Identification of factors associated with sedation tolerance in 5000 patients undergoing outpatient colonoscopy: Canadian tertiary center experience.

AIM: To develop a prediction model aimed at identifying patients that may require higher than usual sedation doses during colonoscopy. METHODS: A retrospective chart review on 5000 patients who underwent an outpatient colonoscopy at St. Paul's Hospital from 2009 to 2010 was conducted in order to develop a model for identifying patients who will require increased doses of sedatives. Potential predictor variables including age, gender, endoscopy indication, high sedation requirements during previous endoscopies, difficulty of the procedure, bowel preparation quality, interventions, findings as well as current use of benzodiazepines, opioids and alcohol were analyzed. The outcome of study was the use of high dose of sedation agents for the procedure. In particular, the high dose of sedation was defined as fentanyl greater than 50 mcg and midazolam greater than 3 mg. RESULTS: Analysis of 5282 patients (mean age 57 ± 12, 49% female) was performed. Most common indication for the procedure was screening colonoscopy (57%). Almost half of our patients received doses exceeding Fentanyl 50 mcg and Midazolam 3 mg. Logistic regression models identified the following variables associated with high sedation: Younger age (OR = 0.95 95%CI: 0.94-0.95; P < 0.0001); abdominal pain (OR = 1.45, 95%CI: 1.08-1.96); P = 0.01) and Inflammatory Bowel Disease (OR = 1.45, 95%CI: 1.04-2.03; P = 0.02) as indications for the procedure; difficult procedure as defined by gastroenterologist (OR = 1.73, 95%CI: 1.48-2.03; P < 0.0001); past history of abdominal surgery (OR = 1.33, 95%CI: 1.17-1.52; P <0.0001) and previous colonoscopy (OR = 1.39, 95%CI: 1.21-1.60; P = 0.0001) and alcohol use (OR = 1.26, 95%CI: 1.03-1.54; P = 0.02). Age and gender adjusted analysis yielded inflammatory bowel disease as an indication (OR = 3.17, 95%CI: 1.58-6.37; P = 0.002); difficult procedure as defined by an endoscopist (OR = 5.13 95%CI: 2.97-8.85; P = 0.0001) and current use of opioids, benzodiazepines or antidepressants (OR = 2.88, 95%CI: 1.74-4.77; P = 0.001) having the highest predictive value of high sedation requirements. Our prediction model using the following pre-procedural variables including age, gender, indication for the procedure, medication/substance use, previous surgeries, previous high sedation requirements for colonoscopy yielded an area under the curve of 0.76 for Fentanyl ≥ 100 mcg and Midazolam ≥ 3 mg. CONCLUSION: Pre-procedural planning is the key in conducting successful, efficient colonoscopy. Logistic regression analysis of 5000 patients who underwent out-patient colonoscopy revealed the following factors associated with increased sedation requirement: Younger age, female gender, difficult endoscopy, specific indications as well as cardiopulmonary complications and current use of opioids/benzodiazepines. Age and gender adjusted analysis yielded similar results. These patients are more likely to need a longer recovery periods post-endoscopy, which could result in additional time and personnel requirements. The final predictive model has good predictive ability for Fentanyl ≥ 100 mcg and Midazolam ≥ 3 mg and fair predictive ability for Fentanyl ≥ 50 mcg and Midazolam ≥ 2 mg. The external validity of this model is planned to be tested in another center.

The effect of chewing gum on small-bowel transit time in capsule endoscopy: a prospective, randomized trial.

BACKGROUND: Approximately 1 in 6 capsule endoscopies (CEs) does not visualize the entire small bowel at completion of the examination because of limited battery life. OBJECTIVE: To determine whether chewing gum can reduce the small-bowel transit time and increase CE completion rates. DESIGN: Prospective, single-blind, randomized, controlled trial. SETTING: A tertiary university-affiliated hospital. PATIENTS: Consecutive patients 19 years of age and older undergoing outpatient small-bowel CE from October 2010 to July 2012 were assessed for eligibility. Those with previous gastric or small-bowel surgery or ileostomy, dysphagia prohibiting capsule ingestion, diabetes mellitus with evidence of end-organ damage, use of narcotics or prokinetics within 5 days before the procedure, clinical hyper-/hypothyroidism, and symptoms suggestive of acute bowel obstruction were excluded. INTERVENTION: Gum chewing for at least 20 minutes every 2 hours starting at the time of capsule ingestion. MAIN OUTCOME MEASUREMENTS: Small-bowel transit time, gastric transit time, and completion rate were measured. RESULTS: Chewing gum did not have any significant effect on gastric transit time (rate ratio 1.06; 95% CI, 0.73-1.55; P = .75), small-bowel transit time (rate ratio 0.91; 95% CI, 0.62-1.35; P = .65), or completion rate (91.67% chewing gum vs 88.71% control, P = .58) of CE. LIMITATION: Single-center study involving relatively healthy subjects. Procedures were done on an outpatient basis so participants were not monitored for adherence to protocol. CONCLUSIONS: Chewing gum does not speed up capsule transit or increase completion rate of CE in patients without risk factors for incomplete studies. ( CLINICAL TRIAL REGISTRATION NUMBER: NCT01241825.).

Do we eradicate Helicobacter pylori in hospitalized patients with peptic ulcer disease?

BACKGROUND: Helicobacter pylori infection is the most common chronic infection in humans. It is a major contributor to the cause of duodenal and gastric ulcers worldwide. Its eradication has been shown to reduce rates of H pylori-related ulcers as well as other complications such as gastric cancer. OBJECTIVE: To determine the rate of appropriate treatment in patients following a diagnosis of H pylori infection on biopsy during esophagoduodenoscopy for upper gastrointestinal bleeding over a four-year period at a tertiary centre in Vancouver, British Columbia. Also evaluated was the rate of eradication confirmation using the urea breath test. METHODS: A retrospective review of 1501 inpatients who underwent esophagoduodenoscopy for upper gastrointestinal bleeding (January 2006 to December 2010) was undertaken. Patients who were biopsy stain positive for H pylori were selected for drug review either via a provincial database (PharmaNet) or via records from patients' family practitioners. Data were also obtained via two provincial laboratories that perform the urea breath test to determine the rates of confirmation of eradication. RESULTS: Ninety-eight patients had biopsy-proven H pylori. The mean (± SD) age was 56.13±17.9 years and 65 were male. Data were not available for 22 patients; the treatment rate was 52.6% (40 of 76). Of those treated, 12 patients underwent a post-treatment urea breath test for eradication confirmation. CONCLUSION: There was substantial discrepancy between the number of diagnosed H pylori infections and the rate of treatment as well as confirmation of eradication. Numerous approaches could be taken to improve treatment and eradication confirmation.

Diagnostic yield of capsule endoscopy in the setting of iron deficiency anemia without evidence of gastrointestinal bleeding.

BACKGROUND: The diagnostic yield of capsule endoscopy (CE) in the setting of iron deficiency anemia (IDA) without evidence of occult/overt bleeding has been questioned. Often, these patients have nongastrointestinal causes of iron deficiency but undergo CE to exclude a potential small bowel source. OBJECTIVE: To assess the diagnostic yield of CE, the characteristics predicting positive results, the presumed etiology of IDA in negative/normal CE and patient management after CE. METHODS: A retrospective review of 934 patients who underwent CE between December 2001 and February 2010 was conducted. All patients had undergone previous negative endoscopic examinations before CE. Patients with IDA but no evidence of overt/occult bleeding were separated into three categories based on CE findings: group A - positive; group B - negative/normal; and group C - incomplete/indeterminate. RESULTS: A total of 101 capsules in 97 patients were evaluated. Group A had 25 subjects with positive findings on CE, 18 of whom were managed supportively. Group B consisted of 69 subjects with negative/normal CE, 60 of whom were treated supportively. Group C consisted of three subjects with incomplete CE results. CONCLUSION: In patients with IDA without evidence of gastrointestinal bleeding, CE had a low diagnostic yield (25.7%), which increased to 45.5% after adjusting for low dietary iron intake and menorrhagia. However, CE did not alter management in most patients regardless of findings, and many of the lesions requiring intervention were within reach of standard endoscopes. No predictor of positive results was found. In this patient population, careful history taking and thorough endoscopy could improve CE utilization, although its value is still relatively limited.

Incomplete colonoscopy: maximizing completion rates of gastroenterologists.

BACKGROUND: Cecal intubation is one of the goals of a quality colonoscopy; however, many factors increasing the risk of incomplete colonoscopy have been implicated. The implications of missed pathology and the demand on health care resources for return colonoscopies pose a conundrum to many physicians. The optimal course of action after incomplete colonoscopy is unclear. OBJECTIVES: To assess endoscopic completion rates of previously incomplete colonoscopies, the methods used to complete them and the factors that led to the previous incomplete procedure. METHODS: All patients who previously underwent incomplete colonoscopy (2005 to 2010) and were referred to St Paul's Hospital (Vancouver, British Columbia) were evaluated. Colonoscopies were re-attempted by a single endoscopist. Patient charts were reviewed retrospectively. RESULTS: A total of 90 patients (29 males) with a mean (± SD) age of 58 ± 13.2 years were included in the analysis. Thirty patients (33%) had their initial colonoscopy performed by a gastroenterologist. Indications for initial colonoscopy included surveillance or screening (23%), abdominal pain (15%), gastrointestinal bleeding (29%), change in bowel habits or constitutional symptoms (18%), anemia (7%) and chronic diarrhea (8%). Reasons for incomplete colonoscopy included poor preparation (11%), pain or inadequate sedation (16%), tortuous colon (30%), diverticular disease (6%), obstructing mass (6%) and stricturing disease (10%). Reasons for incomplete procedures in the remaining 21% of patients were not reported by the referring physician. Eighty-seven (97%) colonoscopies were subsequently completed in a single attempt at the institution. Seventy-six (84%) colonoscopies were performed using routine manoeuvres, patient positioning and a variable-stiffness colonoscope (either standard or pediatric). A standard 160 or 180 series Olympus gastroscope (Olympus, Japan) was used in five patients (6%) to navigate through sigmoid diverticular disease; a pediatric colonoscope was used in six patients (7%) for similar reasons. Repeat colonoscopy on the remaining three patients (3%) failed: all three required surgery for strictures (two had obstructing malignant masses and one had a severe benign obstructing sigmoid diverticular stricture). CONCLUSION: Most patients with previous incomplete colonoscopy can undergo a successful repeat colonoscopy at a tertiary care centre with instruments that are readily available to most gastroenterologists. Other modalities for evaluation of the colon should be deferred until a second attempt is made at an expert centre.

Factors associated with positive findings from capsule endoscopy in patients with obscure gastrointestinal bleeding.

BACKGROUND & AIMS: Capsule endoscopy (CE) is used most frequently to identify causes of obscure gastrointestinal bleeding (OGIB). Identifying factors associated with the detection of lesions by CE could improve resource utilization and thereby improve patient selection for CE examination. We sought to identify clinical factors associated with positive findings from CE in patients with OGIB. METHODS: We analyzed data from 698 CE procedures performed between December 2001 and April 2011 at St Paul's Hospital, Vancouver, Canada (50.3% of patients were female; mean age, 63.4 years). A positive finding was defined as a lesion that was believed to be the source of the bleeding (ulceration, mass lesion, vascular lesion, or visible blood). Univariate and multivariate logistic regression analyses were used to correlate demographic and clinical parameters with positive findings. RESULTS: A lesion believed to be the cause of bleeding was identified in 42% of cases. In univariate analysis, the number of esophagogastroduodenoscopies (EGDs), the presence of connective tissue disease or diabetes with end-organ damage, Charlson comorbidity index scores, and increasing transfusion requirements were significantly associated with identification of causative pathology from CE (all P < .027). In multivariate analysis, increasing number of EGDs (odds ratio [OR], 1.17; 95% confidence interval [CI], 1.00-1.37), increasing transfusion requirements (3-9 units: OR, 1.70; 95% CI, 1.08-2.66, and ≥10 units: OR, 2.72; 95% CI, 1.69-4.37), and connective tissue disease (OR, 2.24; 95% CI, 1.14-4.41) were all significantly associated with identification of positive findings by using CE (all P < .045). CONCLUSIONS: Patients with a higher number of precapsule EGDs or transfusions, or connective tissue disease, are superior candidates for analysis of OGIB by CE.

Factors associated with incomplete small bowel capsule endoscopy studies.

AIM: To identify patient risk factors associated with incomplete small bowel capsule endoscopy (CE) studies. METHODS: Data from all CE procedures performed at St. Paul's Hospital in Vancouver, British Columbia, Canada, between December 2001 and June 2008 were collected and analyzed on a retrospective basis. Data collection for complete and incomplete CE study groups included patient demographics as well as a number of potential risk factors for incomplete CE including indication for the procedure, hospitalization, diabetes mellitus with or without end organ damage, limitations in mobility, renal insufficiency, past history of bowel obstruction, abdominal surgery, abdominal radiation therapy and opiate use. Risk factors were analyzed using a univariable and multivariable logistic regression model. RESULTS: From a total of 535 CE procedures performed, 158 were incomplete (29.5%). The univariable analysis showed that CE procedures performed for overt gastrointestinal bleeding (P = 0.002), and for patients with a prior history of abdominal surgery (P = 0.023) or bowel obstruction (P = 0.023) were significantly associated with incomplete CE studies. Patients on opiate medications (P = 0.094) as well as hospitalized patients (P = 0.054) were not statistically significant, but did show a trend towards incomplete CE. The multivariable analysis showed that independent risk factors for an incomplete CE procedure include prior history of bowel obstruction [odds ratios (OR) 2.77, P = 0.02, 95% confidence intervals (CI): 1.17-6.56] and procedures performed for gastrointestinal bleeding (Occult OR 2.04, P = 0.037, 95% CI: 1.04-4.02 and Overt OR 2.69, P = 0.002, 95% CI: 1.44-5.05). Patients with a prior history of abdominal surgery (OR 1.46, P = 0.068, 95% CI: 0.97-2.19), those taking opiate medications (OR 1.54, P = 0.15, 95% CI: 0.86-2.76) and hospitalized patients (OR 1.82, P = 0.124, 95% CI: 0.85-3.93) showed a trend towards statistical significance. CONCLUSION: We have identified a number of risk factors for incomplete CE procedures that can be used to risk-stratify patients and guide interventions to improve completion rates.

Endoscopic management of gastric variceal bleeding with cyanoacrylate glue injection: safety and efficacy in a Canadian population.

BACKGROUND:  Gastric variceal bleeding (GVB) is a major cause of morbidity and mortality among patients with portal hypertension. Endoscopic band ligation and standard sclerotherapy have been used but have significant limitations. Decompression through transjugular intrahepatic portosystemic shunt insertion has been shown to be effective. Gastric variceal injection therapy with a commercially available cyanoacrylate glue is less invasive than transjugular intrahepatic portosystemic shunt insertion and has recently been shown to be effective for acute hemostasis.  OBJECTIVE: To assess the immediate and long-term outcomes of cyanoacrylate glue injection therapy for GVB. METHODS: A retrospective chart review was conducted to identify patients treated with cyanoacrylate injection for GVB at two tertiary care hospitals over a period of six years. The outcomes assessed included complications, acute hemostasis, rebleeding rate and all-cause mortality. RESULTS: Thirty-seven patients (60% men) underwent cyanoacrylate glue injections for GVB. The median follow-up period was 14 months and included 29 patients (eight were lost to follow-up). Initial hemostasis was achieved in 35 patients (95%). No significant complications from cyanoacrylate injection were observed. Early rebleeding was rare (8%) and late rebleeding occurred in only 28% of patients. The all-cause mortality rate was 28.6% during the median follow-up period.  CONCLUSION: The data suggest that cyanoacrylate injection therapy is safe and effective for the prevention of short- and long-term bleeding from gastric varices. Furthermore, although these patients had significant comorbid disease, survival in the follow-up time period was greater than 70%.

Diagnostic yield of repeat capsule endoscopy and the effect on subsequent patient management.

BACKGROUND: Capsule endoscopy (CE) has been shown to produce a high diagnostic yield in patients with obscure gastrointestinal bleeding (OGIB); however, in those with negative studies, management is controversial. Very few studies have reported on repeat CE in the same patient; data regarding this diagnostic strategy are limited. OBJECTIVE: To determine the diagnostic yield of repeated CE studies and how this yield affects subsequent patient management. METHODS: A retrospective chart review of all patients who underwent CE at St Paul's Hospital (Vancouver, British Columbia) between December 2001 and June 2009 was conducted. Patients who underwent subsequent repeat CE were identified and divided into one of four subgroups. Findings were classified as positive or negative. RESULTS: Eighty-two of 676 patients underwent more than one CE study. Group 1 (incomplete study) included 22 patients (27%) and yielded 10 positive findings (45%). Group 2 (screening) comprised four patients (5%) and yielded two positive findings (50%). Group 3 (ongoing symptoms despite previous negative study) totalled 26 patients (32%) and yielded 10 positive findings (38%). Group 4 (previous positive study with treatment/investigation) included 30 patients (37%) and yielded 23 positive findings (77%). Overall, the present study found positive findings in 55% (45 of 82) of repeated CE cases, which resulted in a change in management in 39% (n=32) of the patients. CONCLUSION: Due to the high diagnostic yield and noninvasive nature of CE, repeat CE appears to be of benefit and should be considered for specific patients before other types of small bowel studies.