Ondasetron in Premedication During Unsedated Upper Digestive Endoscopy: Evaluation of Tolerance and Acceptability

Ondasetron in Premedication During Unsedated Upper Digestive Endoscopy: Evaluation of Tolerance and Acceptability | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Ondasetron in Premedication During Unsedated Upper Digestive Endoscopy: Evaluation of Tolerance and Acceptability Tony Akilimali Shindano, Espoir Batumike Murhi, Raissa Iranga Boroto, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5299111/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: The practice of gastroduodenal endoscopy under conscious sedation is still limited in many low-income countries due to additional costs generated as well as concerns related to the management of many constraints and other adverse effects. The aim of this study is to evaluate the practice of this act without any sedation but with addition of a potent antinauseant in premedication. Methodology: This was a prospective single center study conducted from 2020 to 2022 in Bukavu, East of the Democratic Republic of the Congo. Endoscopies were performed without sedation, but by additionally associating a protocol using a sublingual spray of ondasetron. Clinical data, data related to the endoscopic procedure and those related to patients’ opinions before and after the procedure were respectively analyzed. Results: The study enrolled 145 patients, of whom 76 (52.4%) were men. Only 12 patients (8.28%) reported a poor tolerance during the procedure. The patients (91.72%) who have well tolerated the procedure were those who followed instructions well and in whom the introduction of the endoscope was easy (p < 0.001). In multivariate analysis, only the easy introduction of the endoscope appeared to be the main determinant of tolerance (adjusted OR 44.34 [2.78; 708.22] , p=0.007). Conclusion : Unsedated upper digestive endoscopy using ondansetron in premedication seems to be well tolerated but this tolerance also depends on good conditions of patients’ preparation as well as good mastering of first stages of the exploration. Gastroduodenal endoscopy Ondasetron tolerance acceptability DRC Figures Figure 1 What's known - Conscious sedation greatly improves tolerance of gastroduodenal endoscopy. - A few undesirable effects sometimes limit the systematic use of this practice - Gastroduodenal endoscopy performed without sedation is associated with fairly moderate tolerance of the procedure Study novelties: - The study evaluates for the first time the addition of ondasetron to the pre-endoscopy premedication procedure. - The study provides data on the tolerability of sedation-free endoscopy in the Congolese population of eastern DRC. - The protocol used in our study seems to greatly improve the tolerance of the endoscopic procedure without sedation INTRODUCTION Upper gastro-intestinal or gastroduodenal endoscopy (GDE) is one of the most widely performed diagnostic procedures worldwide. It is performed either by direct inspection or, increasingly, by flexible video-endoscopes. It has the advantage of assessing and helping to treat the main diseases of the upper digestive tract. It is increasingly performed under conscious sedation to improve tolerance. It has been reported that up to 5% of patients refuse to undergo it without sedation, and that 10% require good persuasion to undergo it when it is recommended in these conditions [1,2,3,4]. However, some manifestations and complications sometimes limit the use of sedation. These include the risk of hypoxia, an increase in post-procedure monitoring time or personnel, a rise in the cost of the examination, effects linked to absence from work after the endoscopy, or the need to be accompanied home after the procedure. It is estimated that these adverse events occur in around 1/200 GDEs, 60% of which are road accidents [2]. In addition, some practitioners feel that sedation could affect the diagnosis, notably because of the risk of gastro-oesophageal reflux induced by this sedation [5,6]. For these reasons, unsedated GDE remains a preferred approach in some parts of the world [7]. In Sub-Saharan Africa, where universal healthcare coverage is lacking in many countries, endoscopic procedures are still often carried out without sedation, the cost of the procedure being a major factor, bearing in mind the average income of the population and the fact that care is usually remunerated on a fee-for-service basis [3]. The tolerance and acceptance of GDE without sedation has been the subject of several studies around the world, but the reality in the Democratic Republic of the Congo (DRC) is not yet well known. In this vast country, this type of exploration is of fairly recent introduction and is only practiced in certain large cities due to not only lack of equipment and qualified personnel but also accessibility problems. A survey carried out in 2013 found only 14 hepato-gastroenterologists practising it in the DRC, i.e. 1 for every 4 million inhabitants, compared with 1 for every 14 thousand inhabitants in France. And of these 14, only 4 had endoscopic activity [8]. Endoscopy is a fairly recent reality in the province of South-Kivu, and it has only been operational at the Hôpital Provinciale Général de Bukavu (HPGRB) since 2002. Since this examination became a reality in the region, it has been the subject of many false rumors, misinformation and apprehensions among the population. The same applies to certain reluctance on the part of medical staff to recommend it, due to lack of information. To our knowledge, no study to date has assessed its sociological impact on the population. The aim of the present study is to assess the extent of this reluctance and the real reasons for it, the reasons for fear and the degree of tolerance. It is also to determine the real resentment of patients after the examination and identify factors predictive of poor tolerance in order to improve the practice of this exploratory technique. Nausea and eructation are among the symptoms most commonly reported during poorly tolerated endoscopic explorations. To improve clinical tolerance, our study aimed secondarily to evaluate the additive effect of ondasetron, a powerful antinauseant, used as premedication. METHODOLOGY Type and setting of study: This is a cross-sectional study spread over a 3-year period (2020-2022) and carried out at the HPGRB, a university hospital that acts as a reference hospital in the province of South Kivu, which has a population of around 6 million. The province currently has two endoscopy units, and the one at HPGRB is run by a gastroenterologist assisted by an intern in training. Study population: The study population consisted of all the patients who consulted the digestive exploration unit for a GDE. The study included only the patients who underwent diagnostic endoscopic exploration without sedation. It excluded pregnant women and patients under 18 years of age. It also excluded explorations carried out under conscious sedation or general anaesthesia, explorations with endoscopic treatment and explorations involving a technical incident (interruption of electrical supply, material incidents, etc.). Finally, it excluded all the patients who declined to take part in the survey and those who did not have a sufficiently clear understanding of the principle of the survey. Endoscopic procedure and data collection All the GDEs were performed by the same gastroenterologist using video endoscopy and an OLYMPUS multidirectional axial-view fiberscope. Before a patient settled in, the endoscopy nurse ensured that the procedure had been fully explained, including any discomfort that might arise during the procedure. This interview involved psychological preparation of the patient, followed by premedication with Ondasetron sublingual (8mg spray, 15 to 30 minutes before the procedure) and oro-pharyngeal anesthesia with Xylocaine 2% spray. The exploration technique was conventional, with the patient lying in left lateral position. The device was then introduced through the mouth under direct vision, and then the esophagus, the stomach and the first two sections of the duodenum were progressively explored. At the end of the exploration, 5 gastric biopsies were systematically taken (2 from the antrum, 1 from the angle and 2 from the body). Before and after each exploration, every patient was asked to complete a questionnaire comprising three groups of information: - The pre-exploration section essentially covers the patient's clinical data, medical history, the time of last meal, level of information previously received by the patient regarding this exploration, as well as the collection of his or her main apprehensions. - Technical data: this mainly concerned information relating to the process of introducing the endoscope, the patient's degree of cooperation, incidents and accidents during the examination, and the duration and results of the exploration. - Post-exploration data: subjective evaluation of the tolerance of the exploration, as well as the degree of acceptability of a new endoscopic procedure to be carried out under the same conditions. The degree of anxiety or tolerance was assessed using a ruler (visual analogue scale) expressing the different degrees of subjective perception (Endoscopy tolerance assessment tool). The different levels of perception correspond directly to numbers (located on the reverse side of the ruler), enabling scores to be established at the same time (see figure). In this way, we were able to establish different levels of examination tolerance: - Excellent tolerance: 0-2 - Acceptable tolerance: 3-4 - Low tolerance: 5-8 - Intolerance: ˃ 8 Statistical analysis Statistical analyses were performed using Stata 17 software. Quantitative variables were described by means and their standard deviations or medians and their Interquartile ranges. The Kruskal-Wallis, Mann-Whitney and Student's t-tests were used to assess the association between quantitative and categorical variables. Categorical variables were compared using the Chi-square test and Fischer's exact test. Simple logistic regression was performed by calculating the Odds ratio (OR) at its 95% confidence interval (CI). Differences observed were considered significant at a p < 0.05. RESULTS A total of 145 patients took part in the study. Their general data according to tolerance are shown in Table I. Epigastralgia was the main reason for consultation in over two-thirds of subjects (69%), and the main diagnoses reported were gastritis (45.4%) and peptic ulcer disease (21.3%). Twelve percent of patients had already undergone endoscopy, and almost half (47%) had never heard of it (Table II). Overall, only 12 patients (8.3%) reported not tolerating the endoscopic procedure, compared with 91.7% with good or excellent tolerance. Intolerance did not appear to be associated with patient age or gender. A small degree of intolerance was found among illiterate and university patients. Patients who tolerated the exploration well were those who followed the endoscopist's instructions well (=good collaboration) and those in whom the introduction of the endoscope was easy (p< 0.001). These patients were more likely to agree to repeat the endoscopy than those who did not tolerate it well (84.9% vs. 16.7%) [ data not shown ] . In multivariate analysis (Table III), only ease of introduction emerged as the main determinant of good tolerance of the endoscopic procedure (adjusted OR 44.34 [2.78- 708.22], p=0.007). Table I: General characteristics of the study population Variables Intolerance P Value No n=133 (91.7%) Yes n=12 (8.13%) Median age 47 (18 ; 80) 60 (18 ;80) 0.258 Sex Female (n=69 ; 47.6 %) 62 (46.62) 7 (58.33) 0.436 Male (n=76 ; 52.4%) 71 (53.38) 5 (41.67) Level of education None 5 (3.76) 4 (33.33) < 0.001 Primary 37 (27.82) 2 (16.67) Secondary 66 (49.62) 2 (16.67) University 25 (18.80) 4 (33.33) Height (cm) 161.57 ± 8.83 161.08 ± 8.33 0.854 Weight (Kgs) 63.60 ± 13.71 55.23 ± 8.64 0.040 BMI 24.41 ± 5.3 21.16±1.9 0.039 Alcohol consumption 65 (48.87) 5 (41.67) 0.632 Smoking 20 (15.04) 2 (16.67) 0.573 Table II: Univariate analysis of endoscopic procedure tolerance determinants Variables Intolerance P Value No n=133 (91.72%) Yes n=12 (8.27%) Endoscopy indications Epigastralgia 92 (69.17) 9 (75) 0.786 Digestive bleeding/Anemia 27 (20.30) 3 (25) Others 14 (10.53) 0 (0) Medical history and pre-endoscopic information Previous endoscopy 18 (13.53) 0 (0) 0.190 Have received explanations about the procedure 43 (32.33) 4 (33.33) 0.586 Ever heard of endoscopy 72 (54.14) 4 (33.33) 0.140 Time interval since last meal (minutes) 808.50 (450 ; 1200) 781.50 (30 ; 1230) 0.563 Pre-examination apprehensions Subjective anxiety 59 (44.36) 8 (66.67) 0.138 Degree of anxiety (using the tolerance assessment tool) 1.69 ± 2.05 2.91 ± 2.74 0.070 Fear of pain 40 (31.50) 5 (45.45) 0.264 Fear of nausea 4 (3.01) 1 (8.33) 0.355 Fear of vomiting 4 (3.01) 0 (0) 0.705 Fear of suffocation 4 (3 ;01) 0 (0) 0.705 Fear of injury 1 (0.7) 2 (16.67) 0.018 Endoscopy process Easy introduction 119 (89.47) 4 (33.33) < 0.001 Good cooperation (following instructions correctly) 119 (89.47) 5 (41.67) < 0.001 Table III: Multivariate analysis of endoscopic procedure tolerance determinants Variables OR adj (95% CI) f Weight 0.90 (0.78 ; 1.04) 0.148 Level of education None 3.67 (0.03 ; 463.52) 0.598 Primary 0.34 (0.01 ; 8.29) 0.509 Secondary 0.01 (0.00 ; 0.98) 0.049 University 1 Fear of injury Yes 1 No 5.97 (0.01 ; 207413.80) 0.738 Easy introduction Yes 44.34 (2.78 ; 708.22) 0.007 No DISCUSSION The present study, which examined the tolerance and acceptability of endoscopy, was carried out in a tertiary-level hospital in the province of South Kivu in eastern DRC. The results showed that GDE was generally well tolerated (91.7%), despite the absence of sedation. The vast majority of patients were even ready or willing to repeat the examination under the same conditions, should the need arise. The main factor identified as influencing good tolerance was ease of insertion of the endoscope. Ease of insertion was noted in 90.2% of patients. Most patients (84.9%) reported no symptoms other than those anticipated in the pre-endoscopic explanations. This is encouraging for a procedure of this type performed without sedation, and seemed to give patients confidence for a possible subsequent examination of this type. The average exploration time was 5.9 ± 2.3 minutes, close to the averages generally found during explorations performed under sedation. Demortier et al. found a similar mean duration despite sedation ( 9 ). Sombié et al. also found an average duration of 5 minutes for endoscopies performed under the same conditions as our study ( 10 ). These data, therefore, seem to show that the absence of sedation does not significantly prolong the duration of the endoscopic procedure if performed by an experienced operator. Some studies have noted much longer duration with unsedated endoscopy ( 11 , 12 ). More than half of our patients (52.7%) were already familiar with endoscopic exploration, either because they had heard of it or because they had performed it before (12.3%). Nevertheless, 46 patients (33.1%) were apprehensive before the procedure, mainly because of fear of pain during the procedure (31.3%). These results demonstrate a certain weakness in the popularization of endoscopic practice in the study environment and in Sub-Saharan Africa in general. Sombié et al. found similar results, with 51.1% of patients having no prior information on this exploration prior to their first endoscopy ( 10 ). The situation is somewhat different in North Africa, as in Morocco, for example, where a study showed that almost half of endoscopy patients had already undergone at least one previous endoscopy ( 13 ). Of the 145 patients in our sample, 68 were anxious before the examination (46.5%), and these were most afraid of pain during the examination, in contrast to Salwa's study, which found a higher proportion (78.4%) ( 9 ). In our study, only 4.1% of patients reported nausea, in contrast to Sombié's study where nausea was noted in 79.4% of patients ( 10 ). The low proportion of nausea found in our study is probably linked to the protocol used by our Gastroenterology department, which combines Ondasetron with Xylocaine. Indeed, the addition of sublingual Ondasetron, which is a powerful anti-nauseant, as premedication would undoubtedly help minimize this side effect. The endoscopic examination was initially proposed to 147 patients, but 2 of them (not represented in the tables) refused it because of apprehension, giving an acceptability rate of 98.6%. The vast majority of those who finally underwent the test (145) tolerated it very well or found it acceptable (91.7%). Our results seem to provide very encouraging information, reporting very high tolerance rates, close to those of endoscopies under sedation. A good tolerance rate of 60% was found in a comparable study carried out in Kinshasa, DRC ( 15 ). A Senegalese study reported 42.5% cases of intolerance when endoscopy was performed without sedation ( 16 ). In Burkina Faso, the study by Sombié et al. found a rate of 84.6% ( 10 ). In Iraq and Iran, good tolerance rates with unsedated endoscopy were reported in 80.3% and 79% of cases respectively ( 12 , 17 ). The impression that emerges is that good patient preparation, with clear explanations of the procedure and any discomforts, plays a significant role in improving tolerance to endoscopy as demonstrated in other studies ( 18 , 19 ). Indeed, patient acceptance and comfort depend enormously on a good understanding of the indications, the stages of the procedure, the patient's confidence and a clear explanation of the results. This could also explain the high level of tolerance shown by our patients, almost all of whom acknowledged that the examination corresponded perfectly to the explanations given prior to the examination ( 20 , 21 ). The good tolerance rate found in our study could thus be an indicator of good practice of the procedure, but also of a fairly good tolerance of the endoscopy performed with our protocol. Although current recommendations are in favor of conscious sedation, in the absence of this, a protocol similar to the one used in our Department could be a good alternative. Indeed, the addition of Ondasetron seems to us to have the potential to play an important role in improving tolerance rates. In particular, it would improve the process of introducing the device, which has been found to be a major determinant of good tolerance. The use of sedation during the examination is not common practice in our study environment, mainly for economic reasons. Nevertheless, the level of tolerance obtained in our study, comparable to that obtained in Western countries where sedation is widely used, seems to encourage the evaluation of the procedure as applied in our unit. Good tolerance of the first endoscopic procedure remains an important parameter in the subsequent acceptability of the same procedure. Sombié et al. found a rate of acceptability of a subsequent endoscopy comparable to that found in our study (83.7% vs. 84.9%) ( 10 ). A Moroccan study found that only 43% of patients agreed to repeat the examination under the same conditions (i.e. without sedation) should a new indication arise ( 13 ). Finally, it should not be overlooked that patients’ comfort during the examination also depends enormously on the experience of the operator, and that cultural reasons play an important part in the degree of acceptance and tolerance of invasive explorations. Study limitations The present study is monocentric and, therefore, cannot generate conclusions relating to the entire Congolese or South Kivu population. In addition, it has the weakness of not having compared the different premedication protocols: xylocaine alone, xylocaine + ondasetron and endoscopy under conscious sedation. This would better support our conclusions. It also has the disadvantage of considering data from only one endoscopic operator. However, it does have the advantage of evaluating for the first time the degree of acceptability of this exploration, which has only recently been introduced in this community. It also appears to be the first study to evaluate the effect of premedication with Ondasetron. Finally, it should be pointed out that the present data were collected during the COVID-19 epidemic, which may explain a reduction in the number of procedures and perhaps even certain reactions and apprehension on the part of patients in relation to the overall context of this epidemic. CONCLUSION Upper gastro-intestinal endoscopy is a relatively recent procedure in many African countries, including the Democratic Republic of the Congo. Unfortunately, this procedure is still subject to a number of difficulties in terms of generalization, due to apprehensions on the part of patients and the many constraints associated with the use of sedation. Our study showed good results in terms of patients’ tolerance and comfort with an endoscopy protocol without sedation but with the addition of Ondasetron. However, these results need to be confirmed by a large-scale comparative study. Declarations The study obtained the authorization of the ethics committee of the Catholic University of Bukavu. Before enrolment into the study and any procedure, patients were brought to sign an informed consent form. Funding This research was not supported by any specific grant. Author Contribution EBM: produced endoscopic data, assisted in data collection, drafted the manuscript; RID: data analysis; CL: data analysis; TSA: conceived and designed the study, produced endoscopic data, assisted in data analysis and reviewed the manuscript Acknowledgement Our sincere thanks to nurse endoscopist Yvonne BISHWEKA for her participation in generating the data for this study Data Availability The datasets used and analyzed during the current study are openly available in Mendeley Data (shindano, tony (2024), “Ondasetron unsedated endoscopy” doi: 10.17632/c6rygr549w.1 ). References Yahya H, Umar H, Shekari BT, Sani K, Yahya MH. Tolerance and acceptance for unsedated diagnostic upper gastrointestinal endoscopy in Kaduna, North-West Nigeria. Niger Postgrad Med J. 2022 Apr-Jun;29(2):138-145. doi: 10.4103/npmj.npmj_697_21. Campo R, Brullet E, Montserrat A, et al. Identification of factors that influence tolerance of upper gastrointestinal endoscopy. Eur J Gastroenterol Hepatol. 1999;11(2):201-204. doi:10.1097/00042737-199902000-00023 Shaheen NJ, Fennerty MB, Bergman JJ. Less Is More: A Minimalist Approach to Endoscopy. Gastroenterology. 2018;154(7):1993-2003. doi:10.1053/j.gastro.2017.12.044 Lauriola M, Tomai M, Palma R, et al. Intolerance of uncertainty and anxiety-related dispositions predict pain during upper endoscopy. Front Psychol. 2019;10(May):1-13. doi:10.3389/fpsyg.2019.01112 Lee HJ, Kim B, Kim DW, et al. Does sedation affect examination of esophagogastric junction during upper endoscopy? Yonsei Med J. 2015;56(6):1566-1571. doi:10.3349/ymj.2015.56.6.1566 Tai FWD, Ching HL, Sloan M, Sidhu R, McAlindon M. Comparison of patient tolerance and acceptability of magnet-controlled capsule endoscopy and flexible endoscopy in the investigation of dyspepsia. Endosc Int Open. 2022;10(06):E735-E744. doi:10.1055/a-1790-5996 Faulx AL, Catanzaro A, Zyzanski S, et al. Patient tolerance and acceptance of unsedated ultrathin esophagoscopy. Gastrointest Endosc. 2002;55(6):620-623. doi:10.1067/mge.2002.123274 Tshimpi AW. Il faut relancer l’endoscopie digestive en République Démocratique du Congo It is necessary to restart the digestive endoscopy in Democratic Republic of Congo. 2015; 8 (Mars):1922-1923.9. Dumortier J, Ponchon T. Nasogastroscopie : l’âge de raison ?. Hépato-gastro & oncologie digestive. 2009 Jan 1;16(1):29-33. Sombié R, Guingané A, Tiendrébéogo A, Gansané Z, Bougouma A. Évaluation De La Tolérance Et De L’Acceptabilité De L’Endoscopie Digestive Haute Chez 350 Patients. J Africain d’Hepato-Gastroenterologie. 2016;10(1):6-9. doi:10.1007/s12157-015-0630-8 Mulcahy HE, Kelly P, Banks MR, Connor P, Patchet SE, Farthing MJ, Fairclough PD, Kumar PJ. Factors associated with tolerance to, and discomfort with, unsedated diagnostic gastroscopy. Scand J Gastroenterol. 2001 Dec;36(12):1352-7. doi: 10.1080/003655201317097245 al-Atrakchi HA. Upper gastrointestinal endoscopy without sedation: a prospective study of 2000 examinations. Gastrointest Endosc. 1989 Mar-Apr;35(2):79-81. doi: 10.1016/s0016-5107(89)72712-7. Salwa O, Mohamed T, Rachid M, Ahmed B, Wafa B. Acceptabilité de la fibroscopie œsogastroduodénale sans anesthésie chez les patients marocains : étude prospective. Available from: https://www.snfge.org/content/acceptabilite-de-la-fibroscopie- oeso-gastro-duodenale.pdf. Meda Ziemle Clement, Ouattara Alimata, Hien Herve, Ouattara Cheick Ahmed, Ilboudo Bernard, et al. (2023). Acceptability of Oesogastroduodenal Fibroscopy in Private Health Facilities from the City of Bobo-Dioulasso in Burkina Faso. Central African Journal of Public Health, 9(3), 80-88. https://doi.org/10.11648/j.cajph.20230903.13 Lungosi B, Ngilibuma M, Batumona B, Ndarabu T, Monsere T, Kengibe P, Bomba E, Tshimpi A, Mbendi S. Acceptabilité et tolérance d’une endoscopie digestive haute aux CUK : série préliminaire de 22 patients de Septembre à Novembre 2014. Annales Africaines de Médecine. 2015;8:5-6. Ngouala GABB, Bourgi L, Da Veiga JAI, Sakho A. Endoscopie digestive haute à Louga (Sénégal): Profil des patients et difficultés rencontrées. Pan Afr Med J. 2017;27:1-5. doi:10.11604/pamj.2017.27.211.9586 Farhadi A, Fields JZ, Hoseini SH. The assessment of esophagogastroduodenoscopy tolerance a prospective study of 300 cases. Diagn Ther Endosc. 2001;7(3-4):141-7. doi: 10.1155/DTE.7.141. Wilson JF, Moore RW, Randolph S, Hanson BJ. Behavioral preparation of patients for gastrointestinal endoscopy: information, relaxation, and coping style. J Human Stress. 1982 Dec;8(4):13-23. doi: 10.1080/0097840X.1982.9936114. Levy N, Landmann L, Stermer E, Erdreich M, Beny A, Meisels R. Does a detailed explanation prior to gastroscopy reduces the patient's anxiety? Endoscopy. 1989 Nov;21(6):263-5. doi: 10.1055/s-2007-1012965. Balamane, A., Oussalah, A., Bensenane, M., Kaddache, N., Layaïda, K., Gamar, L.,Kecili, L., Bounab, N., Belhocine, K., Debzi, N., Baïod, N. and Boucekkine, T. Impact de l’information du patient avant une endoscopie digestive. Expérience d’un service hospitalo-universitaire. Endoscopy. 2018, 40, 122. https://doi.org/10.1055/s-2008-1066961 Hassini Z, Hassani M J, Hliwa W, Haddad F, Badre W. L’anxiété: facteur de mauvaise acceptabilité de l’endoscopie digestive haute sans sédation [Anxiety: a factor of poor acceptability of upper GI endoscopy without sedation]. Endoscopy. 2018; 10 (50): 908. Additional Declarations No competing interests reported. Supplementary Files Database.xls Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5299111","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":371687703,"identity":"be706fdd-9843-4063-8669-286632240685","order_by":0,"name":"Tony Akilimali Shindano","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2klEQVRIiWNgGAWjYLACxgYJBoYDzAeATAkZgqp5EFrYEkBaeIjVAiQO8BjABfACe/beY5I/d1jk8R0/8/nVjRoLHgb2w0c34LWF51yaNO8ZiWLJM7nbrHOOAR3Gk5Z2A68WiRwzacY2icQNB3K3GeewAbVI8JgR1CL5E6Tl/Jtnxjn/iNQiwQvSciOH+XFuGzFazpwxtgZpmXnjmRlzbp8EDxshv7C39xje/NlWl9h3Pvnx55xvdXL87IeP4dUCBCwSUAYbmMFGQDkIMH9AZ4yCUTAKRsEoQAEAUgtHFA9KwyoAAAAASUVORK5CYII=","orcid":"","institution":"Université Catholique de Bukavu","correspondingAuthor":true,"prefix":"","firstName":"Tony","middleName":"Akilimali","lastName":"Shindano","suffix":""},{"id":371687705,"identity":"5fd02a82-dd79-44aa-81b2-0704cc11b66c","order_by":1,"name":"Espoir Batumike Murhi","email":"","orcid":"","institution":"Université Catholique de Bukavu","correspondingAuthor":false,"prefix":"","firstName":"Espoir","middleName":"Batumike","lastName":"Murhi","suffix":""},{"id":371687706,"identity":"663e4dfc-8fca-49fd-9a18-11327ff641fa","order_by":2,"name":"Raissa Iranga Boroto","email":"","orcid":"","institution":"Université Catholique de Bukavu","correspondingAuthor":false,"prefix":"","firstName":"Raissa","middleName":"Iranga","lastName":"Boroto","suffix":""},{"id":371687708,"identity":"e607d317-69f2-4c65-84d1-dd423034a854","order_by":3,"name":"Corneille Lembembu","email":"","orcid":"","institution":"Université Catholique de Bukavu","correspondingAuthor":false,"prefix":"","firstName":"Corneille","middleName":"","lastName":"Lembembu","suffix":""}],"badges":[],"createdAt":"2024-10-20 15:23:31","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5299111/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5299111/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":68689470,"identity":"11e70f07-626c-4d16-aa50-24c504ab409d","added_by":"auto","created_at":"2024-11-11 05:34:50","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":150495,"visible":true,"origin":"","legend":"\u003cp\u003eEndoscopy tolerance assessment tool\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5299111/v1/1014a4240c2cfc68b740050b.png"},{"id":98622955,"identity":"b85b454d-d405-4dbb-afd5-a1084072a1d3","added_by":"auto","created_at":"2025-12-19 17:03:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":748649,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5299111/v1/f176ffd5-31be-4756-8727-ff9046e6c3d5.pdf"},{"id":68689469,"identity":"89cf6640-f292-4f1a-bf9c-a4cc9766bafa","added_by":"auto","created_at":"2024-11-11 05:34:50","extension":"xls","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":109056,"visible":true,"origin":"","legend":"","description":"","filename":"Database.xls","url":"https://assets-eu.researchsquare.com/files/rs-5299111/v1/47762688de4cf17e83de173a.xls"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eOndasetron in Premedication During Unsedated Upper Digestive Endoscopy: Evaluation of Tolerance and Acceptability\u003c/p\u003e","fulltext":[{"header":"What's known","content":"\u003cp\u003e- Conscious sedation greatly improves tolerance of gastroduodenal endoscopy.\u003c/p\u003e\n\u003cp\u003e- A few undesirable effects sometimes limit the systematic use of this practice\u003c/p\u003e\n\u003cp\u003e- Gastroduodenal endoscopy performed without sedation is associated with fairly moderate tolerance of the procedure\u003c/p\u003e\n\u003ch2\u003eStudy novelties:\u003c/h2\u003e\n\u003cp\u003e- The study evaluates for the first time the addition of ondasetron to the pre-endoscopy premedication procedure.\u003c/p\u003e\n\u003cp\u003e- The study provides data on the tolerability of sedation-free endoscopy in the Congolese population of eastern DRC.\u003c/p\u003e\n\u003cp\u003e- The protocol used in our study seems to greatly improve the tolerance of the endoscopic procedure without sedation\u0026nbsp;\u003c/p\u003e"},{"header":"INTRODUCTION","content":"\u003cp\u003eUpper gastro-intestinal or gastroduodenal endoscopy (GDE) is one of the most widely performed diagnostic procedures worldwide. It is performed either by direct inspection or, increasingly, by flexible video-endoscopes. It has the advantage of assessing and helping to treat the main diseases of the upper digestive tract. It is increasingly performed under conscious sedation to improve tolerance. It has been reported that up to 5% of patients refuse to undergo it without sedation, and that 10% require good persuasion to undergo it when it is recommended in these conditions [1,2,3,4].\u003c/p\u003e \u003cp\u003eHowever, some manifestations and complications sometimes limit the use of sedation. These include the risk of hypoxia, an increase in post-procedure monitoring time or personnel, a rise in the cost of the examination, effects linked to absence from work after the endoscopy, or the need to be accompanied home after the procedure. It is estimated that these adverse events occur in around 1/200 GDEs, 60% of which are road accidents [2]. In addition, some practitioners feel that sedation could affect the diagnosis, notably because of the risk of gastro-oesophageal reflux induced by this sedation [5,6]. For these reasons, unsedated GDE remains a preferred approach in some parts of the world [7].\u003c/p\u003e \u003cp\u003eIn Sub-Saharan Africa, where universal healthcare coverage is lacking in many countries, endoscopic procedures are still often carried out without sedation, the cost of the procedure being a major factor, bearing in mind the average income of the population and the fact that care is usually remunerated on a fee-for-service basis [3].\u003c/p\u003e \u003cp\u003eThe tolerance and acceptance of GDE without sedation has been the subject of several studies around the world, but the reality in the Democratic Republic of the Congo (DRC) is not yet well known. In this vast country, this type of exploration is of fairly recent introduction and is only practiced in certain large cities due to not only lack of equipment and qualified personnel but also accessibility problems. A survey carried out in 2013 found only 14 hepato-gastroenterologists practising it in the DRC, i.e. 1 for every 4\u0026nbsp;million inhabitants, compared with 1 for every 14 thousand inhabitants in France. And of these 14, only 4 had endoscopic activity [8].\u003c/p\u003e \u003cp\u003eEndoscopy is a fairly recent reality in the province of South-Kivu, and it has only been operational at the H\u0026ocirc;pital Provinciale G\u0026eacute;n\u0026eacute;ral de Bukavu (HPGRB) since 2002. Since this examination became a reality in the region, it has been the subject of many false rumors, misinformation and apprehensions among the population. The same applies to certain reluctance on the part of medical staff to recommend it, due to lack of information. To our knowledge, no study to date has assessed its sociological impact on the population.\u003c/p\u003e \u003cp\u003eThe aim of the present study is to assess the extent of this reluctance and the real reasons for it, the reasons for fear and the degree of tolerance. It is also to determine the real resentment of patients after the examination and identify factors predictive of poor tolerance in order to improve the practice of this exploratory technique.\u003c/p\u003e \u003cp\u003eNausea and eructation are among the symptoms most commonly reported during poorly tolerated endoscopic explorations. To improve clinical tolerance, our study aimed secondarily to evaluate the additive effect of ondasetron, a powerful antinauseant, used as premedication.\u003c/p\u003e"},{"header":"METHODOLOGY","content":"\u003cp\u003e\u003cstrong\u003eType and setting of study:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis is a cross-sectional study spread over a 3-year period (2020-2022) and carried out at the HPGRB, a university hospital that acts as a reference hospital in the province of South Kivu, which has a population of around 6 million. The province currently has two endoscopy units, and the one at HPGRB is run by a gastroenterologist assisted by an intern in training.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy population:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study population consisted of all the patients who consulted the digestive exploration unit for a GDE. The study included only the patients who underwent diagnostic endoscopic exploration without sedation. It excluded pregnant women and patients under 18 years of age. It also excluded explorations carried out under conscious sedation or general anaesthesia, explorations with endoscopic treatment and explorations involving a technical incident (interruption of electrical supply, material incidents, etc.). Finally, it excluded all the patients who declined to take part in the survey and those who did not have a sufficiently clear understanding of the principle of the survey.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEndoscopic procedure and data collection\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the GDEs were performed by the same gastroenterologist using video endoscopy and an OLYMPUS multidirectional axial-view fiberscope.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBefore a patient settled in, the endoscopy nurse ensured that the procedure had been fully explained, including any discomfort that might arise during the procedure. This interview involved psychological preparation of the patient, followed by premedication with Ondasetron sublingual (8mg spray, 15 to 30 minutes before the procedure) and oro-pharyngeal anesthesia with Xylocaine 2% spray. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe exploration technique was conventional, with the patient lying in left lateral position. The device was then introduced through the mouth under direct vision, and then the esophagus, the stomach and the first two sections of the duodenum were progressively explored. At the end of the exploration, 5 gastric biopsies were systematically taken (2 from the antrum, 1 from the angle and 2 from the body).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBefore and after each exploration, every patient was asked to complete a questionnaire comprising three groups of information:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e- The pre-exploration section essentially covers the patient\u0026apos;s clinical data, medical history, the time of last meal, level of information previously received by the patient regarding this exploration, as well as the collection of his or her main apprehensions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e- Technical data: this mainly concerned information relating to the process of introducing the endoscope, the patient\u0026apos;s degree of cooperation, incidents and accidents during the examination, and the duration and results of the exploration. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e- Post-exploration data: subjective evaluation of the tolerance of the exploration, as well as the degree of acceptability of a new endoscopic procedure to be carried out under the same conditions.\u003c/p\u003e\n\u003cp\u003eThe degree of anxiety or tolerance was assessed using a ruler (visual analogue scale) expressing the different degrees of subjective perception (Endoscopy tolerance assessment tool). The different levels of perception correspond directly to numbers (located on the reverse side of the ruler), enabling scores to be established at the same time (see figure).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn this way, we were able to establish different levels of examination tolerance:\u003c/p\u003e\n\u003cp\u003e- Excellent tolerance: 0-2\u003c/p\u003e\n\u003cp\u003e- Acceptable tolerance: 3-4\u003c/p\u003e\n\u003cp\u003e- Low tolerance: 5-8\u003c/p\u003e\n\u003cp\u003e- Intolerance: ˃ 8\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStatistical analyses were performed using Stata 17 software. Quantitative variables were described by means and their standard deviations or medians and their Interquartile ranges. The Kruskal-Wallis, Mann-Whitney and Student\u0026apos;s t-tests were used to assess the association between quantitative and categorical variables. Categorical variables were compared using the Chi-square test and Fischer\u0026apos;s exact test.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSimple logistic regression was performed by calculating the Odds ratio (OR) at its 95% confidence interval (CI). \u0026nbsp; Differences observed were considered significant at a p \u0026lt; 0.05.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 145 patients took part in the study. Their general data according to tolerance are shown in Table I. \u0026nbsp; Epigastralgia was the main reason for consultation in over two-thirds of subjects (69%), and the main diagnoses reported were gastritis (45.4%) and peptic ulcer disease (21.3%). Twelve percent of patients had already undergone endoscopy, and almost half (47%) had never heard of it (Table II). Overall, only 12 patients (8.3%) reported not tolerating the endoscopic procedure, compared with 91.7% with good or excellent tolerance. Intolerance did not appear to be associated with patient age or gender. A small degree of intolerance was found among illiterate and university patients. \u0026nbsp;Patients who tolerated the exploration well were those who followed the endoscopist\u0026apos;s instructions well (=good collaboration) and those in whom the introduction of the endoscope was easy (p\u0026lt; 0.001). These patients were more likely to agree to repeat the endoscopy than those who did not tolerate it well (84.9% vs. 16.7%) \u003cem\u003e[\u003c/em\u003e\u003cem\u003edata not shown\u003c/em\u003e\u003cem\u003e]\u003c/em\u003e\u003cem\u003e.\u003c/em\u003e In multivariate analysis (Table III), only ease of introduction emerged as the main determinant of good tolerance of the endoscopic procedure (adjusted OR 44.34 [2.78- 708.22], p=0.007). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable I: General characteristics of the study population\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" align=\"\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003eIntolerance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eP Value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eNo n=133 (91.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eYes n=12 (8.13%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003eMedian age\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e47 (18\u0026nbsp;; 80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e60 (18\u0026nbsp;;80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.258\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Female \u0026nbsp;(n=69 ; 47.6 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e62 (46.62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e7 (58.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.436\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Male \u0026nbsp;(n=76 ; 52.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e71 (53.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e5 (41.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003eLevel of education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;None\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e5 (3.76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e4 (33.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Primary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e37 (27.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e2 (16.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Secondary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e66 (49.62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e2 (16.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;University\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e25 (18.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e4 (33.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003eHeight (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e161.57\u0026nbsp;\u0026plusmn;\u0026nbsp;8.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e161.08\u0026nbsp;\u0026plusmn;\u0026nbsp;8.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.854\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003eWeight \u0026nbsp;(Kgs)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e63.60\u0026nbsp;\u0026plusmn;\u0026nbsp;13.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e55.23\u0026nbsp;\u0026plusmn;\u0026nbsp;8.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.040\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003eBMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e24.41\u0026nbsp;\u0026plusmn;\u0026nbsp;5.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e21.16\u0026plusmn;1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.039\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003eAlcohol consumption\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e65 (48.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e5 (41.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.632\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003eSmoking\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e20 (15.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e2 (16.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.573\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eTable II: Univariate analysis of endoscopic procedure tolerance determinants\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003eIntolerance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eP Value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eNo n=133 (91.72%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eYes n=12 \u0026nbsp;(8.27%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 601px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEndoscopy indications\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003e\u0026nbsp; Epigastralgia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e92 (69.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e9 (75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.786\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Digestive bleeding/Anemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e27 (20.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e3 (25)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Others\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e14 (10.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 601px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedical history and pre-endoscopic information\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003ePrevious endoscopy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e18 (13.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.190\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003eHave received explanations about the procedure\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e43 (32.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e4 (33.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.586\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003eEver heard of endoscopy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e72 (54.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e4 (33.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.140\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003eTime interval since last meal (minutes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e808.50 (450\u0026nbsp;; 1200)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e781.50 (30\u0026nbsp;; 1230)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.563\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 601px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-examination apprehensions\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003eSubjective anxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e59 (44.36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e8 (66.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.138\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003eDegree of anxiety (using the tolerance assessment tool)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e1.69\u0026nbsp;\u0026plusmn;\u0026nbsp;2.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e2.91\u0026nbsp;\u0026plusmn;\u0026nbsp;2.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.070\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003eFear of pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e40 (31.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e5 (45.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.264\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003eFear of nausea\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e4 (3.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e1 (8.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.355\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003eFear of vomiting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e4 (3.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.705\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003eFear of suffocation\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e4 (3\u0026nbsp;;01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.705\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003eFear of injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e1 (0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e2 (16.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.018\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 601px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEndoscopy process\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003eEasy introduction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e119 (89.47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e4 (33.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003eGood cooperation (following instructions correctly)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e119 (89.47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e5 (41.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable III: Multivariate analysis of endoscopic procedure tolerance determinants\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39.5695%;\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30.6291%;\"\u003e\n \u003cp\u003eOR adj (95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.8013%;\"\u003e\n \u003cp\u003e\u003cem\u003ef\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39.5695%;\"\u003e\n \u003cp\u003eWeight\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30.6291%;\"\u003e\n \u003cp\u003e0.90 (0.78\u0026nbsp;; 1.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.8013%;\"\u003e\n \u003cp\u003e0.148\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eLevel of education\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39.5695%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;None\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30.6291%;\"\u003e\n \u003cp\u003e3.67 (0.03\u0026nbsp;; 463.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.8013%;\"\u003e\n \u003cp\u003e0.598\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39.5695%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Primary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30.6291%;\"\u003e\n \u003cp\u003e0.34 (0.01\u0026nbsp;; 8.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.8013%;\"\u003e\n \u003cp\u003e0.509\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39.5695%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Secondary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30.6291%;\"\u003e\n \u003cp\u003e0.01 (0.00\u0026nbsp;; 0.98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.8013%;\"\u003e\n \u003cp\u003e0.049\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39.5695%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;University\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30.6291%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.8013%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eFear of injury\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39.5695%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30.6291%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.8013%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39.5695%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30.6291%;\"\u003e\n \u003cp\u003e5.97 (0.01\u0026nbsp;; 207413.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.8013%;\"\u003e\n \u003cp\u003e0.738\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eEasy introduction\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39.5695%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30.6291%;\"\u003e\n \u003cp\u003e44.34 (2.78\u0026nbsp;; 708.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.8013%;\"\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39.5695%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30.6291%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.8013%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe present study, which examined the tolerance and acceptability of endoscopy, was carried out in a tertiary-level hospital in the province of South Kivu in eastern DRC. The results showed that GDE was generally well tolerated (91.7%), despite the absence of sedation. The vast majority of patients were even ready or willing to repeat the examination under the same conditions, should the need arise. The main factor identified as influencing good tolerance was ease of insertion of the endoscope. Ease of insertion was noted in 90.2% of patients. Most patients (84.9%) reported no symptoms other than those anticipated in the pre-endoscopic explanations. This is encouraging for a procedure of this type performed without sedation, and seemed to give patients confidence for a possible subsequent examination of this type.\u003c/p\u003e \u003cp\u003eThe average exploration time was 5.9 ± 2.3 minutes, close to the averages generally found during explorations performed under sedation. Demortier et al. found a similar mean duration despite sedation (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Sombié et al. also found an average duration of 5 minutes for endoscopies performed under the same conditions as our study (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). These data, therefore, seem to show that the absence of sedation does not significantly prolong the duration of the endoscopic procedure if performed by an experienced operator. Some studies have noted much longer duration with unsedated endoscopy (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMore than half of our patients (52.7%) were already familiar with endoscopic exploration, either because they had heard of it or because they had performed it before (12.3%). Nevertheless, 46 patients (33.1%) were apprehensive before the procedure, mainly because of fear of pain during the procedure (31.3%). These results demonstrate a certain weakness in the popularization of endoscopic practice in the study environment and in Sub-Saharan Africa in general. Sombié et al. found similar results, with 51.1% of patients having no prior information on this exploration prior to their first endoscopy (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). The situation is somewhat different in North Africa, as in Morocco, for example, where a study showed that almost half of endoscopy patients had already undergone at least one previous endoscopy (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOf the 145 patients in our sample, 68 were anxious before the examination (46.5%), and these were most afraid of pain during the examination, in contrast to Salwa's study, which found a higher proportion (78.4%) (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). In our study, only 4.1% of patients reported nausea, in contrast to Sombié's study where nausea was noted in 79.4% of patients (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). The low proportion of nausea found in our study is probably linked to the protocol used by our Gastroenterology department, which combines Ondasetron with Xylocaine. Indeed, the addition of sublingual Ondasetron, which is a powerful anti-nauseant, as premedication would undoubtedly help minimize this side effect.\u003c/p\u003e \u003cp\u003eThe endoscopic examination was initially proposed to 147 patients, but 2 of them (not represented in the tables) refused it because of apprehension, giving an acceptability rate of 98.6%. The vast majority of those who finally underwent the test (145) tolerated it very well or found it acceptable (91.7%). Our results seem to provide very encouraging information, reporting very high tolerance rates, close to those of endoscopies under sedation. A good tolerance rate of 60% was found in a comparable study carried out in Kinshasa, DRC (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). A Senegalese study reported 42.5% cases of intolerance when endoscopy was performed without sedation (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). In Burkina Faso, the study by Sombié et al. found a rate of 84.6% (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). In Iraq and Iran, good tolerance rates with unsedated endoscopy were reported in 80.3% and 79% of cases respectively (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe impression that emerges is that good patient preparation, with clear explanations of the procedure and any discomforts, plays a significant role in improving tolerance to endoscopy as demonstrated in other studies (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Indeed, patient acceptance and comfort depend enormously on a good understanding of the indications, the stages of the procedure, the patient's confidence and a clear explanation of the results. This could also explain the high level of tolerance shown by our patients, almost all of whom acknowledged that the examination corresponded perfectly to the explanations given prior to the examination (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe good tolerance rate found in our study could thus be an indicator of good practice of the procedure, but also of a fairly good tolerance of the endoscopy performed with our protocol. Although current recommendations are in favor of conscious sedation, in the absence of this, a protocol similar to the one used in our Department could be a good alternative. Indeed, the addition of Ondasetron seems to us to have the potential to play an important role in improving tolerance rates. In particular, it would improve the process of introducing the device, which has been found to be a major determinant of good tolerance.\u003c/p\u003e \u003cp\u003eThe use of sedation during the examination is not common practice in our study environment, mainly for economic reasons. Nevertheless, the level of tolerance obtained in our study, comparable to that obtained in Western countries where sedation is widely used, seems to encourage the evaluation of the procedure as applied in our unit.\u003c/p\u003e \u003cp\u003eGood tolerance of the first endoscopic procedure remains an important parameter in the subsequent acceptability of the same procedure. Sombié et al. found a rate of acceptability of a subsequent endoscopy comparable to that found in our study (83.7% vs. 84.9%) (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). A Moroccan study found that only 43% of patients agreed to repeat the examination under the same conditions (i.e. without sedation) should a new indication arise (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFinally, it should not be overlooked that patients’ comfort during the examination also depends enormously on the experience of the operator, and that cultural reasons play an important part in the degree of acceptance and tolerance of invasive explorations.\u003c/p\u003e\n\u003ch3\u003eStudy limitations\u003c/h3\u003e\n\u003cp\u003eThe present study is monocentric and, therefore, cannot generate conclusions relating to the entire Congolese or South Kivu population. In addition, it has the weakness of not having compared the different premedication protocols: xylocaine alone, xylocaine + ondasetron and endoscopy under conscious sedation. This would better support our conclusions. It also has the disadvantage of considering data from only one endoscopic operator. However, it does have the advantage of evaluating for the first time the degree of acceptability of this exploration, which has only recently been introduced in this community. It also appears to be the first study to evaluate the effect of premedication with Ondasetron. Finally, it should be pointed out that the present data were collected during the COVID-19 epidemic, which may explain a reduction in the number of procedures and perhaps even certain reactions and apprehension on the part of patients in relation to the overall context of this epidemic.\u003c/p\u003e \u003cp\u003e\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eUpper gastro-intestinal endoscopy is a relatively recent procedure in many African countries, including the Democratic Republic of the Congo. Unfortunately, this procedure is still subject to a number of difficulties in terms of generalization, due to apprehensions on the part of patients and the many constraints associated with the use of sedation. Our study showed good results in terms of patients’ tolerance and comfort with an endoscopy protocol without sedation but with the addition of Ondasetron. However, these results need to be confirmed by a large-scale comparative study.\u003c/p\u003e"},{"header":"Declarations","content":" \u003cp\u003e The study obtained the authorization of the ethics committee of the Catholic University of Bukavu. Before enrolment into the study and any procedure, patients were brought to sign an informed consent form.\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis research was not supported by any specific grant.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eEBM: produced endoscopic data, assisted in data collection, drafted the manuscript; RID: data analysis; CL: data analysis; TSA: conceived and designed the study, produced endoscopic data, assisted in data analysis and reviewed the manuscript\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eOur sincere thanks to nurse endoscopist Yvonne BISHWEKA for her participation in generating the data for this study\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e \u003cp\u003eThe datasets used and analyzed during the current study are openly available in Mendeley Data (shindano, tony (2024), \u0026ldquo;Ondasetron unsedated endoscopy\u0026rdquo; doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.17632/c6rygr549w.1\u003c/span\u003e\u003cspan address=\"10.17632/c6rygr549w.1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eYahya H, Umar H, Shekari BT, Sani K, Yahya MH. Tolerance and acceptance for unsedated diagnostic upper gastrointestinal endoscopy in Kaduna, North-West Nigeria. Niger Postgrad Med J. 2022 Apr-Jun;29(2):138-145. doi: 10.4103/npmj.npmj_697_21.\u003c/li\u003e\n \u003cli\u003eCampo R, Brullet E, Montserrat A, et al. Identification of factors that influence tolerance of upper gastrointestinal endoscopy. Eur J Gastroenterol Hepatol. 1999;11(2):201-204. doi:10.1097/00042737-199902000-00023\u003c/li\u003e\n \u003cli\u003eShaheen NJ, Fennerty MB, Bergman JJ. Less Is More: A Minimalist Approach to Endoscopy. Gastroenterology. 2018;154(7):1993-2003. doi:10.1053/j.gastro.2017.12.044\u003c/li\u003e\n \u003cli\u003eLauriola M, Tomai M, Palma R, et al. Intolerance of uncertainty and anxiety-related dispositions predict pain during upper endoscopy. Front Psychol. 2019;10(May):1-13. doi:10.3389/fpsyg.2019.01112\u003c/li\u003e\n \u003cli\u003eLee HJ, Kim B, Kim DW, et al. Does sedation affect examination of esophagogastric junction during upper endoscopy? Yonsei Med J. 2015;56(6):1566-1571. doi:10.3349/ymj.2015.56.6.1566\u003c/li\u003e\n \u003cli\u003eTai FWD, Ching HL, Sloan M, Sidhu R, McAlindon M. Comparison of patient tolerance and acceptability of magnet-controlled capsule endoscopy and flexible endoscopy in the investigation of dyspepsia. Endosc Int Open. 2022;10(06):E735-E744. doi:10.1055/a-1790-5996\u003c/li\u003e\n \u003cli\u003eFaulx AL, Catanzaro A, Zyzanski S, et al. Patient tolerance and acceptance of unsedated ultrathin esophagoscopy. Gastrointest Endosc. 2002;55(6):620-623. doi:10.1067/mge.2002.123274\u003c/li\u003e\n \u003cli\u003eTshimpi AW. Il faut relancer l\u0026rsquo;endoscopie digestive en R\u0026eacute;publique D\u0026eacute;mocratique du Congo It is necessary to restart the digestive endoscopy in Democratic Republic of Congo. 2015; 8 (Mars):1922-1923.9.\u003c/li\u003e\n \u003cli\u003eDumortier J, Ponchon T. Nasogastroscopie : l\u0026rsquo;\u0026acirc;ge de raison ?. H\u0026eacute;pato-gastro \u0026amp; oncologie digestive. 2009 Jan 1;16(1):29-33.\u003c/li\u003e\n \u003cli\u003eSombi\u0026eacute; R, Guingan\u0026eacute; A, Tiendr\u0026eacute;b\u0026eacute;ogo A, Gansan\u0026eacute; Z, Bougouma A. \u0026Eacute;valuation De La Tol\u0026eacute;rance Et De L\u0026rsquo;Acceptabilit\u0026eacute; De L\u0026rsquo;Endoscopie Digestive Haute Chez 350 Patients. J Africain d\u0026rsquo;Hepato-Gastroenterologie. 2016;10(1):6-9. doi:10.1007/s12157-015-0630-8\u003c/li\u003e\n \u003cli\u003eMulcahy HE, Kelly P, Banks MR, Connor P, Patchet SE, Farthing MJ, Fairclough PD, Kumar PJ. Factors associated with tolerance to, and discomfort with, unsedated diagnostic gastroscopy. Scand J Gastroenterol. 2001 Dec;36(12):1352-7. doi: 10.1080/003655201317097245\u003c/li\u003e\n \u003cli\u003eal-Atrakchi HA. Upper gastrointestinal endoscopy without sedation: a prospective study of 2000 examinations. Gastrointest Endosc. 1989 Mar-Apr;35(2):79-81. doi: 10.1016/s0016-5107(89)72712-7.\u003c/li\u003e\n \u003cli\u003eSalwa O, Mohamed T, Rachid M, Ahmed B, Wafa B. Acceptabilit\u0026eacute; de la fibroscopie \u0026oelig;sogastroduod\u0026eacute;nale sans anesth\u0026eacute;sie chez les patients marocains : \u0026eacute;tude prospective. Available from: https://www.snfge.org/content/acceptabilite-de-la-fibroscopie- oeso-gastro-duodenale.pdf.\u003c/li\u003e\n \u003cli\u003eMeda Ziemle Clement, Ouattara Alimata, Hien Herve, Ouattara Cheick Ahmed, Ilboudo Bernard, et al. (2023). Acceptability of Oesogastroduodenal Fibroscopy in Private Health Facilities from the City of Bobo-Dioulasso in Burkina Faso. Central African Journal of Public Health, 9(3), 80-88. https://doi.org/10.11648/j.cajph.20230903.13\u003c/li\u003e\n \u003cli\u003eLungosi B, Ngilibuma M, Batumona B, Ndarabu T, Monsere T, Kengibe P, Bomba E, Tshimpi A, Mbendi S. Acceptabilit\u0026eacute; et tol\u0026eacute;rance d\u0026rsquo;une endoscopie digestive haute aux CUK : s\u0026eacute;rie pr\u0026eacute;liminaire de 22 patients de Septembre \u0026agrave; Novembre 2014. Annales Africaines de M\u0026eacute;decine. 2015;8:5-6.\u003c/li\u003e\n \u003cli\u003eNgouala GABB, Bourgi L, Da Veiga JAI, Sakho A. Endoscopie digestive haute \u0026agrave; Louga (S\u0026eacute;n\u0026eacute;gal): Profil des patients et difficult\u0026eacute;s rencontr\u0026eacute;es. Pan Afr Med J. 2017;27:1-5. doi:10.11604/pamj.2017.27.211.9586\u003c/li\u003e\n \u003cli\u003eFarhadi A, Fields JZ, Hoseini SH. The assessment of esophagogastroduodenoscopy tolerance a prospective study of 300 cases. Diagn Ther Endosc. 2001;7(3-4):141-7. doi: 10.1155/DTE.7.141.\u003c/li\u003e\n \u003cli\u003eWilson JF, Moore RW, Randolph S, Hanson BJ. Behavioral preparation of patients for gastrointestinal endoscopy: information, relaxation, and coping style. J Human Stress. 1982 Dec;8(4):13-23. doi: 10.1080/0097840X.1982.9936114.\u003c/li\u003e\n \u003cli\u003eLevy N, Landmann L, Stermer E, Erdreich M, Beny A, Meisels R. Does a detailed explanation prior to gastroscopy reduces the patient\u0026apos;s anxiety? Endoscopy. 1989 Nov;21(6):263-5. doi: 10.1055/s-2007-1012965.\u003c/li\u003e\n \u003cli\u003eBalamane, A., Oussalah, A., Bensenane, M., Kaddache, N., Laya\u0026iuml;da, K., Gamar, L.,Kecili, L., Bounab, N., Belhocine, K., Debzi, N., Ba\u0026iuml;od, N. and Boucekkine, T. Impact de l\u0026rsquo;information du patient avant une endoscopie digestive. Exp\u0026eacute;rience d\u0026rsquo;un service hospitalo-universitaire. Endoscopy. 2018, 40, 122. https://doi.org/10.1055/s-2008-1066961\u003c/li\u003e\n \u003cli\u003eHassini Z, Hassani M J, Hliwa W, Haddad F, Badre W. L\u0026rsquo;anxiété: facteur de mauvaise acceptabilité de l\u0026rsquo;endoscopie digestive haute sans sédation [Anxiety: a factor of poor acceptability of upper GI endoscopy without sedation]. Endoscopy. 2018; 10 (50): 908.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Gastroduodenal endoscopy, Ondasetron, tolerance, acceptability, DRC","lastPublishedDoi":"10.21203/rs.3.rs-5299111/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5299111/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction: \u003c/strong\u003eThe practice of gastroduodenal endoscopy under conscious sedation is still limited in many low-income countries due to additional costs generated as well as concerns related to the management of many constraints and other adverse effects. The aim of this study is to evaluate the practice of this act without any sedation but with addition of a potent antinauseant in premedication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethodology: \u003c/strong\u003eThis was a prospective single center study conducted from 2020 to 2022 in Bukavu, East of the Democratic Republic of the Congo. Endoscopies were performed without sedation, but by additionally associating a protocol using a sublingual spray of ondasetron. Clinical data, data related to the endoscopic procedure and those related to patients’ opinions before and after the procedure were respectively analyzed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe study enrolled 145 patients, of whom 76 (52.4%) were men. Only 12 patients (8.28%) reported a poor tolerance during the procedure. The patients (91.72%) who have well tolerated the procedure were those who followed instructions well and in whom the introduction of the endoscope was easy (p \u0026lt; 0.001). In multivariate analysis, only the easy introduction of the endoscope appeared to be the main determinant of tolerance (adjusted OR 44.34 [2.78; 708.22] , p=0.007).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: Unsedated upper digestive endoscopy using ondansetron in premedication seems to be well tolerated but this tolerance also depends on good conditions of patients’ preparation as well as good mastering of first stages of the exploration.\u003c/p\u003e","manuscriptTitle":"Ondasetron in Premedication During Unsedated Upper Digestive Endoscopy: Evaluation of Tolerance and Acceptability","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-11 05:34:45","doi":"10.21203/rs.3.rs-5299111/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9d2b91d0-dad0-4363-849e-3980ef63c0d3","owner":[],"postedDate":"November 11th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-15T05:54:33+00:00","versionOfRecord":[],"versionCreatedAt":"2024-11-11 05:34:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5299111","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5299111","identity":"rs-5299111","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}