Office-Based Unsedated Ultrathin Esophagoscopy in a Primary Care Setting

Thad Wilkins; Ralph A. Gillies

doi:10.1370/afm.262

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Office-based unsedated ultrathin esophagoscopy
Kalyanakrishnan Ramakrishnan

Published on: 31 March 2005
Comment on Wilkins et al.
Amitabh Chak

Published on: 30 March 2005

Published on: (31 March 2005)
Page navigation anchor for Office-based unsedated ultrathin esophagoscopy
Office-based unsedated ultrathin esophagoscopy
Kalyanakrishnan Ramakrishnan, Oklahoma City, Oklahoma, U.S.A.
Using ultrathin endoscopes, patients can be potentially investigated for a wide variety of airway and upper gastrointestinal tract pathology in an office setting, and without sedation. A significant number (25%) of asymptomatic men older than 50 years may have Barrett’s esophagus and up to 40% of patients developing esophageal adenocarcinomas have no reflux symptoms, making the case for routine screening of the upper gas...
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Using ultrathin endoscopes, patients can be potentially investigated for a wide variety of airway and upper gastrointestinal tract pathology in an office setting, and without sedation. A significant number (25%) of asymptomatic men older than 50 years may have Barrett’s esophagus and up to 40% of patients developing esophageal adenocarcinomas have no reflux symptoms, making the case for routine screening of the upper gastrointestinal tract in this age-group.1
The American Society of Gastrointestinal Endoscopy in March 2000, suggested that ultrathin endoscopy (transnasal or transoral) be used for the same indications as conventional endoscopy, having completion rates of 86-98%, a sensitivity of 92% and specificity of 100% for detecting pathology (slightly lower in transnasal endoscopy), and a low complication rate. Image quality and endoscope characteristics are, however, considered less optimal.2 Since this report, experience has been accumulated using smaller, battery-powered endoscopes.3
Unsedated ultrathin endoscopy (EGD) (both transnasal or transoral) is well tolerated, and compares well with conventional endoscopy for screening for Barrett’s esophagus, though many patients, when offered the choice, request sedation.4 Unsedated EGD is found to be tolerated better by the elderly, those patients with decreased pharyngeal sensitivity, and possibly in those highly motivated and less anxious, who have had prior EGD.5 Recent experience using smaller battery-powered endoscopes have not proven as satisfactory, yielding less optical quality and less accuracy in detecting esophageal pathology (Schatzki’s rings, esophageal erosions), without improving patient tolerance and acceptance. Thinner endoscopes may not be rigid enough to pass through the pylorus, limiting the field of examination, limits the size of the biopsy specimen and therapeutic intervention, which may require repeating the examination with a conventional endoscope.4
It is heartening to see family physicians offering this new technology effectively, as an office procedure. All the pathology in this manuscript appears to be confined to the esophagus, exposing the limitation of this examination. As the science now exists, the role of ultrathin endoscopy appears to be confined to screening for and detecting pathology in the airway, esophagus and the proximal stomach. Questions remain about its accuracy in diagnosis, biopsy and therapeutic capability, ability to examine the distal stomach and duodenum, and probably its cost- effectiveness, which are all fertile fields for future development of this technique. Catanzaro et al suggest that a minimum diameter of 4 mm is required for satisfactory esophageal imaging.3 Widespread patient acceptance of unsedated examination is still in question. A good argument exists in confining its use at present to patients most likely to tolerate it (mentioned above) and least likely to have gastroduodenal pathology (absence of abdominal pain, nausea and a history of peptic ulcer disease).
References
1.Gerson LB, Shetler K, Triadafilopoulos G. Prevalence of Barrett's esophagus in asymptomatic individuals. Gastroenterology. 2002;123(2):461- 467.
2.Nelson DB, MD, Block KP, Bosco JJ, Burdick JS, Curtis WD, Faigel DO. Technology status evaluation report: Ultrathin endoscopes esophagogastroduodenoscopy. Gastrointest Endosc 2000; 51(6): 786-789.
3.Catanzaro A, Faulx A, Pfau PR, Cooper G, Isenberg G, Wong RCK et al. Accuracy of a narrow-diameter battery-powered endoscope in sedated and unsedated patients. Gastrointest Endosc 2002;55(4):484-487.
4.Sorbi D, Chak A. Unsedated EGD. Gastrointest Endosc 2003; 58(1):102 -110.
5.Abraham N, Barkun A, LaRocque M, Fallone C, Mayrand S, Baffis V et al. Predicting which patients can undergo upper endoscopy comfortably without conscious sedation. Gastrointest Endosc 2002; 56(2): 180-189.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (30 March 2005)
Page navigation anchor for Comment on Wilkins et al.
Comment on Wilkins et al.
Amitabh Chak, Cleveland, OH, USA
The striking rise in incidence has made adenocarcinoma of the esophagus an important public health issue (1). Barrett’s epithelium is the precursor of adenocarcinoma in the esophagus and it is reasonable to consider a screening and surveillance strategy for BE. Gastroesophageal reflux disease (GERD) has a strong association with BE. Therefore, gastroenterologists recommend one time endoscopic screening of persons with c...
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The striking rise in incidence has made adenocarcinoma of the esophagus an important public health issue (1). Barrett’s epithelium is the precursor of adenocarcinoma in the esophagus and it is reasonable to consider a screening and surveillance strategy for BE. Gastroesophageal reflux disease (GERD) has a strong association with BE. Therefore, gastroenterologists recommend one time endoscopic screening of persons with chronic GERD symptoms (2). However, the majority of GERD patients never develop BE and there is limited evidence to support this recommendation. Current estimates are that nearly 600 upper endoscopies are required to detect one cancer even in obese, 50 year old white men with GERD – the highest risk subgroup (3). Sedated endoscopic screening is prohibitively expensive. Furthermore, sedation risks offset some of the potential benefit. Obviously, a less expensive, safer screening method needs to be developed.
Unsedated diagnostic endoscopy, although practiced in several other countries, has largely not been accepted by patients or physicians in the United States. The explanation is complex but clearly the discomfort associated with a large bore endoscope is a major deterrent. Advances in technology have led to the development of slimmer instruments. We and others have shown that unsedated endoscopy with these instruments is tolerable, acceptable, and accurate for identifying esophageal pathology (4,5). However, in the context of research, a large proportion of patients have refused unsedated endoscopy, making it difficult to evaluate the practical utility of this approach in clinical practice. Over the past few years, we have unsuccessfully attempted to offer unsedated esophageal screening in our specialty unit. One of the barriers has clearly been the fact that primary care physicians see the majority of GERD patients. Patients seen in the primary care setting appear to be reluctant to make another appointment for a diagnostic test performed by an unfamiliar physician on a different date. We surveyed primary care physicians (unpublished results) and found that cost and lack of evidence were two major barriers to sedated endoscopic screening. Furthermore, a large number of primary care physicians, especially family practitioners, were willing to attempt unsedated esophagoscopies in their offices and felt that it would lead to enhanced screening.
The pioneering observational study reported by Wilkins et al. in the March/April issue of this Journal is a resounding demonstration of the unsedated esophagoscopy screening concept in the primary care setting. Unlike other studies, participation by patients was 100% because this was not primary research, the physician was familiar, and the test was performed at the time of visit. The yield in the study for BE was low (6%), likely because of the low prevalence study population – young (mean age = 48 years), 57% women, and 29% African Americans. However, this series showed the feasibility of unsedated esophagoscopy in the primary care setting. Further studies of this approach in appropriately selected patients by other physicians are awaited.
REFERENCES:
1. Devesa SS, Blot WJ, Fraumeni JF. Changing patterns in the incidence of esophageal and gastric carcinoma in the United States. Cancer 1998;83:2049-53.
2. Lagergren J, Ye W, Bergstrom R, Nyren O. Utility of endoscopic screening for upper gastrointestinal adenocarcinoma. JAMA. 2000 Aug 23- 30;284(8):961-2.
3. Sampliner RE; Practice Parameters Committee of the American College of Gastroenterology. Updated guidelines for the diagnosis, surveillance, and therapy of Barrett's esophagus. Am J Gastroenterol. 2002 Aug;97(8):1888-95.
4. Faulx AL, Catanzaro A, Zyzanski S, Cooper GS, Pfau PR, Isenberg G, Wong RC, Sivak MV Jr, Chak A. Patient tolerance and acceptance of unsedated ultrathin esophagoscopy. Gastrointest Endosc. 2002 May;55(6):620 -3.
5. Catanzaro A, Faulx A, Isenberg GA, Wong RC, Cooper G, Sivak MV Jr, Chak A. Prospective evaluation of 4-mm diameter endoscopes for esophagoscopy in sedated and unsedated patients. Gastrointest Endosc. 2003 Mar;57(3):300-4.
Competing interests: None declared
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Competing Interests: None declared.