Unsedated Peroral Small-Caliber Endoscopy for Screening of Cirrhotics for Esophageal Varices (EV)

Abstract

Background: Screening for EV is recommended for Child's B or C, and selected Child's A cirrhotics. Conventional EGD with sedation(C-EGD)is the standard screening test for EV in US. Conscious sedation is associated with increased direct, indirect costs, and risk of sedation related complications in cirrhotic pts. This study compares the tolerability, accuracy, acceptability and cost of unsedated Peroral Small Caliber Endoscopy(PSC-EGD)with C-EGD for screening of cirrhotics for EV. Methods: 19 consecutive patients with cirrhosis who met current guidelines for screening for EV were evaluated by PSC-EGD before undergoing C-EGD. Pts with history of upper gastrointestinal bleeding, known EV and severe intercurrent illness were excluded. The endoscopist performing C-EGD was blinded to PSC-EGD findings. Pts and endoscopists completed questionnaires on tolerability, acceptability and quality of the examination immediately after PSC-EGD, and again after recovery from sedation after C-EGD. Procedure, sedation and recovery times were recorded. PSC-EGD and C-EGD were performed with Olympus 5.9 mm and 9.8 mm video endoscopes. Pts were also asked to indicate their preference between PSC-EGD and C-EGD for future examinations. Results: On C-EGD 11 of 19 pts had EV, 14 pts had portal hypertensive gastropathy and none had gastric varices. PSC-EGD identified 10 of 11 EV and 12 of 14 portal hypertensive gastropathy. 1 pt with grade 1 EV reported on C-EGD was not detected on PSC-EGD. There was no difference in detecting grade 2 or larger EV and other findings of clinical significance. Patients reported more gagging with PSC-EGD compared to C-EGD (p<0.001) but no significant difference in overall tolerance (p=0.56). Endoscopists reported no significant difference in ease (p=0.51) or quality of examination (p=0.12). Patients were more willing to repeat PSC-EGD compared to C-EGD (p=0.02). 79 % of pts preferred PSC-EGD when asked to choose which test they would like for their next examination. There were no complications with either test. The additional average cost of C-EGD was $97 for conscious sedation including drugs, supplies and nursing time, and $24 for recovery compared to PSC-EGD. The additional time and cost of an attendant to drive the patient home after C-EGD was not calculated in this study, but can be substantial. Conclusions: PSC-EGD is safe, accurate, tolerable, and can significantly decrease the cost for screening of cirrhotics for EV. It is acceptable, and maybe preferred by patients compared to C-EGD.