Gastrointestinal endoscopy: an accurate and safe primary diagnostic and therapeutic modality

Patients Presenting With Anxiety and Mood Disturbance: The Importance of Correct Diagnosis

Difficulties can arise in correctly diagnosing clients who present with mood and anxiety disturbances. Unless a detailed history is taken and a comprehensive interview performed, errors of diagnosis are likely to occur which may result in aversive consequences. To illustrate this likelihood, two cases of persons exhibiting anxiety and mood disturbance are briefly reported. The first case involved a prior diagnosis of psychogenic disorder (Mood Disorder). However, further investigation of the client's symptoms revealed that the anxiety and depression were secondary and caused by an underlying organic disorder. The second case involved a prior diagnosis of a physically based disorder presenting with anxiety and depression (Multiple Sclerosis). However, further investigation of the client's symptoms revealed that the somatic symptoms were secondary and the mood and anxiety disturbance were primary symptoms. A model is presented as a guide to better understand the diagnostic process, comments upon the need for a detailed history and interview are offered, and problems arising from incorrect diagnoses are discussed.

Different perceptions of the burden of upper GI endoscopy: an empirical study in three patient groups

Background

Few studies have evaluated patients’ perceived burden of cancer surveillance tests. Cancer screening and surveillance, however, require a large number of patients to undergo potentially burdensome tests with only some experiencing health gains from it. We investigated the determinants of patients’ reported burden of upper gastrointestinal (GI) endoscopy by comparing data from three patient groups.

Patients and methods

A total of 476 patients were included: 180 patients under regular surveillance for Barrett esophagus (BE), a premalignant disorder; 214 patients with non-specific upper GI symptoms (NS), and 82 patients recently diagnosed with upper GI cancer (CA). We assessed pain, discomfort and overall burden experienced during endoscopy, symptoms in the week afterwards and psychological distress over time (Hospital Anxiety and Depression scale and Impact of Event Scale).

Results

Two-thirds (66%) of patients reported discomfort and overall burden of upper GI endoscopy. Only 23% reported any pain. BE patients reported significantly less discomfort, pain and overall burden than the other patients: those with NS reported more discomfort, CA patients more pain, and both more overall burden. These differences could be statistically explained by the number of previous endoscopies and whether sedation was provided or not, but not by patient characteristics.

Conclusion

The perception of upper GI endoscopy varies by patient group, due to potential adaptation after multiple endoscopies and aspects of the procedure.

National survey of anticoagulation policy in endoscopy

BACKGROUND

Anticoagulated patients who need to undergo endoscopy present unique challenges to the gastroenterologist. The continuation of anticoagulant therapy increases the risk of haemorrhagic complications of gastrointestinal endoscopy. Reversing the anticoagulation increases the risk of thromboembolism. In our experience in various endoscopy units, there are variable policies on the management of anticoagulated patients undergoing gastrointestinal endoscopy.

METHODS

To study the current practice, survey questionnaires were sent to 2320 doctors, working in 231 hospitals across the United Kingdom.

RESULTS

Responses were obtained from 219 hospitals (94.8%), but only from 434 doctors (18.7%). The results show 40.8% endoscopists continued the patients on warfarin when performing a planned upper gastrointestinal endoscopy, whereas 26% stopped it; 33.2% gave varying reports, that is, they used their own judgement according to the disease for which the anticoagulant was being given. For planned lower gastrointestinal endoscopy, 48.7% doctors preferred to stop warfarin; 53.3% of the endoscopists stated that they have a policy in place at their hospital for both upper and lower gastrointestinal endoscopy in anticoagulated patients; 5.5% had a policy for upper gastrointestinal endoscopy only and 6.2% for lower gastrointestinal endoscopy only. Thirty-five per cent doctors reported that they did not have any standard policy. We compared the responses from within a hospital to see whether the doctors were uniformly aware of an existing policy in their hospital. For upper gastrointestinal endoscopy, the responses were the same (either yes or no) by 51% of the doctors, whereas they were different by 49%. For lower gastrointestinal endoscopies, the same response was given by 49% of the doctors, whereas 51% gave different answers. The poor response rate from the doctors, however, makes firm interpretation of the data difficult.

CONCLUSIONS

A wide variation in practice is seen across the country. A robust national guideline to streamline the endoscopy practice in anticoagulated patients is needed.

The evaluation of rectal bleeding in adults. A cost-effectiveness analysis comparing four diagnostic strategies

BACKGROUND

Though primary care patients commonly present with rectal bleeding, the optimal evaluation strategy remains unknown.

OBJECTIVE

To compare the cost-effectiveness of four diagnostic strategies in the evaluation of rectal bleeding.

DESIGN

Cost-effectiveness analysis using a Markov decision model.

DATA SOURCES

Systematic review of the literature, Medicare reimbursement data, Surveillance, Epidemiology, and End Results (SEER) Cancer Registry.

TARGET POPULATION

Patients over age 40 with otherwise asymptomatic rectal bleeding.

TIME HORIZON

The patient's lifetime.

PERSPECTIVE

Modified societal perspective.

INTERVENTIONS

Watchful waiting, flexible sigmoidoscopy, flexible sigmoidoscopy followed by air contrast barium enema (FS+ACBE), and colonoscopy.

OUTCOME MEASURES

Incremental cost-effectiveness ratio.

RESULTS OF BASE-CASE ANALYSIS

The incremental cost-effectiveness ratio for colonoscopy compared with flexible sigmoidoscopy was 5,480 dollars per quality-adjusted year of life saved (QALY). Watchful waiting and FS+ACBE were more expensive and less effective than colonoscopy.

RESULTS OF SENSITIVITY ANALYSES

The cost of colonoscopy was reduced to 1,686 dollars per QALY when age at entry was changed to 45. Watchful waiting became the least expensive strategy when community procedure charges replaced Medicare costs, when age at entry was maximized to 80, or when the prevalence of polyps was lowered to 7%, but the remaining strategies provided greater life expectancy at relatively low cost. The strategy of FS+ACBE remained more expensive and less effective in all analyses. In the remaining sensitivity analyses, the incremental cost-effectiveness of colonoscopy compared with flexible sigmoidoscopy never rose above 34,000 dollars.

CONCLUSIONS

Colonoscopy is a cost-effective method to evaluate otherwise asymptomatic rectal bleeding, with a low cost per QALY compared to other strategies.

Trends in the utilization of diagnostic upper GI endoscopy in New South Wales, Australia, 1988 to 1998

BACKGROUND

Upper endoscopy is frequently performed, yet there are few published data regarding utilization trends. Such data provide an indication of changes in clinical practice over time and identify subpopulations who may be underexposed or overexposed to the procedure.

METHODS

Time series data were analyzed for all diagnostic upper endoscopies performed on residents of an Australia state between mid 1988 and mid 1998. Endoscopy rates by age, gender, and patient status (public vs. privately insured) were calculated.

RESULTS

In 1997/98 the endoscopy rate was 179 of 10,000. The majority were performed on publicly insured patients and women. Over the decade the rate increased by 128%. Rate increases were not constant across time, age, gender, or patient (insurance) status. The greatest increases occurred in the early to mid 1990s, and in patients less than 65 years of age. There was a greater increase (126%) among women 55 to 64 years of age compared with other age categories for both genders. Rates for publicly insured patients increased more than those for privately insured patients, particularly among individuals in the age range 25 to 34 years. Rates for private patients increased more for women than men (81% vs. 59%).

CONCLUSIONS

Rates of utilization of endoscopy increased dramatically during the period from 1988 to 1998, particularly during the earlier part of this decade. The cause(s) of the differences in subpopulation rates warrant investigation, as do their relationship to patient management and outcomes. These data provide opportunities for international comparisons.

Gastrointestinal endoscopy in patients taking antiplatelet agents and anticoagulants: survey of ASGE members. American Society for Gastrointestinal Endoscopy

BACKGROUND

Gastrointestinal endoscopy is often required in patients taking aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), or anticoagulants. Because proper guidelines are lacking, we believe that most endoscopists use their own criteria and judgment for stopping and restarting these agents during the periendoscopic period, and the practice varies widely. The aim of our study was to identify these practices among ASGE members.

METHODS

Questionnaires, each containing 22 questions with 157 responses, were sent to 3300 ASGE members, including all Gastroenterology Fellowship Program Directors. One thousand two hundred sixty-nine questionnaires were received and analyzed.

RESULTS

Physicians stopped aspirin and NSAIDs more frequently before colonoscopy (81%) and ERCP (79%) than before upper endoscopy (51%) (p < 0.001). Ninety percent of physicians stopped aspirin and NSAIDs for 10 or fewer days. Only 20% of physicians performed sphincterotomy when aspirin and NSAIDs were not stopped compared with 88% and 85% (p < 0.001 for both) of physicians performing cold biopsies at esophagogastroduodenoscopy and colonoscopy, respectively, and 77% and 69% performing hot biopsies for the same procedures (p < 0.001 for all compared with sphincterotomy). Depending on the indication for anticoagulation, 51% to 60% of physicians stopped warfarin before upper endoscopy; 71% to 82% before colonoscopy; and 26% to 51% of physicians used a "heparin window." All physicians restarted warfarin immediately after diagnostic endoscopy, whereas 80% restarted it 7 or fewer days after therapeutic endoscopy.

CONCLUSIONS

We conclude that a wide variation exists regarding the management of aspirin, NSAIDs, and anticoagulants in the periendoscopic period. There is a definite need for a consensus statement or guidelines for managing patients taking these agents.

Flexible sigmoidoscopy plus air-contrast barium enema versus colonoscopy for evaluation of symptomatic patients without evidence of bleeding

One hundred forty-nine patients aged 40 years or more with symptoms suggestive of colonic disease but without evidence of gastrointestinal bleeding (absence of hematochezia, normal serum levels of hemoglobin, and at least one test negative for fecal occult blood) were randomized to undergo either initial colonoscopy or initial flexible sigmoidoscopy plus air-contrast barium enema. Patients with incomplete initial colonoscopy and certain patients with polyps seen on flexible sigmoidoscopy plus barium enema underwent the alternative procedure (barium enema or colonoscopy). The main results were as follows: First, the overall prevalence of cancer in the study was very low (0.67%). Second, initial flexible sigmoidoscopy plus barium enema detected more patients with diverticulosis than did initial colonoscopy (46% versus 31%; p = .01). Initial colonoscopy detected more persons with adenomas (p = .06) than did initial flexible sigmoidoscopy plus barium enema. Patients undergoing initial flexible sigmoidoscopy plus barium enema require the alternative procedure (24%) than were patients undergoing initial colonoscopy (6%; p = .002). Third, sensitivity analyses suggested that for most areas in the United States, initial colonoscopy would be more cost-effective for the outcomes of detection of adenomas and detection of large adenomas, although very few patients in the study had large adenomas. We conclude that the prevalence of colorectal cancer in persons with colonic symptoms but no evidence of bleeding is low and is comparable with the prevalence in an asymptomatic population. Cost-effective selection of imaging strategies in this population can be based on demographic factors such as age and sex, which are better predictors of the presence of adenomas than are symptoms.

Diagnostic procedures and health outcomes. Upper gastrointestinal tract investigations in the elderly

OBJECTIVES

To examine the use of upper gastrointestinal endoscopy in people 65 years of age and over in New South Wales, and compare its use between geographic areas, sex and age groups. Also, to investigate the relationship between endoscopy use and peptic ulcer mortality.

DESIGN

A retrospective review of upper gastrointestinal tract (GIT) endoscopy hospital separation data for NSW from 1986 to 1989-1990 and peptic ulcer mortality data from 1979 to 1989.

MAIN OUTCOME MEASURES

Rates per 1000 population aged 65 years and over were calculated for upper GIT endoscopy for each of the four-year age groups and by sex. Peptic ulcer and other digestive system disease rates for endoscopy patients were determined. Correlations between hospital standardised separation rates for endoscopy and standardised mortality rates for gastric cancer and peptic ulcers were calculated. Age and sex standardised death rates were calculated for each year between 1979 and 1989, and changes in death rates over time were determined by regression analysis.

RESULTS

The rate of endoscopies increased significantly (P < 0.001) over the period 1986 to 1989-1990, with the highest rate and greatest increase occurring in patients aged 70 years and over. Men had significantly higher endoscopy rates than women (P < 0.001). Geographic variations in the use of endoscopy were found and were not explained by geographic differences in the proportion of peptic ulcers diagnosed, deaths from peptic ulcers or malignant neoplasms. Despite the increase in endoscopies performed, there was no corresponding significant increase in the rate of peptic ulcers detected. Between 1979 and 1989 peptic ulcer mortality rates for women over 74 years of age increased significantly (P < 0.05); the rate for men did not change.

CONCLUSION

Many endoscopies are performed in people aged 65 years and over in NSW and there has been a substantial increase in endoscopy rates in recent years. While the increase in upper GIT endoscopy may have resulted in a number of health benefits, it does not appear to have resulted in a reduction in peptic ulcer related mortality.