1Upper Gastrointestinal Endoscopy Assessment ManualIntroduction
Radiography has been the mainstream imaging technique in health screenings, but an increasing numberof institutions are introducing upper gastrointestinal endoscopy (endoscopy), even though no standard forscreening has been established.
Atrophic gastritis caused by an infection with Helicobacter pylori (H. pylori) has attracted attention as arisk for gastric cancer, and the “ABC risk classification”1 that combines serum H. pylori antibody testing
and the pepsinogen method is being popularized. Endoscopy plays an important role as a secondary
examination for this classification. In addition, the ability to determine the presence/absence of infection
with H. pylori through appropriate recognition of gastric mucosal findings is becoming necessary.
The Japan Society of Ningen Dock published the “Screening Assessment Guideline”2 in 2003 and therevised version3 in 2008.
Endoscopy in health screenings should be performed safely and accurately, and the appropriate
assessment of findings is important. We hope that this manual will eliminate the disparity among
institutions and provide guidelines for unified high-quality endoscopy.
For details of gastroscopy screening, see the “Gastroscopy Screening Manual”4 published by the JapaneseSociety of Gastrointestinal Cancer Screening.

Examination standard
Spasmolytics/sedatives
Spasmolytics/sedatives should be used in compliance with the Gastroenterological Endoscopy Guideline(Japan Gastroenterological Endoscopy Society) with sufficient safety considerations, such as placementof a monitor.

Operator
Endoscopy should be performed by an experienced endoscopist, such as a specialist certified by the Japan
Gastroenterological Endoscopy Society, a specialist certified by the Japanese Society of Gastroenterology,
or a physician certified by the Japanese Society of Gastrointestinal Cancer Screening.

Target organs
Esophagus, stomach, and duodenum

Image recording
The esophagus, stomach, and duodenum are comprehensively imaged, including the foci.

Biopsy● Assessment categories may be changed based on the results of the biopsy, if performed.
● For patients taking an anticoagulant or antiplatelet medication, conduct a thorough medical interview
and adequately consider the patient’s safety during the biopsy (perform the biopsy in compliance with2

the “Guidelines for Gastroenterological Endoscopy in Individuals under Antithrombotic Agents”6 by
the Japan Gastroenterological Endoscopy Society).

Lavage/disinfection
Clean/disinfect the scope and peripheral devices in compliance with the Gastroenterological Endoscopy
Guideline (Japan Gastroenterological Endoscopy Society).5

Assessment
Sites● Describe the sites that have findings
Esophagus (upper, middle, lower, and esophagogastric junction)
Stomach (fornix, cardiac region, upper body, middle body, lower body, angular region, and antrumregion)(greater curvature, lesser curvature, anterior wall, and posterior wall)
Duodenum (bulb, descending part, and papillary region)* If there are findings in the larynx, hypopharynx, or oral cavity, describe the site and findings.
● The size and number (1, 2, 3…, several or multiple) of localized lesions should be described.

Findings (Table 1-1, 2, 3)
Findings include “suspected” lesions.

Assessment category (Table 2)● If malignancy is suspected, report the result to the patients using a considerate mode of description(e.g., protruding lesion, depressed lesion, ulcerative lesion, and erosive lesion).
● Patients followed up without treatment or followed up postoperatively by their attending physician willbe assessed as C.
If a selection of D1 or D2 cannot be determined, use the assessment category D (Medical care needed).
● Assessment category E may be used for patients currently under treatment.
● Use assessment category D1 or D2 in patients with suspected malignant tumors, at each institution’s
own discretion.

Table 2 Assessment criteria
ANormalB

Mild abnormality

C

Following-up/re-examination/lifestyle instruction needed

D

D1Treatment needed(Medical care needed)

D2

Thorough examination needed

EUnder treatment

3References
1) Japan gastric cancer prediction, diagnosis and treatment Research organization : Manual of Stomach
cancer risk screening. Nanzando, Tokyo, 2009．
2) Yoshio Goto,Masaharu Nara : Health check criteria guidelines. Bunkodo, Tokyo, 2003
3) Kanji Komatsu, Koga Komatsu : Upper Gastrointestinal Endoscopy
Minoru Yamakado, Masahide Abe, Supervision : Yoshio Goto, Masaharu Nara : Medical checkup
judgment standard guidelines [revised new version]. Bunkodo, Tokyo, 2008，169-172.
4) Japanese Society of Gastrointestinal Cancer Screening : Stomach endoscopic examination manual.
Igakushoin, Tokyo, 2010.
5) Japan Gastroenterological Endoscopy Society, Postgraduate Education Committee : Gastrointestinalendoscopy guidelines. Igakushoin, Tokyo, 2006．
6) Kazuma Fujimoto，Mitsuhiro Fujishiro，Mototsugu Kato et.al：Gastrointestinal endoscopy medical
treatment guidelines for antithrombotic drug users．Gastroenterol Endosc2012；54：2073-2102．
7) Kimura K, Takemoto T : An endoscopic recognition of the atrophic border and its significance inchronic gastritis. Endoscopy 1969; 3:87-

Table 1-1. Esophagus
Endoscopic findings

Assessment
category

Advanced esophageal cancer

D

Early esophageal cancer

DEsophageal dysplasia

C, D2

Other malignant tumorD

Esophageal ulcer

D

Reflux esophagitis

B, C

Describe Los Angeles Classification (A, B, C, D)

Esophageal varices

C, D2

Describe color (Cw, CB), form (F1, 2, 3), occupation site (Li,Describe findings

m, s, g), site of redness (RC), and associated esophagitis (E).
Glycogenic acanthosis

B

Ectopic gastric mucosa

B

Isolated venectasia

B

Esophageal hemangioma

B, C

Esophageal lymphangioma

C, D2

Esophageal leiomyoma

C, D2

Esophageal lipoma

C, D2

Other submucosal tumor

C, D2

Esophageal granular cell tumor

D2

Esophageal papilloma

B

Other benign polypC

Candidal esophagitis

C4
Esophageal melanosis

C, D2

Esophageal achalasia

C, D2

Barrett esophagus

B, C

Esophageal hiatus hernia

B

Esophageal diverticulum

B

Extramural exclusion findings

Pay attention to complications by malignant melanoma
Describe presence/absence of SSBE* or LSBE**

C, D2

Other esophageal findings

Assessment category is assigned at the operator’s owndecision

Food residue presentC(observation impossible)
Scope cannot be inserted

Assessment category is assigned at the operator’s own
decision

NormalASSBE*; short segment Barrett’s esophagus, LSBE**; long segment Barrett’s esophagus
Table 1-2 Stomach
Endoscopic findings

Assessment
category

Advanced gastric cancer

D

Early gastric cancer

D

Gastric carcinoid tumor

D

Gastric malignant lymphoma

D

Gastric MALT* lymphoma

D

Other malignant tumor

D

Gastric adenoma

C, D

Submucosal tumor of the stomach

C, D2

Describe findingse.g., GIST**, leiomyoma/leiomyosarcoma, and submucosal
ectopic gastric mucosa≥20 mmD2Gastric hyperplastic polypC, D2Fundic gland polyp

B

Gastric ulcer

D1

Describe active stage (A1, A2) or healing stage (H1, H2)

Gastric ulcer scar

B, C

Describe scar stage (S1, S2)

Post-ESD*** scarC, D2Acute gastric mucosal lesion (AGML)

D1

Atrophic gastritis

C, D

Nodular gastritis

C, D

Enlarged fold gastritis

C, D

Flat erosive gastritis

C, D

Protruding erosive gastritis

C, DIntestinal metaplasia

C, D

Description of Kimura/Takemoto Classification7 is desirable

5
Gastric varices

C, D2

Xanthoma

B

Gastric vasodilation (angiodysplasia)

B

Gastric diverticulum

B

Aberrant pancreas

B

Gastric anisakiasis

D1

Pyloric stenosis

D2

Extramural exclusion findings

C, D2

Other gastric findings
Food residue present (observation

Describe color (Cw, CB), form (F1, 2, 3), and site of redness (RC)Assessment category is assigned at the operator’s own decision
Cimpossible)
Scope cannot be inserted
NormalAssessment category is assigned at the operator’s own decision
AMALT*; mucosa associated lymphoid tissue, GIST**; gastrointestinal stromal tumor, ESD***; endoscopic
submucosal dissection1) Describe whether the patient has never been or is currently infected with H. pylori, or has had H. pylori
eradication, if it can be determined based on the endoscopic findings.
2) Although “red streak (Kammrotung)” may often be diagnosed as superficial gastritis, it has no histologicalgastritis finding, and superficial gastritis has been eliminated from the disease list. In addition, “Hematinattachment” may occasionally be considered (hemorrhagic) erosive gastritis. However, this finding is often
noted in H. pylori negative gastric mucosa similarly to red streak, and neither is handled as endoscopicgastritis.

Table 1-3 Duodenum
Endoscopic findings

Assessment
category

Duodenal cancer/papillary

Dcarcinoma
Duodenal adenoma/papillary

C, D2adenoma
Malignant lymphoma

D

Duodenal carcinoid

D

Invasion of adjacent organ by

De.g., MALT* lymphoma and follicular lymphoma

malignant tumor
Submucosal tumor

C, D2≥20 mmD2

Duodenal polypC, D2

Duodenal ulcer

D1

Describe active stage (A1, A2) or healing stage(H1, H2)

6
Duodenal ulcer scar

B, C

Duodenitis/duodenal erosion

B, C

Ectopic gastric mucosa/gastricB

Describe scar stage (S1, S2)epithelial metaplasia
Hyperplasia of Brunner`s gland

C, D2

Duodenal stenosis

C, D2

Duodenal diverticulum

B

Extramural exclusion

C, D2

Other duodenal findings

Assessment category is assigned at the operator’s
own decision

Scope cannot be inserted

Assessment category is assigned at the operator’s
own decision

NormalA

MALT*; mucosa associated lymphoid tissue

Japan Society of Ningen Dock
Image inspection decision guidelines making committeeChief Commissioner :Members :Shuichi Mihara (Mihara Life Care Clinic)

Kazuhiko Inoue (Kawasaki Medical School)
Kazuaki Kawada (Department of Medical Check-up Center, Transnasal Endoscopy Center,Shizuoka Red Cross Hospital)
Masao Kobayashi (Japanese Red Cross Kyoto Daini Hospital / Gastrointestinal cancer
screening committee, Kyoto Prefectural Medical Association)
Kanji Komatsu (Department of Gastroenterology, Honjo Daiichi Hospital)
Toru Mitsushima (Kameda Makuhari Clinic)

External Evaluation Committee : Takashi Kawai (Tokyo Medical College)
April, 2014