Upper GI Endoscopy and the Disappearing Barium Study
There are some patients whom we cannot help; there are none whom we cannot harm.
Personal communication after an iatrogenic tragedy
It is surely one of medicine's greatest ironies and utter wastes that routine imaging of the upper GI tract changed so profoundly in the past 30 years. The introduction of the fiber optic gastroscope in 1963 initiated this sea change in diagnosis, catching the medical profession in an undertow of fashionable technology.
EGD, short for esophagogastroduodenoscopy, or upper GI endoscopy is an examination of the lining of the esophagus, stomach, and upper duodenum with a small camera (flexible endoscope) inserted through the mouth, down the esophagus and into the stomach and upper small intestine. The procedure is performed in over 10 million patients a year in this country, one million of these in hospitals, the rest in an outpatient setting.
Another, simpler and much cheaper method, virtually without risk or complications is the use of X-rays with barium to outline the esophagus, stomach and intestine, the esophagogram and upper GI series. This routine study has been increasingly abandoned by the medical profession over the past 30 years. By 1985 twice as many hospital GI imaging procedures were EGD compared to the barium study; by 1990 the ratio had increased to over 5:1 in favor of EGD. The actual number of GI series is no longer included in Government statistics (NCHS and NHDS) for hospitals. A leveling off of total EGD procedures seems to have occurred in the past decade, but the decline in barium studies continues, a trend easily confirmed in radiology departments and training centers.
It would seem logical that direct viewing of the upper GI tract has advantages over the indirect visualization with barium X-rays, but this is ingenuous when in thousands of reports of study after study over the past 60 years the accuracy and reliability of the upper GI series has been confirmed, both for the diagnosis of benign and for serious disease. Moreover, the upper GI series gives invaluable information regarding upper GI function, such as swallowing, gastric emptying, stomach irritability, transit time to the small intestine, information which EGD cannot give, since it only visualizes structure, not function.
Over 95 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 gastrointestinal mortality occurs in between 1 in 2000 and 1 in 12,000 patients, and some morbidity in 1 in 200. In one study of hospital-based GI endoscopy 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, keeps global statistics on complication and mortality rate of procedures like EGD. In 1993, I was informed by the American Society of Gastrointestinal Endoscopists, the ASGE (Dr. E.B. Keeffe, Chairman, Standards of Practice Committee) that he was "not aware of any recent data reporting complications or mortality rates for upper and lower gastrointestinal endoscopy." The last survey was done in 1974!
Transmission of infection such as HCV and bacterial infections via endoscopic instruments has been reported in the literature. See here and here. Reports of pathogen transmission resulting from these procedures are rare, estimated at one per 1.8 million procedures (ASGE). Since 1993, there have only been 5 additional reported cases of pathogen transmission during GI endoscopy not including 4 other episodes of transmission of hepatitis C virus (HCV), and each has been associated with a breach in accepted endoscope reprocessing protocols or a lapse in general infection control practices. Admittedly, a breach in these protocols is the culprit, 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.
A complete upper GI study with barium (esophagus, stomach, with "follow through" including upper intestine) costs $272; Medicare allows $155 in a relatively high cost region (Philadelphia and suburban area).
An EGD or upper GI endoscopy is anywhere from three to six times as costly. This site gives a price range of $1,530 to $1,720, and this presumably includes the significant charge for anesthesia which is used in over 95% of patients. A lower fee may be in the $800 range, but a breakdown of charges by geographical areas and including use of hospital endoscopy suites is difficult to obtain.
The Big Picture
Many obvious questions arise in the area of invasive imaging of the gastrointestinal tract, including risk vs. benefit, reliability, cost, and convenience. This is not limited to the U.S., since in Europe upper endoscopy is just as common. Certainly EGD is a crucial method in the diagnosis of gastrointestinal disease, but in view of the problem of patient safety, even mortality, should it be an almost routine procedure in imaging the upper GI tract, when the much less costly upper GI study with barium, a procedure virtually without risk or complication, is available in every radiology office?
This is a question to be asked every physician who orders EGD and every insurer or HMO who pays for it. Certainly, I do not argue the need for EGD in cases of foreign body, upper GI bleeding, or the presence of ominous findings on the upper GI study. But if the upper GI were done first, 9. 5 million or more of 10 million EGD's could be avoided with a savings to the health care system of $10 billion to $17 billion, and the saving of at least 1,000 lives, not to mention tens of thousands of complications. If there is any question about risk and complications of EGD, if and when you are asked to undergo the procedure, make sure you read the Informed Consent which confesses all.
Why EGD has virtually replaced the upper GI barium in imaging patients with gastrointestinal complaints is a complicated question, as is the current widespread use of colonoscopy for screening — 14 million done in 2004 alone. These topics and Barrett's esophagus will be discussed in a future Newsletter. In the meantime, perhaps we can liken the inappropriate use of invasive studies for routine problems as a form of diagnostic seduction. Better yet, how about technological exuberance or technological imperialism?
Martin F. Sturman, MD, FACP
Copyright 2006, Mathemedics, Inc.
EasyDiagnosis is an automated online subscription service that analyses existing medical symptoms and predicts likely causes and conditions. Click here to find out more about this unique service and click here to subscribe.