Yu-Hsi Hsieh

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.

A patient-blinded randomized, controlled trial comparing air insufflation, water immersion, and water exchange during minimally sedated colonoscopy.

OBJECTIVES:Minimal sedation obviates patient recovery burdens, but intolerable pain limits success of cecal intubation. Painless or minimally uncomfortable insertion ensures success of cecal intubation, current patient satisfaction, and willingness to repeat future colonoscopy with minimal sedation. Water immersion (WI) and water exchange (WE), when separately compared with air insufflation (AI), significantly reduced insertion pain. To assess comparative effectiveness, we conducted a randomized controlled trial with head-to-head comparison of these three methods. We hypothesized that WE could produce the highest proportion of patients reporting painless insertion.METHODS:This prospective patient-blinded trial (NCT01535326) enrolled minimally sedated (25 mg intramuscular meperidine) patients randomized to AI, WI, or WE (90 patients/group) to aid insertion. The previously validated primary outcome was the proportion of patients reporting painless insertion.RESULTS:Painless insertion was reported by 30.0% (AI), 43.3% (WI), and 61.1% (WE) of patients (P<0.001). Multivariate logistic regression analysis revealed that, after adjusting for gender, body mass index, abdominal compression, position change, insertion time to cecum, and length of scope at cecum, only WE was significantly associated with painless insertion compared with AI (odds ratio (OR)=0.08, 95% confidence interval (CI)=0.03–0.24, P<0.001) or WI (OR=0.14, 95% CI=0.05–0.40, P<0.001). Adenoma detection rate (ADR) in the right (cecum and ascending) colon was 11.1% (AI), 14.4% (WI), and 26.7% (WE) (P=0.015). The limitations included single site study with unblinded colonoscopist and assistant.CONCLUSIONS:This head-to-head comparison of AI vs. WI vs. WE confirmed that WE was superior to WI and AI, with a significantly greater proportion of patients reporting painless insertion. The significantly higher ADR in the right colon in the WE group warrants further investigations.

The risk for bacterial endocarditis in cirrhotic patients: a population-based 3-year follow-up study

BACKGROUND We noted only rare reports of cirrhotic patients with bacterial endocarditis (BE). There is insufficient data on the risk of BE in liver cirrhosis. This is the first national population-based study evaluating the risk of BE in cirrhotic patients. METHODS We used the National Health Insurance Database, which is derived from the Taiwan National Health Insurance Program. The study cohort comprised 40803 patients with cirrhosis and the comparison cohort consisted of 40841 randomly selected subjects with a similar age and sex distribution. RESULTS Of the total 81644 patients, 192 (0.24%) experienced BE during the 3-year follow-up period, 121 patients from the study cohort (0.30% of the cirrhotic patients) and 71 patients from the comparison group (0.17% of non-cirrhotic patients) (p<0.001). After adjusting for patient age, sex, and comorbid disorders, the Cox regression analysis showed that cirrhotic patients had a high risk of BE compared to non-cirrhotic patients during the 3-year follow-up period (hazard ratio 2.04, 95% confidence interval 1.61-2.44, p<0.001). CONCLUSION We conclude that liver cirrhosis is a risk factor for the occurrence of BE.

High mortality of pneumonia in cirrhotic patients with ascites

BackgroundCirrhotic patients with ascites are prone to develop various infectious diseases. This study aimed to evaluate the occurrence and effect of major infectious diseases on the mortality of cirrhotic patients with ascites.MethodsWe reviewed de-identified patient data from the National Health Insurance Database, derived from the Taiwan National Health Insurance Program, to enroll 4,576 cirrhotic patients with ascites, who were discharged from Taiwan hospitals between January 1, 2004 and June 30, 2004. We collected patients’ demographic and clinical data, and reviewed diagnostic codes to determine infectious diseases and comorbid disorders of their hospitalizations. Patients were divided into an infection group and non-infection group and hazard ratios (HR) were determined for specific infectious diseases.ResultsOf the total 4,576 cirrhotic patients with ascites, 1,294 (28.2%) were diagnosed with infectious diseases during hospitalization. The major infectious diseases were spontaneous bacterial peritonitis (SBP) (645, 49.8%), urinary tract infection (151, 11.7%), and pneumonia (100, 7.7%). After adjusting for patients’ age, gender, and other comorbid disorders, the HRs of infectious diseases for 30-day and 90-day mortality of cirrhotic patients with ascites were 1.81 (1.54-2.11) and 1.60 (1.43-1.80) respectively, compared to those in the non-infection group. The adjusted HRs of pneumonia, urinary tract infection (UTI), spontaneous bacterial peritonitis (SBP), and sepsis without specific focus (SWSF) were 2.95 (2.05-4.25), 1.32 (0.86-2.05), 1.77 (1.45-2.17), and 2.19 (1.62-2.96) for 30-day mortality, and 2.57 (1.93-3.42), 1.36 (1.01-1.82), 1.51 (1.29-1.75), and 2.13 (1.70-2.66) for 90-day mortality, compared to those in the non-infection group.ConclusionInfectious diseases increased 30-day and 90-day mortality of cirrhotic patients with ascites. Among all infectious diseases identified, pneumonia carried the highest risk for mortality.

Bowel Preparation: Is Endoscopic Administration Worth the Extra Risk?

Bowel preparation before colonoscopy is usually considered worse than the actual procedure. The regimen usually consists of the intake of a large amount of fluid (2–4 L) with an unpalatable taste and smell, which might lead to nausea, vomiting, bloating, and abdominal pain in addition to the required diarrhea. In a meta-analysis comparing the effectiveness of different bowel preparation agents, about 29 % of the subjects were unable to ingest the full volume of polyethylene glycol (PEG) solution [1]. Incomplete consumption of the solution usually affects the quality of bowel cleansing, increasing the probability that the procedure will be aborted and then repeated. One of the conventional ways to overcome the barrier of ingesting a large amount of an unpalatable solution is to instill it directly into the stomach with the use of a nasogastric (NG) tube. Nevertheless, shortcomings including subjects’ discomfort, nasopharyngeal trauma, tube misplacement, and pulmonary aspiration have precluded its general use. It is now used only for subjects with dysphagia or with difficulty of ingesting large volume of fluids. Delivering cathartic solutions such as PEG via an esophagogastroduodenoscope into the duodenum is a novel approach to bowel preparation. Although it is impractical to perform esophagogastroduodenoscopy (EGD) just for the sake of infusing bowel preparation regimen, same-day EGD and colonoscopy (bidirectional endoscopy) are commonly performed for the evaluation of gastrointestinal conditions, such as active gastrointestinal bleeding, iron deficiency anemia, positive fecal occult blood test, and abdominal pain. In addition to these indications, asymptomatic subjects undergo bidirectional endoscopy in the course of routine healthcare evaluation or for cancer screening. A recent US study based on a national endoscopic database showed that over 11 % of subjects had received same-day bidirectional endoscopy [2]. Of the procedures, EGD is usually performed before colonoscopy due to its superior tolerability and the lower dose of sedatives needed [3]. Now, we have another reason to perform EGD before colonoscopy—to deliver the bowel preparation regimen. In this issue of Digestive Diseases and Sciences, Jung et al. [4] evaluated the EGD-assisted administration of bowel purgative for colonoscopy. They reported that subjects who received intraduodenal PEG perfusion suffered less nausea and vomiting, felt more comfortable, and were more willing to repeat the bowel preparation method in the future than the subjects receiving oral PEG solutions. The efficacy, as judged by the Aronchick and Ottawa Scales, was comparable between the two groups. The intraduodenal method appeared safe, although more subjects who received intraduodenal PEG reported dizziness. Their findings are consistent with those reported in a non-randomized study by Maeng et al. [5] and in a randomized study by Barcley et al. [6]. Y.-H. Hsieh (&) Division of Gastroenterology, Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, 2 Minsheng Road, Dalin, Chiayi 62247, Taiwan e-mail: hsieh.yuhsi@msa.hinet.net

Effect of renal function impairment on the mortality of cirrhotic patients with hepatic encephalopathy: a population-based 3-year follow-up study.

AbstractKidney is an important organ to clear neurotoxic substance in circulation. However, it is still unknown about the effect of renal function impairment (RFI) on the mortality of cirrhotic patients with hepatic encephalopathy (HE). We used the Taiwan National Health Insurance Database to identify 4932 cirrhotic patients with HE, hospitalized between January 1, 2007 and December 31, 2007. The enrolled patients were followed up individually for 3 years to identify their 3-year mortalities. There were 411 (8.3%) patients with RFI and 4521 (91.7%) patients without RFI. The adjusted hazard ratio (HR) of RFI for 3-year mortality was 2.03 (95% CI, 1.82–2.27). In RFI group, there were 157 (38.2%) patients with acute renal failure (ARF), 61 (14.8%) with hepatorenal syndrome (HRS), 93 (22.6%) with chronic kidney disease (CKD), and 100 (24.3%) with end-stage renal disease (ESRD). Compared with the non-RFI group, the adjusted HR of ARF for 3-year mortality was 2.57 (95% CI, 2.17–3.06), CKD 1.93 (95% CI, 1.55–2.40), ESRD 1.26 (95% CI, 1.01–1.57), and HRS 3.58 (95% CI, 2.78–4.63). Among ESRD patients, there were 99 patients receiving hemodialysis regularly. Compared with the CKD group, the adjusted HR of ESRD with hemodialysis for 3-year mortality was 0.664 (95% CI, 0.466–0.945). RFI increased the 3-year mortality of cirrhotic patients with HE, especially ARF and HRS. HE patients with ESRD receiving hemodialysis had better 3-year survival rate than those with CKD.

No difference in mortality between terlipressin and somatostatin treatments in cirrhotic patients with esophageal variceal bleeding and renal functional impairment.

Objective To study the differences in mortality between terlipressin and somatostatin treatments in cirrhotic patients with esophageal variceal bleeding (EVB) and renal functional impairment (RFI). Methods The National Health Insurance Database, part of the Taiwan National Health Insurance Program, was used to enroll cirrhotic patients who had received endoscopic variceal ligation plus somatostatin or terlipressin for EVB and who were hospitalized between 1 January 2007 and 31 December 2010. The differences in mortality between the two vasoactive agents were compared and the risk factors for 30-day mortality because of EVB were identified. Results A total of 2324 cirrhotic patients with EVB were enrolled. The 30-day mortality data showed no significant differences between the somatostatin and the terlipressin groups (P=0.232). The risk of 30-day mortality was significantly higher in male patients [hazard ratio (HR): 1.50, P=0.002] and patients with hepatic encephalopathy (HR: 1.82, P<0.001), ascites (HR: 1.32, P=0.008), bacterial infections (HR: 2.10, P<0.001), hepatocellular carcinoma (HR: 2.09, P<0.001), and RFI (HR: 3.89, P<0.001). A subgroup analysis of cirrhotic patients with RFI was carried out. The overall 30-day mortality was higher in patients treated with somatostatin than in those treated with terlipressin (52.6 vs. 42.3%), but the difference failed to reach significance (adjust HR: 1.49, 95% confidence interval: 0.94–2.37, P=0.091). Conclusion RFI was the most important risk factor for 30-day mortality in EVB patients. Terlipressin and somatostatin had similar effects on 30-day mortality in cirrhotic patients with EVB and RFI.

The Effect of the First Spontaneous Bacterial Peritonitis Event on the Mortality of Cirrhotic Patients with Ascites: A Nationwide Population-Based Study in Taiwan

Background/Aims Spontaneous bacterial peritonitis (SBP) contributes to poorer short-term mortality in cirrhotic patients with ascites. However, it is unknown how long the effect of the first SBP event persists in these patients. Methods The National Health Insurance Database, derived from the Taiwan National Health Insurance Program, was used to identify and enroll 7,892 cirrhotic patients with ascites who were hospitalized between January 1 and December 31, 2007. All patients were free from episodes of SBP from 1996 to 2006. Results The study included 1,176 patients with SBP. The overall 30-day, 90-day, 1-year, and 3-year mortality rates in this group were 21.8%, 38.9%, 57.5%, and 73.4%, respectively. The overall 30-day, 90-day, 1-year, and 3-year mortality rates in the non-SBP group were 15.7%, 32.5%, 53.3%, and 72.5%, respectively. After adjusting for gender, age, and other medical comorbidities, the adjusted hazard ratios of SBP for 30-day, 30- to 90-day, 90-day to 1-year, and 1- to 3-year mortality were 1.49 (95% confidence interval [CI], 1.30 to 1.71), 1.19 (95% CI, 1.02 to 1.38), 1.04 (95% CI, 0.90 to 1.20), and 0.90 (95% CI, 0.77 to 1.05), respectively, compared with the non-SBP group. Conclusions The effect of SBP on the mortality of cirrhotic patients with ascites disappeared in those surviving more than 90 days after the first SBP event.

Meperidine for patients expected to have poor tolerance to esophagogastroduodenoscopy: A double-blind, randomized, controlled study

Background Anxious patients and those with poor tolerance to previous esophagogastroduodenoscopy (EGD) usually have poor tolerance for EGD. Aims To investigate the effect of meperidine on these patients during EGD. Methods A total of 110 patients undergoing diagnostic EGD were randomized to receive either meperidine (n = 55) or placebo (n = 55) before EGD. The primary outcome was patient discomfort scores during esophageal intubation. Results Patients in the meperidine group reported less discomfort during esophageal intubation (median score of 5.0 and interquartile range (IQR) 1.5–7.0) compared with the control (median score of 6.0, IQR 5.0–8.5, P = .003). Patients in the meperidine group had better tolerance during the procedure (median score of 2 (IQR 1.0–3.0) versus 3 (IQR 1.0–4.0), P = .048), and the endoscopists reported higher overall satisfaction scores (median score of 9 (IQR 7.0–9.0) versus 8 (IQR 7.0–9.0), P = .043). There was significantly less increase in heart rate and blood pressure during the procedure in the meperidine group than in the placebo group (23 bpm (IQR 9–32) versus 30 bpm (IQR 18–52); P = .006); (7 mmHg (IQR 1–14) versus 18 mmHg (IQR 2–30); P = .008). Connect-the-numbers test showed comparable results before and after EGD between the two groups. Conclusion For patients expected to have poor tolerance during EGD, meperidine reduced discomfort, decreased cardiovascular distress, and improved endoscopist satisfaction, without adverse effects on their psychomotor function after the procedure.

Increase your adenoma detection rate without using fancy adjunct tools

The correlation between a low adenoma detection rate (ADR) and interval cancers (ICs) has made ADR one of the most important quality indicators for colonoscopy. Data from nation-wide colorectal cancer (CRC) screening programs showed that there is room for improvement in ADR in order to reduce ICs in Taiwan. Measures with and without adjunct tools have been shown to have the potential to increase ADR, with the latter being more convenient to apply without additional cost. Optimal withdrawal techniques coupled with sufficient withdrawal time, training endoscopists with emphasis on recognition of subtle characteristics of flat lesions, dynamic position changes during the withdrawal phase, removing small polyps found during insertion, and retroflexion in the right colon have all been associated with increased ADR. In particular, water exchange (WE), which is characterized using water in lieu of air and suction removal of infused water during insertion, appears to meet the needs of colonoscopy patients in Taiwan. Analyses of both primary and secondary outcome variables of recently published studies have consistently shown that WE yields higher ADR than traditional air insufflation, even in propofol-sedated patients. Colonoscopists participating in the nationwide CRC screening program in Taiwan should consider applying one or more of the above measures to improve ADR and hopefully reduce ICs.