Guidelines on appropriate indications for upper gastrointestinal endoscopy. Working Party of the Joint Committee of the Royal College of Physicians of London, Royal College of Surgeons of England, Royal College of Anaesthetists, Association of Surgeons, the British Society of Gastroenterology, and the Thoracic Society of Great Britain.

Upper gastrointestinal endoscopy is a valuable diagnostic tool, but for an endoscopy service to be effective it is essential that it is not overloaded with inappropriately referred patients. A joint working party in Britain has considered the available literature on indications for endoscopy, assessed standard practice through a questionnaire, and audited randomly selected cases using an independent panel of experts and an American database system. They used these data to produce guidelines on the appropriate and inappropriate indications for referral for endoscopy, although they emphasise that under certain circumstances there may be reasons to deviate from the advice given. The need for endoscopy is most difficult to judge in patients with dyspepsia, and this aspect is discussed in detail. Early endoscopy will often prove more cost effective than delaying until the indications are clearer.

Prospective audit of perforation rates following upper gastrointestinal endoscopy in two regions of England.

After cardiopulmonary complications, perforation is the second most important cause of complications following flexible upper gastrointestinal endoscopy. A recent audit of 14,149 procedures detected a perforation rate of 0.05 per cent (overall mortality rate 0.008 per cent) during diagnostic endoscopy, and a perforation rate of 2.6 per cent (overall mortality rate 1.0 per cent) following oesophageal intubation or dilatation. The incidence of perforation following both diagnostic and therapeutic upper gastrointestinal endoscopy has not changed over the past 10 years. The risk factors are numerous but this audit demonstrated that inexperience increases the likelihood of perforation.

Prospective audit of upper gastrointestinal endoscopy in two regions of England: safety, staffing, and sedation methods.

A prospective audit of upper gastrointestinal endoscopy in 36 hospitals across two regions provided data from 14,149 gastroscopies of which 1113 procedures were therapeutic and 13,036 were diagnostic. Most patients received gastroscopy under intravenous sedation; midazolam was the preferred agent in the North West and diazepam was preferred in East Anglia. Mean doses of each agent used were 5.7 mg and 13.8 mg respectively, although there was a wide distribution of doses reported. Only half of the patients endoscoped had some form of intravenous access in situ and few were supplied with supplementary oxygen. The death rate from this study for diagnostic endoscopy was 1 in 2000 and the morbidity rate was 1 in 200; cardiorespiratory complications were the most prominent in this group and there was a strong relation between the lack of monitoring and use of high dose benzodiazepines and the occurrence of adverse outcomes. In particular there was a link between the use of local anaesthetic sprays and the development of pneumonia after gastroscopy (p < 0.001). Twenty perforations occurred out of a total of 774 dilatations of which eight patients died (death rate 1 in 100). A number of units were found to have staffing problems, to be lacking in basic facilities, and to have poor or virtually non-existent recovery areas. In addition, a number of junior endoscopists were performing endoscopy unsupervised and with minimal training.

Appropriate use of upper gastrointestinal endoscopy--a prospective audit. Steering Group of the Upper Gastrointestinal Endoscopy Audit Committee.

Work by this group has shown that there is a wide range of opinion as to patients' suitability for endoscopy. In a recent study, 1297 questionnaires were sent to a random selection of doctors, including 350 general physicians, 400 surgeons, 477 gastroenterologists, and 70 general practitioners. The respondent was asked to indicate whether or not he would refer the patient described by each case vignette for endoscopy. Depending on the indication, the positive referral rate varied from 4.5% to 99% overall, and from 4.5% to 63.8% for all those clinical situations that the working party felt to be inappropriate. A second study examined the appropriateness of 400 consecutive cases referred from four units within one health region; these cases were judged independently, and without conferring, by a panel of seven gastroenterologists. The same cases were rated by software that incorporated American opinion (the Rand criteria). Although only 45 (11%) of the cases were classed as inappropriate by the British panel, 120 cases (31%) assessed by the American software were rated inappropriate. These differences occurred largely because in the USA it is recommended that one month's antiulcer treatment be tried before considering endoscopy for dyspepsia and thus many referrals were seen as inappropriate by the American database. Of the 45 cases found to be inappropriate by the British doctors no important abnormality was found at endoscopy; whereas of 120 cases judged inappropriate by the Rand criteria, three duodenal and two gastric ulcers, and one gastric cancer were diagnosed at gastroscopy. This study attempts a quantitative assessment of inappropriate use and serves to encourage further work to define appropriateness.

Small bolus injections of intravenous midazolam for upper gastrointestinal endoscopy: a study of 788 consecutive cases.

1 A recent audit of upper gastrointestinal endoscopy carried out by the Royal College of Surgeons of England has shown that the majority of endoscopists use a bolus injection rather than a slow intravenous titration of benzodiazepine for intravenous sedation. In this study we have confirmed the theoretical premise that a reduced dose of midazolam is required when given as a bolus. A mean dose of 4.65 mg midazolam intravenously has been found to be effective and safe in sedating patients under 70 years (n = 552). The dose of midazolam needed is reduced in older patients: patients over 70 years (n = 236) needed a mean dose of 1.89 mg. 2 Topical pharyngeal anaesthesia was not required with these doses of midazolam, and it was our impression that the examination was equally well tolerated with a similar degree of anterograde amnesia as in the previous study. 3 Our data, together with the results of the audit, would suggest many endoscopists are employing unnecessarily large and at times potentially dangerous doses of intravenous sedation in elderly patients and that the vast majority of upper gastrointestinal endoscopies can be performed successfully, without topical pharyngeal anaesthesia, using a bolus injection techniquewith a reduced dosage of sedative agent.

A comparison of winged steel needles and Teflon cannulas in maintaining intravenous access during gastrointestinal endoscopy.

We have conducted a prospective study in 142 consecutive patients undergoing either gastroscopy or colonoscopy. The patients were randomized to have either a 23-gauge winged steel needle or a 23-gauge Teflon cannula inserted. The two groups were well matched, with 71 patients receiving each device. Intravenous access was achieved in every case. The steel needle was inserted at the first attempt in 65 of 71 cases (91.6%) compared with 67 of 71 cases (94.4%) for the Teflon cannula. Extravasation occurred in only 1 of 71 cases (1.4%) with Teflon cannulas compared with 18 of 71 cases (25.5%) of steel needle use (p < 0.01). Additionally, no Teflon cannula blocked completely, whereas 1 of 71 steel needles (1.4%) did so. Only 1 of 71 (1.4%) of the Teflon cannulas became difficult to flush compared with 12 of 71 steel needles (16.9%). The Teflon cannula was as easy to insert and provided significantly more reliable intravenous access than the steel needle.