Comparison of procedural sequences in same‐day bidirectional endoscopy without benzodiazepine and propofol sedation: starting at the bottom or the top

Background and Study Aims: Same‐day bidirectional endoscopy including esophagogastroduodenoscopy (EGD) and colonoscopy is routinely performed to evaluate anemia and gastrointestinal bleeding, as well as to conduct cancer surveillance. Numerous questions have been raised regarding the most appropriate procedural sequence and the resulting potential procedure interactions. We compared the quality and feasibility of performing EGD and colonoscopy without sedation in patients subjected to EGD‐colonoscopy (Group I) or colonoscopy‐EGD (Group II) sequences. Patients and Methods: A total of 80 patients were prospectively randomized into two groups (40:40). All EGD examinations were recorded on videotape, and the quality of 18 EGD steps was assessed by three endoscopists. In addition, we analyzed the colonoscopic parameters and subjective discomfort scores of patients. Results: Group I displayed significantly superior quality for retroflexion‐related steps (P11–13; all median of Group I vs Group II = 2:3; P < 0.01), visualization of the angular fold (P10; Group I vs Group II = 2:3; P = 0.048), and general assessment of the stomach (P17; Group I vs Group II = 2:3; P = 0.008) and upper GI tract (P15; Group I vs Group II = 2:3; P = 0.047). Colonoscopic insertion time, total time, and prolonged insertion ratio did not differ between the two groups. Questionnaire responses indicated that EGD was perceived to be more stressful in Group II sequence. Conclusions: The quality of EGD steps is influenced by the sequence of bidirectional endoscopy. EGD is perceived to be more stressful to patients when preceded by colonoscopy. Therefore, EGD followed by colonoscopy may be the preferable procedural sequence for same‐day bidirectional endoscopy.     

PROSPECTIVE COMPARISON BETWEEN SEDATED HIGH‐DEFINITION ORAL AND UNSEDATED ULTRATHIN TRANSNASAL ESOPHAGOGASTRODUODENOSCOPY IN THE SAME SUBJECTS: PILOT STUDY

Background: Recently, quality as well as acceptability has been a concern regarding endoscopy. The aim of the present study was to compare the acceptability and quality of sedated high‐definition esophagogastroduodenoscopy (sHD‐EGD) using a newly developed high‐definition videoscope with those of unsedated ultrathin esophagogastroduodenoscopy (uUT‐EGD) using a 5.2 mm videoscope. Methods: Twenty‐two volunteers underwent both peroral sHD‐EGD and transnasal uUT‐EGD on the same day. Sedation consisted of 40 mg of propofol i.v. Both endoscopist and subject satisfaction levels were assessed using a 10 cm visual analogue scale. Results: All 22 subjects completed the sHD‐EGD and 21 subjects completed the uUT‐EGD. The endoscopist and subject satisfaction levels of sHD‐EGD were significantly better than those of uUT‐EGD (overall endoscopist satisfaction: 9 vs 4, P < 0.0001; overall subject satisfaction: 9 vs 3, P < 0.0001). The optical quality of the endoscopic images of sHD‐EGD was significantly higher than that of uUT‐EGD except in the duodenal bulb (overall quality: 8 vs 7, P < 0.0001). The interobserver agreement for EGD findings in sHD‐EGD was better than with uUT‐EGD, although the EGD findings in both sHD‐EGD and uUT‐EGD were similar. After undergoing both procedures, 91% were willing to have sHD‐EGD again compared to 9% with uUT‐EGD. Conclusions: The endoscopist and subject satisfaction levels and image quality of sHD‐EGD were better than those of uUT‐EGD. The routine use of high‐definition videoscopes would be expected to provide better acceptability than that obtained with unsedated endoscopy.     

Which should go first during same‐day bidirectional endosocopy with propofol sedation?

Background and Aim: Same‐day bidirectional endoscopy, including esophagogastroduodenoscopy (EGD) and colonoscopy, is frequently performed to screen for cancer and gastrointestinal bleeding. However, the optimal sequence for the procedures is unclear thus far. The aim of this study was to evaluate the optimal sequence for same‐day bidirectional endoscopy. Methods: Consecutive patients undergoing same‐day bidirectional endoscopy under propofol sedation were randomized to either the colonoscopy‐first group (colonoscopy followed by EGD, n = 87) or the EGD‐first group (EGD followed by colonoscopy, n = 89). We evaluated the propofol dose, procedure duration, patient tolerance and recovery, adverse events, and endoscopic findings. The patient tolerance was assessed with a 0–10 visual analog scale. Results: Total procedure times, patients' tolerance and recovery, adverse events, and endoscopic findings were similar between the two groups. The total propofol dose was significantly higher for the colonoscopy‐first group than for the EGD‐first group (mean 95% credibility limit: 135.7 [70–201.4] mg vs 124.7 [64.1–185.3] mg, respectively, P = 0.024). Patients in the colonoscopy‐first group moved significantly more during colonoscopy than those in the EGD‐first group: 1.1 (0–3.8) versus 0.6 (0–2.9) scores, respectively (P = 0.024). Conclusion: The optimal sequence for same‐day bidirectional endoscopy is EGD followed by colonoscopy. In this order, the procedure is better tolerated, and patients require a lower overall dose of propofol.     

Belching during gastroscopy and its association with gastroesophageal reflux disease

Belching may result from transient lower esophageal sphincter relaxation; therefore, it has been proposed that belching may be a manifestation of gastroesophageal reflux disease (GERD). This study was conducted to investigate the frequency of belching during esophagogastroduodenoscopy (EGD) and its association with GERD. A retrospective review was performed on prospectively collected clinical and endoscopic data from 404 subjects who underwent EGD without sedation from December 2012 to May 2013 in a training hospital in Korea. All detectable belching events during endoscopy were counted. Frequency and severity of belching events were compared between the group with and without GERD using an ordinal logistic regression model. There were 145 GERD patients (26 erosive reflux disease and 119 nonerosive reflux disease [NERD]). In the multivariable analysis, GERD was significantly associated with a higher frequency of belching events (odds ratio = 6.59, P < 0.001). Central obesity, female, and younger age were also risk factors for frequent belching during EGD. Subgroup analyses were performed in subjects without erosive reflux disease (n = 378) and NERD (n = 293). NERD was also a predictive factor for frequent belching during EGD (odds ratio = 6.61, P < 0.001), and the frequency of belching was significantly correlated with GERD severity according to the Los Angeles classification (P < 0.05). Frequent belching during EGD was associated with GERD, including NERD. Future research should focus on its adjuvant role in the diagnosis of GERD/NERD and the necessity for applying differentiated endoscopy strategies for GERD patients, leading to less discomfort during EGD in patients at risk for intolerability.     

A Pilot Study About Tolerability to Double Balloon Endoscopy: Comparison to Esophagogastroduodenoscopy and Colonoscopy

Background Although the diagnostic and therapeutic values of double balloon endoscopy (DBE) have been investigated, the subjective tolerability to DBE has not been assessed. We aimed to evaluate patients’ tolerability to DBE. Methods We prospectively enrolled patients who underwent DBE. For the comparison of tolerability to DBE with that to esophagogastroduodenoscopy (EGD) and colonoscopy, those who had not undergone EGD nor colonoscopy were excluded. A total of 52 patients were included. All procedures were performed under conscious sedation with midazolam with or without pethidine. Patients’ tolerability to DBE, EGD, and colonoscopy was assessed through an interview with a questionnaire using a 10-point Likert scale. Results A total of 36 patients underwent both antegrade DBE and EGD under conscious sedation. The level of abdominal pain during procedures, the level of post-procedural abdominal discomfort, and the proportion of patients with persistent abdominal discomfort until the next morning were higher in antegrade DBE. However, when analyzed in 16 patients who had good quality of sedation, the differences in the level of abdominal pain during procedures and the persistent abdominal discomfort until the next morning disappeared. A total of 23 patients underwent both retrograde DBE and colonoscopy under conscious sedation. Tolerability parameters were not different between retrograde DBE and colonoscopy. Serious complications, including hemodynamic instability, did not occur during all procedures. Conclusion Patients tolerated DBE well. DBE may be performed as comfortably as EGD and colonoscopy if the quality of sedation is good enough.     

A study comparing tolerability, satisfaction and acceptance of three different techniques for esophageal endoscopy: sedated conventional, unsedated peroral ultra thin, and esophageal capsule

Three methods of esophagoscopy are available until now: sedated conventional endoscopy, unsedated ultrathin endoscopy, and esophageal capsule endoscopy. The three methods carry comparable diagnostic accuracy and different complication rates. Although all of them have been found well accepted from patients, no comparative study comprising the three techniques has been published. The aim of this study was to compare the three methods of esophagoscopy regarding tolerability, satisfaction, and acceptance. Twenty patients with large esophageal varices and 10 with gastroesophageal reflux disease were prospectively included. All patients underwent consecutively sedated conventional endoscopy, unsedated ultrathin endoscopy, and esophageal capsule endoscopy. After each procedure, patients completed a seven‐item questionnaire. The total positive attitude of patients toward all methods was high. However, statistical analysis revealed the following differences in favor of esophageal capsule endoscopy: (i) total positive attitude has been found higher (χ²= 18.2, df = 2, P= 0.00), (ii) less patients felt pain (χ²= 6.9, df = 2, P= 0.03) and discomfort (χ²= 22.1, df = 2, P= 0.00), (iii) less patients experienced difficulty (χ²= 13.7, df = 2, P= 0.01), and (iv) more patients were willing to undergo esophageal capsule endoscopy in the future (χ²= 12.1, df = 2, P= 0.002). Esophageal capsule endoscopy was characterized by a more positive general attitude and caused less pain and discomfort. Sedated conventional endoscopy has been found more difficult. More patients would repeat esophageal capsule endoscopy in the future. Patients' total position for all three available techniques for esophageal endoscopy was excellent and renders the observed advantage of esophageal capsule endoscopy over both sedated conventional and unsedated ultrathin endoscopy a statistical finding without a real clinical benefit.     

Outpatient upper gastrointestinal endoscopy: large,prospective study of the morbidity and mortality rate at a single endoscopy unit in England

Background: There are few prospective studies that look at the standards of the practice of esophago‐gastroduodenoscopy (EGD) and its associated morbidity. Patients and methods: Data were recorded prospectively for 1287 consecutive day‐case diagnostic EGD procedures. Thirty days later, 1155 of 1287 patients were successfully contacted. Results: The standards of care, as per various national recommendations, were met. Seven hundred and fifty‐four patients (401/572 [70%] men; 353/715 [49%] women; P = 0.001) chose pharyngeal anesthesis (PA) as premedication. Two women had general anesthesia. There were no immediate clinical complications. Thirty days later, 119/1155 (10%) patients who were contacted reported a problem, one requiring hospital admission. Fifty‐one of 119 had EGD performed under midazolam sedation (MS). Twenty‐five of 119 patients required consultation with a health‐care professional. No death occurred. Seventy‐nine percent of patients contacted who underwent their procedure with PA compared with 95% who had MS, said they would prefer the same premedication if EGD was required again in the future (P = 0.001). In subjects who had PA, 25% of women and 12% of men said they would prefer MS if EGD were required again (P = 0.001). Conclusions: Diagnostic EGD is a safe procedure, but carries a small complication rate. Patients’ gender, age, or patients’ preference for sedation or endoscopist did not affect the morbidity rate. Although the majority, particularly men, chose to have EGD performed unsedated, a significant number, particularly women, would prefer MS if EGD was required again.     

Prospective randomized trial of transnasal versus peroral endoscopy using an ultrathin videoendoscope in unsedated patients

AIM: The aim of this study was to compare the acceptance and tolerance of transnasal and peroral esophagogastroduodenoscopy (EGD) using an ultrathin videoendoscope in unsedated patients. METHODS: A total of 124 patients referred for diagnostic endoscopy were assigned randomly to have an unsedated transnasal EGD (n = 64) or peroral EGD (n = 60) with local anesthesia. An ultrathin videoendoscope with a diameter of 5.9 mm was used in this study. A questionnaire for tolerance was completed by the patient (a validated 0-10 scale where '0' represents no discomfort/well tolerated and '10' represents severe discomfort/poorly tolerated). RESULTS: Of the 64 transnasal EGD patients, 60 patients (94%) had a complete examination. Four transnasal EGD examinations failed for anatomical reasons; all four patients were successfully examined when switched to the peroral EGD. All 60 peroral EGD patients had a complete examination. Between the transnasal and peroral groups, there was a statistically significant difference in scores for discomfort during local anesthesia (1.5 +/- 0.2 vs 2.6 +/- 0.3, P = 0.003), discomfort during insertion (2.3 +/- 0.3 vs 4.3 +/- 0.3, P = 0.001), and overall tolerance during procedure (1.6 +/- 0.2 vs 3.8 +/- 0.2, P = 0.001). In all, 95% of transnasal EGD patients and 75% of peroral EGD patients (P = 0.002) were willing to undergo the same procedure in the future. Four patients in the transnasal EGD group experienced mild epistaxis. CONCLUSION: For unsedated endoscopy using an ultrathin videoendoscope, transnasal EGD is well tolerated and considerably reduces patient discomfort compared with peroral EGD.     

Study comparing oesophageal capsule endoscopy versus EGD in the detection of varices

BACKGROUND: Endoscopic screening and surveillance of cirrhotic patients for oesophageal varices is advocated before initiation of prophylactic therapy for prevention of the first variceal haemorrhage. AIMS: To compare the diagnostic yield of oesophageal capsule endoscopy (ECE) with Esophagogastroduodenoscopy (EGD) for detecting and grading oesophageal varices and to determine patient tolerance for each procedure. PATIENTS: Twenty consecutive cirrhotic patients scheduled for EGD were enrolled in the study. METHODS: Patients underwent ECE followed by EGD. Patients completed a visual analogue scale after each procedure, assessing level of anxiety, pain, overall satisfaction, and willingness to repeat each procedure. RESULTS: On EGD, 19/20 patients had oesophageal varices. ECE detected varices in 13/19 (68% sensitivity). ECE identified nine out of ten varices rated grade II or higher on EGD. The post-study analogue scale showed a greater level of anxiety before EGD (avg. 2.75/10) versus ECE (avg. 1.5/10). CONCLUSIONS: ECE may be used in the assessment of EV. It appears to have more discordance with EGD when evaluating smaller varices. The minimal discomfort, lack of sedation, and decreased risk make ECE a possible substitute to EGD in patients unable or unwilling to undergo EGD.     

Relationship between vomiting reflex during esophagogastroduodenoscopy and dyspepsia symptoms

Aim: Although frequent vomiting reflexes during esophagogastroduodenoscopy (EGD) causes suffering in patients, very few studies have investigated the characteristics of subjects who frequently develop vomiting reflexes. This study examined the incidence of the vomiting reflex and related factors, especially upper gastrointestinal symptoms, among individuals undergoing transoral EGD. Methods: Subjects included 488 consecutive adults (mean age, 56.1 ± 8.9 years) who underwent transoral EGD for gastric cancer screening between February 2010 and March 2011. All procedures were performed by an endoscopist with 15 years of experience. Based on a questionnaire survey using the frequency scale for the symptoms of gastroesophageal reflux disease (FSSG), symptoms (dyspepsia and acid reflux symptoms) and the number of vomiting reflexes during EGD were recorded. Results: Of the 488 subjects, 271 (56%) developed vomiting reflexes (mean, 4.2 times). This reflex‐positive group was younger (54.3 ± 9.5 years) than the reflex‐negative group (58.3 ± 7.7 years, P < 0.001). The number of subjects in the reflex‐positive group with a high FSSG dyspepsia score (2.27 ± 2.57 vs 1.23 ± 1.84; P < 0.001), acid reflux symptom score (1.96 ± 2.22 vs 1.34 ± 2.14; P < 0.01) or an esophageal hiatal hernia (14.8% vs 4.6%; P < 0.001) was significantly higher than in the reflex‐negative group. Multivariate analysis also showed a significant correlation between these four factors and the occurrence of vomiting reflexes. Using an FSSG dyspepsia score of 1 as the cut‐off offered 68% sensitivity and 57% specificity for predicting the occurrence of vomiting reflexes. Conclusion: Based on FSSG questionnaire responses on upper gastrointestinal symptoms, dyspepsia symptoms, in particular, are related to presence of vomiting reflexes during EGD.     

CARDIOVASCULAR TOLERANCE AND AUTONOMIC NERVOUS RESPONSES IN UNSEDATED UPPER GASTROINTESTINAL SMALL‐CALIBER ENDOSCOPY: A COMPARISON BETWEEN TRANSNASAL AND PERORAL PROCEDURES WITH NEWLY DEVELOPED MOUTHPIECE

Background: Transnasal esophagogastroduodenoscopy (EGD) with small‐caliber endoscopy appears to be less stressful to the cardiovascular system and has good patient tolerance. ENDO LEADER, a newly developed mouthpiece for peroral EGD with small‐caliber endoscopy, is expected to reduce patient stress. We compared the patient acceptance, cardiovascular tolerance and autonomic nervous responses between transnasal EGD and peroral EGD with ENDO LEADER. Patients and Methods: A total of 130 patients (transnasal group, 77; peroral group, 53) were enrolled. Pulse rate (P), blood pressure (BP), and peripheral blood oxygen saturation (SpO₂) were monitored. Acceptance of EGD was also assessed. Autonomic nervous responses were evaluated through analysis of heart rate variability using amplitude of the high‐frequency component (HF) and low‐frequency‐to‐high‐frequency power ratio (LF/HF) as indices of cardiac vagal activity and sympathetic activity, respectively. Results: Analysis of patient acceptance showed no differences between the two groups, except with regard to nasal pain. Increases in BP and P between before and during EGD examination were significantly higher in the peroral group. Although throat pain and overall tolerance scores were significantly correlated with ΔBP and ΔP, no correlations with nasal pain score were noted. Heart rate variability analysis revealed that heart rate increased significantly in the peroral group, but there were no differences in ΔHF or ΔLF/HF between the two groups. Conclusions: Patient acceptance was not significantly different between the transnasal and peroral with ENDO LEADER groups; however, transnasal EGD appears to be less stressful to the sympathetic nervous system, leading to smaller elevations in BP, P and heart rate.     

Perception of gastrointestinal endoscopy by patients and examiners with and without background music

BACKGROUND/AIMS: Several studies have reported improved patient comfort with music in the preoperative setting, however music has seldom been assessed during gastrointestinal endoscopy. We aimed to assess how background music may influence the perception of patients and examiners involved in endoscopic examinations. METHODS: 301 patients (128 females, 173 males; mean age 59 years) were included in the study (EGD and colonoscopy) in a prospective fashion. 90 EGD and 61 colonoscopies were performed with music (50.17%) and 102 EGD and 48 colonoscopies without music (49.83%). Patients, nurses and endoscopists completed a questionnaire. RESULTS: No significant differences in demographic data were found between the patients examined with or without music. Tolerance to the examination, pain sensation and perception of the endoscopy room ambiance were similar in both groups. The majority of patients (83.4%) expressed a preference for music during any future endoscopic examination and none perceived the music as disturbing. During the 151 examinations, music was considered unpleasant in 14 examinations by the physicians (9.3%) and in 11 examinations by the nurses (7.3%). CONCLUSIONS: Music has little influence on patients' experience of gastrointestinal endoscopy. Nevertheless, the majority of patients felt music to be helpful and expressed a preference for music during any future examination. This positive attitude to music of patients is in contrast with the assessment of some endoscopists and nurses.     

Dysplasia detection rate of confirmatory EGD in nondysplastic Barrett's esophagus

Current guidelines for endoscopic surveillance of Barrett's esophagus (BE) recommend that patients with newly diagnosed BE undergo confirmatory esophagogastroduodenoscopy (EGD) to exclude the presence of dysplasia. The extent to which confirmatory endoscopy alters management and detects missed dysplasia in newly diagnosed BE has not been reported. The frequency with which confirmatory endoscopy changed surveillance management in patients with newly diagnosed BE was assessed. A two center cohort analysis was conducted on patients newly diagnosed with BE. The rate of dysplasia on confirmatory endoscopy for patients who had nondysplastic BE was obtained. Demographic and endoscopic variables were assessed for association with dysplasia detection using Firth logistic regression model. Out of the 146 patients newly diagnosed with BE and initially determined to be without dysplasia, 12 had dysplasia on the confirmatory second EGD (8.2%). Eleven of 12 cases with dysplasia on confirmatory endoscopy had long‐segment BE (LSBE). Among all the LSBE cases in our cohort, 11 had newly diagnosed dysplasia on confirmatory EGD, 29.7% (11/37). The average number of biopsies obtained from the 11 LSBE cases with dysplasia was comparable with the rest of the LSBE cases without dysplasia (6.73 and 5.42, respectively, P‐value 0.205). The rate of dysplasia detection in short‐segment BE (SSBE) was much lower, 0.95% (1 out of 105). There were no cases of high‐grade dysplasia (HGD) or cancer detected in any SSBE case. HGD was detected on confirmatory EGD in two cases, both were LSBE. Segment length was the only statistically significant factor to predict the presence of dysplasia on confirmatory endoscopy (odds ratio 9.158, P. 0.008). Confirmatory EGD in newly diagnosed LSBE had significant rate of dysplasia detection (29.7%) in this cohort. Among patients with SSBE, there was a low rate of dysplasia detection with confirmatory EGD, less than 1% of cases. No additional cases of HGD or esophageal carcinoma in SSBE cases were detected. This suggests that the yield of confirmatory EGD is greater in patients with LSBE.     

Patient Experiences with Surveillance Endoscopy: A Qualitative Study

Background

Prior studies examining patterns of esophagogastroduodenoscopy (EGD) surveillance in patients with Barrett’s esophagus (BE) demonstrate variable adherence to practice guidelines. In prior studies, memories of endoscopic experiences shaped overall perceptions and subsequent adherence behaviors, but the specific elements of that experience are unclear. We sought to identify specific elements of the EGD experience that frame overall perceptions of surveillance.

Methods

We conducted structured in-depth, qualitative interviews with BE patients with a range of severity (non-dysplastic, low-grade and high-grade dysplasia) who recently completed an EGD. Data collection continued until we reached thematic saturation (n = 20). We applied principles of framework analysis to identify emerging themes regarding patients’ salient EGD experiences. We validated our coding scheme through multidisciplinary consensus meetings comprised of clinician (gastroenterologist and internist) and non-clinician investigators (sociologist and public health expert).

Results

Patient experiences can be conceptualized within a temporal model: prior to, during, and after endoscopy. The most memorable aspects of the EGD experience include physician-patient communication prior to EGD, wait time at the endoscopy center, interpersonal interactions at the time of the EGD, level of pain or discomfort with the procedure, level of trust in the physician following EGD, and gaining a sense of control over BE.

Conclusions

We identified six salient memories before, during, and after the procedure that shape patients’ perceptions of the EGD experience. We offer recommendations for measuring patient experiences using a composite of validated survey items. Future studies should test the relation of patient experience measures and adherence to surveillance EGD.     

Feasibility and safety of string wireless capsule endoscopy in the diagnosis of esophageal varices

OBJECTIVE: To assess the feasibility, safety, accuracy, and acceptability of "string-capsule endoscopy" in the evaluation of esophageal varices. MATERIAL AND METHODS: Strings were attached to the wireless capsule endoscopy device to allow its controlled movement up and down the esophagus. Time of recording and discomfort associated with the procedure was documented. Patient's preference compared to conventional esophago-gastro-duodenoscopy (EGD) was recorded. An independent endoscopist blinded to EGD diagnoses assessed the diagnostic accuracy of pictures obtained. RESULTS: Thirty patients with clinical liver cirrhosis (mean age: 54.4 yr; mean MELD score: 12.5, and mean Child-Pugh score: 6.3) were enrolled; 19 for surveillance and 11 for screening purposes. The procedure was safe (no strings were disrupted and no capsule was lost). The mean recording time was 5.8 min (2.9-8.7), the accuracy 96.7%, and discomfort was minimal. The majority (83.3%) of patients preferred string-capsule endoscopy to EGD. CONCLUSIONS: String-capsule endoscopy was feasible, safe, accurate, highly acceptable, and preferred by cirrhotic patients undergoing screening/surveillance of esophageal varices. The technique may prove to be more cost effective than conventional EGD.     

Safety and Efficacy of Nasogastric Intubation for Gastrointestinal Bleeding After Myocardial Infarction: An Analysis of 125 Patients at Two Tertiary Cardiac Referral Hospitals

Our purpose was to analyze risks versus benefits of nasogastric (NG) intubation for gastrointestinal (GI) bleeding performed soon after myocardial infarction (MI). While NG intubation and aspiration is relatively safe, clinically beneficial, and routinely performed in the general population for recent GI bleeding, its safety after MI is unstudied and unknown. In addition to the usual complications of NG tubes, patients status post-MI may be particularly susceptible to myocardial ischemia or cardiac arrhythmias from anxiety or discomfort during intubation. We studied NG intubation within 30 days of MI in 125 patients at two hospitals from 1986 through 2001. Indications for NG intubation included melena in 55 patients; fecal occult blood with an acute hematocrit decline, severe anemia, or sudden hypotension in 37; hematemesis in 18; bright red blood per rectum in 8; and dark red blood per rectum in 7. The intubation was performed on average 5.3 ± 7.2 (SD) days after MI. NG aspiration revealed bright red blood in 38 patients, “coffee grounds”-appearing blood in 45, and clear (or bilious) fluid in 42. Among 114 of the patients undergoing esophagogastroduodenoscopy (EGD), EGD revealed the cause of bleeding in 79 (95%) of 83 patients with a grossly bloody NG aspirate versus 12 (39%) of 31 patients with a clear aspirate (P < 0.0001, OR = 31.3, OR CI = 9.4–103.1). Among 85 patients undergoing EGD within 16 hr of NG intubation, stigmata of recent hemorrhage were present in 28 (42%) of 66 with a bloody NG aspirate versus 3 (16%) of 19 with a clear aspirate (P = 0.06, OR = 3.93). Among 35 patients undergoing lower GI endoscopy, lower endoscopy revealed the cause of bleeding in 14 (56%) of 25 patients with a clear NG aspirate versus 1 (10%) of 10 patients with a grossly bloody aspirate (P < 0.04, OR = 11.46, OR CI = 1.55–78.3). The two NG tube complications (epistaxis during intubation and gastric erosions from NG suctioning) were neither cardiac nor major (requiring blood transfusions). This study suggests that short-term NG intubation is relatively safe and may be beneficial and indicated for acute GI bleeding after recent MI. Aside from improving visualization at EGD, the potential benefits include providing a rational basis for the timing of endoscopy (urgent versus semielective), for prioritizing the order of endoscopy (EGD versus colonoscopy), and for avoiding or deferring endoscopy in low-yield situations (e.g., colonoscopy when the NG aspirate is bloody). These benefits may be particularly relevant in patients after recent MI due to their increased endoscopic risks.     

Unsedated transnasal ultrathin esophagogastroduodenoscopy may provide betterdiagnostic performance in gastroesophageal reflux disease

Transnasal ultrathin esophagogastroduodenoscopy (N‐EGD) with less gagging reflexes under non‐sedation is likely suitable for the diagnosis of gastroesophageal reflux disease (GERD), however, N‐EGD might have drawbacks, including its low image resolution. Limited information is available regarding the diagnosability of N‐EGD for GERD. We compared the utility and gagging reflexes of three different endoscopies, including N‐EGD, ultrathin transoral EGD (UTO‐EGD) and conventional oral EGD (CO‐EGD), in the diagnosis of GERD. We performed screening endoscopy in 1580 patients (N‐EGD n = 727, UTO‐EGD n = 599, CO‐EGD n = 254) and compared the frequency distributions of the severity of reflux esophagitis, hiatus hernia, and Barrett's epithelium to estimate the diagnostic performance of each endoscopy. We also analyzed patients' tolerability of endoscopy by the subjective evaluation of gagging reflexes. In the diagnosis of reflux esophagitis and Barrett's epithelium, there was no significant difference in the frequency distributions of the severity of the diseases among three EGDs. However, the incidence of Barrett's epithelium was higher than that in the previous nationwide survey of GERD in Japan. The evaluated size of hiatus hernia was smaller in N‐EGD than in two other peroral endoscopies. The size of hiatus hernia correlated significantly with severity of gagging reflexes that was also lowest when diagnosed with N‐EGD. N‐EGD had an equivalent performance in the diagnosis of reflux esophagitis and Barrett's epithelium compared with CO‐EGD. Enlargement of hiatus hernia induced by gagging reflexes was minimal in N‐EGD, resulting in its better performance in the diagnosis of Barrett's epithelium.     

Midazolam versus diazepam for combined esophogastroduodenoscopy and colonoscopy

This study compares the effects of two different benzodiazepines used for conscious sedation during combined upper gastrointestinal endoscopy (EGD) and colonoscopy. Subjects were assessed for their degree of analgesia and amnesia for the procedure, prior experience with endoscopy, and willingness to undergo another similar procedure should such be necessary. The patients were randomized single blind to receive either midazolam or diazepam for their preprocedure sedation. The amount of preprocedure sedation utilized was determined by titration of the dose to achieve slurring of speech. Prior to receiving either agent, the subjects were shown a standard card containing pictures of 10 common objects, were asked to name and remember them, and were told they would be quizzed (at 30 min and 24 hr) after being sedated for their recollection as to the objects pictured on the card. Each subject filled out a questionnaire addressing their perceived discomfort during the endoscopic procedure and their memory of the procedure 24 hr after the procedure. Sixty-three percent of the midazolam-sedated subjects reported total amnesia for their colonoscopy vs 20% of diazepam-sedated patients (P<0.001). Fifty-three percent of midazolam-sedated patients reported total amnesia of their upper gastrointestinal endoscopy vs only 23% of diazepam-sedated subjects (P<0.05). The midazolam-sedated subjects reported experiencing less pain with both upper gastrointestinal endoscopy (P<0.05) and colonoscopy (P<0.001) than did the diazepam-sedated group. Most importantly, the midazolam group was more willing to undergo another similar endoscopic procedure should they be asked to do so by their physician (P<0.05). Subjects greater than 60 years of age required significantly less midazolam for sedation than did the younger subjects (P<0.001). This difference in dosing based upon age was not observed in the diazepam-sedated group. Based upon these data we conclude that midazolam is superior to diazepam in producing conscious sedation for combined upper gastrointestinal endoscopy and colonoscopy with regard to: (1) amnesia for the procedures, (2) discomfort experienced at the time of the procedure, and (3) better patient acceptance of future gastrointestinal endoscopic procedures.This work was supported in part by a grant from the Gastroenterology Medical Research Foundation of Southwestern Pennsylvania.     

A Randomized Prospective Trial Comparing Unsedated Endoscopy via Transnasal and Transoral Routes Using 5.5-mm Video Endoscopy

We performed a randomized prospective trial to compare unsedated endoscopy via transnasal and transoral routes using a small-caliber endoscope. Two hundred patients referred for diagnostic esophagogastroduodenoscopy (EGD) were randomly allocated to two groups: those undergoing transnasal (TN) and transoral (TO) endoscopy. We examined the insertion rate, examination duration, nasal pain, pharyngeal pain, number of occurrences of pharyngeal reflex, severity of discomfort throughout the examination, and rate of adverse events. Patients were asked to rate the severity of their pain or discomfort on a 10-cm visual analog scale (VAS). We identified statistically significant differences between the TN and TO groups in rate of insertion (95% versus 100%, respectively, P < 0.05) and examination duration (9.7 ± 3.0 min versus 8.4 ± 2.7 min, respectively, P < 0.005). Severity of discomfort throughout the examination was comparable in the TN and TO groups (3.0 ± 1.8 versus 2.9 ± 2.3, NS). Nasal bleeding occurred as an adverse event in 4.1% of patients in the TN group. Patients in the TO group were more likely than those in the TN group to prefer the present method in the subsequent endoscopic examination (99.0% versus 82.1%, P < 0.00005). These results indicated that transoral insertion is superior to transnasal insertion in endoscopy procedures performed with small-caliber endoscope.     

Feasibility and safety of string, wireless capsule endoscopy in the diagnosis of Barrett's esophagus

BACKGROUND: Capsule endoscopy is a major technological advancement in the visualization of the small bowell. Its utility in the evaluation of the esophagus is mainly limited by its rapid and unpredictable transmission, thus limiting the number of pictures of the esophagus, in particular, the distal esophagus. METHODS: Strings were attached to the wireless capsule endoscopy device to allow its controlled movement up and down the esophagus. Microbiologic cultures of the capsule's surface after high-level disinfection were carried out after the procedure. At the time of recording, discomfort associated with the procedure was documented. Patient preference compared with conventional EGD was recorded. An independent endoscopist blinded to the EGD diagnoses assessed the diagnostic accuracy of pictures obtained. OBSERVATIONS: Fifty patients with Barrett's esophagus were enrolled: 28 with short-segment Barrett's and 22 with long-segment Barrett's. The procedure was safe (no strings were disrupted, and no capsule was lost), and it rendered negative microbiologic cultures after high-level disinfection. The mean recording time was 7.9 minutes; all patients with both short- and long-segment Barrett's esophagus were successfully identified. The difficulty/discomfort associated with swallowing the device, throat discomfort, gagging, moving the capsule (up and down and upon retrieval of the capsule) was none or minimal in 74%, 98%, 96%, 94%, and 76%, respectively. A single capsule was used in 24 studies, and the majority of patients (92%) preferred string-capsule endoscopy to EGD. CONCLUSIONS: String-capsule endoscopy was feasible, safe, and highly acceptable, and was preferred by patients and may prove to be more cost effective than screening EGD.