Two case reports of novel syndrome of bizarre performance of gastrointestinal endoscopy due to toxic encephalopathy of endoscopists among 181767 endoscopies in a 13-year-university hospital review: Endoscopists, first do no harm!

Abstract

BACKGROUND

Although deficient procedures performed by impaired physicians have been reported for many specialists, such as surgeons and anesthesiologists, systematic literature review failed to reveal any reported cases of deficient endoscopies performed by gastroenterologists due to toxic encephalopathy. Yet gastroenterologists, like any individual, can rarely suffer acute-changes-in-mental-status from medical disorders, and these disorders may first manifest while performing gastrointestinal endoscopy because endoscopy comprises so much of their workday.

CASE SUMMARIES

Among 181767 endoscopies performed by gastroenterologists at William-Beaumont-Hospital at Royal-Oak, two endoscopies were performed by normally highly qualified endoscopists who manifested bizarre endoscopic interpretation and technique during these endoscopies due to toxic encephalopathy. Case-1-endoscopist repeatedly insisted that gastric polyps were colonic polyps, and absurdly “pressed” endoscopic steering dials to “take” endoscopic photographs; Case-2-endoscopist repeatedly insisted that had intubated duodenum when intubating antrum, and wildly turned steering dials and bumped endoscopic tip forcefully against antral wall. Endoscopy nurses recognized endoscopists as impaired and informed endoscopy-unit-nurse-manager. She called Chief-of-Gastroenterology who advised endoscopists to terminate their esophagogastroduodenoscopies (fulfilling ethical imperative of “physician, first-do-no-harm”), and go to emergency room for medical evaluation. Both endoscopists complied. In-hospital-work-up revealed toxic encephalopathy in both from: case-1-urosepsis and left-ureteral-impacted-nephrolithiasis; and case-2-dehydration and accidental ingestion of suspected illicit drug given by unidentified stranger. Endoscopists rapidly recovered with medical therapy.

CONCLUSION

This rare syndrome (0.0011% of endoscopies) may manifest abruptly as bizarre endoscopic interpretation and technique due to impairment of endoscopists by toxic encephalopathy. Recommended management (followed in both cases): 1-recognize incident as medical emergency demanding immediate action to prevent iatrogenic patient injury; 2- inform Chief-of-Gastroenterology; and 3-immediately intervene to abort endoscopy to protect patient. Syndromic features require further study.

Keywords: Endoscopy, Iatrogenic injury, Medical ethics, Hippocratic Oath, Quality improvement, Medical malpractice, Morbidity and mortality

Core tip: Two novel cases are reported of impaired endoscopists manifesting bizarre-endoscopic-interpretation-and-technique due to toxic encephalopathy among 181767 endoscopies performed at William-Beaumont-Hospital-Royal-Oak. Case-1-endoscopist repeatedly insisted that gastric polyps were colonic polyps, and absurdly “pressed” endoscopic steering dials to photograph gastric lesions. Case-2-endoscopist repeatedly insisted that had intubated duodenum when intubating antrum, and erratically turned steering dials and bumped endoscopic tip against antral wall. Endoscopists were advised to terminate their esophagogastroduodenoscopies, fulfilling ethical imperative: “physician-first-do-no-harm”. In-hospital-work-up revealed toxic encephalopathies from urosepsis, or inadvertently ingesting “illicit drug”. Both endoscopists rapidly recovered with medical therapy. These potential-medical-emergencies require aborting endoscopy to prevent iatrogenic patient injury.