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Gastroscopy for Gastric Ulcer
GASTROENTEROLOGY 73:1160-1162, 1977 Copyright © 1977 by the American Gastroenterological Association
Vol. 73, No. 5 Printed in U.SA.
CLINICAL TRENDS AND TOPICS GASTROSCOPY FOR GASTRIC ULCER WILFRED M. WEINSTEIN , M.D. Department of Medicine, Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
Numerous papers concerning fiberoptic gastroscopy for gastric ulcer have been published and they usually contain well deserved praise for the fiber bundle and the revolution it has caused. Occasionally the authors insert qualifying phrases for their colleagues in academia ("controlled studies are required"); for government ("cost effectiveness"), or for an old friend in radiology ("barium X-ray is a valuable adjunct"). However, the word is out-every patient with a proven or suspected gastric ulcer should have a gastroscopy. In fact, the clarion call to the endoscopy room is so loud and pervasive that an endoscopist who refuses to do a gastroscopy on a given patient is often assailed with comments like: "Can you be sure there is no cancer?;" "ivory tower approach;" "take my business elsewhere;" "what about malpractice;" "start doing my own." It often takes more time to persuade a referring physician that gastroscopy may not be indicated than it does to do the procedure. A few nonendoscopists still question the rationale for doing such widespread gastroscopy but the basis for their skepticism is often suspect. Some of them prefer the good old days when one could make the diagnosis of "ulcer disease" with unchallenged abandon and others may be envious of the remuneration associated with the procedure. Gastroscopy is an important tool for evaluating gastric ulcers. In this regard there are a number of established facts: 1. Upper panendoscopy is associated with a low morbidity and rare mortality. 1 2. Gastroscopic examination combined with biopsy and cytology permit us to determine with remarkable accuracy whether a gastric ulcer is malignant or not. Gastroscopy should be performed when the barium X-ray appearance of a gastric ulcer is either suggestive or suspicious for malignancy. 3. Some gastric ulcers undetected on X-ray are detected with gastroscopy. 4. Some apparent ulcers on X-ray cannot be confirmed with gastroscopy. 5. Gastroscopy is infinitely superior to barium X-ray in finding the source of upper gastrointestinal tract bleeding and in assessing patients Received March 21, 1977. Accepted June 13, 1977. Address requests for reprints to: Wilfred M. Weinstein, M.D., Department of Medicine, Division of Gastroenterology, 9-112 Clinical Sciences Building, University of Alberta, Edmonton, Alberta, Canada T6G2G3 . The author is indebted to a number of individuals for engaging in spirited discussions concerning the role of gastroscopy for gastric ulcer. He also thanks Marilyn Weinstein and Drs. David Fleischer, Luciano Barajas, and I. M. Samloff for their blunt opinions concerning the manuscript, and Dee 8 . White for typing.
who may have recurrent ulceration after surgery. 6. Gastroscopy is invaluable in research studies concerning many aspects of gastric ulcer disease. This paper will raise some of the prickly issues and unresolved questions concerning the role of gastroscopy for gastric ulcer. Some of the issues pertain largely to the North American scene. In this context, an endoscopist is defined as a physician who does endoscopy but is · still actively engaged in clinical practice with a major interest in gastrointestinal disorders. Gastroscopy in Patients with Radiologically Documented Gastric Ulcers Indications. Should we do gastroscopy at the outset in all patients who have a benign-appearing gastric ulcer on barium X-ray? The main argument for, is that some benign-appearing gastric ulcers on X-ray are really malignant-3.3 % in the cooperative Veterans Administration study. 2 Furthermore, it is often argued that both patient and referring physician are reassured by having a more definitive test done . at the outset. The main argument against, is that the vast majority of gastroscopies done in patients with 'benign-appearing gastric ulcers will simply confirm the X-ray findings. Furthermore, providing the patient is available for follow-up examination, then the risk of overlooking a cancer is remote (0.6%) 2 even if one relies solely on the criterion of"X-ray healing." My own prejudice is that it is a waste of patient and physician time to do early gastroscopy in all patients who have clinical findings and an X-ray compatible with a benign gastric ulcer. A subcommittee of the American Society for Gastrointestinal Endoscopy met recently to design a prospective study to determine whether all patients with radiographically benign gastric ulcers need gastroscopy. 3 The questions to be evaluated included the percentage of apparently benign ulcers on X-ray found to be malignant on gastroscopy and biopsy, effects on death rates, and cost. They concluded that such a study was not feasible because of the large numbers of patients needed. It was also noted that the individual committee members' opinions varied, with some favoring early gastroscopy for all patients with radiographically benign gastric ulcers and others favoring early gastroscopy only when the X-ray was suspicious or diagnostic of cancer. 3 It was thought that the failure to agree reflected differing value judgments and not just a paucity of concrete data. We all would like to have our approach blessed by a "cost-effectiveness index." However, it may
1160
November 1977
CLINICAL TRENDS AND TOPICS
be impossible to translate data obtained in one center to another center or country. Many physician-endoscopists, especially those in private practice, have an additional problem concerning the indications for gastroscopy. There are increasing demands to do early gastroscopy, and furthermore to act solely as "technicians" and "scope to rule out cancer." Most of us prefer a consultation request for the over-all evaluation of the gastric ulcer patient. However, we succumb to the pressure from our colleagues with variable frequency. One of the obvious reasons we do is that we fear the loss of our "referral base." Some justify giving in by claiming to improve over-all patient care with the practice of incorporating recommendations concerning management into the text of the gastroscopy report. We need not become overly introspective or gloomy about the foregoing. The problem arises in many other branches of medicine and is not confined to gastroscopy alone. It is noted here mainly because it is becoming an important factor when one considers the over-all indications for gastroscopy for gastric ulcer. Those of us who opt for the selective approach in choosing patients for early gastroscopy for gastric ulcer have to assess factors such as history, age, and patient reliability. However, the variable that seems to dominate most often is the quality of the X-ray documentation of the ulcer. Granted, some ulcers are located in regions of the stomach where it is inherently difficult to obtain good views. However, the most common cause of poor quality X-ray documentation is simply failure of the radiologist to outline ulcer size, borders, and location adequately. A more pressing question is whether endoscopy should be used to ensure that every last millimeter of the benign ulcer defect has closed over. It is widely acknowledged that some benign gastric ulcers may take several months to heal. It is also acknowledged that an X-ray may show "complete healing" whereas gastroscopy may show a residual small ulceration. In the name of ensuring "complete healing," patients are now receiving repeated endoscopies (and biopsies) while on treatment for benign gastric ulcer. Studies must be done to determine whether this vigorous therapeutic approach based on complete endoscopic healing really alters the natural history of a disorder that has a distressingly high recurrence rate. In a similar vein, if one insists on complete endoscopic healing, does this also mean that the same patient should have gastroscopy for each minor flare in symptoms in order to detect and treat a possible recurrence at an "early stage?" For the time being it should be considered perfectly acceptable to rely primarily on barium X-ray for the healing test, provided good quality X-ray is available, and assuming that the clinical course of the patient is uncomplicated. Photography . We are told to photograph all gastric ulcers for "documentation." The arguments in favor include: valuable when follow-up endoscopy is performed by an endoscopist other than the one who performed the original examination; teaching value; medicolegal implications; provisions of a photograph of the "pathology" to the referring physician; and, we expect
. 1161
radiologists to take pictures and we should do likewise. There is no doubt the color pictures offer r eferring physicians something concrete to admire. Nevertheless I do not photograph all gastric ulcers and neither do many endoscopists I know. Perhaps we are more demanding of the radiologist because we trust him less or perhaps his pictures still offer potentially more information concerning ulcer depth, contours, and involvement of the adjacent mucosa. There is no doubt that gastrophotography is helpful for further study of the atypical-appearing gastric ulcer. However, in this instance it is equally or more helpful to solicit a second opinion, if possible, from another physician (e ~ g., endoscopist, surgeon, pathologist) right at the time of gastroscopy. Gastrophotography will undoubtedly become routine when physicians who care for gastric ulcer patients will be able to requisition gastroscopy at will from an endoscopy department just as they now requisition barium X-rays from a radiology department. Biopsy. A number of studies have attempted to define the optimal number of biopsies required in order to ensure that gastric malignancy is correctly diagnosed. Opinions vary"· 5 concerning the optimal number of biopsies to obtain, but in most centers the average number taken is probably five. Insufficient emphasis has been placed on the quality of the biopsy. Tissue that is "gristly" and difficult to grasp with the biopsy forceps will yield poor quality sections so one should take more than the usual number of biopsies. The endoscopist or his trained assistant should examine each biopsy for size and this should govern whether more than the usual number of biopsies are obtained. After the first few biopsies, succeeding biopsies may contain significant amounts of clotted blood. This should be dissected away from the tissue if possible, because large amounts of clotted blood in a biopsy compromise the quality of the tissue sections. The biopsies should be taken so that there is circumferential sampling of the inner edges of the ulcer. If opportunistic infection such as candida6 or cytomegalovirus7 is suspected to be associated with a gastric ulcer, then biopsies should be taken for smear and culture. Many opportunistic infections are not yet amenable to specific therapy, but recognition of their presence may provide the first insight into the presence of more disseminated involvement. Sometimes it is difficult to differentiate small ulcers or erosions from adherent mucus or antacid. Biopsy may help if it confirms the presence of an exudate. The pathologist who receives the biopsy specimens must recognize that it is essential to obtain and review multiple sections from these small pieces of tissue. In order to reduce the processing t ime multiple endoscopy biopsy specimens can be embedded in a single paraffin block. Should biopsies be taken as a routine whenever one encounters a gastric ulcer at endoscopy? Often it seems unnecessary when an ulcer appears totally benign. Perhaps further disruption of a benign gastric ulcer by biopsy even delays healing! Some expert endoscopists do not biopsy all gastric ulcers. However, the rest of us
1162
Vol. 73, No.5
CLINICAL TRENDS AND TOPICS
should continue to take biopsies routinely when the prime indication for the gastroscopy is to rule out cancer. Cytology. The established pattern is to rely primarily on biopsy to rule out cancer, but brush cytology is simple to perform and is a valuable adjunct. It is especially helpful when ulcers are located in regions of the stomach that are difficult to visualize for precise biopsy localization. Again, the question arises concerning routine procedure. Should cytology always be done at gastroscopy for gastric ulcer? One compromise approach would be to do brushings whenever biopsies are taken from a gastric ulcer but to defer screening of the slides pending the biopsy result and the other investigative findings. A cytology service will only be effective when there is active communication between clinician and cytopathologist. The cytopathologist must be provided with the final clinical diagnosis in each case. If one uses cytology selectively, then a sufficient number of cases should be provided each year to keep the cytopathologist in fine tune. In turn, the cytopathologist must recognize that the frequent cytodiagnosis of "suspicious" may result in mismanagement and patient anxiety to the point at which it negates any intrinsic value of the procedure. Gastroscopy for Suspected Gastric Ulcer Gastroscopy is usually performed to rule out benign ulcer or cancer in patients who have gastric mucosal deformity on barium X-ray. A more difficult question is whether upper panendoscopy should be done routinely to rule out gastric ulcer and other disorders in patients with "X-ray negative dyspepsia." If a patient has a negative X-ray and ulcer symptoms is it now archaic practice to treat the patient empirically for ulcer disease without first doing endoscopy? Conversely, if endoscopy is done in such a patient and no ulcer is found, should ulcer therapy be withheld? These and related questions have been dealt with recently in a splendid article by Spiro. 8 There is no simple answer. Obvious considerations in such patients include the nature, severity and duration of symptoms, and the frustration levels of the patient and the physician who cares for the patient. Primary care physicians who do not yet have ready access to endoscopic facilities must feel desperate when they read the many pronouncements that endoscopy should be done in all patients with X-ray-negative dyspepsia. They need not feel overly distressed because many endoscopists and other physicians have had similar symptoms for years and have taken antacids surreptitiously without even so much as a barium X-ray! There are predictions from some quarters that gastroscopy can and will replace barium X-ray as the first
route of elective investigation in suspected gastric ulcer and in other disorders as well. It is beyond the scope of this paper and the vision of this writer to take up the issue and to prophesy whether this will eventually come to pass. There is no doubt, however, that endoscopy is increasingly becoming part of the routine work-up for any kind of pain located between the manubrium sterni and the symphysis pubis. Of course, "to rule out gastric ulcer" is only one of the feeble excuses used to justify this uncritical practice. Gastroscopy for Gastric Ulcer- Future Shock Therapeutic endoscopy for gastric ulcer is rapidly becoming a reality. Prelimfnary reports have appeared describing suture removal from the bases of recurrent ulcers, control of bleeding from gastric ulcers, and topical application of drugs to gastric lesions. These and other modalities may ultimately change some of our current approaches to therapy of the complications of gastric ulcer. Fiberoptic gastroscopy for gastric ulcer (and for other conditions) has generated enormous interest throughout the world. It probably stems from a person's fundamental desire to have an accurate visual image of an object of interest, be it Mars, DNA, or a gastric ulcer; Developments in this field have been rapid and predictably they have raised a number of questions. Some of the questions concerning the role of gastroscopy for gastric ulcer will be answered by prospective studies. Other questions will cease to be asked because the instrument makers will dictate our approach with further technical innovations. REFERENCES 1. Silvis SE, Nebel 0, Rogers G, et al: Endoscopic complications. JAMA 235:928-930, 1976 2. Wenger J, Brandborg LL, Spellman FA: Cancer. Part I. Clinical aspects. Gastroenterology 61:598-605, 1971 3. Tedesco FJ, Best WR, Littman A, et al: Role of gastroscopy in gastric ulcer patients. Planning a prospective study. Gastroen· terology 73:170-173, 1977 4. Dekker W, Oushoorn H, Tytgat GN: Evaluatie van de endosco· pie met biopsie bij maligne tumoren van het bovenste deel va de tractus digestivus. Tijdschr Gastroenterol 16:385-95, 1973 5. Rowland R, Durbridge T, Hecker R, et al: How many endoscopic biopsy specimens? Med J Aust 2:172-173, 1976 6. Binder RJ, Nelson JA: Candida albicans ulcer within hiatus hernia sac presenting as an ulcerated mass. Gastroenterology 68:587-90, 1975 7. Campbell DA, Piercey JRA, Shnitka TK, et al: Cytomegalovi· rus-associated gastric ulcer. Gastroenterology 72:533-535, 1977 8. Spiro HM: Moynihan's disease? The diagnosis of duodenal ulcer. N Engl J Med 291:567-569, 1974
Vol. 73, No. 5 Printed in U.SA.
CLINICAL TRENDS AND TOPICS GASTROSCOPY FOR GASTRIC ULCER WILFRED M. WEINSTEIN , M.D. Department of Medicine, Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
Numerous papers concerning fiberoptic gastroscopy for gastric ulcer have been published and they usually contain well deserved praise for the fiber bundle and the revolution it has caused. Occasionally the authors insert qualifying phrases for their colleagues in academia ("controlled studies are required"); for government ("cost effectiveness"), or for an old friend in radiology ("barium X-ray is a valuable adjunct"). However, the word is out-every patient with a proven or suspected gastric ulcer should have a gastroscopy. In fact, the clarion call to the endoscopy room is so loud and pervasive that an endoscopist who refuses to do a gastroscopy on a given patient is often assailed with comments like: "Can you be sure there is no cancer?;" "ivory tower approach;" "take my business elsewhere;" "what about malpractice;" "start doing my own." It often takes more time to persuade a referring physician that gastroscopy may not be indicated than it does to do the procedure. A few nonendoscopists still question the rationale for doing such widespread gastroscopy but the basis for their skepticism is often suspect. Some of them prefer the good old days when one could make the diagnosis of "ulcer disease" with unchallenged abandon and others may be envious of the remuneration associated with the procedure. Gastroscopy is an important tool for evaluating gastric ulcers. In this regard there are a number of established facts: 1. Upper panendoscopy is associated with a low morbidity and rare mortality. 1 2. Gastroscopic examination combined with biopsy and cytology permit us to determine with remarkable accuracy whether a gastric ulcer is malignant or not. Gastroscopy should be performed when the barium X-ray appearance of a gastric ulcer is either suggestive or suspicious for malignancy. 3. Some gastric ulcers undetected on X-ray are detected with gastroscopy. 4. Some apparent ulcers on X-ray cannot be confirmed with gastroscopy. 5. Gastroscopy is infinitely superior to barium X-ray in finding the source of upper gastrointestinal tract bleeding and in assessing patients Received March 21, 1977. Accepted June 13, 1977. Address requests for reprints to: Wilfred M. Weinstein, M.D., Department of Medicine, Division of Gastroenterology, 9-112 Clinical Sciences Building, University of Alberta, Edmonton, Alberta, Canada T6G2G3 . The author is indebted to a number of individuals for engaging in spirited discussions concerning the role of gastroscopy for gastric ulcer. He also thanks Marilyn Weinstein and Drs. David Fleischer, Luciano Barajas, and I. M. Samloff for their blunt opinions concerning the manuscript, and Dee 8 . White for typing.
who may have recurrent ulceration after surgery. 6. Gastroscopy is invaluable in research studies concerning many aspects of gastric ulcer disease. This paper will raise some of the prickly issues and unresolved questions concerning the role of gastroscopy for gastric ulcer. Some of the issues pertain largely to the North American scene. In this context, an endoscopist is defined as a physician who does endoscopy but is · still actively engaged in clinical practice with a major interest in gastrointestinal disorders. Gastroscopy in Patients with Radiologically Documented Gastric Ulcers Indications. Should we do gastroscopy at the outset in all patients who have a benign-appearing gastric ulcer on barium X-ray? The main argument for, is that some benign-appearing gastric ulcers on X-ray are really malignant-3.3 % in the cooperative Veterans Administration study. 2 Furthermore, it is often argued that both patient and referring physician are reassured by having a more definitive test done . at the outset. The main argument against, is that the vast majority of gastroscopies done in patients with 'benign-appearing gastric ulcers will simply confirm the X-ray findings. Furthermore, providing the patient is available for follow-up examination, then the risk of overlooking a cancer is remote (0.6%) 2 even if one relies solely on the criterion of"X-ray healing." My own prejudice is that it is a waste of patient and physician time to do early gastroscopy in all patients who have clinical findings and an X-ray compatible with a benign gastric ulcer. A subcommittee of the American Society for Gastrointestinal Endoscopy met recently to design a prospective study to determine whether all patients with radiographically benign gastric ulcers need gastroscopy. 3 The questions to be evaluated included the percentage of apparently benign ulcers on X-ray found to be malignant on gastroscopy and biopsy, effects on death rates, and cost. They concluded that such a study was not feasible because of the large numbers of patients needed. It was also noted that the individual committee members' opinions varied, with some favoring early gastroscopy for all patients with radiographically benign gastric ulcers and others favoring early gastroscopy only when the X-ray was suspicious or diagnostic of cancer. 3 It was thought that the failure to agree reflected differing value judgments and not just a paucity of concrete data. We all would like to have our approach blessed by a "cost-effectiveness index." However, it may
1160
November 1977
CLINICAL TRENDS AND TOPICS
be impossible to translate data obtained in one center to another center or country. Many physician-endoscopists, especially those in private practice, have an additional problem concerning the indications for gastroscopy. There are increasing demands to do early gastroscopy, and furthermore to act solely as "technicians" and "scope to rule out cancer." Most of us prefer a consultation request for the over-all evaluation of the gastric ulcer patient. However, we succumb to the pressure from our colleagues with variable frequency. One of the obvious reasons we do is that we fear the loss of our "referral base." Some justify giving in by claiming to improve over-all patient care with the practice of incorporating recommendations concerning management into the text of the gastroscopy report. We need not become overly introspective or gloomy about the foregoing. The problem arises in many other branches of medicine and is not confined to gastroscopy alone. It is noted here mainly because it is becoming an important factor when one considers the over-all indications for gastroscopy for gastric ulcer. Those of us who opt for the selective approach in choosing patients for early gastroscopy for gastric ulcer have to assess factors such as history, age, and patient reliability. However, the variable that seems to dominate most often is the quality of the X-ray documentation of the ulcer. Granted, some ulcers are located in regions of the stomach where it is inherently difficult to obtain good views. However, the most common cause of poor quality X-ray documentation is simply failure of the radiologist to outline ulcer size, borders, and location adequately. A more pressing question is whether endoscopy should be used to ensure that every last millimeter of the benign ulcer defect has closed over. It is widely acknowledged that some benign gastric ulcers may take several months to heal. It is also acknowledged that an X-ray may show "complete healing" whereas gastroscopy may show a residual small ulceration. In the name of ensuring "complete healing," patients are now receiving repeated endoscopies (and biopsies) while on treatment for benign gastric ulcer. Studies must be done to determine whether this vigorous therapeutic approach based on complete endoscopic healing really alters the natural history of a disorder that has a distressingly high recurrence rate. In a similar vein, if one insists on complete endoscopic healing, does this also mean that the same patient should have gastroscopy for each minor flare in symptoms in order to detect and treat a possible recurrence at an "early stage?" For the time being it should be considered perfectly acceptable to rely primarily on barium X-ray for the healing test, provided good quality X-ray is available, and assuming that the clinical course of the patient is uncomplicated. Photography . We are told to photograph all gastric ulcers for "documentation." The arguments in favor include: valuable when follow-up endoscopy is performed by an endoscopist other than the one who performed the original examination; teaching value; medicolegal implications; provisions of a photograph of the "pathology" to the referring physician; and, we expect
. 1161
radiologists to take pictures and we should do likewise. There is no doubt the color pictures offer r eferring physicians something concrete to admire. Nevertheless I do not photograph all gastric ulcers and neither do many endoscopists I know. Perhaps we are more demanding of the radiologist because we trust him less or perhaps his pictures still offer potentially more information concerning ulcer depth, contours, and involvement of the adjacent mucosa. There is no doubt that gastrophotography is helpful for further study of the atypical-appearing gastric ulcer. However, in this instance it is equally or more helpful to solicit a second opinion, if possible, from another physician (e ~ g., endoscopist, surgeon, pathologist) right at the time of gastroscopy. Gastrophotography will undoubtedly become routine when physicians who care for gastric ulcer patients will be able to requisition gastroscopy at will from an endoscopy department just as they now requisition barium X-rays from a radiology department. Biopsy. A number of studies have attempted to define the optimal number of biopsies required in order to ensure that gastric malignancy is correctly diagnosed. Opinions vary"· 5 concerning the optimal number of biopsies to obtain, but in most centers the average number taken is probably five. Insufficient emphasis has been placed on the quality of the biopsy. Tissue that is "gristly" and difficult to grasp with the biopsy forceps will yield poor quality sections so one should take more than the usual number of biopsies. The endoscopist or his trained assistant should examine each biopsy for size and this should govern whether more than the usual number of biopsies are obtained. After the first few biopsies, succeeding biopsies may contain significant amounts of clotted blood. This should be dissected away from the tissue if possible, because large amounts of clotted blood in a biopsy compromise the quality of the tissue sections. The biopsies should be taken so that there is circumferential sampling of the inner edges of the ulcer. If opportunistic infection such as candida6 or cytomegalovirus7 is suspected to be associated with a gastric ulcer, then biopsies should be taken for smear and culture. Many opportunistic infections are not yet amenable to specific therapy, but recognition of their presence may provide the first insight into the presence of more disseminated involvement. Sometimes it is difficult to differentiate small ulcers or erosions from adherent mucus or antacid. Biopsy may help if it confirms the presence of an exudate. The pathologist who receives the biopsy specimens must recognize that it is essential to obtain and review multiple sections from these small pieces of tissue. In order to reduce the processing t ime multiple endoscopy biopsy specimens can be embedded in a single paraffin block. Should biopsies be taken as a routine whenever one encounters a gastric ulcer at endoscopy? Often it seems unnecessary when an ulcer appears totally benign. Perhaps further disruption of a benign gastric ulcer by biopsy even delays healing! Some expert endoscopists do not biopsy all gastric ulcers. However, the rest of us
1162
Vol. 73, No.5
CLINICAL TRENDS AND TOPICS
should continue to take biopsies routinely when the prime indication for the gastroscopy is to rule out cancer. Cytology. The established pattern is to rely primarily on biopsy to rule out cancer, but brush cytology is simple to perform and is a valuable adjunct. It is especially helpful when ulcers are located in regions of the stomach that are difficult to visualize for precise biopsy localization. Again, the question arises concerning routine procedure. Should cytology always be done at gastroscopy for gastric ulcer? One compromise approach would be to do brushings whenever biopsies are taken from a gastric ulcer but to defer screening of the slides pending the biopsy result and the other investigative findings. A cytology service will only be effective when there is active communication between clinician and cytopathologist. The cytopathologist must be provided with the final clinical diagnosis in each case. If one uses cytology selectively, then a sufficient number of cases should be provided each year to keep the cytopathologist in fine tune. In turn, the cytopathologist must recognize that the frequent cytodiagnosis of "suspicious" may result in mismanagement and patient anxiety to the point at which it negates any intrinsic value of the procedure. Gastroscopy for Suspected Gastric Ulcer Gastroscopy is usually performed to rule out benign ulcer or cancer in patients who have gastric mucosal deformity on barium X-ray. A more difficult question is whether upper panendoscopy should be done routinely to rule out gastric ulcer and other disorders in patients with "X-ray negative dyspepsia." If a patient has a negative X-ray and ulcer symptoms is it now archaic practice to treat the patient empirically for ulcer disease without first doing endoscopy? Conversely, if endoscopy is done in such a patient and no ulcer is found, should ulcer therapy be withheld? These and related questions have been dealt with recently in a splendid article by Spiro. 8 There is no simple answer. Obvious considerations in such patients include the nature, severity and duration of symptoms, and the frustration levels of the patient and the physician who cares for the patient. Primary care physicians who do not yet have ready access to endoscopic facilities must feel desperate when they read the many pronouncements that endoscopy should be done in all patients with X-ray-negative dyspepsia. They need not feel overly distressed because many endoscopists and other physicians have had similar symptoms for years and have taken antacids surreptitiously without even so much as a barium X-ray! There are predictions from some quarters that gastroscopy can and will replace barium X-ray as the first
route of elective investigation in suspected gastric ulcer and in other disorders as well. It is beyond the scope of this paper and the vision of this writer to take up the issue and to prophesy whether this will eventually come to pass. There is no doubt, however, that endoscopy is increasingly becoming part of the routine work-up for any kind of pain located between the manubrium sterni and the symphysis pubis. Of course, "to rule out gastric ulcer" is only one of the feeble excuses used to justify this uncritical practice. Gastroscopy for Gastric Ulcer- Future Shock Therapeutic endoscopy for gastric ulcer is rapidly becoming a reality. Prelimfnary reports have appeared describing suture removal from the bases of recurrent ulcers, control of bleeding from gastric ulcers, and topical application of drugs to gastric lesions. These and other modalities may ultimately change some of our current approaches to therapy of the complications of gastric ulcer. Fiberoptic gastroscopy for gastric ulcer (and for other conditions) has generated enormous interest throughout the world. It probably stems from a person's fundamental desire to have an accurate visual image of an object of interest, be it Mars, DNA, or a gastric ulcer; Developments in this field have been rapid and predictably they have raised a number of questions. Some of the questions concerning the role of gastroscopy for gastric ulcer will be answered by prospective studies. Other questions will cease to be asked because the instrument makers will dictate our approach with further technical innovations. REFERENCES 1. Silvis SE, Nebel 0, Rogers G, et al: Endoscopic complications. JAMA 235:928-930, 1976 2. Wenger J, Brandborg LL, Spellman FA: Cancer. Part I. Clinical aspects. Gastroenterology 61:598-605, 1971 3. Tedesco FJ, Best WR, Littman A, et al: Role of gastroscopy in gastric ulcer patients. Planning a prospective study. Gastroen· terology 73:170-173, 1977 4. Dekker W, Oushoorn H, Tytgat GN: Evaluatie van de endosco· pie met biopsie bij maligne tumoren van het bovenste deel va de tractus digestivus. Tijdschr Gastroenterol 16:385-95, 1973 5. Rowland R, Durbridge T, Hecker R, et al: How many endoscopic biopsy specimens? Med J Aust 2:172-173, 1976 6. Binder RJ, Nelson JA: Candida albicans ulcer within hiatus hernia sac presenting as an ulcerated mass. Gastroenterology 68:587-90, 1975 7. Campbell DA, Piercey JRA, Shnitka TK, et al: Cytomegalovi· rus-associated gastric ulcer. Gastroenterology 72:533-535, 1977 8. Spiro HM: Moynihan's disease? The diagnosis of duodenal ulcer. N Engl J Med 291:567-569, 1974