Esophagogastroduodenoscopy (EGD) is a useful procedure for the diagnosis of conditions of the upper gastrointestinal (GI) tract. For all upper GI problems except esophageal and gastric motility abnormalities, EGD can often be substituted for radiologic studies. The sensitivity and specificity of EGD are higher than those of radiographs for the diagnosis of upper GI tract inflammation, ulcers and neoplasm.
Becoming competent to perform EGD increases the family physician's knowledge of upper GI pathology and normal physiology and anatomy. The ability to detect significant pathology earlier enhances the quality of care family physicians provide.
Family physicians who perform EGD find it can increase patient satisfaction because patients often prefer to stay with their primary care physician. Patients may be pleased that their family physician is able to do this procedure and may appreciate having their physician with them during a somewhat intimidating diagnostic procedure. The patient-physician bond is strengthened, and the patient's confidence in the physician is increased.
Family physicians are under pressure today to make accurate diagnoses and efficacious treatment plans as efficiently and cost-effectively as possible. In this environment especiallly, EGD is a useful tool in the physician's armamentarium.
Furthermore, family physicians who do upper GI endoscopy invariably note an enhanced relationship with patients, a better working relationship with their gastroenterologist colleagues, a better understanding of the pathology in individual cases, and a much greater comfort level with the chosen treatment as a direct result of having done the procedure themselves.
In a review of 793 EGDs performed by a family physician, 451 biopsies were taken during 385 EGDs.1 546 pathologic dianoses were provided as a result of the biopsies. No major complications occurred -- only one minor complication (a rash from meperidine). The complication rate in this family medicine study was 0.13%. A series of 1,949 endoscopies, including 667 gastroscopies, performed by a Canadian family physician reported two complications for the series as a whole, neither of which arose from a gastroscopy. 2 Such complication rates compare favorably with others in the GI literature. In what is still probably the largest series published to date, a 1976 survey of more than 210,000 esophagogastroduodenoscopies reported an overall complication rate of 0.13% with a 0.008% death rate.3
Each family physician must assess the appropriateness of outpatient EGD in his or her office. The physician should consider his or her competence and comfort with the procedure, the expertise of staff, the set-up of the office, the local standards of care, the economic implications, and, in some cases, the local political climate surrounding procedures and privileges. The physician must also consider specific patient factors such as the urgency and timing of the procedure, and the patient's wishes regarding outpatient EGD.
Currently, economics favor the GI lab setting over the office setting for many family physicians. The scope, video and photography equipment, intravenous (IV) medications and supplies, and nursing staff are provided without additional charge to the physician. Physician payment today is generally provided at the same rate regardless of where the procedure is performed. Many insurance companies do not pay for supplies when procedures are performed in the office, which provides another economic incentive for physicians to do the procedure in the hospital outpatient area. The overall cost to the patient and payer, however, is considerably higher when the procedure is performed outside of the family physician's office.
EGD is safe and rarely causes significant physical stress for the patient. However, IV sedation does carry a measurable risk and thus significant post-procedure observation is required. Physicians who perform procedures requiring IV sedation in their offices should provide the same level of care as is available in an EGD lab in the hospital or out-patient setting. This would include appropriate personnel for assistance and observation and may include oximetry monitoring and telemetry for appropriate patients.
Not all patients are candidates for office EGD, particularly when the physician is first gaining experience with the procedure. For the beginning endoscopist, the following patient characteristics may preclude office EGD:
Of course, these are guidelines and may be altered depending on the geographic area, available facilities, and experience of the endoscopist.
The first national course in EGD for family physicians was sponsored by the American Academy of Family Physicians (AAFP) in 1989. Before that, state chapters provided accredited continuing medical education (CME) in EGD. Today, the AAFP and state chapters have expanded CME opportunities for EGD and other procedures.
Family physicians have gained hospital privileges for EGD in all 50 states, and the number of family physicians performing EGD continues to grow. According to a 2006 AAFP survey.4 3.8% of family physicians surveyed had hospital privileges to perform EGD alone or under supervision or with consultation. By 2011, while the percentage with privileges to perform EGD alone dropped from 3.4% to 2.4%, the total percentage had risen to 6.8%.5
Accoring to a 2003 study, 32% of family medicine residency programs offered training in colonoscopy, and 13% reported actually training one or more residents in the procedure.6
EGD has multiple indications. The most common in a study1 of 793 procedures performed by a family physician were these:
A complete list is quite extensive. Indications include several pre-existing conditions, signs, and symptoms (depending on factors such as severity, response to treatment, length of symptoms, etc.):
The American Society for Gastrointestinal Endoscopy (ASGE) has published a list of indications for GI endoscopy in general (including EGD, colonoscopy, and other modalities) and for EGD specifically.7 That list appears in Table 1 below.
ASGE Guidelines for GI Endoscopy and for EGD
GI endoscopy is generally indicated:
1. If a change in management is probable based on results of endoscopy.
2. After an empirical trial of therapy for a suspected benign digestive disorder has been unsuccessful.
3. As the initial method of evaluation as an alternative to radiographic studies.
4. When a primary therapeutic procedure is contemplated.
GI endoscopy is generally not indicated:
1. When the results will not contribute to a management choice.
2. For periodic follow-up of healed benign disease unless surveillance of a premalignant condition is
GI endoscopy is generally contraindicated:
1. When the risks to patient health or life are judged to outweigh the most favorable benefits of the
2. When adequate patient cooperation or consent cannot be obtained.
3. When a perforated viscus is known or suspected.
EGD is generally indicated for evaluating:
A. Upper abdominal symptoms that persist despite an appropriate trial of therapy.
B. Upper abdominal symptoms associated with other symptoms or signs suggesting structural
disease (e.g., anorexia and weight loss) or new-onset symptoms in patients older than 50 years of
C. Dysphagia or odynophagia.
D. Esophageal reflux symptoms that persist or recur despite appropriate therapy.
E. Persistent vomiting of unknown cause.
F. Other diseases in which the presence of upper GI pathology might modify other planned
management. Examples include patients who have a history of ulcer or GI bleeding who are
scheduled for organ transplantation, long-term anticoagulation or nonsteroidal anti-inflammatory
drug therapy for arthritis, and those with cancer of the head and neck.
G. Familial adenomatous polyposis syndromes.
H. For confirmation and specific histologic diagnosis of radiologically demonstrated lesions:
1. Suspected neoplastic lesion.
2. Gastric or esophageal ulcer.
3. Upper tract stricture or obstruction.
I. GI bleeding:
1. In patients with active or recent bleeding.
2. For presumed chronic blood loss and for iron deficiency anemia when the clinical situation
suggests an upper GI source or when colonoscopy does not provide an explanation.
J. When sampling of tissue or fluid is indicated.
K. Selected patients with suspected portal hypertension to document or treat esophageal varices.
L. To assess acute injury after caustic ingestion.
M. To assess diarrhea in patients suspected of having small-bowel disease (e.g., celiac disease).
N. Treatment of bleeding lesions such as ulcers, tumors, vascular abnormalities (e.g.,
electrocoagulation, heater probe, laser photocoagulation, or injection therapy).
O. Removal of foreign bodies.
P. Removal of selected lesions.
Q. Placement of feeding or drainage tubes (e.g., peroral, percutaneous endoscopic gastrostomy,
percutaneous endoscopic jejunostomy).
R. Dilation and stenting of stenotic lesions (e.g., with transendoscopic balloon dilators or dilation
systems using guide wires).
S. Management of achalasia (e.g., botulinum toxin, balloon dilation).
T. Palliative treatment of stenosing neoplasms (e.g., laser, multipolar electrocoagulation, stent
U. Endoscopic therapy of intestinal metaplasia.
V. Intraoperative evaluation of anatomic reconstructions typical of modern foregut surgery (e.g.,
evaluation of anastomotic leak and patency, fundoplication formation, pouch configuration during
W. Management of operative complications (e.g., dilation of anastomotic strictures, stenting of
anastomotic disruption, fistula, or leak in selected circumstances).
EGD is generally not indicated for evaluating:
A. Symptoms that are considered functional in origin (there are exceptions in which an endoscopic
examination may be done once to rule out organic disease, especially if symptoms are
unresponsive to therapy or symptoms recur that are different in nature from the original symptoms).
B. Metastatic adenocarcinoma of unknown primary site when the results will not alter management.
C. Radiographic findings of:
1. Asymptomatic or uncomplicated sliding hiatal hernia.
2. Uncomplicated duodenal ulcer that has responded to therapy.
3. Deformed duodenal bulb when symptoms are absent or respond adequately to ulcer therapy.
Sequential or periodic EGD may be indicated for:
A. Surveillance for malignancy in patients with premalignant conditions (e.g., Barrett's esophagus,
polyposis syndromes, gastric adenomas, tylosis, or previous caustic ingestion).
Sequential or periodic EGD is generally not indicated for:
A. Surveillance for malignancy in patients with gastric atrophy, pernicious anemia, fundic gland or
hyperplastic polyps, gastric intestinal metaplasia, or previous gastric operations for benign
B. Surveillance of healed benign disease, such as esophagitis and gastric or duodenal ulcer.
Reprinted with permission from Early DS, Ben-Menachem T, Decker GA, et al; ASGE Standards of Practice Committee. Appropriate use of GI endoscopy. Gastrointest Endosc. 2012;75(6):1127-31.
The physician interested in learning EGD can obtain training through a medical school, residency, post-residency fellowships, CME conferences, preceptors, or any of a variety of self-study sources, including atlases, articles, videotapes, audio tapes, and computer-assisted programs. Related endoscopy skills include rigid and flexible sigmoidoscopy, colonoscopy, and nasopharyngolaryngoscopy.
The AAFP outlined requirements for demonstration of proficiency and documentation in 19998. Those requirements are reproduced in Table 2, below.
Demonstration of Proficiency and Documentation for EGD
The learner shall demonstrate adequate clinical knowledge regarding the following:
The learner shall demonstrate technical and clinical skills as he or she does the following. (Since the procedure cannot be completed without all of these steps, possession of the entire skill set is required.)
If administering conscious sedation, the learner shall demonstrate that he or she has performed conscious sedation during the past 24 months with cases reviewed for choice of drug, interval, dosage, and outcome.
The learner shall demonstrate proficiency in post-procedure steps through the following:
After the completion of upper GI endoscopy, appropriate documentation of the procedure is necessary for continuing care of the patient, medicolegal reasons, and billing.
Documentation can be performed by dictating a complete report or by using an endoscopy report form that allows notation of findings by circling the appropriate indications, medications, findings, and pathology. This type of documentation is also helpful when further clinical privileges are being requested and in clinical studies on EGD. A sample endoscopic report form is included as Appendix A.
Adapted from American Academy of Family Physicians. Esophagogastroduodenoscopy: a syllabus for the family physician interested in performing this technique. Leawood, KS: American Academy of Family Physicians 1999.
The Hospital Accreditation Standards 20139 published by the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) states Credentialing involves the collection, verification, and assessment of information regarding three critical parameters: current licensure; education and relevant training; and experience, ability, and current competence to perform the requested privilege(s)," (MS.06.01.03) and "The decision to grant or deny a privilege(s), and/or to renew an existing privilege(s), is an objective, evidence-based process." (MS.06.01.05)
The Joint Commission's standards create no barriers to granting privileges for a given activity to more than one clinical specialty (for example, privileges to perform endoscopy granted to both surgeons and gastroenterologists). The overriding concern is that the physician demonstrate the appropriate education, training, and current competence to perform the procedure in question. The specific criteria regarding education, training, and current competence should be developed by the individual departments and, as specified in standard MS.06.01.05, "All of the criteria used are consistently evaluated for all practitioners holding that privilege."
The American Association for Primary Care Endoscopy (AAPCE) recommends, “that "credentialing for gastrointestinal endoscopy be based primarily upon documentation of prior and/or current proficiency in a clinical setting. Competency should be substantiated by documentation provided by the applicant from prior mentors and/or supervisors. Alternatively, the applicant may be observed performing actual cases by an unbiased proctor (agreed upon by applicant and hospital) who then renders an opinion to the hospital regarding the applicant’s competency. The required number of proctored cases should usually be less than 10. For hospitals that choose to specify required numbers of procedures during training, these requirements should not exceed 50 colonoscopies or 35 esophagogastroduodenoscopies (EGD). No competent primary care physician should be denied privileges based on having been trained in primary care or on a specific number of required procedures during training.10
Physician candidates may be required to provide written documentation of additional training beyond the core curriculum of family medicine residency. This training can include, but is not necessarily limited, to the following:
The department may request written information regarding the number of cases performed and the presence of any complications related to the procedure.
Privileges for invasive procedures are usually granted a provisionally with the requirement that the physician submit progress reports at designated intervals (for example, three, six, and 12 months). The family medicine department would monitor these progress reports for department members and make recommendations for advancement from provisional privileges to active privileges.
During the provisional period, the family medicine department should assign a physician for to proctor the family physician monitored.
To ensure continuous monitoring of quality, physicians may be required to submit an annual census of all invasive procedures, listing many or all complications should they arise. This list should be reviewed by the department chair or his or her designee. Active privileges are renewed every one to two years by the authority of the department chair.
The family physician wishing to apply for privileges to perform EGD should follow a several-step process as instructed below:
1. Prepare a brief resume that describes your educational background including college, medical school, residency, board certification, and recertification.
2. Include your affiliations with hospitals and, state and national medical societies, including the duration of these affiliations. Include any professional honors, elected offices, or committee chair positions.
3. Describe the accredited CME courses you have taken that pertain to GI endoscopy. Include CME and/or self study of gastrointestinal illness (atlases, articles, etc).
4. Describe your years of practice and your record in providing high-quality care for a variety of complicated cases. The physician with a record of exemplary service can point to these experiences as evidence of professional excellence.
5. Include a summary letter from your residency or state AAFP chapter that supports these privileges as being within the scope of the specialty of family practice.
6. Describe the number of rigid sigmoidoscopies, flexible sigmoidoscopies, colonoscopies, and/or upper GI endoscopies that you have performed. Include an inventory that lists the patients by name, age, sex, and indication. Provide diagnostic findings and prominently highlight your lack of complications.
7. Describe hands-on proctorship experiences and/or identify someone who is willing to do cases with you. A hands-on proctorship is not necessarily a prerequisite if you have equivalent training and/or experience.
8. Be prepared, if necessary, to discuss the criteria for EGD credentialing suggested by the ASGE and the AAFP’s position that the ASGE's stance is not supported by current clinical evidence, and may reasonably be interpreted as more aligned with competitive marketplace concerns than patient access to quality care.
9. Describe your plan for quality assurance. This should involve tracking your cases, and providing these data to your department chair after a period of six to 12 months.
10. Provide evidence of your ability to obtain malpractice insurance coverage.
11. Be able to demonstrate an ongoing commitment to GI-related CME.
12. Be cooperative yet persistent during the privileging process. Become thoroughly familiar with your hospital’s bylaws and processes related to credentialing and privileging. Review and understand the privileging materials available from the Academy (see www.aafp.org/online/en/home/practicemgt/privileges/assistancepriv.html. Accessed January 28, 2013.).
Unfortunately, little is known concerning the public health implications of family physicians performing EGDs. However, it is known that patients, particularly in rural areas, often have more ready access to family physicians than other specialists. Thus, when family physicians can offer EGD, it increases patients' access to the procedure. Improved access should lead to earlier diagnosis and treatment as well as greater patient convenience.
Research concerning EGD in primary care has been limited primarily to case series and descriptive studies. These investigations suggest that family physicians can safely, accurately, and effectively perform EGD compared with other specialists or established criteria.
Although findings from case series, descriptive series, and literature reviews are helpful, evidence from randomized, controlled trials or other more powerful study designs is needed. The AAFP supports the need for such research. Clearly, further research is needed in every area of procedural training, performance, and health services. The need to document benefits and harms of procedures, patient preferences, economic costs and savings, and utilization and alternatives will assume greater importance as time goes on.
Several measures might help facilitate needed research:
In an ideal world, the specialty societies would work together to improve patient care by disseminating technology and educating all physicians. Unfortunately, groups such as the ASGE have, in the past, been unwilling to work cooperatively with the AAFP on endoscopy issues. In such situations, the AAFP has had no choice but to develop its own educational programs. In situations where other specialty organizations are willing to partner with the AAFP, the AAFP welcomes the chance to work toward improved patient care by increasing the education of its members.
An example of an informed consent form used by a family medicine program follows as Appendix B.
1. Pierzchajlo PJ, Ackerman RJ & Vogel RL. Esophagogastroduodenoscopy performed by a family physician: a case series of 793 procedures. J Fam Pract 1998;46(1):41-6.
2. Kolber M, Szafran O, Suwal J, et al. Outcomes of 1949 endoscopic procedures: performed by a Canadian rural family physician. Can Fam Physician. 2009;55(2):170-5.
3. Silvis SE, Nebel O, Rogers G, et al. complications. Results of the 1974 American Society for Gastrointestinal Endoscopy Survey. JAMA. 1976;235(9):928-30.
4. American Academy of Family Physicians. Facts About Family Practice. Leawood, KS: American Academy of Family Physicians 2006.
5. American Academy of Family Physicians. Provision of selected services and procedures in hospital practices of family physicians (as of April 2011). In Facts About Family Medicine. Kansas City, MO: American Academy of Family Physicians; 2008. www.aafp.org/online/en/home/aboutus/specialty/facts/17.html. Accessed January 30, 2013.
6. Wilkins T, Hardy H. The current state of esophagogastroduodenoscopy training in family practice residency programs. Fam Med. 2003;35(4):269-72.
7. Early DS, Ben-Menachem T, Decker GA, et al ASGE Standards of Practice Committee. Appropriate use of GI endoscopy. Gastrointest Endosc. 2012;75(6):1127-31.
8. American Academy of Family Physicians. Esophagogastroduodenoscopy: A Syllabus for the Family Physician Interested in Performing This Technique. Leawood, KS: American Academy of Family Physicians 1999.
9. Joint Commission on Accreditation of Healthcare Organizations. Hospital Accreditation Standards 2013. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations 2012.
10. American Association for Primary Care Endoscopy. AAPCE Policy on Credentialing for Gastrointestinal Endoscopy. Leawood, KS; 2009.
(2008) (2013 COD)
Patient's Name: _______________________ Location: ______________________
Date: _____________ Age: _______ Sex: M or F
Race: _____________ Physician:______________________
Office/Hospital ID# (if any): ______________ Assistant(s): ___________________
Pertinent Patient History (e.g., illnesses, medicines, surgery, allergies, duration of problem):
Has the patient completed 7-10 days of medical therapy ? Yes No
Circle the categories of drugs used and indicate the drug, dosage and duration of therapy, if known:
Antacid / Antibiotic / Cytotec / Bismuth / Carafate
PPI:_______________ H2 blocker:_______________ Other:________________
Has the patient been using over the counter or prescription NSAIDs or other known gastric irritants?
If so, please list:____________________________________________________
What are the indications for these procedures? (Circle the numbers of those that apply.)
Medications Used: (Circle drugs used and indicate total dosage.)
Findings: (Circle one for each question)
Pathology Codes: (Codes apply immediately below.)
1. Mild erythema, patchy, no ulcers
2. Moderate erythema, diffuse in area, some petechiae, no ulcers
3. Severe erythema, limited focal mucosal degeneration (i.e., 1-3 ulcers are seen)
4. Severe erythema with diffuse mucosal degeneration (more than 3 ulcers)
5. Other (polyps, cancer, atrophy, or miscellaneous)
Circle one inflammation code for each area: (See above.)
What is your post-endoscopy working diagnosis? (Circle those that apply.)
Will you or did you order upper GI x-rays or barium swallow to confirm and/or complement your endoscopy findings? (Circle one.) Yes No
Were there any complications? (Circle one.) Yes No
Did this procedure change your management plan? (Circle one.) Yes No
Comments - Circle how your management plan or diagnosis changed: (Circle all that apply.)
Exam performed as above,
Please check to see that all items have been completed. Complete information strengthens our ability to document a high quality of care.
EGD is a way for your family doctor to look into your stomach or intestine with a flexible tube and possibly remove a small sample of tissue called a biopsy. The sample of tissue is sent to a lab for testing. EGD is also called by other names such as endoscopy or upper GI endoscopy.
EGD can help your family doctor find out what is causing your symptoms and find the cause. For example, your doctor may find that an ulcer has been causing your pain. The doctor can then recommend medicine or other treatments. EGD can also find early signs of cancer. With some cancers, early diagnosis increases the chances of a cure.
EGD is a generally safe. It causes few complications. But, as with all medical tests or procedures, EGD does have some risks. Your doctor thinks the likely benefits are greater than the risks. Still, you need to understand the risks before you decide to have an EGD. Please read and understand the following:
1. Infection can occur, although this is rare. You might need medications after the procedure.
2. Bleeding can occur, but it is also rare. You could have some spotting or even enough bleeding to need a transfusion. This is not common, but it is possible.
3. Perforation (putting a hole in the intestine) is a serious complication, but it is uncommon. If a perforation occurs, you would need to go to the hospital and might need an operation.
4. You will be given some medicines during EGD. The medicines may have side effects, but your doctor will take steps to lower the risk. The medications your doctor will give you to prevent pain can cause a reaction. One rare side effect is a swelling and redness in the arm. Another might be a severe allergic reaction to the medications. Your doctor will take precautions to minimize this risk.
You can choose to have EGD or choose not to. This sheet is designed to help you make that decision after talking with your doctor about it. You have several choices:
1. If you feel your questions have been answered and you understand and accept the risks and benefits, you can agree to have EGD by signing the bottom of this sheet.
2. If you are not yet ready to decide to have an EGD, you can ask for more time to think about it and discuss it with your doctor.
3. You can refuse to have EGD, but keep in mind that not having the procedure may also involve some risk. For example, your doctor may not be able to find the cause of your problem, or the cause may take longer to find. In the case of cancer, delaying could mean that treatment isn't started soon enough to cure the cancer.
4. In some cases, other tests could be done instead of an EGD. You can ask your doctor about alternatives to EGD. If there are alternatives that your family, friends, or other doctors have discussed with you, tell your family doctor about them so you can discuss whether they would be right for you.
I have read and understood the above. I believe that the benefits of this procedure outweigh its risks. I agree to allow Dr. to perform the procedure.
(August Board 2002) (2013 COD)
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EGD, Training and Credentialing of Family Physicians In (Position Paper)