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
Core Tip

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.