Lack of uniformity in evaluation of endoscopic prognostic features of bleeding ulcers

Management strategies in patients with bleeding ulcers are based on ulcer appearance. We assessed the level of agreement among endoscopists regarding the labeling of endoscopic features of bleeding ulcers and also evaluated the effect of a short teaching session on the level of agreement. Two hundred two endoscopists at the 1992 American College of Gastroenterology Postgraduate Course answered multiple-choice questions using interactive keypads. They were shown 6 slides of typical ulcer stigmata of recent hemorrhage, attended a brief teaching session, and then saw 6 different slides of comparable stigmata plus 2 additional slides. Color of stigmata was assessed in 9 slides. Information on years of endoscopic experience and numbers and types of procedures performed was also obtained. The proportion of correct answers before the teaching session increased significantly with years of experience, reaching a plateau in endoscopists who were 6 years or more beyond training. The proportion of correct answers for physicians performing no more than 5 upper gastrointestinal endoscopies per month was significantly lower than for those performing more than 5 per month: 33/56 (59%) compared with 647/891 (73%), a difference of 14% (95% CI, 0.4% to 27%; p = 0.03), but performance of a greater number of endoscopies was not associated with a further increase in the rate of correct answers. The total number of correct answers increased from 845/1181 (72%) before the teaching session to 1268/1554 (82%) afterwards, a difference of 10% (95% CI, 7% to 13%; p < 0.001). The increase was related to the level of training: fellows, 15% increase in correct answers (95% CI, 9% to 23%; p < 0.001); physicians with 0 to 20 years since training, 8% increase (95% CI, 4% to 12%; p < 0.001); physicians with 20 years or more since training, 3% increase (95% CI, –6% to 12%; p = 0.51), but was not related to the number of procedures performed per month. Agreement on the color of stigmata ranged from 35% to 91%, with a mean of 62%. Endoscopists disagree on labeling of ulcer features more than a quarter of the time, and the rate of disagreement on difficult stigmata is higher. Consensus regarding color is even more variable. Agreement can be modestly improved with a brief period of teaching. Our findings may help explain the variable results in studies of bleeding ulcers. Because patient management is based primarily on interpretation of ulcer features at endoscopy, consensus definitions of stigmata of hemorrhage must be developed and disseminated to ensure appropriate patient care. (Gastrointest Endosc 1994;40:411-7.) (Figure presented.)