Keywords Endoscopy Upper GI Tract - Quality and logistical aspects - Training - Quality management
- Performance and complications
Introduction
Esophagogastroduodenoscopy (EGD) is performed globally to diagnose patients with symptoms
and screen or monitor upper gastrointestinal diseases. Gastric and esophageal cancers
are the third and sixth leading causes of cancer-related deaths, respectively [1 ]. Early detection and treatment are crucial for preventing deaths associated with
these cancers. According to several guidelines, surveillance EGD is recommended for
high-risk patients with esophageal or gastric cancer [2 ]
[3 ]
[4 ]. Patients are recommended to undergo EGD every 6 months to yearly. Gastric cancer
ranks second among all cancer incidences in Japan [5 ]. Therefore, EGD screening is recommended every 2 years as a health checkup for adults
aged > 50 years [6 ].
The two types of EGD are based on the insertion route. Transnasal endoscopy involves
insertion of the endoscope through the nasal passage, resulting in less nausea and
discomfort during the procedure than peroral endoscopy [7 ]. However, transnasal endoscopy requires use of an ultraslim endoscope. Moreover,
it can sometimes be difficult to perform because of variations in the width of the
nasal cavity caused by individual characteristics. Peroral endoscopy is the traditional
method of performing EGD; however, it can cause various types of discomfort. Consequently,
some patients require sedation during the procedures. Although sedation may contribute
to patient satisfaction [8 ]
[9 ]
[10 ]
[11 ], it is associated with a risk of adverse events, and patients and medical staff
require time and effort for preparation and recovery. Moreover, sedation increases
procedure costs [11 ]. Consequently, some patients have to endure discomfort without sedation. In addition,
endoscope diameter has been suggested to be associated with patient discomfort, and
ultraslim endoscopes may potentially reduce patient discomfort compared with standard-diameter
endoscopes [12 ]
[13 ]
[14 ]
[15 ]. However, available data are insufficient to demonstrate their benefits.
To ensure patient satisfaction and prevent trauma during future examinations, EGD
should be performed with minimal discomfort, even without sedation. Pain during EGD
may be attributed to various factors, such as pharyngeal reflex and pressure build-up
by sufflation of air in the digestive tract. However, no study has comprehensively
addressed painful situations during EGD. Longer procedure times, fewer experienced
endoscopists, and large endoscope diameters are thought to be associated with patient
discomfort during EGD; however, only reports suggesting an association with endoscope
diameters currently exist [12 ]
[13 ]
[14 ]
[15 ]. Such data are crucial for endoscopists to develop techniques that can effectively
reduce patient discomfort. Furthermore, objective data are necessary to improve endoscopist
training.
This prospective, exploratory, observational trial aimed to clarify the specific situations
and frequency of pain experienced during EGD. We investigated patient subjective discomfort
during EGD using a questionnaire. Furthermore, we performed an analysis to identify
the associated factors.
Patients and methods
Study design
This prospective, exploratory, observational trial was conducted at Okayama University
Hospital between September 2021 and March 2022. Asymptomatic patients who visited
our hospital for screening or surveillance using EGD were enrolled. Prior to EGD,
each patient provided written informed consent to participate in the study. Patients
who underwent the EGD protocol were given a specialized button integrated with measuring
software (Takei Scientific Instruments, Co., Ltd., Niigata, Japan) to measure pain,
along with an attached biological information monitor. A post-procedure survey, including
the patients and endoscopists, was conducted soon after the procedure. Specific situations,
pain frequency during EGD, and associated factors were analyzed.
Endoscopists
Seven endoscopists participated in this study, including four with more than 10 years
of experience in EGD and three with 6 to 9 years of experience. Except for one, all
endoscopists were certified by the Japan Gastroenterological Endoscopy Society.
Participants
We enrolled patients who visited the Okayama University Hospital and underwent EGD.
Inclusion criteria were as follows: the purpose of EGD was for screening or surveillance
after endoscopic or radiational treatment of esophageal or gastric lesions; patients
aged 20 to 80 years; and those who could voluntarily provide written informed consent.
Exclusion criteria were as follows: patients with abdominal symptoms; patients who
desired sedation during EGD; patients who had previously undergone surgical resection
of the upper gastrointestinal tract; estimated EGD duration exceeding 10 minutes;
patients with known lesions requiring treatment; patients who were pregnant or possibly
pregnant; patients with Eastern Cooperative Oncology Group performance status > 3;
and any other factors deemed inappropriate by the investigators. The endoscopists
provided explanations to patients who met the eligibility criteria and registered
them prospectively. Because previous studies indicated a correlation between endoscope
diameter and pain [12 ]
[13 ]
[14 ]
[15 ], each endoscopist examined 20 patients, with 10 patients each undergoing EGD with
an ultraslim or standard-size endoscope. Endoscope type selection varied according
to physician or patient preference. A total of 140 participants were included in this
study.
EGD protocol
The endoscopy system consisted of a light source (LL-7700; Fujifilm, Tokyo, Japan),
a processor (VP-7000; Fujifilm), and a video monitor ([Fig. 1 ]). The ultraslim endoscope was an EG-L580NW7 (Fujifilm, Tokyo, Japan), while the
standard-size endoscope was an EG-L600ZW7 (Fujifilm, Tokyo, Japan). The diameters
of the ultraslim and standard-size endoscopes were 5.8 mm and 9.9 mm, respectively.
Endoscope type selection varied according to physician or patient preference. Approximately
5 minutes before the procedure, patients consumed a mixture of a mucolytic agent (20,000
U pronase, Pronase MS; Kaken Pharmaceutical Co., Ltd., Tokyo, Japan), 1 g sodium bicarbonate,
and 3 mL dimethicone 2% internal solution (Fushimi Pharmaceutical Co. Ltd., Kagawa,
Japan) diluted in 100 mL of tap water. Topical anesthesia was administered to the
oropharynx using an 8% lidocaine spray (Xylocaine Pump Spray 8%; Sandoz Pharma K.K.,
Tokyo, Japan) immediately before EGD. A patient biological monitoring system, including
percutaneous oxygen saturation (SpO2 ), heart rate (HR), and blood pressure (BP) monitors, was attached to the patients
before the procedure. Data were recorded before and during the procedure. Intervals
for recording SpO2 , HR, and BP were 1 minute, 1 minute, and 5 minutes, respectively. One nurse assisted
the endoscopist during the EGD procedure. The nurse primarily functioned to support
the endoscopist during procedures, such as biopsies. When they did not need to support
the endoscopist, they gently touched the patient’s back to alleviate discomfort. Patients
were instructed to press a button if they experienced any pain, including physical
pain, nausea, or discomfort. They were instructed to keep pressing the button continuously
during the pain and release it when the pain subsided. In addition, they were informed
that they could press the button as many times as they felt pain during EGD. The button-press
data were automatically recorded on a personal computer using measuring software.
The entire EGD procedure was recorded as video data in an institutional database.
Because there was no specific protocol for the EGD procedure, the endoscopists performed
the procedure in their usual manner. Except for one, six endoscopists observed the
esophagus, stomach, duodenum, and esophagus sequentially, whereas one endoscopist
observed the esophagus, duodenum, stomach, and esophagus sequentially. All patients
were surveyed for discomfort during EGD immediately after the procedure.
Fig. 1 Esophagogastroduodenoscopy sites. A patient biological monitoring system, including
percutaneous oxygen saturation, heart rate, and blood pressure monitors, was attached
to patients before the procedure. Data were recorded before and during the procedure.
The patients were instructed to press a button when they experienced pain. The button-press
data were automatically recorded on a bedside personal computer using measurement
software. The entire esophagogastroduodenoscopy procedure was recorded as video data
in an institutional database. SpO2 ; percutaneous oxygen saturation, PC; personal computer.
Analysis of painful situations using button-press data
The button-press data consisted of the start and end times of each button press as
well as the duration of each button press. Button-pressing situations were identified
by reviewing the recorded EGD videos.
For the analysis, button-pressing situations were divided into 13 categories, including
insertion into the pharynx, insertion into the esophagus, observation within the esophagus,
insertion into the stomach, upper-body view, mid-body view (both observing forward
and in retroflexion), antrum, insertion into the pyloric ring, observation of the
duodenum, observation during return through the esophagus, and removal from the esophagus
([Fig. 2 ]).
Fig. 2 Painful situations. Button-pressing situations were divided into 13 categories for
the analysis. These situations included insertion into the pharynx, insertion into
the esophagus, observation within the esophagus, insertion into the stomach, upper-body
view (observing forward and in retroflexion), mid-body view (observing forward and
in retroflexion), antrum, insertion through the pyloric ring, observation of the duodenum,
observation during return through the esophagus, and removal from the esophagus.
Even if the patient pressed the button for a short period, it was counted as the patient
feeling discomfort. However, with such a definition, patients could continue to press
the button during esophageal observation owing to discomfort from esophageal insertion,
potentially leading to an overestimation of esophageal observations. Therefore, we
decided to count esophageal insertion and observation only if the button was continuously
pressed for more than 15 seconds from esophageal insertion to esophageal observation.
However, if the button was released within 15 seconds, only the esophageal insertion
would be counted.
Background data from participants and procedure data from EGD
Characteristics of the study participants were collected prior to the procedure using
a questionnaire. The registered data included sex, age, height, body weight, body
mass index (BMI), ECOG-PS score, drinking and smoking habits, relationship with the
assigned endoscopist, purpose of the EGD, previous EGD experience, previous painful
EGD experience, time since last EGD, and discomfort level during last EGD.
EGD data included total procedure time, use of chromoendoscopy with iodine and indigo
carmine dye, administration of antispasmodic drugs, whether a biopsy was performed,
and histological assessment.
Post-EGD survey
Patients underwent a survey immediately after EGD to assess whether they experienced
discomfort during the examination. The Wong-Baker Faces Pain Rating Scale (0–5) was
used to assess overall discomfort experienced, and patients with scores ≥ 2 were defined
as experiencing discomfort.
Outcomes
The primary objective of this study was to identify situations and frequency of patient
pain, including physical pain, nausea, and any discomfort during EGD, by analyzing
button-press data and differences in endoscope size. Other outcomes included factors
associated with principal painful situations, factors associated with overall discomfort
from the patient survey, and changes in biological data before and during EGD. These
analyses were also conducted considering the endoscope size.
Statistics
All statistical analyses were conducted using the JMP PRO software (ver. 15; SAS Institute
Inc., Cary, North Carolina, United States). Continuous variables were expressed as
medians with ranges. Univariate and multivariate logistic regression analyses were
conducted to identify factors associated with pressing the pain button or experiencing
discomfort. Age, BMI, BP, and HR were considered as continuous variables. Regarding
duration of the EGD procedure, because a 7-minute threshold was considered [16 ], the analysis was conducted by categorizing it as a nominal variable with a cutoff
of 7 minutes. Statistical significance was set at P < 0.05.
Results
To accumulate 140 cases, we surveyed a total of 150 patients; however, we excluded
four patients who did not provide consent, and six were excluded during or after EGD,
including four patients who had measurement failures, one aged > 80 years, and one
who had previously undergone distal gastrectomy.
[Table 1 ] shows characteristics of the 140 patients. Endoscope type selection varied based
on physician or patient preference, resulting in differences in sex and age distributions.
The ultraslim scope group comprised a higher proportion of young individuals and females.
Two patients had tumorous lesions, one with a residual mucosa-associated lymphoid
tissue lymphoma lesion and the other with a mucosal signet ring-cell carcinoma, first
detected during this procedure.
Table 1 Participant background characteristics and procedure data.
Total
Ultraslim
Standard size
P value
BMI, body mass index; ECOG PS, Eastern Cooperative Oncology Group performance status;
EGD, esophagogastroduodenoscopy.
Sex (M/F)
71 (51)/69 (49)
29 (41)/41 (59)
42 (60)/28 (40)
0.042
Age (mean, range)
70 (21–79)
68 (21–79)
72 (33–79)
0.010
BMI kg/m2 (mean, quadrant)
22.8 (20.5–25.1)
23.1 (20.6–25.2)
22.6 (20.5–25.0)
n.s.
ECOG PS (0/1/2)
130/9/1
67/3/0
63/6/1
n.s.
Alcohol consumption (none/past/few/much)
92/14/26/8
49/6/10/5
43/8/16/3
n.s.
Smoking (none/past/current)
76/46/18
40/22/8
36/24/10
n.s.
EGD experience (0/2–5 years/< 6 years)
3/47/90
1/27/42
2/20/48
n.s.
Interval since last EGD (first time/< 2 years/2–5 years/> 6 years)
3/110/24/3
1/51/15/3
2/59/9/0
n.s.
Relationship with the endoscopist
119/15/6
61/6/3
58/9/3
n.s.
Sedation at last EGD (yes/no/first time)
17/120/3
8/61/1
9/59/2
n.s.
Previous painful EGD experience (yes/no/first time)
89/48/3
49/20/1
40/28/2
n.s.
Discomfort level of last EGD (none/mild to moderate/severe/first time)
63/56/18/3
31/26/12/1
32/30/6/2
n.s.
Purpose (surveillance/screening)
15/125
3/67
12/58
n.s.
Scope choice (physician/patient)
106 (76)/34 (24)
41 (59)/29 (41)
65 (93)/5 (7)
< 0.001
Stored images (mean, quadrant)
82 (71–95)
82 (72–93)
82 (68.8–98)
n.s.
8 (6–12)
8 (6–11)
9 (7–12)
n.s.
15 (13–19)
15 (12–19)
15 (13–19)
n.s.
53.5 (44–60)
54 (48–59)
53 (41–62)
n.s.
5 (4–6)
5 (4–6)
5 (3–6)
n.s.
Procedure time (seconds, mean, quadrant)
485.5 (410.8–594.5)
510.5 (425.5–600.8)
461 (384.3–547.5)
n.s.
Antispasmodic drugs
0
0
0
n.s.
Chromoendoscopy
62
30
32
n.s.
Biopsy
24
11
13
n.s.
Number of biopsies
1.5 (1–9)
1.5 (1–3)
1.5 (1–9)
n.s.
Tumorous lesion
2
2
0
n.s.
Situations and frequency of pressing the pain button during EGD
From the button-press data, 78.9% of patients (109/140) pressed the button at least
once during the examination, whereas 21.1% (31/140) did not press the button. Among
the 13 designated regions, 7.1% of patients (10/140) pressed the button in most regions
(≥ 11). Among the designated 13 situations, the site with the highest pressing frequency
was the esophagus (59.3%, 83/140), followed by the duodenum (40.7%, 57/140) ([Fig. 3 ]). Although the difference was not significant, ultraslim endoscopy tended to be
associated with a lower frequency of pressing the pain button during esophageal insertion
(P = 0.06).
Fig. 3 Situation and frequency of pain using button-pressing data. The overall button-pressing
rate was 78.9%, indicating that 21.1% of patients did not press the button during
esophagogastroduodenoscopy. The primary and secondary sites of pain were the esophagus
(59.3%) and duodenum (40.7%), respectively. Although the ultraslim- and standard-size
endoscopes showed no significant differences in any of the situations, there was a
trend towards reduced pain during esophageal insertion with the ultraslim endoscope
(P = 0.06).
Factors associated with pressing the pain button during esophageal insertion and duodenal
observation differed ([Table 2 ]). In the case of esophageal insertion, endoscopist experience played a role, whereas
in duodenal observation, younger and female patients were more likely to press the
pain button.
Table 2 Factors associated with pressing the pain button during esophageal insertion and duodenal
observation.
Odds ratio
95% CI
P value
CI, confidence interval; EGD, esophagogastroduodenoscopy; BMI, body mass index.
Esophageal insertion
Age
Per 1 year
0.98
0.95–1.01
0.22
EGD experience
> 6 times
1.40
0.70–2.83
0.34
Interval since last EGD
> 2 years
0.57
0.25–1.33
0.19
Sex
Male
1.11
0.57–2.19
0.76
Endoscope
Ultraslim
0.52
0.26–1.03
0.06
Endoscopist experience
> 10 years
0.4
0.19–0.81
0.01
Previous painful experience
+
1.78
0.87–3.63
0.11
Previous use of sedation
+
1.77
0.59–5.35
0.31
Smoking
+
1.13
0.58–2.23
0.72
Alcohol consumption
+
0.73
0.36–1.47
0.37
BMI (kg/m2)
Per 1 up
1.00
0.92–1.08
0.98
Duodenal observation
Age
Per 1 year
0.96
0.93–1.00
0.03
EGD experience
> 6 times
1.19
0.59–2.42
0.63
Interval since last EGD
> 2 years
0.55
0.22–1.36
0.20
Sex
Male
0.49
0.25–0.98
0.04
Endoscope
Ultraslim
0.94
0.48–1.85
0.86
Endoscopist experience
> 10 years
1.52
0.76–3.03
0.23
Previous painful experience
+
1.56
0.75–3.24
0.23
Previous use of sedation
+
1.05
0.37–2.95
0.93
Smoking habit
+
0.88
0.45–1.74
0.72
Alcohol consumption
+
0.71
0.35–1.47
0.36
BMI (kg/m2)
Per 1 up
0.98
0.90–1.06
0.55
Assessment of discomfort during EGD procedure using post-procedure survey
In post-EGD surveys, 63.6% of patients (89/140) reported discomfort, indicated by
Wong-Baker Faces Pain Rating Scale scores ≥ 2. Patients who reported discomfort during
EGD had painful experiences with previous EGD and pressed the button during esophageal
insertion ([Table 3 ]). However, longer procedure time and larger endoscope size, which were estimated
to be correlated with discomfort, were not associated with patient discomfort.
Table 3 Factors associated with patient discomfort as reported on the survey.
Univariate
Multivariate
Odds ratio
95% CI
P value
Odds ratio
95% CI
P value
CI, confidence interval; EGD, esophagogastroduodenoscopy; BMI, body mass index.
Pre-procedure factor
Age
per 1 year
0.98
0.95–1.01
0.23
EGD experience
< 6 times
0.74
0.36–1.53
0.42
Interval since last EGD
< 2 years
0.80
0.34–1.88
0.61
Sex
Male
0.77
0.39–1.53
0.45
Endoscope
Ultraslim
0.65
0.32–1.30
0.22
Endoscopist
< 10 years
0.90
0.45–1.80
0.76
Previous painful experience
+
2.63
1.27–5.45
0.01
2.41
1.12–5.22
0.03
Previous use of sedation
+
2.09
0.64–6.80
0.22
Smoking
+
0.92
0.46–1.83
0.81
Alcohol consumption
+
1.07
0.52–2.21
0.86
BMI (kg/m2 )
per 1 up
0.99
0.91–1.08
0.86
Intra-procedure factor
Procedure time
< 7 minutes
0.42
0.18–0.98
0.05
0.43
0.17–1.07
0.07
Biopsy
+
0.95
0.38–2.35
0.91
Pressing the pain button
Esophageal insertion
+
3.28
1.60–6.72
> 0.01
2.84
1.32–6.12
0.01
Duodenum
+
2.14
1.03–4.46
0.04
1.48
0.66–3.30
0.34
Fluctuations in physiological data during EGD
Physiological data and changes before EGD, as well as maximum values during EGD, are
presented in [Table 4 ]. The differences in BP and HR before and at the maximum pain level were 5.5 mm Hg
and 11.3 bpm, respectively. These changes in the discomfort group were significantly
higher than those in the no-discomfort group (11.1 mm Hg vs. 1.1 mm Hg for BP and
14.7 bpm vs. 5.3 bpm for HR).
Table 4 Fluctuations in vital signs during EGD.
All (n = 140)
Discomfort (n = 89)
No discomfort (n = 51)
P value
EGD, esophagogastroduodenoscopy; SpO2 , percutaneous oxygen saturation.
Blood pressure
Before EGD (Mean, quadrant)
142.6 (127 ~ 155)
140.1(124 ~154)
146.9(131 ~158)
0.09
Maximum during EGD (mean, quadrant)
150.1 (133 ~ 168.25)
151.3(134 ~169)
147.9(132.5 ~162.5)
0.49
Difference (mean, quadrant)
7.5 (-5 ~ 18)
11.1(0 ~20)
1.1(-8 ~6)
<0.01
Heart rate
Before EGD (mean, quadrant)
72.5 (64.75 ~ 78)
72.8(64 ~79)
71.9(66 ~76)
0.64
Maximum during EGD (mean, quadrant)
83.7 (71 ~ 92.25)
87.5(74 ~100)
77.1(68.5 ~83)
< 0.01
Difference (mean, quadrant)
11.3 (2.75 ~ 16)
14.7(5 ~24)
5.3(0 ~8)
< 0.01
SpO2
Before EGD (mean, quadrant)
97.5(96 ~99)
97.5(96 ~99)
97.3(96 ~98.5)
0.53
Maximum during EGD (mean, quadrant)
98.7(98 ~100)
98.8(98 ~100)
98.5(98 ~99)
0.17
Difference (mean, quadrant)
1.2(0 ~2)
1.3(0.5 ~2)
1.2(0 ~2)
0.67
Discussion
To the best of our knowledge, this study is the first to reveal painful situations
during EGD, not through a questionnaire but by having patients use a self-push button
during the procedure. In previous studies, investigations of discomfort during EGD
relied on post-procedure questionnaires [12 ]
[13 ]
[14 ]
[15 ], making it difficult to directly reflect the pain experienced by patients during
the procedure. Using an objective method, we demonstrated the major painful situations
during EGD, including esophageal insertion and duodenal observation. Although experienced
endoscopists may already be aware of this through their practical experience, objective
data were lacking prior to this study. In addition, we identified unique factors associated
with each painful situation and patient objective discomfort, which would be of interest
to clinical endoscopists.
Esophageal insertion is generally thought to be painful because the pharyngeal reflex
is a biological reaction in humans. Hence, the result of its being the most painful
situation was clear. However, the 59.3% button-pressing rate during esophageal insertion
indicated that not all patients experienced pain in the area. Some patients were able
to stand the esophageal insertion but experienced more pain after it. Duodenal observation
was ranked second in the button-press data. Because the action of insertion into the
pylorus is separate, this situation simply represents observation of the duodenum.
Endoscopists should be aware that duodenal observation is a common cause of pain.
Intriguingly, discomfort-related factors during esophageal insertion and duodenal
observation were distinct. The only significant factor associated with pressing the
pain button during esophageal insertion was endoscopist experience. Esophageal insertion
requires more technical expertise than other situations, and it is easy to understand
that experience is the best teacher. However, factors influencing discomfort during
duodenal observation included sex and age, which are issues that cannot be easily
addressed through endoscopic techniques or scope modifications. Detection of duodenal
neoplasia has increased in recent years, making duodenal observation increasingly
important [17 ]
[18 ]. Although this study does not clarify which specific manipulation in the duodenum
causes discomfort, it is crucial to recognize that female and younger patients are
particularly susceptible to discomfort during duodenal observation, and this should
be carefully considered during EGD.
The patient survey revealed an overall assessment of discomfort throughout the procedure.
Patients who experienced discomfort during EGD reported significant previous experiences
of discomfort during EGD and pain during esophageal insertion. The former may be due
to personal characteristics or trauma and may be difficult to improve medically. However,
pain during esophageal insertion was related to endoscopist experience and corresponded
with endoscope diameter, which could be improved by the endoscopist gaining more experience
or by feature development of an improved endoscope.
Factors associated with patient discomfort, such as scope size and longer procedure
time, correlated significantly with patient discomfort. Regarding endoscope size,
ultraslim endoscopes tended to demonstrate superiority during esophageal insertion
(P = 0.06), which is consistent with a previous report [12 ]. Similar trends in past reports have enhanced this fact. No noticeable differences
were observed regarding longer procedure times. However, endoscopist characteristics
could not be excluded, which could have led to bias ([Table 5 ]). Therefore, we cannot conclude that reducing overall examination time alleviates
patient discomfort.
Table 5 Endoscopist experience, procedure time, and patient-reported pain during esophageal
insertion and discomfort.
Endoscopist
Endoscopy experience (years)
Procedure time (median, range)
Pain during esophageal insertion (%)
Discomfort with the questionnaire (%)
A
6
8.7 (5.8–14.3)
70 (14/20)
60 (12/20)
B
7
7.9 (4.7–12.0)
85 (17/20)
75 (15/20)
C
8
7.9 (5.6–15.1)
60 (12/20)
60 (12/20)
D
11
15.0 (10.4–27.7)
30 (6/ 20)
45 (9/20)
E
14
7.6 (5.6–9.7)
45 (9/20)
55 (11/20)
F
18
7.7 (5.7–13.2)
55 (11/20)
70 (14/20)
G
19
5.5 (3.8–10)
70 (14/20)
80 (16/20)
There were notable data regarding BP and HR during EGD. Changes in BP and HR before
and during EGD were significant, and the differences were high among those who experienced
discomfort during EGD. The physical burden of EGD is evident, and fluctuations in
vital signs during the procedure are inevitable. However, significant fluctuations
in vital signs during the examination can be considered risk factors for cardiovascular
events. Therefore, endoscopists should be aware that vital signs fluctuate significantly,
especially in patients experiencing discomfort.
This study has some limitations. First, it was an exploratory study primarily aimed
at elucidating painful situations and their frequency during EGD. The sample size
was not statistically significant, and there was no randomization concerning scope
size and endoscopist. As a result, it was challenging to determine whether scope size
affected patient discomfort. However, notably, patients with prior experience of painful
EGD tended to opt for ultraslim endoscopy ([Table 1 ]). Within this trend, the observed reduction in pain frequency with ultraslim endoscopes
during esophageal insertion may have significant implications. Next, we defined 13
observation areas based on our experience. Nevertheless, we could not measure detailed
conditions such as suction, air delivery, or scope compression. Finally, other factors
may reduce patient pain, such as physician communication or the overall atmosphere,
which may play a major role during EGD; however, we could not analyze these factors.
Conclusions
This analysis provides valuable insights into specific pain situations during EGD.
Understanding painful situations and contributing factors may help minimize discomfort.
Further research and interventions aimed at reducing pain during endoscopic procedures
are needed to improve patient satisfaction. Nonetheless, the results of this study
can help endoscopists become aware of patient suffering as detailed in objective data.
