Severe open fractures of the tibia

SIR,-The traditional role of barium radiology is being increasingly challenged by endoscopists. The article by Dr D C Lindsay and colleagues (16 January, p 167) is fairly typical of most reports from endoscopists. Cooperative studies by radiologists and endoscopists usually give a more balanced view. The authors set off on the wrong foot by stating that fibreoptic gastroduodenoscopy is now accepted as the first investigation for the vast majority ofpatients with upper gastrointestinal symptoms. There is considerable evidence to the contrary. '15 For the large bowel the barium enema examination is capable of an accuracy not far below that of total colonoscopy.6 Also radiology is safer and more likely to give a complete examination. Dr Lindsay and colleagues are wrong to imply that because no major complications occurred in their 168 patients the two techniques are equally safe. The list of complications associated with colonoscopy is long and impressive. Quoted mortality rates from simple diagnostic colonoscopy range from 0 03%7 to 0.008%.8 If all the 250 000 patients having a barium enema examination this year in England and Wales were to have a colonoscopy instead up to 75 deaths could be expected. Also the authors use the word "completeness" in an unusual way and this is confusing. Barium enema is complete to the caecum in virtually all patients whereas colonoscopy is incomplete in about 25%. Having a substantial proportion ofpatients with an unexamined caecum and ascending colon obviously limits the value of the technique. As a general policy there is much to be said for continuing to use the double contrast barium enema examination as the initial examination (supplemented when necessary by fibreoptic sigmoidoscopy), except when biopsy or polypectomy may be indicated or in those patients in whom the advantage of the potentially greater accuracy of colonoscopy outweighs the extra risk and high incidence of incomplete examination. Spurred on by the pharmaceutical and optical industries, and with opportunities for self referral, the endoscopy bandwagon is on the move. But the replacement of barium radiology to an extent advocated by endoscopists like Dr Lindsay and colleagues would be expensive, inappropriate, and unnecessary. Radiology is already in place and providing a good service. Therefore it makes both clinical and financial sense for endoscopy to complement and not replace barium studies. Further expansion of the endoscopy service should be concentrated on those areas where a suitable alternative is not so readily available.