Transnasal Endoscopy Service

Dear GP colleagues,

I am writing to let you know that suitable patients referred for Direct Access Endoscopy (DAE) may now be offered Transnasal Endoscopy (TNE).

TNE is an upper GI endoscopy carried out using a much thinner flexible endoscope, which is passed through the nose rather than the mouth. It allows us to assess the oesophagus, stomach and duodenum in the same way as a standard gastroscopy, and biopsies can be taken if needed.

For suitable patients, TNE is carried out without sedation. Patients remain awake and are usually seated for the procedure. A local anaesthetic nasal spray is used to numb the nasal passage. As sedation is not required, patients do not usually need an escort, can go home shortly afterwards, and can return to normal activities sooner.

All DAE referrals will be reviewed for TNE suitability. Patients will not be booked for TNE if they are unsuitable following vetting according to the local SOP, or PGD for the lidocaine/phenylephrine nasal spray used before the procedure.

Patients who may be suitable include those who need a diagnostic upper GI endoscopy and are able to tolerate the transnasal route. TNE may be particularly useful for patients who wish to avoid sedation or who would benefit from a shorter recovery time.

TNE may not be suitable for patients with:

• Previous nasal fracture, significant nasal trauma or nasal surgery

• Nasal polyps or significant deviated nasal septum

• Current significant nasal obstruction

• Known allergy or hypersensitivity to lidocaine, phenylephrine or related local anaesthetics

• Patients with Warfarin and are on Anticoagulation therapy

When referring, please highlight any significant cardiovascular history or severe/poorly controlled hypertension, as phenylephrine can increase blood pressure and may not be suitable for all patients. This includes recent myocardial infarction, angina, cardiac stents, significant arrhythmia, heart failure, severe bradycardia, complete heart block, hypovolaemia or tachycardia, and Hyperthyroidism.

Please also include a clear medication history, particularly if the patient is taking medicines that may interact with lidocaine or phenylephrine nasal spray. This includes MAOIs taken currently or within the last 2 weeks, tricyclic antidepressants, sympathomimetics or decongestants, amphetamine-type medicines, anti-arrhythmics such as amiodarone or mexiletine, beta-blockers, cimetidine, other local anaesthetics, or emergency cardiovascular medicines such as adrenaline, noradrenaline, dopamine or dobutamine.

Please note, if the nasal route cannot be used on the day, the endoscopist may discuss using the same thin scope orally. If this is not suitable or not tolerated, the patient may need to be rebooked for standard gastroscopy with sedation.

Please include any relevant nasal history, anticoagulant use, liver disease, allergies, cardiovascular history, pregnancy or breastfeeding status, and current medication history in the referral. This will help us triage patients safely and avoid delays.

Only routine patients should be referred down the Direct Access Endoscopy route. Any patients considered urgent (such as patients with GI bleeding symptoms not needing admission) should be referred through Advice & Guidance, or via the Upper GI urgent suspected cancer (USC/2ww) route if clinical concerns about malignancy

We are looking into making changes to the DAE referral forms.

Kind regards,

Tara Malihi-Shoja