Unsedated transnasal EGD: an alternative approach to conventional esophagogastroduodenoscopy for documenting Helicobacter pylori eradication

doi:10.1016/S0016-5107(99)70004-0

Gastrointestinal Endoscopy

Volume 49, Issue 3, March 1999, Pages 297-301

https://doi.org/10.1016/S0016-5107(99)70004-0 Get rights and content

Abstract

Background: The aim of this study was to assess the yield of antral biopsies performed via unsedated transnasal esophagogastroduodenoscopy, a technique that does not require conscious sedation with its concomitant costs and complications, for documentation of Helicobacter pylori eradication. Methods: Nineteen patients who were previously CLO test positive on conventional esophagogastroduodenoscopy and subsequently treated for H pylori infection were enrolled. The subjects had not received antibiotic therapy in the prior month and had no prior gastric surgery. By using a GIF-N30 fiberoptic endoscope and a tiny cup biopsy forceps (1.8 mm diameter), unsedated transnasal endoscopy was performed and antral biopsy specimens were taken for a CLO test, histologic analysis (Dieterle stain), and tissue culture. On the same day, the subjects underwent a carbon 13–labeled area urea breath test. All subjects completed a visual analog scale, rating the acceptability of the unsedated transnasal examination and the previous sedated conventional esophagogastroduodenoscopy. Results: There was no statistically significant difference between the results of the CLO tests (5/19 positive) versus the ¹³C-urea breath test (4/19 positive) (p = 0.96), the CLO tests versus histologic findings (5/19 positive) (p = 0.71), or the ¹³C-urea breath test versus histologic findings (p = 0.96). All tissue culture results were negative. The overall acceptability of unsedated transnasal esophagogastroduodenoscopy was similar to that of sedated conventional esophagogastroduodenoscopy. Conclusion: Unsedated transnasal esophagogastroduodenoscopy, a technique that eliminates the costs and complications associated with conscious sedation, is a feasible and accurate alternative to conventional esophagogastroduodenoscopy when documentation of H pylori eradication and confirmation of gastric ulcer healing are both indicated. (Gastrointest Endosc 1999;49:297-301.)

Section snippets

Patients and Methods

We identified the 34 most recent consecutive patients from the Zablocki VA Medical Center in Milwaukee, Wis., who were found to be CLO test (Delta West Pty Ltd, Bentley, Western Australia) positive on conventional endoscopy and subsequently treated for infection with H pylori and invited them to participate in the study. Exclusion criteria included any antibiotic therapy in the prior 30 days, documentation of H pylori status after therapy by another means, inability to give informed consent,

RESULTS

T-EGD with biopsies and the ¹³C-UBT were successfully performed in all 19 patients. The average length of time required for the T-EGD, measured from the time the nose was anesthetized, was 22.5 minutes with a standard error of 1.5 minutes. The overall test results for all 19 subjects are summarized in Table 2.

. Results of CLO tests, ¹³C-UBT, histologic findings, and culture

Patient	1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16	17	18	19	Sensitivity (%	Specificity (%)
CLO	-	+	+	-	-	-	-	-	-	-	-	-	+	-	-	+	-	-	+	100	94
¹³C-UBT	-	-	+	-	-	-	-	-	-	-	-	-	+	-	-	+	-	-	+	100	100

CONCLUSIONS

The present study demonstrates the feasibility and accuracy of unsedated T-EGD with a urease biopsy test in documenting eradication of H pylori infection. Previous studies have already shown that unsedated T-EGD is a feasible³ and reliable alternative to conventional EGD in evaluating upper gastrointestinal pathologic conditions.⁴

In all of the study subjects we were able to reach the second part of the duodenum and obtain good visualization of the mucosa throughout the upper gastrointestinal

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Cited by (56)

Sedation and Monitoring in Endoscopy
2019, Clinical Gastrointestinal Endoscopy
Sedation practices have noticeably changed over the past decade as the utilization of esophagogastroduodenoscopy and colonoscopy has steadily risen. Over time, we have seen a dramatic shift from no or moderate sedation to monitored anesthesia care (MAC) for gastrointestinal endoscopy. This shift has led anesthesiologists into the endoscopy suite with newer sedative medications and increased safety concerns. The consequence of this change in sedation practices requires an endoscopist to have a strong foundation regarding many sedation-related issues, including depth of sedation, appropriate patient selection, choice of sedative medications, methods of sedation delivery, patient monitoring, recovery from sedation, and patient outcomes. With the changing landscape of the health care system, the challenges of quality and cost warrant us to provide the best possible care for our patients in the most efficient manner possible. The endoscopy suite is a unique sedation environment, and the purpose of this chapter is to review all aspects pertaining to current sedation practices in gastrointestinal endoscopy.
"First look" unsedated transnasal esogastroduodenoscopy in patients with upper gastrointestinal bleeding? A prospective evaluation
2014, Clinics and Research in Hepatology and Gastroenterology
Citation Excerpt :
Since 1994, we, and others, have demonstrated that t-EGD is a feasible technique on a routine basis without any sedation [28]. Then, different studies showed that diagnostic t-EGD increases patients’ tolerance [23,29–31] and could therefore reduce the requirement for sedation with similar diagnostic yields [32–35]. Thereafter, we extended the use of t-EGD to specific diagnostic yields including UGIB.
With small diameter endoscopes, transnasal esophagogastroduodenoscopy (t-EGD) is routinely performed. The aim of this prospective observational study was to evaluate the role of t-EGD for upper gastrointestinal bleeding (UGIB).
One hundred and forty-five consecutive patients (mean age, 66 ± 18.4 years) with suspicion of UGIB were classified a priori into 3 groups according to initial clinical presentation: (1) intensive care unit with EGD under sedation, (2) endoscopy unit with EGD under transient sedation and (3) unsedated t-EGD as “first look”. Demographic, clinical and biological parameters, Rockall and Blatchford scores, endoscopic diagnosis and treatment, and outcome were analysed.
Unsedated t-EGD was attempted in 89 patients, performed in 52 (5 failures, 28 contraindications) and the procedure was converted under sedation for 2 patients. Based on ASA classification, clinical (blood pressure, hemodynamical failure) and biological variables (hemoglobin, platelets, creatinine), these patients were less severe than in the other groups. Pre-endoscopic Rockall and Blatchford scores were significantly lower in this group. More patients in this group presented significant cardiovascular co-morbidity (47.2%), taking aspirin, clopidogrel and/or anticoagulant.
Our results strongly support that “first look” unsedated t-EGD can avoid unnecessary sedation in selected patients with UGIB, presenting a low probability for endoscopic haemostatic treatment and high sedation risks.
Sedation and Monitoring in Endoscopy
2011, Clinical Gastrointestinal Endoscopy, Second Edition
Unsedated transnasal versus transoral sedated upper gastrointestinal endoscopy: A one-series prospective study on safety and patient acceptability
2008, Digestive and Liver Disease
While conventional oesophagogastroduodenoscopy is frequently performed under sedation to improve acceptability, transnasal oesophagogastroduodenoscopy would appear to be less invasive.
To compare diagnostic accuracy, feasibility, acceptability and safety of transnasal oesophagogastroduodenoscopy without sedation versus conventional oesophagogastroduodenoscopy under sedation.
Following anxiety assessment, 30 dyspeptic patients underwent transnasal oesophagogastroduodenoscopy under local anaesthesia (lidocaine) and conventional oesophagogastroduodenoscopy under conscious sedation (i.v. midazolam) on two consecutive days. Transnasal oesophagogastroduodenoscopy was performed with an ultrathin and conventional oesophagogastroduodenoscopy with a standard endoscope.
Safety, evaluated by monitoring cardio-respiratory functions. Acceptability, rated according to discomfort and preference between the two examinations. Diagnostic accuracy evaluated taking into account endoscopic patterns and adequacy of biopsy specimens for histology. Feasibility, defined according to endoscopic performance, quality of images and overall opinion of the endoscopist. Only gastric biopsies were evaluated.
All patients but one who refused conventional oesophagogastroduodenoscopy underwent both transnasal oesophagogastroduodenoscopy and conventional oesophagogastroduodenoscopy. No cardiorespiratory complications occurred during either technique. Majority of patients (87%) preferred transnasal oesophagogastroduodenoscopy. Examinations were completed in all cases, with comparable endoscopic patterns. All biopsy specimens were suitable for histology.
Transnasal oesophagogastroduodenoscopy without sedation provides good diagnostic accuracy, is safer and better accepted than conventional oesophagogastroduodenoscopy under sedation and, therefore, represents a valid alternative in routine diagnosis of upper digestive tract diseases.
Feasibility and tolerance of 2-way and 4-way angulation videoscopes for unsedated patients undergoing transnasal EGD in GI cancer screening
2008, Gastrointestinal Endoscopy
Citation Excerpt :
To compensate, meticulous observation with the proper observation distance is necessary to detect subtle lesions. The diagnostic yield of transnasal unsedated upper EGD has been found to be similar to that conventional sedated EGD in evaluation for Helicobacter pylori diagnosis and eradication,17 detection and grading of esophageal varices,18 and detection of Barrett's metaplasia and dysplasia.19 On the other hand, there are limited data on the evaluation of transnasal EGD regarding early gastric cancer.
The differences between 2-way and 4-way angulation endoscopes for use in unsedated patients undergoing transnasal EGD have not been elucidated.
Our purpose was to evaluate the feasibility and tolerance of 2- and 4-way angulation endoscopes for unsedated transnasal EGD in GI cancer screening of elderly people.
A total of 291 patients were randomized to receive unsedated transnasal EGD with a 5.2-mm diameter 2-way angulation endoscope (GIF-N260, Olympus, Tokyo, Japan) (n = 146) or 5.5-mm diameter 4-way angulation endoscope (XGIF-XP240N2, Olympus) (n = 145). The transnasal insertion success rate and incidence of epistaxis were compared. The following parameters were evaluated: overall quality of the examination, ease of passing the endoscope through the pylorus, intubation of the second portion of the duodenum, ability to observe the entire upper GI tract and perform target biopsy, and examination time. Patient tolerance and acceptance were also assessed with regard to nasal pain, choking, gagging, abdominal discomfort, and overall pain and discomfort.
Matsushita Health Care Center, Moriguchi, Japan.
A total of 291 patients had unsedated transnasal EGD as part of a gastric cancer screening program.
Use of the pediatric 4-way angulation endoscope significantly shortened the examination time when biopsy was performed compared with the 2-way angulation instrument, whereas the examination time without biopsy was not significantly different. Other parameters were not significantly different between the 2 endoscopes.
For unsedated transnasal EGD with biopsy, the 5.5-mm 4-way angulation videoscope shortens examination time while providing easy transnasal insertion and improved patient tolerance.
Self-training in unsedated transnasal EGD by endoscopists competent in standard peroral EGD: prospective assessment of the learning curve
2008, Gastrointestinal Endoscopy
Training programs in unsedated transnasal (UT) EGD are scarce.
To prospectively assess the learning curve for unsupervised UT-EGD.
Endoscopy service, without experience in UT-EGD.
Consecutive patients referred for diagnostic EGD.
UT-EGD was attempted in 140 study patients by 2 endoscopists who trained by themselves in UT-EGD (skilled endoscopist [n = 70]; a trainee having recently achieved competency in conventional EGD [n = 70]) and in 10 controls (endoscopist skilled in UT-EGD) by using a 4.9-mm-diameter videoendoscope.
Technical success, sedation administered, patient tolerance acceptance, procedure duration for each decade of 10 consecutive patients investigated by the same endoscopist; intention-to-treat analysis.
Both self-trained endoscopists fulfilled predefined criteria of competency in UT-EGD since the first attempts. They completed examinations of adequate quality with exclusive transnasal scope insertion (n = 139 [99.3%]), no sedation (n = 138 [98.6%]), and patient accepting repeat procedure (n = 135 [96.4%]) in proportions not significantly different from controls for all decades. Compared with a median procedure duration of 5.5 minutes (interquartile range [IQR] 5.0-8.5 minutes) in controls, procedures were significantly longer for all trainee's decades (eg, first decade 20.0 minutes [IQR 15.0-29.0 minutes], P < .001) but none for the skilled endoscopist. Overall discomfort, pain, gagging, and belching were not significantly different for study patients versus controls. Fifty-six of 69 study patients (81%) with a previous history of conventional EGD preferred UT-EGD.
Generalizability to other small-caliber endoscopes.
Endoscopists competent in conventional EGD may obtain excellent results with UT-EGD (except for procedure duration) beginning with their first attempts, even without supervision or structured training.

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^☆: Reprint requests: Reza Shaker, MD, Professor of Medicine, Division of Gastroenterology and Hepatology, Medical College of Wisconsin Froedtert Memorial Lutheran Hospital, 9200 W. Wisconsin Ave., Milwaukee, WI 53226.

^☆☆: 37/1/92976

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Unsedated transnasal EGD: an alternative approach to conventional esophagogastroduodenoscopy for documenting Helicobacter pylori eradication☆,☆☆

Abstract

Section snippets

Patients and Methods

RESULTS

CONCLUSIONS