GASTROSCOPY AND GASTRIC SURGERY
THE following remarks were written in a spirit of self-examination in which the writer endeavored to present his current appraisal of gastroscopy from the point of view of its relationship to gastroenterology and to surgery. The latter consideration was prompted by the increasing role played by gastric surgery in the therapy of stomach disorders and especially gastric ulcer. We regard gastroscopy as an adjunct in the work-up of a gastrointestinal patient. We do not believe that it should be used routinely in all patients any more than a spinal puncture, air encephalogram or retrograde urogram is used. There will be a variation in the percentage of cases gastroscoped, depending on a number of factors: (1) the enthusiasm of the examiner, and his desire to asseIllble a "series" of cases; (2) the type of practice of the examiner and percentage of private cases (the examiner in a free clinic or in government service may be expected to gastroscope a higher percentage of cases than he would if his practice were largely privat.e); (3) whether or not his cases are largely referred by other physicians; (4) the scope of the examiner's practice, i.e., the broad field of internal medicine versus a restricted interest in endoscopy; (5) the reliability of the available roentgen study, whether done by the examiner, a colleague, or separate office or department. We realize that different gastroenterologists will utilize gastroscopy in varying percentages of cases, perhaps with good reason, depending on local conditions which will vary from office to office. However, we believe that a frank statement of one's position is in order, and the present article endeavors to accomplish that purpose. How safe is gastroscopy? On the part of a well-trained examiner, mindful of the contraindications of the procedure and using one of the conventional types of flexible gastroscope, the risk is negligible. The literature contains numerous reports of surveys concerning the frequency, mortality and morbidity of perforation following the use of the flexible gastroscope. For the most part, those reports come from large clinics staffed by well-trained gastroscopists. The writer believes that accidents associated with gastroscopy occur more frequently than reported in the literature, on the theory that a person is hesitant about reporting mishaps which might. discredit him in his institution or locality. In all probability, there are many more accidents with gastroscopy with untrained or poorly trained examiners than are reported in the literature. Certainly, flexible gastroscopy is much less hazardous than straight tube esophagoscopy, in which there is a considerable risk of perforation.
* Associate Professor of Gastroenterology, Graduate School of Medicine, University of Pennsylvania, Philadelphia. 1651
T. A. JOHNSON
Fierst et al. l reviewed the previously reported cases of pneumoperitoneum following gastroscopy, and added one of their own. They concluded that gastric emphysema with pneumoperitoneum and generalized emphysema do occur in the absence of recognizable gross perforation of the stomal'h. They attributed the phenomena to air being forced into the p"rivascl,llar sheaths through a superficial erosion or other weak point in the mucous membrane, comparable to the explanation for pulmonary interstitial emphysema following the rupture of pulmonary alveoli with passage of air int<1 adjacent p~rivascular sheaths, as proposed by Macklin. 2 Fierst sug7 gests that, in the absence of systemic manifestations, operation is not necessarily indicated in pneumoperitoneum following gastroscopy. This writer has had no personal experience with pneumoperitoneum fol· lowing gastroscopy, but the hazard exists, particularly in instances of deep penetrating ga,fltric ulcer in which the floor of the ulcer is in close proximity to the gastric serosa. The safety factor in gastroscopy is related to the contraindications. The mere presence of an intact esophagus is not the sole consideration in determining the safety of the procedure. In a previous artic!e,3 we listed the contraindications categorically as follows: "(1) any lesiun of the esophagus; (2) lesions of the cardia in close apposit.ion to the esophageal opening into the stomach; (3) mediastinal inflammation or tumefaction; (4) moderately severe pulmonary or cardiac disPoase; (5) cirrhosis of the liver'or any other condition which gives rise to esophageal varices; (6) marked spinal curvature; (7) inflammatory conditions of the pharynx; (8) marked general debility; (9) grOf-lS malposition of the stomach; (10) recent li!evere gastric hemorrhage or recent postoperative stomach; (11) suspected chronic perforationof a pept.ic ulcer, gastric or duodenal." Who should do gastroscopy? Any well-tmined gastroenterolo~ist and any internist whose work primarily concerns gastroenterology may do it. The writer believes that the gastric mucosa should be viewed by the p('rson in charge of the case. What otologist would accept an opinion of another observer concerning the appearance of a tympanic membrane in lieu of personal observation of that structure? On the other hand, we accept the fluoroscopic, bservations of the roentgenologist concerning the motility of the stomach without any loss of value by our absence at the time of examination. We do not believe that the purchase of a gastroscope confers any Rpecial ability on the part of the buyer in the use of the instrument. Anyone desiring to do gastroscopy should take the time to observe fifty gastroscopies, after which he may be allowed to pass the instrument on patients that have had the procedure previollsly. One cannot determine the normal expected esophageal resistance to the passage of a flexible gastroscope by reading about it. The neophyte never should perform his first gastroscopy on a case that has not been gastroscoped previout:lly by a competent observer. Once the "feel" of the procedure has been experienced, the new gastroscopist may be encouraged to work on additional cases. All gastroscopists, especially in teaching institutions, owe it to the younger men to see that they receive proper instruction in the use of the gastroscope.
GASTROSCOPY AND GASTRIC SURGERY
The selection of cases for gastroscopy poses a problem. We believe that gastroscopy is indicated only after a thorough history, physical examination and roentgen study of the esophagus and stomach. Gastroscopy is not a routine procedure and should be utilized only in instances in which the procedure may be expected to aid in the diagnosis. A patient with obvious disease of the gallbladder or colon in which there'is no reason to suspect a gastric component, and in which the roent.gen examination of the stomach is normal, is not a candidate for gastroscopy. Gastroscopy is especially indicated in instances in which the history suggests the presence of a gastric disease which is not demonstrable by the usual roentgen study. We realize that it is impossible to correlate t.oo closely the gastroscopic picture of a stomach with the symptoms of the patient. We find it especially difficult when gastritis in one of its forms is seen gastroscopically. One may draw an analogy by the difficult.y of correlating the surface appearance of the pharyngeal memhrane with t.hroat. symptoms in any given instance. The writer has been impressed with the failure of experienced gastroscopists to agree on the signifieanC'e of t.he appearance of the gastric mucosa at any given gastroscopy, not to mention the variable picture seen on successive examinations by the same observer. ', Often \ve debate the practicality of gastroscoping a patient who has roentgen evidence of a large gastric neoplasm resembling carcinoma. In instances of niarked gastric involvement, it seems that gastroscopy offers nothing to}he solution of the problem other than gratifying the curiosity of the observer. In smaller gastric lesions in which there may be some doubt concerning the nature of the suspected neoplasm, gastroscopy often giv~s rewardiI}g information. We particularly dislike gastroscopy when a les,ion occupies the esophagogastric area and offers the possibility of obstrUcting the easy passage of the instrument from the esophagus into the body of the stomach. An experienced gastros('opist may gently pass the gastroscope in suc}l a case, provided the procedure ceases as soon as the tipo( the instrument impinges against any obstruction. If visualization of such tLn area is imperative, we regard straight tube esophagoscopy as the preferable procedure. G~troscopy offers no information in the average case of duodenal ulcer. On the other hand, gastric ulcer offers a tempting field to the gastroscopist. If one works with a group in which it is the policy to resect all stomachs with gastric ulcer, gastroscopy would seem to offer no special advantage. However, in instances in which operation is not contemplated, gastroscopy offers a splendid opportunity to follow a given gastric ulcer. Often the ulcer may be visualized in the healing state long after it ceases to be visible by x-ray. Unfortunately, the contraindications to operation in some of these cases are also cont.raindications to gastroscopy, i.e., severe cardiorespiratory disease and the like. We have had the experience of failing to visualize by gastroscopy a large gastric ulcer easily diagnosed by roentgenogram especially high on the lesser curvature region of the stomach. One realizes all too well the difficulty of adequate visualization of the high lesser curvature of the stomach which constitutes one of the gastroscopic blind spots of the stomach. Ref-
T. A. JOHNSON
erence is often made to the presence of the several "blind spots" in the stomach, i.e., areas impossible to visualize by any of the present types of gastroscopes, although some types of gastroscope offer fewer objections in that respect than others. Gastroscopy is of paramount value in the diagnosis of chronic gastritis, a diagnosis usually impossible to make in the intact patient by any other procedure. Although the types of gastritis may be variously classified, we adhere to the four originally described by Schindler, although he has made some subsequent modifications in his classification. 4 The four types of chronic gastritis, namely, superficial, atrophic, hypertrophic, and postoperative stomach, have been described at length in the literature and require no review here. In their extreme forms, they are readily recognized by gastroscopy. We are not so certain that mild, early forms of gastritis are to be classified with any degree of finality. The superficial type of gastritis, which by definition refers to an irritation of the surface of the stomach, defies classification except as it fails to resemble the normal smooth, pink gastric mucosa. We suppose that the gastric mucosa is extremely sensitive to a great variety of stimuli, both endogenous and exogenous, as suggested by Wolf in his work on the patient Tom, with his gastric fistula. Wolf reports an enormous variation in the color, texture, secretion, and so on of Tom's gastric fistula. If we expect that the average gastric mucosa of any given patient is also variable to that degree, we must be prepared to accept the definition of "normal stomach" as extending over a wide range of variability and quite within the compass of what often is referred to loosely as "superficial" gastritis. There is no doubt about the fact of superficial irritation of marked degree in some gastric mucosae, but too much clinical dependence should not be placed on mild variations in the appearance of gastric mucosa, especially in random, isolated examinations. Mild degrees of gastric atrophy may be simulated by overdistending the stomach during gastroscopy. The experienced gastroscopist uses as little air as is consistent with proper visualization of the stomach. Gastroscopy serves a useful purpose in identifying instances of hypertrophic gastritis. Whereas roentgen evidence is without value in the diagnosis of atrophic gastritis, the presence of hypertrophic gastritis may be suggested by the presence of thick gastric folds observed fluoroscopically or on the roentgen films. Typically, folds due to hypertrophic gastritis cannot be obliterated by manual pressure of the fluoroscopist. Nevertheless, roentgen evidence of hypertrophic gastritis often is proved erroneous when the patient is gastroscoped. The piled-up mucosa may be nothing more than that due to contraction of the muscularis mucosae in which the typical pigskin appearance of the hypertrophied gastric mucosa is lacking. Marked hypertrophy of the gastric mucosa may be readily recognized by gastroscopy. The terms "atrophic gastritis" and "hypertrophic gastritis" traditionally refer to the effects of an inflammatory reaction. There is adequate evidence that gastric atrophy may be present in the absence of any demonstrable prior inflammatory insult. The present concept of the appearance of gastric atrophy in untreated primary pernicious anemia is based on a
GASTROSCOPY AND GASTRIC SURGERY
deficiency rather than on an inflammatory state. A similar interpretation is accepted for gastric atrophy in other disease states. Little has been written about a probable comparable state with reference to gastric hypertrophy. In instances in which the entire gastric membrane shows evidence of a uniform involvement characteristic of so-called hypertrophic gastritis, it seems odd that an inflammatory reaction should cause such a uniform reaction involving the whole gastric area. In inflammation elsewhere in the body, uniformity of involvement is not usual. Even in diffuse inflammation of the small and large bowel, there is a wide variation in the degree of mucosal reaction. We raise that issue merely to indicate that the presence of gastric hypertrophy per se should not necessarily imply a previous or present inflammatory reaction. Gastroscopy has a special role in the recognition of bizarre patterns found in roentgen study. Often the roentgenologist will report a mucosal pattern of the stomach which seems abnormal, but not in itself diagnostic of any particular entity. These abnormal roentgen patterns are often referred to as "indeterminant,"5 a word used to signify a mucosal defect that may be the result of one of a number of factors, e.g., (1) localized gastritis, (2) scarring from peptic ulCer, (3) atypical mucosal fold, (4) small mucosal or submucosal tumor, (5) aberrant pancreatic tissue, (6) polyp or (7) foreign body. It is true that repeated roentgen study, together with the use of air contrast and compression films, will limit the probable diagnoses to one or the other of several entities. Nevertheless, valuable information may be obtained by gastroscopy even if the contribution represents nothing more than the fact that the mocosa is intact over the area of the suspected lesion. Gastroscopy in such a case is quite helpful, especially in lesions involving the body of the stomach. With respect to the immediate prepyloric area, gastroscopy has been something of a disappointment. Often the differential diagnosis between prepyloric ulcer, localized gastritis, submucosal or mucosal neoplasm and benign hypertrophy of the pyloric musculature cannot be made with certainty, even by the most expert roentgen study. Vainly we endeavor to make a helpful suggestion with the use of the gastroscope. Too often the immediate prepyloric area is inaccessible to gastroscopy, and in a given instance one cannot with certainty be sure that he is viewing the area in question. We believe that gastroscopy offers a fertile field as an adjunct in the diagnostic work-up of a patient with symptoms suggestive of a gastric disorder, in whom the roentgen study fails to demonstrate a lesion. The gastroscopist must not take the stand of attempting to explain a bizarre clinical picture entirely on the basis of some minor distortion of the gastric mucosa. Gastroscopy is as yet too recent a procedure to receive ultimate evaluation. As newer models of gastroscopes appear, we may hope that many of the present limitations of the procedure will be eliminated. REFERENCES
1. Fierst, S. M., Robinson, H. M., and Sasagna, L.: Interstitial Gastric Emphysema following Gastroscopy; Its Relation to the Syndrome of Pneumoperitoneum
T. A. JOHNSON
and Generalized Emphysema with no Evident Perforation. Ann. Int. Med., 84:1202, 1951.
2. Macklin, C. C.: Transport of Air along Sheaths of Pulmonic Vessels from Alveoli to Mediastinum Arch. Int Med., 64:913, 1939. 3. Johnson, T. A.: Clinical Value of Gastroscopy. M. Clin. North America, 80:302, 1946.
4. Schindler, R., and Blomquist, 0.: Chronic Gastritis. in Johnson, T. A.: Management of Common Gastro-intestinal Diseases. Philadelphia, J. B. Lippincott Company, 1948. 5. Widmann, B. P.: Personal communication.