Effect of Prophylactic Subcutaneous Scopolamine Butylbromide on Death Rattle in Patients at the End of Life: The SILENCE Randomized Clinical Trial

IMPORTANCE

Death rattle, defined as noisy breathing caused by the presence of mucus in the respiratory tract, is relatively common among dying patients. Although clinical guidelines recommend anticholinergic drugs to reduce the death rattle after nonpharmacological measures fail, evidence regarding their efficacy is lacking. Given that anticholinergics only decrease mucus production, it is unknown whether prophylactic application may be more appropriate.

OBJECTIVE

To determine whether administration of prophylactic scopolamine butylbromide reduces the death rattle.

DESIGN, SETTING, AND PARTICIPANTS

A multicenter, randomized, double-blind, placebo-controlled trial was performed in 6 hospices in the Netherlands. Patients with a life expectancy of 3 or more days who were admitted to the participating hospices were asked to give advance informed consent from April 10, 2017, through December 31, 2019. When the dying phase was recognized, patients fulfilling the eligibility criteria were randomized. Of the 229 patients who provided advance informed consent, 162 were ultimately randomized. The date of final follow-up was January 31, 2020.

INTERVENTIONS

Administration of subcutaneous scopolamine butylbromide, 20 mg four times a day (n = 79), or placebo (n = 78).

MAIN OUTCOMES AND MEASURES

The primary outcome was the occurrence of a grade 2 or higher death rattle as defined by Back (range, 0-3; 0, no rattle; 3, rattle audible standing in the door opening) measured at 2 consecutive time points with a 4-hour interval. Secondary outcomes included the time between recognizing the dying phase and the onset of a death rattle and anticholinergic adverse events.

RESULTS

Among 162 patients who were randomized, 157 patients (97%; median age, 76 years [IQR, 66-84 years]; 56% women) were included in the primary analyses. A death rattle occurred in 10 patients (13%) in the scopolamine group compared with 21 patients (27%) in the placebo group (difference, 14%; 95% CI, 2%-27%, P = .02). Regarding secondary outcomes, an analysis of the time to death rattle yielded a subdistribution hazard ratio (HR) of 0.44 (95% CI, 0.20-0.92; P = .03; cumulative incidence at 48 hours: 8% in the scopolamine group vs 17% in the placebo group). In the scopolamine vs placebo groups, restlessness occurred in 22 of 79 patients (28%) vs 18 of 78 (23%), dry mouth in 8 of 79 (10%) vs 12 of 78 (15%), and urinary retention in 6 of 26 (23%) vs 3 of 18 (17%), respectively.

CONCLUSIONS AND RELEVANCE

Among patients near the end of life, prophylactic subcutaneous scopolamine butylbromide, compared with placebo, significantly reduced the occurrence of the death rattle.

TRIAL REGISTRATION

trialregister.nl Identifier: NTR6264.

Presumed Central Anticholinergic Syndrome from Inadvertent Intravenous Hyoscine Hydrobromide (Scopolamine) Injection

We present a case of presumed central anticholinergic syndrome due to a drug administration error. A 35-year-old woman was slow to emerge from anaesthesia for laparoscopic biliary surgery. Postoperative neurological and metabolic abnormalities were later diagnosed as central anticholinergic syndrome. Only after resolution of the clinical problems did the drug error origin of the syndrome become apparent. It was realized that hyoscine hydrobromide (scopolamine) had been inadvertently administered intraoperatively for biliary relaxation, instead of hyoscine butylbromide. This case report describes central anticholinergic syndrome and highlights potential problems involved for anaesthetists administering drugs they do not commonly use.

Prophylactic effect of scopolamine butylbromide, a competitive antagonist of muscarinic acetylcholine receptor, on irinotecan-related cholinergic syndrome

Background/aim

Cholinergic syndrome frequently occurs within the first 24 h after irinotecan injection. We evaluated the prophylactic effect of scopolamine butylbromide on irinotecan-related cholinergic syndrome.

Patients and methods

Fifty-nine patients who received irinotecan-based regimens at our outpatient chemotherapy clinic between April 2013 and May 2014 were enrolled. Patients who developed irinotecan-related cholinergic syndrome were prophylactically administered scopolamine butylbromide at the next scheduled treatment. Risk factors for irinotecan-related cholinergic syndrome were determined using logistic regression analysis.

Results

Irinotecan-related cholinergic syndrome occurred in 50.8% of patients. Scopolamine butylbromide administration significantly reduced the incidence to 3.4% (P < 0.01). The irinotecan dose (≥ 150 mg/m²) was the only risk factor associated with irinotecan-related cholinergic syndrome. The incidence of cholinergic syndrome in patients with this risk factor was 75%.

Conclusion

Scopolamine butylbromide was effective in preventing irinotecan-related cholinergic syndrome. It is recommended for patients receiving ≥ 150 mg/m² irinotecan who may develop cholinergic syndrome at high frequency.

Hyoscine Butylbromide for the Management of Death Rattle: Sooner Rather Than Later

CONTEXT

Death rattle (DR) is a dramatic sign in the dying patient. Existing studies with anticholinergic agents are controversial, as this class of drugs has been commonly administered without considering the rationale of the mechanism of action. A meaningful use of these drugs may provide a better outcome.

OBJECTIVES

The aim of this study was to assess the efficacy of hyoscine butylbromide (HB), given prophylactically in comparison with HB administered once DR occurs.

METHODS

Dying patients having a score of ≥3 in the Richmond Agitation-Sedation Scale-palliative version were included in the study. HB (60 mg/day) was given when DR occurred (Group 1) or as pre-emptive treatment (Group 2). The onset of DR (death rattle free time) and intensity of DR were recorded at intervals until death.

RESULTS

Eighty-one and 51 patients were randomized to Group 1 and 2, respectively. Patients in Group 2 survived longer than those in Group 1 (P < 0.05). DR occurred in 49 (60.5%) and three patients (5.9%) in Group 1 and 2, respectively (P = 0.001). A significant difference in the number of patients reporting DR was found at intervals examined (30 minutes, one hour, and then every six hours until death [P = 0.001]). In Group 1 and 2, DR free time was 20.4 (20.5) and 27.3 hours (25.2), respectively (P = 0.001). In Group 1, the treatment was considered effective in 10 patients (20.4%) only, after a mean of 14.4 hours (SD 8.57).

CONCLUSION

The prophylactic use of HB is an efficient method to prevent DR, whereas the late administration produces a limited response, confirming data from traditional studies performed with anticholinergics. This could be considered a new paradigm to manage a difficult and dramatic sign, such as DR.

The Management of Inoperable Gastrointestinal Obstruction in Terminal Cancer Patients

The aim of the study was to assess vomit and pain control in terminal cancer patients with inoperable gastrointestinal obstruction, using a pharmacologic symptomatic treatment which prevents recourse to nasogastric tube placement and intravenous hydration, in hospital and home care settings. Twenty-two symptomatic patients, who were judged as inoperable, were treated with a pharmacologic association of morphine hydrochloride and scopolamine butylbromide as analgesics and haloperidol as an antiemetic. The drugs were administered by continuous subcutaneous infusion via a syringe driver or intravenously only when a central venous catheter had been inserted previously. Daily recordings included assessment of pain, number of vomiting episodes, dry mouth, drowsiness, and thirst sensation. Data were examined before starting the treatment (T0), 2 days after (T2) and 2 days before death (T-2). They showed that there was a significant decrease in the pain score (p less than 0.001) on T2 and a further decrease on T-2 (p less than 0.05). Vomiting was controlled in all patients, with the exception of three patients with upper abdomen obstruction who required nasogastric tube placement. Dry mouth showed an upward trend throughout the observation period (p less than 0.05) but was successfully treated by administering liquids by mouth or ice-cubes to suck. Drowsiness too presented an upward trend from T0 to T-2 (p less than 0.001). Only one patient out of 16 who reported to be thirsty required intravenous hydration. We believe that in terminal cancer patients, vomit and pain resulting from inoperable intestinal obstruction, with the exception of obstruction of the upper abdomen, can be controlled through administration of analgesic and antiemetic drugs, in the hospital and at home, without recourse to nasogastric tube placement or intravenous hydration.

Hyoscine N-Butylbromide for Preventing Propofol Injection Pain: A Randomized, Placebo-Controlled and Double-Blind Study

OBJECTIVE

In this study, the aim was to investigate the effect of hyoscine N-butylbromide (HnBB) pretreatment on pain during propofol injection.

SUBJECTS AND METHODS

In this prospective, randomized, placebo-controlled and double-blind trial, 60 patients scheduled to undergo routine outpatient surgery under general anesthesia were randomly allocated to 2 groups, the HnBB (n = 30) and sodium chloride (n = 30) groups. Twenty seconds after the injection of 20 mg HnBB or 0.9 % sodium chloride, a 50-mg dose of propofol was injected in 2-3 s. Ten seconds later, the pain intensity was assessed using a 4-point scale: no pain (0), mild (1), moderate (2), and severe (3) pain. The Student t test was used for the analysis of parametric data and the Pearson χ2 test for categorical data.

RESULTS

The occurrence of pain in the HnBB group (43.3%) was significantly lower than the control group (73.3%) (p < 0.018). Of the 30 patients in each group, 10 in the control group and 3 in the HnBB group experienced severe pain (p = 0.001).

CONCLUSIONS

Pretreatment with 20 mg HnBB significantly reduced propofol injection pain compared to placebo.

Effects of Hyosine N-butyl bromide on the detection of polyps during colonoscopy

BACKGROUND/AIMS

Colonoscopy has a significant miss rate for colorectal polyp screening. The present study hypothesized that reduced colonic spasm with antispasmodic agents might yield a better visual field to result in enhanced polyp detection rate.

METHODOLOGY

In a prospective, randomized, double-blind study design, muscle spasm was recorded during insertion and withdrawal during routine colonoscopy, and the number of polyps detected were compared between two groups of 58 patients characterized with either hyosine N-butyl bromide (Hyosine group) or placebo (Placebo group) injected at reaching the cecum.

RESULTS

The number of patients with decrease in spasm score of 0, 1, and 2 between insertion and withdrawal were 5 (8.6%), 31 (53.4%), and 22 (37.9%) in the Hyosine group, and 10 (17.2%), 46 (79.3%), and 2 (3.4%) in the Placebo group, respectively (p < 0.001). In patients with spasm score > or = 3 during insertion, more polyps per patient were likely to be detected in the Hyoscine group than the Placebo group (1.21 +/- 2.23 vs. 0.41 +/- 0.91; p = 0.060).

CONCLUSIONS

Our study suggests that hyosine might increase the detection rate of polyps in patients with moderate to marked degree of colonic spasm during colonoscope insertion. Further large scale studies are needed to validate our observations.

Interactions between symptoms and motor and visceral sensory responses of irritable bowel syndrome patients to spasmolytics (antispasmodics)

AIM

to evaluate and correlate the symptomatic, motor and sensory responses to two widely used categories of spasmolytic agents in irritable bowel syndrome (IBS).

METHODS

118 patients with IBS, diagnosed by Rome II criteria and 45 healthy individuals were studied. In the IBS subjects, pain severity, as well as the sensory response to rectal balloon distention and rectal and sigmoid motility, were studied at baseline and after two weeks therapy with either oral buscopan (20 mg three times a day, n=37), a buscopan suppository (30 mg once daily, n=21), oral drotaverine (80 mg three times a day, n=30), calcium gluconate tablets (one three times a day, n=16) as a control for oral agents, or calendula suppository (once daily, n=14) as a control for those who received a suppository.

RESULTS

Buscopan, whether administered as a tablet or a suppository, produced a significant reduction in pain scores among IBS patients with predominant diarrhea. No significant differences were evident among other IBS subgroups or in response to drotaverine. None of the interventions had any effect on any of the parameters of rectal or sigmoid motility studied. However, both buscopan and drotaverine led to a significant augmentation of the rectal threshold for discomfort/pain among IBS subjects with predominant diarrhea [21.78 + or - 2.8 vs 39.60 + or - 2.4 (p<0.05), 20.5 + or - 2,8 vs 36.84 + or - 3.8 (p<0.05) and 22.18 + or - 2.8 vs 36.9 + or - 2.42 (p<0.05) for oral buscopan, rectal buscopan and oral drotaverine, respectively].

CONCLUSION

We conclude that the clinical benefits of supposed spasmolytic (anti-spasmodic) agents may relate more to effects on visceral sensation than motility.

Hyoscine butylbromide - a review on its parenteral use in acute abdominal spasm and as an aid in abdominal diagnostic and therapeutic procedures

BACKGROUND

Being a quaternary ammonium compound derived from scopolamine, the alkaloid hyoscine butylbromide (HBB) exerts anticholinergic effects without side effects related to the central nervous system because it does not pass the blood-brain barrier. Clinical experience with this antispasmodic dates back to the 1950s and led to its registration for treating abdominal cramps/spasm and for diagnostic imaging purposes. OBJECTIVES AND SCOPE: This review focuses on the therapeutic efficacy and safety of the parenteral administration of HBB for treating biliary and renal colic and acute spasm in the genito-urinary tract. In addition, its value for diagnostic or therapeutic procedures in the abdomen, as well as for labour and palliative care, is reviewed. With the generic and trade name of the drug combined with various search terms related to the relevant clinical applications, a thorough literature search was performed in the Medline and EMBASE databases in April 2008.

FINDINGS

In most clinical studies, recommended doses of 20-40 mg HBB were injected, mainly intravenously. Fast pain reduction was achieved by HBB in renal colic; about 90% of the patients showed good to moderate analgesic responses after 30 min and the onset of action was noticeable within 10 min. Similarly, a pain reduction of 42-78% was observed in patients with biliary colic within 30 min after a single intravenous injection of 20 mg. In contrast, no analgesic efficacy of a single injection of 20 mg was found after surgical or shock-wave procedures in the urogenital area. Administration of HBB prior to, or during, radiological imaging distended the gastrointestinal (GI) tract in double-contrast barium and computed tomographic colonography studies and reduced motion artefacts in magnetic resonance imaging. This improved diagnostic image quality and organ visualisation. Pre-medication led to shorter and easier endoscopy in some, but not all, studies. Because of cervical relaxation, HBB shortened total labour duration with 17-67%. It also relieved pain and reduced GI secretions in terminal cancer patients with inoperable bowel obstruction. With regard to its safety profile, parenteral administration of HBB is associated with mild and self-limiting adverse events, typical for anticholinergic drugs.

CONCLUSIONS

These clinical results of rapid action and beneficial efficacy combined with good tolerability support the use of HBB in a range of indications related to acute abdominal spasm, in labour and palliative care and for supporting diagnostic and therapeutic abdominal procedures, where spasm may be a problem.

Effect of intravenous Buscopan on colonic distention during computed tomography colonography

OBJECTIVE

This study was designed to assess whether spasmolytic drugs are helpful in computed tomography colonography (CTC), as there is conflict in the literature.

METHOD

We assessed retrospectively in a blinded fashion colonic distention in 149 individuals, one-half of whom had intravenous (IV) Buscopan during CTC. Colonic segments (n = 1788) were analyzed by 2 observers, and allocated to one of 4 grades of distention. We also recorded the presence and severity of diverticular disease.

RESULTS

Buscopan increased the likelihood of optimal distention by an OR of 5 when considering individual colonic segments from ascending colon to sigmoid, with little effect on rectum or cecum. Considering the colon as a whole, the OR of optimal distention occurring throughout the entire colon was 7.9 times greater with Buscopan than without. In the sigmoid colon, Buscopan had a significantly greater impact on obtaining optimal distention in those with diverticulosis than in those without.

CONCLUSION

Buscopan increases the probability of obtaining optimal distention during CTC, especially in the sigmoid colon in diverticular disease. Buscopan is likely to improve polyp conspicuity and patient comfort, and to reduce both the examination time and the interpretation time. We recommend routine use of Buscopan during CTC.

Giant hypertrophic gastritis (Menetrier's-like disease) in an Old English sheepdog

An 11-year-old, male Old English sheepdog was admitted for weight loss and intermittent vomiting of 1 month's duration. A cranioventral abdominal mass, anemia, hypoproteinemia, and hypoalbuminemia were the prominent abnormal findings. Imaging studies identified a remarkably thickened gastric wall with multilobulated folds protruding into the gastric lumen. Gastrotomy revealed the presence of giant cerebriform rugal folds arising from the fundus and body of the stomach. Pronounced gastric glandular hyperplasia and lack of evidence of cellular atypia were suggestive of giant hypertrophic gastritis. The dog was treated with prednisolone, cimetidine, and hyoscine butylbromide, only to experience a short-term remission.

Role of hyoscine N-butyl bromide (HBB, buscopan) as labor analgesic

BACKGROUND

Hyoscine N-butyl bromide (HBB) acts by inhibiting cholinergic transmission in the abdomino-pelvic parasympathetic ganglia, thus relieving spasm in the smooth muscles of gastrointestinal, biliary, urinary tract and female genital organs, especially the cervico-uterine plexus and aiding cervical dilatation.

AIM

The study was undertaken to observe the effects of 40 mg intravenous HBB as a labor analgesic and labor accelerant.

SETTINGS AND DESIGN

This prospective randomized control trial was carried out on 104 primigravidae with single live fetus in cephalic presentation, with spontaneous onset of labor, between 37-40 weeks of gestation.

MATERIALS AND METHODS

Women were consecutively randomized into study (group I) and control (group II) groups, each with 52 patients after excluding high risk factors like preeclampsia, antepartum hemorrhage, previous uterine scar, and any contraindications to vaginal delivery. Group I received 40 mg HBB as a slow intravenous injection in the active phase of labor while Group II received 2 mL normal saline. Pain scores were assessed at baseline and two hours later. Secondary outcome measures compared were progress of labor based on injection delivery interval, mode of delivery and neonatal condition at birth.

STATISTICAL ANALYSIS

Statistical significance was assessed by using Student's t-test and Chi-square test. P-value < 0.05 was taken as significant.

RESULTS

Pain relief of 35.6% was noted on visual analog score with the use of HBB. Mean duration of labor was 3 hours 46 minutes in Group I compared to 8 hours 16 minutes in Group II (P value: < 0.001). Mode of delivery and neonatal outcome were comparable. No adverse maternal effects were noted.

CONCLUSIONS

Intravenous Hyoscine N-Butyl Bromide causes pain relief of up to 36% and shortens the duration of active phase without any untoward short term fetal or maternal effects.

Effects of Spascupreel versus hyoscine butylbromide for gastrointestinal cramps in children

BACKGROUND

Gastrointestinal spasms and cramps are common in children as well as in adults. Alternative medical practices such as chiropractice and homeopathy are becoming increasingly popular in Europe and the USA. The effectiveness and tolerability of the homeopathic preparation Spascupreel was compared with that of hyoscine butylbromide treatment in children <12 years of age.

METHODS

An observational cohort study in 204 children <12 years was conducted over a 1 week treatment period. The efficacy of the respective therapies were evaluated on the effect on severity of spasms and clinical symptoms (pain/cramps, sleep disturbances, distress, eating or drinking difficulties and frequent crying). Compliance was evaluated on a four-point scale from 'very good' to 'low'. Evaluation was done by the practitioner based on information given by the patient or minder.

RESULTS

The analysis showed comparative improvements with the homeopathic preparation and hyoscine butylbromide therapy on severity of spasms, pain/cramps, sleep disturbances, eating or drinking difficulties, and frequent crying, all as evaluated by the practitioner. Both treatments were very well tolerated.

CONCLUSIONS

For patients opting for a homeopathic therapy, Spascupreel seems to be an effective and well tolerated alternative to conventional therapies in children suffering from gastrointestinal spasms.

Role of intravenously administered hyoscine butyl bromide in retrograde terminal ileoscopy: A randomized, double-blinded, placebo-controlled trial

AIM: To evaluate the role of hyoscine butyl bromide in facilitating retrograde ileoscopy.

METHODS: Retrograde terminal ileoscopy was attempted in 200 consecutive patients undergoing colonoscopy. After intubation of the cecum and visualization of the ileocecal valve, hyoscine butyl bromide injection or normal saline was given intravenously to the patients in a double blind random fashion. The pulse rate and oxygen saturation were measured continuously. After completion of the procedure, endoscopists were then asked to score the ease of intubation and the ease of visualization of the terminal ileum on a visual scale of 1 to 10. The patients were also asked to score the pain after receiving hyoscine butyl bromide injection on a score of 1 to 10.

RESULTS: Terminal ileoscopy could be performed in 188 patients. The mean (SD) visual analogue score for the ease of intubation of the cecum was 7.4 (0.65) in the injection group and 5.9 (0.8) in the placebo group (P < 0.001). The mean (SD) length of ileum visualized in the injection group was 14.4 (3.3) cm and 10.4 (2.7) cm in the placebo group (P < 0.001). The mean (SD) visual analogue score for ease of visualization of the terminal ileum was 7.5 (0.69) in the injection group and 5.9 (0.7) in the placebo group (P < 0.001). The pain score experienced by the patients was 6.5 (0.7) in the injection group and 6.7 (0.69) in the placebo group (P < 0.008). Although the pulse rate increased significantly in patients receiving the drug, no statistically significant difference was noted in the oxygen saturation between the two groups either before or after administration of the drug. No complications were observed in either of the groups.

CONCLUSION: Hyoscine butyl bromide injection is a useful adjunct in helping the intubation and visualization of terminal ileum during colonoscopy.

CT urography: a comparison of strategies for upper urinary tract opacification

A consensus is yet to be reached regarding the best strategy for ensuring maximum ureteric delineation during CT urography (CTU). In this study we have compared various CTU protocols to try to establish the best method for ureteric delineation. Saline infusion in the supine position, saline infusion in the prone position, furosemide administration (10 mg, iv) and buscopan administration (20 mg iv) with saline infusion in the prone position were tried in four groups, each having 15 patients who were undergoing CTU. The pelvicalyceal system and ureter were divided into six segments, to each of which an opacification score was assigned (0, unopacified segment; 1, less than 50% opacified segment; 2, 50-99% of the segment opacified; or 3, completely opacified segment) and the results compared. Furosemide administration resulted in complete opacification of 93% of the ureters (28 of 30). In the distal (below the sciatic notch) ureter, the mean score with furosemide was 2.9, while that with saline, supine and prone positioning was 1.87 and 1.83, respectively, and this difference was highly significant (P = 0.0002 and P = 0.0001). It was also significantly higher than the buscopan group (score 2.3, P = 0.002). Also in the lower (the iliac crest to the sciatic notch) and upper (above the iliac crest) ureter, furosemide had significantly higher scores than saline infusion in either position. Saline infusion in the supine and prone positions had very similar scores in all segments that were less than the buscopan group, but this difference was not statistically significant. During CT urography, furosemide administration in low doses is the most effective and convenient technique for ureteric opacification.

Comparison of glucagon and scopolamine butylbromide as premedication for colonoscopy in unsedated patients

PURPOSE

Premedication with glucagon or hyoscyamine is reported to be effective in reducing colonic spasm. However, these drugs can be associated with unfavorable events. This prospective study was designed to compare the effects of premedication with glucagon with those of scopolamine butylbromide on cardiopulmonary parameters, intubation time, and patient discomfort in unsedated patients undergoing diagnostic colonoscopy.

METHODS

One hundred consecutive adult patients (65 males) undergoing colonoscopy without sedation were randomized to receive 1 mg of glucagon (n = 50) or 20 mg of scopolamine butylbromide (n = 50), intramuscularly. Physiologic changes, including systolic blood pressure, heart rate, and oxygen saturation, were monitored before colonoscope insertion and at three-minute intervals during colonoscopy. The percentages of completed procedure and time to cecal intubation were recorded. Patients were asked to rate pain by using a five-point pain score (0 = no pain; 4 = severe pain).

RESULTS

The percentages of completed procedure (96 vs. 98 percent), time to cecal intubation (16.3 vs. 14.5 minutes), and pain score (1.7 vs. 1.5) did not differ significantly between two groups. An increase in heart rate of more than ten beats per minute from baseline during colonoscopy occurred significantly more often in scopolamine group (44 percent of 50 patients) than in the glucagon group (12 percent of 50 patients; P = 0.0004). There were no significant differences between the two study groups with regard to changes in systolic blood pressure and decrease in oxygen saturation during colonoscopy.

CONCLUSIONS

Premedication with 1 mg of glucagon facilitates favorable examination with respect to physiologic changes compared with 20 mg of scopolamine. These features favor glucagon as the preferred premedication for patients undergoing colonoscopy.

Tramadol and hyoscine N-butyl bromide combined in infusion solutions: compatibility and stability

BACKGROUND

More than two-thirds of patients with metastatic cancer experience pain. Tramadol is one of the most interesting and useful weak opioids used by palliative care units to treat moderate to moderately severe pain. Relief of distressful symptoms in terminally ill patients is of prime importance; a common practice is to administer opioid analgesics in conjunction with other drugs as hyoscine N-butyl bromide, which is very useful in reducing secretions in patients with inoperable malignant bowel obstruction. The pursuit for excellence in symptom control in patients unable to take oral medication has led to the administration of medications by other routes such as the subcutaneous route.

PURPOSE

The purpose of this study was to fulfill the lack of information regarding the compatibility and physical stability of tramadol hydrochloride and hyoscine N-butyl bromide combined in infusion solutions.

METHODS

The stability of nine admixtures (stored in polypropylene syringes) at 4 and 25 degrees C was assessed over a period of 15 days.

RESULTS

Nonstatistically significant losses of tramadol HCl and a maximum loss of 7% for hyoscine N-butyl bromide were obtained. Therefore, tramadol HCl (dose range, 100-400 mg/day) can be formulated together in saline with hyoscine N-butyl bromide (dose range 40-80 mg/day) for s.c. infusion using a 60-ml drug infuser for a duration of 7 days.

Multidetector-row helical CT enteroclysis

The authors illustrate the technique for small-bowel imaging using enteroclysis with multidetector-row computed tomography (MDCT), underscoring the important role played by CT in the assessment of the small bowel thanks to the advent of first the spiral and later the multidetector technique. The paper makes a detailed comparison of the various methods that have been used in CT study of the small bowel and proposes a standardised technique to achieve correct distension of bowel loops and adequate evaluation of bowel wall vascularity, making reference to the well-consolidated experiences of the various Italian research groups. The paper accurately describes the different procedures required for CT assessment of the small bowel, from nasojejunal intubation to the selection of the most appropriate acquisition phases for assessment of bowel wall vascularity.

A case of sudden death after intramuscular injection of butylscopolamine bromide

A 40-year-old man experienced cardiopulmonary arrest after intramuscular injection of 20 mg of butylscopolamine bromide. No pathological changes were found at autopsy, and 1.19 microg/mL of butylscopolamine bromide was detected in his serum. Since he had taken no other drugs, his severe symptoms were thought to have been caused by an anaphylactic reaction to butylscopolamine bromide. Butylscopolamine bromide has been used for many years worldwide, and is considered to be a safe drug, with no reports of severe side effects following intramuscular injection. Since an anaphylactic reaction may not be related to a particular medication, the possibility of such a severe reaction must be considered, even during administration of an ostensibly safe drug such as butylscopolamine bromide.

[The analgesic effect of exercise during labor]

OBJECTIVE

The aim of this study was to test for an analgesic effect of exercise during labor.

PATIENTS AND METHODS

50 women in labor exercised continuously with moderate intensity on a bicycle ergometer for 20 minutes. During rest and exercise, they rated their pain on a visual analogue scale (VAS). Venous blood was sampled for beta-endorphin, cortisol and catecholamines during rest and directly after exercise.

RESULTS

84 percent of the women perceived uterine contractions during exercise as less painful than at rest. 76.2 percent objectified the pain relief by a reduction in VAS units 1.67 +/- 1.01. Beta-endorphin levels were much higher after exercise than at rest (P < 0.001). During exercise the fetal heart rate rose slightly within the reference range. Uterine contractions were more frequent during and after exercise than at rest (P < 0.05).

CONCLUSION

Exercising on a bicycle ergometer during labor seems to be safe for the fetus, a stimulus to uterine contractions, and a source of analgesia, possibly due to the release of beta-endorphin.

Morphine, haloperidol and hyoscine N-butyl bromide combined in s.c. infusion solutions: Compatibility and stability

The administration of drugs by subcutaneous infusion is routinely practiced in palliative medicine for the management of patients who are no longer able to take oral medication. It is common for two or more drugs to be combined in subcutaneous solutions. The combination of an opioid with other drugs (haloperiol lactate and hyoscine N-butyl bromide) can be very valuable. Unfortunately, the compatibility and stability of morphine hydrochloride, haloperidol lactate and hyoscine N-butyl bromide combined in the same solution has not yet been determined. Therefore, this study examined the stability of ternary solutions containing morphine HCl, haloperidol lactate and hyoscine N-butyl bromide at different dose ranges. Twelve different solutions were assessed for 15 days after preparation in polypropylene syringes using 0.9% saline as diluent. Triplicate syringes were stored at 25 degrees C. HPLC was the analytical technique used to measure morphine HCl, haloperidol lactate and hyoscine N-butyl bromide. Initial concentration ranges were 1.67-10.0 mg/ml for morphine HCl, 0.417-0.625 mg/ml for haloperidol lactate and, 5.0-6.67 mg/ml for hyoscine N-butyl bromide. All three drugs were very stable (>92.5%) when stored at 25 degrees C. The clinical performance of the admixture was retrospectively assessed in 21 terminal oncology patients. Total symptom control was achieved in 17 out of 21 patients with very good local tolerance.

Efficacy of hyoscine-N-butyl bromide (Buscopan) suppositories as a cervical spasmolytic agent in labour

OBJECTIVE

To evaluate the efficacy and safety of hyoscine-N-butyl bromide (Buscopan) suppositories in the active phase of labour, i.e. once the labour is established.

METHODS

A non-randomised controlled prospective study was carried out on 200 women in labour. In the active phase of labour, at 3 cm or more cervical dilatation, 100 women were administered Buscopan via suppository and 100 women (control) were not given any drug.

RESULTS

The duration of first stage of labour was 123.86 +/- 68.89 (mean(+)-standard deviation) minutes in the study group and 368.05 +/- 133.0 min in the control group. These differences were statistically significant. There were no differences in the duration of the second and third stages of labour. There was no increased incidence of operative deliveries in the study group. No adverse effects were noted on the mother or fetus.

CONCLUSION

Hyoscine-N-butyl bromide (HBB, Buscopan) suppositories were highly effective in shortening the duration of the first stage of labour.

Pitfalls and feasibility of a protocol of virtual colonography designed for the screening of colo-rectal pre-cancerous lesions

PURPOSE

To evaluate the pitfalls occurring during the virtual colonoscopy examination performed with a protocol designed for screening purposes.

MATERIALS AND METHODS

40 patients underwent a spiral CT for virtual colonoscopic evaluation with the following parameters: collimation 3 mm, feed 6 mm.rot(-1), pitch 2 and increment 1 mm in supine position. Virtual colonography examination was carried out using a dedicated workstation equipped with a software which allows to generate 3D images and virtual endoscopic views. Colon distension, fluid and fecal material were assessed on a 3 point scale.

RESULTS

Distension score was 0.50. Left colon and cecum score was 0.32 while in the sigmoid and rectum the score was worse with 0.86. Fluid and fecal residues scores were 0.31 and 0.19 respectively. On almost half of the patients additional scans would be necessary. The main cause of additional scans is suboptimal intestinal preparation and colon distension.

CONCLUSION

The use of virtual colonoscopy for screening purposes will be possible through the further technical development and with the optimisation of the protocols, particularly by the improvement of colon cleansing and distension.

Gastrointestinal uptake of FDG after N-butylscopolamine or omeprazole treatment in the rat

OBJECTIVE

Gastrointestinal (GI) uptake of 2-[18F]-fluoro-2-deoxy-D-glucose (FDG) is frequently observed in whole-body positron emission tomography (PET) images. Such physiological uptake may interfere with accurate interpretation. The aim of the present study was to determine whether physiological gastrointestinal FDG uptake can be decreased by means of an antiperistaltic agent, N-butylscopolamine, or a gastric secretion inhibitor, omeprazole.

METHODS

Sprague-Dawley rats were divided into three groups: omeprazole-treated (n = 6), N-butylscopolamine-treated (n = 7), and control group (n = 6). The rats in the omeprazole-treated group were administered omeprazole (1.0 mg/kg) intravenously 45 minutes before FDG injection. The rats in the N-butylscopolamine-treated group were administered N-butylscopolamine (1.0 mg/kg) intramuscularly 10 minutes before FDG injection. Sixty minutes after FDG injection under overnight fasting state, the gastrointestinal tissues were excised and weighed to determine the radioactivity of 18F using a gamma counter.

RESULTS

The mean values of FDG uptake in the esophagus, stomach, small intestine, cecum and colon of the N-butylscopolamine-treated group vs. the omeprazole-treated group were 148% vs. 162%, 109% vs. 113%, 113% vs. 88%, 102% vs. 85%, 105% vs. 70% of the control group, respectively. There were no statistical differences in FDG uptake rate in the esophagus, stomach, or cecum among the three groups. FDG uptake rates in the small intestine and colon of the omeprazole-treated group were significantly lower than those in the control group.

CONCLUSION

Physiological FDG uptake in the GI tract was not decreased by the administration of N-butylscopolamine. Omeprazole was effective in decreasing FDG uptake in the small intestine and colon. Omeprazole has a potential to decrease FDG uptake rate in a limited part of the GI tract.

Intravenous hyoscine as a premedication for colonoscopy: a randomized double-blind controlled trial

BACKGROUND AND STUDY AIMS

There is wide variation in the use of antispasmodics to facilitate colonoscopy, both within and between countries, and its use before such procedures remains controversial. The aim of this study was to determine whether there was any objective benefit in using hyoscine as a premedication for colonoscopy in a district general hospital.

PATIENTS AND METHODS

Consecutive day-case patients undergoing colonoscopy were included in the study. They were prospectively randomly allocated to receive either intravenous hyoscine (n = 61) or intravenous placebo (n = 56) as part of their premedication.

RESULTS

Our analysis demonstrated no statistically significant difference between the two groups with respect to the median time from colonoscope insertion to caecal intubation (9.7 minutes in the hyoscine group vs. 8.3 minutes in the placebo group) or the median total procedure time (14.8 minutes in the hyoscine group vs. 13.8 minutes in the placebo group). There was also no statistically significant difference in success rates for caecal intubation between the two groups ( P < 0.06). However a type II error cannot be excluded because of the small sample size.

CONCLUSION

This study demonstrated no obvious benefit in the routine use of hyoscine as a premedication for colonoscopy in a district general hospital setting.

Real-time high-resolution MRI for the assessment of gastric motility: pre- and postpharmacological stimuli

PURPOSE

To determine the practicality of MRI using a new real-time sequence for the assessment of gastric motion, and quantify the effects of motility-modifying substances.

MATERIALS AND METHODS

Six healthy volunteers ingested 400 mL of a high-calorie liquid nutrient. Two-dimensional real-time TrueFISP sequences were acquired for up to 30 minutes following the ingestion. The acquisition plane was chosen parallel to the axis of the gastric antrum. The examination was performed on three separate days with and without i.v. administration of 10 mg metoclopramide or 20 mg scopolamine. A motility index was calculated for each real-time data set.

RESULTS

Delineation of the gastric lumen proved easy and robust. The intravenous application of motility-modifying agents resulted in significant changes in the motility index. The administration of metoclopramide resulted in an average increase of the index by a factor of 1.5, whereas the application of scopolamine led to a decrease of the index by a factor of 3.0.

CONCLUSION

TrueFISP MRI performed well in depicting the gastric lumen and assessing gastric motility. Furthermore, we were able to evaluate and quantify the effect of motility-modifying agents. The noninvasive nature of MRI makes this imaging modality an attractive alternative to conventional invasive diagnostic tools for gastric motility disorders and monitoring of therapy.

A 22-year experience with quinacrine sterilization in a rural private clinic in Midnapore, India: a report on 5 protocols and 1838 cases

OBJECTIVES

Evaluate the safety and effectiveness of quinacrine for non-surgical female sterilization in five different protocols.

METHODS

The 5 trials were conducted sequentially. The first and largest, with 985 cases, tested the use of a curved inserter to place a 50 mg dose of quinacrine near each tubal ostia. The next 3 trials were carried out to determine the effect of adjunct procedures on the efficacy of the standard recommended protocol. The three adjuncts were 75 mg of intrauterine diclofenac, 10 mg medroxyprogesterone IM and either 10 mg of atropine IM or 20 mg of hyoscine butylbromide IM The final trial focused on the currently recommended protocol.

RESULTS

The 100 mg dose placed at the tubal ostia with the curved inserter resulted in a failure rate of 9.0% at 20 years. Diclofenac or medroxyprogesterone did not improve efficacy over quinacrine alone. Atropine or hyoscine butylbromide substantially diminished the effectiveness of the quinacrine. The failure rate with the standard protocol in our series of 122 cases was 0.8% at 3.5 years. Side effects were minor. There were no deaths nor serious complications with any of these protocols.

DISCUSSION

All 5 protocols appeared to be safe and the standard one was the most effective.

Efficacy of IV Buscopan as a muscle relaxant in CT colonography

The aim of this study was to examine the efficacy of IV Buscopan as a muscle relaxant in CT colonography in terms of colonic distension and polyp detection, and to determine its particular efficacy in patients with diverticular disease. Seventy-three consecutive patients were randomised to receive IV Buscopan or no muscle relaxant prior to CT colonography. CT colonography was performed using a Siemens Somatom 4-detector multislice CT scanner. The following parameters were recorded: degree of colonic distension using a 4-point scale; diagnostic adequacy of colonic distension; presence or absence of diverticular disease; and presence of colonic polyps. Accuracy of polyp detection was assessed using subsequent conventional colonoscopy as a gold standard. There was no significant difference between the two groups in the number of segments that were deemed to be optimally or adequately distended (p=0.37). Although IV Buscopan did improve distension of certain segments, this effect was not sufficient to improve the number of diagnostically adequate studies in the Buscopan group (p=0.14). In patients with diverticular disease, IV Buscopan did not have any significant effect on segments affected by diverticulosis but was associated with an improvement in distension of more proximal segments. There was no significant difference between the two groups in terms of polyp detection (p=0.34). The addition of prone scanning to supine scanning was found to be the most useful technique for maximising colonic distension. Intravenous Buscopan at CT colonography does not improve the overall adequacy of colonic distension nor the accuracy of polyp detection. In patients with sigmoid diverticular disease IV Buscopan improves distension of more proximal colonic segments and may be useful in selected cases, but our results do not support its routine use for CT colonography.

Compatibility of haloperidol and hyoscine-N-butyl bromide in mixtures for subcutaneous infusion to cancer patients in palliative care

The administration of drugs by s.c. infusion is routinely practiced in palliative medicine for the management of patients who are no longer able to take oral medication. It is not uncommon for two or more drugs to be combined in s.c. infusion solutions. Unfortunately, the compatibility and stability of haloperidol and hyoscine- N-butyl bromide has not yet been determined. The objective of this study was to study the compatibility and stability of solutions containing both drugs in polypropylene syringes. Nine different solutions were assessed for up to 15 days following preparation. The solutions were prepared in polypropylene syringes with 0.9% saline as a diluent and stored at 4 degrees C and 25 degrees C. High-performance liquid chromatography was the analytical technique used to measure haloperidol and hyoscine- N-butyl bromide. The initial concentration ranges were 0.3125-1.25 mg/ml for haloperidol and 2.5-10.0 mg/ml for hyoscine- N-butyl bromide. Haloperidol was precipitated at a concentration of >/=1.25 mg/ml when it was combined with hyoscine- N-butyl bromide. Concentrations of hyoscine- N-butyl bromide lower than 10 mg/ml in mixtures with haloperidol or 0.625 mg/ml of haloperidol in mixtures with hyoscine- N-butyl bromide for s.c. infusion allow for the administration of both drugs without any significant loss after storage at 25 degrees C for periods of up to 15 days, with approximately >/=90% and 88%, respectively, of haloperidol and hyoscine- N-butyl bromide remaining. However, after storage of the mixtures for equivalent periods at 4 degrees C the losses of hyoscine- N-butyl bromide observed at the end of the study were higher than 20%, while the percentages of haloperidol remaining after 15 days at this temperature were >/=94.37%.

Effect of subcutaneous butylscopolamine administration in the reduction of peristaltic artifacts in 1.5-T MR fast abdominal examinations

In abdominal MR imaging, ghost artifacts from noncyclic bowel movements can reduce the quality of the images. Although pharmacologic suppression of motion is effective, no study has being conducted to analyze the influence of drug motion suppression on fast breath-hold 1.5-T examinations of the upper abdomen. A prospective, randomized, double-blind trial was conducted in 50 patients. Patients were randomly distributed into two groups: The control group received only an oral solution, whereas the other group received the oral solution plus a subcutaneous injection of 20 mg of butylscopolamine 10 min before the MR examination. Breath-hold T1-weighted gradient-recalled-echo (GRE) MR images were obtained in a 1.5-T superconductive unit. Quantitative image analysis was performed with region-of-interest (ROI) measurements of the signal intensity of the liver and in background air anterior and lateral to the patient. A qualitative analysis of the subjective quality of the T1-weighted images was also done, and the adverse reactions were registered. The groups were homogeneous regarding age, gender, and weight distribution. No significant differences in the signal intensity of the liver and in the incoherent noise measurements were found between the two groups. Gastrointestinal noise showed significant differences between groups, with lower values for the butylscopolamine group compared with the control group. There was also a statistically significant difference in the image quality between groups, and optimal studies were only found in the butylscopolamine group, where most patients had a good-quality evaluation. Regarding adverse events, there were non-significant differences between groups. In conclusion, administration of an antiperistaltic agent to reduce the movements of the gastrointestinal tract diminishes the motion artifacts generated on MR imaging of the abdomen, even at high field strength and with fast imaging sequences. Images of the upper abdomen obtained after pharmacologic suppression of the gastrointestinal movement are of significantly superior quality.

Randomized trial of trigger point injection for renal colic

BACKGROUND

Many drugs have been utilized for the treatment of renal colic, but to date no drugs that relieve pain quickly and completely have been developed. Thus, we conducted a prospective trial to evaluate the effects of trigger point injection on renal colic. In this study, we used a local injection of lidocaine to the trigger point of patients experiencing renal colic, and evaluated the efficacy in patients using the visual analog scale.

METHODS

Sixty patients with renal colic were enrolled in this study and divided into two groups by a simple randomization: (i) the butylscopolamine group (n = 30, intravenous injection of butylscopolamine bromide and sulpyrine); and (ii) the lidocaine group (n = 30, local anesthesia to the trigger point with lidocaine).

RESULTS

Renal colic had disappeared completely at the end of the trigger point injection in 15/30 patients and the average time required to produce a 50% improvement in symptoms was 9 min in all patients in the group. In the lidocaine group, only one patient needed an additional anodyne treatment after 60 min and none of the 29 patients whose pain disappeared within 60 min needed further anodyne treatment within 24 h. These results were all significantly superior to those of the conventional treatment. No side-effects and complications were observed.

CONCLUSION

Trigger point injection, in our experience, is an easy, safe and effective method for the amelioration of renal colic. It was significantly superior to the combination of intravenous butylscopolamine and sulpyrine.

Findings at helical CT-enteroclysis in symptomatic patients with crohn disease: correlation with endoscopic and surgical findings

PURPOSE

The purpose of our study was to assess the diagnostic potential of helical CT-enteroclysis (HCTE) and to correlate our findings to endoscopic and surgical results.

METHODS

Twenty-eight consecutive patients suffering from histologic proven Crohn disease underwent HCTE and endoscopy within 4 weeks. HCTE findings were read by two observers in consensus and compared with endoscopic and surgical results.

RESULTS

Morphological signs of an acute or recurrent bowel inflammation were found in 25 of 28 (89%) patients. HCTE demonstrated accurately all mural and extramural changes of the inflamed bowel walls. Moreover, in 18 of 25 (72%) patients, HCTE depicted additional pathologic changes such as fistulas, abscesses, and skip lesions, all of which could not be visualized by endoscopy.

CONCLUSION

HCTE is an accurate technique to detect mural and extramural abnormalities in patients with Crohn disease. HCTE should be considered as a complementary imaging method to endoscopy, and should be the first imaging method especially when Crohn-associated complications are suspected.

Patient pain during colonoscopy: an analysis using real-time magnetic endoscope imaging

BACKGROUND AND STUDY AIMS

Colonoscopy is generally perceived as being a painful procedure. Contributory factors are: stretching of the colonic wall and mesenteric attachments from looping of the instrument shaft, overinsufflation, the degree of torque or force applied to the colonoscope shaft, and patient pain threshold. The aim of this study was to determine the frequency of pain episodes experienced during diagnostic colonoscopy and the corresponding colonoscope configuration, utilizing real-time magnetic endoscope imaging (MEI).

PATIENTS AND METHODS

Consecutive outpatients undergoing colonoscopy were studied. Patients with previous colonic resections were excluded. Procedures were commenced with antispasmodics only, and patient sedation was self-administered whenever significant discomfort was experienced, using a patient-controlled analgesia (PCA) syringe pump. All "demands" were correlated with the MEI record, which was subsequently analysed.

RESULTS

A total of 650 demands were recorded in 102 patients. Seventy-seven percent of all demands occurred with the colonoscope tip in the sigmoid colon, 7 % in the descending colon, 6 % at the splenic flexure, 5 % in the transverse colon, and 4 % in the proximal colon. Ninety percent of all pain episodes coincided with either looping (79 %) or straightening of the colonoscope shaft (11 %); presumed overinsufflation being an infrequent cause of pain (9 %). Of the loops encountered during colonoscopy, the N-sigmoid spiral loop was associated with the majority of pain episodes (56 %). Looping was both more frequent ( P = 0.0002) and less well tolerated in women than in men ( P = 0.0140).

CONCLUSIONS

This study is the first to document pain at colonoscopy accurately. Looping, particularly in the variable anatomy of the sigmoid colon, is the major cause of pain, especially in women. Use of MEI may improve pain control by facilitating the straightening of loops within the sigmoid colon, and by enabling the endoscopist to target patient analgesia.

Physical compatibility and in vivo evaluation of drug mixtures for subcutaneous infusion to cancer patients in palliative care

The objectives of this study were first to investigate the compatibility and physical stability of drug admixtures destined for s.c. administration through elastomeric infusion pumps to terminally ill cancer patients followed up at home by staff of the Palliative Care Unit (AECC), "La Paz" Hospital, Madrid and secondly, to evaluate the local side-effects related to the infusion of some of the drug mixtures to a population of 50 patients. The drug mixtures prepared included combinations of two, three, four and five of the following drugs: morphine hydrochloride, 60 mg/day; midazolam hydrochloride, 15 mg/day; haloperidol lactate, 7.5 mg/day; hyoscine-N-butyl-bromide, 60 mg/day; dexamethasone sodium phosphate, 16 mg/day; metoclopramide hydrochloride, 40 mg/day, and tramadol, 400 mg/day. Out of 86 mixtures evaluated in vitro, 52 were found to be physically compatible. Precipitation was always obtained when dexamethasone sodium phosphate at the concentrations assayed was combined with haloperidol lactate and/or midazolam hydrochloride. However, no precipitation occurred when morphine hydrochloride, the opioid most frequently used in patients of this type, and dexamethasone sodium phosphate were combined. Of the drug mixtures that were physically compatible, 18 were administered to the patient population evaluated. Very good symptom control was obtained with all of them, and especially with the mixture of morphine + midazolam + haloperidol + hyoscine, which is the one most frequently administered to cancer patients for palliative care in the final stages of life in our Unit.

Safety and efficacy of glucagon as a premedication for upper gastrointestinal endoscopy--a comparative study with butyl scopolamine bromide

BACKGROUND

Glucagon inhibits digestive motility and is used for endoscopic premedication; however, its effect on cardiopulmonary function during endoscopy has not yet been fully investigated.

AIM

To clarify the efficacy and safety of glucagon compared with butyl scopolamine bromide as upper gastrointestinal endoscopy premedication.

METHODS

Two hundred and forty consecutive patients over 40 years of age, referred for upper gastrointestinal endoscopy, without any complications, were studied. These patients were randomly premedicated with butyl scopolamine bromide (SC group) or glucagon (G group). Time course changes in blood pressure, arterial oxygen saturation, heart rate and the number of retching episodes during endoscopy were examined. The efficacy of glucose tablets after upper gastrointestinal endoscopy to prevent hypoglycaemia caused by glucagon was evaluated. Cardiopulmonary parameters were also examined in 77 complicated patients with glucagon premedication (GC group).

RESULTS

A continuous increase in heart rate during upper gastrointestinal endoscopy was observed in the SC group, but not in the G and GC groups. Blood pressure, arterial oxygen saturation and number of retching episodes were not different between the groups. Hypoglycaemia-related symptoms were frequent in the G group without glucose tablets, but were prevented by the administration of glucose.

CONCLUSIONS

Glucagon has a weaker effect on cardiopulmonary function during upper gastrointestinal endoscopy than butyl scopolamine bromide. Glucose administration prevents hypoglycaemia-related symptoms caused by glucagon.

Effects of gastrointestinal stimulant and suppressant pretreatment on the pharmacokinetics of AS-924, a novel ester-type cephem antibiotic

The effects of pretreatment with the gastrointestinal stimulant domperidone and the suppressant scopolamine butylbromide on the absorption of AS-924, a novel prodrug-type cephem antibiotic, were investigated in six healthy adult male volunteers by a cross-over method. The T(max) of ceftizoxime (CTIZ), the active moiety of AS-924, was slightly prolonged by scopolamine butylbromide (T(max)=1.8 vs. 1.5 h for the group without pretreatment). However, there were no significant differences in pharmacokinetic parameters including T(max), cumulative urinary excretion rates of CTIZ and cumulative urinary excretion rates of pivaloylcarnitine for 12 h after the dosing between the pretreated and control groups. Domperidone did not affect the absorption of AS-924.

The effect of timing of intravenous muscle relaxant on the quality of double-contrast barium enema

AIM

To determine whether the timing of buscopan administration during double-contrast barium enema examination (DCBE) affects diagnostic quality.

MATERIALS AND METHODS

In a prospective setting, 100 consecutive adult out-patients referred for DCBE received 20 mg buscopan (hyoscine-N-butylbromide) intravenously, either before infusion of barium suspension (Group A) or after barium infusion and gas insufflation (Group B). A subjective assessment of ease of contrast medium infusion was made at the time of examination and the films subsequently analysed by two radiologists unaware of the mode of relaxant administration, who noted the quality of mucosal coating and made subjective and objective measurements of segmental distension.

RESULTS

There was no significant difference in screening times, infusion difficulty or colonic contrast medium coating between the two groups. Subjective assessment of distension of the caecum, ascending colon, transverse colon and rectum were not significantly different. Patients receiving intravenous relaxant after barium and gas infusion had less subjective descending (P = 0. 05) and sigmoid (P = 0.04) colon distension, but there was no significant difference with respect to maximal bowel diameter in any of the segments measured.

CONCLUSION

The timing of intravenous administration during DCBE is likely to have no significant effect on the diagnostic quality of the study.

[The optimization of MR cholangiopancreatography]

PURPOSE

To improve the image quality of magnetic resonance cholangiopancreatography (MRCP) by modification of examination conditions.

MATERIALS AND METHODS

MRCP of 72 patients was performed with a 1.5 T system (Magnetom Vision, Siemens, 25 mT/m) using two breath-hold techniques, half-fourier acquisition with multislice T2-WI HASTE in MIP technique, and single shot T2-WI turbo-spin-echo (RARE) with different slice thicknesses. The effects of n-butylscopolamine were assessed. Furthermore, oral contrast agents [barium sulfate, Fe(II)-gluconate, Fe(II,III)-oxide] in various concentrations were used. The slice thickness was varied for the RARE sequence (3-7 cm).

RESULTS

N-butylscopolamine had no influence on image quality. Improvements could be attained by variation of the slice thickness. A significant reduction of disturbing background noise was obtained by oral application of iron gluconate, or iron oxide-containing contrast media. Similar improvements were achieved with barium sulfate.

CONCLUSIONS

Variation of slice thickness allows an improvement of MRCP quality. Oral contrast media improve the image quality of MRCP. The expense of contrast media may be a determinant of choice.

The frequency and significance of silent myocardial ischemia due to hyoscine butylbromide use in peripheral angiography

PURPOSE

Hyoscine-N-butylbromide (HB) is an anticholinergic drug used in digital subtraction angiography of the aortoiliac region because it decreases bowel gas movement artifact. HB also causes an increase in heart rate. We investigated whether this could cause silent myocardial ischemia (SMI) in susceptible patients during peripheral angiography.

METHODS

Thirty-six patients undergoing peripheral angiography were randomized into two groups, with 17 patients receiving 20 mg HB intraarterially during the angiogram and 19 patients receiving no drug. All patients were fitted with a Holter monitor that recorded the electrocardiogram before, during, and after the angiogram. Heart rate trends and ST segments were then analyzed.

RESULTS

Patients given HB had a statistically significant rise in heart rate compared with the control group. Although the difference was not statistically significant, two (12%) patients receiving HB had procedural ST depression compared with none in the control group. Pre- and postprocedural episodes of ST depression were common, occurring in 41% of patients receiving HB and 37% of patients receiving no drug, and were associated with an increase in heart rate.

CONCLUSION

The infrequent episodes of procedural SMI, potentially caused by the positive chronotropic effects of HB, are probably insignificant when compared with the high frequency of SMI episodes occurring outside the procedure.

CT appearances of mucosa-associated lymphoid tissue (MALT) lymphoma

Mucosa-associated lymphoid tissue (MALT) lymphoma is a low-grade lymphoma that differs from high-grade non-Hodgkin lymphoma both clinically and histologically. The CT appearances of MALT lymphoma are described. Of 40 patients referred with biopsy-proven MALT lymphoma, only seven had not had gastrectomy or chemotherapy prior to CT examination. The CT scans of these seven cases were analysed for the degree and extent of gastric wall thickening, enlargement of abdominal and extra-abdominal lymph nodes, and presence of extra-nodal disease. In all patients the stomach was distended with oral contrast medium and scans performed at narrow collimation, after intravenous administration of 20 mg hyoscine butylbromide. In six patients focal thickening of the gastric wall was 1 cm or less. One patient had thickening of over 4 cm. There was no enlargement of abdominal or extra-abdominal lymph nodes or extension to adjacent organs. Thus on CT, at presentation, MALT lymphoma results in minimal gastric wall thickening, unlike high-grade non-Hodgkin lymphoma, which typically causes bulky gastric disease, nodal enlargement and extension into adjacent organs. CT is therefore of limited value in monitoring response to treatment. With disease greater than minimal thickening, transformation to a higher grade should be considered.

Urodynamic features of the gastric pouch after radical cystectomy and the relationship to oral intake

PURPOSE

We studied the motility of orthotopic bladder substitution with stomach (gastric pouch) in adults with bladder cancer and the effect of oral intake as measured on urodynamics. We also investigated the probable relationship between continence and sensitivity of the proximal urethra. Anticholinergic medication effects on pouch motility were tested.

MATERIALS AND METHODS

Six patients with a gastric pouch were questioned about quality of life 6 to 43 months after surgery, and examined urodynamically before and after oral intake. During the examination the proximal urethra (directly under the anastomosis between the pouch and urethra) was electrically stimulated to determine sensitivity. We tried to inhibit the peristaltic contractions with 20 mg. butylscopolamine intravenously.

RESULTS

The main difference before and after oral intake was the onset time of peristaltic contractions. After eating the contractions began at a lower filling volume, which was statistically significant. There were no or insignificant differences in capacity and urodynamic parameters. We were successful in inhibiting the peristaltic contractions with anticholinergic medication.

CONCLUSIONS

The gastric pouch is a valuable bladder substitute with sufficient volume, antireflux characteristics, satisfactory continence rate and adequate voiding behavior. Oral intake causes motor activity of the gastric pouch at a lower fill volume than fasting during urodynamic investigation. Anticholinergic medication may be useful for inhibiting peristalsis in the gastric pouch.

The analgesic effect of intravenous tenoxicam in symptomatic treatment of biliary colic: a comparison with hyoscine N-butylbromide

This was conducted to evaluate the analgesic effect of intravenous tenoxicam (non-steroidal anti-inflammatory drug) in the treatment of biliary colic pain and compared with spasmolytics. Thirtytwo patients (26 women, 6 men, mean age 47, range 38-55 years) with acute biliary colic were entered for study. They were allocated randomly to receive either tenoxicam 20 mg i.v. or hyoscine N-butylbromide 20 mg i.v. The patients recorded their pain severity on 5 point scale. The results showed that tenoxicam caused significant pain relief in 10 out of 16 patients at 30 min (mean pain score decreased from 2.75 +/- 0.93 to 0.49 +/- 0.51, p < 0.05) and in other 4 patients at 60 min (mean pain score decreased to 0.58 + 5.7, p < 0.05). None of these patients developed acute cholecystitis or pain relapse over a period of 24 h follow up. With use of hyoscine N-butylbromide, 7 out 16 patients had significant pain relief at 30 min (mean pain score decreased from 2.62 +/- 1.01 to 0.57 +/- 0.53, p < 0.05) and 3 other patients relieved at 60 min (mean pain score decreased to 0.66 +/- 0.57, p < 0.05). Four patients showed pain relapse within 24 h and needed pethidine-rescue treatment, two of them developed acute cholecystitis. Three out of 6 patients who showed no response to hyoscine N-butylbropmide and treated with 100 mg pethidine progressed to acute cholecystitis. We concluded that intravenous tenoxicam has rapid and prolong analgesic effects in the treatment of acute biliary colic as compared to hyoscine N-butylbroimde and it prevents the progression to acute cholecystitis.

Compared effect of a genetically engineered glucagon and hyoscine N-butylbromide on double-contrast barium meal study

The aim of this study was to compare the effects of a genetically engineered glucagon (geG) and hyoscine N-butylbromide (HBB) on the quality of double-contrast barium meal (DCBM) study. Two hundred sixty-four patients scheduled for DCBM were randomized to receive intravenously geG 0.25 mg (geG-25), or geG 0.5 mg (geG-50), or HBB 20 mg as hypotonic agent. The evaluation concerned: duration of isolated visualization of the stomach (A); gastric mucosal coating (B); visualization of areae gastricae (C); quality of duodenal cap (D) and loop (E) study; delay, if any, of duodenal study (F). Global significant differences (P from 0.0183 to < 0.0001) were found for A, C, D, and F. GeG-50 allowed the longest isolated gastric visualization (P < 0.0001); geG-25 allowed more extensive visualization of areae gastricae than HBB (P = 0.0006); HBB allowed a better study of duodenal cap (P = 0.0052) and loop (P = 0.0190) than geG-25; geG-50 prolonged the examination time (P < 0.01). No adverse effect was observed with geG within 1 h after DCBM. In conclusion, geG can be safely used as a hypotonic agent in DCBM. When DCBM is focused on the stomach, 0.25 mg of geG is the optimal choice; if DCBM is focused on the duodenum, 0.5 mg of geG (with a prolonged examination time) or 20 mg of HBB (with a less effective study of the stomach) should be used.

[Analgesic-antispasmodic effect and safety of lysine clonixinate and L-hyoscinbutylbromide in the treatment of dysmenorrhea]

The purpose of this longitudinal open but not comparative study was to confirm the safety and efficacy of Lysine clonixinate (125 mg) and hyoscinbutylbromide (10 mg) capsules, during a period of observation of there menstrual cycles on 30 women with uterine dysfunction due to primary or secondary dysmenorrhea. The time of evolution for primary dysmenorrhea was of 4.46 years, and for secondary was of 1.77 years. Some associated manifestations of dysmenorrhea were: nausea (92%), vomit (92%), general pain (82.1%), abdominal pain (85.7%) and headache (46.4%). Regarding to the menstrual pain intensity, at first was highly severe in 10.7% severe in 42.9%, and moderate in 46.4%. At the end of the study, only 1 of 28 patients showed menstrual pain of moderate intensity. Only three adverse effects of light intensity were found without needing treatment, related to the manifestations of gastralgia and sleepiness. The association of a spasmolytic analgesic (Lysine clonixinate and hyoscinbutylbromide bromide) on the treatment for primary or secondary dysmenorrhea, reduces and prevents the menstrual pain (colic) as well as the associated manifestations with few spasmolytic association is efficacy and safety.

[Clinical phase III study of cimetropium bromide (DA3177) on the pain with upper urinary calculus: a double-blind study in comparison with scopolamine butylbromide. DA3177 Study Group]

A double-blind study was conducted to evaluate the efficacy, safety and usefulness of cimetropium bromide (DA3177) in the patients with pain caused by upper urinary calculus at a daily dose of 75 mg t.i.d. (Group D, 97 patients) in comparison with scopolamine butylbromide at a daily dose of 60 mg t.i.d. (Group B, 101 patients). According to patient's impression, the rate of "moderately improved" or better was significantly higher in Group D (68.7%) than in Group B (53.5%; Wilcoxon 2 sample test: p = 0.0044). For pain, the rate of "moderately improved" or better was 69.1% in Group D and 60.4% in Group B. In global improvement, the rate of "moderately improved" or better was significantly higher in Group D (70.1%) than in Group B (61.4%; Wilcoxon 2 sample test: p = 0.0469). The rate of "no problem in safety" showed no significant difference between Group D (91.5%) and Group B (93.3%). Adverse reactions occurred in 8.5% in Group D and 6.7% in Group B. The major adverse reactions were "dry mouth", "abdominal distension", "constipation" and "nausea". The rate of "useful" or better was 68.7% in Group D, and 60.4% in Group B. In conclusion, DA3177 was confirmed to be a useful drug for patient with pain caused by upper urinary calculus.

The value of hyoscine butylbromide in abdominal MR imaging with and without oral magnetic particles

PURPOSE

The purpose of this article was to assess the impact of intravenous (IV) anticholinergic hyoscine butylbromide in abdominal magnetic resonance (MR) imaging with oral magnetic particles (OMP) [ABDOS-CAN, Ferristene (USAN), Nycomed Imaging AS, Oslo, Norway].

MATERIALS AND METHODS

In 31 patients with abdominal tumors, T1-weighted spin-echo (SE) images (SE 600/ 15; 1.5 T) were obtained without and with IV hyoscine butylbromide (20 mg) before and after administration of 800 ml of OMP. Two blinded readers assessed motion artifacts, bowel-wall visualization, and lesion delineation on the four sets of T1-weighted images. The two-tailed Wilcoxon paired sample test was used for statistical analysis (p < .05).

RESULTS

Hyoscine butylbromide reduced motion artifacts and improved bowel-wall visualization on precontrast and OMP-enhanced images at a statistically significant level (p = 0.0006-0.037). The lowest degree of artifacts was recorded on OMP images with hyoscine butylbromide. OMP with hyoscine butylbromide significantly improved lesion delineation compared to studies without antiperistaltic drug before (p = 0.019) and after OMP administration (p = 0.01).

CONCLUSIONS

The authors conclude that the use of IV hyoscine butylbromide is recommended for OMP-enhanced abdominal MR imaging with T1-weighted SE pulse sequences at 1.5 T.