Over the last decade, an increasing demand for gastrointestinal (GI) endoscopy has occurred[ ¹]. Unfortunately, the rise in quantity has not always been accompanied by a parallel rise in quality. Several studies, based on the American Society for Gastrointestinal Endoscopy (ASGE) guidelines[ ²], showed a substantial rate of inappropriateness of indications for esophagogastroduodenoscopy (EGD) and colonoscopy and a parallel decrease in the diagnostic yield of these endoscopic procedures[ ^{3 - 10}]. The inappropriate rate is higher in outpatients and in endoscopic units of non-academic hospitals[ ^{5 , 9}]. These represent the vast majority of patients submitted for GI endoscopy in Portuguese hospitals.

The study was performed from October 2005 to June 2006 in an endoscopy unit of a non-academic hospital (São Bernardo Hospital, Setúbal). In Portugal, non-academic hospitals give assistance to 75% of the population. At our hospital, like in most Portuguese hospitals, GI endoscopy can be requested by hospital-based specialists without prior evaluation by a gastroenterologist, but primary care physicians cannot directly refer patients to endoscopy. The population of our geographical area includes around 270 000 inhabitants and is characterized by a high prevalence of gastric and colorectal cancer. Outpatients ( n = 789) referred for EGD ( n = 381) and colonoscopy ( n = 408) were included in this study. All patients gave written informed consent for the endoscopic procedure. Referring physicians were unaware of the study.

Data were collected prospectively and uniformly according to a previously defined protocol. Before beginning the procedure, endoscopists determined the indications for the examination based on the clinical history. The exam was performed regardless of the indication, unless a contraindication was present. The endoscopic examination was carried out using standard, forward-viewing video endoscopes or colonoscopes by gastroenterologists ( n = 6) or by trainees in gastroenterology ( n = 3). After the procedure, demographic data, indications and endoscopic findings were reported in the same chart.

The indications were classified, by agreement of two endoscopists, according to the practice guidelines of the ASGE as appropriate, non-appropriate and uncertain (when the data did not allow a correct classification).

Endoscopic findings were classified as “clinically relevant”, when they affected the therapeutic decisions and prognosis, and “not clinically relevant”. Clinically significant findings for EGD included erosive esophagitis, candida esophagitis, Barrett’s esophagus, esophageal cancer, benign esophageal stenosis, achalasia, esophageal varices, Mallory-Weiss tears, gastric ulcer, gastric polyps, gastric cancer, benign gastric stenosis, angiodysplasia (when the indications were hematochezia, fecal occult blood or iron deficiency anemia), duodenal ulcer and duodenal cancer. Clinically relevant findings for colonoscopy included colorectal cancer, malignant polyps, advanced adenomas (> 1 cm, villous component or high-grade dysplasia), inflammatory bowel disease, angiodysplasia (when the indications were hematochezia, fecal occult blood or iron deficiency anemia) and radiation colitis. When there was more than one endoscopic diagnosis, the most severe one was used for analysis.

To evaluate the association between appropriateness and the presence of clinically relevant endoscopic diagnoses, patients in whom the endoscopic procedure was performed because of an ASGE indication were compared with those in whom an ASGE indication was absent or uncertain.

GI endoscopy plays a central role in gastroenterology as an accurate and safe procedure for diagnosis, follow-up, treatment or exclusion of clinically important gastrointestinal disease[ ^{11 , 12}]. For this reason, most GI endoscopic centers in Europe and the United States implement some type of open-access service[ ^{10 , 13 , 14}]. This has led to an increasing demand for endoscopic procedures and, consequently, an increase in the costs and the waiting lists[ ^{1 , 10}]. Therefore, adherence to appropriate indications for endoscopic procedures is essential to the rational use of finite resources.

Several studies show a substantial overuse of EGD (12% to 39%) and colonoscopy (15% to 43%) and a parallel decrease in the diagnostic yield of these endoscopic procedures[ ^{3 - 10}]. The rate of inappropriateness is higher in outpatients and in endoscopic units of non-academic hospitals[ ^{4 , 5}]. These represent the vast majority of patients submitted to GI endoscopy in Portuguese hospitals.

In order to address this problem, we decided to perform a prospective study in this specific scenario. Overuse of EGD (11.5%) and colonoscopy (15%) was low in this prospective study, compared to other studies conducted in Europe, particularly in this subset of patients. In part, this could be due to the fact that primary care physicians cannot directly refer patients to our endoscopic unit, as many studies have shown that they have a high overuse rate[ ^{4 , 6}]. The inappropriate rate of colonoscopies was significantly higher in female patients compared with male patients. This probably reflects the higher prevalence of functional gastrointestinal disorders in women[ ^{15 , 16}]. Like in the study of Hassan et al[ ⁴], the percentage of not accepted indications was higher in scheduled procedures compared with those performed as an urgent procedure, but it did not reach statistical significance. This was also the case for patients younger than 45 years in EGD. Interestingly, in colonoscopy, the overuse was superior in patients older than 45 years, a finding similar to that reported by Minoli et al[ ⁵]. The main inappropriate indications for EGD were surveillance for malignancy in patients with prior gastric operations and surveillance of healed benign disease. For colonoscopy, they were abdominal pain and chronic constipation. Special attention should be given to these topics when implementing educational programs for referring physicians.

The other aim of this study was to assess the relationship of the appropriateness of indications with the endoscopic findings. One-third of colonoscopies were normal, twice the number of normal EGDs. In both procedures, the percentage of normal exams was higher in non-appropriate indications and in patients younger than 45 years. More important than the number of normal exams, the efficacy of an endoscopic procedure is usually defined as its diagnostic yield, that is, the ability to detect a finding that is potentially relevant to patient care[ ¹⁷]. In our study, clinically significant abnormalities were found in about one-third of EGDs and one-fifth of colonoscopies. These numbers are lower than those reported in most published studies, particularly regarding colonoscopy[ ^{4 - 9}]. This is mainly due a more restricted criteria applied in this study for the classification of a diagnosis as clinically relevant. In other studies, all adenomas were considered clinically relevant, as well as all angiodysplasias, which was not the case in this study. The probability of detecting a clinically relevant finding was significantly higher when EGDs and colonoscopies were performed for an appropriate as compared to an inappropriate indication, as has been previously reported[ ^{4 - 9}]. The diagnostic yield of GI endoscopies performed for an uncertain indication (anemia not otherwise specified) were similar to the ones performed for an appropriate indication. This probably reflects the fact that these patients indeed had iron deficiency anemia and should be incorporated in the appropriate examinations group. The probability of detecting a clinically relevant finding was also significantly higher for some specific indications, namely, surveillance of malignancy in Barrett’s esophagus, portal hypertension evaluation, dysphagia/odynophagia and for therapeutic procedures in EGD and surveillance for colonic neoplasia in inflammatory bowel disease, screening for synchronous cancer or neoplastic polyps and for therapeutic procedures in colonoscopies. On the other hand, EGDs performed for dyspepsia, iron deficiency anemia, surveillance for malignancy in patients with chronic gastritis and surveillance for malignancy in patients with prior gastric operations and colonoscopies performed for abdominal pain and chronic constipation had a relatively low diagnostic yield. While the latter are inappropriate indications, the former two are indications considered appropriate by the ASGE guidelines. The low diagnostic yield of dyspepsia, found also in other studies[ ⁴], probably reflects the contamination of this group by dyspeptic patients younger than 45 years (one-quarter of the total number of dyspeptic patients). The percentage of significant lesions in patients referred for iron deficiency anemia (13.0%) was low compared to previous published data (40%)[ ^{18 - 21}]. If we included the patients with anemia not otherwise specified in this group, the percentage of significant lesions would increase to 24.4%, still lower than expected. This can be due in part to a higher number of lesions beyond the reach of EGD in our population where the incidence of colorectal cancer is very high. A higher number of relevant endoscopic findings were also found in EGDs performed in patients older than 45 years when compared with younger patients and in urgent colonoscopies compared to elective ones. The former can be used as a useful parameter in scheduling the exams.

In this study, 25 neoplastic lesions were detected, 10 in EGDs and 15 in colonoscopies. All cancers in EGDs were detected in appropriate exams. This finding is very important because Portugal is a country that has a high prevalence of gastric cancer and because there has been some concern about the efficacy of ASGE guidelines in selecting those patients at risk for upper GI neoplasia from those who are not, following from the studies by Gonvers et al[ ²²] and Rossi et al[ ²³] that found a substantial number of cancer in inappropriate EGDs. With regard to colonoscopy, 12 malignancies were detected in exams with an appropriate ASGE indication, 2 in exams with an uncertain indication and 1 in an exam without an appropriate ASGE indication. As previously discussed, the exams performed for anemia not otherwise specified probably correspond to iron deficiency anemia and should be given the same importance of an appropriate indication when scheduling this subgroup of examinations. The single malignancy found at a colonoscopy in the group of patients with inappropriate indications was located in the sigmoid and was detected in a 78-year-old patient with chronic constipation who had never had a colonoscopy. Due to the age of the patient, if we considered this exam as screening for colonic neoplasia consistent with the concept of “colonoscopy once in a life”[ ²⁴], all neoplastic lesions in this study would be detected in appropriate exams. In addition, only 6 other significant lesions were found in inappropriate examinations, a number much lower than in previous studies[ ^{4 - 9 , 24}].