Reliability and utility of the Toronto Upper Gastrointestinal Cleaning Score f optimizing mucosal visualization during esophagogastroduodenoscopy

Background and study aims: Esophagogastroduodenoscopy (EGD) is a key tool for diagnosing upper gastrointestinal lesions, but its accuracy relies on optimal mucosal visualization. Currently, there are few validated instruments to objectively assess mucosal cleanliness. This study aimed to validate the Toronto Upper Gastrointestinal Cleaning Score (TUGCS) and explore its association with lesion detection. Patients and methods: In this prospective, single-center study, 175 patients undergoing diagnostic EGD were enrolled. Interobserver and intraobserver reliability of the TUGCS was assessed using intraclass correlation coefficients (ICCs) among expert and non-expert endoscopists. Secondary outcomes included detection of endoscopic lesions, which were analyzed using multivariate logistic regression adjusted for age, procedure duration, and indication. Additional analyses included Spearman’s correlation and z-tests. Results: TUGCS demonstrated excellent interobserver reliability (ICC = 0.95; 95% confidence interval 0.93-0.96) and intra-observer agreement (ICC = 0.896 for non-experts, 0.924 for experts). The score correlated strongly with subjective assessments (P = 0.68; P < 0.001). Both TUGCS as a continuous variable and TUGCS ≥ 6 were independently associated with increased detection of gastroduodenal findings as a composite outcome, when adjusted for age, sex, simethicone use, and procedure duration. Conclusions: TUGCS is a reliable and reproducible tool across varying levels of endoscopic expertise. Higher scores were associated with improved detection of gastroduodenal pathology, supporting its utility as a quality metric in EGD. Multicenter studies are warranted to validate its role in broader clinical practice.