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Esophagogastroduodenoscopy performed by a family physician: a case series of 793 procedures.

BACKGROUND. Primary care physicians are performing an increasing number of

gastrointestinal endoscopies. The purpose of this research is to present a large

case series of diagnostic esophagogastroduodenoscopies (EGDs) performed by a

family physician in a solo rural practice.

METHODS. We present a retrospective chart review, including demographic

characteristics, indications, endoscopic and pathologic findings, and

complications for every EGD performed by a family physician over a 7-year

period.

RESULTS. Seven hundred ninety-three EGDS were performed on 602 patients (421

women, 181 men), with a mean age of 51.8 years. In 99% of procedures, the second

portion of the duodenum was intubated. The most common indications for EGD were

abdominal pain (60.5%), gastrointestinal bleeding (23.0%), dysphagia (11.6%),

and heartburn (10.7%). A total of 451 biopsies were obtained in 385 procedures,

mostly from the distal esophagus (38%) or gastric antrum (37%). Common

endoscopic diagnoses were gastritis (54%), esophagitis (25%), and normal study

(15%). There were only two malignancies detected, one gastric lymphoma and one

carcinoma metastatic to the stomach. One minor complication (0.1 3%) occurred,

an immediate urticarial rash after intravenous meperidine.

CONCLUSIONS. Experienced family physicians can safely and competently perform

diagnostic EGD and provide this important service to their community.

KEY WORDS. Esophagogastroduodenoscopy; physicians, family. (J Fam Pract 1998;

46.41-46)

As the practice of medicine has

progressed, technical procedures such as

gastrointestinal endoscopy have

become despecialized.[1] For example,

flexible sigmoidoscopy is now

performed by 29% to 57% of US family physicians and

42% of general internists, according to recent

national surveys.[2-4] Esophagogastroduodenoscopy

(EGD) has become the primary diagnostic tool for

evaluation of upper gastrointestinal symptoms.[4-7]

Primary care physicians perform EGD

considerably less often than flexible sigmoidoscopy, and

physicians may find it difficult to acquire

endoscopic skills after residency training.[8-10]

In Great Britain, a national group representing

endoscopy experts has recently given their

endorsement to general practitioners' learning and

performing diagnostic EGD in the office setting.[7]

Gastroenterologists at the Ochsner Clinic in New

Orleans have trained a physician assistant to do

EGDs in their setting; details of 178 procedures

have been reported." Part of the controversy over

procedural competence may relate to the much

higher reimbursement when the procedure is done

in the hospital or a surgical center compared with a

private office.[13-14] Another controversy relates to the

role of EGD in the evaluation of dyspepsia;

American guidelines suggest empirical treatment in

most cases, resorting to EGD only for persistent

symptoms or failed therapy, while some European

experts recommend doing EGD early in otherwise

healthy patients with these symptoms.[6,15-17] As many

as 1% of some populations may have endoscopy

each year, and access to this technology can be a

problem, particularly in rural areas.[6] Some experts

recommend that rather than training primary care

physicians to do EGD, the procedure should be

made available on demand, similar to the way a

primary care physician orders a CT scan or bone

marrow biopsy.[5,18-22]

We report a series of 793 EGDs performed by a

single family physician (R.P.). At the time of the

study, he was in solo practice of family medicine in

a town in rural south Georgia with a county

population of 32,000. His number of outpatient visits

averaged 35 to 45 per day, and he saw 3 to 8

hospitalized patients per day. The practice provided the

full spectrum of family medicine, except for

obstetrical services. More than 80% of patient visits were

by adults. This physician saw patients in the office,

hospital, and in local nursing homes. He also had

minor laboratory and radiologic services available

in his office. A case series of 751 colonoscopies

performed by this family physician was recently

published in the Journal.[23]

METHODS

All EGD procedures were performed in the

endoscopy suites of two small hospitals in south

Georgia between November 1988 and December

1995. Patients fasted overnight, then supplied their

preoperative history, received a physical

examination, and gave their informed consent. All patients

received intravenous fluids; and pulse, blood

pressure, and oxygen saturation were monitored during

the procedure. Almost all patients received

intravenous sedation. The first 150 procedures were

performed with Olympus fiberscopes (Olympus Optical

Co, Ltd, Tokyo, Japan), and the remaining EGDs

were performed with Pentax videoscopes (Pentax

Precision Instrument Corp, Orangeburg, NY), with

images edited, formatted, and printed by Pentax's

proprietary software. Unstable patients or those

with brisk gastrointestinal bleeding were referred to

other physicians, as were patients requiring

therapeutic procedures such as dilation, injection of

varices, or endoscopic retrograde

cholangiopancreatography.

We performed a retrospective review of patients'

charts and the endoscopy logbook for all

procedures. Name, date of procedure, age, sex, and

method of sedation were recorded for each patient.

The indication(s) for EGD was noted. This family

physician followed the accepted indications for

EGD, in particular the 1985 American College of

Physicians guidelines on endoscopy in patients with

dyspepsia, which suggest an empiric medication trial

before EGD in most patients.[15] The adequacy of

patient preparation was subjectively rated by the

endoscopist as excellent, fair, or inadequate. The

depth of scope insertion and location of any lesions

were recorded using the following locations:

oropharynx, proximal esophagus, distal esophagus,

gastric cardia, body of stomach, antrum, pylorus,

first portion of duodenum, and second portion of

duodenum. Endoscopic diagnoses were noted, and

the location and pathologic diagnosis for each

biopsy was noted. This physician's policy was to take

biopsy samples of gastric ulcers at least six times,

including samples of the edge and center of the

ulcer. Biopsy samples were taken four to six times

for other lesions, such as esophagitis or presumed

Barrett's epithelium. Multiple biopsies of one

anatomic lesion were counted as a single biopsy in

this report. When the rapid urease test for the

detection of Helicobacter pylori (H pylori) became

available (CLO test, Delta West Pty, Ltd, Bentley, Western

Australia), this technique was performed in selected

patients with gastric ulcers, duodenal ulcers, or

gastritis.[24] Finally, all complications were noted in the

logbook and in the patients' records.

All data were entered retrospectively by a single

research assistant over an 8-week period; no charts

were missing or unavailable. Data was entered

directly into a database program, using the

Statistical Package for the Social Sciences

(SPSS/PC+), which was also used for analysis.

Differences in proportions were tested by the [X.sup.2]

critical ratio test.[25] Probability (P) values were adjusted

using Holm's Sequential Rejective Algorithm for

multiple comparisons.[26]

RESULTS

Six hundred two patients (421, 69.9% women; 181,

30.1% men) underwent 793 EGDs during the 7-year

period. Of the 602 patients, 471 had only one

procedure, 87 had 2 procedures, 30 had 3, 12 had 4, and 2

had 5 procedures. The mean age of patients

undergoing EGD was 51.8 years, with a range from 10 to 93

years. The age distribution was bimodal, with peaks

at the age range of 41 to 45 years and again at the age

range of 71 to 75 years. The frequency of EGDs

ranged from 4 per month during the first year to a

stable rate of 10 to 12 per month for the last 3 years.

Fifty-nine procedures were supervised by

another physician before this family physician began

performing EGD independently. Only 48

procedures (6.1%) were performed on inpatients; the

remainder were outpatients. The vast majority

(720, 90.8%) of EGDs were performed on

patients followed by the physician in his private

practice; the remaining 73 (9.2%) were referred

by another physician. Of the 602 patients who

underwent EGD, 254 (42.2%) also underwent

colonoscopy by this family physician during the

study period.

Intravenous sedation doses were recorded for

790 procedures. Midazolam was used in 785/790

cases (99.4%), at a mean dose of 3.8 mg (range 1

to 11 mg). Meperidine was used in 736/790 cases

(93.2%), at a mean dose of 39.3 mg (range 12.5 to

100 mg). The mean midazolam dose fell 12.5%,

from 4.0 mg in the first decile of patients to 3.5

mg in the final decile. The mean dose of

meperidine fell more dramatically, from 52.5 mg in the

first decile to 24.4 mg in the final decile a 53.5%

decline. A total of 105 patients also received

naloxone.

In 785 cases (99.0%), the endoscope reached the

second portion of the duodenum. Of the eight

patients with incomplete endoscopic examinations,

four had pyloric stenosis, and four had the

procedure terminated early due to agitation. The adequacy

of patient preparation was rated as excellent by the

endoscopist in all cases.

There were 1027 indications for the 793 EGDs

(Table 1). Abdominal pain, mostly dyspepsia despite

medical therapy, was by far the most common

indication (480 cases, 60.5%), followed by

gastrointestinal bleeding (182 cases, 23.0%), dysphagia (92 cases,

11.6%), and heartburn (85 cases, 10.7%). The

bleeding indications included 114 cases of melena, 46

cases of hematemesis, 14 cases where blood was

noted at the cecum at colonoscopy, and 8 cases

where the site of bleeding was not documented.

Only 38 patients underwent EGD because of

abnormal findings on an upper GI radiograph. There were

no substantial differences between men and women

regarding EGD indication, except that anemia was a

more common indication in women (8.5%) than in

men (2.7%, P = .03).

TABLE 1

Indications for 793 EGDs Performed by a Family Physician

Indication                        No. (%)



Abdominal pain, dyspepsia        480 (60.5)

Gastrointestinal bleeding        182 (23.0)

Dysphagia                         92 (11.6)

Heartburn                         85 (10.7)

Anemia                            54 (6.8)

Abnormal UGI radiograph           38 (4.8)

Gastritis follow-up               33 (4.2)

Barrettis esophagus follow-up     18 (2.3)

Nausea, vomiting                  15 (1.9)

Other indications                 30 (3.8)



Total(*)                        1027





(*) Total is [is greater than] 793 because individual procedures could

have more than one indication. EGD denotes

esophagogastroduodenoscopy; UGI, upper gastrointestinal.

There were 451 biopsies taken during 385 EGDs.

Of these 385 procedures, 325 had a single site biopsy

sample taken, 54 had samples taken at 2 sites, and 6

had samples taken at 3 sites. In 408 cases (51.5%),

there were no biopsies performed. The majority of

biopsy samples were taken of either the distal

esophagus (173, 38.4%) or the gastric antrum (165, 36.6%).

hi addition, a CLO test for H pylori was also

performed in 323 procedures (40.7%). This test was

positive in 120 of 323 cases (37.2%).

Endoscopic and pathologic diagnoses are

recorded in Tables 2 and 3. The most common endoscopic

diagnoses were gastritis (413 cases), acid

esophagitis (195 cases), duodenitis (134 cases), and normal

study (115 cases). Fifty-four patients had a gastric

ulcer and 47 had a duodenal ulcer. More men than

women had an endoscopic diagnoses of duodenitis

(24.3% vs 13.9%, P =.003) and duodenal ulcer (11.1%

vs 3.9%, P [is less than] .001).

TABLE 2

Endoscopic Diagnoses Reported from 793 EGDs Performed by a

Family Physician

Endoscopic Diagnosis(*)     No. (%)



Gastritis                431 (54.4)

Acid esophagitis         195 (24.6)

Duodenitis               134 (16.9)

No diagnosis (normal)    115 (14.5)

Hiatal hernia             77 (9.7)

Barrett's esophagus       58 (7.3)

Gastric ulcer             54 (6.8)

Duodenal ulcer            47 (5.9)

Other diagnoses          153 (19.2)



Total                   1264





(*) Diagnoses outnumber procedures because some procedures have more

than one endoscopic diagnosis

EGD denotes esophagogastroduodenoscopy.

TABLE 3

Pathologic Diagnoses of 451 Biopsies from 385 EGDs Performed by

a Family Physician

Pathologic Diagnosis(*)     No. (%)



Gastritis, antritis      182 (40.4)

Esophagitis               98 (21.7)

No diagnosis (normal)     59 (13.1)

Helicobacter pylori       54 (12.0)

Barrett's esophagus       39 (8.6)

Ulceration                32 (7.1)

Duodenitis                32 (7.1)

Cytologic atypia          12 (2.7)

Malignancy                 2 (0.4)

Other diagnoses           36 (8.0)



Total                    546





(*) Diagnoses outnumber biopsies because some biopsies had more than

one pathologic diagnosis.

EGD denotes esophagogastroduodenoscopy.

A total of 546 pathologic diagnoses were provided

for the 451 biopsies. The diagnosis of gastritis or

antritis was the most common pathologic finding,

accounting for 182 cases. Following this, the most

common pathologic findings were esophagitis (98

cases), no diagnosis or normal tissue (59 cases), and

histologic evidence of H pylori infection (54 cases).

There were no substantial differences between men

and women.

In 90 cases, the clinician made an endoscopic

diagnosis of esophagitis and obtained a specimen for

pathologic examination. In 70% of these cases, the

pathology report demonstrated esophagitis, in

12.2% the pathology report demonstrated

Barrett's esophagus, and in 17.8% the pathologist

reported normal tissue. In 123 cases, there was

an endoscopic diagnosis of gastritis, with

corresponding biopsies. The pathology report

demonstrated gastritis in 83.7%, normal tissue in 15.4%,

and cancer in 0.8%. Similarly, in 39 cases there

was an endoscopic diagnosis of benign gastric

ulcer that was confirmed by biopsy. The

pathology report confirmed benign lesions in 96.4%; in

one case (3.6%), the pathology report indicated a

gastric lymphoma.

12 cases, a pathologic diagnosis of

cytologic atypia was made. All of the atypia diagnoses

were made by a single pathologist in the first 2

years of the study. This pathologist used the term

atypia to describe reactive changes; none of

these biopsies demonstrated dysplasia. Two to 7

years of follow-up failed to show any progression

to malignancy among these patients. There were

only two malignancies diagnosed during the

entire study period: one gastric lymphoma and

one carcinoma metastatic to the stomach.

A minor complication occurred in one

(0.13%) of the 793 procedures. This patient

experienced an immediate urticarial rash following

intravenous infusion of meperidine. After

treatment with intravenous diphenhydramine and

dexamethasone, the rash promptly resolved, and

the procedure was successfully completed.

There were no other complications. One patient

was referred immediately to a general surgeon.

This patient had a duodenal vessel visibly

pumping blood at EGD. A general surgeon on site was

unable to stop the bleeding endoscopically. The

patient underwent emergency surgery without

complications.

DISCUSSION

In 1989, Wigton et al[4] found that in a national

survey of US general internists 7% performed EGD.

The percentage rose to 15% in nm areas and

was also higher in smaller hospitals. In a

companion survey of internal medicine residencies,

he also found that only 1% of internal medicine

residents mastered EGD during residency;

implying that most general internists doing EGD

acquired the skill after residency training.[9] In a

1993 survey of 2280 US family physicians, 2% were

performing EGD in their offices, and 2.7% had

hospital privileges for this procedure.[3] Thomas and

colleagues[27] reported in 1997 that 24% of US family

practice residencies provide EGD training to their

residents. Others have reviewed this technology for

family physicians.[28-30]

There is limited literature on the performance of

upper GI endoscopy by primary care physicians.

Graham[31] reported on 646 EGDs performed by

general practitioners in rural Australia, and Woodliff[32]

reported on 166 procedures done by a family

physician in this country; both series documented good

diagnostic accuracy and an absence of

complications. There are other case series by primary care

physicians, with similar findings.[33-35] In 1993, Rodney

and colleagues[36,37] reported the experiences of 13

family physicians across the United States who

performed 2500 EGDs with a single complication (a

patient required overnight observation for bleeding).

This safety record occurred even though this series

included the first EGDs performed by these

physicians.

In the study reported herein, the complication

rate (I complication, 0.13%) compares favorably

with those reported in the GI literature. hi the largest

series yet published, with over 210,000 procedures,

Silvis and colleagues[38] reported an overall

complication rate of 0.13%, with 0.008% deaths.

Complications are more common when EGD is done

to evaluate upper GI bleeding. In this group, Gilbert

et al[39] found a complication rate of 0.9%, with 0.13%

deaths.

Only two (0.3%) malignancies were found among

the 793 EGDs reported in the present study. In eight

EGD series from primary care settings, malignancy

was reported in 0.4% to 3.4% of procedures.[19-22,31-33,37]

The low rate of malignancy in the present study is

probably not the result of inadequate examination,

because 99.0% of patients had complete

examinations to the second portion of the duodenum. It is

likely that patients selected for endoscopy by a

primary care physician may be healthier than

patients studied by other specialists.[19,20] However, the major

"soft" indication for EGD is dyspepsia, and US family

physician endoscopist used the conservative 1985

American College of Physicians guideline on

endoscopic evaluation of patients with dyspepsia, an

algorithm which suggests empiric medical treatment

before EGD in most cases.[15]

The rate of gastric ulcer (54 of 793 procedures,

6.8%) in our study compares with a range of 6% to

12% reported from other EGD case series in

primary care settings. Similarly, the rate of duodenal

ulcers (5.9%) compares with a range of 6% to 14%

from these seriesl[19-22,31-33,37] The vast majority of

patients in the series in our study had received

courses of antiulcer treatment, usually [H.sub.2]-blockers,

prior to EGD.

The most common indication for EGD in our

study series was abdominal pain or dyspepsia. This

corroborates data from other primary care

series.[22,33,37] In a study of EGDs performed on patients

insured by Medicare, GI bleeding, an abnormal

finding on a GI radiograph, and dysphagia were all more

common indications than dyspepsia.[6] As a physician

gains more experience, follow-up procedures for

gastric ulcer, gastritis, and Barrett's esophagus, for

example, may become more common. One of the

malignancies in this series was discovered at an

EGD done to follow the healing of a gastric ulcer.

Testing for H pylori became widespread during

this study; therefore, the impact of this organism in

our series is likely underrepresented. We reported

120 CLO tests positive for H pylori, and the

organism was documented by biopsy samples from 54

patients.

There is disagreement regarding the number of

supervised EGDs needed to assure technical

competence, with suggested numbers ranging from 7 to

more than 100.[4,40-43] Part of this wide range is likely

related to the prior endoscopic experience of

physicians. Primary care physicians who do EGD

generally have generally had substantial prior experience

with flexible sigmoidoscopy. General internists

performing EGD estimate that 25 supervised EGDs are

necessary to attain competence.1 Further, diagnostic

EGD probably requires fewer supervised procedures

than more complex procedures, including the

treatment of bleeding ulcers, management of difficult

strictures, and so forth.[44] The American College of

Physicians,[43] for example, recommends 50

supervised procedures. We feel that primary care

physicians experienced in flexible sigmoidoscopy can

generally become technically competent in

diagnostic EGD after 25 procedures. Clinicians with strong

psychomotor skills may need even fewer supervised

procedures.[37] Technical competence is only one

aspect of performing EGD; cognitive skills such as

recognition of pathologic states and complications,

appropriate disease management, and intravenous

sedation skills are more difficult to evaluate.

CONCLUSIONS

This is the largest case series of EGD reported by a

single primary care physician, and the

complication rate compares favorably with the largest

series in the GI literature.[38] The family physician in

this study acquired all his endoscopic skills after

residency training and now provides diagnostic

upper GI endoscopic services for selected patients

in his community.

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Author:Pierzchajlo, Richard P.J.; Ackermann, Richard J.; Vogel, Robert L.
Publication:Journal of Family Practice
Date:Jan 1, 1998
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