Silvia Paggi

Water-aided colonoscopy: a systematic review

BACKGROUND Water-aided methods for colonoscopy are distinguished by the timing of removal of infused water, predominantly during withdrawal (water immersion) or during insertion (water exchange). OBJECTIVE To discuss the impact of these approaches on colonoscopy pain and adenoma detection rate (ADR). DESIGN Systematic review. SETTING Randomized, controlled trial (RCT) that compared water-aided methods and air insufflation during colonoscope insertion. PATIENTS Patients undergoing colonoscopy. INTERVENTION Medline, PubMed, and Google searches (January 2008-December 2011) and personal communications of manuscripts in press were considered to identify appropriate RCTs. MAIN OUTCOME MEASUREMENTS Pain during colonoscopy and ADR. RCTs were grouped according to whether water immersion or water exchange was used. Reported pain scores and ADR were tabulated based on group assignment. RESULTS Pain during colonoscopy is significantly reduced by both water immersion and water exchange compared with traditional air insufflation. The reduction in pain scores was qualitatively greater with water exchange as compared with water immersion. A mixed pattern of increases and decreases in ADR was observed with water immersion. A higher ADR, especially proximal to the splenic flexure, was obtained when water exchange was implemented. LIMITATIONS Differences in the reports limit application of meta-analysis. The inability to blind the colonoscopists exposed the observations to uncertain bias. CONCLUSION Compared with air insufflation, both water immersion and water exchange significantly reduce colonoscopy pain. Water exchange may be superior to water immersion in minimizing colonoscopy discomfort and in increasing ADR. A head-to-head comparison of these 3 approaches is required.

The Impact of Narrow Band Imaging in Screening Colonoscopy: A Randomized Controlled Trial

BACKGROUND & AIMS Narrow band imaging (NBI) is an imaging technique that allows a better definition of capillary pattern and improves the contrast between adenomas and the surrounding mucosa. Conflicting data exist on the ability of NBI to improve detection of colonic neoplasm; the impact of NBI is being tested in several screening scenarios. We evaluated whether the routine use of NBI, compared with white light (WL), during the withdrawal phase of screening colonoscopy improved adenoma detection. METHODS This randomized controlled study included consecutive 50- to 69-year-old patients with positive immunologic fecal occult blood tests. They were randomly assigned to groups that were examined with WL (n = 108) or NBI (n = 103) during the withdrawal phase of their colonoscopies. The primary end point was the adenoma detection rate. The prevalence of non-polypoid and the total number of adenomas were also evaluated. RESULTS The number of total and mean per-patient adenomas were 201 (1.95 +/- 2.3) and 198 (1.83 +/- 2.1) in the NBI and WL groups, respectively (P = .69). The adenoma detection rates were 57.3% for patients examined by NBI and 58.3% for those examined by WL (P = .88). A total of 41 non-polypoid adenomas were identified (26 in the NBI and 15 in the WL groups, P = .16). The flat adenoma detection rates were 21.4% and 9.3% in the NBI and WL groups, respectively (P = .019). CONCLUSIONS The routine use of NBI in screening colonoscopy did not increase the adenoma detection rate. NBI seems to improve the detection of flat adenomas, although additional studies are necessary.

Warm water infusion versus air insufflation for unsedated colonoscopy: a randomized, controlled trial.

BACKGROUND Uncontrolled data suggest that warm water infusion (WWI) instead of air insufflation (AI) during the insertion phase of unsedated colonoscopy improves patient tolerance and satisfaction. OBJECTIVE We tested the hypothesis that water could increase the proportion of patients able to complete unsedated colonoscopy and improve patient tolerance compared with the conventional procedure. DESIGN Randomized, controlled trial. SETTING Single center, community hospital. PATIENTS Consecutive outpatients agreeing to start colonoscopy without premedication. METHODS Patients were randomly assigned to either WWI or AI insertion phase of colonoscopy. Sedation and/or analgesia were administered on patient request if significant pain or discomfort occurred. MAIN OUTCOME MEASUREMENTS Percentage of patients requiring sedation/analgesia. Pain and tolerance scores were assessed at discharge by using a 100-mm visual analog scale. RESULTS A total of 230 subjects (116 in the WWI group and 114 in the AI group) were enrolled. Intention-to-treat analysis showed that the proportion of patients requesting sedation/analgesia during the procedure (main outcome measurement) was 12.9% in the WWI group and 21.9% in AI group (P = .07). Cecal intubation rates were 94% in the WWI group and 95.6% in the AI group (P = .57). Median (interquartile range) scores for pain were 28 (12-44) and 39 (14-54) in WWI and AI groups, respectively (P = .05); corresponding figures for tolerance were 10 (3-18) and 14 (5-42), respectively (P = .01). The adenoma detection rates were 25% and 40.1% for the WWI and AI groups, respectively (P = .013). LIMITATIONS Single-center study, endoscopists not blinded to randomization. CONCLUSIONS WWI instead of AI is not associated with a statistically significant decrease in the number of patients requiring on-demand sedation, although it significantly improves the overall patient tolerance of colonoscopy. The finding of a lower adenoma detection rate in the WWI group calls for further evaluations. ( CLINICAL TRIAL REGISTRATION NUMBER NCT00905554).

Dual cut-off transient elastography to assess liver fibrosis in chronic hepatitis B: a cohort study with internal validation.

Aliment Pharmacol Ther 2011; 34: 353–362

Constipation in the Elderly

Constipation is a highly prevalent and bothersome disorder that negatively affects patients’ social and professional lives and places a great economic burden on both patients and national health services. An accurate determination of the prevalence of constipation is difficult because of the various definitions used, but many epidemiological studies have shown that it affects up to 20% of the population at any one time. Although constipation is not a physiological consequence of normal aging, decreased mobility and other co-morbid medical conditions may contribute to its prevalence in older adults. Functional constipation is diagnosed when no secondary causes can be identified.Patients have some unusual beliefs about their bowel habits. Systematic attention to history, examination and investigation, especially in older people, can be highly effective in resolving problems and in enhancing quality of life.There is a considerable range of treatment modalities available for patients with constipation, but the clinical evidence supporting their use varies widely. However, if constipation is not managed proactively, patients can experience negative consequences, such as anorexia, nausea, bowel impaction or bowel perforation.The clinical benefits of various traditional pharmacological and non-pharmacological agents remain unclear. The first steps in the treatment of simple constipation include increasing intake of dietary fibre and the use of a fibre supplement. Patients with severe constipation or those unable to comply with the recommended intake of fibre may benefit from the addition of laxatives. More recently, newer agents (e.g. tegaserod and lubiprostone), have been approved for the treatment of patients with chronic constipation. Additional work is needed to determine what role, if any, these agents may play in the treatment of patients with chronic constipation.The purpose of this review is to identify evidence-based interventions for the prevention and management of constipation in the elderly.

Accuracy of narrow-band imaging in predicting colonoscopy surveillance intervals and histology of distal diminutive polyps: results from a multicenter, prospective trial

BACKGROUND In vivo prediction of colorectal polyp histology by narrow-band imaging (NBI) could potentially avoid post-polypectomy histologic examination or resection of diminutive lesions, thereby reducing costs and risk. OBJECTIVE To assess whether NBI is able to predict colonoscopy surveillance intervals and histology of distal diminutive polyps according to American Society for Gastrointestinal Endoscopy (ASGE) criteria. DESIGN Prospective, multicenter study. SETTING Five endoscopic centers. PATIENTS Consecutive patients undergoing colonoscopy in 5 centers were included. INTERVENTION Participating endoscopists were required to pass a before-study qualifying examination. Histology of polyps that were <10 mm was predicted at NBI and assigned a designation of high or low confidence. MAIN OUTCOME MEASUREMENTS Accuracy of high-confidence NBI prediction for polyps ≤5 mm in predicting surveillance intervals and negative predictive value (NPV) for adenomatous histology in the rectosigmoid colon were compared with the ASGE thresholds (90% agreement, 90% NPV). RESULTS A total of 278 patients (mean age, 63 years; 58% male) were enrolled. At colonoscopy, 574 (97.3%) polyps <10 mm (429 ≤5 mm, 60% adenomatous) were retrieved for histologic analysis. Sensitivity, specificity, positive and negative predictive values, and accuracy of high confidence-NBI predictions for adenomatous histology in lesions ≤5 mm were 90%, 88%, 89%, 89%, and 89%, respectively. High-confidence characterization of polyps ≤5 mm predicted the correct surveillance interval in 92% to 99% of cases, according to the American and European guidelines. NPV of high-confidence NBI for adenomatous histology for the rectosigmoid colon lesions ≤5 mm was 92%. LIMITATIONS Only experienced endoscopists were included. CONCLUSION High-confidence prediction of histology for polyps ≤5 mm appears to be sufficiently accurate to avoid post-polypectomy histologic examination of the resected lesions as well as to allow rectosigmoid hyperplastic polyps to be left in place without resection. ( CLINICAL TRIAL REGISTRATION NUMBER NCT01675752.).

Transient elastography assessment of the liver stiffness dynamics during acute hepatitis B

Background and aims The diagnostic accuracy of transient elastography (TE) for assessment of hepatic fibrosis is hampered by several factors, including acute parenchymal injury. Evaluation of liver stiffness (LS) using TE during acute hepatitis B may help to assess chronic hepatitis B patients with flares. Patients and methods Twelve patients consecutively referred for acute hepatitis B, underwent sequential examinations with TE and laboratory examinations for 24 weeks. Results On admission, aminotransferase ranged from 487 to 6067 IU/l (median=2590 IU/l) and LS ranged from 7.1 to 57 kPa (median=15.6 kPa) with nine (75%) patients showing LS greater than 11.9 kPa, that is, the predictive cutoff for cirrhosis. LS levels correlated significantly with bilirubin, only (r=0.58, P<0.05). During follow-up, LS declined from 15.6 to 5.2 kPa at week 24, with a significant reduction being observed at week 2 for aminotransferase (from 2590 to 452 IU/l, P<0.0001) and at week 6 for both LS (from 15.6 to 6.0 kPa, P=0.008) and bilirubin (from 10.7 to 0.95 mg/dl, P<0.01). Median decline of LS significantly correlated with bilirubin decline (rs=0.70, P<0.05). At week 24, 10 (83%) patients showed LS of less than 7.9 kPa and two (17%) patients had LS values between 7.9 and 11.9 kPa, including the only patient who developed chronic hepatitis B. Conclusion In patients with acute hepatitis B, the initial high values of LS mimicking LS cutoff of cirrhosis, likely reflect the liver cell inflammation, oedema and swelling as they progressively taper down during hepatitis resolution.

A non-invasive algorithm accurately predicts advanced fibrosis in hepatitis C: A comparison using histology with internal–external validation

BACKGROUND/AIMS Biochemical tests and ultrasonography (US) are useful in the non-invasive assessment of liver fibrosis in patients with chronic hepatitis C (CH-C); however histology remains the reference standard. This multicenter, cross-sectional cohort study evaluated the accuracy of APRI (AST-to-platelet-ratio-index) and liver surface ultrasound nodularity (LSN), singularly and sequentially combined in an algorithm, in diagnosing advanced fibrosis (i.e. METAVIR F3,F4), to derive a prediction rule to confirm or exclude F3,F4. METHODS Four hundred and thirty consecutive CH-C patients with elevated ALT, grouped into a first cohort (training set), and an internal and an external validation cohort, were studied. APRI and LSN were compared to liver biopsy and sequentially combined in order to obtain a predictive rule for advanced fibrosis METAVIR F3,F4. RESULTS LSN was negative and APRI < or = 1 in 185/430 patients, whereas LSN was positive and APRI>2 in 46/430 cases, with a 94% diagnostic accuracy for presence/absence of F3, F4, respectively. In a further 60/430 patients, F3,F4 was detected with an accuracy of 83%. In the remaining cases no classification was possible. CONCLUSIONS An algorithm based on APRI and LSN confirms or excludes F3,F4 in 54% of CH-C patients with elevated ALT and suggests a highly probable diagnosis in a further one-sixth of patients, thus rendering liver biopsy unnecessary in these patients.

Split-dose preparation for colonoscopy increases adenoma detection rate: A randomised controlled trial in an organised screening programme

Objective Although a split regimen of bowel preparation has been associated with higher levels of bowel cleansing, it is still uncertain whether it has a favourable effect on the adenoma detection rate (ADR). The present study was aimed at evaluating whether a split regimen was superior to the traditional ‘full-dose, day-before’ regimen in terms of ADR. Design In a multicentre, randomised, endoscopist-blinded study, 50–69-year-old subjects undergoing first colonoscopy after positive-faecal immunochemical test within an organised colorectal cancer organised screening programmes were 1:1 randomised to receive low-volume 2-L polyethylene glycol (PEG)-ascorbate solution in a ‘split-dose’ (Split-Dose Group, SDG) or ‘day-before’ regimen (Day-Before Group, DBG). The primary endpoint was the proportion of subjects with at least one adenoma. Secondary endpoints were the detection rates of advanced adenomas and serrated lesions at per-patient analysis and the total number of lesions. Results 690 subjects were included in the study. At per-patient analysis, the proportion of subjects with at least one adenoma was significantly higher in the SDG than in the DBG (183/345, 53.0% vs 141/345, 40.9%, relative risk (RR) 1.22, 95% CI 1.03 to 1.46); corresponding figures for advanced adenomas were 26.4% (91/345) versus 20.0% (69/345, RR 1.35, 95% CI 1.06 to 1.73). At per-polyp analysis, the total numbers of both adenomas and advanced adenomas per subject were significantly higher in the SDG (1.15 vs 0.8, p <0.001; 0.36 vs 0.22, p<0.001). Conclusions In an organised screening setting, the adoption of a split regimen resulted into a higher detection rate of clinically relevant neoplastic lesions, thus improving the effectiveness of colonoscopy. Based on such evidence, the adoption of a split regimen for colonoscopy should be strongly recommended. Clinical trial registration number NCT02178033.

Double-balloon endoscopy in clinical practice: where are we now?

Double‐balloon endoscopy (DBE) was developed in 2000 for the diagnosis and treatment of small bowel diseases. Although use rates still differ between Eastern and Western countries, DBE quickly reached a broad global diffusion. Together with capsule endoscopy (CE), DBE represented ‘a revolution’ for the management of small bowel diseases because of its therapeutic capabilities. At present, the main indications for DBE in clinical practice are obscure gastrointestinal bleeding, Crohns disease and familial polyposis. In the setting of obscure gastrointestinal bleeding, DBE seems to have similar diagnostic performances as capsule endoscopy, but it allows for a more definitive diagnosis and the treatment of identified lesions. The main contribution of DBE in the management of Crohns disease patients is its therapeutic capabilities. Indeed, several recently published studies have suggested that endoscopic dilation of small bowel strictures can delay or, in the near future, could even replace surgical interventions. Also, for patients with familial polyposis syndromes, DBE can represent a viable alternative to small bowel surgery. The complication rate of DBE appears to be low; major complications, such as pancreatitis, bleeding and perforation, have been reported in approximately 1% of all diagnostic DBE whereas the complication rate for therapeutic procedures is about 5%.