Parkar in this issue on page 412, gives a little piece of advice to General Practitioners on the role of OGDscopy.1 His observations should be carefully read and followed by our readers.
In olden days, OGDscopy was known as gastroscopy. But since the entity of reflux oesophagitis is as common, if not more common than gastritis, the terminology was changed to OGDscopy, starting with the letter 'O' indicating 'oesophago'. Since duodenitis is a separate entity especially related to the intestinal parasites, the letter 'D' has been included, so that the endoscopist may have a good look at the duodenum also. Though duodenitis due to hookworms is hardly ever seen in modern days, we often request the endoscopist to give us a small sample of duodenal juice to confirm giardiasis or strongyloides infection, both of which are often missed by stool examination.
It is interesting to note that in foreign countries where the government pays for healthcare, OGDscopy is normally not advised in patients below the age of 40 and the patient can be safely treated on clinical diagnosis. In our country, the patients who are illiterate, are happy to undergo the investigation and get therapeutic benefit. The gastroenterologists are of course the gainers. Really speaking, most of the times, these reports do not help to improve the clinical diagnosis. For example, 'Reflux oesophagitis' due to GERD is now known as TLOSR (Transient Lower Oesophageal Sphincter Relaxation), where apart from 24 hours constant pH monitoring of the oesophagus, no other investigation can prove the diagnosis. Vice versa even if the patient's endoscopy shows evidence of reflux oesophagitis he may not need any treatment if he has no symptoms. Although one of the most important advantages and benefits of OGDscopy is to make the diagnosis of antral gastritis due to H pyloridis - an entity which is extremely common, there are many non-invasive measures like stool and blood examination to diagnose the condition in a patient complaining of symptoms of gastritis. The endoscopic appearance may be rarely normal to the naked eye and biopsy may prove the diagnosis.
Regarding endoscopy of lower GI tract, the terminology of sigmoidoscopy, colonoscopy and ileocolonoscopy must be understood by medical practitioners because the cost of ileocolonoscopy will be double that of sigmoidoscopy. Ileoscopy is a very good investigation to diagnose ileocaecal Koch's and Crohn's disease. As a routine investigation there is no extra benefit by looking at terminal ileum especially considering the cost effectiveness factor.
Similarly sigmoidoscopy alone can diagnose majority of the cancers of colon, as well as ulcerative colitis and other inflammatory diseases of the bowel. If combined with a biopsy, it can help the practitioners to improve the diagnosis in majority of the patients at half the cost of colonoscopy.
Colonoscopy is hardly ever liked by any patient, who after paying heavily, invariably grumbles not only about the discomfort involved in the procedure but also the side effects of bowel preparation after drinking a sachet of Peglec. Ideally to make it cost effective, colonoscopy should only be asked for in a problem patient - for example when you are searching for colon cancer or in a patient having occult bleeding or symptoms of colonic obstruction.
Unfortunately, fibreoptic sigmoidoscopes are missing from the market and since our young gastroenterologists spend heavily on buying colonoscopes, many of them would like to see the whole colon and even the ileum. However, at such a heavy cost, this may not be acceptable to many clinicians!
1. MN Parkar. My experience of endoscopies in private practice. Bombay Hospital Journal 2005; 47 : 4.