UNSEDATED ULTRATHIN ENDOSCOPY FOR VARICEAL SURVEILLANCE IN THE OUTPATIENT SETTING – EVIDENCE INTO PRACTICE

Aims Risk of bleeding from oesophageal varices and the need for prophylaxis is determined by the endoscopic appearance of varices and therefore upper gastrointestinal (UGI) endoscopy is recommended by guidelines at diagnosis of cirrhosis and regular intervals thereafter. However, the point prevalence of varices is low (25%) meaning that the majority of these endoscopies are unnecessary. Recent advances in endoscope technology have resulted in the development of narrow diameter or ultrathin (< 6 mm) endoscopes which have the advantage of being more tolerable than conventional UGI endoscopes. We hypothesised that unsedated ultrathin endoscopy for diagnosis of varices could be implemented in the outpatient setting and would be acceptable to patients.

Methods Patients with cirrhosis awaiting UGI endoscopy for variceal screening or surveillance were identified from the endoscopy waiting list. UGI endoscopy was performed by a single operator trans-orally using the EG Scan ll disposable endoscope. Varices were graded using the Modified Paquet classification. Video recordings of endoscopic procedures were reviewed by assessors blinded to the endoscopy reports and clinical details and agreement was assessed using the kappa statistic.

Results 41 patients (80% male) have undergone unsedated ultrathin endoscopy. Median age was 59 (IQR 57–67) All procedures were successful and were tolerated well in 98% of cases. Median procedure time was 2 minutes (IQR 1–3). Varices were found in 40% (17% Grade 1 and 23% Grade 2). Patients with grade 2 varices were prescribed non-selective beta-blockers at the clinic appointment. Kappa statistic for the finding of any varices was 0.636 p = 0.001 and 0.8–1.0 for diagnosis of grade 2 varices p < 0.0001.

Conclusions Our pilot study confirms the feasibility, accuracy and safety of unsedated ultrathin endoscopy in the outpatient setting. This service appears to be acceptable and more convenient for patients and is likely to result in significant cost savings associated with variceal surveillance.