There are some patients whom we cannot help; there are none whom we cannot harm.
Personal communication after a diagnostic tragedy
It is surely one of medicine’s greatest ironies and utter wastes that routine imaging of the upper gastrointestinal (GI) tract has changed so profoundly in the past 30 years. The introduction of the fiber optic gastroscope in 1963 initiated this sea change in diagnosis, catching the medical profession in an undertow of fashionable technology.
EGD, short for esophagogastroduodenoscopy, or upper GI endoscopy is an examination of the lining of the esophagus, stomach, and upper duodenum with a small camera (flexible endoscope) inserted through the mouth, down the esophagus and into the stomach and upper small intestine. The procedure is performed in over 10 million patients a year in this country, one million of these in hospitals, the rest in an outpatient setting, almost invariably in the U.S. with “conscious sedation,” a euphemism for general anesthesia.
Another, simpler and much cheaper method, virtually without risk or complications is the use of X-rays with barium to outline the esophagus, stomach and intestine, the esophagogram and upper GI series. This routine study has been increasingly abandoned by the medical profession over the past 30 years. By 1985 twice as many hospital GI imaging procedures were EGD compared to the barium study; by 1990 the ratio had increased to over 5:1 in favor of EGD. The actual number of GI series is no longer included in Government statistics (NCHS and NHDS) for hospitals.
It would seem logical that direct viewing of the upper GI tract has advantages over the indirect visualization with barium X-rays, but this is ingenuous when in thousands of reports of study after study over the past 60 years the accuracy and reliability of the upper GI series has been confirmed, both for the diagnosis of benign and for serious disease.
The additional unaccounted cost to the health care system of needless upper GI endoscopy is in the neighborhood of $10-$15 billion.