Comparison of transnasal small-caliber vs. peroral conventional esophagogastroduodenoscopy for evaluating varices in unsedated cirrhotic patients

Background and study aims: We aimed to evaluate the accuracy of transnasal small-caliber esophagogastroduodenoscopy (TNSC-EGD) compared with peroral conventional EGD (POC-EGD) for evaluating varices in unsedated patients with liver cirrhosis. The success rate, safety, endoscopist satisfaction, and patient tolerability of TNSC-EGD were also addressed.

Patients and methods: One hundred patients with liver cirrhosis participated in this randomized crossover trial, and 84 subjects completed both procedures. Of the 84 patients, 28 had marked bleeding diathesis (platelet count ≤ 50 000/mm³ and/or prothrombin time ≥ 1.7 INR). Endoscopists and patients answered questionnaires using a 100-mm visual analog scale about, respectively, their satisfaction and their tolerance of the procedure.

Results: The success rate of TNSC-EGD was comparable to that of POC-EGD (96 % vs. 99 %). Nasal mucosal hemorrhages induced by TNSC-EGD occurred in 5 patients (6 %), but were easily controlled. Compared to the POC-EGD reference test, diagnostic accuracies of TNSC-EGD for detecting esophageal varices, gastric varices, and red color signs were 98 %, 98 %, and 96 %, respectively. Concordance rates on grading esophageal varices and gastric varices were excellent at 93 % (κ = 0.85) and 96 % (κ = 0.87). Endoscopist satisfaction was not significantly different between TNSC-EGD and POC-EGD, whereas patient tolerance of TNSC-EGD was significantly greater than that of POC-EGD (79.0 ± 14.4 vs. 69.5 ± 16.1; P = 0.001).

Conclusion: TNSC-EGD without sedation was found to be feasible, safe, and accurate for evaluating esophageal varices, gastric varices, and red color signs in patients with cirrhosis – even in those with marked bleeding diathesis. Furthermore, it was significantly better tolerated by patients, without altering endoscopist satisfaction. Our findings indicate that TNSC-EGD without sedation might be viewed as a potential alternative to POC-EGD for evaluation of varices.

References

• 1 Boyer T D. Natural history of portal hypertension.  Clin Liver Dis. 1997;  1 31-44
• 2 Garcia-Tsao G, Sanyal A J, Grace N D et al. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis.  Hepatology. 2007;  46 922-938
• 3 Eisen G M, Baron T H, Dominitz J A et al. Complications of upper GI endoscopy.  Gastrointest Endosc. 2002;  55 784-793
• 4 Assy N, Rosser B G, Grahame G R et al. Risk of sedation for upper GI endoscopy exacerbating subclinical hepatic encephalopathy in patients with cirrhosis.  Gastrointest Endosc. 1999;  49 690-694
• 5 Dean R, Dua K, Massey B et al. A comparative study of unsedated transnasal esophagogastroduodenoscopy and conventional EGD.  Gastrointest Endosc. 1996;  44 422-424
• 6 Bampton P A, Reid D P, Johnson R D et al. A comparison of transnasal and transoral oesophagogastroduodenoscoy.  J Gastroenterol Hepatol. 1998;  13 579-584
• 7 Campo R, Montserrat A, Brullet E. Transnasal gastroscopy compared to conventional gastroscopy: a randomized study of feasibility, safety and tolerance.  Endoscopy. 1998;  30 448-452
• 8 Zaman A, Hahn M, Hapke R et al. A randomized trial of peroral versus transnasal unsedated endoscopy using an ultrathin videoendoscope.  Gastrointest Endosc. 1999;  49 279-284
• 9 Dumortier J, Ponchon T, Scoazec J Y et al. Prospective evaluation of transnasal esophagogastroduodenoscopy: feasibility and study on performance and tolerance.  Gastrointest Endosc. 1999;  49 285-291
• 10 Sorbi D, Gostout C J, Henry J et al. Unsedated small-caliber esophagogastroduodenoscopy (EGD) versus conventional EGD: a comparative study.  Gastroenterology. 1999;  117 1301-1307
• 11 Preiss C, Charton J P, Schumacher B et al. A randomized trial of unsedated transnasal small-caliber esophagogastroduodenoscopy (EGD) versus peroral small-caliber EGD versus conventional EGD.  Endoscopy. 2003;  35 641-646
• 12 Saeian K, Staff D, Knox J et al. Unsedated transnasal endoscopy: a new technique for accurately detecting and grading esophageal varices in cirrhotic patients.  Am J Gastroenterol. 2002;  97 2246-2249
• 13 Madhotra R, Mokhashi M, Willner I et al. Prospective evaluation of a 3.1-mm battery-powered esophagoscope in screening for esophageal varices in cirrhotic patients.  Am J Gastroenterol. 2003;  98 807-812
• 14 Darwin P, Zangara J, Heller T et al. Unsedated esophagoscopy for the diagnosis of esophageal varices in patients with cirrhosis.  Endoscopy. 2000;  32 971-973
• 15 Catanzaro A, Faulx A, Pfau P R et al. Accuracy of a narrow-diameter battery-powered endoscope in sedated and unsedated patients.  Gastrointest Endosc. 2002;  55 484-487
• 16 Pungpapong S, Keaveny A, Raimondo M et al. Accuracy and interobserver agreement of small-caliber vs. conventional esophagogastroduodenoscopy for evaluating esophageal varices.  Endoscopy. 2007;  39 673-680
• 17 Japanese Research Society for Portal H. The general rules for recording endoscopic findings of esophagogastric varices – revised edition [in Japanese].  Kanzou (Acta Hepatol Jpn). 1991;  33 277-281
• 18 Boustière C, Dumas O, Jouffre C et al. Endoscopic ultrasonography classification of gastric varices in patients with cirrhosis. Comparison with endoscopic findings.  J Hepatol. 1993;  19 268-272
• 19 Cohen L B, Delegge M H, Aisenberg J et al. AGA Institute review of endoscopic sedation.  Gastroenterology. 2007;  133 675-701
• 20 Mosca S, Balzano A. Is routine topical anesthesia or conscious sedation necessary in upper endoscopy, especially in patients with liver cirrhosis?.  Endoscopy. 2001;  33 639-640
• 21 Kazemi F, Kettaneh A, N’Kontchou G et al. Liver stiffness measurement selects patients with cirrhosis at risk of bearing large oesophageal varices.  J Hepatol. 2006;  45 230-235
• 22 Vizzutti F, Arena U, Romanelli R G et al. Liver stiffness measurement predicts severe portal hypertension in patients with HCV-related cirrhosis.  Hepatology. 2007;  45 1290-1297
• 23 Kim Y J, Raman S S, Yu N C et al. Esophageal varices in cirrhotic patients: evaluation with liver CT.  AJR Am J Roentgenol. 2007;  188 139-144
• 24 Kim S H, Kim Y J, Lee J M et al. Esophageal varices in patients with cirrhosis: multidetector CT esophagography – comparison with endoscopy.  Radiology. 2007;  242 759-768
• 25 Perri R E, Chiorean M V, Fidler J L et al. A prospective evaluation of computerized tomographic (CT) scanning as a screening modality for esophageal varices.  Hepatology. 2008;  47 1587-1594
• 26 Eisen G M, Eliakim R, Zaman A et al. The accuracy of PillCam ESO capsule endoscopy versus conventional upper endoscopy for the diagnosis of esophageal varices: a prospective three-center pilot study.  Endoscopy. 2006;  38 31-35
• 27 Lapalus M G, Dumortier J, Fumex F et al. Esophageal capsule endoscopy versus esophagogastroduodenoscopy for evaluating portal hypertension: a prospective comparative study of performance and tolerance.  Endoscopy. 2006;  38 36-41
• 28 de Franchis R, Eisen G M, Laine L et al. Esophageal capsule endoscopy for screening and surveillance of esophageal varices in patients with portal hypertension.  Hepatology. 2008;  47 1595-1603
• 29 Lapalus M G, Soussan Ben E, Gaudric M et al. Esophageal capsule endoscopy vs. EGD for the evaluation of portal hypertension: a French prospective multicenter comparative study.  Am J Gastroenterol. 2009;  104 1112-1118
• 30 Maffei M, Dumonceau J M. Transnasal esogastroduodenoscopy (EGD): comparison with conventional EGD and new applications.  Swiss Med Wkly. 2008;  138 658-664
• 31 Dumortier J, Josso C, Roman S et al. Prospective evaluation of a new ultrathin one-plane bending videoendoscope for transnasal EGD: a comparative study on performance and tolerance.  Gastrointest Endosc. 2007;  66 13-19
• 32 Horiuchi A, Nakayama Y, Hidaka N et al. Prospective comparison between sedated high-definition oral and unsedated ultrathin transnasal esophagogastroduodenoscopy in the same subjects: pilot study.  Dig Endosc. 2009;  21 24-28