Onofre Alarcon

Clinical practice guidelines: quality of colonoscopy in colorectal cancer screening.

1. Collecting the evidence about the quality of colonoscopy screening for colorectal cancer (CRC) in order to serve as a tool for screening programs, endoscopy units and endoscopists that perform screening colonoscopies. 2. Defining and establishing quality indicators and minimum requirements based on available evidence that endoscopy units and endoscopists involved in CRC screening programs should meet. 3. Providing evidence about procedures that may improve the quality of colonoscopy.

Clinical indications for computed tomographic colonography: European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastrointestinal and Abdominal Radiology (ESGAR) Guideline

This is an official guideline of the European Society of Gastrointestinal Endoscopy (ESGE) and the European Society of Gastrointestinal and Abdominal Radiology (ESGAR). It addresses the clinical indications for the use of computed tomographic colonography (CTC). A targeted literature search was performed to evaluate the evidence supporting the use of CTC. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was adopted to define the strength of recommendations and the quality of evidence. Main recommendations 1 ESGE/ESGAR recommend computed tomographic colonography (CTC) as the radiological examination of choice for the diagnosis of colorectal neoplasia. ESGE/ESGAR do not recommend barium enema in this setting (strong recommendation, high quality evidence). 2 ESGE/ESGAR recommend CTC, preferably the same or next day, if colonoscopy is incomplete. Delay of CTC should be considered following endoscopic resection. In the case of obstructing colorectal cancer, preoperative contrast-enhanced CTC may also allow location or staging of malignant lesions (strong recommendation, moderate quality evidence). 3 When endoscopy is contraindicated or not possible, ESGE/ESGAR recommend CTC as an acceptable and equally sensitive alternative for patients with symptoms suggestive of colorectal cancer (strong recommendation, high quality evidence). 4 ESGE/ESGAR recommend referral for endoscopic polypectomy in patients with at least one polyp  ≥  6  mm in diameter detected at CTC. CTC surveillance may be clinically considered if patients do not undergo polypectomy (strong recommendation, moderate quality evidence). 5 ESGE/ESGAR do not recommend CTC as a primary test for population screening or in individuals with a positive first-degree family history of colorectal cancer (CRC). However, it may be proposed as a CRC screening test on an individual basis providing the screenee is adequately informed about test characteristics, benefits, and risks (weak recommendation, moderate quality evidence).

Uso médico de Internet entre los pacientes de una consulta general de enfermedades del aparato digestivo

INTRODUCTION: The use of the Internet to gain health information has increased in Spain. This is changing the way patients access medical information and, in turn, the physician-patient relationship. OBJECTIVES: To analyze the use of the Internet for medical purposes by patients attending a digestive diseases office and to determine the profile of patients seeking this information. MATERIAL AND METHODS: A questionnaire was administered to consecutive patients attending a general digestive diseases office for the first time. RESULTS: Four hundred twenty-three patients completed the questionnaire (56% women, 44% men, mean age 42.63 [15.994] years). A total of 2.4% had only not completed basic education, 14% had completed basic education, 32.8% had completed high school, 50.6% had university degrees, and 0.2% did not answer. More than three-quarters (76.4%) had a computer at home and 72% had internet access. Forty-two percent looked for health information on the internet. Seventeen percent had searched for specific information on their illnesses before consulting and 66% believed the internet is a good resource for obtaining medical information. Seventy percent would be interested in a specific web page on digestive disease topics and 75% would use e-mail to consult with their physicians. The group that most frequently looked for medical information consisted of patients aged 45 years or younger with secondary school or university education. CONCLUSIONS: In our environment, patients with digestive diseases routinely use the Internet to search for medical information. These patients have a high degree of confidence in the information obtained and would be interested in a specific website devoted to diseases of the digestive system. The patients that most frequently searched for health information were aged less than 45 years old and had secondary school education or university degrees.

Idoneidad de las indicaciones de la endoscopia digestiva alta en unidades de acceso abierto

Resumen Introduccion : La solicitud de la endoscopia digestiva alta (EDA) por el medico generalista de atencion primaria puede acortar sensiblemente el tiempo de espera para esta exploracion y agilizar la toma de decisiones en pacientes con patologia del tracto digestivo alto. El objetivo de este estudio es comparar la idoneidad de las indicaciones de la EDA diagnostica entre medicos generalistas y gastroenterolgos en unidades de endoscopia de acceso abierto. Pacientes y metodos : Las indicaciones de la EDA se evaluaron prospectivamente durante 9 meses mediante los criterios de idoneidad establecidos por la American Society for Gastrointestinal Endoscopy (ASGE) y por los criterios de un panel de expertos europeos (EPAGE). Previamente se instruyo a los medicos generalistas sobre las indicaciones, riesgos y beneficios de la EDA y los criterios para la remision de pacientes a 2 unidades de endoscopia de acceso abierto. Resultados : Los pacientes remitidos para una EDA por los 2 grupos de medicos a estas unidades fueron comparables respecto a sexo, edad, motivo de la endoscopia y presencia de sintomas de alarma. Segun los criterios de la ASGE, presentaron una indicacion inapropiada 25 (18,4%) de los 136 pacientes remitidos por medicos generalistas y 32 (18,6%) de los 172 pacientes remitidos por gastroenterologos (diferencia no significativa). Segun los criterios del EPAGE, 16 (11,8%) de los pacientes remitidos por medicos generalistas y 19 (11%) de los enviados por gastroenterologos (diferencia no significativa) tenian una indicacion inapropiada. Conclusion : El grado de idoneidad en las indicaciones de la EDA que consiguen los medicos generalistas de atencion primaria es similar al que alcanzan los medicos gastroenterologos. Este dato puede ser importante a la hora de evaluar la implementacion de unidades de endoscopia digestiva de acceso abierto en nuestro pais.

One-day versus two-day cleansing for colon capsule endoscopy: a prospective randomized pilot study

BACKGROUND Standard bowel cleansing for colon capsule endoscopy (CCE) requires a liquid diet and bowel laxatives for at least 2 days, which is a major drawback of this procedure and affects tolerance and acceptability. OBJECTIVE To compare the quality of colon cleanliness achieved with one-day versus two-day bowel preparation in outpatients undergoing CCE. METHODS Patients were randomly assigned to one of two groups: group I (one-day schedule, n=20) received a fiber-free diet and 3 L of polyethylene glycol (PEG) on day 0; group II (two-day schedule, n=20) received a liquid diet and 3 L of PEG in the evening of day -1, and 1L of PEG in the early morning of day 0. In both groups, the patients received 15 mg bisacodyl on day -1 and one or two additional sodium phosphate (NaP) boosters following capsule ingestion. Each colon segment was assessed for cleanliness using a four-point grading scale (excellent=1, good=2, fair=3, and poor=4). For the final analysis, colon cleanliness was rated as adequate (good or excellent) or inadequate (fair or poor). RESULTS Overall colon cleanliness was adequate in 94% (CI 91-97) of patients in group I versus 80% (CI 72-88) in group II (P=0.27). No significant differences were observed in the per-segment quality of colon cleansing between the two groups. CCE reached the rectum in 80% (CI 73-87) of patients in group I versus 75% (CI 67-83) in group II (p=0.59). CONCLUSION The quality of colon cleanliness achieved with one-day bowel preparation is equivalent to that of the standard two-day schedule in patients undergoing CCE.

Cuestionario específico de calidad de vida para pacientes con estreñimiento: desarrollo y validación del CVE-20

Fundamento y objetivo: El estrenimiento afecta mucho la calidad de vida, pero apenas hay cuestionarios especificos que evaluen en que medida. El objetivo de este trabajo ha sido desarrollar y validar un cuestionario capaz de medir la calidad de vida en pacientes con estrenimiento. Pacientes y metodo: Se ha realizado un estudio multicentrico espanol en 2 fases: a) desarrollo del cuestionario (entrevista a pacientes con estrenimiento, obtencion del cuestionario piloto, analisis cuantitativo y factorial, analisis de Rasch y diseno del cuestionario especifico) y b) validacion del cuestionario en 136 pacientes con estrenimiento (segun criterios de Roma II). Se dividio a estos pacientes en 2 grupos: a) grupo de fiabilidad (n = 55; pacientes que no precisaban iniciar o cambiar el tratamiento actual; retest a los 15 dias), y b) grupo de sensibilidad al cambio (n = 81; requerian iniciar o cambiar el tratamiento; retest a los 3 meses). Se recogieron las variables sociodemograficas y clinicas, y se evaluo la calidad de vida mediante el cuestionario general EuroQoL-5D (EQ-5D) y el especifico disenado en la fase anterior (25 items). Se analizaron la factibilidad, fiabilidad y validez (de constructo, convergente y longitudinal). Resultados: En la fase de desarrollo se obtuvo un cuestionario piloto de 51 items, que se redujeron a 25 en la fase de validacion; lo completaron correctamente 126 pacientes. El tiempo medio de respuesta fue de 12 min. La validez de constructo redujo el cuestionario a 20 items (CVE-20) con 4 dimensiones: emocional, fisica general, fisica rectal y social. La fiabilidad fue alta para la puntuacion global (alfa de Cronbach = 0,87), siendo para las diferentes dimensiones de 0,79; 0,73; 0,75, y 0,60, respectivamente. Las puntuaciones del CVE-20 se relacionaron con los cambios en el EQ-5D. La fiabilidad test-retest fue buena, con un coeficiente de correlacion intraclase de 0,89 (extremos: 0,80-0,88 en las diferentes dimensiones). La diferencia minima clinicamente importante fue de 17 puntos (intervalo de confianza del 95%,11-23). La validez de constructo demostro una correlacion elevada entre el CVE-20 y la gravedad del estrenimiento. Conclusiones: El CVE-20 es el primer cuestionario especifico en castellano para pacientes con estrenimiento; es valido, fiable, sensible a los cambios y cumple con los criterios psicometricos requeridos para la utilizacion en la practica diaria y estudios clinicos.

3335 Conscious sedation during upper gastrointestinal endoscopy reduces the fear of a new gastroscopy.

Introduction: There is a growing controversy regarding whether or not there is a need to use sedation in order to carry out an upper gastrointestinal endoscopy (UGE). One of the features a diagnostic test must have is acceptability to the patient, for which purpose the anxiety levels in contemplation of the carrying out of the test must be low. Objetives: To evaluate the fears of the patient facing an UGE. To determine whether the use or not of conscious sedation has any influence on the above mentioned fears. Patients and Methods: A prospective study, including 123 patients who were to have an UGE with sedation on an outpatient basis: 41 without a previous UGE -30 male, 11 female; average age 48.9 ± 16.6 years-; 32 with previous outpatient UGE without sedation (as use to be done in Spain) -21 male, 11 female; average age 50.5 ± 15.1 years- and 50 with previous UGE with conscious sedation with midazolam -31 male, 19 female; average age 51.3 ± 14.2 years-. There were no differences between the patients in the three groups regarding the educational level, pre-existing illnesses, alcohol or sedative drugs use. All the patients were administered a questionnaire previous to the endoscopy, evaluating by means of a numerical scale the presence of fear to feel pain, nausea-vomiting, the sensation of lack of air and fear of the diagnosis. Results: 87.5% of the patients with previous UGE without sedation and 82.9% of the patients without previous UGE presented with some fear, as against 12.5% of the patients with previos UGE with sedation (p

3336 A previous interview with a nurse will enable a proper selection to be made of patients for selective sedation in upper gastrointestinal endoscopies.

Introduction: It has been shown that some patients can tolerate an upper gastrointestinal endoscopy (UGE) well without sedation, but there is no agreement about an effective method of selection of the patients. Objective: To compare the effectiveness (tolerance and acceptance) of three systems for the selection of patients for sedation in gastroscopy: systematic sedation, selective sedation after interview and no sedation -the customary method in Spain. Patients and methods: Prospective stud, with 75 patients who were due to undergo an UGE on an outpatient basis. In the universally sedated group (n=26) all the patients were sedated; in the selective sedated group (n=26) a nurse with experience in endoscopy gave information to the patient, who decide whether to use sedation or not; finally a control group of patients who were not offered sedation was included (n=23). Prior to sedation a numer of control variables were taken. There were no differences between the groups as regards sex, age, smoking, alcohol intake, use of axiety reducing drugs, previosu illnesses and anxiety prior to the test. Patients with previous endoscopies were excluded. The sedation was done with midazolam adjusted to the weight and age of the patient. One month after the endoscopy a telephone interview was carried out. Tolerance was assessed by means of a combined numerical scale (values 0 to 26) of different items and acceptance by means of an ordinal scale (0 to 4). Results: There were no differences with the tolerance between the groups with universal sedation (average score 6 ± 1.5) and selective sedation (7 ± 3). There were differences between these two groups and the group of unsedated patients (11.5 ±3, p