Darin Krygier

The impact of patient education on the quality of inpatient bowel preparation for colonoscopy

BACKGROUND For patients requiring colonoscopy while admitted to hospital, achieving adequate cleansing of the colon is often difficult. OBJECTIVES To assess the impact of patient education, in the form of both counselling and written instructions, on bowel cleanliness at colonoscopy. METHODS A total of 38 inpatients at a tertiary care hospital in Vancouver, British Columbia, who were referred to the gastroenterology service for colonoscopy were enrolled in the present study. Sixteen patients were randomly assigned to the intervention group, while 22 patients comprised the control group. Both groups received a clear liquid diet and 4 L of a commercially available bowel preparation. The intervention group also received a brief counselling session and written instructions outlining the methods and rationale for bowel preparation before colonoscopy. Bowel cleanliness was assessed by the endoscopist using a five-point rating scale. RESULTS The two groups were similar with respect to demographics, the indication for colonoscopy and findings at colonoscopy. The median bowel cleanliness scores in the control group and the enhanced-instruction group were 3.0 and 2.0, respectively (P=0.001). CONCLUSION Patient counselling and written instructions are inexpensive, safe and simple interventions. Such interventions are an effective means of optimizing colonoscopy preparation in the inpatient setting.

The use of budesonide in the treatment of autoimmune hepatitis in Canada.

BACKGROUND Autoimmune hepatitis (AIH) is a chronic inflammatory disease that is successfully treated with prednisone and/or azathioprine immunosuppressive therapy in 70% to 80% of patients. The remaining patients are intolerant or refractory to these standard medications. Budesonide, a synthetic glucocorticoid, undergoes a high degree of first-pass metabolism, reducing its systemic bioavailability, and has a 15-fold greater affinity for the glucocorticoid receptor than prednisolone. Budesonide may be a potentially useful systemic steroid-sparing immunosuppressive agent in the treatment of AIH. OBJECTIVE To review the Canadian experience using budesonide to treat AIH. METHODS Patients with AIH currently or previously treated with budesonide were identified through the Canadian Association for the Study of the Liver membership. Data were collected regarding their clinical and treatment history. RESULTS A total of nine patients were identified. All patients were female, with an average age of 39 years (range 12 to 66 years). The indications for budesonide were adverse side effects of prednisone in two patients, noncompliance with prednisone and azathioprine in one patient and intolerance to azathioprine resulting in prednisone dependence in the remaining six patients. Patients were treated in doses ranging from 9 mg daily to 3 mg every other day for 24 weeks to eight years. Seven of nine patients had a complete response, defined as sustained normalization of the aminotransferase levels. The remaining two patients were classified as nonresponders (less than a 50% reduction in pretreatment aminotransferase levels). CONCLUSIONS In Canada, budesonide has been successfully used in seven of nine patients with autoimmune hepatitis who were either intolerant to prednisone and azathioprine or prednisone-dependent. No adverse effects were reported with budesonide. Budesonide is potentially a valuable treatment option for AIH patients refractory or intolerant to standard therapy, and is deserving of further study.

Clozapine-induced fatal fulminant hepatic failure: A case report

Fulminant hepatic failure (FHF) refers to the rapid development of severe acute liver injury with impaired synthetic function and encephalopathy in a person who previously had a normal liver or had wellcompensated liver disease. The potential causes of FHF are numerous, but viral or toxin-induced hepatitis are the most common. Clozapineinduced hepatotoxicity has rarely been reported in the literature, occurs via an unknown mechanism and results in liver biochemical abnormalities that are usually of no clinical significance. In approximately 30% to 50% of patients treated with clozapine, there is an asymptomatic rise in serum aminotransaminase levels; however, there are no current guidelines for routine monitoring of liver function tests and liver enzymes during its use. Fatal fulminant hepatitis has only been reported in three patients receiving clozapine. A case of fatal FHF that occurred in a schizophrenic woman who began clozapine therapy shortly before her illness developed is described.

How to manage difficult Crohn’s disease: optimum delivery of anti-TNFs

Crohn’s disease is a chronic inflammatory condition that can involve any portion of the GI tract, leading to disabling symptoms and complications. Standard treatment with 5-aminosalicylic acid, antibiotics, corticosteroids and immunosuppressives has limited efficacy and is associated with serious potential adverse events. The anti-TNF-α agents are effective in the induction and maintenance of remission in luminal and fistulizing Crohn’s disease. Recent evidence suggests that early treatment with anti-TNF agents and immunosuppressives may alter the natural history of the disease and prevent late complications. In those patients who have lost response to, or are intolerant of, a single anti-TNF agent, increasing the dose of the medication or switching to alternate biologic agents, such as another anti-TNF drug or natalizumab, have been shown to be effective treatments.

The inpatient colonoscopy: A worthwhile endeavour

In the November 2008 issue of The Canadian Journal of Gastroenterology, the difficulties and limitations associated with the performance of colonoscopy in hospitalized patients were discussed. In contrast, the present article will discuss the rationale behind the use of inpatient colonoscopy and present the evidence that supports this practice. Dr Darin Krygier The most evident advantage to the performance of inpatient colonoscopy is clearly its ability to expedite the assessment of patients who would otherwise wait weeks or months to have the procedure performed as an outpatient. The Canadian Association of Gastroenterology has published target wait times (1) that have been deemed acceptable for patients waiting to be assessed by a gastroenterologist, ranging from two weeks for those with suspected malignancy and inflammatory bowel disease, to two months for those with iron deficiency anemia and positive fecal occult blood tests (1,2). Recent studies suggest that total wait times exceed the consensus targets, with 51% to 88% of patients not being seen within the target wait time. Given the large backlog of patients waiting to be assessed by most gastroenterologists, it is not surprising that the wait time for outpatient endoscopy often exceeds six to 12 months. As a result, colonoscopy performed while hospitalized can greatly expedite the management of patients with gastrointestinal issues. Another benefit of inpatient colonoscopy is the ability to perform the procedure in patients who may not otherwise reliably make themselves available for outpatient procedures, often due to socioeconomic or other situational factors. Additionally, it facilitates the preprocedural care of those patients who require such interventions as prophylaxis against bacterial endocarditis and titration of systemic anticoagulation. These patients can often be more difficult to coordinate before outpatient colonoscopy.

Does training and experience influence the accuracy of computed tomography colonography interpretation

AIM To evaluate the effect of experience on the accuracy rate of computed tomography colonography (CTC) interpretation and patient preferences/satisfaction for CTC and colonoscopy. METHODS A prospective, non-randomized, observational study performed in a single, tertiary care center involving 90 adults who underwent CTC followed by colonoscopy on the same day. CTC was interpreted by an abdominal imaging radiologist and then a colonoscopy was performed utilizing segmental un-blinding and re-examination as required. A radiology resident and two gastroenterology (GI) fellows blinded to the results also interpreted the CTC datasets independently. Accuracy rates and trend changes were determined for each reader to assess for a learning curve. RESULTS Among 90 patients (57% male) aged 55 ± 8.9 years, 39 polyps ≥ 6 mm were detected in 20 patients and 13 polyps > 9 mm in 10 patients. Accuracy rates were 88.9% (≥ 6 mm) and 93.3% (> 9 mm) for the GI Radiologist, 89.8% (≥ 6 mm) and 98.9% (> 9 mm) for the Radiology Resident and 86.7% and 95.6% (≥ 6 mm) and 87.8% and 94.4% (> 9 mm) for each of the GI fellows respectively. The readers accuracy rate did not change significantly with the percentage change rate ranging between -1.7 to 0.9 (P = 0.12 to 0.56). Patients considered colonoscopy more satisfactory than CTC (30% vs 4%, P < 0.0001), they felt less anxiety during colonoscopy (36% vs 7%, P < 0.0001), they experienced less pain or discomfort during colonoscopy compared to CTC (69% vs 4%, P < 0.0001) and colonoscopy was preferred by 77% of the participants as a repeat screening test for the future. CONCLUSION No statistically significant learning curve was identified in CTC interpretation suggesting that further study is required to identify the necessary training to adequately interpret CTC scans.

The inpatient Colonoscopy: A Difficult Endeavor

The performance of colonoscopy on patients admitted to hospital is a common occurrence. There are a variety of indications for inpatient colonoscopies ranging from acute gastrointestinal bleeding to iron deficiency anemia to occult blood positivity. The practice of colonoscopy for these patients has become relatively commonplace, with most physicians rapidly scheduling the procedure and, in fact, many booking the patient directly to the endoscopy unit and obtaining the full history and consent at the time of the procedure. This practice of inpatient colonoscopy clearly has some advantages with expedited assessment; however, there are a number of issues that limit the benefit of this procedure and may, in some cases, counterbalance the potential gain from the procedure. In the next two sections of ‘Ask the Expert’ we will present a ‘Pro and Con’ discussion for inpatient colonoscopy. In contradistinction to most ‘Pro/Con’ arguments, we have chosen to start with the limitations of colonoscopy in the setting of patients admitted to hospital. The opposing view will be presented in next month’s Journal. Dr Robert Enns There is a plethora of literature on inpatient colonoscopy that demonstrates benefit and safety (1–6). At first glance, it seems that colonoscopy is something that should be offered routinely to inpatients without hesitation. Although the benefit has been demonstrated in many studies, most of these have concerned themselves with acute gastrointestinal bleeding. There are a number of reasons why the physician should hesitate before proceeding with an urgent colonoscopy.