The Fine Needle Aspiration Cytology, Endoscopy: When and for Whom?, and CAT Scans: A technology running wild?
Item
- Title
- The Fine Needle Aspiration Cytology, Endoscopy: When and for Whom?, and CAT Scans: A technology running wild?
- Creator
- Ulhas Jajoo
- Sujar Jajoo
- S P Kalantri
- Date
- 1989
- extracted text
-
96
BACKGROUND PAPER III
XV' ANNUAL MEET OF MEDICO FRIEND CIRCLE aT aLWaYE KERALA
v
APPROPRIATE TECHNOLOGY- The Fing- Needle Aspiration Cytology
Though a pathologist is supposed to rffer the final
diagnosis in a perplexing medical problem, he requires a
surgeon's knife*to" get the material and an elaborate laboratory
to process it. The invasive procedure scares many. The felt
need is mother of invention. The fine needle aspiration cytology
was thus born in 1904 but it took almost 50 years to reach tn
its adolescence. This technique lends itself to out-patient
diagnosis, hence is eminently suited for use in peripheral
medical centres. It is safe, more acceptable,non-traumatic,
repeatable and inexpensive. It requires a fine needle a
syrienge to aspirate out the material from palpable/ultraso
nographically guided mass, which has to be stained on a slide
for microscopic examination. The results are available within
an hour.
The fine needle aspiration has been done from masses as
varied as lymph glands,thyroid, breast lump, bone tumours, soft
tissue masses, liver,prostate etc. The studies done in India
reveal that the procedure enjoys high sensitivity (77 to 96%)
in diagnosis of tubercular lymphadenitis. The high specificity
(around 95%) in the diagnosis of tubercular/reactive/malignant
lymph glands is an asset in the diagnosis of pathological glands.
The results are equally satisfactory- for soft tissue/thyroid/
breast masses.
The procedure requires a trained pathologist(cytolegist)
and thus is appropriate at cottage hospital level. The minimum
that it can do is to screen all such palpable masses before any
referal for invasive procedure is planned.
Dr. Ulhas Jajoo
REFERENCES;
1 .
Gupta S.K., Dutta J.K., Aikat M, Gupta B.D. et al;
Evaluation of Fine Needle Biopsy in Diagnosis of
Tumours; Ind. J. Can.; 12, 257-67, 1975.
2.
Rajwanshi A, Bhambhani S, Das D.K.; Fine Needle
Aspiration Cytology in Diagnosis of Tuberculosis;
Acta Cytol; 3(1),13-16,1987.
3.
Metre M.S., <Jayaram G: Acid Fast. Bacilli in Aspiration
- ~
~ 31(1)
Smears from Tuberculous
Lymphnodes
;Acta Cytol;
17-19, 1987.
4.
Baily T.M. AkhtarM., All M.A.; Fine Needle .aspiration
Biopsy in The Diagnosis of Tuberculosis:Acta.Cytol,
29(5); 732-35; 1985.
5.
Debajyoti Malakar:A Clinical Evaluation of the Utility
of Fine Needle Aspiration Biopsy as a Diagnosis
Technique: A Thesis for M.D., Nagpur University,M.G.I.M.
S. Sevagram 1988.
(2)
BACKGROUND PAPER IV
ENDOSCOPY: WHEN AND FOR WHOM?
i
It has been almost 22 years since Hirschowitz described
the first clinical use of endoscopy. Since then it has firmly
established itself as a diagnostic and therapeutic tool in
gastroenterology per excellence. In this paper, however, I shall
try to put endoscopy and its diagnostic utility ih proper
perspective.
Three common indications for doing upper gut endoscopy,
not necessarily in the order of preference, are:(i)acid peptic
disease,cancer and upper gut bleeding. Let us see what is the
overall impact of diagnostic endo'jcopy in the management of
these patients.
Acid Peptic Disease: The prevalence of dyspepsia, which inclu
des such diverse and vague terms as gases,belching,heartburn,
indigestion, pain and so on, is so high in the general population
that it is very tempting to endoscope every patient with
dyspepsia to rule out peptic ulcer. One might argue that since
on clinical grounds one can never be sure' whether one is
(
dealing with ulcer or something else- a view shared by a text
book of medicine (1)- endoscopy could provide useful insight
in these problems.
. ->
We do not .deny the ability of endoscopy to'pick up ulcers.
Its definite edge over radiography in peptic ulcers was never in
doubt, more so after the publication of the best'controlled
study till date comparing these two technologies.(2) The
study found endoscopy to be'more specific (92 per cent versus
54 percent) and specific (100 per cent versus 92 percent)
than barium radiographs for diagnosing peptic ulcers.
Given a very high prevalence of acid peptic disease in
the general population, the uncertainty which clouds clinical
wisdom when dealing with ulcers, and the distinct superiority
of endoscopy over barium x-rays, one might justify'routine’
endoscopy on the grounds that:
(i)
Since ulcer or 1 no ulcer' can not be differentiated
from history or physical examination;
(ii)
Since an early diagnosis of ulcer can spare a patient
needless antidepressants and antispasmodic drugs so
commonly used for non-ulcer dyspepsia; and
Since malignancy can masquarade as ulcer sometimes, it
is better to endoscope every patient with such, problems
to have his ulcer confirmed or ruled out.
Obviously, endoscopies based on this logic arc- neither
desirable nor feasible. To be rationale, an approach to endoscopy
in upper gut problems must take into consideration the following
facts :
(iii)
(i) It is true that the clinical distinction between ulcer
and non-ulcer dyspepsia is not so sharp. But the natural history
of peptic ulcer is so unpredictable that an early and precise
diagnosis of peptic ulcer gives no guarantee that appropriate
therapy would result in successful outcome. When as many .as 20
to 60 per cent of ulcers respond to placebo, as many ulcers
recur after anti-ulcer drugs (3)endoscopy loses much of its.
charm. Further most patients with non-ulcer dyspepsia also
require the same drugs as an ulcer patient would need.
-3.
(3)
<
(ii) Consider cost. Less than half the amount that a
patient spends on getting his endoscopy done to have his ulcer
confirmed can buy him full six week course of cimetidine or
ranitidine the currently used, ulcer healing drugs.
(iii) The notion that since a cancer might masquerade as
an ulcer also doesn't justify endoscopy as a routine procedure.
Much less than one per cent of patients with recent onset dys
pepsia have malignancy. Most will respond to a trial of therapy
directed towards their dyspeptic symptoms. Perhaps 30 pe • rent
of patients with dyspeptic symptoms lasting for more than x4
days despite therapy will need endoscopy. (i)
Cancer:
Cancer; An endoscopist can crrrectly
correctly identify 75 per cent of
malignant ulcers by endoscopic visual criteria. Tissue
aqd cytological diagnosis would raise the diagnostic yield to
almost 95 per cent (1) Endoscopy, should, however, be re.- wed
for only those patients, in whom clinical suspicion of
'malignancy is farily high.
Upper GIT Bleeding: These three conditions account for -,r per
JJL/UU.UU.
o ,
1
cent of bleeding from the upper gut:(i) ruptured
varices, a complication of chronic liver disease;(ii)bl- .-ding
peptic ulcer;(iii) multiple drug induced erosions in the stomach.
Though endoscopy can reliably locate and identify the source of
bleeding, it is surprising th.it no study till date has s-io.-n that
aggressive endoscopy in upper gut bleeding affects final
tcome
(4) Thus except as a part of well planned out research,
diagnostic endoscopy here may not pay much dividends.
Endoscopy would, however, be useful in those co.idir.*ons
where conventional bai’iugj x-rnys suggest surgical interver‘ion.
It has been suggested that endoscopy can avoid surgery in / per
cent of such potential surgical cases. (5).
Colonic Diseases: -Western text-books was eloquent on the use
fulness of fibre-optic endoscopy for evaluation of un-expldned
iron defici ncy anaemia and for early detection of colonic cancer.
In our experience:
(i) Colonic lesions seldom account for chronic bi loss
on important cause of iron deficiency anaemia. Distal lesions 5
piles for instance, are more common here and lend easily to
physical examination by a simple proctoscope.
(ii) Polyps, cancer and diverticuli of the colon ar- •
distinctly infrequent. Aggressive colonoscopy for these le.ions
would certainly be not cost effective. Further, even those
patients with colonic malignancy turn up rather late witn an
over-grown, advanced cancer, a double contrast braium enema would
be as effective as an endoscope in most of these situations.
(iii) Inflammatory bowel diseases are also relamiv.'.y rare
in our country. Crohn's disease is almost unheard of Ulcerative
colitis can easily be identified on the basis of clinical xamination and barium enemas.
(iv) Colonoscopy is a highly skilled investigation,-'roper
technique is the key, otherwise as high as in 35 per cent if
cases right colon can not be visualised.
In conclusion, one must answer these questions before subj cting
a patient to endoscopy:
(i) What is the natural history of the disease?
(ii) Can endoscopy wait a fair drug trial?
(iii) Can simple radiography be as effective?(ivj Will better diagnosis necessarily mean better' treatment.
Medical College,
Sev.agram
Wardha 442 102.
SU.US JaJOO
(4)
The chart given below shows the preferred diagnostic techni ue
in the evaluation of upper and lower gut problems. Please note
that we have taken into account of only the diagnostic efficacy
of these investigative tools.
1.
2.
3.
4.
5.
6.
7.
s:
I
Dysphagia
. 1/ Dysmetility
II/Reflux esophagitis
III/Benign stricture .
IV/Cancer
V/Hiatus hernia
Vl/Polyps
Ra diography,Manometry .
Radiography & oesophageal pH recording
Radiggraphy & Endoscopy together
Endoscopy
Radiography9 endoscopy
Radiography,endoscopy together
Upper GIT bleed
Gastric Ulcer
Duodenitis/DJ
Recurrent ulcer
Gastric Cancer
Chronic colonic bleed
Endoscopy
Endoscopy
Radiography,endoscopy together
Endoscopy .
Endoscope
I/Inflammation
II/Polyp/Cancer
III/Barium enema+
Barium enema
Flexible Sigmoidoscopy
Colonoscopy
Acute lower GIT bleed
Colonoscopy & angi ography together.
REFERENCES:
1.
2.
3.
4.
Text book of Medicine edited by Cecil
-do Text book of medicine (Oxford)
i
background paper v
CAT Scans:
A Technology running wild?
Perhaps no other investigation in neurology has proved as much
useful and as informative ad CAT scan. Rightly considered by the
neurologists as a revolutionary advance,CAT, as things stand
today is undoubtedly numero uno investigation for most neurjlQgied
disorders. Besides being safe, non-invasive and accurate, CAT
w
has been shown to improve therapy and reduce the need for other
diagnostic invasive procedures.
So far so good. But when we discuss the utility of CAT scan,
we must also take into consideration the socio-economic perspe
ctives of the population that is likely to be benefitted by this
technology. Consider, for instance:
(i) Cost. CAT units are mightily costly; almost worth 7 million
rupees. The high cost of CAT not only includes an initial investiment ( cost of the machine, premises where the machine is installed,
auxilliary equipments such as air condioners, stabilizers etc.)
but also the running cost ( power, contrast media, image
recording, salaries of personnel, X-ray tubes, spare parts and
so on...)
(ii)lt is possible that irrational use of CAT scans in those
patients who are least likely to be benefited from, it may
displace those ptients for whom CAT scan might be life saving.
-5-
(5)
4
(iii) Further, CT scans may provide better diagnosis, but tney may
not affect the final outcome of a disease. Studies have- reported
its lack of cost-effectivity when it is used tn evaluate patients
with headachesand other chronic symptoms, or to confirm diagnostic
findings previously noted by other imaging or clinical ter;s.
Let us take those clinical situations where CAT scans are most
commonly used or abused.
Headache: A consensus development conference held at the national
institute of health in November 1981 opined that CAT scans should
not be used as a routine screening procedure, when a lew diagnostic
yield is anticipated. The’e is also little justification for the
procedure following minor trauma, simple or periodic headaches,
synoscope or dissiness not accompanied by other neurological signs.
The committee also opened that most patients wit’;
->dache
(1)
should be considered for CA1 screening only if the symptoms are
severe, constant, unusual or associated with abnormal neurological
signs.
The classic study by Larson ct al (2) drives this point ’ie-.e. In
165 selected cases with headache, the study assessed the impact
of diagnostic CA't scanning on the evaluation and overall manage
ment of patientst The results of the study revealed that 2. careful
history and physical examination were adequate scrrens tc detect
lintracranial masses or systemic diseases associated with .eadache.
In patients from normal findings from neurological exami.ia ion,
no clinically important .bnormalities were detected by C'.y scans,
skull x-rays, angiography or radio-nuclide brain scans. 11-. cost
of finding a brain tumour was estimated to be at least f.i2o5 for
patients with abnormality on neurological examination and, 11' 11901
for patients with normal findings on examination. The auth rs feel
that neurological evaluation of heacache patients with
al
findings is expensives yr.l clinically unrewarding.
Brain Tumours; That Cm'-, scans contribute a great deal i.i +ae
diagnosis of brain tumours can not be denied. A co-operati’- e
study by 5 university hospitals sponsored by the nation;?... manner
institute, USA has found that (il 98 per cent of all int''cranial
tumours could be picked ’ ? by CAT" scans(ii)CAT scans recu- :d
the cost of diagnosis of intracrinial turmours by 25 per cent,
and (iii) angiograpay was as useful as, but more dangerous than,
CAt scans.
•
We, Ihowever feel
. that
....
such economic
.
and health benefits-Of CAT
scans as fewer days in hospital,
’, fewer complications',
complications, re
rc.'t.'-ed
: cred
number of diagnostic procedures,'fewer invasive studies ana
avoidance of exploratory'- surgery might be difficult to demchstrate in most of the developing countries.
The blind faith of patients and physicians alike . it this
technology at the slightest suspicion of brain tumour furl.er
alarms us. The ' just in case' approach is neither ethical nor
rational, And yet is it not a common sight to see so mqriy hams,
Shyams and Sitas with th. vaguest of neurological,symptoms to
be subjected to CAT scan:.: to have a brain tumour ruled cut?
Seizures: What was true with patients with headaches auc
suspected brain tumours fs equally true and patients wltr
seizures. ' A good history and a detailed neurological examination
is worth two CAT scans'.. says an article in the recently published
Post graduate medicine
nmal.
In a study by Harwood Nash et al (3), which highly;!• :-.ed
the wealth of information physical oxamiwition can pre vide-, the
results of CAT'scans we. normal in 80 par cent of children in
whom seizures were the ■ aly sign at presentation^in only 3
per cent a surgically tr stable lesion was found), where;'.?
-6'"
(6)
findings were abnormal in almost 70 per cent of those with
additional neurological signs. Older text-books of medicine
I
stress for intensive investigations of patients with 'epilepsy
of late onset'. However, compared to degenerations and atheros
clerotic strokes, tumours play only a small role in producing
seizures. Furthermore in practice, missing a primary cerebral
tumour is not quite so devastating r.s most non-neurologists would
believe. Most of the tumours are in-operable,often form part
of diffuse metastasis, and treatment is usually ineffective even
if an early diagnosis of dissemination is made. (4) An aggressive
approach to pick up epileptogenic tumours in old persons in
particular may not benefit them much.
Head Inquiry: -Mild head injury requires no more therapy than
reassurance to the patient. Even in moderate head injury masterly
inactivity would be most appropriate. It is for those who are
severely head-injured that CA’i' scan deserves an urgent consider
ation. Evidence definitely suggests that early removal of (within
four hours)acute subdural haematomas decreases morbidity and
mortality.An appropriately timed CAT scan in head injury would
thus:(i) pick up surgically drainable haematomas rather early,
(ii) eliminate unnecessary surgery and (iii) make medical
treatment more effective*
A point to ponder here is, if a severly head-injured victim has
to survive - or die - , first four hours are indeed crucial.
The chances of leading a useful and productive life or to remain
in a vegetative state hinge on the first four hours. Which means
that a patient must rapidly pass through the hurdles of being
taken to a hospital, a neurologist, a CaT centre and finally a
neurosurgeon, all within four hours. It will be interesting to
find out as to how many severly head-injured victims are CAT
scanned and haematoma-evacuated within the first four hours.
Stroke; The exact false-positive and false-negative rates for
the use- of GA1’ scan in acute stroke has yet to be determined.
If figures from different studies are pulled together, then
it seems that 20 to 40 per cent of acute strokes will fail to .
have any abnormality on their CaT scans.
The suggestion that CA1 scan should be done routinely on all
patients with stroke has been questioned by Larson et al. They
noted that although the introduction of CAT scanners has led to —
increased efficiency and specificity in the diagnosis of stroke, "
it did not alter clinical management or outcome. (4)Norris
and Hachinski support conclusion: they noted that rec.nt
availability of CAT scanners did not affect diagnostic accuracy,
which was more closely related to the attending physician( and
the passage of time).(5) Ona can conclude, says a patient-oriented
text book on.stroke, that CaT scans may We need in only two
situations in stroke: first when some alternate diagnosis which
can be picked up by CaT scanner is clinically suspected, and
secondly when it is important to identify a cerebral haemorrhage.
(6)
The additional Use of CaT scanners thus results in little obvious
improvement in the care of patients with cerebro-vascular diseases
but it does increase the cost of treatment.
' Summing Up:
Given the diagnostic power that it possesses, and the
razzle dazzle that it has created in the minds of most of the
doctors,CAT scanners run, if they haven't done it so far-, a '
definite risk of getting toutine in practice. It is an excellent
example of 'technology running wild', a feeling which,,may old
neurologists also share. Isn't it illogical to order CaT scan
for a patient of tubercular meningitis to detect hydrocephalus,
-7-
(7;
when he can not even buy his anti-TB drugs? Or trying '"o
differentiate cerebral infraction from cerebral haemori’hags in
an old man past SO? Or trying to justify CAT in clinically benign
headaches on ' just in case' logic? Or utilizing this technology
to search a cause for seizures in an already over-grown cancer?
CAT scan is a good tool. But it is only a means, not an end in
itself.
Medical College
Sevagram
Wardha 442 102
SP KALANTRI
REFERENCES;
1.
Computed Tnimography of the brain
J Am Med asso 1982; 247 ;y| 955-58.
2.
Larson IEB,Omenn GS and Lewis
, H.Diagnostic evaluation
of headache. J Am Med asso ('); 243;359-362.
3.
Larson EB at al. Computed tomography in patients •/it?
cerebro-vascular accidents, ma J Roent 1978;131:35~4O.
4.
Hopkins A. Epplepsy. In Oxford text-book of Medicine
Oxford University press, 1984. p.- 21. 135.
5.
Norris JW,Hachinski VC. Misdiagnosis of Stroke.
Lancet 1982; 1; 328-30.
6.
Wade DT et al. Stroke. Chapman '.nd Hall Medical
London, 1985. p. 32.
Consensus confcre.ee
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