Carbon dioxide insufflation during colonoscopy can significantly decrease post-interventional abdominal discomfort in deeply sedated patients: A prospective, randomized, double-blinded, controlled trial

Effects of Hot Pack Therapy on Post-Colonoscopy Pain: A Prospective, Randomized, Controlled Study

BACKGROUND

Post-colonoscopy pain (PCP) is a negative condition that causes physical and psychological distress to patients and may lead to noncompliance with treatment and follow-up. The most common hypothesis for the cause of PCP is the inflation of the lumen with air to examine the mucosa. There are no previous studies that have examined the effects of thermal therapy in patients with PCP.

AIMS

In this study, we aimed to investigate the effects of the Hot Pack (HP) method in patients with PCP.

DESIGN

Randomized, controlled, prospective study.

METHODS

Patients were randomized 1:1 into 2 groups of HP and control. In the HP group, hot packs of 40-45°C, kept in a hydrocollator heating unit for 30-35 minutes and wrapped in towels, were applied to the umbilical and hypogastric region of patients in the supine position for 30 minutes. Visual analog scale (VAS) scores were used to measure the pain after colonoscopy. Visual analog scores at 1, 6, and 24 hours were recorded and compared in both groups.

RESULTS

There was a significant difference in the presence and severity of pain between the two groups at 1 and 6 hours after colonoscopy (p < .001 and p = .004, respectively). There was no significant difference in pain scores at 24 hours between two groups.

CONCLUSIONS

This study showed that the application of HP to patients after colonoscopy is effective in reducing pain in the early period.

Effect of Abdominal Compression on Total Single-Balloon Enteroscopy Rate: A Randomized Controlled Trial

OBJECTIVE

To evaluate whether abdominal compression significantly increased the total enteroscopy rate in single-balloon enteroscopy (SBE).

METHODS

Consecutive patients who underwent SBE at 2 hospitals were prospectively included between June 1, 2020, and September 30, 2021. They were randomly divided into an abdominal compression group and a non-abdominal compression group with use of sealed envelopes generated by a computer. Total enteroscopy rates were compared between the groups.

RESULTS

The study included 200 patients. The total enteroscopy rates were 73% and 16% in the abdominal compression and non-abdominal compression groups, respectively (relative risk, 13.55; 95% CI, 6.79 to 27.00; P<.001). The total enteroscopy rate was higher in the 70 patients who were identified to have undergone no previous abdominal surgery or small intestinal stenosis than in the 32 patients who had undergone such procedures in the abdominal compression group (84% vs 47%; relative risk, 6.08; 95% CI, 2.36 to 15.67; P<.001). Relevant positive findings were not significantly different between the groups (58% vs 45%; P=.07). Binary logistic regression analysis found abdominal compression to be associated with a better total enteroscopy rate (odds ratio, 16.68; 95% CI, 7.92 to 35.15; P<.001), and the presence of previous abdominal surgery or small intestinal stenosis was associated with difficulty in completing the total enteroscopy procedure (odds ratio, 0.26; 95% CI, 0.12 to 0.58; P<.01).

CONCLUSION

Abdominal compression significantly increased the total enteroscopy rate in SBE. Complete total enteroscopy may be challenging in patients with a history of abdominal surgery or small intestinal stenosis.

Key factors for improving adenoma detection rate

INTRODUCTION

Colonoscopy is a fundamental tool in colorectal cancer (CRC) prevention. Nevertheless, one-fourth of colorectal neoplasms are still missed during colonoscopy, potentially being the main reason for post-colonoscopy colorectal cancer (PCCRC). Adenoma detection rate (ADR) is currently known as the best quality indicator correlating with PCCRC incidence.

AREAS COVERED

We performed a literature review in order to summarize evidences investigating key factors affecting ADR: endoscopists education and training, patient management, endoscopic techniques, improved navigation (exposition defect), and enhanced lesions recognition (vision defect) were considered.

EXPERT OPINION

'Traditional' factors, such as split dose bowel preparation, adequate withdrawal time, and right colon second view, held a significant impact on ADR. Several devices and technologies have been developed to promote high-quality colonoscopy, however artificial intelligence may be considered the most promising tool for ADR improvement, provided that endoscopists education and recording are guaranteed.

Transient End-Tidal Carbon Dioxide Elevation During Pediatric Upper Endoscopy With Carbon Dioxide Insufflation: Is It True Hypercapnia?

BACKGROUND

Endoscopic insufflation, long performed using air, is being replaced by carbon dioxide (CO2) at many pediatric centers, despite limited published data on its use in children. We have previously demonstrated that CO2 use during esophagogastroduodenoscopy (EGD) in non-intubated children is associated with transient elevations of end-tidal CO2 (EtCO2). This observation raised concerns about possible CO2 inhalation and systemic absorption. Here, we investigate this concern by concurrently measuring both EtCO2 and transcutaneous CO2 (tCO2) during upper endoscopic procedures in children.

AIM

To determine if elevations in EtCO2 levels seen in non-intubated children undergoing CO2 insufflation during EGD are associated with elevated systemic CO2 levels.

METHODS

Double-blinded, prospective, randomized clinical trial. Children were randomized 1:1 to receive either CO2 or air for endoscopic insufflation. EtCO2 was sampled with a CO2-sampling nasal cannula and tCO2 was monitored using the Radiometer transcutaneous monitoring device.

RESULTS

Fifty nine patients were enrolled; 30 patients in the CO2 insufflation group and 29 in the air group. All patients underwent a procedure involving an EGD. Transient elevations in EtCO2 (defined as >60 mmHg) were observed only in the CO2 insufflation group. This contrasted with the similar elevations of tCO2 between the CO2 and air insufflation groups. None of these events were of clinically significant magnitude or duration.

CONCLUSION

This study demonstrates that the observed transient elevations in EtCO2 seen during EGD in non-intubated children receiving CO2 insufflation are most likely measurements of eructated CO2 without evidence of excessive systemic absorption of CO2.

Is Carbon Dioxide Insufflation During Endoscopy in Children as Safe and as Effective as We Think?

OBJECTIVES

Distension of the gastrointestinal lumen is crucial for visualization and advancement during endoscopic procedures. An increasing number of pediatric centers now use carbon dioxide (CO2) preferentially over air as many adult studies and a few pediatric studies have concluded that CO2 is better tolerated than air, especially for colonoscopy.

AIMS

The aim of the study was to determine if CO2 is as safe and as effective as air and if it reduces abdominal discomfort and distension in children undergoing upper endoscopy and colonoscopy.

METHODS

Double blinded, prospective, randomized clinical study. Patient- and nursing-reported outcomes of pain and distension were recorded. End tidal CO2 (EtCO2) was monitored continuously with a CO2-sampling nasal cannula for patients undergoing procedural sedation and via the endotracheal tube for those who were intubated.

RESULTS

One hundred seventy-eight patients with 180 procedures were enrolled, 91 procedures were randomized to receive CO2, and 89 to air. Groups did not differ significantly with respect to nursing-assessed abdominal discomfort, change in girth from baseline, or endoscopist-perceived ease of inflation. Use of CO2 was associated with transient spikes in the EtCO2 (≥60 mmHg) in a significant number of patients during sedated upper endoscopy without endotracheal intubation. There was a reduction of bloating and flatulence for all procedures in the CO2 group.

CONCLUSIONS

The benefits of using CO2 for insufflation were minimal in our patients. The observed transient elevations of EtCO2 during sedated upper endoscopy raise concerns of possible systemic hypercarbia. The wisdom of its routine use for all pediatric endoscopic procedures is questioned.

A meta-analysis of carbon dioxide versus room air insufflation on patient comfort and key performance indicators at colonoscopy

BACKGROUND

Carbon dioxide (CO₂) has been used as an alternative to air insufflation at endoscopy with good results; however, uptake of the technique has been poor, possibly due to perceived lack of outcome equivalency. This meta-analysis evaluates the effectiveness of CO₂ versus air in reducing pain post-colonoscopy and furthermore examines other key performance indicators (KPIs) such as sedative use, procedure times and polyp detection rates.

METHODS

This meta-analysis was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Pubmed, Pubmed Central, Embase and Cochrane Library were searched for randomized studies from 2004 to 2019, reporting outcomes for patients undergoing colonoscopy with air or CO₂ insufflation, who reported pain on a numerical or visual analogue scale (VAS). Results were reported as mean differences (MD) or pooled odds ratios (OR) with 95% confidence intervals (95% CI).

RESULTS

Of 3586 citations, 23 studies comprising 3217 patients were analysed. Patients undergoing colonoscopy with air insufflation had 30% higher intraprocedural pain scores than those receiving CO₂ (VAS 3.4 versus 2.6, MD -0.7, 95% CI - 1.4-0.0, p = 0.05), with a sustained beneficial effect amongst those in the CO₂ group at 30 min, 1-2-h and 6-h post procedure (MD - 0.8, - 0.6 and - 0.2, respectively, p < 0.001 for all), as well as less distension, bloating and flatulence (p < 0.01 for all). There were no differences between the two groups in KPIs such as the sedation required, procedure time, caecal intubation or polyp detection rates.

CONCLUSIONS

CO₂ insufflation improves patient comfort without compromising colonoscopic performance.

Colonoscopy using back brace support belt: A randomized, prospective trial

Background and Aim

Looping is a major problem in colonoscopy, and it prolongs procedure time. We evaluated the efficacy and safety of an external abdominal compression device (back brace support belt; Maxbelt) with respect to cecal insertion time and other outcomes.

Methods

We performed a prospective study on outpatients undergoing elective colonoscopy in Toyoshima Endoscopy Clinic. Subjects were randomly assigned to groups and were subjected to either Maxbelt (n = 39) or no device (control, n = 38) during colonoscopy. The colonoscopist was blinded to the study. The primary outcome that was observed was insertion time.

Results

The intubation time of the Maxbelt group was shorter than that of the no device group, but the difference was not significant (3.29 vs 4.49 min, P = 0.069). After stratifying by age, the use of Maxbelt significantly decreased cecal intubation time in elderly participants (age ≥ 45) compared to no device group (3.27 vs 5.00 min, P = 0.032). The use of the Maxbelt significantly decreased insertion difficulty encountered by the colonoscopist (P = 0.01). There was no difference in adenoma detection rate, manual pressure, position change, and adverse event.

Conclusions

The use of a back brace support belt could be a viable approach for colonoscopy in elderly patients. (University Hospital Medical Information Network: UMIN000029361).

Randomized controlled trial of probiotic use for post-colonoscopy symptoms

BACKGROUND

Symptoms of bloating, discomfort and altered bowel function persist post-colonoscopy in up to 20% of patients. A previous randomized controlled trial of probiotics for post-colonoscopy symptoms has demonstrated a reduction in duration of pain with the use of probiotics. This was performed with air insufflation and the question was asked whether the effect would persist with the use of carbon dioxide to insufflate the colon.

METHODS

Eligible patients were recruited and randomized to receive either probiotic or placebo capsules post colonoscopy. A questionnaire was completed documenting the presence of pre-procedural and post-procedural symptoms for the following 2 weeks. The results were entered into a database and processed by an independent statistician. The primary outcome was mean pain score and incidence of bloating over the first 7 days and at 14 days post procedure. The secondary outcome was the time to return of normal bowel function.

RESULTS

Two hundred and forty participants were recruited and randomized (120 probiotic and 120 placebo). Data were available for 75 patients in the probiotic and 75 in the placebo group. There was no significant difference between groups in post-procedural discomfort, bloating nor time to return of normal bowel function. Subgroup analysis of the patients with preexisting symptoms showed a reduction in incidence of bloating with the use of probiotics.

CONCLUSION

There may be a role for the use of probiotics in the subgroup of patients with preexisting symptoms; however, routine use of probiotics to ameliorate post-procedural symptoms of carbon dioxide insufflation colonoscopy cannot be advocated.

Insufflation With Carbon Dioxide During Pediatric Colonoscopy for Control of Postprocedure Pain

GOALS

To determine if carbon dioxide (CO2) insufflation in children would improve postprocedure pain following colonoscopy in children.

BACKGROUND

CO2 insufflation during colonoscopy has been found to reduce postcolonoscopy pain in the adult population, but limited data exist in pediatrics.

MATERIALS AND METHODS

We conducted a prospective study with 40 pediatric patients scheduled for outpatient colonoscopy. Patients were enrolled continuously and were randomized to receive CO2 or air insufflation. Patients and colonoscopists were blinded to insufflation method. End tidal CO2 (EtCO2) was documented throughout the procedure. Abdominal pain was established preprocedure then at 1-, 6-, and 24-hour postprocedure. Subject demographics, indications, colonoscopists' year of training, time to cecum, adverse events, and final diagnoses were recorded.

RESULTS

Twenty patients were randomized to each group. Patients receiving air had a statistically significant increase in pain from baseline at 1- and 6-hours after colonoscopy (P=0.007 and 0.008). This was not seen in the CO2 group (P=0.740 and 0.289). There was an increase in postprocedure pain in the air group compared with CO2 group at the 1-hour mark (P=0.032). EtCO2 increased during the procedure, regardless of insufflation method, but no difference was seen between groups (P=0.822).

CONCLUSIONS

Our results demonstrate that higher levels of pain were reported by patients following air compared with those receiving CO2 insufflation. This is the first study to show CO2 is as safe as air, with no increase in EtCO2 between groups in the pediatric population. CO2 is an effective and safe modality and should be considered for pediatric colonoscopies.

Is water exchange superior to water immersion in detecting adenomas during colonoscopies? Results from a Bayesian network meta-analysis

AIM

Water-assisted colonoscopy (water exchange [WE] and water immersion [WI]) has been shown to improve the adenoma detection rate. However, few studies have compared these two methods head-to-head. Thus, we conducted a network meta-analysis to integrate both direct and indirect evidence comparing the effectiveness of these two procedures.

METHOD

We searched PubMed, Web of Science, and the Cochrane Central Register of Controlled Trials for original papers and abstracts published up to March 2018. Randomized controlled trials (RCTs) reporting data in accordance with the eligibility criteria were included in this study. We performed a Bayesian random effects network meta-analysis with mixed comparisons.

RESULTS

Twenty-nine studies (n = 11464 patients) including 6 direct and 23 indirect comparisons were included in this network meta-analysis. There was a statistically significant difference in the efficacy of adenoma detection when WE was compared with WI (risk ratio [RR]: 1.2, 95% credible interval [CrI]: 1.1-1.3), air insufflation (AI; RR: 1.3, 95% CrI: 1.1-1.4), and carbon dioxide (CO2) insufflation (RR: 1.2, 95% CrI: 1.1-1.5). The different methods were ranked in order from the most to least effective in adenoma detection as follows: WE, WI, AI, and CO2. Moreover, although there were no significant differences in pain scores, willingness to repeat, caecal intubation rate, or total procedure time between WI and WE colonoscopy, WE required a longer caecal intubation time than WI.

CONCLUSION

This network meta-analysis supposes that WE may be superior to WI in detecting adenomas during colonoscopies without affecting other technical features or patient acceptance.

Carbon dioxide insufflation during endoscopic resection of large colorectal polyps can reduce post-procedure abdominal pain: A prospective, double-blind, randomized controlled trial

Background

Studies of the use of CO₂ insufflation during endoscopic resection of large colorectal polyps (LCPs) are lacking.

Objective

We evaluated the effect of CO₂ insufflation on pain after endoscopic resection of LCPs.

Methods

In a prospective randomized controlled trial (RCT), 132 patients were randomly assigned to groups who underwent endoscopic resection with CO₂ insufflation (CO₂ group, n = 66) or air insufflation (air group, n = 66). The primary outcome was abdominal pain post-procedure (PP). The secondary outcomes were abdominal distension, rates of technical success, amounts of sedatives prescribed, use of analgesics, and adverse events.

Results

Baseline patient characteristics were similar between the groups. The mean abdominal pain score was 12.3 in the CO₂ group vs. 17.5 in the air group at 1 h PP (p  =  0.047). Also, the proportion of patients without pain was significantly higher in the CO₂ group at 1 h PP (p = 0.008). The pain score differed more in the endoscopic submucosal dissection group and long-time group. The secondary outcomes were not significantly different between the two groups.

Conclusions

The results of this RCT demonstrate the superiority of CO₂ insufflation for endoscopic resection of LCPs in terms of decreasing PP abdominal pain (KCT0001636).

Bayesian network meta-analysis: Efficacy of air insufflation, CO2 insufflation, water exchange, and water immersion in colonoscopy

BACKGROUND AND AIM

Colonoscopy is an excellent screening tool for colorectal cancer. There are four colonoscopy techniques: air insufflation, CO₂ insufflation, water exchange, and water immersion. Some studies reported that the latter three methods are better than the criterion standard (air insufflation), whereas some studies did not. In order to evaluate the efficacy of the four colonoscopy techniques, a network meta-analysis was carried out.

METHODS

We searched randomized controlled trials (RCT) published up to September 2017 from PubMed, Embase, Cochrane library, and Web of Science. Studies referencing the comparison between at least two of air insufflation, CO₂ insufflation, water exchange, and water immersion were selected. Primary outcomes included pain score during insertion, polyp detection rate, and adenoma detection rate, and secondary outcomes included cecal intubation time and cecal intubation rate. Mean differences or odds ratios and their corresponding 95% credible intervals were pooled with Bayesian modeling.

RESULTS

Forty RCT with 13 734 patients were included in this network meta-analysis. Our analysis showed that air insufflation had the highest pain score (surface under the cumulative ranking curve [SUCRA]: 98.8%) and the lowest detection rate of adenoma (SUCRA: 21.3%) and polyp (SUCRA: 16.8%). Water exchange had the lowest pain score (SUCRA: 1.1%) and highest detection rate of adenoma (SUCRA: 96.0%) and polyp (SUCRA: 98.9%), although it led to the longest cecal intubation time (SUCRA: 86.9%).

CONCLUSIONS

Air insufflation might be the most unsatisfactory colonoscopy. Meanwhile, water exchange might be the most efficient colonoscopy.

Optimal procedural sequence for same-day bidirectional endoscopy with moderate sedation: A prospective randomized study

BACKGROUND AND AIM

Same-day bidirectional endoscopy (BDE) is a commonly performed procedure, but the optimal sequence for the procedure with moderate conscious sedation is not well established. This study investigated the optimal sequence for same-day BDE under moderate conscious sedation and carbon dioxide insufflation in terms of sedation doses, patient discomfort, and colonoscopy performance.

METHODS

A prospective randomized controlled study of 120 patients who were scheduled for BDE examination was performed. Colonoscopy followed by esophagogastroduodenoscopy (EGD) examination was performed in 60 patients (colonoscopy-EGD group), and EGD followed by colonoscopy examination was performed in another 60 patients (EGD-colonoscopy group). Endoscopists and patients completed a questionnaire to assess objective and subjective discomfort.

RESULTS

Baseline demographics, procedure indications, bowel preparation quality, cecal intubation rate/time, colonoscopy withdrawal time, endoscopic interventions, BDE procedure time, colon polyp/adenoma detection rates, patient discomfort, and adverse events were similar between the two study groups. The total doses of fentanyl and midazolam were significantly higher for the colonoscopy-EGD group than for the EGD-colonoscopy group (83.4 ± 17.7 vs 68.7 ± 18.6 μg and 6.3 ± 1.4 vs 5.2 ± 1.3 mg, P < 0.0001 and P < 0.0001, respectively). The recovery time to discharge was significantly longer for the colonoscopy-EGD group than for the EGD-colonoscopy group (43.5 ± 16.2 vs 34.5 ± 8.9 min, P = 0.0003).

CONCLUSIONS

Esophagogastroduodenoscopy followed by colonoscopy is the optimal sequence for same-day BDE under moderate conscious sedation and carbon dioxide insufflation. Following this order allows for a reduction of sedation doses and for shorter recovery times.

Effects of carbon dioxide insufflation during direct cholangioscopy on biliary pressures and vital parameters: a pilot study in porcine models

BACKGROUND AND AIMS

Direct per-oral cholangioscopy allows endoscopic visualization of the biliary tract. Insufflation with carbon dioxide (CO₂) is an alternative to saline solution irrigation during direct cholangioscopy. There are no data on maximal CO₂ insufflation in direct cholangioscopy without causing biliary barotrauma or fatal gas embolism. We aimed to evaluate the safety of increasing CO₂ insufflation in direct cholangioscopy without causing biliary barotrauma or fatal gas embolism.

METHODS

This was an in vivo animal study. Four domestic pigs, under general endotracheal anesthesia, were used. The first animal was used to validate the feasibility of direct cholangioscopy and biliary pressure measurements, after which all animals underwent laparotomy, insertion of a pressure transducer in the cystic duct, and direct transpapillary placement of the cholangioscope. The common bile duct (CBD) and cystic duct were ligated to contain the instilled gas and exclusively expose the biliary tree. Insufflation of CO₂ started at 200 mL/min and was continuously increased until there was evidence of bile duct rupture (as measured by a drop in intraductal pressures) or instability of vital signs (hypotension, bradycardia, bradypnea, O₂ desaturation). Necropsy was performed on all animals to assess the liver and biliary system for evidence of barotrauma.

RESULTS

CO₂ was insufflated up to 8 L/min without causing bile duct rupture or instability in vital signs despite increasing CBD pressure with insufflation. There was significant correlation between CO₂ flow with partial pressure of CO₂ in arterial blood (PaCO₂) (coefficient, 0.96-1.00; P < .01) and end tidal expired CO₂ (EtCO₂) (coefficient, 0.94-1.00; P < .01). However, the pulse rate, respiratory rate, arterial blood pressure, and O₂ did not correlate with the amount of CO₂ flow. There was no evidence of hepatic or biliary barotrauma on necropsy.

CONCLUSIONS

This pilot experience in porcine models suggests that CO₂ insufflation is safe for direct cholangioscopy and does not result in biliary barotrauma or vital signs instability.

Diagnosis and treatment of ischemic colitis

Ischemic colitis (IC) is a common reason of acute lower gastrointestinal bleeding, and it is frequently seen in elderly people. In recent years, both the incidence and prevalence of IC have been rising. Most episodes of IC are transient and self-limited and only a minority of cases are severe. IC often has missed and delayed diagnosis. This review mainly focuses on the progress in the understanding of the diagnosis and therapy of IC.