Diagnostic yield of upper endoscopy according to appropriateness: A systematic review

Background/aim: Despite some official guidelines are available, a substantial rate of inappropriateness for upper gastrointestinal (UGI) endoscopies has been reported. This study aimed to estimate the inappropriate rate of UGI in different countries, also including the diagnostic yield. Methods: A systematic review of studies on UGI endoscopy appropriateness was performed by adopting official guidelines as reference standard. Diagnostic yield of relevant endoscopic findings and cancers was compared between appropriate and inappropriate procedures. The Odd Ratio (OR) values and the Number-Needed-to-Scope (NNS) were calculated. Results: Data of 23 studies with a total of 53,392 patients were included. UGI indications were overall inappropriate in 21.7% (95% CI = 21.4–22.1) of the patients. The inappropriateness rate significantly (P < 0.0001) decreased from 35.1% in the earlier studies to 22.1%–23% in the more recent ones. A relevant finding was found in 43.3% of appropriate and in 35.1% of inappropriate endoscopies (P < 0.0001; OR: 1.42, 95% CI = 1.36–1.49; NNS = 12). Prevalence of cancers was also higher in appropriate than in inappropriate UGIs (2.98% vs. 0.09%, P < 0.0001; OR = 3.33; NNS = 48). The prevalence of detected cancers significantly (P < 0.004) increased from 1.38% in the earlier studies to 2.11% in the more recent ones, whilst prevalence of other relevant findings remained similar. Conclusions: Rate of inappropriate UGI endoscopies is still high. Diagnostic yield of appropriate endoscopies is higher than that of inappropriate procedures, including upper GI cancers. Therefore, implementation of guidelines in clinical practice is urged.