World J Gastroenterol 2013 January 7; 19(1): 103-107

ISSN 1007-9327 (print) ISSN 2219-2840 (online)

Online Submissions: http://www.wjgnet.com/esps/

[email protected]
doi:10.3748/wjg.v19.i1.103

2013 Baishideng. All rights reserved.

BRIEF ARTICLE

A pilot study of single-use endoscopy in screening acute

gastrointestinal bleeding
Jae Hee Cho, Hee Man Kim, Sangheun Lee, Yu Jin Kim, Ki Jun Han, Hyeon Geun Cho, Si Young Song
recorded and compared.

Jae Hee Cho, Hee Man Kim, Sangheun Lee, Yu Jin Kim,
Ki Jun Han, Hyeon Geun Cho, Division of Gastroenterology,
Department of Internal Medicine, Myongji Hospital, Kwandong
University College of Medicine, Goyang 412-270, South Korea
Jae Hee Cho, Hee Man Kim, Department of Internal Medicine, Graduate School, Yonsei University College of Medicine,
Seoul 120-752, South Korea
Si Young Song, Division of Gastroenterology, Department of
Internal Medicine, Brain Korea 21 Project for Medical Science,
Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul 120-752, South Korea
Author contributions: Cho JH, Kim HM, Han KJ, Cho HG
and Song SY designed the research; Lee S and Kim YJ performed the research; Cho JH, Kim HM and Lee S analyzed the
data; and Kim HM wrote the paper.
Supported by Basic Science Research Program through the
National Research Foundation of Korea, the Ministry of Education, Science and Technology, No. 2011-0008901; and Research
Program of Clinical Professor Research committee of Myongji
Hospital, No. 20120106
Correspondence to: Hee Man Kim, MD, Division of Gastroenterology, Department of Internal Medicine, Myongji Hospital,
Kwandong University College of Medicine, Goyang 412-270,
South Korea. [email protected]
Telephone: +82-31-8105412 Fax: +82-31-9690500
Received: April 9, 2012
Revised: September 19, 2012
Accepted: September 22, 2012
Published online: January 7, 2013

RESULTS: Between January and March, 2011, 13 patients that presented with hematemesis (n = 4), melena (n = 6), or bleeding from a previous nasogastric
feeding tube (n = 3), were enrolled in this study. In
12 patients with upper GI bleeding, the EG scan device revealed that 7 patients had active bleeding and
5 patients had inactive bleeding, whereas conventional
EGD revealed that 8 patients had active bleeding and
4 patients had inactive bleeding. The sensitivity and
specificity of the EG scan device was 87.5% and 100%
for active bleeding, with conventional EGD serving as
a reference. No complication were reported during the
EG scan procedures.
CONCLUSION: The EG scan is a feasible device for
screening acute upper GI bleeding. It may replace nasogastric lavage for the evaluation of acute upper GI
bleeding.
2013 Baishideng. All rights reserved.

Key words: Gastrointestinal hemorrhage; Bleeding; Endoscopy; Nasogastric tube; Lavage

Cho JH, Kim HM, Lee S, Kim YJ, Han KJ, Cho HG, Song SY. A
pilot study of single-use endoscopy in screening acute gastrointestinal bleeding. World J Gastroenterol 2013; 19(1): 103-107
Available from: URL: http://www.wjgnet.com/1007-9327/full/
v19/i1/103.htm DOI: http://dx.doi.org/10.3748/wjg.v19.i1.103

Abstract
AIM: To investigate the feasibility of a single-use endoscopy as an alternative procedure to nasogastric lavage
in patients with acute gastrointestinal (GI) bleeding.

INTRODUCTION

METHODS: Patients who presented with hematemesis, melena or hematochezia were enrolled in this
study. EG scan and conventional esophagogastroduodenoscopy (EGD) were subsequently performed.
Active bleeding was defined as blood in the stomach,
and inactive bleeding was defined as coffee ground
clots and clear fluid in the stomach. The findings were

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Acute upper gastrointestinal (GI) bleeding is managed

by early conventional endoscopy within 24 h of presentation [1-3]. In high-risk upper GI bleeding, urgent
endoscopy reduces mortality; therefore, risk stratification is important [4,5]. Nasogastric lavage is a routine
procedure used to evaluate acute upper GI bleeding and

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Cho JH et al . Single-use endoscopy in gastrointestinal bleeding

to assess risk before performing conventional endoscopy. The findings of nasogastric lavage help doctors
decide whether to perform an early conventional endoscopy[1,6-8]. However, the effect of nasogastric lavage
on clinical outcomes and mortality remains controversial[3,9-12]. Nasogastric intubation and lavage is one of the
most painful procedures performed in the emergency
department[13,14].
A novel single-use endoscopy device (EG scan:
IntroMedic Co., Ltd., Seoul, South Korea) has been
developed from the MiroCam capsule endoscopy
technology created by the IntroMedic company and
Professor Si Young Song of Yonsei University College
of Medicine[15,16]. The EG scan machinery (version)
is composed of an optical probe, a handle for control,
and a display monitor. The optical probe is disposable
(Figure 1), and the largest diameter is 6 mm, similar to a
nasogastric tube with diameter of 16 French (Figure 2).
The optical probe can be deflected to 60o upward or 60o
downward, but not left or right. The optical probe is inserted though the mouth or nose using display monitor
to visualize the process, and the probe can only be used
once. The machinery of the full EG scan system is as
small as a laptop computer and is portable. It can operate anywhere electric power is supplied. It is easy to use
and is accessible for use by a non-GI endoscopist.
The EG scan has the potential to improve the easy
and accuracy of diagnosis due to its visual monitoring
capabilities for the evaluation of acute GI bleeding in
decision making for early conventional upper endoscopy.
It is also less painful and has a lower risk of complication than a blindly inserted nasogastric tube. We aimed
to test the feasibility of the EG scan to assess GI bleeding for guidance of early conventional endoscopy in patients with acute GI bleeding as an alternative procedure
to nasogastric lavage.

Figure 1 EG scan device. The EG scan (version) is composed of a disposable optical probe, a handle, and a display monitor.

Figure 2 Comparison of diameters. A: The diameters of GIF-Q260 (Olympus)

endoscopy; B: An optical probe of an EG scan device; C: An optical probe of a
16-Fr nasogastric tube.

The findings from the 2 procedures were compared.

Blood in the stomach was categorized into active
bleeding, and coffee ground clots and clear fluid were
categorized into inactive bleeding. In the EGD, highrisk lesions were defined as spurting, oozing of blood,
or non-bleeding visible vessels, or by the Forrest classificationsa,b, or a[17,18].

MATERIALS AND METHODS

Patients who were older than 18 years old and had clinical manifestations suspected of being acute GI bleeding
were enrolled in this study. Acute GI bleeding was defined as presentation with hematemesis, melena, or hematochezia within 24 h. Patients who visited the emergency room for acute GI bleeding or in-patients who
had been admitted to intensive care unit or general ward
and presented with acute GI bleeding in Myongji Hospital were enrolled in this study. Patients with confirmed
lower GI bleeding were excluded from this study.
When the patients were hemodynamically stable, an
EG scan (version) was immediately performed at the
patients bedside by one PGY-4 medical resident. The
EG scans optical probe was inserted through the mouth
using the display monitor to visualize the process. The
findings of the EG scan were recorded. Thereafter, conventional esophagogastroduodenoscopy (EGD) was instantly performed by one qualified endoscopist, who had
not been informed of the findings from the EG scan.

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Statistical analysis
To investigate the diagnostic efficacy of the EG scan
device, the sensitivity, specificity, positive predictive value
and negative predictive value for active bleeding were calculated, with conventional EGD serving as a reference.

RESULTS
Thirteen patients with acute GI bleeding were enrolled
between January and March 2011 (Table 1). Of the 13
patients, 12 patients had symptoms suspicious of upper
GI bleeding: 6 patients presented with melena, 3 patients
presented with hematemesis, and 3 patients presented
with bleeding from a previously located nasogastric tube
for feeding or drainage. One patient presented with hematemesis, but the final focus of bleeding was identified
as lung cancer.

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Table 1 Clinical features and the findings of EG scan and esophagogastroduodenoscopy in all patients
Age
(yr)

Sex

Reason for
endoscopy

1
2

52
47

M
F

Hematemesis
Hematemesis

3
4

87
79

M
M

Hematemesis
Melena

88

Melena

6
7

74
63

M
M

Melena
Melena

8
9

85
50

F
M

Melena
Melena

10

72

11

89

12

80

13

73

No.

EG scan
Underlying disease/condition
Heavy alcoholics
Liver cirrhosis
ESRD
Old stroke
Pneumonia
Abdominal aorta aneurysm
Cardiac arrest
Pneumonia
Old stroke
Valvular heart disease
Coumadin toxicity
Acute myocardial infarction
None

EGD

Performance Bleeding
location
status

Diagnosis

Risk

ER
ER

Active
Active

Active
Active

Mallory-Weiss syndrome
Gastric varix bleeding

High
High

ER
ICU

Inactive
Active

Active
Active

Gastric ulcer with bleeding

Gastric ulcer with bleeding

High
High

ICU

Active

Active

Gastric ulcer with bleeding

High

Inactive
Inactive

Low
Low

ER
Inactive
General ward Inactive

Blood clots from NG

Stroke
Parkinsons disease
tube for feeding
F Fresh blood from NG
Aspiration pneumonia
tube for feeding
M Fresh blood from NG Postoperative state for gastric
tube for drainage
cancer
M
Hematemesis
COPD with acute exacerbation
Lung cancer

Bleeding
status

ICU
ER

Active
Inactive

Active
Inactive

ICU

Inactive

Inactive

Duodenal ulcer
Gastric ulcer and duodenal
ulcer
Gastric ulcer with bleeding
Duodenal ulcer with visible
vessel
Multiple gastric hematin,

ICU

Active

Active

Gastric ulcer with bleeding

High

ICU

Active

Active

Anastomosis site bleeding

High

ER

Active

Active

Hemoptysis (Ingestion of
blood from lung cancer)

Not related

High
High
Low

M: Male; F: Female; NG: Nasogastric; ER: Emergency room; ICU: Intensive care unit; Active: Blood; Inactive: Coffee ground or clear; COPD: Chronic obstructive pulmonary disease; ESRD: End stage renal disease; EGD: Esophagogastroduodenoscopy.

Figure 3 A concordant case of acute gastrointestinal bleeding from Mallory-Weiss syndrome. A:

EG scan shows blood at the esophagogastric junction; B: Conventional esophagogastroduodenoscopy
(GIF-Q260) shows oozing from the tear wound of the
esophagogastric junction.

In the 12 patients with upper GI bleeding, 7 patients

were diagnosed as having active bleeding by the EG
scan, with the same finding by conventional EGD (Figure
3). In 5 patients diagnosed as having inactive bleeding by
EG scan, 4 patients were confirmed as having inactive
bleeding. The remaining patient was reported as active
bleeding by conventional EGD. The sensitivity of the
EG scan was 87.5% for active bleeding, and the specificity of the EG scan was 100% for inactive bleeding, with
conventional EGD serving as a reference. The positive
predictive value for active bleeding was 100%, and the
negative predictive value for active bleeding was 80%,
with conventional EGD serving as a reference. No complication were reported during the EG scan procedures.

to evaluate acute upper GI bleeding before conventional

EGD in a manner similar to nasogastric lavage. The sensitivity, specificity, and positive predictive values of the
EG scan procedure were significant although the results
are preliminary. Only one of 12 patients with upper GI
bleeding had a discrepancy between the EG scan results
and the EGD results. The cause of this discrepancy was
possibly a gastric ulcer that had an inactive period of
bleeding during the EG scan, whereas blood spurted
from the ulcer during the EGD. Therefore, the result
was not associated with the accuracy of the EG scan.
In a large-scale study using a Canadian retrospective
registry, a bloody nasogastric aspirate has a sensitivity of
48.4%, a specificity of 75.8%, and a negative predictive
value of 77.9% of for high-risk endoscopic lesions[17]. In
a prospective study, 73% of Greek patients with upper
GI bleeding and a bloody nasogastric aspirate have active bleeding[19]. In a retrospective cohort study with GI

DISCUSSION
In our small-scale pilot study, the EG scan was shown

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Cho JH et al . Single-use endoscopy in gastrointestinal bleeding

bleeding patients without hematemesis, the sensitivity of

a positive nasogastric aspirate is 42%[10]. With respect to
these findings, the EG scan is worth consideration of a
large-scale controlled study as an alternative procedure
to nasogastric lavage.
An EG scan probe can be inserted through a patients
mouth as it is in conventional EGD. This method can
avoid pain during the nasal insertion of a nasogastric
tube. The visual monitoring of the EG scan may prevent
serious complications related to the blind insertion of a
nasogastric tube, such as nasopharynx perforation, esophageal perforation and displacement into the trachea[11,20-22].
In addition, the EG scans optical probe can be inserted
through a patients nose in the same manner in which a
nasogastric tube is inserted. In our study, the pain related
to the insertion of the EG scan was not investigated and
should be part of the evaluation in a further study.
In critically ill patients with other morbidities such
as acute myocardial infarction and COPD, conventional
EGD has an increased complication rate[23-26]. When
these patients are suspected of having acute GI bleeding,
it is necessary to exactly assess the acuity, severity, and
location of the GI bleeding. In these high-risk patients,
the EG scan could play the role of a bridge to conventional EGD by assessing the exact status of GI bleeding.
In our study, critically ill patients with acute myocardial
infarction, cardiac arrest, and pneumonia received an
EG scan with high performance and without any complications.
In Korea, the prices of a nasogastric tube and lavage are approximately 10 United States dollars and 20
United States dollars, respectively, whereas the price of
a disposable optical probe of EG scan is approximately
100 United States dollars. The cost of performing EG
scan is currently more expensive than nasogastric lavage.
However, an EG scan may screen active bleeding more
precisely than nasogastric lavage and may eventually reduce unnecessary emergency EGDs and costs. The cost
and effectiveness of the EG scan must be confirmed
through large-scale studies. Additionally, the price of an
EG scan could be decreased by advancements in electronics in the future, and this technology could replace
nasogastric lavage.
However, the EG scan has several weaknesses. First,
EG scan versiondoes not provide air inflation; therefore, it is difficult to find the focus of the bleeding in
the stomach. Recently, an EG scan version with an air
inflation function has been released that could resolve
this problem. Second, there is no method to clear the
cover glass in front of the camera during the procedure,
which means that vision can be impaired when secreted
materials become stuck to the cover glass. Additionally,
angulation of the head of the optical probe is limited up
to 60o upward or 60o downward. Further development
of the technique will compensate for these weak points
when using the EG scan.
In conclusion, the EG scan was developed for singleuse and as a portable device. It is feasible for screening

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acute upper GI bleeding with high sensitivity and specificity. If larger, controlled trials looking at the predictive
value, the cost, patient discomfort, and the relative side
effect profile of immediate endoscopy or nasogastric
lavage in comparison to the EG scan prove positive, this
device has the potential to replace nasogastric lavage or
universal urgent EGD in an emergency room, ward or
intensive care unit setting.

COMMENTS
COMMENTS
Background

Nasogastric lavage is an important method to evaluate acute gastrointestinal

bleeding. However, the findings of nasogastric lavage sometimes indicate false
positive or false negative active bleeding, and nasogastric tube insertion is very
painful to patients. A more precise and less painful procedure has been needed.

Research frontiers

The EG scanTM (IntroMedic Co., Ltd., Seoul, South Korea) is a novel disposable
endoscopy tool using the mechanism of capsule endoscopy, and its machinery
is small enough to be portable. It has been developed to be used in outpatient
clinics quickly and comfortably.

Innovations and breakthroughs

This is the first study to investigate the diagnostic efficacy of the EG scan for
screening active bleeding. The promising results suggest that the EG scan
should be a candidate procedure as a substitute to nasogastric lavage, although this is a pilot study with a small sample size.

Applications

These preliminary findings suggest that the EG scan may be a substitute for nasogastric lavage. This device can also be used as esophagoscopy in outpatient
clinics and as a flexible rectosigmoidoscopy. In the future, the portable nature
of this device may enable EG scans to be used for patients in an emergency
outside of a hospital.

Terminology

A single-use endoscopy tool is disposable after use. Early endoscopy is an

endoscopic procedure used within 24 h of presentation to diagnose or treat
diseases. Active bleeding is defined as the existence of blood in the stomach,
and inactive bleeding is defined as the existence of coffee ground clots or clear
fluid in the stomach. A high-risk ulcer is one with current bleeding or high risk of
bleeding.

Peer review

This pilot study shows that the EG scan, a novel single-use endoscopy device,
can screen active bleeding simply and easily. It is a portable system suitable
for fast diagnosis in emergency rooms and intensive care units, although the
efficacy should be confirmed in large-scale trials.

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