title: Unsedated transnasal small-caliber esophagogastroduodenoscopy in elderly and bedridden patients.
abstract: OBJECTIVE
  To evaluate the safety of unsedated transnasal small-caliber esophagogastroduodenoscopy (EGD) for elderly and critically ill bedridden patients.
  
  
  METHODS
  One prospective randomized comparative study and one crossover comparative study between transnasal small-caliber EGD and transoral conventional EGD was done (Study 1). For the comparative study, we enrolled 240 elderly patients aged > 65 years old. For the crossover analysis, we enrolled 30 bedridden patients with percutaneous endoscopic gastrostomy (PEG) (Study 2). We evaluated cardiopulmonary effects by measuring arterial oxygen saturation (SpO(2)) and calculating the rate-pressure product (RPP) (pulse rate x systolic blood pressure/100) at baseline, 2 and 5 min after endoscopic intubation in Study 1. To assess the risk for endoscopy-related aspiration pneumonia during EGD, we also measured blood leukocyte counts and serum C-reactive protein (CRP) levels before and 3 d after EGD in Study 2.
  
  
  RESULTS
  In Study 1, we observed significant decreases in SpO(2) during conventional transoral EGD, but not during transnasal small-caliber EGD (0.24% vs -0.24% after 2 min, and 0.18% vs -0.29% after 5 min, P = 0.034, P = 0.044). Significant differences of the RPP were not found between conventional transoral and transnasal small-caliber EGD. In Study 2, crossover analysis showed statistically significant increases of the RPP at 2 min after intubation and the end of endoscopy (26.8 and 34.6 vs 3.1 and 15.2, P = 0.044, P = 0.046), and decreases of SpO(2) (-0.8% vs -0.1%, P = 0.042) during EGD with transoral conventional in comparison with transnasal small-caliber endoscopy. Thus, for bedridden patients with PEG feeding, who were examined in the supine position, transoral conventional EGD more severely suppressed cardiopulmonary function than transnasal small-caliber EGD. There were also significant increases in the markers of inflammation, blood leukocyte counts and serum CRP values, in bedridden patients after transoral conventional EGD, but not after transnasal small-caliber EGD performed with the patient in the supine position. Leukocyte count increased from 6053 +/- 1975/L to 6900 +/- 3392/L (P = 0.0008) and CRP values increased from 0.93 +/- 0.24 to 2.49 +/- 0.91 mg/dL (P = 0.0005) at 3 d after transoral conventional EGD. Aspiration pneumonia, possibly caused by the endoscopic examination, was found subsequently in two of 30 patients after transoral conventional EGD.
  
  
  CONCLUSIONS
  Transnasal small-caliber EGD is a safer method than transoral conventional EGD in critically ill, bedridden patients who are undergoing PEG feeding.
authors: Division of Internal Medicine, Izumo-City General Medical Center, Izumo-shi, Shimane, Japan.
authors: Mika
authors: M
authors: Yuki
authors: Yuji
authors: Y
authors: Amano
authors: Yoshinori
authors: Y
authors: Komazawa
authors: Hiroyuki
authors: H
authors: Fukuhara
authors: Toshihiro
authors: T
authors: Shizuku
authors: Shun
authors: S
authors: Yamamoto
authors: Yoshikazu
authors: Y
authors: Kinoshita
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002097:C-Reactive Protein / Q000378:metabolism; D018592:Cross-Over Studies; D004724:Endoscopy / Q000379:methods; D016145:Endoscopy, Digestive System / Q000295:instrumentation / Q000379:methods*; D005260:Female; D005773:Gastroscopy / Q000379:methods; D005774:Gastrostomy / Q000379:methods; D006801:Humans; D007249:Inflammation; D008168:Lung / Q000502:physiology; D008297:Male; D011015:Pneumonia, Aspiration; D011446:Prospective Studies
chemical_list: D002097:C-Reactive Protein