One bite or two? A prospective trial comparing colonoscopy biopsy technique in patients with chronic ulcerative colitis.

BACKGROUND AND STUDY AIMS: Surveillance for mucosal dysplasia in patients with chronic ulcerative colitis requires numerous biopsies (often over 40). The aim of the present study was to determine if two biopsies could be obtained with jumbo forceps before removing them from the instrument (double biopsy technique), as opposed to one biopsy per pass, without sacrificing the histological quality of the biopsy material. METHODS: Twelve patients with chronic ulcerative colitis underwent colonoscopy, and four-quadrant biopsies were obtained at 10 cm intervals. For biopsies at each interval, two quadrants were obtained using the double biopsy technique and the other two quadrants were obtained individually. Two pathologists blinded to the biopsy technique examined each biopsy for technical and diagnostic qualities. The primary outcome was the histological adequacy in the evaluation of dysplasia. RESULTS: A total of 468 biopsies were obtained. A higher proportion of double-biopsy specimens were inadequate for dysplasia assessment compared with single-biopsy specimens (OR=2.78, 95% CI 1.37 to 5.59; P=0.005). In the double biopsy technique group, 14 samples were deemed inadequate due to actual tissue specimen loss, compared with eight samples in the single biopsy technique. However, when analysis was repeated using only the retrieved specimens, the double biopsy technique continued to be at higher risk of obtaining inadequate specimens (OR=14.5, 95% CI 2.1 to 98.7; P=0.006). CONCLUSIONS: The results of the present study suggest that the double biopsy technique is vulnerable to specimen loss and reduced histological quality, and the adoption of this technique as an equivalent method for tissue sampling may be premature.

Canadian consensus on medically acceptable wait times for digestive health care.

BACKGROUND: Delays in access to health care in Canada have been reported, but standardized systems to manage and monitor wait lists and wait times, and benchmarks for appropriate wait times, are lacking. The objective of the present consensus was to develop evidence- and expertise-based recommendations for medically appropriate maximal wait times for consultation and procedures by a digestive disease specialist. METHODS: A steering committee drafted statements defining maximal wait times for specialist consultation and procedures based on the most common reasons for referral of adult patients to a digestive disease specialist. Statements were circulated in advance to a multidisciplinary group of 25 participants for comments and voting. At the consensus meeting, relevant data and the results of voting were presented and discussed; these formed the basis of the final wording and voting of statements. RESULTS: Twenty-four statements were produced regarding maximal medically appropriate wait times for specialist consultation and procedures based on presenting signs and symptoms of referred patients. Statements covered the areas of gastrointestinal bleeding; cancer confirmation and screening and surveillance of colon cancer and colonic polyps; liver, biliary and pancreatic disorders; dysphagia and dyspepsia; abdominal pain and bowel dysfunction; and suspected inflammatory bowel disease. Maximal wait times could be stratified into four possible acuity categories of 24 h, two weeks, two months and six months. FUTURE DIRECTIONS: Comparison of these benchmarks with actual wait times will identify limitations in access to digestive heath care in Canada. These recommendations should be considered targets for future health care improvements and are not clinical practice guidelines.

Combined low volume polyethylene glycol solution plus stimulant laxatives versus standard volume polyethylene glycol solution: a prospective, randomized study of colon cleansing before colonoscopy.

INTRODUCTION: The effectiveness of polyethylene glycol solutions (PEG) for colon cleansing is often limited by the inability of patients to drink adequate portions of the 4 L solution. The aim of the present study was to determine whether a reduced volume of PEG combined with stimulant laxatives would be better tolerated and as or more effective than the standard dose. METHODS: Patients undergoing outpatient colonoscopy were randomly assigned to receive either low-volume PEG plus sennosides (120 mg oral sennosides syrup followed by 2 L PEG) or the standard volume preparation (4 L PEG). The subjects rated the tolerability of the preparations and their symptoms. Colonoscopists were blind to the colonic cleansing preparation and graded the cleansing efficacy using a validated tool (the Ottawa scale). RESULTS: The low-volume PEG plus sennosides preparation was significantly better tolerated than the standard large volume PEG (P<0.001) but was less efficacious (P=0.03). Thirty-eight per cent of patients in the large volume PEG group were unable to finish the preparation, compared with only 6% in the reduced volume group. There were no adverse events reported. CONCLUSIONS: Although the low-volume PEG plus sennosides preparation was better tolerated, it was not as effective as standard large-volume PEG. However, in view of the significant difference in tolerance, further research investigating possible improvements in the reduced-volume regimen seems warranted.

A prospective randomized trial comparing low-dose oral sodium phosphate plus stimulant laxatives with large volume polyethylene glycol solution for colon cleansing.

This study examined whether the combination of a single dose (45 ml) oral sodium phosphate (NaP), four bisacodyl tablets (5 mg), and one bisacodyl enema (10 mg) preparation, Fleet Prep Kit 3 (FPK #3), was better tolerated and more efficacious than 4 L polyethylene glycol solution (PEG) for colonic cleansing prior to colonoscopy. One hundred and seventy-one patients were enrolled in this prospective, randomized, single-blinded study designed to detect a 20% or greater difference in patient tolerance and effectiveness in colonic cleansing between the two agents. The single dose of NaP and the bisacodyl tablets were administered at 1900 h and at 2100 h, respectively, the evening prior to colonoscopy and the bisacodyl enema 2 h before the procedure. PEG was consumed over 1-2 h the evening prior to colonoscopy. Most patients (84%) found the FPK #3 easy or tolerable compared to only 33% receiving PEG (p < 0.001). Over 40% could not complete the PEG. There was no detectable difference in the efficacy between the two preparations (p= 0.74). Comparison of biochemical and hemodynamic values obtained before and after colonic cleansing did not reveal any significant differences apart from hyperphosphatemia in a few patients (16%) receiving FPK #3 and minor changes in blood urea nitrogen and chloride. These findings suggest that FPK #3 is better tolerated and as safe as PEG but does not provide more efficacious cleansing of the colon.

Carbohydrate-electrolyte rehydration protects against intravascular volume contraction during colonic cleansing with orally administered sodium phosphate.

BACKGROUND: Colonic cleansing with sodium phosphate causes intravascular volume contraction in some patients. This study tested the hypothesis that carbohydrate-electrolyte oral rehydration would attenuate the hypovolemic changes associated with administration of sodium phosphate. METHODS: Adult outpatients were randomized to ingest either regular clear fluids or a carbohydrate-electrolyte rehydration solution during precolonoscopy purgation by ingestion of aqueous sodium phosphate. Investigators were blinded to the treatment assignment of patients. Clinical hemodynamic measurements and biochemical tests were obtained at baseline and after bowel preparation. Tolerability and colonoscopic visualization were assessed with questionnaires. RESULTS: One hundred sixty-eight patients completed the study (81 clear fluids, 87 rehydration). By comparison with clear fluids, rehydration resulted in significantly less intravascular volume contraction. Changes in estimated central venous pressure and orthostatic pulse were significantly greater in the clear fluid group versus the rehydration group (p < 0.03). Changes in biochemical parameters after purgation also suggested a greater degree of volume contraction in the clear fluid versus rehydration group. Colonoscopic visualization was superior in the rehydration versus clear fluid group (p < 0.01); tolerability of the preparations was similar between groups (p = 0.2). CONCLUSIONS: Carbohydrate-electrolyte rehydration protects against intravascular volume contraction during preparation for colonoscopy by ingestion of sodium phosphate. This approach is well tolerated by patients and improves colonic cleansing.

The IBS-36: a new quality of life measure for irritable bowel syndrome.

OBJECTIVE: We aimed to develop and validate a quality of life instrument for patients with irritable bowel syndrome (IBS). METHODS: Using focus groups, existing questionnaires, and literature reviews, five IBS patients and nine gastroenterologists compiled and pilot tested for content validity a 70-item questionnaire. The questionnaire was then administered to 107 IBS patients, and using these data, the 70-item questionnaire was reduced to 36 questions through statistical and consensus methodology. The IBS-36 questionnaire was tested for construct validity, reliability, reproducibility, and responsiveness using a gold standard of structured interviews by three gastroenterologists, the Medical Outcomes Study Short Form Quality of Life Questionnaire, and the Coping Resource Inventory. RESULTS: The IBS-36 consists of 36 questions scored on a 7-point Likert scale. It has a very high internal consistency (Cronbach's alpha = 0.95) and a high test-retest reliability (Spearman's r = 0.92) and correlates as hypothesized with the Medical Outcomes Study Short Form Quality of Life Questionnaire (p < 0.001), McGill pain scores (p < 0.001), and IBS patient-reported sleep, symptom, and pain scores (ps = 0.030, <0.001, and <0.001, respectively). CONCLUSIONS: The IBS-36 addresses all areas of quality of life affected by IBS and is easy to administer and score. The IBS-36 is a well-validated, condition-specific quality of life measure for IBS patients that is sensitive to clinical intervention and highly correlated with established quality of life measures and patient-reported symptom scores.