An endoscopy uses a flexible tube equipped with a camera (endoscope) to examine the upper or lower digestive tract. An upper endoscopy, or esophagogastroduodenoscopy (EGD), involves inserting the scope through the mouth to inspect the esophagus, stomach, and the first part of the small intestine. While sedation is the standard approach in many countries, particularly the United States, it is possible to perform an upper endoscopy without it. Forgoing sedation involves trade-offs between procedural comfort and recovery time.
Sedation: The Default Approach
Medical professionals recommend sedation for endoscopic procedures to ensure patient comfort and a high-quality examination. Sedation minimizes patient movement, which allows the endoscopist to perform the procedure accurately and efficiently, especially when taking biopsies or performing minor interventions. Common forms include moderate sedation, sometimes called “twilight sleep,” or deep sedation using agents like propofol. Sedation reduces anxiety and prevents the natural gag reflex triggered by the scope.
Unsedated Endoscopy: When and How
An unsedated endoscopy is a feasible option, primarily for upper GI procedures, and is common in European and Asian countries. Patients often choose this route if they have a severe allergy to sedatives, a heart or lung condition that makes sedation risky, or if they wish to avoid post-procedure grogginess. A major benefit is the ability to drive home and return to normal activities immediately.
To manage discomfort, the primary technique uses topical anesthesia, such as a lidocaine spray, to numb the throat. This local anesthetic temporarily suppresses the gag reflex and dulls the sensation of the scope passing into the esophagus. Another specialized technique is transnasal endoscopy (TNE), which uses an ultrathin scope (less than 6mm) passed through the nasal cavity instead of the mouth. The smaller scope diameter and nasal route improve tolerability, though the nasal passage must first be numbed.
Patient Experience and Recovery Differences
During an unsedated EGD, the patient is fully aware of the procedure, including the sensation of the endoscope moving and air being inflated into the stomach for better viewing. Although topical anesthetic is used, patients should expect some discomfort, often during scope insertion. The entire procedure is short, typically lasting five to ten minutes, and the patient can communicate with the medical staff throughout.
Recovery differences are a major factor in choosing sedation. Patients receiving moderate or deep sedation require a mandatory recovery period, usually one to two hours, until the effects wear off. They must arrange for a driver and cannot operate machinery or make important decisions for the rest of the day. In contrast, unsedated patients have immediate cognitive function, are discharged within minutes of the scope’s removal, and are permitted to drive and return to work right away.
Upper vs. Lower GI Procedures
The option for an unsedated procedure is almost exclusively limited to upper GI endoscopies (EGD). The upper tract is relatively straight, and the procedure is completed quickly, making it feasible to endure without medication. While some patients may attempt a colonoscopy without sedation, it is not common practice.
A colonoscopy examines the lower GI tract and involves navigating the entire length of the large intestine, which has multiple bends. The procedure is significantly longer than an EGD and requires the scope to travel a much greater distance. It often requires air insufflation, which can cause cramping and considerable pain as the scope moves through the colon. For this reason, the vast majority of colonoscopies are performed with deep sedation to ensure patient comfort and allow the endoscopist to complete the full examination.