Actual Colonic Perforation in Virtual Colonoscopy: Report of a Case

Computed tomography colonography, also termed virtual colonoscopy, is a new imaging method to investigate the colon, which may be a potential alternative to the conventional endoscopic colonoscopy in some cases. The high safety profile of this imaging method was considered as an additional advantage of this procedure. A case of colonic perforation in computed tomography colonography is presented, highlighting a potential risk related to this procedure. It is assumed that perforation was the result of overinflation of air into an obstructed colon caused by a lesion at the rectosigmoid junction. Thus, it is suggested that in such cases, air insufflation should be gradual, thereby minimizing the risk of perforation.     

Colonoscopy in the evaluation of strictures

This is a review of 181 consecutive colonoscopic procedures performed to resolve the etiology of colonic strictures when the barium enema was inconclusive. In 54 percent, it was possible to intubate the colon above the stricture and thus resolve the problem. In 46 percent, it was impossible to traverse the stricture. In this group, it was nevertheless possible to resolve the problem in another 13 percent using the combined technique of biopsy and cytology. Thus, colonoscopy was helpful and determinate in 67 percent.     

Gastrointestinal and Nongastrointestinal Complications of Esophagogastroduodenoscopy and Colonoscopy in the Real World: A Nationwide Standard Cohort Using the Common Data Model Database

Background/AimsThe global trend of an expanding aged population has increased concerns about complications correlated with gastrointestinal (GI) endoscopy in elderly patients; however, there have been few reports published on this issue.MethodsIn this retrospective, observational cohort study performed between 2012 and 2017, serious complications of esophagogastroduodenoscopy (EGD), colonoscopy, and colonoscopic polypectomy were compared between patients according to age (≥65 years vs 18–64 years). We used the Health Insurance Review and Assessment-National Patient Samples database, previously converted to the standardized Observational Medical Outcomes Partnership-Common Data Model. Serious complications within 30 days of the procedure included both GI complications (bleeding and perforation) and non-GI complications (cerebrovascular accident [CVA], acute myocardial infarction [AMI], congestive heart failure [CHF], and death).ResultsA total of 387,647 patients who underwent EGD, 241,094 who underwent colonoscopy, and 89,059 who underwent colonoscopic polypectomy were assessed as part of this investigation. During the study period, endoscopic procedures in the older group steadily increased in number in all endoscopy groups (all p<0.001). Further, pooled complication rates of bleeding, CVA, AMI, CHF, and death were approximately three times higher among older patients who underwent EGD or colonoscopy. Moreover, pooled complication rates of CVA, AMI, CHF, and death were approximately 2.2 to 5.0 times higher among older patients who underwent colonoscopic polypectomy.ConclusionsElderly patients experienced approximately three times more GI and non-GI complications after EGD or colonoscopy than young patients. Physicians should pay attention to the potential risks of GI endoscopy in elderly patients.     

Bowel Preparation for Colonoscopy in Very Old Patients

Background: Colonoscopic preparations are defectively tolerated among many very old patients and the quality of preparation is often inadequate. Methods: Seventy-two patients aged 80 years or more were randomized to receive either NaP (37) or PEG (35) preparation. Patients' and endoscopists' opinions of the preparation and colonoscopy were ascertained, the adverse effects were recorded, clinical indicators of dehydration such as tongue dryness, upper body muscle weakness and confusion were assessed and laboratory tests were taken before and after the preparation. Results: Patients' evaluations showed no significant difference regarding the tolerance of preparations. Only the frequency of nausea was higher in the NaP group (16%/9%, P?=?0.01). Assessment of the indicators of dehydration showed a difference only in tongue dryness in the NaP group (P?=?0.02). The quality of preparation was evaluated by endoscopists as good or excellent in 81% of cases in the NaP group and in 77% of cases in the PEG group. The median values of potassium decreased from 4.0?mmol/L to 3.7?mmol/L (P?P?Conclusion: Sodium phosphate and PEG preparations are almost equally tolerated and effective in very old inpatients. NaP preparations cause more changes in the levels of potassium and sodium. For those elderly patients who are vulnerable to complications caused by electrolyte disturbances we recommend PEG preparation.     

Management of the Poorly Prepared Colonoscopy Patient: Colonoscopic Colon Enemas as a Preparation for Colonoscopy

Purpose Colonoscopic colon enema is an option for the management of patients who are suboptimally prepared for colonoscopic examination because of retained fecal material. Methods After colonoscopy is performed and the colonoscopist has reached the right colon and the colon is deemed to be inadequately prepared, the contents of two commercially available bisacodyl enemas are combined and instilled into the right colon via the colonoscope biopsy channel. Patients are allowed to recover from propofol sedation, expel the lumenal contents, resedated, and examined. Results In this fashion, 21 patients during a 19-month period were successfully cleansed of their retained fecal contents, permitting satisfactory colonoscopic examinations. This avoided the need for postponement of the procedure. Conclusions Colonoscopic colon enema is an innovative and simple option available to the colonoscopist to manage the patient with an inadequately prepared colon. Presented at the meeting of the American College of Gastroenterology, Philadelphia, Pennsylvania, October 12 to 17, 2007.     

Postcolonoscopy appendicitis in a patient with active ulcerative colitis

Complications due to diagnostic colonoscopy are uncommon and acute appendicitis is a very rare complication of colonoscopy. This poses a diagnostic challenge as the presentation of appendicitis is similar to that of other complications of colonoscopy such as perforation or postpolypectomy syndrome. It is hypothesized that postcolonoscopy appendicitis might be associated with obstruction of the appendiceal lumen with fecal matter during colonoscopy. None of the previous reports in the literature have described findings of appendicitis after colonoscopy in a patient with active ulcerative colitis. We present a case of a 28 year-old man with active ulcerative colitis who underwent colonoscopy and subsequently developed acute appendicitis.     

Preparation for Colonoscopy in Hospitalized Patients

Successful colonoscopy depends on good preparation of the colon before the procedure. Inadequate preparation may lead to cancelled or repeat procedures and compromise patient safety, quality of care, and cost effectiveness. The primary aim of this study was to isolate factors that affect preparation success, especially in older, more severely ill, bedridden patients. The secondary aim was to examine the possible differences in preparation quality between ambulatory and hospitalized patients and the impact of a staff educational program on the preparation of hospitalized patients for colonoscopy. The study group included 303 consecutive ambulatory patients and 104 hospitalized patients referred for colonoscopy between January and March 2002, before the department introduced an educational program on colonoscopy preparation, and 310 ambulatory patients and 105 hospitalized patients referred for colonoscopy between January and March 2003. All patients completed an ad hoc questionnaire, and the findings were compared between ambulatory and hospitalized patients and between patients treated before and after the educational program. Polyethylene glycol was used significantly more often for colonoscopy preparation in hospitalized patients than in ambulatory patients (53.1% versus 8.8%; P=.0001). The hospitalized group was characterized by more incomplete or repeated colonoscopies and poorer preparation quality. On multivariate analysis, the variables found to be independent predictors of good preparation were successful patient completion of the preparatory procedure according to instructions, colonoscopy performed for follow-up after polypectomy, and preparation with sodium phosphate. The educational intervention had no impact on the quality of preparation. In conclusion, sodium phosphate preparation and complete adherence to preparation instructions are the most important factors for successful colonoscopy preparation. Current preparatory methods for hospitalized and severely ill patients need to be revised.     

Sedation-Free Colonoscopy

PURPOSE The administration of sedative drugs at colonoscopy has its drawbacks, such as increasing the rate of complications and the cost. There are a number of potential advantages to performing colonoscopy without sedation. The aim of this study is to evaluate patient tolerance and acceptance during sedation-free colonoscopy.METHODS Pain during sedation-free colonoscopy was evaluated in consecutive series of 675 patients in a prospective manner from January 1, 2003, to February 18, 2004. We recorded the degree of patient pain during colonoscopy, willingness to undergo sedation-free colonoscopy in the future, the complication rate, and the intubation time. The assisting endoscopy nurses and patients independently assessed the pain level immediately after the procedure using a four-point pain scale (nil, mild, moderate, severe).RESULTS Almost all colonoscopies (99.6 percent: 672/675) were successful. There were four complications related to colonoscopy (bleeding after polypectomy). Patients and nurses rated pain by a four-point pain scale as follows. For the patients: nil, 69.6 percent (470/675); mild, 28.0 percent (189/675); moderate, 2.2 percent (15/675); severe, 0.1 percent (1/675). For the nurses: nil, 76.1 percent (514/675); mild, 22.7 percent (153/675); moderate, 0.9 percent (6/675); severe, 0.3 percent (2/675). Patients rarely suffered from severe pain during carefully performed colonoscopies. The pain level of almost all colonoscopies was acceptable by patients, with only six patients (1.0 percent) stating that they would never undergo a colonoscopy without sedation in the future because of unbearable pain.CONCLUSIONS This study suggests that carefully performed sedation-free colonoscopy rarely causes complications and is well accepted by most patients. Sedation-free colonoscopy is more cost-effective, may be safer, and should be offered as an alternative to colonoscopy with sedation.     

Haemoperitoneum post colonoscopy in a continuous ambulatory peritoneal dialysis patient

We present the case of a patient on peritoneal dialysis (PD) who had an uneventful oesophagogastroduodenoscopy and colonoscopy. His peritoneal dialysis after colonoscopy had bright red peritoneal dialysate. The patient was completely asymptomatic and a CT scan was performed which did not reveal any retroperitoneal haematoma and showed no signs of perforation or splenic tear. His PD dialysate cleared up with time. We do not find any such case in the literature in which a patient has had haemoperitoneum after a colonoscopy without any obvious cause to account for it. Our patient was unique due to his CAPD in combination with his immunosuppression for his kidney transplant which may have predisposed him to the intraperitoneal bleed after colonoscopy or it may just have been a normal phenomenon after colonoscopy. More studies need to be done as the realisation of its pathology can prevent unnecessary testing and avoid patient and healthcare worker’s anxiety.     

小儿纤维结肠镜检查283例报告

本文报道小儿纤维结肠镜检查283例,小儿大肠息肉摘除术132例,均未发生并发症。总结分析了小儿大肠疾病的临床表现,纤维结肠镜与病理检查结果。对小儿纤维结肠镜插入深度,结,直肠疾病检出率及急诊纤维结肠镜检查术等进行了讨论。     

Water-Related Techniques for Performance of Colonoscopy

Background Passage through difficult colonic segments, cecal intubation rate, time to reach the cecum, procedure-related discomfort, and medication requirement are important outcome measures of a colonoscopic examination. Several techniques of water infusion to aid insertion have been described. Raising awareness of these simple inexpensive methods may help to enhance colonoscopists’ performance. Aim To review water-related methods that facilitated colonoscope insertion. Method A literature search (Medline, PubMed) was conducted using the following terms: sigmoidoscopy, colonoscopy, and water infusion, irrigation, or loading. The effects of water infusion in sedated and unsedated patients are tabulated and discussed. Results Five reports described the use of water infusion in conjunction with usual air insufflation. Enhanced cecal intubation, decreased time to reach the cecum, and attenuated abdominal discomfort were reported. Dose of medication used for sedation was not reduced. The sixth report described a novel method of water infusion in lieu of air insufflation during insertion. When patients accepted sedation on demand, the novel method permitted 52% to complete colonoscopy without sedation. Conclusion Warm water infusion as an adjunct to usual air insufflation enhances colonoscopy outcome. Randomized controlled trials comparing the novel method with usual air insufflation deserve to be considered.     

Can oral anticoagulation be managed using telemedicine and patient self-testing? A pilot study

We report a feasibility study of patient self‐testing telemedicine for anticoagulant management using TOPCARE (Telematic Homecare Platform in Cooperative Health Care Provider Networks, developed by the European Commission for a user‐friendly information society). TOPCARE comprises a Home Telematic Box (TOPCARE BOX), a central database held on a remote server and secure computer terminals in the anticoagulant clinic. The TOPCARE BOX transmits encrypted International Normalized Ratio (INR) results from the CoaguChek S monitor (Roche Diagnostics) via the patient's telephone line to the database, which is accessed by health‐care professionals via the Internet. The database displays the patient's anticoagulant record, highlighting out of range results, overdue tests and quality control results. The database can also send information back to the TOPCARE box, although currently only the next test date can be transmitted. 23 patients, on long‐term oral anticoagulation were recruited from the hospital anticoagulant clinic. After completing a nurse‐led training course, patients tested their INR weekly on a CoaguChek S and transmitted their results via the TOPCARE BOX. The nurse specialist accessed the patient's results, electronically entered the date of the next test. Changes in warfarin dose were telephoned. Four patients dropped out early in the study and 19 patients received TOPCARE BOXs of which nine were fully functional. Unintentional software misconfiguration meant that remaining 10 TOPCARE BOXs were nonfunctional (these were later reconfigured but not reintroduced into the study). Patients successfully transmitted 222 results over a 5‐month period using the TOPCARE system. Early server problems were resolved, but intermittent problems with database access persisted and five results were not received by the server. Although concerns were raised regarding technical problems, feedback from patients and staff was favourable and the system thought to be user‐friendly. In conclusion, this pilot study showed that telemedicine is a feasible option for anticoagulant management, but that the technology requires thorough testing prior to installation.     

异丙酚静脉麻醉辅助结肠镜检查的应用研究

目的 探讨应用异丙酚作镇静麻醉辅助结肠镜检查的可行性，评价其效果和安全性。方法 将2210例结肠镜检查患者随机分为2组：麻醉组（2000例）静脉注射异丙酚至患者进入4级镇静状态后进行结肠镜检查。对照组（210例）按常规进行结肠镜检查。观察2组检查前，检查开始后1，5，20min和检查结束后的血压，脉搏，血氧饱和度以及检查反应和入镜时间。结果 检查过程中，麻醉组的平均收缩压各时段无明显变化（P＞0．05），对照组变化明显（P＜0．01）。2组的平均舒张压，脉搏和血氧饱和度在相应各时段的变化均无显著性差异（P＞0．05）。麻醉组的入镜时间和检查反应明显优于对照组（P＜0．01）。结论 异丙酚辅助结肠镜检查是安全有效，其入镜时间和检查反应优于普通检查。     

Colonoscopy in Hong Kong Chinese children

AIM:To investigate the safety and diagnostic yield of colonoscopy in Chinese children in whom the procedure is not often done.METHODS:We conducted a retrospective review of all colonoscopies in consecutive children who underwent their fi rst diagnostic colonoscopy from Jan 2003 to 2008.RESULTS:Seventy-nine children (48 boys,31 girls;mean age 9.2 ± 4.2 years) were identified and reviewed with a total of 82 colonoscopies performed.Successful caecal and ileal intubation rates were 97.6% and 75.6% respectively.Forty patients (50.6%) had a positive diagnosis made in colonoscopy and that included colonic polyps (23),Crohn’s disease (12),ulcerative colitis (1),and miscellaneous causes (4).80% of polyps were in the rectosigmoid colon.All but one were juvenile hamartomatous polyps.The exceptionwas an adenomatous polyp.The mean ages for children with inflammatory bowel disease (IBD) and polyps were 11.3 and 4.3 years respectively.There was no procedure-related complication.CONCLUSION:Colonoscopy is a safe procedure in our Chinese children.The increasing diagnosis of IBD in recent decades may reflect a rising incidence of the disease in our children.     

溃疡性结肠炎患者内镜分析

目的 回顾性探讨昆明市近10年来溃疡性结肠炎(UC)住院患者内镜表现.方法 选取昆明市1998年1月～2009年3月期间7家大型综合医院379例住院的炎症性肠病患者作为调查对象,诊断均符合2007年中华医学会消化病学分会的UC诊治标准,分析UC患者内镜下表现.结果 有98.2％的病例接受结肠镜检查,其诊断符合率为88.4％.100％为活动期,其中轻度38.3％,中度42.2％,重度19.5％.分型如下:直肠型者13.2％,直肠和乙状结肠型26.9％,左半结肠型34.9％,右半结肠型3.2％,全结肠型21.7％.内镜下表现病变呈弥漫性分布90.50％,充血水肿86.20％,糜烂或溃疡76.90％,活动性出血60％,脓性分泌物25％,假性息肉18％.结论 昆明市UC患者的病期以中度为主,病变范围以左半结肠型和直肠和乙状结肠型为主,以弥漫性分布、充血水肿、糜烂或溃疡为主要表现.     

Appropriateness of Colonoscopy in the Era of Colorectal Cancer Screening: A Prospective,Multicenter Study in a Private-Practice Setting (Berlin Colonoscopy Project 1, BECOP 1)

Purpose The introduction of reimbursement for screening colonoscopy in Germany more than one year ago raised concerns that the consequent workload might lead to underuse of diagnostic colonoscopy for symptomatic patients. Available appropriateness criteria for diagnostic colonoscopy have been rarely tested in a realistic outpatient setting. This study was designed to test current appropriateness criteria for diagnostic colonoscopy to better select patients and potentially provide more capacity for screening cases. Secondary goals were yield and quality control in both the diagnostic and screening cases. Methods A prospective study was initiated in 39 private-practice offices to collect data on consecutive colonoscopies conducted during a 6-day study period. A detailed questionnaire was developed to define indications and symptoms, and all findings at colonoscopy were recorded. Colonoscopies were further analyzed and stratified into a screening and a diagnostic group. In the diagnostic group, indications were assessed according to the current guidelines for appropriateness (American Society for Gastrointestinal Endoscopy, European Panel for the Appropriateness of Gastrointestinal Endoscopy), and the results were correlated with the percentage of relevant findings (tumors, inflammatory conditions). Results During the study period, 1,397 colonoscopies (57 percent screening, 43 percent diagnostic) were analyzed (male/female ratio = 39/61 percent; mean age, 61 years). Fourteen percent and 37 percent, respectively, of the 605 diagnostic colonoscopies were regarded as inappropriate relative to the criteria of the American Society for Gastrointestinal Endoscopy and the European Panel for the Appropriateness of Gastrointestinal Endoscopy. However, the percentage of relevant inflammatory and neoplastic findings (polyps, cancer, inflammatory bowel disease, benign strictures) was only 5 to 10 percent higher in the appropriate group than in the inappropriate group. On the basis of these data, a hypothetical model for selecting appropriate indications was developed: if patients older than aged 50 years with pain, bleeding, and diarrhea, but not constipation, are regarded as having an appropriate indication, such an approach would save 20 percent of colonoscopies in these main indication groups (bleeding, pain, diarrhea, constipation), with a hypothetical miss rate for relevant findings (as defined above) of 5 percent. Conclusions Currently used appropriateness criteria for diagnostic colonoscopy increase the yield of relevant findings but lead to a miss rate for relevant findings in the range of 10 to 15 percent. Simple selection criteria based on age and symptoms could be more suitable and should be tested in a larger group of patients. *For members participating in this study, see the Appendix. Supported by unrestricted grants from Olympus Co. Europe/Hamburg and Falk Foundation/Freiburg, Germany.     

Recurrent life-threatening thromboembolism and catastrophic antiphospholipid syndrome in a patient despite sufficient oral anticoagulation

We report on a 32-year old female patient with primary antiphospholipid syndrome (PAPS) and several thromboembolic events despite stable doses of oral anticoagulation, good patient compliance and maintained INR values of >3. Over the preceding 3 years the patient had presented a wide spectrum of manifestations of APS, including recurrent venous and arterial thromboses, cardiac, gynecological (HELLP syndrome), neurological involvements, livedo reticularis, a mild thrombocytopenia and the most feared manifestation of the catastrophic antiphospholipid syndrome (CAPS). Life-threatening bilateral subdural bleeding occurred while she was anticoagulated. The clinical features appeared to be refractory to oral anticoagulation with phenprocoumon. They were life threatening on each occasion and she developed repetitive episodes of organ damage with cardiac insufficiency (NYHA III), pulmonary hypertension and other residual defects. Even during heparinization recurrent thromboembolism supervened as well as livedo reticularis of the extremities. Lupus anticoagulants (LAC), anticardiolipin (aCL) antibodies and anti-₂-glycoprotein-1 (₂GPI) titers were all markedly elevated. This case report shows that recurrent episodes of thrombosis can occur despite seemingly adequate anticoagulation in patients with CAPS.Abbreviations aCL Anticardiolipin - aPL Antiphospholipid - APS Antiphospholipid syndrome - ARDS Adult respiratory distress syndrome - ₂GP1 ₂-glycoprotein-1 - CAPS Catastrophic APS - HELLP syndrome Hemolysis, elevated lever enzymes, low platelet count - ICA Index of circulating antibodies - INR International normalized ratio - LAC Lupus anticoagulants - NYHA New York Heart Association - SLE Systemic lupus erythematosus     

高原地区结肠镜检查质量临床观察及干预对策分析

目的分析高原环境对结肠镜检查质量的影响。方法收集2016年1月—2018年5月在青海省人民医院完成结肠镜检查且结果无异常的450例健康体检者资料。根据患者居住地区海拔高度,分为对照组（海拔>1 500~<2 500 m,120例）、高海拔组（海拔2 500~<3 500 m,170例）、超高海拔组（海拔3 500~<5 500 m,160例）,分析进镜时间、退镜时间、结肠清洁率、盲肠达镜率、镜检过程中腹痛腹胀症状等指标与海拔的关系。结果对照组、高海拔组和超高海拔组平均进镜时间为9.23 min、17.69 min和24.51 min,多元回归分析发现,高海拔组比对照组平均延长8.20 min,超高海拔组比对照组平均延长15.11 min（P<0.001）。对照组、高海拔组和超高海拔组平均退镜时间为7.17 min、7.28 min和7.93 min,多元回归分析发现,高海拔组与对照组比较差异无统计学意义（P>0.05）,但超高海拔组相比对照组延长了0.76 min（P<0.001）。对照组、高海拔组和超高海拔组的肠道清洁优良率分别为41.7%（50/120）、17.6%（30/170）和12.5%（20/160）,Logistic回归分析发现,高海拔组比对照组肠道清洁程度下降一个等级的可能性增加1.96倍,超高海拔组比对照组肠道清洁程度下降一个等级的可能性增加8.76倍（P<0.001）。对照组、高海拔组和超高海拔组盲肠达镜率分别为91.7%（110/120）、85.9%（146/170）和81.2%（130/160）,高海拔组与对照组比较差异无统计学意义（P>0.05）,超高海拔组与对照组比较差异有统计学意义（OR=0.38,95%CI：0.17~0.82,P=0.015）。随着患者居住地海拔升高,结肠镜检查中患者腹痛、腹胀等症状逐渐加重,3组间差异有统计学意义（P<0.05）。结论高原地区结肠镜检查质量低,检查前选择性干预可提高高原地区结肠镜检查质量。     

Colonoscopy in the Elderly: Low Risk, Low Yield in Asymptomatic Patients

Purpose Current colonoscopy guidelines do not address the issue of when to stop performing screening and surveillance colonoscopy in the elderly. We reviewed our experience and results of colonoscopy in patients aged 80 years and older to assess the risks and diagnostic yield in this population. Methods We reviewed retrospectively the endoscopic and pathologic reports from consecutive colonoscopies performed on patients aged 80 years and older at a single, high-volume endoscopy center between August 1999 and May 2003. Patient characteristics, indications for examination, findings at colonoscopy, and complications were recorded and analyzed. Results A total of1,199 colonoscopic examinations were performed on 1,112 patients. Average age was 83.1 (range, 80–100) years. Male:female distribution was 1:1.7. Leading exclusive indications for colonoscopy included: polyp surveillance, 227 (19 percent); altered bowel habits, 168 (14 percent); iron-deficiency anemia, 132 (11 percent); and cancer follow-up, 108 (9 percent). Eighty-six examinations (7 percent) were performed solely for an indication of colorectal cancer screening. Twenty-two percent of patients had more than one indication for colonoscopy. Forty-five malignancies were found (3.7 percent). No cancers were found in the screening group, and two malignancies (0.7 percent) were detected in patients undergoing colonoscopy for polyp surveillance. There were eight (0.6 percent) reported major complications. Conclusions Colonoscopy can be performed safely in patients aged 80 years and older. However, the diagnostic yield is low, particularly in patients undergoing routine screening or surveillance examinations. Colonoscopy should for the most part be limited to elderly patients with symptoms or specific clinical findings. Read at the meeting of The American Society of Colon and Rectal Surgeons, Philadelphia, Pennsylvania, May 2 to 5, 2005.