Splenic injury from colonoscopy: a review and management guidelines

Splenic injury is an uncommon complication of colonoscopy. Less than 100 cases are reported in the English language literature. The exact mechanism of injury to the spleen during colonoscopy is unknown; various authors propose several risk factors and possible mechanisms. Splenic injury can be graded or classified according to the extent of laceration and the severity of the resultant hematoma. The management options range from observation to emergency splenectomy. Computed tomography scan is the most important imaging modality to diagnose splenic injury. Early recognition and appropriate management is of paramount importance in the management of this condition. A high index of suspicion in a patient with persistent abdominal pain after colonoscopy is key especially when a perforated viscous is ruled out. This article outlines the clinical presentation of splenic injury after colonoscopy and delineates a management algorithm.     

Venodilatation techniques to enhance venepuncture and intravenous cannulation

Venepuncture and venous cannulation are the most commonly performed invasive medical procedures in hospitalized patients. Venodilatation can facilitate these procedures and minimize discomfort for patient and practitioner alike. This article describes useful venodilatation techniques that can be employed by medical personnel.     

Surveillance after endovascular abdominal aortic aneurysm repair

(EVAR) Endovascular Aneurysm Repair of abdominal aortic aneurysms have mandated the need for surveillance imaging and other follow-up testing to minimize the complications of endograft failure and potential for abdominal aortic aneurysms rupture. The 2-dimensional and 3-dimensional contrast-enhanced computed tomography imaging currently serves as the gold standard for serial (EVAR) Endovascular Aneurysm Repair assessment, but this recommendation is being modified by successful clinical experience using duplex ultrasound, magnetic resonance imaging, and implantable wireless sac pressure sensors. Nearly all stent graft devices and abdominal aortic aneurysm-related complications after (EVAR) Endovascular Aneurysm Repair can be detected using available surveillance modalities assuming a compliant patient during follow-up. Alternating complementary surveillance techniques (contrast and noncontrast computed tomography, ultrasound, and pressure measures) can be used to reduce contrast dye and radiation exposure and can be tailored to patients with chronic renal insufficiency.     

Colonoscopic perforation: its emergency treatment.

One of the accepted complications of colonoscopy is perforation. This is known to occur in greater frequency in patients having undergone previous pelvic or colonic surgery, as well as patients suffering from diverticulosis. A case is presented of colonic perforation during diagnostic examination in an area of adhesions secondary to pelvic surgery. Immediately after the perforation, the patient entered into vascular collapse and respiratory distress, with a distended abdomen. The introduction of a large bore intravenous catheter into the abdominal cavity with the release of the pneumoperitoneum resulted in an instantaneous return of vital signs and the patient subsequently underwent surgery and recovered. It is felt that this method of emergency treatment can be life-saving in a patient perforating during colonoscopy.     

Use of a variable-stiffness colonoscope allows completion of colonoscopy after failure with the standard adult colonoscope

BACKGROUND AND STUDY AIMS: Experts fail to reach the cecum in 2 - 10% of colonoscopies. The purpose of this case series was to evaluate the efficacy of a small-caliber, variable-stiffness colonoscope in patients with incomplete colonoscopy. PATIENTS AND METHODS: The variable-stiffness colonoscope (Olympus America XPCF-140AL) was used by the same examiner to reattempt colonoscopy immediately in all patients in whom colonoscopy to the cecum with the standard colonoscope was incomplete. RESULTS: Sixteen of 385 attempted colonoscopies (4.2%) did not reach the cecum with the standard colonoscope due to looping (n = 12), fixed angulation of the sigmoid colon (n = 3), and diverticulosis (n = 1). The procedures were deemed a failure after a mean of 28 min, despite the use of abdominal pressure and positional change in all patients. Fifteen of the 16 patients (94 %) had a complete colonoscopy with the variable-stiffness colonoscope. One patient had an incomplete colonoscopy with the variable-stiffness colonoscope due to an obstructing mass in the transverse colon that was not reached by the standard colonoscope. With the variable-stiffness colonoscope, the mean time to cecal intubation was 10.3 min; four patients (25 %) required a change in patient position, and six patients (37.5 %) required abdominal pressure. CONCLUSIONS: A variable-stiffness colonoscope allowed completion of colonoscopy in all patients without obstruction who had an incomplete colonoscopy with the standard colonoscope. Further study is needed to determine whether the variable-stiffness colonoscope should be used routinely for colonoscopy.     

The water method significantly enhances patient-centered outcomes in sedated and unsedated colonoscopy

Failure of cecal intubation when using air insufflation during scheduled unsedated colonoscopy in veterans prompted a literature search for a less uncomfortable approach. Water-related maneuvers as "adjuncts" to air insufflation were identified as effective in minimizing discomfort, although medication requirement was not reduced and willingness to repeat unsedated colonoscopy was not addressed. These adjunct maneuvers were combined with turning the air pump off to avoid colon elongation during insertion. Warm water infusion in lieu of air insufflation was evaluated in observational studies. Subsequent refinements evolved into the water method - a combination of air exclusion by aspiration of residual air to minimize angulations at flexures and a dynamic process of water exchange to remove feces in order to clear the view and aid insertion. In subsequent randomized controlled trials, the water method significantly reduced medication requirement, increased the proportion of patients in whom complete unsedated colonoscopy could be achieved, reduced patient recovery time burdens (sedation on demand), decreased abdominal discomfort during and after colonoscopy, enhanced cecal intubation, and increased willingness to repeat the procedure (scheduled unsedated). Supervised education of trainees and self-learning by an experienced colonoscopist were feasible. Lessons learned in developing the water method for optimizing patient-centered outcomes are presented. These proof-of-principle observations merit further research assessment in diverse settings.     

Perioperative assessment of the obstetric patient undergoing abdominal surgery.

Care of the obstetric patient undergoing nonobstetric surgery can be challenging. Approximately 1 in 500 pregnancies is complicated by a nonobstetric surgical condition. To adequately care for the mother and fetus, the nurse must know the physiological changes that occur during pregnancy, and make an aggressive attempt to maintain those changes. This article reviews common reasons for abdominal surgery during pregnancy, the physiological changes that occur during pregnancy, techniques to maintain those responses, and discusses issues related to fetal monitoring and postoperative care.     

Trucs et astuces à utiliser pour les difficultés liées à la localisation

During the endoscopic resection of a difficult polyp, after accessing the lesion, it is necessary to position so as to have an optimal use and thus more safe of instruments. Using basic techniques enables complete colonoscopy in more than 90% of cases. The most important technique is to reduce loops to facilitate the progress and the resection. There are different types of loops whose reduction requires a specific maneuver. The different loops have been studied by X-ray equipment and to the devices giving a representation of the endoscope in the space. Mobilizing the patient can facilitate the progression or visualization of the mucosa. The abdominal pressure can be a valuable aid to reach the cæcum. Using overtubes, endoscopes with variable stiffness or double-balloon endoscopes can compensate for failures of standard colonoscopy. Once reaches, before resection, it is necessary to try to position the polyp at 6 o’clock by applying a rotation to the endoscope. This operation is easier with an unbuckled endoscope. The retrovision may facilitate the exposure of a polyp near the anus, behind a big fold or behind the caecal valve. Large polyps are removed from the withdrawal with an unloop endoscope and to avoid resect a polyp near a cancer. Using these techniques allows easier access to lesions, better positioning and therefore resection in safer conditions can be achieved.     

肠镜检查中的护理配合技巧

完成全结肠检查是准确诊断结肠病变的必要条件,肠镜检查中护理配合对于完成全结肠观察至关重要。本文针对肠镜检查时护理配合技巧作一归纳总结,包括双人肠镜检查时的插镜技巧,以及肠镜检查时体位调整和腹部按压对于顺利插镜的价值。无论双人插镜法还是单人插镜法,医护之间密切配合有助于提高检查效率,完成全结肠检查。     

A novel system for the improvement of colonic cleansing during colonoscopy

Suboptimal bowel cleansing prior to colonoscopy impairs the efficacy and safety of the procedure. A new system for intracolonic cleansing has been developed, which includes a disposable catheter device that is inserted through the working channel of a standard colonoscope and an irrigation unit with predefined pressure and flow rate. The aim of the current study was to assess the safety and efficacy of this novel system for the improvement of bowel cleansing during colonoscopy. A total of 42 patients with suboptimal bowel preparation were systematically allocated, in a 1:1 ratio, to either the study group (JetPrep system, n = 21) or the control group (syringe irrigation, n = 21). The cleansing efficacy was evaluated using a segmental scoring scale to rate the bowel preparation level before and after irrigation. One patient from the study group was excluded from the efficacy analysis due to treatment with both techniques. The JetPrep system was significantly superior to syringe irrigation (P = 0.0001). No adverse events were reported. This study suggests that the safety profile of the JetPrep system is comparable to standard irrigation and shows that the device significantly improves suboptimal bowel preparation.     

温水灌注法在困难结肠镜检查中的应用研究

目的研究温水灌注法对困难结肠镜检查中的成功率、插镜时间、操作难易度及患者耐受度等方面的影响。方法非麻醉结肠镜检查的排便困难、肠易激综合征(IBS)和既往有盆腔/腹部手术史患者200例,随机分为温水灌注组(实验组)和传统注气法组(对照组),比较两组患者插镜成功率、插镜时间及患者耐受程度等方面的差异。结果 200例患者完成实验,均未发生肠穿孔等并发症。实验组的全结肠检查成功率、达盲时间、操作者满意度和再检意愿均明显高于对照组(P0.05)。在腹部按压和体位变换使用率、腹痛评分方面,实验组明显低于对照组(P0.05)。两组息肉检出率差异无统计学意义(P0.05)。结论温水灌注肠镜能有效提高困难肠镜的患者耐受度、加快插管进程,提高工作效率,是一种理想的进镜法,值得推广。     

Traces: making sense of urodynamics testing--part 7: Evaluation of bladder filling/storage: Evaluation of urethral sphincter incompetence and stress urinary incontinence

The "Traces" series discusses how the urodynamic clinician generates usable data from a filling cystometrogram. Part 7 focuses on the question, "Is the urethral sphincter mechanism competent?" From a practical viewpoint, this question can be divided into two queries: 1) does this patient have observable urodynamic stress urinary incontinence (SUI), and 2) does this patient have intrinsic urethral sphincter incompetence, also referred to as intrinsic sphincter deficiency or a low pressure urethra? Signs of SUI include clinician observation of urine loss with coughing or during Valsalva's maneuver. Urodynamic SUI is the observation of urine loss with increased abdominal and intravesical pressures in the absence of a detrusor contraction. The most commonly used techniques for assessment of urethral sphincter function and SUI are the urethral pressure profile and the abdominal leak point pressure. Both are useful for answering these queries, but both tests are vulnerable to physiologic and technical artifacts that must be minimized to produce technically accurate and clinically meaningful results.     

Bilateral tension pneumothoraces and subcutaneous emphysema following colonoscopic polypectomy: a case report and discussion of anesthesia considerations

A 78-year-old man presented preoperatively with severe abdominal pain, dyspnea, and subcutaneous emphysema in his face, neck, and chest approximately 8 hours after colonoscopy with a sigmoid polypectomy. A pneumoperitoneum, free air in the mesentery, pneumoretroperitoneum, pneumomediastinum, and bilateral pneumothoraces were diagnosed using radiography and computed axial tomography. He emergently underwent an exploratory laparotomy with colostomy following bilateral chest tube placement. At laparotomy, a perforation of the posterior sigmoid colon was identified at the site of earlier polypectomy. The patient remained intubated and mechanically ventilated for 3 days postoperatively. Perforations of the colon during colonoscopies are the most serious complication of the procedure. Continued insufflation of air or carbon dioxide into a perforated colon can result in extraluminal gas that can result in life-threatening tension pneumothoraces. This case examines the consequences of colonic perforation and the anesthetic management for the definitive surgical treatment of a posterior sigmoid wall perforation. Anesthesia providers' awareness of the risk factors for colonic perforation due to colonoscopy, early signs and symptoms of perforation, and knowledge of the surgical and anesthetic management of perforation could lead to early recognition and intervention and likely to improved patient outcomes.     

A nursing approach to the equine standing surgical patient

Abstract

Veterinary literature has shown increasing interest in the development of surgical techniques on the standing horse to avoid the risks of general anaesthesia. The diverse, often complex and lengthy procedures now possible present their own risks to both patient and staff, particularly if the patient becomes anxious. Sedated equines can still react unpredictably, but Veterinary Nurses with an understanding of equine behaviour and perception can use their skills to minimise stress and discomfort in their patients to reduce the risks further. This article discusses how physiological knowledge combined with patient observation in practice can improve patient welfare and personnel safety during standing procedures.     

Physical therapists as scar modifiers

Hypertrophic scars, a common sequelae to burn injuries, represent an overgrowth of dermal components like collagen. To the burn-injured patient, the red, raised, rigid scars represent impaired function and distorted appearance. Physical therapists modify scars by treating with pressure and stretching to minimize the devastating effects. Healing time, location of the injury, condition of the unhealed and healed areas, and treatment cost influence physical therapy. This article describes scarring and provides practical guidelines for pressure materials and stretching techniques. With an appropriate program, caring for a patient with burns becomes extremely beneficial and rewarding.     

匹维溴铵在拟诊腹泻型肠易激综合征患者结肠镜检查肠道准备中的应用

目的:探讨匹维溴铵在拟诊腹泻型肠易激综合征患者结肠镜检查肠道准备中的应用价值。方法:选取2018年7月～2019年11月收治的拟诊腹泻型肠易激综合征计划行结肠镜检查患者80例为研究对象,随机分为匹维溴铵组和常规组,各40例。常规组给予50%硫酸镁200 ml进行肠道准备,匹维溴铵组在常规组基础上联合口服匹维溴铵进行肠道准备。观察两组患者肠道清洁质量、进镜时间、技术难度、结肠镜完成率、术中肠痉挛、术中腹痛和术后2 h腹部不适发生情况。结果:两组肠道清洁质量评分和结肠镜完成率比较,差异无统计学意义(P0.05)。与常规组比较,匹维溴铵组进镜时间显著缩短,技术难度显著降低,术中肠痉挛评分显著下降,术中腹痛和术后2 h腹部不适评分显著降低,差异均具有统计学意义(P0.05)。结论:拟诊腹泻型肠易激综合征患者肠道准备中应用匹维溴铵可以降低结肠镜技术难度,提高耐受性,减轻术中肠痉挛,减轻术中腹痛和术后腹部不适。     

Practical uses of chromoendoscopy and magnification at colonoscopy

New technologies in the form of high-magnification or zoom colonoscopy complemented by chromoscopic agents permits early detection of neoplastic colorectal lesions, particularly flat and depressed types. Establishing suitability for endoscopic resection or surgical excision can be enhanced using these techniques. Chromoscopic colonoscopy may play an important role in the routine endoscopic colorectal cancer surveillance programs in patients assuming a high risk of colorectal neoplasia. This article summarizes recent data regarding the prevalence and histopathologic characteristics of flat and depressed colorectal lesion in Western cohorts and describes how their detection and management can be improved by chromoscopy and magnification technology. The techniques required for chromoscopic colonoscopy and magnification imaging are outlined along with a review of the literature on these subjects.     

舒适护理在结肠镜检查中的应用效果

目的:探讨舒适护理在电子结肠镜检查中的应用效果。方法:将94例行电子结肠镜检查的患者随机分为试验组和对照组各47例,对照组予常规护理,试验组在此基础上加用舒适护理。比较两组患者在电子结肠镜检查中生命体征的变化及患者舒适度。结果:试验组患者舒适护理后的心率及血压变化明显低于自身干预前水平及同期的对照组水平(P<0.05);检查过程中试验组患者的舒适度明显优于对照组(P<0.05)。结论:在电子结肠镜检查中应用舒适护理可有效减轻患者检查中心率及血压的波动,提高舒适度,使患者能顺利完成检查,明显改善了护理服务质量。     

Breathlessness associated with abdominal spastic contraction in a patient with C4 tetraplegia: a case report

A tetraplegic patient with C4 cervical cord injury reported breathlessness during episodes of spastic contraction of the abdominal muscles. To determine the mechanism, we performed electrophysiologic testing of the phrenic nerves. We measured abdominal pressure, esophageal pressure, and transdiaphragmatic pressure (Pdi) during a maximal inspiratory effort (Pdi max), a maximal sniff maneuver (sniff Pdi) during resting breathing, and during the episodes of breathlessness. Electrophysiologic testing of the phrenic nerves showed axonal neuropathy on the left. Sniff Pdi and Pdi max were 38cmH(2)O and 42cmH(2)O, respectively. Transient spastic contractions of abdominal muscles were associated with an increase in abdominal pressure greater than 30cmH(2)O, with a decrease in abdominal volume; this rise in abdominal pressure was transmitted to the esophageal pressure. Inspiration became effective only when esophageal pressure fell below the resting baseline value. Achieving this decrease required an increase in inspiratory effort, characterized by swings in esophageal pressure and Pdi of 30cmH(2)O and 40cmH(2)O (approximately 100% of Pdi max), respectively. During these periods, minute ventilation was markedly reduced. This is the first report that spastic abdominal muscle contractions can impose a significant load on the diaphragm, uncovering moderate diaphragmatic weakness. This has important clinical implications; abolition of the spastic abdominal muscle contraction in this patient completely resolved her intermittent respiratory symptoms.     

无痛结肠镜1292例临床分析

目的 对无痛方法进行结肠镜诊治结直肠疾病的有效性、安全性等进行临床评价。方法 2578例患者，随机分为对照组1286例和无痛组1292例，观察两组患者肠镜检查中血压、心率、血氧饱和度变化及操作时间、成功率、不良反应和满意率。结果 无痛组操作过程中血压、心率、血氧饱和度较对照组稳定；操作时间两组无明显差异；无痛组成功率100％，对照组94．71％；无痛组不良反应显著低于对照组（P〈0．01）；无痛组Ⅰ级满意率95．59％，与对照组（0）比较，差异具有统计学意义（P〈0．01）。结论 无痛肠镜不仅能显著提高满意率、减少病人的痛苦，而且可提高检查成功率和减少不良反应，具有显著的临床应用价值。