Pre-Endoscopy Drink of Simethicone and N-Acetylcysteine Significantly Improves Visualization in Upper Gastrointestinal Endoscopy

Abstract

Introduction With the advancements in diagnostic and therapeutic upper gastrointestinal endoscopy (UGIE), clear mucosal visualization is essential to ensure optimal outcomes. Though routinely followed in Japan and Korea, pre-endoscopic preparation is seldom used in India. We evaluated the efficacy of a pre-endoscopic drink of N-acetylcysteine (NAC) and simethicone in improving mucosal visibility during UGIE. Patients and Methods This study was a retrospective, investigator blind study with a case–control study design. Cases included patients who received a pre-endoscopy drink of NAC and simethicone in 100 mL water administered 10 to 30 minutes prior to UGIE. Controls only had mandatory fasting for 6 to 8 hours prior to UGIE. Propensity score matching was done to ensure comparability between the groups. Digital images were taken at six standard landmarks during UGIE and stored. A blinded investigator subsequently analyzed the images and rated the mucosal visibility on a 3-point scale. The difference in the mean mucosal visibility between the cases and controls was compared. Results Mean mucosal visibility during UGIE was significantly better using NAC with simethicone as compared with no preparation at esophagus (1.14 [0.37] vs. 1.47 [0.62], p < 0.05), gastric fundus (1.10 [0.30] vs. 1.55 [0.64], p < 0.05), gastric body (1.22 [0.50] vs. 1.62 [0.73], p < 0.05), gastric antrum (1.13 [0.37] vs. 1.47 [0.62], p < 0.05), and duodenal bulb (1.13 [0.34] vs. 1.33 [0.56], p < 0.05). In distal duodenum, though visibility improved with NAC with simethicone, the difference was insignificant. There were no adverse events related to the pre-endoscopy drink. Conclusion A pre-endoscopy drink of NAC with simethicone can significantly improve mucosal visibility during UGIE. It is safe, cheap, easily available and maybe considered for routine utilization for ensuring optimal endoscopic outcomes.

Minimizing the Risks of Simethicone in Endoscope Reprocessing

“…5,6,36 Another 4 randomized trials supporting the use of simethicone pre-gastroscopy have been published after these meta-analyses. [42][43][44][45] European guidelines recommend adding simethicone to bowel prep before colonoscopy 46,47 Two meta-analyses found simethicone added to the bowel prep improved mucosal visibility and bowel cleanliness. 30,31 Three RCTs found simethicone increased the adenoma detection rate.…”

“…Three meta-analyses support the use of simethicone given orally before gastroscopy showing that simethicone improves mucosal visibility and increases lesion detection 5,6,36. Another 4 randomized trials supporting the use of simethicone pre-gastroscopy have been published after these meta-analyses 42–45…”

Endoscopy Flashback 2021: Thanking the Authors and Reviewers of the Journal of Digestive Endoscopy

“…Addition of GOV3 in Sarin's classification will make it more comprehensive, uniform, and reproducible for future studies. Anikhindi et al, 2 in their case-control study demonstrated that a safe, cheap, and easily available pre-endoscopy drink of N-acetylcysteine with simethicone can significantly improve mucosal visibility during upper gastrointestinal endoscopy. This helps in ensuring optimal endoscopic outcomes.…”