To the stomach and beyond- via the nostril?

So you’ve been told you need an endoscopy. It’s very likely you need it to investigate that reflux you’ve been suffering from for so very long. Even so, it could be altogether for a whole set of different symptoms or perhaps for the exclusion of serious conditions such as strictures, Barrett’s oesophagus, peptic ulcer disease and cancers. Like a lot of people, you’ve probably heard of unwarranted horror stories about endoscopy or perhaps even had one yourself. You may have a significant gag reflex and perhaps for comforts sake, this time around, an endoscopy or OGD (Oesophagogastroduodenoscopy) with sedation is the way forward for you?

Well, consider this:

1. Conventional oral OGD (CO-OGD)
Is the standard diagnostic tool used to visualize the upper part of the gastrointestinal tract which can be done with or without sedation.

2. CO-OGD without sedation
Can be uncomfortable, which decreases the tolerability of the procedure, and thus potentially decrease the quality of examination as a result of retching and general discomfort.

3. Sedation
Generally results in better patient tolerance and comfort, BUT,
Is associated with substantial cost and requires additional monitoring.
May impact on patients day post procedure (e.g. unable to drive or work )
Increased total procedure time.
Increased risk of adverse cardio-respiratory events, especially in elderly patients and patients with co-morbidities.

So what now?

Well, there is the Trans nasal endoscopy (TNE).

TNE is essentially an OGD scope but its access into the oesophagus is gained not via the mouth but instead via the nostril using an ultrathin endoscope. The patient will either be sat upright across from the gastroenterologist or be in the lying down position on the bed.

Its un-sedated approach avoids sedation related complications but if sedation is still required, it still avoids the gagging, choking sensation and retching associated with CO-OGD. It is by virtue of its route (i.e. reduced pharyngeal stimulation), the TNE leads to superior tolerability and therefore patient satisfaction. During the un-sedated TNE the patient is also able to speak and observe the procedure which allows the patient to discuss the endoscopic images with the gastroenterologist. In addition to being able to see the nasal cavity, pharynx, larynx and vocal cords, since TNE does not require a mouthpiece, it is also a useful technique in patients with dental problems or unconscious patients who cannot open their mouth.

Indications of the TNE is essentially that of a CO-OGD with a few exceptions (see next paragraph). Although mostly used for diagnostic purposes, it also used in various therapeutic procedures which include the insertion of various feeding tubes, treatment of gastrointestinal strictures and to assist in advanced endoscopic techniques such as endoscopic mucosal resections.

As with everything, limitations do exist and they include the need of nasal pretreatment (which is not a real limitation per se), may not be appropriate for patients with significant nasal problems, a narrow working channel limits every single therapeutic procedure delivery via the TNE and extreme flexibility of the scope body can be a little tricky to handle (but never a problem for an experienced gastroenterologist).

In any case, there is an alternative to the CO-OGD and maybe it is something that may be of benefit to you, the patient, in your overall experience of the necessary endoscopy.

by Dr Prabhjot Singh Sidhu