Rationalising endoscopy in gastroenterology: a safety-first framework for when to defer, replace or individualise investigation

Endoscopy is central to modern gastroenterology, but in selected clinical scenarios, its incremental diagnostic yield may be limited while adding procedural risk, sedation burden, cost, waiting-list pressure and environmental impact. Rationalising endoscopy is not rationing: it means performing invasive procedures when they are likely to change diagnosis, treatment, prognosis or patient-centred goals and using validated alternatives when they can answer the clinical question safely. This narrative review provides a practical safety-first framework for frontline clinicians considering when to defer, replace or individualise gastroscopy, colonoscopy, endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasonography (EUS). Examples include low-risk upper and lower gastrointestinal symptoms, selective gastric ulcer follow-up, frailty-informed polypectomy and surveillance decisions, avoidance of diagnostic ERCP, selective EUS staging and MRI-based surveillance of low-risk presumed branch-duct intraductal papillary mucinous neoplasm. Recent UK guidance is used to illustrate how rationalisation can be embedded in safe, governed pathways. These strategies should be embedded within local governance, multidisciplinary review where appropriate, shared decision-making and explicit safety-netting. Alarming features, abnormal imaging, progressive symptoms, persistent iron deficiency anaemia or clinician concern should override low-risk categorisation.