Alessandra Baccarin

Carbon dioxide insufflation or warm-water infusion versus standard air insufflation for unsedated colonoscopy: a randomized controlled trial.

BACKGROUND: The increasing demand for colonoscopy has renewed the interest for unsedated procedures. Alternative techniques, such as carbon dioxide insufflation and warm-water infusion, have been advocated to improve patient tolerance for colonoscopy in comparison with air insufflation. OBJECTIVE: The aim of this study was to evaluate the benefits of carbon dioxide insufflation and warm-water irrigation over air insufflation in unsedated patients. DESIGN: This study was a randomized, controlled trial. SETTING: This study was conducted at a nonacademic single center. PATIENTS: Consecutive outpatients agreeing to start colonoscopy without premedication were included. INTERVENTIONS: Patients were assigned to either carbon dioxide insufflation, warm-water irrigation, or air insufflation colonoscopy insertion phase. Sedation/analgesia were administered on patient request if significant pain or discomfort occurred. MAIN OUTCOME MEASURES: The primary outcome measured was the percentage of patients requiring sedation/analgesia. Pain and tolerance scores were assessed at discharge by using a 100-mm visual analog scale. RESULTS: Three hundred forty-one subjects (115 in the carbon dioxide, 113 in the warm-water, and 113 in the air group) were enrolled. Intention-to-treat analysis showed that the proportion of patients requesting sedation/analgesia during colonoscopy was 15.5% in the carbon dioxide group, 13.2% in the warm-water group, and 25.6% in the air group (p = 0.04 carbon dioxide vs air; p = 0.03 warm water vs air). Median (interquartile range) scores for pain were 30 (10–50), 28 (15–50), and 46 (22–62) in the carbon dioxide, warm-water, and air groups (carbon dioxide vs air, p < 0.01; warm water vs air, p < 0.01); corresponding figures for tolerance were 20 (5–30), 19 (5–36), and 28 (10–50) (carbon dioxide vs air, p < 0.01; warm water vs air, p < 0.01). LIMITATIONS: This investigation was limited because it was a single-center study and the endoscopists were not blinded to randomization. CONCLUSIONS: Carbon dioxide insufflation was associated with a decrease in the proportion of patients requesting on-demand sedation, improved patient tolerance, and decreased colonoscopy-related pain in comparison with air insufflation. The findings regarding warm-water irrigation confirmed the previously reported advantages, so that warm-water irrigation and carbon dioxide insufflation could represent competitive strategies for colonoscopy in unsedated patients.

Non-invasive assessment of liver fibrosis in chronic hepatitis B

The goal of this review is to provide a comprehensive picture of the role, clinical applications and future perspectives of the most widely used non-invasive techniques for the evaluation of hepatitis B virus (HBV) infection. During the past decade many non-invasive methods have been developed to reduce the need for liver biopsy in staging fibrosis and to overcome whenever possible its limitations, mainly: invasiveness, costs, low reproducibility, poor acceptance by patients. Elastographic techniques conceived to assess liver stiffness, in particular transient elastography, and the most commonly used biological markers will be assessed against their respective role and limitations in staging hepatic fibrosis. Recent evidence highlights that both liver stiffness and some bio-chemical markers correlate with survival and major clinical end-points such as liver decompensation, development of hepatocellular carcinoma and portal hypertension. Thus the non-invasive techniques here discussed can play a major role in the management of patients with chronic HBV-related hepatitis. Given their prognostic value, transient elastography and some bio-chemical markers can be used to better categorize patients with advanced fibrosis and cirrhosis and assign them to different classes of risk for clinically relevant outcomes. Very recent data indicates that the combined measurements of liver and spleen stiffness enable the reliable prediction of portal hypertension and esophageal varices development.

The impact of hyoscine-N-butylbromide on adenoma detection during colonoscopy: meta-analysis of randomized, controlled studies

BACKGROUND Hyoscine-N-butylbromide (HBB) can induce flattening of colon folds through inhibition of smooth muscle activity, which improves mucosal visualization. Whether this affects polyp detection is controversial. OBJECTIVE To evaluate whether HBB, administered during colonoscopy, improves polyp and adenoma detection. DESIGN We performed a comprehensive search in MEDLINE and EMBASE databases to identify randomized, placebo-controlled trials (RCTs) in which HBB was administered during colonoscopy and which also reported the detection rate for polyps and/or adenomas (PDR and/or ADR, respectively). SETTING Meta-analysis of 5 RCTs. PATIENTS A total of 1998 patients (1006 receiving HBB) were included in the study. INTERVENTIONS Intravenous administration of 20 mg (2 mL) HBB or 2 mL saline solution at the time of cecal intubation. MAIN OUTCOME MEASUREMENTS The PDR was the primary outcome variable. Secondary outcomes included the ADR, the advanced adenoma detection rate (adv-ADR), and the mean number of polyps and adenomas per patient (PPP and APP, respectively). RESULTS The PDR, ADR, and adv-ADR did not differ significantly between the 2 groups. The odds ratios (95% confidence interval [CI]) for PDR, ADR, and adv-ADR were 1.09, 95% CI, 0.91-1.31; 1.13, 95% CI, 0.92-1.38; and 0.9, 95% CI, 0.63-1.30, respectively. In addition, no significant differences were observed in PPP and APP between the 2 groups. LIMITATIONS Small number of studies included. Limited data about secondary outcomes and safety. CONCLUSION Our meta-analysis does not provide evidence that routine HBB administration at cecal intubation improves PDR or ADR. More studies are needed for final conclusions, particularly on HBBs effect on PPP and APP.

Liver stiffness measurement reliability and main determinants of point shear-wave elastography in patients with chronic liver disease

Liver stiffness (LS) measured by transient elastography (TE) accurately predicts the severity of chronic liver diseases (CLD). Point quantification shear‐wave elastography (pSWE) is a new technique incorporated into a conventional ultrasound system for measuring LS. We evaluated pSWE feasibility, reproducibility and diagnostic accuracy in consecutively recruited CLD patients who concomitantly underwent TE and liver biopsy.

2-Litre polyethylene glycol-citrate-simethicone plus bisacodyl versus 4-litre polyethylene glycol as preparation for colonoscopy in chronic constipation.

BACKGROUND Chronic constipation is a risk factor of inadequate bowel preparation for colonoscopy; however, no large clinical trials have been performed in this subgroup of patients. AIMS To compare bowel cleansing efficacy, tolerability and acceptability of 2-L polyethylene-glycol-citrate-simethicone (PEG-CS) plus 2-day bisacodyl (reinforced regimen) vs. 4-L PEG in patients with chronic constipation undergoing colonoscopy. METHODS Randomized, observer-blind, parallel group study. Adult outpatients undergoing colonoscopy were randomly allocated to 2-L PEG-CS/bisacodyl or 4-L PEG, taken as split regimens before colonoscopy. Quality of bowel preparation was assessed by the Ottawa Bowel Cleansing Scale (OBCS). The amount of foam/bubble interfering with colonic visualization was also measured. RESULTS 400 patients were enrolled. There was no significant difference in successful cleansing (OBCS score ≤6): 80.2% in the 2-L PEG-CS/bisacodyl vs. 81.4% in the 4-L PEG group. Significantly more patients taking 2L PEG-CS/bisacodyl showed no or minimal foam/bubbles in all colonic segments (80% vs. 63%; p<0.001). 2-L PEG-CS/bisacodyl was significantly more acceptable for ease of administration (p<0.001), willingness to repeat (p<0.001) and showed better compliance (p=0.002). CONCLUSION Split 2-L PEG-CS plus bisacodyl was not superior to split 4-L PEG for colonoscopy bowel cleansing in patients with chronic constipation; however, it performed better than the standard regimen in terms of colonic mucosa visualization, patient acceptance and compliance.

Bowel ultrasound imaging in patients with cystic fibrosis: Relationship with clinical symptoms and CFTR genotype

BACKGROUND Ultrasound imaging is used to assess bowel abnormalities in gastrointestinal diseases. We aimed to assess the rate of predefined bowel ultrasound signs and their relationship with gastrointestinal symptoms and the cystic fibrosis transmembrane conductance regulator (CFTR) genotype in cystic fibrosis patients in regular follow-up. METHODS Prospective study of 70 consecutive patients with cystic fibrosis and 45 controls who underwent abdominal ultrasound; pertinent findings were related to gastrointestinal symptoms and, in cystic fibrosis patients, to pancreatic status, malabsorption degree, lipase intake, CFTR genotype (classified as severe or mild against functional class of CFTR mutations). RESULTS 96% patients showed at least one abnormal bowel ultrasound sign. Most frequent signs were lymph node enlargement (64%), bowel loop dilatation (55%), thick corpuscular intraluminal content (49%), bowel wall hypervascularization (26%), thickened bowel wall (22%) and intussusception (17%). Patients with recurrent abdominal pain showed more bowel wall hypervascularization than patients without recurrent pain (47% vs. 19%, respectively; p = 0.02) and intussusception (58% vs. 17%, respectively; p < 0.01). Genotype was not associated to specific bowel ultrasound signs. Patients with bowel loop intussusception showed greater lipase intake than those without intussusception (8.118 ± 2.083 vs. 5.994 ± 4.187, respectively; p < 0.01). CONCLUSION Cystic fibrosis patients present a higher rate of bowel ultrasound abnormalities than controls. Bowel ultrasound abnormalities are associated with abdominal symptoms.

One or two operator technique and quality performance of colonoscopy: A randomised controlled trial

BACKGROUND The two-operator technique for colonoscopy, with the endoscopy assistant actively advancing and withdrawing the scope, is still commonly practiced in Europe. As uncontrolled data has suggested that the one-operator technique is associated with a higher adenoma detection rate, we tested the hypothesis that the two-operator-technique can achieve comparable performances in terms of adenoma detection. METHODS Non-inferiority trial in which consecutive adult outpatients were randomised to undergo colonoscopy by one (one-operator) or by four endoscopists. Each performed half the procedures by one-operator and half by two-operator technique independently of routine clinical practice. Main outcome measure was adenoma detection rate. RESULTS 352 subjects (49% males, mean age 60 ± 12.1 years) were randomised to one (n=176) or to two-operator technique (n=176) colonoscopy. No significant differences were found in adenoma detection (33% vs. 30.7%, p=0.65), or cecal intubation rate, procedure times, and patient tolerability. No differences were found in the subgroup analysis according to routinely adopted colonoscopy technique. CONCLUSIONS This study does not confirm a higher adenoma detection rate for one-operator technique colonoscopy. Changing current practice to improve adenoma detection rate for endoscopists routinely using two-operator technique is not warranted.

Effects of a Gluten-Containing Meal on Gastric Emptying and Gallbladder Contraction

The ingestion of gluten has been associated with gastrointestinal symptoms even in the absence of detectable immune responses. Little is known about the pathophysiological effects of gluten on the upper gastrointestinal tract. We aimed to assess whether the ingestion of gluten leads to an impairment of the physiological mechanisms of gastric emptying, gallbladder contraction and relaxation. A total of 17 healthy subjects underwent ultrasound evaluation of gastric emptying dynamics and gallbladder contractions at baseline and every 30 min after a standard gluten-containing and gluten-free meal (250 kcal, 70% carbohydrates). The pattern of gastric emptying was similar after a standard meal with or without gluten, but differed in terms of the peak of the antral filling curve, which was wider (mean area 5.69, median 4.70, range 3.71‒9.27 cm2 vs. mean 4.89, median 4.57, 2.27‒10.22 cm2, p = 0.023) after the gluten-containing meal. The pattern of gallbladder contractions was different after the gluten-free meal (p < 0.05), with higher gallbladder volumes in the late refilling phases. The results of this study show that gluten ingestion exerts objective effects on gastric and gallbladder motility. Although the underlying pathophysiological mechanism remains unknown, these results could account for some of the gluten-related symptoms reported by patients with celiac disease and non-celiac gluten sensitivity.

An Unusual Case of Abdominal Distension

59-year-old white woman was referred to our Aunit because of recurrent abdominal pain and a migrating abdominal mass that had been noticed during the past few months. Her past medical history included an episode of acute colonic diverticulitis 1 year previously, which had been treated by a conservative approach. After a short period of good health, the aforementioned symptoms presented. The patient underwent abdominal ultrasound, which documented left colonic wall thickness without loss of layering, with a hypoechoic parasigmoid mass that was suspect for an abscess. These findings were not confirmed by a subsequent ultrasound examination. Clinical examination confirmed a 5-cm palpable soft mass located in the right lower-abdominal quadrant, without abdominal tenderness. Routine blood test results were normal. A computed tomography scan showed a 10-cm sigmoid colonic diverticulum with a wide neck, occupying the central and upper abdominal quadrants (Figures A and B). Intraoperative findings confirmed the diagnosis of a giant sigmoid diverticulum (GSD) in a subset of colonic diverticulosis. The patient was treated by sigmoidectomy, with concomitant primary end-to-end anastomosis. The postsurgical course was uneventful. A GSD is defined as a diverticulum larger than 4 cm in diameter, and it is a rare finding within the diverticular disease burden. Up to 90% of cases occur in the sigmoid colon, and the pathogenesis still is obscure. A unidirectional flap-valve mechanism is supposed to be at the base of the GSD formation, according to the hypothesis that bowel gas and debris can enter but cannot leave the diverticulum, thus causing a gradual increase in size, culminating in a GSD. Common symptoms include vague abdominal pain and a migrating mass; some patients complain of diarrhea, constipation, fever, nausea and vomiting, or rectal bleeding. Complications of a GSD include peritonitis, secondary to perforation, abscess, and volvulus. The diagnosis is confirmed by radiologic investigations, mainly by a computed tomography scan or a barium enema. Elective surgery, preferably by a 1-stage resection with primary end-to-end anastomosis, is the recommended treatment for symptomatic noncomplicated GSD in low-risk patients. A transitory colostomy with secondary anastomosis may represent a viable option, mainly for complicated disease.

Bulging or Mass? This Is the Question

Obscure gastrointestinal bleeding (OGIB) is the leading indication for capsule endoscopy (CE), accounting for 70–80% of all procedures performed [1]. The CE diagnostic yield in this setting (50–60%) is superior to that of other diagnostic techniques in the study of the small bowel [2]. This mostly depends on the capability of CE to identify small/flat lesions, often missed by other techniques. On the other hand, protruding lesions (polyps or masses), due to a lack of insufflation, can be difficult to identify; therefore, distinction between masses and bulges still represents a challenging task for CE.