Same day bidirectional endoscopy- does the order of the procedures matter?

Introduction Patients commonly have same day bidirectional endoscopy performed. There is no consensus on which order oesophagogastroduodenoscopy (OGD) and colonoscopy should be performed and how this impacts on completion rates, discomfort levels and patient9s overall satisfaction. The authors aimed to evaluate these outcomes by comparing patients who had same day bidirectional endoscopy procedures randomised to either OGD first or colonoscopy first. Methods 70 patients who were due to have same day bidirectional endoscopy in a District General Hospital between December 2009 and September 2010 were prospectively randomised to either having an OGD first (Group A, n=35) or colonoscopy first (Group B, n=35). Power calculations to determine sample size based on previously published data1 showed that 70 patients would be required to demonstrate a difference of 10% between groups at the 5% level of significance with a power of 80%. Sex, age, body mass index (BMI) and previous endoscopy experience were recorded. Procedural completion time, quality of bowel preparation and endoscopic findings were documented. Patients were asked to grade anticipated procedural discomfort scores, actual procedure discomfort and postprocedure discomfort scores on a Numeric Rating Scale ranging from 0 to 10 as well as asked to complete a Hospital Anxiety and Depression Scale. Patients were also questioned on their overall satisfaction with the procedures. Results 70 patients (36 male, 34 female; median 68 (36–87) years) were recruited with a mean BMI of 28 (19–54). After randomisation 17 males were in Group A and 19 in Group B. Both groups were similar in mean age, BMI, anxiety score and procedural completion times. Sedation and analgesic usage, previous endoscopic procedures and quality of bowel preparation were also similar in the two groups. Indications for bidirectional endoscopy were iron deficiency anaemia (60), chronic diarrhoea (9) and polyp surveillance (1). No statistically significant difference was noted in the mean discomfort scores given for colonoscopy between the two groups (5.2 vs 5.3). However, there was a significant reduction in the discomfort scores given for OGD when this was performed first rather than second (mean score 4.6 vs 6.3; p=0.02). Overall satisfaction rates were also slightly higher in group A than B (9.7 vs 9.6), but this did not reach statistical significance. Conclusion This results suggest that when undertaking same day bidirectional endoscopy, an OGD followed by a colonoscopy is the favoured order, with reduced patient discomfort. It may be that the abdominal bloating caused by colonoscopy leads to reduced tolerance of subsequent OGD.