A campaign has been launched in the USA called Choosing Wisely®, perhaps it is an interesting choice of words as in Arabic some patients refer to their doctor as حكيم hakeem (wise one). The campaign is an attempt by the American Board of Internal Medicine (ABIM) Foundation and other American Boards to get physicians to think carefully and wisely before choosing tests. Here are 5 things they highlighted in conjunction with the American Gastroenterological Association:
- Use the lowest effective dose of a Proton Pump Inhibitor or H2 receptor antagonist, neither are risk free.
- Do not retest with interval testing (i.e. Faecal Occult Bloods) if the patient has a normal high quality (i.e. adequate prep & resection of polyps) colonoscopy – follow up 10 years. Interval retesting generates unnecessary repeat colonscopies.
- If no high risk polyps found repeat in 5 years. High risk i.e villous adenoma, >3 polyps, >1cm. If high risk repeat in 3 years .
- Barrett’s oesophagus : 1,1,3 i.e. Normal endoscopy, normal at repeat in one year can have three yearly screening.
- Stop ordering CT abdomens so frequently! For this I will quote from Dr David Johnson, Professor of Medicine and Chief of Gastroenterology at Eastern Virginia Medical School. He reminds us that the lifetime increased risk of intra abdominal malignancy caused by lifetime radiation exposure goes from average to high after an exposure of 5mSv. Do you know how many mSv are delivered by a single abdominal CT?
Read the following short quote and find out:
“The fifth point is another pet peeve of mine. Patients with irritable bowel syndrome (IBS), established by ROME III criteria, who have had one CT scan, should not have a repeat CT unless there is significant change in clinical symptoms. Now, why is that? It is because of the radiation exposure. If you read the medical literature, it is replete with the recognition that radiation is bad. We see this in our inflammatory bowel disease (IBD) patients. There is considerable concern for an acceleration of interval cancer risk in patients who have repetitive scans. Abdominal CT scan exposes patients to 5-10 mSv of ionizing radiation. What do you think is the threshold dose to increase risk from average to high for intra-abdominal cancer over a lifetime of exposure? It’s 5 mSv. So, one CT scan already puts you over the lifetime increased risk for cancer. We know that these people will have subsequent exposures to radiation from CT scans. How many of your patients go to an emergency room and get a CT scan for every sneeze, wheeze, or bleed? They all get CTs, don’t they? Nonetheless, in patients who have had stone protocols for nephrolithiasis or ureterolithiasis, the exposure is in the range of 60-80 mSv. When you start to talk about IBS patients, abdominal pain equals CT. You can buy that once, maybe, but the patient should not have a repeat CT scan unless there are interval changes.”
Dr David Johnson, Professor of Medicine and Chief of Gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia.