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I have every sympathy with Dr Neale’s opinion and feel he is entirely correct in worrying about the apparently overwhelming tendency for technological investigation and expertise instead of a more considered diagnostic and management approach (Gut 2003;52:770–1). I would also agree with his view of the aspirations of many gastroenterological specialist registrars, apparent from talking to many of them. He has highlighted the potential problems of such a technical dictum and not even mentioned what might happen when further advances in imaging obviate the need particularly for diagnostic colonoscopy.
What will all the technicians do?
However, Dr Neale has perhaps been a little over cautious in condemning colonoscopy in case No 1. I would agree that colonoscopy in case No 2 with a macrocytic anaemia and possible haematemesis must be regarded as a very doubtful indication. However, in case No 1, with a marked microcytic anaemia and recurrent melaena without a definite cause in the upper gastrointestinal tract, many would regard visualisation of the colon by whatever means prudent, although given the likely comorbidity a non-invasive test might have been better, depending on resources. It is clear that in both of these typical cases appropriate thought had not gone into the diagnostic approach but also interestingly that in these days of great service pressures it was possible to perform oesophagogastroduodenoscopy and colonoscopy before haematinic estimations. In both cases the colonoscopist must share the blame for taking an overly technical view; bowel preparation may be rather unpleasant but that is no reason to continue and perform an unnecessary investigation if the patient turns up on a list. I would echo Dr Neale’s thoughtful suggestion that we need to concentrate more on efficacy and safety of care.
I thank Dr Beales for his comments. Clearly, it is always easy to be wise in retrospect. However, we teach students to make a diagnosis by listing the positive findings and linking these to build a coherent diagnosis.
In case No 1, the house officer noted aspirin ingestion, melaena, a hard liver edge, and thrombocytopenia. He suggested cancer of the gut with hepatic metastases. This was reasonable enough even though it did not include thrombocytopenia.
The next logical step might have been scanning of the upper abdomen in which case splenomegaly would have been added to the list and from there it was only a short step to hepatic cirrhosis and possible reinterpretation of the erythematous/exudative gastritis.
We also teach that patients be told the risk-benefit ratio of any procedure.1 Frank melaena is a rare presentation of cancer of the colon and the risk of colonoscopy is perhaps 0.2%.
I leave the reader to decide if the present day gastroenterologist should concentrate on honing specialist technical skills to gather information or should develop as a consultant who weighs the evidence as it unfolds.
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