Esophagogastroduodenoscopy performed by a family physician: a case series of 793 procedures.
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
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;
As the practice of medicine has
progressed, technical procedures such as
gastrointestinal endoscopy have
become despecialized. 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.
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. 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
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.
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
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. 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. 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. Probability (P) values were adjusted
using Holm's Sequential Rejective Algorithm for
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
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
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).
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).
Endoscopic Diagnoses Reported from 793 EGDs Performed by a
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.
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
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
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
In 1989, Wigton et al 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. 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. Thomas and
colleagues reported in 1997 that 24% of US family
practice residencies provide EGD training to their
residents. Others have reviewed this technology for
There is limited literature on the performance of
upper GI endoscopy by primary care physicians.
Graham reported on 646 EGDs performed by
general practitioners in rural Australia, and Woodliff
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
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 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 found a complication rate of 0.9%, with 0.13%
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.
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. 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
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. The American College of
Physicians, 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. 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.
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. 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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