How to Write an Appropriate Endoscopy Report
An appropriate endoscopy report must be electronic and systematically structured to include three distinct temporal phases: pre-procedure features, intra-procedure features, and post-procedure features, with clear documentation of all technical aspects, findings, therapeutic interventions, adverse events, conclusions, and recommendations. 1
Pre-Procedure Documentation
The report must begin with comprehensive baseline information 1:
- Patient identification and demographics - Include age, gender, and relevant medical history 2
- Indication for the procedure - Clearly state whether for assessment, surveillance, or therapeutic intervention 1
- Disease characteristics - Document phenotype, current treatment regimen, and active symptoms 1
- Bowel preparation details - Specify volume, split-dosing regimen, and quality using validated scales such as the Boston Bowel Preparation Scale 1
- Sedation plan - Document type of sedation, anesthesiology assistance if applicable, and medications with specific doses 1
- Consent documentation - Confirm informed consent was obtained 2
- Overall anticipated duration of the procedure 1
Intra-Procedure Technical Documentation
Equipment and Technical Specifications
Document all technical aspects with precision 1:
- Endoscopic instrument type - Specify standard definition (SD) versus high definition-white light endoscopy (HD-WLE) 1
- Advanced imaging techniques - If using dye-chromoendoscopy (DCE) such as indigo carmine or methylene blue, document type, concentration, and dilution; if using virtual electronic chromoendoscopy (VCE) such as iSCAN, Narrow Band Imaging (NBI), or Blue Laser Imaging (BLI), document specific settings 1
- Device settings for any specialized equipment used 1
Procedural Quality Indicators
Critical technical elements that must be documented 1:
- Digital anorectal examination and perianal inspection - Particularly essential in perianal Crohn's disease and cuff diseases 1
- Retroflexion in the rectum - Document whether performed 1
- Extent of examination - Include maximal extent reached and specific reasons for any failure of ileal intubation 1
- Withdrawal time - Record the time spent withdrawing the scope 1
- Technical limitations encountered during the procedure 1
- Patient tolerance throughout the procedure 1
Findings Documentation
For Inflammatory Bowel Disease
Standardized scoring systems are mandatory 1:
- Ulcerative colitis - Use Mayo Endoscopic Score (MES), Ulcerative Colitis Endoscopic Index of Severity (UCEIS), or PICaSSO score for virtual chromoendoscopy 1
- Crohn's disease - Use Simple Endoscopic Score for Crohn's Disease (SES-CD) or Crohn's Disease Endoscopic Index of Severity (CDEIS); SES-CD is simpler and more commonly used in clinical practice 1
- Post-surgical Crohn's disease - Document using Modified Rutgeerts score for neoterminal ileum and anastomotic changes 1
- Pouch assessment - Use Pouchitis Disease Activity Index (PDAI) and document distensibility of pouch body 1
- Capsule endoscopy - Use Lewis score, Capsule Endoscopy Crohn's Disease Activity Index (CECDAI), or Niv score 1
Lesion Characterization
Use the systematic "Five S" approach for any detected lesions 1:
- Shape of the lesion
- Size with measurements
- Site with precise anatomical location
- Surface characteristics
- Surrounding area description
Biopsy Documentation
Precise documentation of tissue sampling 1:
- Localization - Specify exact anatomical location of each biopsy
- Number of biopsies taken from each site
- Type - Distinguish between random quadrantic biopsies versus targeted biopsies 1
- Purpose - Document whether for histological inflammatory activity assessment, dysplasia surveillance, or malignancy evaluation 1
Therapeutic Interventions
If any therapeutic procedures performed, document comprehensively 1:
- Stricture management - Describe stricture type (inflammatory vs. fibrotic, passable vs. non-passable), technique used (balloon dilation, electroincision, stricturotomy, stent placement), and technical specifications including balloon size, graded dilation approach, wire-guide use, scope orientation, and duration of balloon insufflation 1
- Polypectomy or resection - Document technique (EMR, ESD), equipment used (clip placement, knife type, electrocautery mode), and completeness of resection 1
- Hemostasis procedures - Detail methods used for bleeding control 1
Adverse Events
Any adverse event or incident must be documented immediately 1:
- Describe the nature of the complication (bleeding, perforation, mucosal tearing, cardiopulmonary events)
- Document interventions performed in response
- Record patient's hemodynamic status and response to intervention 1
Photo and Video Documentation
Photo documentation or video recording is a mandatory reporting requirement 1:
- Capture representative images of all significant findings
- Document normal landmarks to confirm complete examination
- Record therapeutic interventions performed 1
Post-Procedure Documentation
Conclusions and Diagnoses
Provide clear synthesis of findings 1:
- Endoscopic diagnosis with comparison to previous examinations when available
- Assessment of disease activity - Document whether improved, stable, or worsened compared to prior studies 1
- Adequacy of examination - State whether complete or incomplete and reasons for any limitations 1
Follow-Up Plan
Explicit recommendations are essential 1:
- Next clinical appointment timing
- Next surveillance endoscopy - Specify timing based on risk stratification 1
- Changes in therapy recommended based on findings 1
- Further imaging if indicated (CT, MRI, ultrasound) 1
- Post-procedural care - Include medications, timing of feeding, dietary restrictions, and monitoring requirements 1
Patient Communication
Summary information must be provided to the patient or family 2:
- Explain findings in understandable terms
- Clarify follow-up requirements
- Provide written instructions for post-procedure care 2
Critical Pitfalls to Avoid
Incomplete documentation of technical specifications - Failure to document equipment type, imaging modalities, and their settings prevents quality assurance and limits comparison with future examinations 1.
Omission of validated scoring systems - Descriptive terms alone without standardized scores (MES, UCEIS, SES-CD, Rutgeerts) reduce reproducibility and prevent objective disease monitoring 1.
Inadequate biopsy documentation - Not specifying the exact location and number of biopsies compromises histopathological correlation and surveillance protocols 1.
Missing withdrawal time and quality indicators - These metrics are essential for quality assurance and procedure adequacy assessment 1.
Failure to document adverse events - Any complication, regardless of severity, must be recorded for patient safety, quality improvement, and medicolegal purposes 1.