A Randomized Trial of Unsedated Transnasal Small-Caliber Esophagogastroduodenoscopy (EGD) versus Peroral Small-Caliber EGD versus Conventional EGD

Background and Study Aims: Unsedated esophagogastroduodenoscopy (EGD) has advantages over sedated EGD - e. g., prevention of side effects related to sedation, less patient monitoring, and less expense. This study compared the feasibility and tolerance of transnasal small-caliber (TSC-EGD) and peroral small-caliber EGD (PSC-EGD) with conventional EGD (C-EGD).
Patients and Methods: A total of 150 patients referred for diagnostic EGD were randomly allocated to undergo either TSC-EGD, PSC-EGD, or C-EGD under local anesthesia if they agreed to receive sedation only on demand or in case of intolerance. Patients, endoscopists, and nurses completed questionnaires on the tolerability and quality of the examinations using a visual analogue scale (VAS), ranging from 1 (best/nonexistent) to 10 (worst/unbearable) after EGD. Small-caliber EGD and C-EGD were performed with 5.9-mm and 9.8-mm video endoscopes (Olympus), respectively.

Results: The patients' age, sex, experience with EGD, and anxiety before EGD did not differ significantly between the three groups, each consisting of 50 patients. TSC-EGD failed in four of the 50 patients (8 %) because of a narrow nasal tract; they underwent PSC-EGD. Complete examinations, including the second part of the duodenum and biopsy sampling, were possible in all patients. Patients examined with an ultrathin instrument required sedation significantly less often (TSC-EGD 6 %, PSC-EGD 18 %, C-EGD 44 %; P < 0.01) and consequently spent less time in the recovery room. TSC-EGD was initially more painful on insertion, but caused less gagging (P<0.01) than peroral EGD during the whole procedure. TSC-EGD caused mild epistaxis in one case.

Conclusions: TSC-EGD was carried out safely and completely in 92 % of the patients. TSC-EGD and PSC-EGD were better tolerated and required sedation less often than conventional EGD. Transnasal diagnostic EGD appears to be a promising alternative to peroral EGD, as it is associated with less gagging and a high level of patient satisfaction.

References

• 1 Bell G D. Premedication and intravenous sedation for gastrointestinal endoscopy.  Aliment Pharmacol Ther. 1990;  4 103-122
• 2 Arrowsmith J B, Gerstman B B, Fleischer D E, Benjamin S B. Results from the American Society for Gastrointestinal Endoscopy/U.S. Food and Drug Administration collaborative study on complication rates and drug use during gastrointestinal endoscopy.  Gastrointest Endosc. 1991;  37 421-427
• 3 Froehlich F, Gonvers J J, Fried M. Conscious sedation, clinically relevant complications and monitoring of endoscopy: results of a nationwide survey in Switzerland.  Endoscopy. 1994;  26 231-234
• 4 Al-Atrakchi H A. Upper gastrointestinal endoscopy without sedation: a prospective study of 2000 examinations.  Gastrointest Endosc. 1989;  35 79-81
• 5 Sorbi D, Gostout C J, Henry J, Lindor K D. Unsedated small-caliber esophagogastroduodenoscopy (EGD) versus conventional EGD: a comparative study.  Gastroenterology. 1999;  117 1301-1307
• 6 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
• 7 Craig A, Hanlon J, Dent J, Schoeman M. A comparison of transnasal and transoral endoscopy with small-diameter endoscopes in unsedated patients.  Gastrointest Endosc. 1999;  49 292-296
• 8 Mulcahy H E, Riches A, Kiely M. et al . A prospective controlled trial of an ultrathin versus a conventional endoscope in unsedated upper gastrointestinal endoscopy.  Endoscopy. 2001;  33 311-316
• 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 Quine M A, Bell G D, McCloy R F. et al . Prospective audit of upper gastrointestinal endoscopy in two regions in England: safety, staffing, and sedation methods.  Gut. 1995;  36 462-467
• 11 Hart R, Classen M. Complications of diagnostic gastrointestinal endoscopy.  Endoscopy. 1990;  22 229-233
• 12 Scott-Coombes D M, Thompson J N. Hypoxia during upper gastrointestinal endoscopy is caused by sedation.  Endoscopy. 1993;  25 308-309
• 13 Dean R, Dua K, Massey B. et al . A comparative study of unsedated transnasal esophagogastroduodenoscopy and conventional EGD.  Gastrointest Endosc. 1996;  44 422-424
• 14 Campo R, Montserrat A, Brullet E. Transnasal gastroscopy compared to conventional gastroscopy: a randomized study of feasibility, safety and tolerance.  Endoscopy. 1998;  30 448-442
• 15 Christensen M, Achiam M, Trap R. et al . Transnasal gastroscopy.  Dan Med Bull. 2000;  47 218-220
• 16 Saeian K, Townsend W F, Rochling F A. et al . Unsedated transnasal EGD: an alternative approach to conventional esophagogastroduodenoscopy for documenting Helicobacter pylori eradication.  Gastrointest Endosc. 1999;  49 297-301
• 17 Dua K S, Ruan E, Shaker R. Transnasal pharyngoesophagogastroduodenoscopy (T-PEGD) in a patient with acute upper gastrointestinal bleeding.  Endoscopy. 1996;  28 530