What are the guidelines for performing an Oesophagogastroduodenoscopy (OGD) with biopsy?

Guidelines for Performing Oesophagogastroduodenoscopy (OGD) with Biopsy

When performing an OGD with biopsy, clinicians should follow standardized protocols for specific clinical scenarios to ensure high-quality examination and appropriate tissue sampling for accurate diagnosis.

Pre-procedure Preparation

• Patients should be assessed for fitness to undergo a diagnostic OGD prior to the procedure 1
• Patients should receive appropriate information about the procedure before undergoing an OGD 1
• An appropriate time slot of at least 20 minutes should be allocated for a standard diagnostic endoscopy, with longer slots for surveillance or high-risk conditions 1
• Informed consent should be obtained before performing an OGD 1
• A safety checklist should be completed before starting an OGD 1

Endoscopist Qualifications and Equipment

• Only an endoscopist with appropriate training and relevant competencies should independently perform OGD 1
• Endoscopists should aim to perform a minimum of 100 OGDs per year to maintain high-quality examination standards 1
• UGI endoscopy should be performed with high-definition video endoscopy systems, with the ability to capture images and take biopsies 1

During the Procedure

• A complete OGD should assess all relevant anatomical landmarks and high-risk stations 1
• Photo-documentation should be made of relevant anatomical landmarks and any detected lesions 1
• The quality of mucosal visualization should be reported 1
• Adequate mucosal visualization should be achieved by a combination of adequate air insufflation, aspiration and the use of mucosal cleansing techniques 1
• For surveillance procedures (Barrett's esophagus, gastric atrophy/intestinal metaplasia), inspection time during diagnostic OGD should be recorded 1

Biopsy Protocols for Specific Conditions

Esophageal Conditions

• Barrett's Esophagus:

  • The length of a Barrett's segment should be classified according to the Prague classification 1
  • When no lesions are detected within a Barrett's segment, biopsies should be taken in accordance with the Seattle protocol (quadrantic biopsies at 2 cm intervals) 1
  • Where a lesion is identified within a Barrett's segment, it should be described using the Paris classification and targeted biopsies taken 1

• Eosinophilic Esophagitis:

  • Biopsies from two different regions in the esophagus should be taken to rule out eosinophilic esophagitis in those presenting with dysphagia/food bolus obstruction, where an alternate cause is not found 1

• Esophageal Ulcers and Severe Esophagitis:

  • Oesophageal ulcers and esophagitis that is grade D or atypical in appearance should be biopsied, with further evaluation in 6 weeks after PPI therapy 1

• Squamous Neoplasia:

  • If squamous neoplasia is suspected, full assessment with enhanced imaging and/or Lugol's chromo-endoscopy is required 1

• Strictures:

  • Strictures should be biopsied to exclude malignancy before dilatation 1
  • All strictures should be biopsied for histological analysis to exclude malignancy and eosinophilic esophagitis 1
  • If biopsies are negative but clinical or endoscopic features are atypical or suspicious for malignancy, repeat biopsy after cross-sectional imaging (CT or EUS) 1

Gastric Conditions

• Gastric Ulcers:

  • Gastric ulcers should be biopsied and re-evaluated after appropriate treatment, including H. pylori eradication where indicated, within 6-8 weeks 1

• Gastric Atrophy or Intestinal Metaplasia:

  • Where there are endoscopic features of gastric atrophy or intestinal metaplasia, separate biopsies from the gastric antrum and body should be taken 1

• Gastric Polyps:

  • The presence of gastric polyps should be recorded, with the number, size, location and morphology described, and representative biopsies taken 1

• H. pylori Testing:

  • Where gastric or duodenal ulcers are identified, H. pylori should be tested and eradicated if positive 1, 2

Duodenal Conditions

• Celiac Disease:

  • Where celiac disease is suspected, a minimum of four biopsies should be taken, including representative specimens from the second part of the duodenum and at least one from the duodenal bulb 1, 2, 3

• Duodenitis:

  • When duodenitis is identified, biopsies should be obtained to confirm the diagnosis histologically and assess for potential causes 2

Suspected Malignancy

• A malignant-looking lesion should be described, photo-documented and a minimum of six biopsies taken 1
• When investigating iron deficiency anemia, separate biopsies from the gastric antrum and body should be taken, as well as duodenal specimens if celiac serology is positive or has not been previously measured 1

Post-procedure Protocol

• A checklist should be undertaken after completing an OGD, before the patient leaves the room 1
• After OGD, readmission, mortality, and complications should be audited 1
• A report summarizing the endoscopy findings and recommendations should be produced and key information provided to the patient before discharge 1
• A method for ensuring histological results are processed must be in place 1
• Endoscopy units should audit rates of failing to diagnose cancer at endoscopy 1, 4

Common Pitfalls to Avoid

• Taking an inadequate number of biopsies can compromise quality assurance and diagnostic accuracy 4
• Failure to follow standardized biopsy protocols for specific conditions (e.g., Seattle protocol for Barrett's) can lead to missed diagnoses 1
• Not re-evaluating gastric ulcers after treatment can result in missed malignancy 1
• Inadequate mucosal visualization due to poor technique or preparation can lead to missed lesions 1