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## Complete Summary

#### GUIDELINE TITLE

Tissue sampling and analysis.

#### BIBLIOGRAPHIC SOURCE(S)

Faigel DO, Eisen GM, Baron TH, Dominitz JA, Goldstein JL, Hirota WK,
Jacobson BC, Johanson JF, Leighton JA, Mallery JS, Peterson KA, Raddawi
HM, Varg JJ 2nd, Waring JP, Fanelli RD, Wheeler-Harbough J. Tissue
sampling and analysis. Gastrointest Endosc 2003 Jun;57(7):811-6. \[91
references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12776025)

#### 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\
 CONTRAINDICATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Malignant, inflammatory, and infectious processes of the esophagus,
stomach, small intestine, and colon that require tissue sampling and
analysis

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation

#### CLINICAL SPECIALTY

Gastroenterology

#### INTENDED USERS

Physicians

#### GUIDELINE OBJECTIVE(S)

To provide a practical basis for tissue analysis (biopsy, snare
excision, cytology, and culture) during gastrointestinal (GI) endoscopy

#### TARGET POPULATION

Patients with suspected or confirmed gastrointestinal malignancy,
inflammation, or infection

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Tissue sampling techniques

    -   Pinch forceps biopsy

    -   Brush cytology

    -   Snare excision

    -   Fine-needle aspiration (FNA)

2.  Endoscopy

3.  High-resolution magnifying endoscopy

4.  Chromoendoscopy

5.  Flexible sigmoidoscopy

6.  Colonoscopy

7.  Systematic biopsy

8.  Four-quadrant biopsy

9.  Endoscopic mucosal resection (EMR)

10. Brushing culture

11. Viral culture

12. *Helicobacter pylori* testing

    -   Gastric biopsy

    -   Rapid urease test (RUT)

13. Gastric polypectomy

14. Colon polypectomy

#### MAJOR OUTCOMES CONSIDERED

Not stated

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

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

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

In preparing this guideline, a MEDLINE literature search was performed,
and additional references were obtained from the bibliographies of the
identified articles and from recommendations of expert consensus.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

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

Expert Consensus

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

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

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

Guidelines for the appropriate use of endoscopy are based on a critical
review of the available data and expert consensus.

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

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Not stated

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not applicable

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

Recommendations are followed by evidence grades (A-C) identifying the
type of supporting evidence. Definitions of the evidence grades are
presented at the end of the \"Major Recommendations\" field.

Histopathologic evaluation is helpful to differentiate malignant,
inflammatory, and infectious processes. Tissue biopsy specimens are
routinely obtained from any suspicious lesion during endoscopic
evaluation. When the gross endoscopic appearance is normal, histologic
analysis may still provide useful information. Tissue analysis is
occasionally performed to document the outcome of prior endoscopic or
medical therapy. When the gross endoscopic appearance reveals a specific
condition, tissue analysis is unnecessary if therapy will not be
altered. Tissue biopsy should be avoided when there is an increased
potential for hemorrhage such as in patients with coagulopathies.

**Techniques**

Numerous techniques and devices have been designed to obtain adequate
tissue samples. Pinch biopsy is done with biopsy forceps and is the most
commonly used form of tissue sampling. Multiple biopsies improve the
diagnostic yield; the size, location, specimen orientation, fixation,
and staining are also important. Pinch biopsy forceps usually obtain
mucosal specimens. Occasionally, jumbo biopsy forceps may also reach the
submucosa. However, these forceps require a biopsy channel of at least
3.6 mm and yield 2 to 3 times the surface area but are not generally
deeper specimens. Brush cytology may be a useful adjunct to pinch biopsy
and helpful in the diagnosis of certain malignancies and infections.
Snare excision is used for removal of large polyps. A combination of
techniques can increase diagnostic accuracy. Endoscopic ultrasound
(EUS)-guided fine-needle aspiration (FNA) is capable of sampling
subepithelial lesions and those extrinsic to the gastrointestinal (GI)
tract such as lymph nodes and pancreatic masses and is more fully
discussed in the American Society for Gastrointestinal Endoscopy (ASGE)
Status Evaluation Report \"Tissue Sampling During Endosonography.\"

**Esophagus**

Malignant tumors of the esophagus can be diagnosed by biopsy alone in
95% of cases, except when obstruction prevents adequate visualization
and biopsy of the lesion. Eight to 10 biopsy specimens should be
obtained. The addition of brush cytology may increase the diagnostic
yield. The most common inflammatory condition, reflux esophagitis,
occurs in patients with gastroesophageal reflux disease (GERD).
Endoscopy with tissue analysis is indicated to evaluate for the presence
of Barrett\'s esophagus or to rule out infection or malignancy
masquerading as gastroesophageal reflux disease. Erosive changes seen on
endoscopy correlate well with histology, but isolated erythema is an
unreliable criterion for esophagitis. Conversely, abnormal histology
(inflammatory cell infiltration with polymorphonuclear cells or
eosinophils) may be found by biopsy in patients with reflux symptoms who
have normal-appearing esophageal mucosa. Biopsy and cytology specimens
of abnormal-appearing mucosa may be needed to exclude malignancy,
infectious esophagitis, certain autoimmune disorders, and to detect
Barrett\'s esophagus.

Barrett\'s esophagus is a condition in which the normal squamous mucosa
is replaced by metaplastic specialized intestinal epithelium and
requires endoscopic biopsy for diagnosis. Patients with Barrett\'s
esophagus are at increased risk for esophageal adenocarcinoma, and their
identification allows for inclusion in surveillance programs.
Histopathology reveals columnar epithelium without a brush border and is
distinguished from gastric mucosa by the identification of goblet cells,
which may be aided by the use of special stains (alcian blue). Severe
ulcerative esophagitis may obscure underlying Barrett\'s mucosa, and
inflammation-induced atypia may be confused with dysplasia. In these
instances, aggressive medical therapy to heal esophagitis clarifies
subsequent histopathologic interpretation.

Biopsies are also performed to detect dysplasia or adenocarcinoma. If
dysplasia is known or suspected to be present, then 4-quadrant biopsies
at 1- to 2-cm intervals with additional specimens from any mucosal
abnormalities should be taken. A 2-cm protocol missed 50% of cancers in
patients with high-grade dysplasia, which were detected in a 1-cm
protocol. Although large-capacity \"jumbo\" forceps have been advocated,
a retrospective study found that 4-quadrant biopsies every 2 cm missed
the same proportion of cancers when done with large-capacity (4/12, 33%)
or standard-sized (6/16, 38%) forceps. The turn-and-suction technique is
advocated, in which the open forceps is drawn close to the endoscope\'s
tip, the scope turned toward the wall, suction applied, the forceps
advanced, closed, and the specimen obtained. For patients with
high-grade dysplasia who opt against esophagectomy, this technique
performed at 3- to 6-month intervals has been reported to accurately
detect carcinoma, 96% of which were confined to the mucosa.

High-resolution magnifying endoscopy and chromoendoscopy with methylene
blue has been advocated to increase the detection of short-segment
Barrett\'s esophagus by directing biopsy location. Chromoendoscopy with
Lugol\'s solution and methylene blue has been reported to increase the
detection of squamous cell carcinoma and neoplastic areas within
Barrett\'s esophagus, respectively, although the value of methylene blue
in the surveillance of Barrett\'s esophagus has been questioned.
Analyzing the biopsy specimens with flow cytometry and DNA analysis may
identify patients with aneuploidy, polyploidy or 17p (p53)
loss-of-heterozygosity and predict an increased cancer risk.

Discrete lesions of the esophagus may be removed by endoscopic mucosal
resection (EMR). This involves a submucosal injection of saline to raise
the lesion followed by snare-cautery excision. This technique has been
successfully used on neoplastic lesions arising in Barrett\'s esophagus
and for benign esophageal tumors.

Infectious esophagitis occurs primarily in immunocompromised patients
such as those on systemic anti-immune therapy, inhaled steroids,
patients with cancer (especially those on chemotherapy), those with
diabetes, and patients with acquired immunodeficiency syndrome (AIDS).
The most common infectious agents are *Candida* species, Herpes simplex
virus (HSV), and cytomegalovirus (CMV). Fungal esophagitis appears
endoscopically as white plaques over the inflamed mucosa. Brushings and
biopsy specimens are obtained, but brush cytology is more sensitive.
Viral esophagitis manifests as ulcers. Specimens should be taken from
both the edge and the center of the ulcer. Histopathology is usually
diagnostic but multiple specimens (up to 10) may be required in patients
with AIDS. Viral culture may help provide a definitive diagnosis but may
be less sensitive than histology for CMV.

**Stomach**

Gastric neoplasia can present as an ulcerative, polypoid, or submucosal
lesion, or as thick gastric folds. Adequate tissue sampling sometimes
requires a combination of techniques. Pinch biopsy has the highest
diagnostic yield for ulcerative or polypoid masses. Multiple biopsy
specimens should be obtained from the edge of each quadrant of an ulcer
and from the base. Brush cytology may increase the yield over biopsy
alone. Biopsy should be performed on polypoid lesions, and polyps
greater than 2 cm should be removed when technically feasible. Gastric
polypectomy may carry a higher risk of bleeding than colon polypectomy;
therefore, post-procedure acid suppressive therapy should be considered.

EMR is used in the stomach to sample thick gastric folds to exclude
malignancy, and for treatment of early gastric cancer (EGC). Candidate
early gastric cancer lesions for EMR are generally less than 20 mm and
confined to the mucosa by endoscopic ultrasound or endoscopic criteria.
The lesion is lifted from the submucosa by an endoscopic fluid
injection, and the lesion excised by using one of several described
techniques (see Technology Status Evaluation Report - Endoscopic Mucosal
Resection).

Patients with peptic ulcer disease, gastric mucosa-associated lymphoid
tissue (MALT), lymphoma, and possibly those at increased risk for
developing gastric cancer (e.g., family or personal prior history of
gastric cancer) should all have their *Helicobacter pylori* status
determined. Tissue-based tests are performed on endoscopically obtained
forceps biopsies of gastric mucosa. These include testing the sample for
urease activity (rapid urease test), histologic examination for typical
curved bacilli, and culture. In untreated patients, biopsy specimens
should be obtained from the lesser curvature of the antrum near the
incisura angularis. Rapid urease tests (RUT) are inexpensive, highly
specific, and can be performed in the endoscopy unit providing results
in 1 hour. Less-than-perfect sensitivity has lead to recommendations
that a second test be performed if the rapid urease test is negative.
Specimens submitted for histologic examination should be assessed for
the presence of inflammatory cells and for typical curved bacilli, the
latter of which may require the use of special stains. The presence of
significant gastric inflammatory cell infiltration in the absence of
bacteria should prompt additional testing with serology, a urea-breath
test, or stool antigen testing. Bacterial culture allows for
determination of antimicrobial resistance but lacks sensitivity and is
cumbersome to perform. The sensitivity of these tissue-based tests may
be decreased in patients using proton pump inhibitors or antibiotics,
those who have recently been treated for *H pylori* (but may have
persistent infection), or in the setting of gastrointestinal bleeding.
In these patients, multiple biopsy specimens from the antrum and corpus
should be obtained, and a negative rapid urease test should be confirmed
with an alternative test. If possible, patients should be asked to cease
taking proton pump inhibitors for at least 1 week before testing for *H
pylori*.

**Small Intestine**

Biopsy is an essential part of the investigation of patients with
suspected small bowel disease. Peroral biopsy samples have traditionally
been obtained from the region of the ligament of Treitz. Endoscopic
biopsy is now more commonly used and has the advantage of being a
shorter, more comfortable procedure wherein multiple directed biopsy
specimens can be obtained. Pinch biopsies will usually yield tissue
adequate for diagnosis in diffuse mucosal disease if at least 3 biopsy
specimens are taken from a site distal to the duodenal bulb in order to
avoid misinterpretation of biopsy findings related to Brunner\'s glands.
In diseases in which involvement may be patchy, multiple biopsies from
more distal sites of the small intestine using longer and
smaller-caliber endoscopes may be necessary. Biopsy may be useful in
establishing the diagnosis even in macroscopically normal tissue.

Small bowel biopsies remain the reference standard for accurately
diagnosing mucosal malabsorption syndromes. A small bowel biopsy is
still considered necessary to confirm the suspicion of celiac disease,
even in the presence of positive screening blood tests (e.g., endomysial
antibodies or tissue transglutaminase). This should be done before
treatment is started, because false-positive blood tests may occur.

Infection of the small bowel may be diagnosed by histologic examination.
*Giardia lamblia* and a number of other protozoal agents may be
associated with inflammatory changes in the small intestinal mucosa, and
detection of the mature adult organism, its trophozoites, or a component
of the life cycle in or on the surface epithelium may lead to a specific
diagnosis. In some patients the morphologic appearance may be similar to
eosinophilic gastroenteritis, a diagnosis that can only be established
after parasitic disease has been excluded.

Patients with immunodeficiency, including post-transplantation or human
immunodeficiency virus (HIV) infection, may harbor agents such as
*Isospora belli*, *Cryptosporidia*, *Cyclospora*, and *Microsporidia*,
which may be detected on small intestinal biopsy specimens. Other
pathogens detected on a small bowel biopsy in an immune deficient
patient include CMV, fungal organisms such as Candida species and
histoplasmosis, and Mycobacterium avium-intracellulare complex. It may
be useful to use a large cup jumbo forceps rather than a conventional
biopsy forceps if two biopsy specimens are to be taken in sequence
before withdrawing the biopsy forceps (Double-bite technique). It is
also advisable to use a needle to transfer the biopsy out of the forceps
to the fixative rather than shaking it off in a fixative bottle because
this may alter the surface epithelium and result in the loss of any
adherent exudates.

Tumors of the duodenum should be evaluated by endoscopy and biopsy. The
choice of forward- or side-viewing instruments and sampling technique
depends on the location and size of the tumor.

Duodenal, jejunal, and gastric polyps may occur in 33 to 100% of
patients with familial adenomatous polyposis (FAP). Gastric polyps in
patients with FAP are most often fundic gland polyps, which have no
malignant potential, but biopsy should be considered to exclude adenoma.
Duodenal polyps are typically adenomatous and occur primarily in the
ampulla or periampullary region. Upper gastrointestinal polyps may
appear synchronous or metachronous to the identification of colonic
polyps. Adenocarcinoma developing from periampullary adenomas is a
well-recognized entity and is the most common cause of death in patients
with FAP once colorectal cancer is excluded. Although its efficacy is
yet to be established, a surveillance program is advisable. There are
case reports of pancreatitis related to endoscopic biopsy of the
papilla. Despite this, complications related to endoscopic biopsy or
removal of duodenal adenomas at a distance from the papilla appears to
be uncommon.

**Colon**

Previous guidelines have outlined the general indications for
colonoscopy and biopsy in patients with colonic polyps and inflammatory
bowel disease.

Visual evidence of a lesion warrants histopathologic evaluation. If
lesions are too numerous for removal, representative samples should be
obtained for analysis. Diminutive polyps found during screening
sigmoidoscopy should be biopsied; larger polyps should be completely
removed at subsequent colonoscopy. Detection of adenomas or carcinoma is
an indication for complete examination of the colon. The published
reports as to the significance of hyperplastic polyps detected during
sigmoidoscopy remains conflicted, although most gastroenterologists in
the United States do not feel that these polyps indicate an increased
risk of harboring significant proximal neoplasia.

For the evaluation of colitis, endoscopy and biopsy may be useful in
distinguishing between different causes of colitis, assisting in the
management of inflammatory bowel disease, and establishing the extent of
bowel involved. Biopsy specimens obtained during the acute phase of a
bloody diarrheal illness may differentiate acute self-limited colitis
from an initial or recurrent attack of chronic ulcerative colitis or
ischemic colitis. Terminal ileal biopsy may be useful in the diagnosis
of Crohn\'s disease, infectious ileitis, and lymphoid nodular
hyperplasia. Both Crohn\'s disease and ulcerative colitis are associated
with an increased risk of developing colorectal cancer. Surveillance
colonoscopy looking for dysplasia is recommended, beginning at 8 years
of disease when the cancer risk starts to increase. A longer delay is
suggested in patients with left-sided disease only (e.g., 15 years). In
patients with pancolitis, 4-quadrant biopsy specimens taken every 10 cm,
with biopsies every 5 cm in lower 25 cm, is a frequent approach. In
cases of left-sided colitis, specimens should also be taken in the
proximal colon to reassess extent of disease.

The approach to dysplastic lesions in patients with chronic colitis is
evolving. When dysplastic mass lesions are large, irregular, or
associated with strictures, surgery is required. However, when
typical-appearing adenomas are encountered in a colitic segment they
should be removed and the surrounding mucosa biopsied. If the polyp is
completely removed and there is no surrounding dysplasia, then this may
be regarded as an adequately treated sporadic adenoma and endoscopic
surveillance continued.

It remains unclear as to the number and location that biopsy specimens
should be taken in assessing a patient with chronic diarrhea and a
grossly normal colon. Microscopic colitis is diagnosed by compatible
histologic features in a patient with chronic watery diarrhea whose
endoscopic and microbial evaluations are normal. Biopsy specimens taken
during a flexible sigmoidoscopy may be adequate to diagnose this disease
entity.

**Summary**

Tissue sampling is useful in differentiating malignant, inflammatory,
and infectious processes **\[C\]**. Techniques include pinch forceps
biopsy, brush cytology, snare excision, and fine-needle aspiration
**\[B\]**. For malignant lesions, maximal yield is attained with 8 to 10
biopsies **\[A\]**. Patients with Barrett\'s esophagus should undergo
systematic biopsy to evaluate for dysplasia **\[C\]**. Patients with
Barrett\'s esophagus and high-grade dysplasia should have 4-quadrant
biopsies performed every 1 to 2 cm to detect underlying carcinoma **\[A,
B\]**. Endoscopic mucosal resection may be used to remove malignant or
premalignant mucosal lesions **\[B\]**. Infectious conditions require
multiple biopsies, and if ulcers are present these should be obtained
from both the center and edge; brushing and viral culture are adjunctive
techniques **\[B\]**. *H pylori* infection can be assessed by gastric
biopsy submitted for histologic examination or rapid urease test
**\[A\]**. Biopsy of the incisura angularis gives the highest yield for
*H pylori* in untreated patients, but those who have been treated or are
taking proton pump inhibitors or antibiotics should have specimens of
the corpus and fundus taken as well **\[A\]**. Gastric polyps should be
extensively sampled or removed when feasible **\[C\]**. Gastric
polypectomy may carry a higher risk of bleeding than colon polypectomy
and postprocedure acid suppressive therapy should be considered
**\[B\]**. Random biopsies of the small intestine are indicated in the
evaluation of diarrheal states, celiac disease, or infections **\[C\]**.
Duodenal adenomas may be sporadic or associated with FAP and should be
sampled or removed when feasible **\[C\]**. Colon lesions should be
endoscopically excised (polypectomy, EMR) or sampled if lesions are too
numerous or removal is not technically feasible **\[C\]**. In patients
with acute colitis, biopsy may help establish an etiology **\[B\]**.
Patients with longstanding chronic colitis should undergo systematic
surveillance to detect dysplasia, which may indicate an increased risk
of cancer **\[B\]**. In patients with diarrhea, random biopsy of
normal-appearing colonic mucosa may reveal microscopic colitis
**\[B\]**.

**[Definitions]{.underline}**

A.  Prospective controlled trials

B.  Observational studies

C.  Expert opinion

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and classified for some of
the recommendations using the following scheme:

A.  Prospective controlled trials

B.  Observational studies

C.  Expert opinion

When little or no data exist from well-designed prospective trials,
emphasis is given to results from large series and reports from
recognized experts. Guidelines for appropriate utilization of endoscopy
are based on a critical review of the available data and expert
consensus.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Appropriate utilization of tissue analysis (biopsy, snare excision,
cytology, and culture) during gastrointestinal endoscopy

#### POTENTIAL HARMS

There are case reports of pancreatitis related to endoscopic biopsy of
the papilla. Despite this, complications related to endoscopic biopsy or
removal of duodenal adenomas at a distance from the papilla appears to
be uncommon.

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

Tissue biopsy should be avoided when there is an increased potential for
hemorrhage such as in patients with coagulopathies.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

Controlled clinical studies are needed to clarify aspects of this
statement, and revision may be necessary as new data appear. Clinical
consideration may justify a course of action at variance to these
recommendations.

### 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

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Faigel DO, Eisen GM, Baron TH, Dominitz JA, Goldstein JL, Hirota WK,
Jacobson BC, Johanson JF, Leighton JA, Mallery JS, Peterson KA, Raddawi
HM, Varg JJ 2nd, Waring JP, Fanelli RD, Wheeler-Harbough J. Tissue
sampling and analysis. Gastrointest Endosc 2003 Jun;57(7):811-6. \[91
references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12776025)

#### ADAPTATION

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

#### DATE RELEASED

2003 Jun

#### GUIDELINE DEVELOPER(S)

American Society for Gastrointestinal Endoscopy - Medical Specialty
Society

#### SOURCE(S) OF FUNDING

American Society for Gastrointestinal Endoscopy

#### GUIDELINE COMMITTEE

Standards of Practice Committee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Committee Members*: Douglas O. Faigel, MD (*Chair*); Glenn M. Eisen, MD
(*Past Chair*); Todd H. Baron, MD; Jason A. Dominitz, MD; Jay L.
Goldstein, MD; William K. Hirota, MD; Brian C. Jacobson, MD, MPH; John
F. Johanson, MD; Jonathan A. Leighton, MD; J. Shawn Mallery, MD; Kathryn
A. Peterson, MD; Hareth M. Raddawi, MD; John J. Vargo II, MD; J. Patrick
Waring, MD; Robert D. Fanelli, MD (*SAGES Representative*); Jo
Wheeler-Harbough, RN (*SGNA Representative*)

#### 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 (ASGE) 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

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on March 23, 2005. The
information was verified by the guideline developer on March 31, 2005.

#### COPYRIGHT STATEMENT

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

### DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/10/2008