Treatment of fecal impaction with pulsed irrigation enhanced evacuation

Mechanical colon cleansing for screening colonoscopy: A randomized controlled trial

OBJECTIVE

Effective screening colonoscopy depends on the quality of colon preparation. This study aimed to compare pulsed irrigation evacuation (PIE), polyethylene glycol (PEG) and sodium phosphate colon preparations.

METHODS

Outpatients at a VA hospital were randomized using sealed envelopes. Preparations consisted of polyethylene glycol 4L, Fleet sodium phosphate 90 mL with four to six glasses water twice daily and 296 mL of magnesium citrate in the evening with PIE prior to colonoscopy. Colon cleansing was assessed blindly using a five-point scale: 0 (very poor) to 4 (excellent).

RESULTS

Altogether 391 patients participated in the study (129 in the PEG group, 127 in the sodium phosphate and 135 in the PIE group), with a mean age of 62 years, of whom 75% were men. PIE and sodium phosphate were superior to PEG: median cleansing scored 4 (excellent) versus 3 with PEG (P < 0.01). Inadequate preparations were more common with PEG than PIE (18% vs 5%) (P < 0.01). Side-effects included vomiting: 37% in the sodium phosphate group versus 5% in the PEG and 2% in the PIE groups (P < 0.01). The three preparations were judged intolerable in ≤ 5%.

CONCLUSIONS

PIE and sodium phosphate are superior to PEG for colon preparations. PIE is the preferred preparation for those at high risk of unsatisfactory preparations or with unsatisfactory traditional preparations.

Comparison between pulsed irrigation enhanced evacuation and polyethylene glycol-electrolyte lavage solution for bowel preparation prior to elective colonoscopy in veterans with spinal cord injury

BACKGROUND

Poor preparation for elective colonoscopy is common in persons with spinal cord injury (SCI). This unsatisfactory outcome is likely due to long-standing difficulty with evacuation and decreased colonic motility. Our objective was to determine the most effective preparation for elective colonoscopy applying a novel and traditional approach to bowel cleansing.

METHODS

Twenty-four subjects with SCI were consented and scheduled to receive one of the two possible arms: pulsed irrigation enhanced evacuation (PIEE) or polyethylene glycol-electrolyte lavage solution (PEG; CoLyte(®)). The quality of the preparation was scored during the colonoscopy by applying the Ottawa scoring system.

RESULTS

Patients with SCI who received PIEE tended to have lower Ottawa scores and a higher percentage of acceptable preparations than did those who received PEG; however, the results were not statistically different.

CONCLUSION

In this preliminary study in subjects with SCI, neither PIEE nor PEG produced acceptable bowel preparation for elective colonoscopy. Future studies should confirm our findings and consider studying alternative, more efficacious approaches to bowel cleansing prior to colonoscopic procedures in patients with SCI, which should provide better outcomes. Registration number for clinicaltrials.gov: NCT00745095.

Faecal impaction: in-hospital complications and their predictors in a retrospective study on 130 patients

AIM

Faecal impaction may be a medical emergency. The frequency of complications of this condition and their predictors are not known. We determined the clinical presentation, the in-hospital complications and their predictors in 130 patients diagnosed with faecal impaction.

METHOD

This was a retrospective study of the medical records of 130 patients who presented with faecal impaction to a tertiary care center in Beirut, Lebanon, between 1992 and 2009. The clinical outcome and complications were reviewed. The association between in-hospital complications and other variables was determined.

RESULTS

The mean age of the patients was 67.1 years. Ninety-eight (75.3%) patients had at least one of the following: heart disease (36.3%), neurological disease (28.8%) or diabetes (22.6%), and 26.7% were bedridden. The site of impaction was the rectum in 66.4%. The patients were treated by manual disimpaction (34.5%), enema (89.1%) or oral laxatives (84.0%). A delay in treatment of more than 6 h occurred in 70 (53.8%) patients. In-hospital complications occurred in 34 (24.6%) patients, the most common of which were infectious (16 cases), systemic inflammatory response syndrome (16 cases), cardiopulmonary (14 cases) and death (one patient). Time to the start of treatment was longer in patients who developed complications compared with those who did not (10.1 h vs 7.1 h; P = 0.02). Patients > 80 years of age, or patients with heart or neurological disease were at a higher risk of developing complications (P = 0.03, P = 0.03 and P = 0.02, respectively).

CONCLUSION

Treatment delay, increasing age and the presence of heart or neurological disease seem to be predictors of in-hospital complications in patients with faecal impaction.

Rectal irrigation in the management of functional bowel disorders: a review

Faecal incontinence and constipation are examples of functional bowel disorders that can lead to distressing psychological and physical symptoms which seriously impact upon quality of life. Rectal irrigation has been introduced as a treatment option for such patients. This article critically reviews and evaluates the current evidence on the effectiveness of rectal irrigation as a management option for functional bowel disorders. The review was conducted using BIOSIS, AHMED, CINAHL, MEDLINE, and Web of Knowledge. From 1051 articles identified through the literacy search, only nine were specifically concerned with the evaluation of rectal irrigation as a treatment option for functional bowel disorders. The results of the literature review do indicate that rectal irrigation could be a successful treatment option for some people, however, variations between studies and methodological limitations mean evidence of the effectiveness of rectal irrigation is lacking.

Long-term safety of pulsed irrigation evacuation (PIE) use with chronic bowel conditions

We wanted to determine the long-term effects of pulsed irrigation evacuation on the colon. Sigmoidoscopy/colonoscopy was performed on four patients with spinal cord injuries who have used this procedure an average of 3.5 times weekly, for an average of 6.7 years. No gross or microscopic abnormalities were identified in any of these individuals. Impactions as well as other complaints were markedly diminished or absent following the initiation of this therapy. Pulsed irrigation evacuation is a safe and effective method for long-term treatment of chronic neurogenic bowel.

Management and causes of acute large-bowel obstruction

Acute LBO has many possible causes. In the United States, the most common cause is colorectal carcinoma. Mechanical obstruction should be differentiated from pseudo-obstruction by contrast enema or colonoscopy because the treatments differ. The high postoperative mortality and morbidity of LBO compared with elective resection are explained by the multiple associated pathophysiologic changes of obstruction. Management of this condition requires careful assessment, awareness, and expertise in the current modalities of treatment. Gangrene and perforation should be avoided because they limit treatment options and are associated with an increase in mortality. We prefer, in most instances, to perform a single-stage procedure, which has the advantages of reduced hospital stay (and cost) and avoidance of a stoma. However, the appropriate treatment needs to be tailored to the individual situation. Recent developments in nonoperative decompressing procedures may demonstrate advantages in the future.