The use of upper gastrointestinal endoscopy (UGIE) continues to rise, often beyond evidence-based indications. The EPAGE criteria were developed to standardize and rationalize endoscopy indications, but their real-world performance remains uncertain. This study evaluated the applicability of EPAGE criteria in daily practice and assessed the association between indication appropriateness and clinically significant endoscopic findings.

We conducted a retrospective study including all UGIE procedures performed at Sahloul University Hospital (Sousse, Tunisia) from May to July 2023. Indications were classified according to EPAGE categories (“necessary and appropriate,” “appropriate,” “uncertain,” “inappropriate,” or “non-applicable”) using the official EPAGE software. Exams with indications not covered by EPAGE were excluded. Significant endoscopic lesions were recorded, and their association with EPAGE categories was statistically analyzed.

Among 290 UGIE procedures, 42 (14.5%) were excluded; 248 examinations were analyzed (mean age 59.2 years; sex ratio M/F=0.7). The most frequent indications were upper GI bleeding (28.3%), dyspepsia (24.2%), and iron-deficiency anemia (15.3%). EPAGE classification rated indications as necessary/appropriate in 60.5%, appropriate in 23.4%, uncertain in 3.9%, inappropriate in 12.9%, and non-applicable in 15.5%.Clinically significant lesions were found in 79% of cases with necessary/appropriate indications. A significant association was observed between EPAGE appropriateness and endoscopic yield (p = 0.02). However, even in inappropriate or uncertain indications, significant lesions were detected in 40% of examinations, including 5 peptic ulcers and 3 neoplastic lesions.

While most UGIE indications met EPAGE criteria, the substantial proportion of significant findings among procedures deemed inappropriate or uncertain suggests that current EPAGE recommendations may lack sensitivity in real-world clinical settings. These results support the need for updating and refining EPAGE criteria to better match contemporary diagnostic practices.