Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Sedation-free gastrointestinal endoscopy

Jonathan Cohen, MD
Section Editor
John R Saltzman, MD, FACP, FACG, FASGE, AGAF
Deputy Editor
Kristen M Robson, MD, MBA, FACG


The development of gastrointestinal endoscopy has greatly expanded the diagnostic and therapeutic capabilities of gastroenterologists. Adequate patient tolerance is essential for successful completion of a safe examination and compliance with subsequent follow-up. As a result, endoscopists have developed skills in administering a variety of sedative and analgesic agents to facilitate procedures and enhance patient comfort.

Most of the attention has been placed on selecting the optimal regimen for producing procedural sedation and monitoring patients adequately during the procedures. There has been some attempt to determine which patients and which procedures require deeper sedation to achieve optimal conditions. Finally, there has been an effort to make some of the diagnostic procedures more tolerable to avoid the cost and risk of procedural sedation altogether.

This topic review will focus on sedation-free endoscopy. Standard methods of procedural sedation and their complications, recommendations for procedural sedation, and the management of patients who are difficult to sedate are discussed separately. (See "Overview of procedural sedation for gastrointestinal endoscopy" and "Adverse events related to procedural sedation for gastrointestinal endoscopy" and "Alternatives and adjuncts to moderate procedural sedation for gastrointestinal endoscopy".)


Unsedated endoscopy may be advantageous for several reasons. First, it significantly decreases the risk of hypoxemia and respiratory depression. Second, it reduces the procedure and recovery room time, and the associated costs. Third, it allows patients to leave the endoscopy unit after the procedure without delay and return to work if they so choose, which may produce economic benefit by reducing the indirect costs of endoscopy. Furthermore, a number of studies have demonstrated satisfactory outcomes when focusing on parameters such as successful completion of examinations, patient satisfaction with their comfort level, and their willingness to undergo future examinations without sedation (see below). As a result, in many countries, upper endoscopy, and to a lesser extent, colonoscopy, are commonly performed without routine procedural sedation [1-3]. By contrast, sedation-free endoscopy is not widely accepted in the United States [4].

The use of procedural sedation varies considerably among different countries, reflecting different practice standards and social customs. As an example, in a survey of International Editors for the journal Gastrointestinal Endoscopy, sedation was always or usually administered in 44 percent of procedures in Asia, 56 percent in Europe, and 72 percent in the Americas (Canada, Central and South America) [5]. In the United States, only flexible sigmoidoscopy is typically performed without sedation.

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Oct 2017. | This topic last updated: May 04, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Ristikankare MK, Julkunen RJ. Premedication for gastrointestinal endoscopy is a rare practice in Finland: a nationwide survey. Gastrointest Endosc 1998; 47:204.
  2. Rex DK, Imperiale TF, Portish V. Patients willing to try colonoscopy without sedation: associated clinical factors and results of a randomized controlled trial. Gastrointest Endosc 1999; 49:554.
  3. Mulcahy HE, Connor P. Declining use of sedation for routine diagnostic upper GI endoscopy. Gastrointest Endosc 1999; 49:B199.
  4. Faulx AL, Vela S, Das A, et al. The changing landscape of practice patterns regarding unsedated endoscopy and propofol use: a national Web survey. Gastrointest Endosc 2005; 62:9.
  5. Wang TH, Lin JT. Worldwide use of sedation and analgesia for upper intestinal endoscopy. Sedation for upper GI endoscopy in Taiwan. Gastrointest Endosc 1999; 50:888.
  6. Froehlich F, Schwizer W, Thorens J, et al. Conscious sedation for gastroscopy: patient tolerance and cardiorespiratory parameters. Gastroenterology 1995; 108:697.
  7. al-Atrakchi HA. Upper gastrointestinal endoscopy without sedation: a prospective study of 2000 examinations. Gastrointest Endosc 1989; 35:79.
  8. De Gregorio BT, Poorman JC, Katon RM. Peroral ultrathin endoscopy in adult patients. Gastrointest Endosc 1997; 45:303.
  9. Tan CC, Freeman JG. Throat spray for upper gastrointestinal endoscopy is quite acceptable to patients. Endoscopy 1996; 28:277.
  10. Solomon SA, Kajla VK, Banerjee AK. Can the elderly tolerate endoscopy without sedation? J R Coll Physicians Lond 1994; 28:407.
  11. Dhir V, Swaroop VS, Vazifdar KF, Wagle SD. Topical pharyngeal anesthesia without intravenous sedation during upper gastrointestinal endoscopy. Indian J Gastroenterol 1997; 16:10.
  12. Schutz SM, Lee JG, Schmitt CM, Baillie J. Patient satisfaction with conscious sedation for endoscopy. Gastrointest Endosc 1994; 40:119.
  13. Lieberman DA, Wuerker CK, Katon RM. Cardiopulmonary risk of esophagogastroduodenoscopy. Role of endoscope diameter and systemic sedation. Gastroenterology 1985; 88:468.
  14. Andrus JG, Dolan RW, Anderson TD. Transnasal esophagoscopy: a high-yield diagnostic tool. Laryngoscope 2005; 115:993.
  15. Postma GN, Cohen JT, Belafsky PC, et al. Transnasal esophagoscopy: revisited (over 700 consecutive cases). Laryngoscope 2005; 115:321.
  16. Zaman A, Hahn M, Hapke R, et al. A randomized trial of peroral versus transnasal unsedated endoscopy using an ultrathin videoendoscope. Gastrointest Endosc 1999; 49:279.
  17. Dean R, Dua K, Massey B, et al. A comparative study of unsedated transnasal esophagogastroduodenoscopy and conventional EGD. Gastrointest Endosc 1996; 44:422.
  18. Dumortier J, Napoleon B, Hedelius F, et al. Unsedated transnasal EGD in daily practice: results with 1100 consecutive patients. Gastrointest Endosc 2003; 57:198.
  19. Craig A, Hanlon J, Dent J, Schoeman M. A comparison of transnasal and transoral endoscopy with small-diameter endoscopes in unsedated patients. Gastrointest Endosc 1999; 49:292.
  20. Dumortier J, Ponchon T, Scoazec JY, et al. Prospective evaluation of transnasal esophagogastroduodenoscopy: feasibility and study on performance and tolerance. Gastrointest Endosc 1999; 49:285.
  21. Campo R, Montserrat A, Brullet E. Transnasal gastroscopy compared to conventional gastroscopy: a randomized study of feasibility, safety, and tolerance. Endoscopy 1998; 30:448.
  22. Madhotra R, Mokhashi M, Willner I, et al. Prospective evaluation of a 3.1-mm battery-powered esophagoscope in screening for esophageal varices in cirrhotic patients. Am J Gastroenterol 2003; 98:807.
  23. Birkner B, Fritz N, Schatke W, Hasford J. A prospective randomized comparison of unsedated ultrathin versus standard esophagogastroduodenoscopy in routine outpatient gastroenterology practice: does it work better through the nose? Endoscopy 2003; 35:647.
  24. Preiss C, Charton JP, Schumacher B, Neuhaus H. A randomized trial of unsedated transnasal small-caliber esophagogastroduodenoscopy (EGD) versus peroral small-caliber EGD versus conventional EGD. Endoscopy 2003; 35:641.
  25. Mokhashi MS, Wildi SM, Glenn TF, et al. A prospective, blinded study of diagnostic esophagoscopy with a superthin, stand-alone, battery-powered esophagoscope. Am J Gastroenterol 2003; 98:2383.
  26. Garcia RT, Cello JP, Nguyen MH, et al. Unsedated ultrathin EGD is well accepted when compared with conventional sedated EGD: a multicenter randomized trial. Gastroenterology 2003; 125:1606.
  27. Horiuchi A, Nakayama Y. Unsedated ultrathin EGD by using a 5.2-mm-diameter videoscope: evaluation of acceptability and diagnostic accuracy. Gastrointest Endosc 2006; 64:868.
  28. Jobe BA, Hunter JG, Chang EY, et al. Office-based unsedated small-caliber endoscopy is equivalent to conventional sedated endoscopy in screening and surveillance for Barrett's esophagus: a randomized and blinded comparison. Am J Gastroenterol 2006; 101:2693.
  29. Seow-Choen F, Leong AF, Tsang C. Selective sedation for colonoscopy. Gastrointest Endosc 1994; 40:661.
  30. Herman FN. Avoidance of sedation during total colonoscopy. Dis Colon Rectum 1990; 33:70.
  31. Cataldo PA. Colonoscopy without sedation. Dis Colon Rectum 1996; 39:257.
  32. Ristikankare M, Hartikainen J, Heikkinen M, et al. Is routinely given conscious sedation of benefit during colonoscopy? Gastrointest Endosc 1999; 49:566.
  33. Eckardt VF, Kanzler G, Schmitt T, et al. Complications and adverse effects of colonoscopy with selective sedation. Gastrointest Endosc 1999; 49:560.
  34. Ristikankare M, Julkunen R, Mattila M, et al. Conscious sedation and cardiorespiratory safety during colonoscopy. Gastrointest Endosc 2000; 52:48.
  35. Takahashi Y, Tanaka H, Kinjo M, Sakumoto K. Prospective evaluation of factors predicting difficulty and pain during sedation-free colonoscopy. Dis Colon Rectum 2005; 48:1295.
  36. Terruzzi V, Meucci G, Radaelli F, et al. Routine versus "on demand" sedation and analgesia for colonoscopy: a prospective randomized controlled trial. Gastrointest Endosc 2001; 54:169.
  37. Mahajan RJ, Johnson JC, Marshall JB. Predictors of patient cooperation during gastrointestinal endoscopy. J Clin Gastroenterol 1997; 24:220.
  38. Cohen J, Haber GB, Lavell L, et al. Predictors of patient satisfaction after colonoscopy: A prospective study of 601 patients (abstract). Gastrointest Endosc 1996; 43:309.
  39. Holme O, Bretthauer M, de Lange T, et al. Risk stratification to predict pain during unsedated colonoscopy: results of a multicenter cohort study. Endoscopy 2013; 45:691.
  40. Johnson JE, Morrissey JF, Leventhal H. Psychological preparation for an endoscopic examination. Gastrointest Endosc 1973; 19:180.
  41. Wilson JF, Moore RW, Randolph S, Hanson BJ. Behavioral preparation of patients for gastrointestinal endoscopy: information, relaxation, and coping style. J Human Stress 1982; 8:13.
  42. Levy N, Landmann L, Stermer E, et al. Does a detailed explanation prior to gastroscopy reduce the patient's anxiety? Endoscopy 1989; 21:263.
  43. Leung FW, Aharonian HS, Leung JW, et al. Impact of a novel water method on scheduled unsedated colonoscopy in U.S. veterans. Gastrointest Endosc 2009; 69:546.
  44. Leung J, Mann S, Siao-Salera R, et al. A randomized, controlled trial to confirm the beneficial effects of the water method on U.S. veterans undergoing colonoscopy with the option of on-demand sedation. Gastrointest Endosc 2011; 73:103.
  45. Radaelli F, Paggi S, Amato A, Terruzzi V. Warm water infusion versus air insufflation for unsedated colonoscopy: a randomized, controlled trial. Gastrointest Endosc 2010; 72:701.
  46. Leung FW, Harker JO, Jackson G, et al. A proof-of-principle, prospective, randomized, controlled trial demonstrating improved outcomes in scheduled unsedated colonoscopy by the water method. Gastrointest Endosc 2010; 72:693.
  47. Amato A, Radaelli F, Paggi S, et al. Carbon dioxide insufflation or warm-water infusion versus standard air insufflation for unsedated colonoscopy: a randomized controlled trial. Dis Colon Rectum 2013; 56:511.