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PubMed2001

Unsedated transnasal laryngo-esophagogastroduodenoscopy: an alternative to conventional endoscopy.

The introduction, refinement, and subsequent widespread use of flexible fiberoptic endoscopes have revolutionized the diagnosis and management of upper gastrointestinal (GI) disorders. There has been a simultaneous increase in the cost of managing upper GI disorders, which is in part attributed to the high price of endoscopy. Unfortunately, in the current cost-conscious health-care environment, the high cost of endoscopy has resulted in the underuse of this valuable clinical tool. Unsedated transnasal laryngo-esophagogastroduodenoscopy (T-EGD) is a new technique for upper endoscopy that uses an ultrathin endoscope and has a comparable yield to conventional upper endoscopy but obviates the need for conscious sedation because it is better tolerated. Studies have found that T-EGD is a feasible alternative to conventional endoscopy in terms of safety, efficacy, and cost containment. This article reviews these factors, the technique of T-EGD, patient and endoscopist considerations, tissue sampling, and the characteristics of ultrathin endoscopes used for T-EGD.

Procedural Sedation↗

PubMed1989

Radiologists and endoscopy: a survey of the attitudes and intentions of radiologists in training.

A postal survey of senior registrars in radiology in this country was carried out to assess attitudes towards radiologists taking part in endoscopy services. One hundred and ninety-six senior registrars from 37 training centres recognised by the Royal College of Radiologists completed the questionnaire (a response of 74%). Thirty-nine per cent of respondents had some practical experience of endoscopy before commencing training in radiology. Twenty-eight per cent of respondents declared a major interest in gastrointestinal radiology. Sixty four per cent felt that radiologists should perform endoscopy (87% in the case of those with a major interest in gastrointestinal radiology). Thirty-seven per cent were interested in providing, or participating in, an endoscopy service after obtaining a consultant post. Despite this level of interest, only 18% of respondents felt that they had adequate access to endoscopy training and only 3% were aware of the training recommendations of the British Society, of Gastroenterology.

Attitude of Health Personnel↗

PubMed2004

Simethicone for small bowel preparation for capsule endoscopy: a systematic, single-blinded, controlled study.

BACKGROUND: Capsule endoscopy is a new imaging method for visualization of the entire small bowel. However, no standardized protocol for bowel preparation for capsule endoscopy has been evaluated. METHODS: Capsule endoscopy was performed in 36 consecutive patients, all of whom fasted for 12 hours before ingestion of the capsule. Before capsule endoscopy, 18 patients received 80 mg simethicone and 18 had no supplemental medication for bowel preparation. Two observers, both experienced endoscopists, independently reviewed the examinations in a single-blinded and randomly assigned fashion. Mucosal visibility and intraluminal gas bubbles were assessed and graded by both observers. RESULTS: Bowel preparation with simethicone resulted in significantly better visibility because of fewer intraluminal bubbles (p<0.01). Interobserver agreement was excellent (r>/=0.8; k 0.78: 95% CI[0.57, 0.98] ). No adverse effect of simethicone was observed. CONCLUSIONS: Simethicone may be added to the routine preparation for capsule endoscopy to improve the visibility of small bowel mucosa.

Adolescent↗

PubMed2004

Training with a computer-based simulator achieves basic manual skills required for upper endoscopy: a randomized controlled trial.

BACKGROUND: Changes in medical practice have constrained the time available for education and the availability of patients for training. Computer-based simulators have been devised that can be used to achieve manual skills without patient contact. This study prospectively compared, in a clinical setting, the efficacy of a computer-based simulator for training in upper endoscopy. METHODS: Twenty-two fellows with no experience in endoscopy were randomly assigned to two groups: one group underwent 10 hours of preclinical training with a computer-based simulator, and the other did not. Each trainee performed upper endoscopy in 19 or 20 patients. Performance parameters evaluated included the following: esophageal intubation, procedure duration and completeness, and request for assistance. The performance of the trainees also was evaluated by the endoscopy instructor. RESULTS: A total of 420 upper endoscopies were performed; the computer pretrained group performed 212 and the non-pretrained group, 208. The pretrained group performed more complete procedures (87.8% vs. 70.0%; p < 0.0001), required less assistance (41.3% vs. 97.9%; p < 0.0001), and the instructor assessed performance as "positive" more often for this group (86.8% vs. 56.7%; p < 0.0001). The length of procedures was comparable for the two groups. CONCLUSIONS: The computer-based simulator is effective in providing novice trainees with the skills needed for identification of anatomical landmarks and basic endoscopic maneuvers, and in reducing the need for assistance by instructors.

Adult↗

PubMed2005

A prospective trial comparing wireless capsule endoscopy and barium contrast series for small-bowel surveillance in hereditary GI polyposis syndromes.

BACKGROUND: Capsule endoscopy has demonstrated its clinical utility in the evaluation of the small bowel, and, accordingly, it has been suggested that it could be useful for the identification of small-intestinal polyps in patients with polyposis syndromes. The objective was to establish the effectiveness of wireless capsule endoscopy for detecting small-bowel polyps in patients with hereditary GI polyposis syndromes in comparison with barium contrast series. METHODS: Consecutive patients with GI polyposis syndromes were included. Small-bowel follow-through series and capsule endoscopy were performed within 1 week, in a blind fashion. The number and the location of polyps were analyzed. RESULTS: Twenty-four patients with familial adenomatous polyposis (n = 20) or Peutz-Jeghers syndrome (n = 4) were included. Capsule endoscopy detected small-bowel polyps in 7 of 24 patients (29%), whereas a barium contrast study identified small-intestinal polyps in only 3 of these 7 patients. In the 4 remaining patients, all of them with familial adenomatous polyposis, polyps detected by the capsule but missed in radiographic series were located at either ileum (2 patients), jejunum (1), or duodenum (1). No procedure-related complication was observed in any patient. CONCLUSIONS: Wireless capsule endoscopy is a highly accurate technique for the detection of small-bowel polyps in patients with hereditary GI polyposis syndromes, and it represents a valuable alternative to barium contrast series in the surveillance of patients with Peutz-Jeghers syndrome.

Administration, Rectal↗

PubMedDate not supplied

Topical anesthesia with 50 mg of lidocaine spray facilitates upper gastrointestinal endoscopy.

To investigate the value of 50 mg of topical lidocaine spray in upper gastrointestinal endoscopy, a randomized double-blind placebo-controlled study was undertaken with 50 mg of lidocaine spray as the active treatment. All patients were sedated with diazepam after administration of the spray. Included in the study were 158 consecutive patients aged 18 years or older being treated at the endoscopy unit of Scunthorpe district general hospital. Tolerance to upper gastrointestinal endoscopy as assessed by endoscopists and patients was evaluated. Of the 158 patients, 85 received the placebo spray and 73 the lidocaine spray. Patient acceptability for upper gastrointestinal endoscopy was significantly greater in the lidocaine group than in the placebo group (p = 0.001), and tolerance to the procedure as assessed by the endoscopist was also significantly greater in the lidocaine group than in the placebo group (p = 0.008). We conclude that topical anesthesia with 50 mg of lidocaine spray facilitates upper gastrointestinal endoscopy for the endoscopist and increases patient tolerance for the procedure.

Anesthesia, Local↗

PubMed1997

Combined magnification endoscopy with chromoendoscopy in the evaluation of patients with suspected malabsorption.

BACKGROUND: Magnification endoscopy and chromoendoscopy together have been used to evaluate mucosal detail in a number of conditions, including Barrett's esophagus and flat colonic polyps, but they have not been used to evaluate villous atrophy in the proximal small intestine. METHODS: Thirty-four patients suspected of having a malabsorption syndrome (either celiac disease or tropical sprue) were evaluated using an Olympus magnification gastroscope in both normal and high magnification settings. Indigo carmine dye spraying techniques were used to assist in evaluating duodenal mucosa for evidence of villous atrophy. The accuracy of endoscopically predicted villous atrophy was assessed by histologic evaluation of biopsy specimens taken in the descending duodenum. RESULTS: Magnification endoscopy with dye spraying was both highly sensitive (94%) and specific (88%) in identifying patients with villous atrophy. This technique was more accurate (91%) in identifying patients with partial atrophy than standard endoscopy (9%, p < 0.01) and was also useful in identifying patients with patchy villous atrophy (5 of 5) to allow directed biopsies of abnormal tissue. CONCLUSION: Magnification endoscopy with chromoendoscopy is a promising technique for the evaluation of patients with suspected malabsorption. This technique is especially valuable in patients with partial atrophy, where villous abnormalities can be patchy and the duodenum usually appears normal during standard endoscopy.

Atrophy↗

PubMed1998

Placebo-controlled trial assessing the use of oral midazolam as a premedication to conscious sedation for pediatric endoscopy.

BACKGROUND: This study was performed to evaluate the effect of midazolam, as premedication before intravenous conscious sedation, on preprocedural, procedural, and post-procedural patient comfort and anxiety in children undergoing endoscopy. METHODS: A placebo-controlled, double-blind, randomized study was conducted in 123 children (age 7.75 +/- 4.46 years, 56% male) using oral midazolam (0.5 mg/kg, maximum 20 mg) as a premedication before insertion of an intravenous access device (i.v.) and upper endoscopy. Patients were evaluated with regard to changes in vital signs, level of sedation during i.v. placement, level of pre- and post-procedure conscious sedation, ease of separation from parents, ease and duration of procedure, recovery time, and amnesia to objects shown before i.v. placement and immediately before the start of the procedure. RESULTS: A significant difference was noted in the study group for the following parameters: level of sedation for i.v. placement (p < 0.0001), pre-procedural sedation (p < 0.001), ease of i.v. insertion (p < 0.003), ease of separation from parents (p = 0.022), and ease of the nursing personnel's ability to monitor the patient during the procedure (p = 0.0012). The patient's amnesia to an object shown immediately before beginning the endoscopy was increased (p < 0.001). Patients and parents were also more satisfied with the procedure process (p < 0.05). No significant difference was noted with regard to the length or performance of the procedure or recovery time or in the dose of i.v. medication required for successful completion of the endoscopy. CONCLUSION: Oral midazolam is an effective and safe premedication for children undergoing upper endoscopy and should be used in all anxious children and in patients previously judged to be difficult to sedate.

Administration, Oral↗

PubMed1999

Risk of sedation for upper GI endoscopy exacerbating subclinical hepatic encephalopathy in patients with cirrhosis.

BACKGROUND: The risk of exacerbating subclinical hepatic encephalopathy associated with the administration of sedative drugs in patients with cirrhosis undergoing diagnostic upper gastrointestinal (GI) endoscopy for portal hypertension remains to be determined. METHODS: Ten adult patients with cirrhosis completed number connection tests before sedation for endoscopy and at discharge from the endoscopy unit 2 hours post-procedure. Control patients consisted of five patients with cirrhosis undergoing the same procedure for the same indication who did not receive sedation and 12 patients with no evidence of liver disease who received sedation before diagnostic endoscopy for a variety of GI complaints. The control populations were age, gender, education level, and, in the case of patients with cirrhosis, Child Pugh s score matched to the patients with cirrhosis who received sedation. RESULTS: The mean (+/- SEM) age of patients with cirrhosis who received sedation was 59.6 +/- 3.8 years. Seven of the ten (70%) were men. Their mean Child Pugh s score was 7.2 +/- 1.5. Nine of the ten (90%) had abnormal baseline number connection tests results (mean for the group 52.3 +/- 6.7 seconds) the extent of which correlated with Child Pugh s scores (p < 0.005). Individually, the baseline number connection tests results were normal in one (10%), mild in six (60%), moderate in one (10%), and severe in two (20%). After the procedure (before discharge) the mean number connection tests result was 61.5 +/- 7.9 seconds (p = 0.01 when compared with baseline). The results were now normal in none (0%), mild in four (40%), moderate in four (40%), and severe in two (20%). Pre- and post-procedure number connection tests results did not change in the non-sedated cirrhotic or sedated non-liver disease control patients. CONCLUSIONS: The results of this study indicate that (1) the majority of patients with cirrhosis and suspected portal hypertension have evidence of subclinical hepatic encephalopathy, (2) the extent of encephalopathy correlates with the Child Pugh's score, (3) sedation with midazolam for upper GI endoscopy exacerbates the encephalopathy, and (4) this adverse effect is still evident 2 hours after the procedure.

Adult↗

PubMed1998

The value of screening for psychiatric disorders prior to upper endoscopy.

Gastrointestinal (GI) complaints are among the most common symptoms in primary care yet are frequently unexplained and often lead to costly diagnostic testing. We sought to determine the prevalence of psychiatric disorders in patients with unexplained GI complaints undergoing upper endoscopy, and the likelihood of endoscopic abnormalities in patients with and without psychiatric diagnoses. We prospectively evaluated 116 adult patients who were undergoing upper endoscopy to evaluate GI complaints. All subjects received a structured psychiatric interview prior to endoscopy using PRIME-MD, and endoscopists were blinded to the PRIME-MD results. Psychiatric disorders were detected in 70 (60%) patients. Overall, there were 113 diagnoses (some patients had multiple disorders) with the most common being somatoform (44%), depressive (29%), and anxiety (19%) disorders. Only 29 patients had major endoscopic abnormalities, including esophageal disease (14), peptic ulcer (9), severe gastritis (4), gastric cancer (1), and esophageal cancer (1). There was a much higher prevalence of psychiatric disorders in patients without major endoscopic abnormalities (74% vs. 21%, p < 0.0001). Psychiatric disease was strongly predictive of endoscopic findings (OR for major abnormality = 0.11 in women, and 0.40 in men), especially if somatoform disorder was present (OR = 0.15). We conclude that, with a simple questionnaire, psychiatric disorders can be diagnosed in a large proportion of patients with unexplained GI complaints who are referred for upper endoscopy. The presence of a psychiatric disorder, particularly if somatoform, makes it unlikely that endoscopy will reveal significant GI disease.

Adult↗

PubMed2001

Can nasal endoscopy be used to predict residual symptoms after adenoidectomy for nasal obstruction?

BACKGROUND: the efficacy of adenoidectomy in relieving nasal symptoms has been questioned. Although enlarged adenoids are often blamed for nasal obstruction, other causes can be missed if examination is not thorough. We suggest that endoscopy at the time of adenoidectomy may be useful to confirm large adenoids and exclude other causes, and the findings may help predict residual symptoms 2 years after adenoidectomy. METHOD: a prospective study of a consecutive series of children undergoing adenoidectomy for nasal obstruction was performed. All underwent endoscopy with a 4-mm rigid endoscope without decongestants under GA immediately prior to adenoidectomy. Two years later a postal symptom questionnaire was sent, with telephone follow up for non-responders. The findings on endoscopy were compared with residual symptoms at 2 years. RESULTS: Forty-eight children aged 2-9 (mean 4) years were enrolled, 26 of them female. At 2 years follow up, data were available for 34 children (71%). Complete obstruction of the posterior choanae of the nose by adenoids was seen in 21 (62%). Additional findings (e.g. septal deviation, hypertrophic mucosa on the turbinates) were present in 22 (65%). Of them 9 (26%) had residual nasal symptoms. Of the children with less than occlusive adenoids, six (50%) out of 12 had residual symptoms, compared with three (14%) out of 21 with occlusive adenoids (chi(2)=4.91, P<0.05). Although residual symptoms were more common in those with additional findings on the original endoscopy (32 vs. 17%), this did not reach statistical significance. CONCLUSIONS: residual nasal symptoms are common when children are followed up in the medium term. The findings on endoscopy may predict the success of adenoidectomy in relieving the symptoms, and may help to guide further treatment.

Adenoidectomy↗

PubMed2006

Assessment of patient satisfaction with endoscopy using an interactive voice response system.

AIM: The aim of this study was to determine the feasibility of patient's satisfaction assessment after endoscopy using an interactive voice response (IVR) system. METHODS: A specific IVR system was developed for this study and proposed to patients by 161 private gastroenterologists after an endoscopic procedure. No reminder was used for the patients not calling spontaneously the IVR. RESULTS: After endoscopy, 31% of the patients called the IVR and 1052 answered the entire questionnaire. The answers obtained by the IVR and a face-to-face interview were concordant for 98.8% of the questions. The endoscopy was carried out with anesthesia for 94% of the patients and 95% stated they would agree to undergo the procedure again under the same conditions. This was independently associated with the presence of explanations about the procedure before its realization, male gender and, for the patients having had a colonoscopy, difficulties in taking the bowel cleaner and the presence of pain after the colonoscopy. CONCLUSION: This study shows the feasibility of patient's satisfaction assessment with endoscopy using an IVR system under routine conditions of endoscopy practice.

Aged↗

PubMedDate not supplied

Percutaneous biliary endoscopy.

The development of small-diameter flexible endoscopes has expanded the role of biliary endoscopy to include percutaneous interventions. Percutaneous biliary endoscopy is a technique that is easily learned. The equipment for percutaneous biliary endoscopy is readily available since most hospitals have an appropriate-sized choledochoscope and light source for intraoperative use. Therefore, the initial capital costs associated with flexible biliary endoscopy are minimal. Percutaneous biliary endoscopy in the interventional radiology suite is an ideal arrangement to facilitate a wide variety of biliary diagnostic and interventional procedures.

Biliary Tract Diseases↗

PubMed2003

The advantages and disadvantages of endoscopy.

Endoscopy is generally a very safe and effective tool in the diagnosis and therapy of various gastrointestinal (GI) disorders, and must be used in conjunction with other diagnostic modalities. Endoscopy should not be a substitute for a complete work-up. There are many advantages of endoscopy, including minimal morbidity and mortality, and the sensitivity of this modality in the diagnosis of mucosal disorders of the GI tract. However, complications may occur, and there are limitations to endoscopy. This article will provide an overview of when to choose GI endoscopy and when other procedures might provide more information.

Animals↗

PubMed1998

The minimal standard terminology for digestive endoscopy: introduction to structured reporting.

The wider use of computers for the management of endoscopic data and the use of electronic endoscopes for the production of high quality endoscopic images has made the standardization of terminology and images formats necessary in digestive endoscopy reports. The European Society for Gastrointestinal Endoscopy and the American Society for Gastrointestinal Endoscopy have combined their efforts to propose a Minimal Standard Terminology for Computerized Databases in Endoscopy. This terminology is based on the following principles: no term describing findings less frequent than 1%, of the daily practice, and no term based on subjective impressions. The Minimal Standard Terminology has been developed according to the natural process of constructing an endoscopic report in natural language and deals with the following: reasons for performing the examination, endoscopic findings, endoscopic diagnosis, additional therapeutic and diagnosis procedures (biopsies, etc.). It is subdivided according to the main organs examined with an endoscopy. Until now, the Minimal Standard Terminology was tested in many centers and was shown to accurately cover 95% of routine examinations for the upper gastrointestinal tract, colonoscopy and cholangio-pancreatography. It is currently being tested in an a prospective way in several centers in Europe (with a grant from the European Commission DGXIII-C4) and in the USA (with grant from the AHDHF).

Endoscopy, Digestive System↗

PubMed2001

Appropriateness of upper gastrointestinal endoscopy: a hospital-based study.

Aims of this study were to evaluate: (1) whether upper gastrointestinal endoscopy (UGE) is used appropriately according to the American Society for Gastrointestinal Endoscopy (ASGE) and British Society of Gastroenterology (BSG) guidelines in a hospital setting and (2) whether there is any relationship between appropriateness of UGE and the presence of lesions detected by endoscopy. Indications and endoscopic findings for 734 consecutive UGE performed in 697 inpatients were retrospectively evaluated using ASGE and BSG guidelines to determine appropriateness of referrals. UGE showing endoscopic findings that had direct therapeutic or prognostic consequences were classified as "positive"; the other UGEs were classified as "negative." In all, 46% of UGEs were "positive," 54% "negative," and 61.7% and 23.2% of UGEs were inappropriate according to ASGE and BSG guidelines, respectively (P < 0.001). The probability of finding a positive endoscopy was significantly higher in UGE rated as appropriate than in those rated as inappropriate on the basis of ASGE guidelines (P < 0.001), but not on the basis of BSG guidelines. Endoscopies rated as inappropriate according to ASGE and BSG criteria showed a positive finding in 37.3% and 42.3% of cases, respectively (not significant difference). Multivariate analysis showed that the positive finding is directly related to age (P < 0.05), male gender (P < 0.001), prior UGE (P < 0.05), hematemesis (P < 0.001), and inversely related with upper abdominal pain (P < 0.01) and dyspepsia (P < 0.05). In hospitalized patients, UGE is frequently used for inappropriate indications, according to both ASGE and BSG guidelines. However, the actual clinical usefulness of appropriateness criteria, such as those proposed by ASGE and BSG, is questionable, as their strict observance could lead to missing a large number of significant endoscopic findings.

Adult↗

PubMed1996

A double-blind randomized trial of low-dose versus high-dose topical anaesthesia in unsedated upper gastrointestinal endoscopy.

BACKGROUND: Upper gastrointestinal endoscopy is frequently performed on unsedated subjects. Pharyngeal anaesthesia is thought to improve patient tolerance to the procedure but the optimum dose of anaesthesia is not known. The aim of this study was to assess the benefits of low-dose vs. high-dose topical anaesthesia in unsedated gastroscopy. METHODS: One hundred and fourteen subjects attending for diagnostic gastroscopy were studied. Patients were randomized to receive either 30 mg or 100 mg of topical pharyngeal lidocaine spray prior to endoscopy in a double-blind fashion. Subjects completed a questionnaire before and after endoscopy. RESULTS: A similar proportion of patients in each group required intravenous sedation because of discomfort or anxiety during the procedure (P = 0.48). The high-dose group experienced less discomfort during endoscope insertion (P = 0.002) and throughout the examination (P = 0.01). Overall satisfaction was almost identical in the two groups (P = 0.85) and a similar percentage of the high-dose and low-dose groups stated that they would request sedation prior to future endoscopy (37 vs. 44%; P = 0.48). Further analysis showed that apprehensive patients and younger patients reported relatively high levels of discomfort, and that female subjects were more likely to express a preference for sedation at any future gastroscopy. CONCLUSION: High-dose pharyngeal anaesthesia reduces patient discomfort during unsedated upper gastrointestinal endoscopy. However, patient tolerance is also influenced by clinical features, which might be useful in deciding which patients are suitable for this procedure.

Administration, Topical↗

PubMed1998

Randomized controlled trial of omeprazole or endoscopy in patients with persistent dyspepsia: a cost-effectiveness analysis.

BACKGROUND: Cost-effectiveness analysis, Helicobacter pylori research and the development of proton pump inhibitors are having an increasing impact on the management of dyspepsia. However, clinical trials have not always included both H. pylori diagnosis and proton pump inhibitors in their protocols. METHODS: Patients who were referred for upper gastrointestinal endoscopy by their general practitioner were randomized to either prompt endoscopy followed by directed medical treatment (conventional group, n=38), or to empirical treatment with omeprazole and, in the case of symptom relapse, serological screening for H. pylori infection followed by eradication therapy in seropositive patients (empirical group, n=42). The study lasted for up to 1 year. RESULTS: In the empirical group, only 13 patients (31%) underwent endoscopy. The average number of days for which the patients kept records of their dyspeptic symptoms was 266 (95% CI: 226-307) in the empirical group, of which 166 (95% CI: 128-204) were symptom-free. In the conventional group, 159 (95% CI: 119-198) out of 255 days (95% CI: 209-302) were recorded as symptom-free. The average medical cost in the empirical group was $284 (95% CI: 218-350) and in the conventional group $491 (95% CI: 383-600). In the empirical group, two malignancies were found, whereas in the conventional group one malignancy was found. CONCLUSIONS: The empirical drug treatment strategy in patients with persistent dyspeptic symptoms resulted in 69% fewer diagnostic endoscopies with lower medical costs and equal effectiveness in the first year, compared to prompt endoscopy followed by directed medical treatment.

Adult↗