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!

作     者：Mitchell S Cappell 

作者机构：Division of Gastroenterology & Hepatology William Beaumont Hospital Oakland University William Beaumont School of Medicine 

出 版 物：《World Journal of Gastroenterology》 (世界胃肠病学杂志（英文版）)

年 卷 期：2020年第26卷第9期

页      面：984-991页

核心收录：

学科分类：1002[医学-临床医学] 100201[医学-内科学(含：心血管病、血液病、呼吸系病、消化系病、内分泌与代谢病、肾病、风湿病、传染病)] 10[医学] 

主　　题：Endoscopy Iatrogenic injury Medical ethics Hippocratic Oath Quality improvement Medical malpractice Morbidity and mortality 

摘      要：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 *** gastroenterologists,like any individual,can rarely suffer acute-changes-inmental-status from medical disorders,and these disorders may first manifest while performing gastrointestinal endoscopy because endoscopy comprises so much of their *** 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 ***-1-endoscopist repeatedly insisted that gastric polyps were colonic polyps,and absurdly“pressedendoscopic steering dials to“takeendoscopic 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 *** nurses recognized endoscopists as impaired and informed *** called Chief-of-Gastroenterology who advised endoscopists to terminate their esophagogastroduodenoscopies(fulfilling ethical imperative of“physician,firstdo-no-harm),and go to emergency room for medical *** endoscopists ***-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 *** rapidly recovered with medical *** This rare syndrome(0.0011%of endoscopies)may manifest abruptly as bizarre endoscopic interpretation and technique due to impairment of endoscopists by toxic encephalopathy.