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In 1984, Sir Christopher Booth (President British Society of Gastroenterology (BSG) 1979) gave a lecture in Berlin on the effect of technology on clinical practice. He lauded the rapidly expanding benefits of diagnostic and interventional gastrointestinal endoscopy but was led to ask “Will the gastroenterologist simply become a technician who carries out a series of complex but personally satisfying techniques?”1
Most gastroenterologists remain general physicians but in talking with specialist registrars I have been surprised by their overwhelming interest in honing endoscopic skills. If this leads to a simplistic approach to the investigation of possible gastrointestinal pathology, it has its dangers. Analysis of two cases in the past month reminded me of this.
Case No 1
An elderly man was admitted to hospital with severe anaemia. The houseman obtained a history of aspirin ingestion and, over the preceding few weeks, recurrent melaena. He described feeling a hard liver edge. A blood count showed haemoglobin (Hb) 4.3, mean corpuscular volume (MCV) 55.7, white blood cell count (WCC) 6.6, and platelets 63. The patient was transfused and without further investigation the physician/gastroenterologist arranged for oesophago-gastro-duodenoscopy (OGD) and colonoscopy.
At OGD the stomach was described as showing a moderate erythematous/exudative gastritis. At colonoscopy no abnormality was seen apart from a little fresh bleeding, the cause of which was not apparent. The patient was allowed to go home only to be admitted 36 hours later with faecal peritonitis. The colon had been perforated at the rectosigmoid junction. The patient recovered well from reparative surgery but died six weeks later of multiorgan failure. At necropsy he was found to have cirrhosis of the liver. In retrospect, photographs of the gastric mucosa were consistent with portal gastropathy.
Case No 2
An elderly man taking diclofenac for osteoarthritis of the hip began drinking heavily after the death of his wife. One Saturday he felt faint, vomited black fluid, and passed melaena. After the weekend he was admitted to hospital. His blood count showed Hb 9.7, MCV 105, WCC 10.3, and platelets 240. As in case No 1, he was listed for OGD and colonoscopy. At OGD he was found to have a marked antral gastritis and multiple duodenal erosions in a deformed duodenal cap. At colonoscopy, multiple diverticulae were found in the sigmoid colon through one of which instrumental perforation occurred. The patient was referred promptly for surgery. There was little faecal contamination and the patient recovered well after resection of a short length of colon.
In both of these cases the physician-gastroenterologists appeared to be working to the dictum: bleeding from the gut requires OGD and colonoscopy. Yet in neither case was the need for colonoscopy clearly indicated. So was Chris Booth right to be concerned about what technology has done to gastroenterology? Or is it just fortuitous that I should be asked about these two cases so close to one another?
In the USA, many health care organisations suggest that this sort of issue should be addressed by paying more attention to the balance between underuse, overuse, and misuse of medical interventions.2 So perhaps the programmes for meetings of the BSG should not be just sectionalised by organ and disease processes. A section devoted to efficiency, care, and safety in gastroenterological practice could gather together contributions having a direct and immediate bearing on clinical care. For as Sir Cyril Chantler said, when addressing the Institute of Health Services Research in the USA, “Medicine used to be simple, ineffective and relatively safe. Now it is complex, effective and potentially dangerous”.3 And we should all remain aware of this.