Case Report
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Mar 7, 2020; 26(9): 984-991
Published online Mar 7, 2020. doi: 10.3748/wjg.v26.i9.984
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!
Mitchell S Cappell
Mitchell S Cappell, Division of Gastroenterology & Hepatology, William Beaumont Hospital, Royal Oak, MI 48073, United States
Mitchell S Cappell, Oakland University William Beaumont School of Medicine, Royal Oak, MI 48073, United States
Author contributions: Cappell MS designed the research, performed the research, analyzed the data, and wrote the paper.
Informed consent statement: Informed written consent was obtained from the patients for publication of this report and accompanying images.
Conflict-of-interest statement: None. Dr. Cappell, as a consultant of the United States Food and Drug Administration (FDA) Advisory Committee for Gastrointestinal Drugs, affirms that this paper does not discuss any proprietary confidential pharmaceutical data submitted to the FDA and reviewed by Dr. Cappell. Dr. Cappell was until 2 years ago a member of the speaker’s bureau for AstraZeneca and Daiichi Sankyo, co-marketers of Movantik. Dr. Cappell has had one-time consultancies for Mallinckrodt and Shire > 1 year ago. This work does not discuss any drug manufactured or marketed by AstraZeneca, Daiichi Sankyo, Shire, or Mallinckrodt.
CARE Checklist (2016) statement: The author has read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Mitchell S Cappell, MD, PhD, Professor, Division of Gastroenterology and Hepatology, William Beaumont Hospital, MOB Suite 602, Thirteen Mile Rd, Royal Oak, MI 48073, United States.
Received: October 16, 2019
Peer-review started: October 16, 2019
First decision: November 22, 2019
Revised: December 4, 2019
Accepted: February 21, 2020
Article in press: February 21, 2020
Published online: March 7, 2020

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.


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.


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.