This case involves a middle-aged man who presented to the hospital complaining of difficulty swallowing which had persisted for several hours before he arrived. According to the patient, he had been at a business dinner with several clients when a piece of food became lodged in his esophagus. A chest x-ray revealed the obstruction within the patient’s esophagus, and an endoscopy was scheduled with a gastroenterologist at the same hospital. During the procedure, the patient vomited a substantial quantity of barium that the patient had swallowed earlier in order to obtain images of his esophagus. As a result, the patient developed a severe case of pneumonia, which required an extended stay in the hospital to treat and nearly killed the patient on multiple occasions.
Question(s) For Expert Witness
- 1. Do you routinely treat patients similar to the one described in the case?
- 2. Have you ever had a patient develop the outcome described in the case?
- 3. Are there specific precautions needed before performing an endoscopy after a barium swallow?
Expert Witness Response E-000006
Typically the supervision of CRNA’s in the inpatient setting will be done by anesthesia, not GI, but every institution is different. Barium is not typically given when there is a possible impaction/obstruction, as it does lead to an increased risk of aspiration. Typically on cases where there is obstruction, protecting the airway by intubating the patient is standard of care, an this is also typically done by the anaesthesia provider. I am a board certified GI affiliated with an academic health center. I typically treat similar patients, and I do endoscopies on patients with suspected food impaction on a weekly basis. I have not had a patient aspirate during endoscopy. I have regularly performed endoscopy in a hospital endoscopy suite. I will be alone in the room with CRNA’s and AA’s and will give them orders and instructions, however their supervision is the responsibility of an anesthesiologist.
This double board certified expert has been practicing for nearly 25 years. Fellowship trained in Gastroenterology, he is a member of multiple prestigious gastrointestinal societies and has been running his own gastroenterological practice for the past 19 years. He is also currently an Assistant Professor of Medicine at a prominent medical school, as well as the Medical Director of the Department of Endoscopy at an academic hospital.
Expert Witness Response E-007578
I am a member of the Quality Assurance in Endoscopy Committee of the American Society of Gastrointestinal Endoscopy where I have chaired guidelines on Safety in the Endoscopy Unit. I routinely treat patients with food impactions that require endoscopy. This is especially frequent since I practice in a busy, urban trauma center in Boston. Standard requirements are to remain free of clear liquids for 2 hours and all other liquids/foods for at least 4-6 hours. Most endoscopists would not perform an endoscopy after a barium swallow with high grade obstruction because a) the risk of aspiration and b) inability to visualize anything due to the thick coating of barium.
This board-certified and fellowship-trained expert currently serves as Assistant Professor of Medicine and Attending Gastroenterologist at a major university medical center. She is a fellow of the American College of Gastroenterology and belongs to a number of additional prestigious societies in the field. She has published multiple peer-reviewed articles, textbook chapters, and abstracts on gastroenterology procedures and is highly regarded in the gastroenerological space.