How Often Should an Endoscopy Be Normal?

An interesting retrospective study (S Wang et al. JPGN 2018; 66: 876-81) looks at a total of 218 endoscopies in 164 children and examines findings in relation to gastrointestinal symptoms.  The results focus mainly on upper endoscopy as there were only 20 who had isolated colonoscopy.

Key findings.

  • 164 of 612 (26.8%) of all new patients had an endoscopy
  • Among upper endoscopy, 72% were histologically normal, and 56% were macroscopically normal.  The authors suspect those with abnormal macroscopic appearance and normal histology were mainly errors in interpretation.
  • In those with isolated colonoscopy, 25% were histologically and macroscopically abnormal; thus, complete concordance among the 20 cases.
  • In those with combined procedures, the likelihood of abnormalities was higher at 53% for both histology and macroscopically being abnormal.  This higher rate was driven mainly by the increased suspicion and diagnosis of inflammatory bowel disease in this subset of 74 patients.
  • Overall, 49% of all first diagnostic endoscopies were completely normal, though 65% were histologically normal.
  • For upper endoscopy, in those who had performance for isolated abdominal pain, the histologic yield was 11%.  It was also 11% for reflux.  The symptom with highest yield was vomiting, yet even for this, the findings were normal in about 80%.
  • For colonoscopy, rectal bleeding had the highest yield, but 72% were normal in this small cohort, indicating that a trial of conservative management may be appropriate.

An important point in the discussion.  The authors take an exception to the idea that normal findings are reassuring.  “When procedures are performed despite the expectation of normality this has not been shown to lead to better clinical outcomes of patients…abdominal pain was unaffected by whether or not the patient had undergone endoscopy>”

My take: I agree with the authors that the histologic findings are more likely significant than macroscopic findings in the majority of patients.  However, it is worth noting that mild histologic findings are of dubious importance in many cases.  Ultimately, identifying strategies to maximize diagnostic yield is needed to provide more cost-effective care and minimize the risks of unnecessary procedures.

 

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