Cappell MS. 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! World J Gastroenterol 2020; 26(9): 984-991 [PMID: 32206008 DOI: 10.3748/wjg.v26.i9.984]
Corresponding Author of This Article
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. mitchell.cappell@beaumont.edu
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Gastroenterology & Hepatology
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Case Report
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Mar 7, 2020 (publication date) through Feb 23, 2026
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Publication Name
World Journal of Gastroenterology
ISSN
1007-9327
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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA
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Cappell MS. 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! World J Gastroenterol 2020; 26(9): 984-991 [PMID: 32206008 DOI: 10.3748/wjg.v26.i9.984]
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).
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. mitchell.cappell@beaumont.edu
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 Processing time: 141 Days and 11.3 Hours
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.
