1

Upper Gastrointestinal Radiography Screening
Assessment Manual
Introduction
Upper Gastrointestinal Radiography has achieved numerous successful results as the mainstream
examination of gastric cancer screening for more than 50 years. In cancer screening as secondary prevention,in particular, only gastric cancer screening by radiography has been recommended as a population-based
gastric cancer screening, based on evaluation on various aspects such as efficacy with mortality rate reduction
effect as index, efficiency from the viewpoint of cost-benefit, and invested resource effectiveness, as well as
safety and simplicity.1
Ever since it was called the Japanese Society of Gastric Mass-Screening (JSGMS), the Japanese Societyof Gastrointestinal Cancer Screening (JSGCS) has pursued and intended improvement in the accuracy ofgastrointestinal radiography by setting committees and working groups over several phases with various
names, such as standard procedure, imaging standard, and imaging method. They first handled indirect
radiography only, and then, in response to popularization and expansion of institutional gastric cancer
screening, they reported guidelines for direct imaging in addition to indirect imaging in 2005.2 The previous
guideline of our society 3 was developed based on direct imaging specified in these guidelines of JSGMS (atthat time).
Thereafter, in response to rapid popularization of digital devices and identification of concept of
population-based screening versus opportunistic screening, JSGCS revised the classification of fluorography
or film radiography to standard imaging divided into population-based and opportunistic ones in 2011.4) This
population-based standard imaging primarily aims at early detection of gastric cancer, whereas
opportunistic imaging assumes institutional screening, such as health screening.
Health screening aims at not only secondary prevention, but also primary prevention. In this context,
upper gastrointestinal radiography in health screening is concurrently a cancer screening and healthcheckup procedure for the upper gastrointestinal tract, not only for the stomach but also for theesophagus to the descending part of duodenum.
Based on the current situation with improvement in imaging as described above and identificationof gastric mucosal atrophy such as H. pylori gastritis as a high risk outcome of gastric cancer, thepresent manual has been prepared in pursuit of a desirable mode of gastrointestinal radiography aspart of health screening.

Implementation of upper gastrointestinal radiography1.

Although various modes of upper gastrointestinal radiography may be possible, the imaging method
and operation procedure will comply with those of the “Gastric Cancer Radiographic Screening
Technical Sector Textbook 2011” 5) published by Japan Quality Assurance Organization of
Gastroenterological Cancer Screening (JQAOGCS) in terms of the purpose of health screening andaccuracy control.

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Target Organs
Esophagus, stomach, and duodenum (bulb and descending part)● If the pharyngolaryngeal region or the duodenum below the transverse part is imaged with abnormal
findings, it goes without saying that such images will also be interpreted and assessed.
● If any extra gastrointestinal abnormality is noted, record it and notify the subject of that as necessary,
regardless of whether it is benign/malignant.
● Explain in advance that highly accurate radiography is available now, but accuracy at 100% isunavailable and accurate images are not always obtained. Also explain that cooperation between thesubject and the radiological technician is necessary to obtain good images.

Contrast medium
As positive contrast medium, use about 150 mL of high concentration thin barium sulfate suspension at≥200% w/v (herein after abbreviated as the medium). As the negative contrast medium, 5 g of the blowing
agent is administered with a small amount of the medium or a water-diluted medium. Attention should be
paid so as not to administer the blowing agent with too much water, because concentration of the medium or
adherence of the medium to the gastric mucosa is lowered.

Pretreatment
There is less limitation in health screening performed under the provision of physicians, who are equippedwith sufficient resources and staff than in gastric cancer mass screening. Therefore, a spasmolytic can beadministered to reduce the flow of medium out or control gastric peristalsis. However, accidents and side
effects due to the use of spasmolytics occur at a low but non-negligible incidence. In screening healthy
individuals, risk by the examination itself should be reduced as much as possible, despite the screening being
opportunistic.
Accordingly, spasmolytics should not be used without maximum preparation and precaution.

Positioning and number of images
The Standard Imaging Method (for opportunistic screening) in New Gastric Radiography Guidelines 2011by JSGCS 4 shall be observed.
The order of the positions and their target sites are as follows:

Esophagus: 2 shots
1) Upright and right anterior oblique

The upper esophagus

position (upper)2) Upright and right anterior oblique

The lower esophagus to the gastric cardiac region

position (lower)
Stomach: 14 shots3) Supine position

The gastric body to the posterior wall of the prepylor

3us4) Supine and right anterior oblique

The greater curvature of the body to the lesser curvature of

positionthe prepylorus, a little to the posterior wall5) Supine and left anterior oblique

The posterior wall of the body a little to the lesser

positioncurvature, to the posterior wall of the prepylorus a little to
the greater curvature

6) Prone position (head down tilt)

The middle body to the anterior wall of the prepylorus

7) Prone and left anterior oblique

The anterior wall of the middle body a little to the great

position (head down tilt)

curvature, to the anterior wall of the prepylorus a little tothe lesser curvature

8) Prone and right anterior oblique

The cardia region to the anterior wall of the upper stomach

position(upper body and fornix)9) Right lateral position

The anterior and posterior wall of the cardiac region
centering around the lesser curvature

10) Semi-supine and left anterior

The cardiac region to the posterior wall the upper body

oblique position
11) Supine and left anterior oblique

The posterior wall of the upper body a little to the lesser

position (spreading medium)curvature12) Upright and right anterior oblique

The posterior and anterior wall of the upper body a little toposition

the greater curvature, and duodenal bulb

13-16) Upright position with

4 shots [body, angle, antrum, and pyloric region]

compression
Although the Guidelines of 2005 excluded the upright filling image from 8 basic images for indirect
radiography, they included this in 4 additional images for direct radiography along with esophageal andcompressed images. However, the revised Guideline of 2011 removed the upright filling image from all 16
shots. It was considered that diagnostically significant filling image was difficult to take with a small amountof the medium and double contrast is sufficient for diagnosis, and the less important image was omitted fromthe limited number of images even in an indoor screening. However, although in a minority, some consider
upright filling image to be necessary, because it can assess the whole shape of the stomach.
Points to be noted in radiography are the same as in the previous guideline.3 It should always be borne inmind that operating as rapidly as possible is a more essential condition to obtain good images thanstreamlining screening. Particularly, if no spasmolytic is used, it is important that the radiological technician
takes an attitude to make the subject relieved from the psychological tension in the examination room.
Each facility may add the original shots to the above 16 essential shots. It is reasonable to add necessary
shots by the other position if they are not sufficient to depict findings capable of providing diagnosis. （前文と内容が似るため、うまく合わせると良いかもしれません）

Interpretation

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Since mass screening is secondary prevention for early detection of cancer, two basic assessment
categories are present: “thorough examination needed” and “no thorough examination needed.” However, if
the examination is performed as part of health screening, a sort of multiphasic health check-up, elements ofa health check-up should be added to specialized cancer screening.
That is to say, it needs to be a cancer screening, and at the same time, also needs to assess the health of theupper gastric tract itself. Merely picking up findings and guiding to endoscopy is not considered to be“interpretation.” Instead of merely assessing whether or not thorough examination is needed, giving meaning
to significant findings to make radiological diagnosis can be considered as interpretation.
The present manual adopts a diagnostic/assessment category based on the premise that interpretation should
further make qualitative diagnosis than gastric cancer mass screening would make.
Although some consider that the assessment of the background mucosa is also necessary, because it isdesirable to make local diagnosis after diagnosing the background mucosa, such as gastric atrophy status,
this will be left to each institution’s discretion.
Sites and locations in the gastric wall (Table 1)
The upper gastrointestinal sites are described with various terminologies, such as terminologies in theJapanese Classification of Cancer, anatomic terminologies of the sites, and the terminologies for endoscopy.
Although each terminology has its own significance, the classification shown in the table has been adopted
pursuant to the terminology commonly used in radiography.
● The esophagus is divided into three regions – upper, middle, and lower. The cervical esophagus isincluded in the upper esophagus, whereas the abdominal esophagus in the lower esophagus. However,other descriptions are also permitted if they are universal and allow retrospective comparison andconsideration with radiograms.
● The cardiac region is an area in which the cardiac glands are distributed, in its basic histological meaning,but it is very difficult to image the histological cardiac gland region in a radiogram. Although an image
with the medium favorably adhered to the mucosa indicates the esophagogastric junction in a wavy
streak shadow, it is difficult to image with standard imaging.
In the present manual, the esophageal cardiac region is defined to be the part within 2 cm adoral to theesophagogastric junction, His angle, or the extension from the adoral end of the vertical fold of thegreater curvature along the gastric wall and the part within 2 cm distally is defined to be the gastriccardiac region.
● The term gastric fornix (fundus) is based on the fact that this region is the most dorsal in supine position.
This site is radiologically defined to be the part above the horizontal line, extending from the lower endof the cardia (not cardiac region) to the greater curvature in general (excluding the cardiac region).
The definition as the part above the “second gastric angle” is also acceptable, which is used in someinstitutions.
● Although the gastric corpus is definitely from the cardia to the gastric angle in the lesser curvature side,
it is often indefinite in the greater curvature side for the region covered by the gastric corpus, with an
ambiguous border with the greater curvature-side gastric angle region. The border between the corpus

5and the gastric angle is basically defined based on the status of the fold and the mucosa (particularly ingastric areas). The gastric corpus is trisected into the upper, middle, and corpus regions in both greaterand lesser curvature sides.
● The gastric angle region is a part that spreads to the greater curvature, including the gastric angle in a
fan shape. The term gastric angle refers to the inflexion point between the corpus and the antrum partat which the stomach flexes. It should be noted that “gastric angle” and “gastric angle region” aredifferent. The greater curvature-side gastric angle region is defined to be up to the adoral end of thepyloric antrum region. It spreads to the adoral and anal side centering on the opposite point of thegastric angle in the greater curvature in a fan shape.
● The antrum region spreads from the prepyloric region to the gastric angle, and the length in the greater
curvature is the same as that in the lesser curvature.
● If the border between the gastric corpus region and the gastric angle region is unclear, the region fromthe border with the fundus to the border with the pyloric antrum region may be quadrisected into theupper corpus, middle corpus, lower corpus, and gastric angle region.
● The prepyloric region is defined to be the pylorus and the part up to about 2 cm adoral to it. The region
is defined to be within about 2 cm width, similarly to the cardiac region, because the retraction ring is
not always imaged clearly in radiograms, although it seems histologically appropriate to define theprepyloric region to be the part from the retraction ring to the pylorus.
● For the duodenum, some argue that the duodenal bulb and the postbulbar duodenum should be
differentiated. However, because most duodenal diseases occur in the duodenal bulb and the superior
duodenal angulus (SDA) or inferior duodenal angulus (IDA) is not always imaged clearly, postbulbar
duodenum is not daringly defined here. Nevertheless, each institution may define the postbulbar
duodenum ad libitum.
* It is assumed that consensus on classification among academic societies and organizations related toradiology will be complied with, for example among JSGCS, JQAOGCS, and the Japan RadiologicalSociety (JRS), if such consensus is proposed.

Description of interpretation and assessment (Table 1-2, 3)
Technologist’s check field
It is essential for radiological technologists (hereinafter referred to as technologists) to improve theirskills in order to obtain better images. Although some consider that participation of technologists ininterpretation is inappropriate, the technologist who has taken the image just remarks the findings he/she
considers significant. Check of findings in itself is not “interpretation” and not applicable to participationof the technologist in interpretation. Checks by the technologist, including observation under fluoroscopy,
are not only favorable for the improvement of the technologist’s skill but also very useful for interpretationby the physician. Improvement in skill to check the imaged findings is directly linked to improvement inimaging technique.
Physicians interpret, taking into consideration the findings checked by technologists and theinformation under fluoroscopy, but this is not applicable to emergency cases, of course.

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The technologist’s check field may be prepared in each institution’s own form, desirably in a form
allowing the technologist to describe in free form. Although the present manual daringly shows an
exemplary tabular form of the technologist’s check field, this may be changed in each institution’s own
form.
Description of interpretation results by physician
Record of interpretation results is to identify the rationale leading to the assessment. Therefore, theinterpretation result table presented here can absolutely be insufficient. Description should basically be
accompanied by drawings (sketch or image marking). This is particularly essential in cases of assessment“C” or severer, in order to evaluate the change with time in the future. It is greatly useful to depict
abnormal findings that cannot be expressed sufficiently in a table, such as record of their detailed shapeand size, in order to improve interpretation skill.
In preparing a request form for thorough examination (referral form), the findings need to indicate
clearly what disease is suspected and to what degree in the referral, and such information can usually not
be provided sufficiently in text form.
Although an exemplary Interpretation Report Table is presented here, this is only an example and each
institution may prepare its own forms, as long as such forms provide interpretation results in addition tofindings and disease terms presented in the present manual.
It is also acceptable that description schema of findings is defined in advance, from which physicians
mark the applicable codes of findings within the list, with the aim of fostering physicians to read images.

Findings (Table 2)
It would still be difficult to say that terminologies for findings obtained in upper gastrointestinal
radiography are unified, particularly for detailed and minute findings. In addition, different expressions
may often be used even for the same findings. In such a context, the present manual adopts expressions
with few differences among researchers and terms considered to be established and popular to a certain
degree in history.
Additionally, with the aim to avoid misuse of terms that are sometimes encountered, marginal findings
and gastric mucosal fold findings are differentiated from each other, just as rough categories and direct
findings such as niche and shadow defect are differentiated from each other.
Although the basics have been established in the over-50-year-history of gastric diagnostic radiology,
expression or diagnostics for detailed findings (minute convexo-concave in the mucosa or disturbed
marginal ridge line) has not been finalized yet. Therefore, no finding more detailed than the above isdaringly presented here.

Interpretation, diagnosis, and assessment (Table 3)
Assessment table
Assessments and assessment categories are listed in two forms: Table A and B. It is more desirable touse Table B in view of the context of development in diagnostic radiology from the past and improvement

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in screening accuracy. However, Table A has been set, because using terms such as “cancer” or “malignant”
easily in the field of health screening might pose excessive anxiety to subjects or unnecessarily confuse
them.
Table A aims to avoid communication with subjects using terms such as “malignant” or “suspected tobe malignant” casually. However, using only Table A results in very insufficient accuracy control, because
it does not definitely indicate what assessment has been made in actual interpretation.
If Table A is used, radiologic diagnosis in a form equivalent to Table B or more detailed should be recorded
and archived.
If Table B is used, careful consideration is essential; for example, preparing a result table form for
subjects separately from the table for record, or taking measures to reduce the subject’s psychologicalburden in explanation or notification of results.
Double reading
Mode of interpretation will be double reading (double check). Note that double reading is nonsimultaneous and that simultaneous interpretation by more than one physician is not double reading.
Although simultaneous reading by more than one physician is useful in learning reading skill, it does notlead to prevention of “overlook” for which double reading is performed. Double reading is an action to
improve reading accuracy that starts from the fact that “human error cannot be eliminated completely.”
As this is an action to prevent an error or failure (e.g., overlook) from proceeding to accident or hazard(miss), it is an essential system in screening with the use of imaging.
Make radiologic diagnosis in all subjects
Since the basics of radiologic diagnostics have already been established and current institutional
radiography has been improved to provide images with accuracy sufficient for diagnosis, it is legitimate
to make diagnosis also for improvement in reading accuracy. If a case is assessed as “thoroughexamination needed” because it cannot be considered as being “normal” or “no thorough examinationneeded”, such an assessment cannot be an “interpretation.” An assessment is considered to be an“interpretation” only if diagnosis is made by integrating significant findings noted on the image.
Abolition of assessment category by finding
The previous guidelines3 also defined assessment categories for each finding. However, as assessment
is made not based on a single finding in interpretation, but made by integrating more than one finding inmost cases and diagnosis made for all subjects, the assessment category field was deleted from Table 2
findings table.
Actual assessment
A case that is considered to be related to lifestyle is assessed as “C”, and lifestyle improvement
instruction is actively introduced; unless it is assessed as “thorough examination needed” or “treatment
needed.”8

Considering that health screening is also for primary prevention contrarily to specialized cancer screening,
it is not allowed to take no measure for cases that can have their health improved by changing lifestyle.
Comparative reading
Advanced digitalization has made it easier to compare images with previous ones. Comparative reading
is essential if previous images are available. Comparative reading not only prevents overlook of slightchanges but also allows omission of unnecessary thorough examinations. This helps to achieve not only
improvement in examination accuracy but also a streamlined health screening system.

Accuracy control
As described in previous guidelines3, accuracy control checklists have been prepared regarding
examination and reading/assessment for population-based screening. In health screening, it is necessary to
not only comply with this checklist but also pursue accuracy control more than that in gastric cancer mass
screening.
To achieve this goal, improvement in accuracy of the whole screening system should be pursued withcollaboration between physicians and technologists, as well as all staff involved in screening.
Collection and control of accuracy indices
Recognition of accurate cancer detection rate, rate of “thorough examination needed,” and thoroughexamination rate is essential to screening institutions. To achieve this, it is also important to construct a close
cooperative relationship with institutions providing thorough examinations, allowing feedback to each other.
Although follow-up inspection is a difficult operation that requires a lot of human resources and time,
accuracy cannot be improved without recognizing and investigating false-negative cases and false-positive
cases.
Accuracy indices such as sensitivity and specificity can be obtained only through these activities, for which
the whole screening staff, including physicians, should make efforts with subjective collaboration.
Taking into consideration that early cancer detection is not the only aim of health screenings, recognitionof diseases other than cancers should also be considered sufficiently.
Ensuring implementation of prognosis research
Prognosis research is essential to investigate efficacy. Since the purpose of cancer screening is to reduce
mortality rate due to certain target cancers, a cancer screening cannot be considered effective unless its
decreasing effect on mortality rate is demonstrated, no matter how many early cancer cases the screening
detects. As described above, radiology is the only screening method that is recognized to have a decreasing
effect on mortality rate due to gastric cancer.
Health screening, on the other hand, has the primary purpose to eliminate health inhibiting factors anddecrease mortality risk, not in the whole group but in each individual.
However, whether or not mortality risks of individuals have been reduced cannot be determined without
prognosis research. If only cancer detection rate, rate of “thorough examination needed”, and thorough9examination rate are collected and managed, neither reduction of mortality risks nor elimination of healthinhibiting factors in individuals, the purposes of health screenings, can be ensured.
It should be strongly recognized that screening without follow-up research or prognosis research cannot be
considered to be adequate, and that such screening should not be implemented.

Conclusion
Although priority of endoscopy is rapidly increasing in upper gastrointestinal examination of institutional
screening, such as health screening, radiology is still the mainstream examination.
In general, cancer screening is considered such that “the intended goal cannot be reached unless thescreening is performed in methods considered to be effective at high accuracy (including the examination
but also system).” Radiology is still the only method that has been confirmed to be effective as gastric cancer
screening, only if it is performed at accuracy above a certain level.
The present manual has been prepared to indicate the methods capable of guaranteeing the minimal
efficacy in any institution.
We have prepared the present manual wishing that accurate radiology will be performed not only in some
excellent institutions, but in all institutions. We hope all institutions providing health screening will utilize
the present manual.

References
1) "Study on establishment of appropriate method of cancer screening and its evaluation method" by
Ministry of Health, Labor and Welfare cancer research grant-Stomach cancer screening guidelines based on
effectiveness evaluation 2006
2) New stomach X-ray (direct and indirect) guidelines, Japanese Society of Gastrointestinal Cancer
Screening 2005
3) Daisuke Shibuya: Upper Gastrointestinal Radiography Screening．Supervision:Yoshio Goto, Masaharu
Nara，Author: Minoru Yamakado, Masahide Abe，Health check criteria guidelines, Bunkodo, Tokyo,
2008, 164-168.
4) New stomach X-ray (direct and indirect) guidelines, Japanese Society of Gastrointestinal Cancer
Screening 2011, Igaku shoin, Tokyo, 2011.
5) Japan Qality Assurance Organization of Gastroenterological Cancer Screening, Stomach cancer X-ray
examination, technical department text, 2011

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Results of upper gastrointestinal radiology screening
Table 1. Description of results
Table 1-1. Sites of findings
Esophagus
1. Upper esophagus
2. Middle esophagus
3. Lower esophagus
Stomach
4. Cardiac region (within about 2 cm from esophagogastric junction)
5. Gastric fornix (the region cranial to the level of the cardia, fundus)
6. Upper gastric corpus
7. Middle gastric corpus
8. Lower gastric corpus
9. Gastric angle region
10. Pyloric antral region
11. Prepyloric region (pyloric ring and the region within about 2 cm adoral to it)
Duodenum
12. Duodenal bulb
13. Postbulbar duodenum and the region anal to it
14. Extraluminal (excluding those with findings in the gastrointestinal tract on X-ray)
21. esophagus over wide region 22. stomach over wide region 23. Duodenum over wide region
Location in the gastric a. Anterior wall
wall

curvatureb. Posterior wall c. Greater curvaturee. All circumferenced. Lesser

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Table 1-2. Definitions of assessment categories
A: Normal
B: Mild abnormality
C: Following-up/lifestyle instruction/re-examination needed
D: Medical care needed (D1: Treatment; D2: Thorough examination)
E: Under treatment
Note:* Cervical esophagus is included in upper esophagus and abdominal esophagus in lower esophagus.
* If a finding covers more than one site/location in the gastric wall, describe all sites/locations involved.
(e.g., a finding on an area spreading from the lower corpus through the posterior wall of the gastric angle
to the lesser curvature, describe as 10. 11, b. d.)* If a lesion broadly spreads over 3 areas or more, indicate the esophageal area as 21, gastric area as 22, andduodenal area as 23
Table 1-3. Description of interpretation/assessment
Technologist’s check
It is desirable that the technologist checks the images before the physician’s interpretation.
Although freehand sketch is desirable in the technologist’s check, a technologist’s check field may be
included.
* An exemplary technologist’s check field is shown below:
Technologist’s check (example)
Site

Findings

Disease suspected

Remarks (comment to physician)* Describe the disease suspected as a technologist as much as possible.
* If a check field is included as shown above, sketch the findings as much as possible.
* The technologist may describe in the check field only the findings he/she recognized.
Description of interpretation/assessment
The physician’s interpretation shall basically be made in double reading (double check) by more than one
physician.
The interpreting physician should record accurate and detailed reading results basically by browsing thetechnologist’s check and previous data. In this viewpoint, the description table below is minimallydetailed and very inadequate, particularly if presence of a lesion is definitely diagnosed or a malignant
disease is suspected.
Record findings more thoroughly than the finding classification listed in Table 2 by describing
handwritten sketch in a blank sheet, writing in schemas prepared by imaging position, or marking on thecaptured images.

12Physician’s interpretation table (example)
Site

Comment on findings

Diagnosis(detailed findings)

Assessment
category

Lesion 1
Lesion 2
Lesion 3[Exemplary description]
A convergence of mucosal fold is present from the lower gastric corpus to the lesser curvatureposterior wall of the gastric angle region. The fold is interrupted with granular mucosa defined by aclear border in the central part, and IIc is suspected
Lesion 1

Site

Findings

Assessment

Category

10, 11, b.

2, 13, 15

g.4

D2

Granular mucosa with a clear orborder in the center of FC

suspected

gastric

cancer (IIc?)

Note:* Particularly in cases assessed as “D,” the lesion(s) must be sketched or marked on the image with arecording of the size and detailed shape. (It is difficult to describe size and detailed findings in the remark
field of the Physician’s interpretation tables.)* Although the layout of the Physician’s interpretation table or sketch field may be defined originally byeach institution, the above requirements should all be met.

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Table 2. Findings
0. No abnormal findings
1. Niche
2. Convergence of mucosal fold
3. Shadow defect (the contour line is interrupted; may be expressed even without a filling
picture)4. Mass shadow
5. Translucency (including not only so-called “no contrast picture” but also cases where themedium that should be adhered to is repelled)
6. Indentation
7. Deformation (excluding indentation: short lesser curvature, poor stretching, narrowing, anddilation are also included)
8. Exclusion picture
9. Irregular contour line (including all findings of loss of continuity in smooth contour line curve,
such as double line, rigid line, and irregular line)
10. Fine barium pooling or fleck
11. Convergence of mucosal fold-like finding
12. Bulky fold
13. Interrupted fold
14. Irregular fold (other than 11, 12, or 13)
15. Irregular mucosa (including poor medium adhesion, granular, nodular, and irregular area)
16. Esophageal hiatus hernia
17. Gastrointestinal foreign matter-like shadow (including food residue)
18. Post-gastrointestinal operation
19. Extragastrointestinal tumor-like shadow
20. Stone
21. Calcification picture
22. Others ()

Note* Because qualitative diagnosis is difficult based only on the above findings, describe detailed findings in
the comment field or sketch field. (Particularly if malignancy is suspected or an assessment is made as
thorough examination needed, detailed description of the abnormal finding used as the rationale isessential, such as location, shape, and size.)* Expression or diagnostics of detailed findings (e.g., expression of fine convexo-concave in the mucosa
and irregular contour) have not been finalized yet. The method to describe more detailed findings than theabove is not daringly described as a unified opinion here. However, if the Japanese Society of
Gastrointestinal Cancer Screening (JSGCS) or the non-profit Japan Quality Assurance Organization of
Gastroenterological Cancer Screening (JQAOGCS) presents a return/report about that, we consider the
method including the above classification findings.

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Table 3. Interpretation and assessment category
Table A
Diagnosis

Assessment
categorya. NormalA

e1 Esophageal protruding lesionD

e2 Suspected esophageal protruding lesion

D2

e3 Esophageal depressive lesion

D2

e4 Suspected esophageal depressive lesion

D2

e5 Esophageal polypC or De6 Esophageal diverticulum

D or Be7 Esophageal varices

D2

e8 Esophagitis

D2 or Ce9 Achalasia

D2

e10 Other findings in the esophagus ()

g1 Gastric protruding lesion (excluding polyps)D

g2 Suspected gastric protruding lesion (excluding polyps)

D2

g3 Gastric depressive lesion (excluding gastric ulcer)D

g4 Suspected gastric depressive lesion (excluding gastric ulcer)

D2

g5 Submucosal tumor of the stomach

C or D

g6 Gastric ulcer

D1

g7 Suspected gastric ulcerC

g8 Gastric ulcer scar

B or C

g9 Fundic gland polypB

g10 Gastric polyp (polyp other than fundic gland polyp)

C or D

g11 Gastric diverticulumB

g12 Acute gastric (mucosal) lesion

C or D1

g13 Gastric erosion (excluding superficial gastritis)

B or C

g14 Chronic gastritis (atrophic, hyperplastic, and hypertrophic, etc.)

B or C

g15 Other gastric lesion ()

d1 Duodenal ulcer

Dl

d2 Duodenal ulcer scar

B or C

d3 Duodenal diverticulum

B or Cd4 Other duodenal findings ()

o1 Gallstone

D2 or Co2 Visceral inversionBo3 Others ()

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Table B
Diagnosis

Assessment
categorya. NormalA

e.1 Esophageal cancer

De.2 Suspected esophageal cancer

D2e.3 Esophageal tumor (including polyps)

D2e.4 Suspected esophageal tumor

D2

e.5 Esophageal ulcer

B or D2

e.6 Suspected esophageal ulcer

D2

e.7 Esophageal diverticulum

D or Be.8 Esophageal varices

D2

e.9 Esophagitis

D or Ce.10 Achalasia

D2

e.11 Other findings in the esophagus ()

g.1 Gastric cancer

D

g.2 Suspected gastric cancer

D2

g.3 Submucosal tumor of the stomach

D2 or B

g.4 Gastric ulcer

D1

g.5 Suspected gastric ulcer

D2

g.6 Gastric ulcer scarC

g.7 Fundic gland polypB

g.8 Gastric polyp (polyps other than fundic gland polyp)

C or D

g.9 Gastric diverticulumBg.10 Acute gastric (mucosal) lesion

B or Cg.11 Gastric erosion (excluding superficial gastritis)

C or D1

g.12 Chronic gastritis (atrophic, hyperplastic, and hypertrophic, etc.)

B or Cg.13 Other gastric lesions ()

d.1 Duodenal ulcer

D1d.2 Duodenal ulcer scar

B or C

d.3 Duodenal diverticulumB

d.4 Other duodenal findings ()

o.1 Gallstone

D2 or Co.2 Visceral inversionBo.3 Others (

)

Notes
* Use Table A or B depending on the judgment of a situation in each institution.
* Benign diseases should be assessed not as unified assessment category, but taking into consideration severity

16of the abnormality, medical history, present illness, previous background, and life status.
* If which of D1 or D2 to select cannot be determined, select assessment category “D: Medical care needed.”* Cases followed up without treatment or under postoperative follow-up by their attending physician will beapplicable to Assessment “C.”* Gastroesophageal reflux disease will be indicated as esophagitis only if erosion is noted in the lower
esophagus on the radiogram and symptoms are present.
* So-called “takoibo erosion” is also included in “gastric erosion.”* “Chronic gastritis” is defined to be a case with strong atrophy or a case where hyperplastic, metaplastic, or
thickening change is noted.
* If a case is diagnosed to be chronic gastritis, assess the case taking severity of atrophy and age into
consideration.
* In a case of gastritis where infection with H. pylori is suspected, care should be taken, because easily
assessing as “B” means “no treatment is necessary.” Such a case rather needs to be assessed as “C” toconsider H. pylori eradication or to schedule regular control screening.
* Previous data must be browsed to reflect current assessment, if available. Browse other laboratory data asnecessary.
* If ABC risk classification for gastric cancer or H. pylori (HP) test has been performed, provide a message
so as not to lead to misunderstanding.
* Describe precautions for HP-eradicated group also.
* For postoperative cases or cases with intragastric foreign matter or food residue, select Others and describe
the detail in the parenthesis.
Japan Society of Ningen Dock

Upper Gastrointestinal Radiography Screening Committee
Chief Commissioner

Takeshi Kusano (Institute for Kagoshima Gastrointestinal Cancer Screening)

Members

Hitoshi Sasamori (Makita General Hospital)

Ryugo Sato (JA Oita Koseiren)
Yoshinori Sugino (Keio University)
Haruhiko Nakao (Sasebo chou Hospital)
Masato Noguchi (Japanese Red Cross Fukui Hospital)
External Evaluation Committee Members
Daisuke Sibuya (Cancer Detection Center, Miyagi Cancer Society,Japanese Society of Gastrointestinal Cancer Screening
April, 2014