed consent clearly explaining the risks, benefits, alternatives, sedation plan, and potential diagnostic and therapeutic interventions is obtained. These elements should be documented by the endoscopist before the procedure. Endoscopists should ensure that adequate visualization of the upper gastrointestinal mucosa, using mucosal cleansing and insufflation as necessary, is achieved and documented. A high-definition white-light endoscopy system should be used for upper endoscopy instead of a standard-definition white-light endoscopy system whenever possible. The endoscope used for the procedure should be documented in the procedure note. Image enhancement technologies should be used during the upper endoscopic examination to improve the diagnostic yield for preneoplasia and neoplasia. Suspicious areas should be clearly described, photodocumented, and biopsied separately. Endoscopists should spend sufficient time carefully inspecting the foregut mucosa in an anterograde and retroflexed view to improve the detection and characterization of abnormalities. Endoscopists should document any abnormalities noted on upper endoscopy using established classifications and standard terminology whenever possible. Endoscopists should perform biopsies for the evaluation and management of foregut conditions using standardized biopsy protocols. Endoscopists should provide patients with management recommendations based on the specific endoscopic findings (eg, peptic ulcer disease, erosive esophagitis), and this should be documented in the medical record. If recommendations are contingent upon histopathology results (eg, H pylori infection, Barrett's esophagus), then endoscopists should document that appropriate guidance will be provided after results are available. Endoscopists should document whether subsequent surveillance endoscopy is indicated and, if so, provide appropriate surveillance intervals. If the determination of surveillance is contingent on histopathology results, then endoscopists should document that surveillance intervals will be suggested after results are available. Esophagogastroduodenoscopy (EGD) is a common and generally very safe procedure for the diagnosis and management of upper gastrointestinal (GI) symptoms and conditions involving the esophagus, stomach, and duodenum. Defining what constitutes a high-quality EGD poses somewhat of a challenge because the spectrum of indications and the breadth of benign and (pre)malignant disease pathology in the upper GI tract is very broad. This is in contrast to colonoscopy, for example, in which the predominant indication in the ambulatory setting is colorectal cancer screening and polyp detection and removal. Standardizing the measures defining a high-quality upper endoscopic examination is one of the first steps for assessing quality. The benchmarks for what defines high quality are somewhat arbitrary, but ultimately are driven by studies evaluating threshold measures and the associations with clinical, economic, and patient-reported outcomes at the individual and population levels. Numerous barriers to the widespread implementation of quality benchmarks in upper endoscopy were identified recently, and there are ongoing efforts by national and international gastroenterology societies to address these challenges.1Bazerbachi F. Chahal P. Shaukat A. Improving upper gastrointestinal endoscopy quality.Clin Gastroenterol Hepatol. 2023; 21: 2457-2461Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar The scope of this Clinical Practice Update includes best practice advice on how to perform a high-quality upper endoscopic examination and encompasses the following: (1) optimization of endoscopic detection of upper GI pathology (eg, mucosal cleansing, visualization time); (2) evaluation of suspected esophageal and gastric premalignancy (eg, the role of image-enhanced endoscopy, use and documentation of standardized biopsy protocols); and (3) postprocedure follow-up evaluation (eg, Helicobacter pylori testing/treatment, need and interval for subsequent endoscopic surveillance, and medication management including the timing of resumption of antithrombotics). The benefits of performing an endoscopic procedure regardless of indication—screening, surveillance, diagnostic, or therapeutic—must be balanced against the potential harms. Inappropriate use of upper endoscopy exposes patients to unnecessary procedural risks, in addition to excessive financial burdens placed on payors and patients. Before performing the procedure, informed consent outlining the risks, benefits, alternatives, and potential complications associated with the procedure should be obtained and documented. A large meta-analysis of 53,392 patients identified a high frequency of inappropriate indications for upper endoscopy (21.7%; 95% CI, 21.4–22.1). Notably, there was a higher diagnostic yield in patients who had an appropriate indication for the examination (odds ratio [OR], 1.42; 95% CI, 1.36–1.49).2Zullo A. Manta R. De Francesco V. et al.Diagnostic yield of upper endoscopy according to appropriateness: a systematic review.Dig Liver Dis. 2019; 51: 335-339Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar Although the indications for upper endoscopy can be optimized to improve diagnostic sensitivity, inappropriate use of endoscopy wastes limited resources and may negatively impact environmental sustainability. Accordingly, it is important to follow society guidelines for upper endoscopy indications and to provide clear documentation in the endoscopy report.3Park W.G. Shaheen N.J. Cohen J. et al.Quality indicators for EGD.Gastrointest Endosc. 2015; 81: 17-30Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar Endoscopists also should provide guidance to patients regarding recommended periprocedural management of antithrombotic drugs. Recent retrospective studies have shown poor compliance with GI society recommendations among endoscopists for the periprocedural management of antithrombotic agents, which has been associated with an increased risk of cardiovascular events.4Bruno M. Marengo A. Elia C. et al.Antiplatelet and anticoagulant drugs management before gastrointestinal endoscopy: do clinicians adhere to current guidelines?.Dig Liver Dis. 2015; 47: 45-49Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar,5Jiang W. Suen B.Y. Ho H.T. et al.Impact of physicians' and patients' compliance on outcomes of colonoscopic polypectomy with anti-thrombotic therapy.Clin Gastroenterol Hepatol. 2021; 19: 2559-2566.e1Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar Endoscopists should refer to published guidelines regarding the temporary interruption, reversal, and resumption of antithrombotic treatment.6Barkun A.N. Douketis J. Noseworthy P.A. et al.Management of patients on anticoagulants and antiplatelets during acute gastrointestinal bleeding and the peri-endoscopic period: a clinical practice guideline dissemination tool.Am J Gastroenterol. 2022; 117: 513-519Crossref PubMed Scopus (11) Google Scholar,7Abraham N.S. Barkun A.N. Sauer B.G. et al.American College of Gastroenterology-Canadian Association of Gastroenterology Clinical Practice Guideline: management of anticoagulants and antiplatelets during acute gastrointestinal bleeding and the periendoscopic period.Am J Gastroenterol. 2022; 117: 542-558Crossref PubMed Scopus (44) Google Scholar Specific guidance regarding interruption of other medication classes before upper endoscopy is outside of the scope of this Clinical Practice Update. However, given the increasing use of glucagon-like peptide-1–receptor agonists for obesity and diabetes, it is important for endoscopists to recognize their potential association with delayed gastric emptying based on limited data. The American Society of Anesthesiologists has advocated holding 1 dose of medication before endoscopy to reduce aspiration risk.8Hjerpsted J.B. Flint A. Brooks A. et al.Semaglutide improves postprandial glucose and lipid metabolism, and delays first-hour gastric emptying in subjects with obesity.Diabetes Obes Metab. 2018; 20: 610-619Crossref PubMed Scopus (100) Google Scholar, 9Friedrichsen M. Breitschaft A. Tadayon S. et al.The effect of semaglutide 2.4 mg once weekly on energy intake, appetite, control of eating, and gastric emptying in adults with obesity.Diabetes Obes Metab. 2021; 23: 754-762Crossref PubMed Scopus (126) Google Scholar, 10American Society of Anesthesiologists consensus-based guidance on preoperative management of patients (adults and children) on glucagon-like peptide-1 (GLP-1) receptor agonists 2023.https://www.asahq.org/about-asa/newsroom/news-releases/2023/06/american-society-of-anesthesiologists-consensus-based-guidance-on-preoperativeDate accessed: September 2, 2023Google Scholar As clinical data become more readily available, endoscopists should watch for additional guidance from professional societies. The goal of the upper endoscopic examination is to detect and treat abnormalities in the upper GI tract. Careful mucosal inspection is key to adequately identifying and characterizing abnormalities (Figure 1). This is particularly important because recent studies have reported high rates of missed upper GI cancers. A systematic review and meta-analysis of 81,184 patients with upper GI cancers showed that 10.7% (95% CI, 8.0%–13.7%) of these cancers were diagnosed within 3 years of a previous EGD marked as negative for malignancy.11Alexandre L. Tsilegeridis-Legeris T. Lam S. Clinical and endoscopic characteristics associated with post-endoscopy upper gastrointestinal cancers: a systematic review and meta-analysis.Gastroenterology. 2022; 162: 1123-1135Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar Another systematic review found that 23.9% (15.3%–35.4%) of all cases of esophageal adenocarcinoma in patients with baseline nondysplastic Barrett's esophagus were diagnosed within 1 year of an EGD marked as negative for malignancy.12Desai M. Lieberman D. Srinivasan S. et al.Post-endoscopy Barrett's neoplasia after a negative index endoscopy: a systematic review and proposal for definitions and performance measures in endoscopy.Endoscopy. 2022; 54: 881-889Crossref PubMed Scopus (6) Google Scholar These reviews suggest that clinically significant neoplasia was missed on the recent endoscopy, underscoring the importance of adequate visualization and inspection of the entire upper GI tract mucosa. Adequate mucosal visualization is achieved only after aspiration of luminal contents, full insufflation, and use of mucosal cleansing agents as necessary. Adequate insufflation fully distends the GI tract lumen as well as expands the mucosal folds, thereby greatly increasing the visible surface area and ability to detect abnormalities. This is particularly relevant in the stomach where even large lesions can hide between folds or be covered by fluid or debris. All fluid and debris should be aspirated and the mucosal surface cleansed by flushing water through the accessory channel of the endoscope. Premedication with oral defoaming agents (simethicone), mucolytics (N-acetylcysteine), and proteolytic enzymes (pronase) has been studied in numerous clinical trials.13Elvas L. Areia M. Brito D. et al.Premedication with simethicone and N-acetylcysteine in improving visibility during upper endoscopy: a double-blind randomized trial.Endoscopy. 2017; 49: 139-145PubMed Google Scholar, 14Monrroy H. Vargas J.I. Glasinovic E. et al.Use of N-acetylcysteine plus simethicone to improve mucosal visibility during upper GI endoscopy: a double-blind, randomized controlled trial.Gastrointest Endosc. 2018; 87: 986-993Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar, 15Zhang L.Y. Li W.Y. Ji M. et al.Efficacy and safety of using premedication with simethicone/pronase during upper gastrointestinal endoscopy examination with sedation: a single center, prospective, single blinded, randomized controlled trial.Dig Endosc. 2018; 30: 57-64Crossref PubMed Scopus (15) Google Scholar, 16Liu X. Guan C.T. Xue L.Y. et al.Effect of premedication on lesion detection rate and visualization of the mucosa during upper gastrointestinal endoscopy: a multicenter large sample randomized controlled double-blind study.Surg Endosc. 2018; 32: 3548-3556Crossref PubMed Scopus (23) Google Scholar Simethicone and pronase each show an improvement in mucosal visualization in most studies, and the addition of N-acetylcysteine or pronase to simethicone further increases visualization based on some, but not all, studies.14Monrroy H. Vargas J.I. Glasinovic E. et al.Use of N-acetylcysteine plus simethicone to improve mucosal visibility during upper GI endoscopy: a double-blind, randomized controlled trial.Gastrointest Endosc. 2018; 87: 986-993Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar,17Asl S.M. Sivandzadeh G.R. Efficacy of premedication with activated dimethicone or N-acetylcysteine in improving visibility during upper endoscopy.World J Gastroenterol. 2011; 17: 4213-4217Crossref PubMed Scopus (29) Google Scholar, 18Chang W.K. Yeh M.K. Hsu H.C. et al.Efficacy of simethicone and N-acetylcysteine as premedication in improving visibility during upper endoscopy.J Gastroenterol Hepatol. 2014; 29: 769-774Crossref PubMed Scopus (37) Google Scholar, 19Chang C.C. Chen S.H. Lin C.P. et al.Premedication with pronase or N-acetylcysteine improves visibility during gastroendoscopy: an endoscopist-blinded, prospective, randomized study.World J Gastroenterol. 2007; 13: 444-447Crossref PubMed Scopus (59) Google Scholar, 20Kuo C.H. Sheu B.S. Kao A.W. et al.A defoaming agent should be used with pronase premedication to improve visibility in upper gastrointestinal endoscopy.Endoscopy. 2002; 34: 531-534Crossref PubMed Scopus (53) Google Scholar In these trials, oral administration of these agents 15 to 30 minutes before endoscopy appears safe and efficacious. However, theoretical concerns from anesthesia providers about intraprocedural aspiration may limit the generalizability of this practice. Mucosal irrigation with dilute simethicone is a commonly used practice to improve visualization, although this has not been studied in clinical trials. A concern has been raised regarding the potential for biofilm development and infectious risk resulting from the retention of simethicone droplets within the endoscope waterjet channel or working channel despite high-level disinfection. This concern has led multiple professional societies to suggest that if simethicone use is believed to be necessary, the lowest concentration (≤0.5%) and the smallest volume of simethicone should be used, with delivery via the working channel rather than the waterjet channel.21Day L.W. Muthusamy V.R. Collins J. et al.Multisociety guideline on reprocessing flexible GI endoscopes and accessories.Gastrointest Endosc. 2021; 93: 11-33.e6Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar High-definition white-light endoscopy (HD-WLE) systems are superior to standard-definition WLE systems for neoplasia detection22Sami S.S. Subramanian V. Butt W.M. et al.High definition versus standard definition white light endoscopy for detecting dysplasia in patients with Barrett's esophagus.Dis Esophagus. 2015; 28: 742-749Crossref PubMed Scopus (39) Google Scholar (Figure 1). Although HD imaging is a standard feature of newer-generation endoscopes, legacy standard-definition scopes remain in use. Moreover, to provide true HD image resolution, each component of the system (eg, the endoscope video chip, the processor, the monitor, and transmission cables) must be HD compatible. HD processors and monitors can up-convert input image signals from standard-definition endoscopes through pixel interpolation, although this ultimately may limit image quality.23Kwon R.S. Adler D.G. Chand B. et al.High-resolution and high-magnification endoscopes.Gastrointest Endosc. 2009; 69: 399-407Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar The use of image enhancement technologies (IET) further improves the detection of preneoplasia and neoplasia. IETs use endoscope and processor-based technology to provide contrast enhancement of the mucosal surface and blood vessels. Narrow band imaging (NBI; Olympus Medical Systems, Tokyo, Japan), i-Scan (PENTAX Endoscopy, Tokyo, Japan), and linked color imaging (LCI)/blue laser imaging (FUJIFILM, Tokyo, Japan) are the most readily available IETs in the United States. In patients with Barrett's esophagus, multiple studies have shown a 10% to 20% increased rate of detection and visual characterization of dysplastic lesions using NBI, LCI/blue laser imaging, or i-Scan, which ultimately may improve the yield of targeted biopsies.24de Groof A.J. Fockens K.N. Struyvenberg M.R. et al.Blue-light imaging and linked-color imaging improve visualization of Barrett's neoplasia by nonexpert endoscopists.Gastrointest Endosc. 2020; 91: 1050-1057Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar, 25Tokunaga M. Matsumura T. Ishikawa K. et al.The efficacy of linked color imaging in the endoscopic diagnosis of Barrett's esophagus and esophageal adenocarcinoma.Gastroenterol Res Pract. 2020; 20209604345Crossref PubMed Scopus (10) Google Scholar, 26Ang T.L. Pittayanon R. Lau J.Y. et al.A multicenter randomized comparison between high-definition white light endoscopy and narrow band imaging for detection of gastric lesions.Eur J Gastroenterol Hepatol. 2015; 27: 1473-1478Crossref PubMed Scopus (67) Google Scholar Similarly increased detection of neoplasia in the stomach is reported with the use of IETs compared with HD-WLE alone. In a large multicenter trial of patients undergoing screening upper endoscopy, NBI detected more focal gastric lesions compared with HD-WLE (40.6% vs 29%; P = .003), with an associated increased detection of gastric intestinal metaplasia (17.7% vs 7.7%; P = .001).26Ang T.L. Pittayanon R. Lau J.Y. et al.A multicenter randomized comparison between high-definition white light endoscopy and narrow band imaging for detection of gastric lesions.Eur J Gastroenterol Hepatol. 2015; 27: 1473-1478Crossref PubMed Scopus (67) Google Scholar A recent tandem trial with LCI showed a significantly lower rate of missed upper GI neoplasia compared with HD-WLE (0.67% vs 3.5%; relative risk, 0.19; 95% CI, 0.07–0.50).27Ono S. Kawada K. Dohi O. et al.Linked color imaging focused on neoplasm detection in the upper gastrointestinal tract.Ann Intern Med. 2021; 174: 18-24Crossref PubMed Scopus (66) Google Scholar There is a paucity of comparative studies between the different IETs, as well as only limited data comparing each of the IETs with HD-WLE. The available data certainly show the augmented potential for detecting neoplastic lesions with IETs. Developing familiarity with any IET will be important in reducing the rate of missed lesions during endoscopic examinations. At a minimum, IETs should be used to further characterize abnormalities seen on HD-WLE and in patients for whom there is concern for upper GI preneoplasia or neoplasia. Recent advances in artificial intelligence have heralded the development of computer-aided detection and computer-aided diagnosis systems that appear to improve the detection and visual characterization of colon polyps. Computer-aided detection and computer-aided diagnosis systems for upper endoscopy are still in the early phases of development but do show similar promise for improving the detection and characterization of upper GI tract neoplasia.28Sharma P. Hassan C. Artificial intelligence and deep learning for upper gastrointestinal neoplasia.Gastroenterology. 2022; 162: 1056-1066Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar Ensuring sufficient inspection time of the upper GI tract mucosa once adequate mucosal visualization is achieved is another key aspect of the high-quality endoscopic examination (Figure 1). A longer examination time is associated with higher detection rates of preneoplastic and neoplastic lesions. Studies evaluating upper endoscopy in patients with obscure bleeding suggest a 3% to 25% miss rate for putative bleeding lesions in the upper GI tract. Although this miss rate is not related exclusively to examination time, it does underscore the importance of a careful endoscopic examination regardless of indication.29Fisher L. Lee Krinsky M. Anderson M.A. et al.The role of endoscopy in the management of obscure GI bleeding.Gastrointest Endosc. 2010; 72: 471-479Abstract Full Text Full Text PDF PubMed Scopus (198) Google Scholar The optimal amount of time spent inspecting each of the esophageal, gastric, and duodenal compartments separately for improved diagnostic yield remains to be determined. However, a total EGD duration of longer than 7 minutes has been associated with increased detection of Barrett's esophagus, gastric intestinal metaplasia, and upper GI cancer.30Teh J.L. Tan J.R. Lau L.J. et al.Longer examination time improves detection of gastric cancer during diagnostic upper gastrointestinal endoscopy.Clin Gastroenterol Hepatol. 2015; 13: 480-487.e2Abstract Full Text Full Text PDF PubMed Scopus (125) Google Scholar Based on 1 post hoc analysis of a multicenter prospective clinical trial (1 German, 1 French, and 3 US sites) that included patients with either suspected or established Barrett's esophagus, the duration of inspection time per centimeter of Barrett's esophagus was correlated directly with the detection rate of high-grade dysplasia and adenocarcinoma.31Gupta N. Gaddam S. Wani S.B. et al.Longer inspection time is associated with increased detection of high-grade dysplasia and esophageal adenocarcinoma in Barrett's esophagus.Gastrointest Endosc. 2012; 76: 531-538Abstract Full Text Full Text PDF PubMed Scopus (166) Google Scholar In this study, endoscopists with an average inspection time of longer than 1 minute per centimeter of Barrett's esophagus detected a higher percentage of patients with endoscopically suspicious lesions (54.2% vs 13.3%; P = .04), and showed a suggestive trend toward a higher detection rate of advanced neoplasia including adenocarcinoma (40.2% vs 6.7%; P = .06) compared with endoscopists who spent less time inspecting the Barrett's segment.31Gupta N. Gaddam S. Wani S.B. et al.Longer inspection time is associated with increased detection of high-grade dysplasia and esophageal adenocarcinoma in Barrett's esophagus.Gastrointest Endosc. 2012; 76: 531-538Abstract Full Text Full Text PDF PubMed Scopus (166) Google Scholar Data regarding optimal endoscopy times for maximal gastric neoplasia detection specifically in US populations are limited. A retrospective analysis of a Singaporean population determined that endoscopists who spent longer than 7 minutes to perform the entire EGD had 2.5-fold higher odds of detecting high-risk gastric lesions (OR, 2.50; 95% CI, 1.52–4.12) and 3.4-fold higher odds of detecting neoplasia (OR, 3.42; 95% CI, 1.25–10.38) compared with endoscopists who conducted shorter examinations.30Teh J.L. Tan J.R. Lau L.J. et al.Longer examination time improves detection of gastric cancer during diagnostic upper gastrointestinal endoscopy.Clin Gastroenterol Hepatol. 2015; 13: 480-487.e2Abstract Full Text Full Text PDF PubMed Scopus (125) Google Scholar Consistent with these findings, another retrospective study of 55,786 consecutive patients from Japan who underwent EGD showed that endoscopists who spent at least 5 to 7 minutes of inspection time during the EGD had higher odds of detecting gastric neoplasia (OR, 1.90; 95% CI, 1.06–3.40) as compared with endoscopists with inspection times slower than 5 minutes.32Kawamura T. Wada H. Sakiyama N. et al.Examination time as a quality indicator of screening upper gastrointestinal endoscopy for asymptomatic examinees.Dig Endosc. 2017; 29: 569-575Crossref PubMed Scopus (43) Google Scholar Data are limited, but these findings generally have been consistent irrespective of training level.30Teh J.L. Tan J.R. Lau L.J. et al.Longer examination time improves detection of gastric cancer during diagnostic upper gastrointestinal endoscopy.Clin Gastroenterol Hepatol. 2015; 13: 480-487.e2Abstract Full Text Full Text PDF PubMed Scopus (125) Google Scholar Although the specific duration of an EGD to maximize diagnostic yield has yet to be determined, it is clear that increased inspection time is associated with higher odds of detecting significant pathology. A high-quality upper endoscopic examination includes a standardized photodocumentation protocol of anatomic stations, which should be performed in tandem with careful inspection after adequate mucosal visualization is achieved. The objective of image documentation is to show that a thorough and complete examination was performed (including adequate insufflation and mucosal cleansing), to document any abnormal findings, show pertinent negative features (eg, normal esophagus in a patient with dysphagia), as well as to provide a comparison for future examinations. Photodocumentation should strike a balance between conveying valuable information while also minimizing unnecessary additional procedural and postprocedural time. At a minimum, photodocumentation with a