Bowel preparation with split-dose polyethylene glycol before colonoscopy: a meta-analysis of randomized controlled trials.

BACKGROUND: Polyethylene glycol (PEG) is a commonly used bowel preparation for colonoscopy. Unfortunately, the standard large-volume solution may reduce patient compliance. Split-dosing of PEG has been studied in various randomized, controlled trials (RCTs). However, results have been conflicting. OBJECTIVE: We conducted a meta-analysis to assess the role of split-dose PEG versus full-dose PEG for bowel preparation before colonoscopy. DESIGN: Multiple databases were searched (January 2011). RCTs on adults comparing full-dose and split-dose of PEG for bowel preparation before colonoscopy were included and analyzed by calculating pooled estimates of quality of bowel preparation, preparation compliance, willingness to repeat the same preparation, and side effects by using odds ratio (OR) by fixed and random-effects models. SETTING: Literature search. PATIENTS: Per RCTs. MAIN OUTCOME MEASUREMENTS: Satisfactory bowel preparation, willingness to repeat same bowel preparation, patient compliance, and side effects. RESULTS: Five trials met inclusion criteria (N = 1232). Split-dose PEG significantly increased the number of satisfactory bowel preparations (OR 3.70; 95% CI, 2.79-4.91; P < .01) and willingness to repeat the same preparation (OR 1.76; 95% CI, 1.06-2.91; P = .03) compared with full-dose PEG. Split-dose PEG also significantly decreased the number of preparation discontinuations (OR 0.53; 95% CI, 0.28-0.98; P = .04) and nausea (OR 0.55; 95% CI, 0.38-0.79; P < .01) compared with full-dose PEG. LIMITATIONS: Limited number of studies. CONCLUSIONS: The use of a split-dose PEG for bowel preparation before colonoscopy significantly improved the number of satisfactory bowel preparations, increased patient compliance, and decreased nausea compared with the full-dose PEG.

Effect of music on patients undergoing colonoscopy: a meta-analysis of randomized controlled trials.

PURPOSE: Music has been utilized as a therapeutic tool during colonoscopy, but various randomized controlled trials (RCTs) have been inconsistent. We conducted a meta-analysis to analyze the effect of music on patients undergoing colonoscopy. PATIENTS AND METHODS: Multiple medical databases were searched (12/06). Only RCTs on adult subjects that compared music versus no music during colonoscopy were included. Meta-analysis was analyzed for total procedure time, dose of sedative medications (midazolam and mepiridine), and patients' pain scores, experience, and willingness to repeat the same procedure in the future. RESULTS: Eight studies (N = 712) met the inclusion criteria. Patients' overall experience scores (P < 0.01) were significantly improved with music. No significant differences were noted for patients' pain scores (P = 0.09), mean doses of midazolam (P = 0.10), mean doses of meperidine (P = 0.23), procedure times (P = 0.06), and willingness to repeat the same procedure in future (P = 0.10). CONCLUSIONS: Music improves patients' overall experience with colonoscopy.

Prophylactic antibiotics in necrotizing pancreatitis: a meta-analysis.

PURPOSE: Prophylactic antibiotics have been used in acute necrotizing pancreatitis with mixed results. This meta-analysis analyzes the effects of prophylactic antibiotics in necrotizing pancreatitis. METHODS: Multiple databases and abstracts were searched for randomized trials comparing treatment with prophylactic antibiotics to treatment without prophylactic antibiotics in necrotizing pancreatitis. Prophylactic antibiotics' effects were analyzed by calculating pooled estimates of mortality, infected pancreatic necrosis, length of hospital stay, nonpancreatic infections, and surgical intervention. RESULTS: Seven studies (n = 429) met the inclusion criteria. Prophylactic antibiotics for acute necrotizing pancreatitis significantly decreased the length of hospital stay (P = 0.04) and the rate of nonpancreatic infections (P < 0.01). No significant differences were noted for mortality (P = 0.22), infected necrosis (P = 0.18), and surgical intervention (P = 0.40). CONCLUSIONS: Prophylactic antibiotics in necrotizing pancreatitis reduced the length of hospital stay and rate of nonpancreatic infections but did not decrease mortality, infected necrosis, or surgical intervention.

En bloc endoscopic submucosal dissection of a 14-cm laterally spreading adenoma of the rectum with involvement to the anal canal: expanding the frontiers of endoscopic surgery (with video).

BACKGROUND: Endoscopic submucosal dissection (ESD) was recently developed in Japan for en bloc removal of laterally spreading tumors (LSTs). Although initially used for gastric tumors, ESD has now been applied to lesions elsewhere in the gut. Recent reports from Japan included removal of colorectal lesions up to 10 cm. OBJECTIVE: To show the feasibility of ESD to remove en bloc, very large LSTs of the rectum, even when there is involvement to the dentate line. DESIGN: Case report. SETTING: The procedure was performed at an American GI unit. The patient was admitted to the hospital after the procedure for observation. PATIENTS: A 53-year-old patient, with a 14-cm tubulovillous adenoma of the rectum, which, at its maximal extent, involved two thirds of the circumference of the rectum. The tumor extended distally to the dentate line. INTERVENTIONS: En bloc submucosal dissection with a conventional needle-knife to remove the neoplasm. MAIN OUTCOME MEASUREMENTS: Completeness of en bloc removal of the tumor and subsequent follow-up endoscopy that showed no residual neoplasm. RESULTS: The tumor was able to be removed en bloc by ESD. The distal margin included squamous mucosa. At a 2.5-week endoscopic follow-up, a 3-mm focus of residual polyp was seen and removed. At the time of the last follow-up, there was complete healing of the wound and no residual neoplasm. LIMITATIONS: Single case. CONCLUSIONS: This case demonstrated the feasibility of using ESD to remove large laterally spreading rectal tumors, including when there was involvement to the dentate line (and the dissection line must include squamous mucosa of the anal canal). ESD is a promising alternative to conventional surgical techniques; however, additional published experience is needed.

How adequate is digital rectal exam for prostate cancer screening at colonoscopy? Can adequacy be improved?

PURPOSE: Screening by digital rectal exam (DRE) has been advocated as a means of detecting early-stage prostate cancer. We sought to determine the adequacy of prostate palpation at DRE at colonoscopy, and to devise a method of improving adequacy when the gland is incompletely felt. MATERIALS AND METHODS: Adequacy of prostate palpation in the left lateral position was prospectively assessed in 200 males 40 years or older undergoing colonoscopy, and correlated with body mass index (BMI) and National Institutes of Health (NIH) weight categories. If the prostate was incompletely felt, the patient was asked to flex his knee(s) up toward his chest, and then the exam was repeated. RESULTS: The prostate was incompletely felt on initial DRE in 65 of 200 patients (32.5%). Raising the knee(s) toward the chest permitted complete palpation in 62 of those 65 cases. Incomplete palpation showed a strong correlation with BMI (P < 0.0001) and weight category: 3/36 (8.3%) for patients with normal body weight, 14/89 (15.7%) for overweight, 42/68 (61.8%) for obesity, and 6/7 (85.7%) for extreme obesity (P < 0.0001). There were 13 patients in whom no part of the prostate gland could be felt on the initial DRE, and which also correlated with NIH weight class (P < 0.0001). CONCLUSIONS: The prostate gland is often incompletely palpated at DRE in the left lateral position at colonoscopy, and shows a strong correlation with obesity. Adequacy can be dramatically improved by having the patient raise his knee(s) up toward his chest, a maneuver that takes just seconds to perform.

Bravo (wireless) ambulatory esophageal pH monitoring: how do day 1 and day 2 results compare?

AIM: To investigate if differences exist for patients' gastroesophageal reflux as measured by the Bravo ambulatory esophageal pH system between d 1 and d 2. METHODS: A retrospective study of 27 consecutive adult patients who underwent Bravo esophageal pH monitoring was performed. Patients underwent EGD under IV conscious sedation prior to Bravo placement. Acid reflux variables and symptom scores for d 1 were compared to d 2. RESULTS: The mean doses of fentanyl and midazolam were 90.4 microg and 7.2 mg, respectively. D 1 results were significantly more elevated than d 2 with respect to total time pH < 4, upright position reflux, and mean number of long refluxes. No statistical difference was noted between the two days for supine position reflux, number of refluxes, duration of longest reflux, episodes of heartburn, and symptom score. CONCLUSION: Patients undergoing Bravo esophageal pH monitoring in association with EGD and moderate conscious sedation experience significantly more acid reflux on d 1 compared to d 2. The IV sedation may be responsible for the increased reflux on d 1. Performed this way, 48-h Bravo results may not be entirely representative of the patients' true GE reflux profile.

Effect of music on patients undergoing outpatient colonoscopy.

AIM: To evaluate the effect of relaxing music during colonoscopy under low-dose conscious sedation, on patient satisfaction, scope insertion time and procedure duration, medication doses, and the perceived adequacy of sedation and scope insertion difficulty on the part of the endoscopist. METHODS: One hundred and sixty-seven consecutive adult outpatients presenting for routine colonoscopy under low-dose conscious sedation were randomized to undergo their procedures either with music played during the procedure or no music played. RESULTS: There were no statistical differences between the two groups in terms of meperidine dose, midazolam dose, time to reach the cecum, total procedure time, endoscopist assessment of scope insertion difficulty, endoscopist assessment of adequacy of sedation, or the pain experience of the patients during their procedure. The music group did report significantly better overall procedure satisfaction as compared to the non music group on two of our three different scales. CONCLUSION: While music does not result in shortened procedure times, lower doses of sedative medications or perceived patient pain, the patients who have music playing during their procedures report modestly greater satisfaction with their procedures.

Usefulness of a pediatric colonoscope for routine colonoscopy in women who have undergone hysterectomy.

BACKGROUND: Colonoscopy can be difficult in some women who have undergone hysterectomy, which can be associated with a fixed, angulated sigmoid colon caused by postoperative pelvic adhesions. Our goal was to determine whether colonoscopy is easier and more comfortable for women after hysterectomy when performed with a pediatric colonoscope, which is thinner in diameter and more flexible than a standard "adult" colonoscope. METHODS: One hundred women with a history of hysterectomy undergoing outpatient colonoscopy were randomized in unblinded fashion to colonoscopy with a standard colonoscope (CF-100L or CF-Q140L, Olympus) or with a pediatric colonoscope (PCF-100, Olympus). All procedures were performed by a faculty endoscopist and timed. After examination, the endoscopist graded procedure difficulty, and patients were given a questionnaire that assessed their experience. RESULTS: The cecum was intubated more frequently in the pediatric colonoscope group than in the standard colonoscope group (96.1% vs. 71.4%, p < 0.001). Success increased in the standard colonoscope group to 89.8% when the pediatric colonoscope was used to complete the examination. There were no differences in the two groups in terms of mean total procedure times (21.4 minutes vs. 22.6 minutes), mean doses of meperidine administered (57 mg both groups), mean doses of midazolam administered (1.5 mg vs. 1.7 mg), scales of procedure difficulty as graded by the endoscopists, and comfort scales as graded by patients. For the cases in which the cecum was intubated, the mean time to reach the cecum (11.7 minutes for the pediatric colonoscope group vs. 12.7 minutes for the adult) was similar. CONCLUSIONS: The pediatric colonoscope is a reasonable choice for colonoscopy in women who have had a hysterectomy. Alternatively, if the endoscopist elects to start the procedure with a standard colonoscope, it is helpful to have a pediatric colonoscope available for use should a fixed, angulated sigmoid colon be encountered that cannot be easily or safely traversed with the standard colonoscope.

Severe gastroesophageal reflux disease.

Preview Medical and surgical choices for treating gastroesophageal reflux disease have never been better. In the last few years, potent medications have been introduced that suppress gastric acid production and have promotility effects, and laparoscopic approaches to antireflux surgery have been developed. In this article, Dr Marshall reviews current management techniques and explains how to decide which to recommend in a given patient with severe disease.

Acute polyarthritis.

Preview Although erythema infectiosum occurs primarily in children, the infection may be responsible for acute arthritis or arthralgia in adults. In this article, a case of acute symmetric polyarthritis affecting one of the authors is described. His symptoms were caused by parvovirus B19 infection, which was probably acquired from one of his children who had had erythema infectiosum a short time earlier.

Current options in gallstone management.

Preview Should surgery to remove gallstones be deferred until symptoms occur? When should therapy with oral bile acids, lithotripsy, or methyl tert-butyl ether be considered? How should nonspecific dyspeptic symptoms in a patient with cholelithiasis be managed? Dr Marshall discusses these and other questions and controversies.