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## Complete Summary

#### GUIDELINE TITLE

Quality indicators for colonoscopy.

#### BIBLIOGRAPHIC SOURCE(S)

Rex DK, Petrini JL, Baron TH, Chak A, Cohen J, Deal SE, Hoffman B,
Jacobson BC, Mergener K, Petersen BT, Safdi MA, Faigel DO, Pike IM.
Quality indicators for colonoscopy. Gastrointest Endosc 2006 Apr;63(4
Suppl):S16-28. \[107 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16564908)

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Colonic disorders, including:

-   Diarrhea of unexplained origin

-   Iron deficiency anemia

-   Colonic neoplasia

-   Polyps

-   Inflammatory bowel disease

-   Colitis

-   Crohn\'s colitis

-   Gastrointestinal bleeding

-   Acute nontoxic megacolon

-   Sigmoid volvulus

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Prevention\
Screening

#### CLINICAL SPECIALTY

Gastroenterology

#### INTENDED USERS

Advanced Practice Nurses\
Nurses\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

To establish competence in performing colonoscopy and help define areas
of continuous quality improvement

#### TARGET POPULATION

Patients undergoing colonoscopy

#### INTERVENTIONS AND PRACTICES CONSIDERED

Colonoscopy

#### MAJOR OUTCOMES CONSIDERED

Safety and efficacy of procedure

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Studies were identified through a computerized search of Medline
followed by review of the bibliographies of relevant articles. When such
data were absent, indicators were chosen by expert consensus.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Expert Consensus (Committee)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

The American Society for Gastrointestinal Endoscopy (ASGE) and the
American College of Gastroenterology (ACG), as leaders in promoting the
highest quality patient care, formed a task force to identify end points
that could be used to document high-quality endoscopic services. In most
cases these end points will require validation before they can be
generally adopted. The task force consisted of expert endoscopists
selected by the board of directors of the ASGE and the ACG.

The task force developed quality indicators for the 4 major endoscopic
procedures: colonoscopy, esophagogastroduodenoscopy (EGD), endoscopic
retrograde cholangiopancreatography (ERCP), and endoscopic
ultrasonography (EUS). Wherever possible, these indicators were chosen
because there were published supporting data. These studies were
identified through a computerized search of Medline followed by review
of the bibliographies of relevant articles. When such data were absent,
indicators were chosen by expert consensus. The goal was to create a
comprehensive list of potential quality indicators, recognizing that
only a small subset may ultimately be implemented. The resultant quality
indicators were graded on the strength of the supporting evidence.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**Grades of Recommendation**

  -------------------------------------------------------------------------------
  **Grade of         **Clarity   **Methodologic           **Implications**
  recommendation**   of          strength/supporting      
                     benefit**   evidence**               
  ------------------ ----------- ------------------------ -----------------------
  1A                 Clear       Randomized trials        Strong recommendation;
                                 without important        can be applied to most
                                 limitations              clinical settings

  1B                 Clear       Randomized trials with   Strong recommendation;
                                 important limitations    likely to apply to most
                                 (inconsistent results,   practice settings
                                 nonfatal methodologic    
                                 flaws)                   

  1C+                Clear       Overwhelming evidence    Strong recommendation;
                                 from observational       can apply to most
                                 studies                  practice settings in
                                                          most situations

  1C                 Clear       Observational studies    Intermediate-strength
                                                          recommendation; may
                                                          change when stronger
                                                          evidence is available

  2A                 Unclear     Randomized trials        Intermediate-strength
                                 without important        recommendation; best
                                 limitations              action may differ
                                                          depending on
                                                          circumstances or
                                                          patients\' or societal
                                                          values

  2B                 Unclear     Randomized trials with   Weak recommendation;
                                 important limitations    alternative approaches
                                 (inconsistent results,   may be better under
                                 nonfatal methodologic    some circumstances
                                 flaws)                   

  2C                 Unclear     Observational studies    Very weak
                                                          recommendation;
                                                          alternative approaches
                                                          likely to be better
                                                          under some
                                                          circumstances

  3                  Unclear     Expert opinion only      Weak recommendation;
                                                          likely to change as
                                                          data become available
  -------------------------------------------------------------------------------

\*Adapted from Guyatt G, Sinclair J, Cook D, Jaeschke R, Schunemann H,
Pauker S. Moving from evidence to action: grading recommendations---a
qualitative approach. In: Guyatt G, Rennie D, eds. Users\' guides to the
medical literature. Chicago: AMA Press; 2002. p. 599-608.

#### COST ANALYSIS

Cost-benefit analyses of colonoscopy for the detection of neoplastic
lesions are well within acceptable rates (approximately \$20,000 per
year of life saved).

#### METHOD OF GUIDELINE VALIDATION

Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

The task force consisted of expert endoscopists selected by the board of
directors of the American Society for Gastrointestinal Endoscopy (ASGE)
and the American College of Gastroenterology (ACG). These documents were
then reviewed and approved by the governing boards.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

Recommendations were graded on the strength of the supporting evidence
(Grades 1A-3). Definitions of the recommendation grades are presented at
the end of the \"Major Recommendations\" field.

**Preprocedure**

The preprocedure period encompasses the time from first contact by the
patient until administration of sedation or instrument insertion. The
aspects of patient care addressed in prior documents apply here as well,
including timely scheduling, patient preparation, identification,
history and physical examination, appropriate choice of sedation and
analgesia, evaluation of bleeding risk, etc. Because many examinations
are currently being performed for colon cancer screening and are
elective, care must be taken to be certain that all potential risks have
been reduced to as low as practically achievable.

The American Society for Gastrointestinal Endoscopy (ASGE) and the U.S.
Multi-Society Task Force on Colon Cancer have published appropriate
indications for colonoscopy (Tables below).

1.  Appropriate indication. The ASGE and the U.S. Multi-Society Task
    Force on Colon Cancer have published appropriate indications for
    colonoscopy (Tables below). An indication should be documented for
    each procedure, and when it is a nonstandard indication it should be
    justified in the documentation. **(1C+)**

> *Discussion*. In the average-risk population, colonoscopic screening
> is recommended in all current guidelines at 10-year intervals.  Direct
> observational data to support this interval are lacking. However, in a
> cohort of average risk persons who underwent an initial colonoscopy
> with negative results, a repeat colonoscopy 5 years later had a very
> low yield. Two studies of flexible sigmoidoscopy showed that the
> protective effect of endoscopy with polypectomy was present for
> intervals of 10 years and 16 years and could not exclude longer
> durations of effect. Thus, although colonoscopy is not perfectly
> protective, its protective effect is prolonged. These data support the
> continued use of the 10-year interval.

**Table: Colonoscopy Indications\***

+-----------------------------------------------------------------------+
| A.  Evaluation on barium enema or other imaging study of an           |
|     abnormality that is likely to be clinically significant, such as  |
|     a filling defect or stricture                                     |
|                                                                       |
| B.  Evaluation of unexplained gastrointestinal bleeding               |
|                                                                       |
|     1.  Hematochezia                                                  |
|                                                                       |
|     2.  Melena after an upper gastrointestinal source has been        |
|         excluded                                                      |
|                                                                       |
|     3.  Presence of fecal occult blood                                |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| C.  Unexplained iron deficiency anemia                                |
|                                                                       |
| D.  Screening and surveillance for colonic neoplasia                  |
|                                                                       |
|     1.  Screening of asymptomatic, average-risk patients for colonic  |
|         neoplasia                                                     |
|                                                                       |
|     2.  Examination to evaluate the entire colon for synchronous      |
|         cancer or neoplastic polyps in a patient with treatable       |
|         cancer or neoplastic polyp                                    |
|                                                                       |
|     3.  Colonoscopy to remove synchronous neoplastic lesions at or    |
|         around time of curative resection of cancer followed by       |
|         colonoscopy at 3 years and 3-5 years thereafter to detect     |
|         metachronous cancer                                           |
|                                                                       |
|     4.  After adequate clearance of neoplastic polyp(s) survey at 3-  |
|         to 5-year intervals                                           |
|                                                                       |
|     5.  Patients with significant family history                      |
|                                                                       |
|         a.  Hereditary nonpolyposis colorectal cancer: colonoscopy    |
|             every 2 years beginning at the earlier of age 25 years or |
|             5 years younger than the earliest age of diagnosis of     |
|             colorectal cancer. Annual colonoscopy should begin at age |
|             40 years.                                                 |
|                                                                       |
|         b.  Sporadic colorectal cancer before age 60 years:           |
|             colonoscopy every 5 years beginning at age 10 years       |
|             earlier than the affected relative or every 3 years if    |
|             adenoma is found                                          |
|                                                                       |
|     ```{=html}                                                        |
|     <!-- -->                                                          |
|     ```                                                               |
|     6.  In patients with ulcerative or Crohn\'s pancolitis 8 or more  |
|         years\' duration or left-sided colitis 15 or more years\'     |
|         duration every 1-2 years with systematic biopsies to detect   |
|         dysplasia                                                     |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| E.  Chronic inflammatory bowel disease of the colon if more precise   |
|     diagnosis or determination of the extent of activity of disease   |
|     will influence immediate management                               |
|                                                                       |
| F.  Clinically significant diarrhea of unexplained origin             |
|                                                                       |
| G.  Intraoperative identification of a lesion not apparent at surgery |
|     (e.g., polypectomy site, location of a bleeding site)             |
|                                                                       |
| H.  Treatment of bleeding from such lesions as vascular malformation, |
|     ulceration, neoplasia, and polypectomy site (e.g.,                |
|     electrocoagulation, heater probe, laser or injection therapy)     |
|                                                                       |
| I.  Foreign body removal                                              |
|                                                                       |
| J.  Excision of colonic polyp                                         |
|                                                                       |
| K.  Decompression of acute nontoxic megacolon or sigmoid volvulus     |
|                                                                       |
| L.  Balloon dilation of stenotic lesions (e.g., anastomotic           |
|     strictures)                                                       |
|                                                                       |
| M.  Palliative treatment of stenosing or bleeding neoplasms (e.g.,    |
|     laser, electrocoagulation, stenting)                              |
|                                                                       |
| N.  Marking a neoplasm for localization                               |
+-----------------------------------------------------------------------+

American Society for Gastrointestinal Endoscopy. Appropriate use of
gastrointestinal endoscopy. Gastrointest Endosc 2000;52:831-7.

**Table 3: Indications for Colonoscopy and Appropriate Intervals\***

  -----------------------------------------------------------------------
  **Indication**                                 **Interval\***
  ---------------------------------------------- ------------------------
  Bleeding                                        

  Positive FOBT                                  NR

  Hematochezia                                   NR

  Iron deficiency anemia                         NR

  Melena with negative                           NR
  esophagogastroduodenoscopy                     

  Screening                                       

  Average risk                                   10 y (begin at age 50 y)

  Single FDR with cancer (or adenomas) at age    10 y (begin at age 40 y)
  [\>]{.underline} 60 y                          

  [\>]{.underline}2 FDRs with cancer (or         5 y (begin at age 40 y
  adenomas) or 1 FDR diagnosed at age \<60 y     or 10 y younger,
                                                 whichever is earlier)

  Prior endometrial or ovarian cancer diagnosed  5 y
  at age \<50 y                                  

  HNPCC (begin age 20-25 y)                      1-2 y

  Abdominal pain, altered bowel habit#            

  Positive sigmoidoscopy (large polyp or polyp    
  of \<1 cm shown to be an adenoma)\^            

  Postadenoma resection                           

  1-2 tubular adenomas of \<1 cm                 5-10 y

  3-10 adenomas or adenoma with villous          3 y
  features, [\>]{.underline}1 cm or with HGD     

  \>10 adenomas                                  \<3 y

  Sessile adenoma of [\>]{.underline}2 cm,       2-6 m
  removed piecemeal\*\*                          

  Postcancer resection                           Clear colon, then 1 y,
                                                 then 3 y, then 5 y

  Ulcerative colitis, Crohn\'s colitis           2-3 y until 20 y after
  surveillance after 8 y of pancolitis or 15 y   onset of symptoms, then
  of left-sided colitis                          1 y
  -----------------------------------------------------------------------

FOBT, Fecal occult blood test; NR, interval not recommended; FDR,
first-degree relative; HNPCC, hereditary nonpolyposis colorectal cancer;
HGD, high-grade dysplasia.

\*From: Rex DK, Bond JH, Winawer S, et al. Quality in the technical
performance of colonoscopy and the continuous quality improvement
process for colonoscopy: recommendations of the U.S. Multi-Society Task
Force on Colorectal Cancer. Am J Gastroenterol 2002;97:1296-308. Updated
based on guideline revisions in press. Used with permission.

#If colonoscopy has negative results and symptoms are stable, repeat
examination should be done according to screening recommendations.

\^See postadenoma resection recommendation.

\*\*The goal is to reexamine the site for residual polyp; repeating a
flexible sigmoidoscopy is adequate for a distal polyp.

2.  Informed consent is obtained, including specific discussions of
    risks associated with colonoscopy. **(3)**

> *Discussion*. As with all other endoscopic procedures, consent must be
> obtained before the procedure from the patient or guardian on the same
> day (or as required by local law or per policy of the institution) as
> the procedure. Consent may be obtained in the procedure room. It must
> include a discussion of the risks, benefits, and alternatives to the
> procedure.

3.  Use of recommended postpolypectomy and postcancer resection
    surveillance intervals (Tables above). **(1A)**

> *Discussion*. For colonoscopy to be both effective and cost-effective
> and to minimize risk, the intervals between examinations should be
> optimized. Intervals between examinations can only be effective in
> prevention of incident colorectal cancer when the colon is effectively
> cleared of neoplasia. Therefore, detailed and effective examination of
> the colon, as discussed below, is critical to the effectiveness of
> recommended intervals between colonoscopies. The recommended intervals
> assume cecal intubation, adequate bowel preparation, and careful
> examination.
>
> Colonoscopy, even when performed carefully, is not expected to prevent
> all incident colorectal cancers. Some colorectal cancers arise because
> of genetic factors that make the adenoma-to-carcinoma sequence faster.
> In addition, in some instances, colonoscopic polypectomy may not be
> effective in eradicating polyps. Because colonoscopy can be an
> expensive procedure and is associated with a low risk of serious
> consequences, intervals between examinations are recommended on the
> basis of the best available evidence and experience that indicates a
> balance between the protective effect of high-quality clearing
> colonoscopy with the risks and cost of colonoscopy.
>
> Recent evidence from 4 surveys indicated that postpolypectomy
> surveillance colonoscopy in the United States is frequently performed
> at intervals that are shorter than those recommended in guidelines.
> These surveys underscore the importance of measuring intervals between
> examinations in continuous quality improvement programs. Some
> endoscopists in these studies performed colonoscopy in patients with
> only small hyperplastic polyps or a single tubular adenoma at 1 year,
> an interval abandoned in guidelines after publication of the National
> Polyp Study randomized trial in 1993. Surgeons were more likely than
> gastroenterologists to use short intervals. These data underscore the
> need for endoscopic leaders to promote continuous quality improvement
> among all specialties practicing colonoscopy in a given community.
>
> Diminutive hyperplastic polyps, when found only in the rectosigmoid
> colon, can be considered normal. The presence of small distal
> hyperplastic polyps only should not alter the recommended interval for
> surveillance. Appropriate intervals in patients with large
> hyperplastic polyps located in the proximal colon, or in patients who
> have many hyperplastic polyps (30 or more) are not yet established,
> but close follow-up may be appropriate.
>
> Patients who have evidence of colonic bleeding that occurs after a
> colonoscopy with negative results may need repeat examinations at
> intervals shorter than those recommended in the Tables above. However,
> the use of fecal occult blood testing for the first 5 years after a
> colonoscopy is discouraged because the positive predictive value of
> guaiac-based fecal occult blood testing during that interval is
> extremely low. Additional study of fecal immunochemical testing for
> blood in this setting as an adjunct to colonoscopy is warranted.

4.  The use of recommended ulcerative colitis and Crohn\'s colitis
    surveillance. **(2C)**

> *Discussion*. In ulcerative colitis and Crohn\'s colitis, surveillance
> refers to interval examinations of patients with long-standing disease
> who have undergone an initial examination in which dysplasia is not
> detected. The term is also used when patients who are asymptomatic are
> prospectively entered into interval colonoscopy programs on the basis
> of their duration of disease. Surveillance does not refer to
> diagnostic examinations or examinations in previously diagnosed
> patients to assess symptoms. Both ulcerative colitis and Crohn\'s
> colitis of long duration are associated with an increased risk of
> colorectal cancer. There are no randomized trials to support the
> effectiveness of surveillance colonoscopy in ulcerative colitis or
> Crohn\'s colitis, but case control studies in ulcerative colitis
> suggest a survival benefit for patients who participate in
> surveillance. Surveys of practitioners in the United States and the
> United Kingdom demonstrate that many practitioners are not familiar
> with surveillance recommendations, have a poor understanding of
> dysplasia, and make inappropriate recommendations in response to
> findings of dysplasia.
>
> Patients should be encouraged to undergo surveillance colonoscopy, and
> surveillance has emerged as a standard of medical care in the United
> States. The onset of disease is timed to the onset of symptoms for the
> purpose of timing the initiation of surveillance in both ulcerative
> colitis and Crohn\'s colitis. Because the yield of ulcerative colitis
> in surveillance for cancer and severe dysplasia is relatively low, it
> is important to not overuse surveillance colonoscopy during the first
> 20 years because overuse is not cost-effective. Shorter intervals
> between examinations are indicated for patients with long-duration
> disease and may be initiated earlier in the course of disease in
> patients with established risk modifiers, such as a family history of
> colorectal cancer or a personal history of primary sclerosing
> cholangitis. Persons with primary sclerosing cholangitis who are
> discovered to have asymptomatic ulcerative colitis should begin
> surveillance at the time ulcerative colitis is diagnosed.

5.  Preparation: in every case the procedure note should document the
    quality of preparation. **(2C)**

> *Discussion*. In each colonoscopy, the colonoscopist should document
> the quality of the bowel preparation. In clinical trials of bowel
> preparation, terms used to commonly characterize bowel preparation
> include \"excellent,\" \"good,\" \"fair,\" and \"poor.\" In clinical
> practice, these terms do not have standardized definitions. In
> clinical trials on the effectiveness of various laxative regimens for
> bowel preparation, excellent is typically defined as no or minimal
> solid stool and only small amounts of clear fluid requiring
> suctioning. \"Good\" is typically no or minimal solid stool with large
> amounts of clear fluid requiring suctioning. \"Fair\" refers to
> collections of semisolid debris that are cleared with difficulty.
> \"Poor\" refers to solid or semisolid debris that cannot be
> effectively cleared. These terms can be interpreted as having more to
> do with retained intraluminal contents that often can be removed by
> suctioning rather than the quality of inspection allowed after
> suctionable material has been fully removed; however, these terms are
> probably reasonable guides to the appropriate use of bowel
> descriptors.
>
> Poor bowel preparation is a major impediment to the effectiveness of
> colonoscopy. Poor preparation prolongs cecal intubation time and
> withdrawal time and reduces detection of both small2 and large2
> polyps. In every colonoscopic practice, some colonoscopies must be
> repeated at intervals shorter than those recommended in Table 3
> because of inadequate preparation. The task force recommends that the
> procedure be considered adequate if it allows (within the technical
> limitations of the procedure) detection of polyps 5 mm or larger. The
> economic burden of repeating examinations because of inadequate bowel
> preparation is substantial. No thresholds are recommended by the
> committee for the percentage of examinations that are repeated for
> poor preparation because the percentage of patients requiring repeat
> examination may depend mostly on patient population characteristics.
> However, measurement of individual practitioners\' percentage of
> examinations requiring repeat because of preparation is recommended.
> Individual endoscopists may compare their percentages to others within
> the same practice or to other endoscopists practicing in the same
> hospital. This can allow identification of outliers within that
> hospital for whom corrective measures should be taken.

**Intraprocedure**

Quality evaluation of the colon consists of intubation of the entire
colon and a detailed mucosal inspection. Cecal intubation improves
sensitivity and reduces costs by eliminating the need for radiographic
procedures or repeat colonoscopy to complete examination. Careful
mucosal inspection is essential to effective colorectal cancer
prevention and reduction of cancer mortality. The detection of
neoplastic lesions is the primary goal of most colonoscopic
examinations.

Cost-benefit analyses of colonoscopy for the detection of neoplastic
lesions are well within acceptable rates (approximately \$20,000 per
year of life saved). However, complications, repeat procedures, and
inappropriate surgical intervention for endoscopically removable polyps
can significantly reduce this benefit. It is incumbent on endoscopists
to evaluate their practices and seek to make improvements wherever
possible to reduce the costs associated with neoplasia detection.

6.  Cecal intubation rates: visualization of the cecum by notation of
    landmarks, and photodocumentation of landmarks should be documented
    in every procedure. **(1C)**

> *Discussion*. Cecal intubation should be documented by naming the
> identified cecal landmarks. Most important, these include the
> appendiceal orifice and the ileocecal valve. In cases where there is
> uncertainty as to whether the cecum has been entered, visualization of
> the lips of the ileocecal valve (i.e., the orifice) or intubation of
> the terminal ileum will be needed. Experienced colonoscopists can
> verify cecal intubation in real time in 100% of cases, because there
> is no other portion of the gastrointestinal tract with a similar
> appearance. It can be helpful to document other landmarks, such as the
> cecal sling fold or intubation of the terminal ileum.
>
> Photography of the cecum is also recommended. Still photography of the
> cecum may not be convincing in all cases because of variations in
> cecal anatomy. Thus, the ileocecal valve may not be notched or may not
> have a lipomatous appearance; however, still photography is convincing
> in a substantial majority of cases, and its use allows verification of
> cecal intubation rates of individual endoscopists in the continuous
> quality improvement program. The best photographs of the cecum to
> prove intubation are of the appendiceal orifice, taken from a distance
> sufficiently far away that the cecal strap fold is visible around the
> appendix, and a photograph of the cecum taken from distal to the
> ileocecal valve. Photographs of the terminal ileum are sometimes
> convincing if they show villi, circular valvulae connivente, and
> lymphoid hyperplasia, but they are less likely to be effective
> compared with the above-mentioned photographs. Videotaping of the
> cecum is not necessary in clinical practice because its feasibility
> remains low at this time; however, the appearance of the cecum is
> unmistakable in real time and videotaping of the cecum can be a very
> effective way of documenting cecal intubation for an examiner whose
> rates of cecal intubation require verification.
>
> Effective colonoscopists should be able to intubate the cecum in
> [\>]{.underline}90% of all cases and in [\>]{.underline}95% of cases
> when the indication is screening in a healthy adult. All colonoscopy
> studies done for screening have reported cecal intubation rates of 97%
> or higher. Cases in which procedures are aborted because of poor
> preparation or severe colitis need not be counted in determining cecal
> intubation rates. It is also not necessary to count cases in which the
> initial intent of the procedure is colonoscopic treatment of a benign
> or malignant stricture or a large polyp (provided that complete
> colonic imaging by some method has been previously performed). All
> other colonoscopies, including those in which a previously unknown
> benign or malignant stricture is encountered, should be counted.

7.  Detection of adenomas in asymptomatic individuals (screening).
    **(1C)**

> *Discussion*. Among healthy asymptomatic patients undergoing screening
> colonoscopy, adenomas should be detected in [\>]{.underline}25% of men
> and [\>]{.underline}15% women more than 50 years old.

8.  Withdrawal times: studies have demonstrated increased detection of
    significant neoplastic lesions in colonoscopic examinations where
    the withdrawal time is 6 minutes or more. Mean withdrawal time
    should be [\>]{.underline}6 minutes in colonoscopies with normal
    results performed in patients with intact colons. **(2C)**

> *Discussion*. In instances of low detection rates of adenomas,
> measurement of withdrawal time is appropriate as a quality indicator.
> To measure withdrawal time, the time at which the cecum is reached and
> the time at which the scope is withdrawn from the anus must be noted.
> Some electronic report-generating systems allow the time to be noted
> electronically when cecal photographs are taken. On the basis of the
> mean withdrawal times of an examiner with very low miss rates5 and
> previously cited evidence that the detection rate of large adenomas
> was greater for examiners who took longer than 6 minutes for
> withdrawal during screening colonoscopy, it is recommended that the
> withdrawal phase of colonoscopy in patients without previous surgical
> resection should last at least 6 minutes on average. Application of
> this standard to an individual case is not appropriate because colons
> differ in length and in some instances a very well prepared colon of
> relatively short length and with nonprominent haustral markings can be
> carefully examined in less than 6 minutes. Further, recent evidence
> suggests that colonoscopies with a wide angle of view allow quicker
> examination without increasing miss rates for polyps.

9.  Biopsy specimens should be obtained from the colon in patients with
    chronic diarrhea. **(2C)**

> *Discussion*. Patients with microscopic colitis (collagenous and
> lymphocytic colitis) may have normal-appearing mucosa at colonoscopy.
> The diagnosis requires biopsy of otherwise unremarkable-appearing
> colon. All patients undergoing colonoscopy for the evaluation of
> chronic diarrhea should have biopsy specimens obtained. The optimal
> number and location of biopsy specimens is not established. Inclusion
> of samples from the proximal colon improves the sensitivity for
> collagenous colitis.

10. Number and distribution of biopsy samples in ulcerative colitis and
    Crohn\'s colitis surveillance. Goal: 4 per 10-cm section of involved
    colon or approximately 32 biopsy specimens in cases of panulcerative
    colitis. **(1C)**

> *Discussion*. Systematic biopsy of the colon and terminal ileum can
> assist in establishing the extent of ulcerative colitis and Crohn\'s
> disease and in differentiating ulcerative colitis from Crohn\'s
> disease. During surveillance, a systematic biopsy protocol is needed
> to maximize the sensitivity of surveillance for dysplasia. The
> recommended protocol includes biopsies in all 4 quadrants from each 10
> cm of the colon. This typically results in 28 to 32 biopsy samples as
> a minimum. The procedure report in ulcerative colitis surveillance
> examinations should note the number and locations of specimens from
> flat mucosa and the location and endoscopic appearance of any mass or
> suspicious polypoid lesions that were sampled or removed.

11. Mucosally based pedunculated polyps and sessile polyps \<2 cm in
    size should not be sent for surgical resection without an attempt at
    endoscopic resection or documentation of endoscopic inaccessibility.
    **(3)**

> *Discussion*. Patients with sessile polyps \<2 cm in size should
> seldom be referred for surgical resection because these polyps are
> readily resectable in most cases by competent colonoscopists.
> Consistent referral of sessile polyps \<2 cm in size for surgical
> resection is inappropriate. In some cases, these polyps may be
> difficult to access or properly position for polypectomy, and referral
> to a more experienced endoscopist may be appropriate.
>
> Certainly endoscopists should not attempt removal of polyps they
> consider beyond their skill or comfort level, and they should feel
> comfortable in referring such polyps to other endoscopists for a
> second opinion (e.g., review of photographs) or endoscopic resection.
> Many sessile polyps \>2 cm in size are also removable endoscopically,
> depending on their location within the colon, their size, and the
> ability to access them endoscopically. Essentially all mucosally based
> pedunculated polyps can be removed endoscopically. All polyps referred
> for surgical resection should be photographed to document the need for
> surgical resection in the continuous quality improvement process.
> Review of photographs by a second, more experienced endoscopist can be
> useful to ensure the appropriateness of surgical referral. When
> surgical referral is pursued, correlation of photographs and
> endoscopic and pathologic measurements of polyp size should be
> undertaken to confirm the appropriateness of surgical referral.

**Postprocedure**

The aspects of postprocedure care that have been discussed in previous
sections also apply here. A complete and accurate report, describing the
procedure and findings, must be completed immediately after the
procedure. The report should include photo documentation of
abnormalities and identification of any biopsy specimens obtained.
Expectations for follow-up care and determination of who will provide
the follow-up should be specified.

The postprocedure interval also provides an opportunity to determine the
safety of the procedure as performed by any given endoscopist. Although
some complications are discovered immediately, each practitioner should
establish a system to contact patients after a period of time to
determine whether any delayed complications have occurred. Methods to
report and evaluate these complications should be in place so that
systematic errors can be discovered and corrected.

12. Incidence of perforation by procedure type (all indications vs
    screening) is measured. **(2C)**

> *Discussion*. Perforation is the most serious complication in the
> short term during or after colonoscopy. About 5% of colonoscopic
> perforations are fatal. Considering all the available data,
> perforation rates greater than 1 in 500 overall or greater than 1 in
> 1,000 in screening patients should raise concerns as to whether
> inappropriate practices are the cause of the perforations.
>
> Perforations are of two general types. Diagnostic perforations occur
> as a result of insertion of the colonoscope. They are most commonly
> mechanical and caused by rupture of the side of the instrument through
> the rectosigmoid region. They typically result in large rents in the
> colon that may be recognized during the procedure. Mechanical
> perforations can also result from barotraumas. Barotrauma perforations
> are the result of pneumatic pressures in the cecum that exceed its
> bursting pressure. They are most likely to occur when the colonoscope
> has passed either a stricture or severe diverticular disease and the
> patient has an ileocecal valve that is competent to air. Barotrauma
> perforations can probably be avoided in most cases by judicious use of
> air during insufflation, particularly after passing strictures,
> perhaps by insufflation of carbon dioxide rather than air, and by
> ensuring that the air pump and the light source will not continue to
> insufflate air when intraluminal pressures exceed the bursting
> pressure of the colon. Mechanical perforations can also occur during
> attempts to pass benign or malignant strictures.
>
> Perforations may also result from polypectomy. In virtually every
> case, they are the result of the electrocautery burn. The risk of
> perforation is greatest with large polyps in the proximal colon.
> Submucosal saline solution injection polypectomy is now frequently
> used by gastroenterologists,  although no standardized guidelines
> regarding the size and location of polyps that require submucosal
> saline solution injection have been developed. In experimental models,
> injection reduces the chance of electrocautery damage to the
> muscularis propria, but no randomized controlled clinical trial has
> been performed that demonstrates reduction of risk of perforation or
> postpolypectomy syndrome by injection. Therefore, colonoscopists
> should be familiar with and comfortable with the technique of
> submucosal saline solution injection, but clinical judgment is
> necessary in determining which polyps should undergo submucosal
> injection.
>
> Anecdotal reports have suggested an increased risk of complications
> associated with the use of hot biopsy forceps, and forceps removal of
> small polyps reduces the chance of complete removal. Cold snaring is
> attractive for the removal of small polyps because it effectively
> removes small polyps and has been associated with exceedingly low
> risks of complications. Cold snaring often results in immediate
> bleeding that is of no clinical significance and allows effective
> retrieval of polyps.

13. Incidence of postpolypectomy bleeding is measured. **(2C)**

> Bleeding is the most common complication of polypectomy. Bleeding can
> be either immediate (during the procedure) or delayed. In general, the
> use of blended or cutting current is associated with an increased risk
> of immediate bleeding, whereas pure low-power coagulation is
> associated with a greater risk of delayed bleeding. In clinical
> practice, the use of pure low-power coagulation or blended current is
> common, and the use of pure cutting current for polypectomy is rare.
>
> Endoscopic series suggests that the overall risk for postpolypectomy
> bleeding should be less than 1%. Overall, bleeding rates for
> polypectomy that exceed this rate should prompt review by experts from
> within or outside the institution regarding whether polypectomy
> practices are appropriate. In general, the risk of bleeding increases
> with the size of the polyps and with a more proximal colonic location.
> For polyps larger than 2 cm, particularly in the proximal colon,
> bleeding rates may exceed 10%.
>
> Inclusion of epinephrine in submucosal injection fluid has been shown
> to reduce the risk of immediate bleeding but not delayed bleeding.
> Because the overall risk of immediate bleeding with pure low-power
> coagulation current is low and immediate bleeding can generally be
> treated successfully by experienced endoscopists, there is no mandate
> to include epinephrine in injection fluid. Many experts prefer
> pretreatment of pedunculated polyps with thick stalks by epinephrine
> injection or placement of detachable snares. Two trials have
> demonstrated benefit from the use of detachable snares. However, the
> clinical benefit may be marginally significant, and therefore the use
> of detachable snares in clinical practice for pedunculated polyps is
> not mandated.

14. Postpolypectomy bleeding should be managed nonoperatively. In the
    presence of continuous bleeding, repeat colon examination and
    endoscopic treatment of polypectomy sites results in successful
    hemostasis. **(1C)**

> *Discussion*. In general, \>90% of postpolypectomy bleeding can be
> managed nonoperatively. Immediate postpolypectomy bleeding can
> generally be treated effectively by endoscopic means and should seldom
> require operative treatment. After transection, immediate bleeding
> from the stalk of the pedunculated polyp can be treated by regrasping
> the stalk and holding it for 10 to 15 minutes. This causes spasm in
> the bleeding artery. Immediate bleeding can also be treated by
> application of clips or by injection of epinephrine, followed by
> application of multipolar cautery.
>
> Delayed bleeding frequently stops spontaneously. In-hospital
> observation may be appropriate if the patient has comorbidities or
> lives far from the treating physician. Repeat colonoscopy in patients
> who have stopped bleeding is optional and should be performed at the
> discretion of the colonoscopist. Patients seen for delayed bleeding
> who are continuing to pass bright red blood are usually having an
> arterial hemorrhage. Prompt repeat colonoscopy, which may be performed
> without bowel preparation, is warranted. Treatment can be either by
> application of clips or by injection in combination with multipolar
> cautery. Multipolar cautery is generally applied at low power, without
> forceful tamponade (especially in the proximal colon), and continued
> until there is subjective cessation of bleeding. Findings in the base
> of the bleeding polypectomy site can include an actively bleeding
> visible vessel, a nonbleeding visible vessel, an apparent clot without
> bleeding, or an apparent clot with bleeding. Rebleeding seldom occurs
> after postpolypectomy bleeding has either stopped spontaneously or
> from endoscopic therapy.

**[Definitions]{.underline}**:

**Grades of Recommendation**

  -------------------------------------------------------------------------------
  **Grade of         **Clarity   **Methodologic           **Implications**
  recommendation**   of          strength/supporting      
                     benefit**   evidence**               
  ------------------ ----------- ------------------------ -----------------------
  1A                 Clear       Randomized trials        Strong recommendation;
                                 without important        can be applied to most
                                 limitations              clinical settings

  1B                 Clear       Randomized trials with   Strong recommendation;
                                 important limitations    likely to apply to most
                                 (inconsistent results,   practice settings
                                 nonfatal methodologic    
                                 flaws)                   

  1C+                Clear       Overwhelming evidence    Strong recommendation;
                                 from observational       can apply to most
                                 studies                  practice settings in
                                                          most situations

  1C                 Clear       Observational studies    Intermediate-strength
                                                          recommendation; may
                                                          change when stronger
                                                          evidence is available

  2A                 Unclear     Randomized trials        Intermediate-strength
                                 without important        recommendation; best
                                 limitations              action may differ
                                                          depending on
                                                          circumstances or
                                                          patients\' or societal
                                                          values

  2B                 Unclear     Randomized trials with   Weak recommendation;
                                 important limitations    alternative approaches
                                 (inconsistent results,   may be better under
                                 nonfatal methodologic    some circumstances
                                 flaws)                   

  2C                 Unclear     Observational studies    Very weak
                                                          recommendation;
                                                          alternative approaches
                                                          likely to be better
                                                          under some
                                                          circumstances

  3                  Unclear     Expert opinion only      Weak recommendation;
                                                          likely to change as
                                                          data become available
  -------------------------------------------------------------------------------

\*Adapted from Guyatt G, Sinclair J, Cook D, Jaeschke R, Schunemann H,
Pauker S. Moving from evidence to action: grading recommendations---a
qualitative approach. In: Guyatt G, Rennie D, eds. Users\' guides to the
medical literature. Chicago: AMA Press; 2002. p. 599-608.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified for each recommendation.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

A high quality endoscopy ensures that the patient receives an indicated
procedure, that correct and clinically relevant diagnoses are made (or
excluded), that therapy is properly performed, and that all these are
accomplished with minimal risk.

#### POTENTIAL HARMS

The risks of endoscopy include bleeding, perforation, infection,
sedation adverse events, missed diagnosis, missed lesions, and
intravenous site complications.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   Underlying this discussion of quality indicators is the assumption
    that adequate training and credentialing has taken place before a
    practitioner begins the practice of endoscopy. The American Society
    for Gastrointestinal Endoscopy (ASGE) has guidelines specifically
    addressing standards for training, assessing competence, and
    granting privileges to perform endoscopy. It is the task force\'s
    recommendation that these guidelines be adopted by facilities where
    endoscopic procedures are performed.

-   The list of potential quality indicators was meant to be a
    comprehensive listing of measurable endpoints. It is not the
    intention of the task force that all end points be measured in every
    practice setting. In most cases, validation may be required before a
    given end point may be universally adopted.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Staying Healthy

#### IOM DOMAIN

Effectiveness\
Patient-centeredness\
Safety

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Rex DK, Petrini JL, Baron TH, Chak A, Cohen J, Deal SE, Hoffman B,
Jacobson BC, Mergener K, Petersen BT, Safdi MA, Faigel DO, Pike IM.
Quality indicators for colonoscopy. Gastrointest Endosc 2006 Apr;63(4
Suppl):S16-28. \[107 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16564908)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2006 Apr

#### GUIDELINE DEVELOPER(S)

American College of Gastroenterology - Medical Specialty Society\
American Society for Gastrointestinal Endoscopy - Medical Specialty
Society

#### SOURCE(S) OF FUNDING

American Society for Gastrointestinal Endoscopy

#### GUIDELINE COMMITTEE

ASGE/ACG Taskforce on Quality in Endoscopy

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Taskforce Members*: Douglas K. Rex, MD; John L. Petrini, MD; Todd H.
Baron, MD; Amitabh Chak, MD; Jonathan Cohen, MD; Stephen E. Deal, MD;
Brenda Hoffman, MD; Brian C. Jacobson, MD, MPH; Klaus Mergener, MD, PhD;
Bret T. Petersen, MD; Michael A. Safdi, MD; Douglas O. Faigel, MD (*ASGE
Co-Chair*); Irving M. Pike, MD (*ACG Co-Chair*)

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[American Society for Gastrointestinal Endoscopy Web
site](http://www.asge.org/uploadedFiles/Publications_and_Products/Practice_Guidelines/2006_quality.pdf).

Print copies: Available from the American Society for Gastrointestinal
Endoscopy, 1520 Kensington Road, Suite 202, Oak Brook, IL 60523

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   Bjorkman, DJ, Popp, JW. Measuring the quality of endoscopy.
    Gastrointest Endosc 2006 Apr;63(4 Suppl):S1-2. Available in Portable
    Document Format (PDF) from the [American Society for
    Gastrointestinal Endoscopy Web
    site](http://www.asge.org/nspages/practice/patientcare/sop/index.cfm).

-   Faigel, DO, Pike, IM, Baron, TH, Chak, A, Cohen, J, Deal, SE,
    Hoffman, B, Jacobson, BC, Mergener, K, Petersen, BT, Petrini, JL,
    Rex, DK, Safdi, MA. Quality indicators for gastrointestinal
    endoscopic procedures: an introduction. Gastrointest Endosc 2006
    Apr;63(4 Suppl):S3-9. Available from the [American Society for
    Gastrointestinal Endoscopy Web
    site](http://www.asge.org/PublicationsProductsIndex.aspx?id=352).

Print copies: Available from the American Society for Gastrointestinal
Endoscopy, 1520 Kensington Road, Suite 202, Oak Brook, IL 60523

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on September 15, 2006.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

#### NGC DISCLAIMER

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