includes oesophagogastroduodenoscopy (OGD), colonoscopy, push enteroscopy,
capsule endoscopy and Endoscopic Retrograde CholangioPancreatography (ERCP).
This article shall focus on OGD and colonoscopy as they are the most frequently
carried out procedures in our centre. Gastrointestinal
Endoscopy is classified as an invasive investigation and because of that it has
the possibility of associated complications. It is estimated that sedation is
directly responsible for between 30-50% of all equipment, supply and labor
costs associated with diagnostic upper gastrointestinal endoscopy (1, 2)
Most endoscopists within our local context routinely use conscious sedation for
majority of procedures despite the fact that unsedated endoscopy has been shown
to be a feasible procedure (2) and is likely to play a more
prominent role in future. In one British study, sedation rate for outpatient
diagnostic endoscopy declined by 54% from 1990 to 1998 (3), which is
an adequate evidence that unsedated endoscopy is technically feasible in select
patient populations. However,
some evidence points to the fact that low prevalence of unsedated endoscopy is
more to do with patient preference as opposed to physician preference(4).
This paper shares our experience with and thoughts on unsedated endoscopy in local
Methods: A retrospective descriptive
analysis of patients who underwent GI endoscopy for various reasons between
September, 2016 and March, 2017 was undertaken. Results: 153 endoscopies were
carried out by the author within this period. Majority were for persistent dyspeptic
symptoms and GI bleeding. No complications were encountered. Verifiable records
where either sedation or unsedated endoscopies only were considered. There was
no statistically significant difference in sex, while age was evenly
distributed with the youngest patient being 17 years old and the eldest was 84
years old. The total number of patients who underwent unsedated endoscopy was
95 and sedation was used in 20 patients overall.
Conclusion: Unsedated endoscopy is a feasible
alternative to conscious sedation with similar success rates and at lesser costs
and morbidity. Besides it is quicker for patients to return to normal activities
after such procedures if unsedated option is used. We recommend its widespread
acknowledgement and use in our population, as far as feasible.
endoscopy, sedation, ease of procedure, discomfort, feasible.
benefits of endoscopy have increased enormously as it has matured from purely being
a diagnostic tool to becoming a therapeutic sub-specialty. Endoscopy is
performed frequently on outpatient basis. The procedure has low complication
and mortality rates (5). Patients rarely require admission post
procedure. Routine counseling about the post procedure process including
recovery time from the effects of sedation is rarely done. Local practice has
been dictated largely by western culture and practice. Local data is thus
endoscopy is a procedure that takes on an average 5 to 10 minutes, with colonoscopy
taking between 15 to 30 minutes depending on anatomy, pathology, intra-procedure
complications, need for intervention such as polypectomy, and the expertise of
factors such as delays in patient admission, inadequate patient counseling,
preset mind for sedation, fear of pain/chocking, healthcare costs, have all
impacted adversely on the uptake of the procedure. Post sedation, patients are
advised to avoid activities that require mental concentration.
introduction of a flexible fibre-optic scope through the mouth via the
esophagus into the stomach and proximal duodenum. Patients are usually sprayed
with Xylocaine10 % solution – a numbing agent, at the back of the throat to dampen
the gag reflex which has been shown to greatly improve procedure acceptability (6).
The scope is then advanced past the upper esophageal sphincter; this can be
done voluntarily by asking the patient to swallow the scope or passively under
direct vision on the screen for sedated patients. Generally, the gag reflex, apprehension
and fear of suffocation present as the greatest challenge to OGD.
Colonoscopy the scope is introduced via the anus into the large bowel, thus is
more passive. Pressure symptoms and sometimes pain is experienced while
navigating the splenic and hepatic flexures and also due to insufflation, anal
fissures also sometimes cause pain as the scope advances past them. The GI
mucosa has no pain fibers, the pain thus is usually the referred pain. Thus the
Diagnostic and interventional procedures such as: biopsies, excision,
sclerotherapy etc. are all usually painless. Studies have shown acceptable
outcomes with parameters such as satisfactory completion of procedure, patient satisfactory
comfort level, and their willingness to undergo unsedated endoscopy in future. Thus,
in many countries endoscopy is commonly performed without routine procedural
sedation (7). This paper is to share our experience with Endoscopy
without Sedation in patients in local settings, issues emanating, patient
satisfaction and reasons for converting to sedated endoscopy.
study was conducted at a high volume centre over an eight month period
(September, 2016 to April, 2017). All patients were seen at the
gastroenterology clinic and evaluated. Unsedated endoscopy was offered to all
patients. All patients received Xylocaine
10% throat spray. Where patient consent was unforthcoming for unsedated
procedure, sedation was used. In addition, where the patient could not tolerate
the procedure unsedated, sedation was also employed. All patients were
constantly kept in confidence and encouraged to give feedback throughout the
procedure, as also after the procedure was completed. Patient next of kin was
sometimes allowed inside room for psychological support in extremely apprehensive
Unsedated endoscopy patients who immediately returned to their work place, the
sedated patients required pulse oximetery and active observation, in the
recovery for over few hours and were advised to bring along help to take them
home, or avail taxi service to return to work/home. Verbal feedback was
obtained post procedure regarding acceptability, comfort and whether or not the patient would be willing to undergo
the procedure without sedation in future.
study, 168 patients who were subjected to gastrointestinal endoscopy by the author
were evaluated. The patients ranged
between 17 and 84 years of age. There was no significant gender difference.
Total of 138 (82.1%) patients after due counseling and consent, were undertaken for endoscopic procedure without
any sedation, whether before or during the procedure; whereas, 30 (17.8%) patients
required sedation, either before or during the procedure because of
apprehension or discomfort, restricting completion of procedure without
sedation. There were 86 male patients and 82 female patients included in this
study. Interestingly, male patients tolerated unsedated endoscopy better when
compared to females. Of the 86 male patients, 84 unsedated endoscopic procedure
could be undertaken with reasonable comfort. Two patients, though had unsedated
endoscopy, complained discomfort and unhappiness over the procedure; whereas,
of the 82 female patients in only 69 patients could the procedure be completed
without sedation, remaining 13 female patients’ required sedation either before
or during the procedure, for successful completion. There were two complaints
received from female patients who were administered sedation during the
procedure, who expressed unhappiness and dissatisfaction over the procedure,
even going to the extent of raising questions about the endoscopic skills of
the author. No complications,
whatsoever, were encountered during any procedure. Vast majority of the
patients having been explained before the procedure were extended the privilege
of watching the procedure live with the author explaining about each event. On an
average it took 8 minutes for OGD and 15 minutes for colonoscopy to complete. All
unsedated patients barring few expressed their willingness to have repeat
endoscopy without sedation.
summarizes data from a center in Nairobi, which is a center with high volume of
endoscopies, engaging many visiting faculty members besides the author. Whereas
in some countries, besides some centers within some developed countries,
unsedated endoscopy is a routine. In countries like Finland sedated endoscopy
is an exception. However, in UK and America most endoscopies are performed with
sedation, yet in some centers within USA, unsedated endoscopy is popular. Many
centers globally are adopting day care practices to cut down on the costs,
prompting them to shift to unsedated endoscopy.
endoscopy tower used is an Olympus 190 series, technically a small caliber
endoscope. Before shifting to Nairobi, the author worked in Nakuru where he
practiced unsedated endoscopy with over 90% uptake, successfully and without
sedation is still widespread despite the well-known risks associated with
sedation such as phlebitis related to intravenous sedatives and analgesics. Propofol
can cause pain on injection, though less likely to cause phlebitis. The most
frequent and serious complications of procedural sedation are cardiopulmonary
such as hypoxemia, hypoventilation, airway obstruction, hypotension, vasovagal
episodes, arrhythmias, and aspiration. Considering this, how far is it
justified to carry out sedated intervention endoscopically, particularly, in
the developing World where supporting emergency services are deficient is a
question to ponder on?
overall incidence of cardiopulmonary complications is low yet preparedness is
mandatory. In a prospective survey of 14,149 upper endoscopies and a
retrospective study of 21,011 procedures, the rate of early cardiopulmonary
events was 2 to 5.4 per 1000 cases and the mortality rate, which included cases
of aspiration pneumonia, pulmonary embolism, and myocardial infarction, was 0.3
to 0.5 per 1000 cases (11, 12).
studies from some countries in Europe show major differences among countries on
the rate of use of sedation in endoscopy.
In Norway, mean sedation rate was 37 %( 8) for colonoscopy
while in contrast a similar study in the UK showed a sedation rate of 94.6% (8).
A study on
sedation practices for gastrointestinal endoscopy in Europe, North America,
Asia, Africa and Australia in 2010 concluded that in North America and
Australia, almost all routine endoscopic procedures are performed with
conscious sedation. However in Europe, Asia and Africa, the sedation rate
varies among countries and even among centres of the same country. The
countries that participated from Africa were Morocco, Tunisia and Egypt, as
ESGE members; in these countries, the sedation rates for upper GI endoscopy
ranged between 25 and 50%( 8).
addition, local anaesthetic sprays have been effective, and they are safer
endoscopy is technically feasible in select patient populations. Some patients
refuse to consider unsedated endoscopy, and those who do undergo record more
levels of discomfort. Whether patients accept unsedated endoscopy in favor of
potential benefits has not been evaluated fully, and may require larger
randomized studies locally.
has low complication rate when done by trained and experienced hands, but overall
complication rate is low.
utilizing smaller caliber scopes is available, and we are yet to see
what impact this will have on uptake of unsedated endoscopy.
endoscopy is a feasible, safer and less resource taxing alternative to routine
procedural sedation and we propose it for adoption in local setting with high
rates of sedation use in endoscopy. We recommend trials that will offer great
insight as to patient perspective as uptake increases.
Source of support: Nil
Conflict of interest: none declared.
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