Premedication with simethicone and N-acetyl cysteine in esophagogastroduodenoscopy: Is it time to use it in practice?

We read with great interest the recent article by Krishnamurthy V et al ¹ , evaluating simethicone and N-acetyl cysteine combination as premedication before esophagogastroduodenoscopy (EGD). We would like to congratulate the authors for conducting this study with a large sample size and with potential implication for improvement in the quality of EGD with focus on diagnostic yield and patient comfort. However, there are few areas about which we seek clarification.

The study included patients prospectively undergoing EGD for various indications. However, the number of endoscopists and their experience in performing endoscopy was not clear, which can affect the outcomes of the study, given the nature of outcomes being subjective and is likely to cause bias.

It has been found in prior studies that premedication with simethicone might lead to improved diagnostic yield in detecting subtle mucosal lesions ² . However, its efficacy in improving diagnosis of early gastric cancer and refining quality of images with narrow band imaging should be explored.

Finally, it would be interesting to know whether use of different series of scopes would have affected the outcomes of the study or the results were the same regardless, which would make the results of the use of this combination prior to endoscopy more generalized to useful prior to EGD irrespective of the scope.

Furthermore, prospective studies are required to validate the findings of this study in other procedures such as colonoscopy, endoscopic retrograde cholangiopancreatography, and capsule endoscopy before the method is incorporated as standard practice for patients undergoing endoscopic procedures.