Upper GI Endoscopy and the Disappearing Barium Study II

The feasibility of an operation is not the best indication for performance.  

Lord Cohen of Birkenhead (former physician to the Queen of England.)

Over 85 million Americans are affected by digestive complaints, the vast majority of which are benign conditions. In the past 10-15 years, the indications for imaging studies have been narrowed in view of the enormous effectiveness of drugs like Zantac©, Pepcid©, and the proton pump inhibitors, (“PPI’s”), such as Prevacid©, and Prilosec© in the 30 million patients with dyspepsia, ulcer, dyspepsia and most of the 65 million with reflux. Yet the number of EGD’s continues unabated.

Risk vs. Benefit in GI Imaging

Because EGD is so unpleasant that a struggling patient without proper restraint could suffer perforation of the esophagus or stomach, the procedure is done overwhelmingly with “conscious sedation.” That this term is a euphemism for general anesthesia with loss of protective reflexes, such as movement, gagging, cough, etc., is demonstrated by the virtual routine use of EKG and pulse oxygen monitoring during the procedure. Despite precautions, a distinct risk is introduced by the use of anesthesia; moreover, rare misadventures due to the performance of the procedure itself add to the dangers. Upper GI mortality occurs between 1 in 2,000 and 1 in 12,000 and morbidity in some 1 in 200. In one study the rate of occurrence of cardiovascular complications (defined as arrhythmia, chest pain or anginal equivalent, hypotension, or myocardial infarction occurring within 24 hours after endoscopy) was 308 per 100,000 procedures or 3 per 1000 procedures, “2 to 70 times higher than previously reported”!

Numerous other statistics are available, but often hidden in the literature. Reporting rates for drug reactions is estimated at 10%, but no one, to my knowledge, has kept global or national statistics on complication and mortality rate of procedures like EGD for over 25 years.

Transmission of infection such as hepatitis C, bacterial infections and even AIDS, via endoscopic instruments has been reported in the literature. Reports of pathogen transmission resulting from these procedures are rare, and each has been associated with a breach in accepted endoscope reprocessing and infection control protocols. But are these complicated and expensive procedures performed 100% of the time? Moreover, as with other complications and mortality, there remains the reporting problem which inevitably underestimates risk and misadventures.

More to follow.

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