External Abdominal Pressure Research Articles

External abdominal pressure radiography versus survey radiography for the diagnosis of hiatal hernia in brachycephalic dogs

Hiatal hernia (HH) is a common disorder in brachycephalic dogs with upper airway obstruction. The breathing effort results in an exaggerated transdiaphragmatic pressure gradient during inspiration that can displace the gastroesophageal junction causing gastroesophageal reflux. The diagnosis is challenging because the HH usually occurs intermittently and is often missed on survey radiography. In this retrospective study, the application of external abdominal pressure to mimic the transdiaphragmatic pressure gradient during radiographic screening for HH was evaluated in 146 dogs. Hiatal hernia was diagnosed with external abdominal pressure radiographs in 6.8% (10/146 dogs), whereas it was diagnosed via survey radiography in only 2% (3 dogs). In conclusion, the radiographic diagnosis of HH in brachycephalic dogs can be improved by performing external abdominal pressure radiographs.

Examining the association of external abdominal pressure with muscle mass and low back pain in older adults

Examining the association of external abdominal pressure with muscle mass and low back pain in older adults

Effects of External Abdominal Pressure Support on Dynamic Balance: A Randomized Crossover Study.

Abdominal pressure is vital in protecting the lumbar spine and controlling postural balance. Dynamic balance is associated with movement stability, adaptation to load, and reduced injury risk. Although trunk stability has been examined using belts and braces, the effects of external abdominal pressure support (APS) on balance control remain unknown. In this study, we aimed to determine the effects of external APS on dynamic balance. Overall, 31 young adults participated in this randomized crossover study. External APS was provided using a device that could be pressurized and decompressed by inflating a cuff belt wrapped around the trunk. The modified Star Excursion Balance Test was performed under external APS and non-APS conditions. The maximum anterior, posterolateral, and posteromedial values normalized to the spinal malleolar distance and their respective composite values were compared between the two conditions with and without APS. Posterolateral, posteromedial, and composite values were significantly higher in the APS condition than in the non-APS condition (p < 0.001). The external APS was effective in immediately improving dynamic balance. Furthermore, APS was effective in dynamic balance control as it improved stability during anterior trunk tilt, which displaces the center of gravity forward.

Is it feasible to measure intra-abdominal pressure using a balloon-tipped rectal catheter? Results of a validation study

The gold standard to measure intra-abdominal pressure (IAP) is intra-vesical measurement via the urinary bladder. However, this technique is restricted in ambulatory settings because of the risk of iatrogenic urinary tract infections. Rectal IAP measurements (IAPrect) may overcome these limitations, but requires validation. This validation study compares the IAPrect technique against gold standard intra-vesical IAP measurements (IAPves). IAPrect using an air-filled balloon catheter and IAPves using Foley Manometer Low Volume were measured simultaneously in sedated and ventilated patients. Measurements were performed twice in different positions (supine and HOB 45° elevated head of bed) and with an external abdominal pressure belt. Sixteen patients were included. Seven were not eligible for analysis due to unreliable IAPrect values. IAPrect was significantly higher than IAPves for all body positions (p < 0.01) and the correlation between IAPves and IAPrect was poor and not significant in each position (p ≥ 0.25, R2 < 0.6, Lin’s CCC < 0.8, bias − 8.1 mmHg and precision of 5.6 mmHg with large limits of agreement between − 19 to 2.9 mmHg, high percentage error 67.3%, and low concordance 86.2%). Repeatability of IAPrect was not reliable (R = 0.539, p = 0.315). For both techniques, measurements with the external abdominal pressure belt were significantly higher compared to those without (p < 0.03). IAPrect has important shortcomings making IAP estimation using a rectal catheter unfeasible because the numbers cannot be trusted nor validated.

The Impact of the Colonoscopy Starting Position and Its Potential Outcomes.

Based on the literature review, many studies have been inconclusive in regards to adenoma detection and procedural positioning during a colonoscopy. Scope looping can make cecal intubation challenging, changing the positioning of the patient and application of external abdominal pressure can overcome this difficulty. A colonoscopy in a prone position can overcome these challenges and reduce cecal intubation time. It can thus improve the safety of the patient and the staff by minimizing the movement of a sedated patient.

PD40-01 ACCURACY OF CYSTOGRAPHY IN CHILDREN UNDER GENERAL ANESTHESIA WITH SUSPECTED VESICOURETERAL REFLUX

You have accessJournal of UrologyCME1 May 2022PD40-01 ACCURACY OF CYSTOGRAPHY IN CHILDREN UNDER GENERAL ANESTHESIA WITH SUSPECTED VESICOURETERAL REFLUX Michael Frumer, Bezalel Sivan, Tal May, Roy Morag, Dmitry Khunovich, and David Ben Meir Michael FrumerMichael Frumer More articles by this author , Bezalel SivanBezalel Sivan More articles by this author , Tal MayTal May More articles by this author , Roy MoragRoy Morag More articles by this author , Dmitry KhunovichDmitry Khunovich More articles by this author , and David Ben MeirDavid Ben Meir More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002601.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Cystography under general anesthesia has proven a safe procedure in several studies. Some radiologists prefer to insert the catheter and perform examinations under anesthesia for their and the child's convenience. This study compares cystography under light sedation to cystography under general anesthesia. METHODS: A prospective study of children who had vesicoureteral reflux (VUR) on cystography without general anesthesia, and underwent endoscopic injection of bulking agent into the ureter. Pre-operative clinical and radiological data were recorded. All children subsequently underwent a cystography under general anesthesia prior to injection using standardized method, which included bladder filling to iliac crest level, and external abdominal pressure to look for active reflux. This cystography was compared to cystography performed without general anesthesia. Chi-square and Mann–Whitney U tests were used to compare proportions and medians between groups. RESULTS: Between October 2017 and January 2021, 92 renal units in 8 boys and 38 girls were evaluated. Median age was 3 years (IQR 1.5, 5). Median time from cystography without to cystography with general anesthesia was 3.7 months (IQR 2.6, 5.9). Of the 92 renal units, 73 had VUR on cystography without general anesthesia, considered as gold standard. VUR grades by the gold standard are presented in Table 1. On dichotomous analysis (no VUR vs. any VUR) sensitivity, specificity, negative predictive value and positive predictive value of cystography with general anesthesia were 41% (30/73), 79% (15/19), 26% (15/58), and 88% (30/34) (Table 2). Cohen’s Kappa coefficient between the two cystography was 0.11, indicating poor agreement. In subgroup analyses, the sensitivity of cystography with general anesthesia for filling phase VUR was 45% (29/64) vs. 11% (1/9) for voiding phase VUR (P=0.05). CONCLUSIONS: Cystography with general anesthesia was poorly correlated to cystography performed while the child was lightly sedated. Clinical decision relying on this cystography is questionable. Source of Funding: none © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e683 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Michael Frumer More articles by this author Bezalel Sivan More articles by this author Tal May More articles by this author Roy Morag More articles by this author Dmitry Khunovich More articles by this author David Ben Meir More articles by this author Expand All Advertisement PDF DownloadLoading ...

S2367 Push Enteroscopy-Assisted ERCP for Treatment of Biliary Obstruction and Cholangitis in a Patient With Kasai Porto-Enterostomy

INTRODUCTION: Biliary obstruction and acute cholangitis are late complications in patients with Kasai porto-enterostomy performed for biliary atresia. Patients typically present with fevers and jaundice and can progress to liver failure. Only a few cases have reported successful endoscopic treatment for biliary obstruction in adults with a previous Kasai procedure. Here we describe the case of a 34-year-old female with Kasai porto-enterostomy with recurrent cholangitis. A successful enteroscopy-assisted ERCP was performed with resolution of symptoms. CASE DESCRIPTION/METHODS: A 34-year-old female with a history of biliary atresia status post Kasai procedure done shortly after birth presented with intermittent fevers, refractory pruritus, and recent hospitalization for acute cholangitis. Her workup revealed elevated liver tests and serum bile acids. MRCP showed right intrahepatic bile duct (RHD) dilatation with peribiliary cysts, trace left intrahepatic bile duct (LHD) dilatation and focal stricture at the porto-enterostomy anastomosis. We performed an enteroscopy-assisted ERCP with the patient in supine position. A pediatric colonoscope with a clear cap was used to access the biliary limb. After applying external abdominal pressure, the porto-enterostomy was reached and showed a severely stenosed opening of the bile ducts (Figure 1). The RHD was deeply cannulated using a 0.025” hydrophilic-tipped guidewire. Cholangiogram showed dilated RHD up to 10mm with severe stricture at the porto-enterostomy (Figure 2). The stricture was dilated with a balloon dilator first to 3mm then 4mm. A 5Fr x 4cm plastic stent with a single internal flange and single external pigtail was placed into the RHD. Cannulation of the LHD was unsuccessful due to complete obstruction of the ducts. A submucosal ink injection was used to mark the biliary limb. The patient was discharged home the same day. Both her fever and pruritus resolved and she has not had further episodes of cholangitis. Her liver tests improved markedly (Table 1). On repeat ERCP, the prior stent was exchanged for a 7Fr x 5cm stent. Liver enzymes normalized. No late complications occurred. DISCUSSION: Enteroscopy-assisted ERCP is a feasible treatment for biliary obstruction in patients with Kasai porto-enterostomy. Altered anatomy and limited choice of tools make interventions challenging. This procedure should be considered as an alternative to more invasive percutaneous and surgical techniques and as part of a multidisciplinary approach.Table 1.: Serum Bile Acids, Hepatic Panel, Complete blood count, C-reactive Protein prior to ERCP vs. 4 and 12 weeks post ERCP with stent placementFigure 1.: Severely stenosed bile ducts (black arrow).Figure 2.: Cholangiogram with dilated right intrahepatic bile duct.

1452 Unusual Complication Following Screening Colonoscopy

INTRODUCTION: Colonoscopy in general can be a challenging procedure as the colon is often quite mobile and tortuous. While abdominal pain is relatively common during and after the procedure, evaluation is always required to rule out serious causes such as colonic perforation and organ injury. CASE DESCRIPTION/METHODS: A 62-year-old female with a history of a left nephrectomy (23 years ago) underwent a screening colonoscopy (performed with good bowel preparation, under conscious sedation, and the whole colon was described as significantly redundant, tortuous and endoscopically normal) at the referring facility. She developed worsening left sided abdominal pain, nausea and vomiting three days after the procedure (managed at several occasions with bowel rest and antibiotics for presumed enteritis/diverticulitis). CT scan, 3 months following colonoscopy showed a complex irregular collection involving pancreatic tail and splenic flexure with adjacent partially rim-enhancing fluid collection abutting the greater curvature of the stomach. A CT guided percutaneous aspiration of fluid collection showed a markedly elevated lipase and amylase. This was concerning for pancreatic duct (PD) leak. She underwent an ERCP and placement of 3 Fr by 13 cm single pigtailed Advantix stent and 5 Fr by 3 cm Geenen stent for a confirmed PD leak. Although no definite fistulous communication to colon was seen on the fluoroscopic images, an immediate post ERCP non-contrast CT scan revealed contrast in the left colon concerning for a colo-pancreatic fistula. Her clinical symptoms resolved immediately following procedure. A follow up ERCP after 4 weeks confirmed no further PD leak. DISCUSSION: This patient's presentation is most consistent with chronic PD leak. The likely explanatory mechanisms include traction on fibrous surgical adhesions between the splenic flexure and distal pancreas, direct blunt trauma by passage of the colonoscope through the splenic flexure, and external abdominal pressure around the left colon. This case illustrates that it is possible for a patient with pre-existing risk factors to develop a significant pancreatic injury following colonoscopy. Careful review of patient's surgical history at time of informed consent is essential to identify those at risk and to take preventive measures including avoiding and reducing endoscope looping, avoiding excessive force and minimizing air insufflation.

1877 An Unfortunate Turn of Events: A Rare Case of Splenic Hematoma Following Colonoscopy for Post-Polypectomy Bleeding

INTRODUCTION: Post-polypectomy bleeding has been reported to occur in 0.3 to 6.1% of colonoscopic polypectomies. Splenic injury after colonoscopy is a rare complication with a described incidence of less than 0.017%. CASE DESCRIPTION/METHODS: A 66-year-old male with a past medical history of hypertension was admitted with post-colonoscopic polypectomy bleed. He underwent a colonoscopy in July 2018 for a history of adenomatous polyps. The colonoscopy revealed multiple non-bleeding polyps (about 15) throughout the large bowel and 8 polyps were removed with endoscopic mucosal resection (EMR). A follow up colonoscopy was performed for resection of the remaining polyps in October 2018. He presented to the hospital one-week post second colonoscopy with acute onset of hematochezia. On presentation, he was afebrile, with HR 64 and BP 108/62. Labs were notable for hemoglobin of 7.1 g/dl (from a baseline of 11 to 12 g/dl) concerning for post-polypectomy bleeding. Colonoscopy repeated after admission showed no active bleeding; a clean based ulcer was noted in the transverse colon at the site of EMR which was the likely source of bleeding. Hospital course was complicated by severe left upper quadrant pain and shock with BP dropping to 70s/40s requiring ICU admission one day after the colonoscopy. He was found to be coagulopathic with an INR of 4.9 requiring vitamin K and FFP. Hemoglobin dropped to 5.3 g/dl and he received a total of 10 units of pRBC transfusions. CTA abdomen/pelvis showed a splenic hematoma measuring 12.3 x 10 x 17 cm. Splenectomy was deferred per surgery recommendations and coil embolization of the proximal splenic artery was successfully performed. He improved clinically after splenic artery embolization and was discharged home with follow-up. DISCUSSION: Splenic injury is a potentially catastrophic complication of colonoscopy with a reported mortality of about 5%. Several mechanisms of splenic injury associated with colonoscopy have been described which include difficult procedure, traction on the splenocolic ligament, external abdominal pressure during colonoscopy, perforation of the splenic flexure and direct trauma to the spleen, and traction of adhesions between the spleen and colon. Patient-related risk factors such as abdominal surgeries leading to adhesions, splenomegaly and pancreatitis increase the likelihood of splenic injury during the procedure. With increasing number of cases, further studies are required to re-assess the incidence and risk factors for splenic injury after colonoscopy.

ColoWrap Compression Device May Speed Cecal Intubation in Obese Patients

ColoWrap is an abdominal binder designed to supply external abdominal pressure and prevent looping during colonoscopy.To assess the efficacy of

The role of routinely given hyoscine-N-butylbromide in colonoscopy: a double-blind, randomized, placebo-controlled, clinical trial

Objective: Hyoscine-N-butylbromide (HBB) has been proposed to ease colonoscopy and improve mucosal visualization, yet the results from previous studies are conflicting. In our prospective, double-blind, placebo-controlled, randomized study we aimed at evaluating whether routine administration of HBB, before and during colonoscopy, ease the procedure or increase the detection rate for polyps. Material and methods: One hundred fifty outpatients scheduled for an elective colonoscopy were randomized to receive intravenous injections of either 10 mg hyoscine-N-butylbromide or saline before insertion and at cecum. Patient tolerance and technical ease of colonoscopy were evaluated by visual analogue scale (VAS). Procedure times were recorded. Number of detected polyps per patient was evaluated as well. Heart rate was monitored with a pulse oximetry. Results: HBB did not improve patient tolerance or technically ease the procedure as evaluated by VAS. However, HBB led to faster ileal intubation (1.5 vs 2.0 min, p < 0.001) and shorter total procedure time (22.0 vs 24.0 min, p = 0.03). Patients who received HBB also needed less often external abdominal pressure (48.6 vs 66.7%, p = 0.03). HBB did not improve polyp detection rate (0.89 vs 0.91, p = 0.90). HBB induced a significant rise in heart rate (p < 0.001) and more often tachycardia (17.6 vs 0%, p < 0.001). Conclusions: Routine administration of HBB before and during colonoscopy yields only limited improvement in the technical performance of the examination compromised by high incidence of tachycardia.

Colonoscopy core curriculum

Colonoscopy core curriculum

The Non-pneumatic Anti-Shock Garment: How Applier Strength and Body Mass Index Affect External Abdominal Pressure

Objective: To assess the amount of abdominal pressure generated by the Non-pneumatic Anti-Shock Garment (NASG), a first-aid counter pressure device for obstetric hemorrhage, and to evaluate if body mass index (BMI) and ap- plier strength, affect pressure. Study Design: A pilot study convenience sample of 20 non-pregnant volunteers underwent external abdominal pressure monitoring with NASG placement. Mean pressure and the effects of BMI and applier strength were examined. Results: The mean external abdominal pressure significantly increased from 1.0 mmHg at baseline to 67 mmHg on NASG application, returning to 1.0 mmHg upon removal (p=0.005). Greater mean pressure was exerted by a strong applier ver- sus a weak applier, irrespective of BMI (p<0.001). Pressure had an inverse relationship with BMI, particularly with a strong applier (r=-0.905, p<0.001). The difference between pressures achieved in an underweight patient with a strong ap- plier and an overweight patient with a weak applier was significant (73.2 vs 35.7 mmHg; p=0.051). Conclusion: This pilot study demonstrates a significant increase in abdominal pressure with device application and sig- nificant variation with BMI and applier strength. These findings may have important implications for optimizing device usage.

Hypothesis: Preeclampsia is a venous disease secondary to an increased intra-abdominal pressure

It is hypothesized that in some women an excessively high intra-abdominal pressure (IAP) compresses the inferior vena cava, uterine veins, portal vein, hepatic veins, splenic vein and renal veins which lead to a decreased flow in these vascular beds, producing lower extremity edema, fetal-placental ischemia, a glomerulopathy with proteinuria and hypertension, hepatic ischemia and thrombocytopenia, increased uric acid, and hemolysis/elevated liver enzymes/low platelet known as the HELLP syndrome. There can be variability in the expression of these components. Placental-fetal ischemia could lead to expression of soluble fms-like tyrosine kinase1 (sFLT) and endoglin which have been shown to cause additional diffuse endovascular damage. A further increase in IAP pushes the diaphragm cephalad, increasing intrathoracic pressure leading to upper extremity edema, decreased internal jugular venous flow, cerebral vascular engorgement, raised intracranial pressure, and if unresolved, seizures. Placental/fetal ischemia and hepatic ischemic necrosis may lead to diffuse inflammation and a septic inflammatory response syndrome (SIRS) which may become a vicious cycle, perpetuating the ischemia. It is further hypothesized that application of an externally applied negative abdominal pressure device will lower IAP and possibly reverse the pathophysiology of preeclampsia. As the abnormal placental proteins develop weeks before clinical preeclampsia, early application of external negative abdominal pressure may prevent development of the syndrome.

The Influence of Abdominal Pressure on Lower Extremity Venous Pressure and Hemodynamics: A Human In-vivo Model Simulating the Effect of Abdominal Obesity

Objective To demonstrate that abdominal pressure impacts venous flow and pressure characteristics. Methods Venous pressure at the femoral vein was measured in 6 non-obese subjects (mean BMI 22 ± 2 kg/m 2) that were exposed to a circumferential cuff placed around the abdominal trunk and inflated to 20 and 40 mmHg. In a second step non-obese subjects ( n = 10, BMI 21.8 ± 1.8 kg/m 2) exposed to this cuff compression were studied for duplexsonographic parameters at the femoral vein. Duplexsonographic results were compared to subjects with abdominal obesity ( n = 22, BMI 36.2 ± 5.9 kg/m 2) in whom duplexsonographic parameters at the femoral vein were studied without cuff compression. Results Intravenous pressure increased with pressure application in all participants ( p = 0.0025). Duplex examination of 10 non-obese subjects revealed increasing venous diameter ( p < 0.0001) and decreasing venous peak and mean velocity (all p < 0.0001) when cuff pressure was applied. Duplex parameters with cuff pressure application of 20 and 40 mmHg respectively, were similar to those in obese subjects that were studied without pressure application. Conclusions External abdominal pressure application creates venous stasis in lower limbs. Results of this study indicate that abdominal obesity might induce resistance to venous backflow from the lower limbs.

Increasing abdominal pressure with and without PEEP: effects on intra-peritoneal, intra-organ and intra-vascular pressures.

BackgroundIntra-organ and intra-vascular pressures can be used to estimate intra-abdominal pressure. The aim of this prospective, interventional study was to assess the effect of PEEP on the accuracy of pressure estimation at different measurement sites in a model of increased abdominal pressure.MethodsCatheters for pressure measurement were inserted into the stomach, urinary bladder, peritoneal cavity, pulmonary artery and inferior vena cava of 12 pigs. The pressures were recorded simultaneously at baseline, during 10 cm H20 PEEP, external abdominal pressure (7 kg weight) plus PEEP, external abdominal pressure without PEEP, and again under baseline conditions.Results (mean ± SD)PEEP alone increased diastolic pulmonary artery and inferior vena cava pressure but had no effect on the other pressures. PEEP and external abdominal pressure increased intraperitoneal pressure from 6 ± 1 mm Hg to 9 ± 2 mm Hg, urinary bladder pressure from 6 ± 2 mm Hg to 11 ± 2 mm Hg (p = 0.012), intragastric pressure from 6 ± 2 mm Hg to 11 ± 2 mm Hg (all p ≤ 0.001), and inferior vena cava pressure from 11 ± 4 mm Hg to 15 ± 4 mm Hg (p = 0.01). Removing PEEP and maintaining extraabdominal pressure was associated with a decrease in pulmonary artery diastolic but not in any of the other pressures. There was a significant correlation among all pressures. Bias (-1 mm Hg) and limits of agreement (3 to -5 mm Hg) were similar for the comparisons of absolute intraperitoneal pressure with intra-gastric and urinary bladder pressure, but larger for the comparison between intraperitoneal and inferior vena cava pressure (-5, 0 to -11 mm Hg). Bias (0 to -1 mm Hg) and limits of agreement (3 to -4 mm Hg) for pressure changes were similar for all comparisonsConclusionsOur data suggest that pressure changes induced by external abdominal pressure were not modified by changing PEEP between 0 and 10 cm H20.

Prone positioning for ARDS following blunt chest trauma in late pregnancy

After a road traffic accident a pregnant patient at 34 weeks of gestation developed ARDS following blunt chest trauma, for which she required mechanical ventilation. Twenty-four hours after the accident, ongoing severe hypoxaemia with atelectasis mainly in the dorsal parts of the lung led to the decision to manage the patient in the prone position. Prone positioning over 8 h resulted in a persistent improvement of oxygenation, which allowed extubation the following day. At term, however, our patient was admitted with dyspnoea, chest pain, haemodynamic instability and fetal bradycardia, for which she required emergency caesarean section followed by thoracotomy for haemothorax, from which she eventually made a full recovery. We have demonstrated that prone positioning can be used safely and effectively in a pregnant patient. It might be superior to other therapeutic options for improvement of oxygenation in pregnant patients. Careful positioning avoiding any external abdominal pressure and continuous fetal monitoring are mandatory.

1694: Hand Assisted Ureteroscopy: Semi-Rigid Ureteroscopy of the Proximal Ureter can be Aided by External Abdominal Pressure

You have accessJournal of UrologyModerated Poster, Wednesday, May 25, 2005, 3:30 - 5:30 pm1 Apr 20051694: Hand Assisted Ureteroscopy: Semi-Rigid Ureteroscopy of the Proximal Ureter can be Aided by External Abdominal Pressure Brian D.M. Blew, A. Joel Dagnone, Kenneth T. Pace, and R. John D'A Honey Brian D.M. BlewBrian D.M. Blew More articles by this author , A. Joel DagnoneA. Joel Dagnone More articles by this author , Kenneth T. PaceKenneth T. Pace More articles by this author , and R. John D'A HoneyR. John D'A Honey More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(18)35816-6AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "1694: Hand Assisted Ureteroscopy: Semi-Rigid Ureteroscopy of the Proximal Ureter can be Aided by External Abdominal Pressure." The Journal of Urology, 173(4S), pp. 459–460 © 2016 by American Urological AssociationFiguresReferencesRelatedDetails Volume 173Issue 4SApril 2005Page: 459-460 Advertisement Copyright & Permissions© 2016 by American Urological AssociationMetricsAuthor Information Brian D.M. Blew More articles by this author A. Joel Dagnone More articles by this author Kenneth T. Pace More articles by this author R. John D'A Honey More articles by this author Expand All Advertisement PDF DownloadLoading ...

The Impact of the Endoscopy Nurse on Colonoscopy Completion Rates

The Impact of the Endoscopy Nurse on Colonoscopy Completion Rates Madhusudhan R. Sanaka, Nirav Shah, Kevin D. Mullen, Saeid Amini, Arthur J. McCullough Background: Colonoscopy is a technically demanding procedure, frequently requiring multiple maneuvers including change in patient’s position and application of appropriate external abdominal pressure by the nurse to assist in completion of procedure. Hence, the endoscopy nurse may have an important role in colonoscopy completion rates. Aims: To determine and compare the colonoscopy incompletion rates among individual endoscopy nurses in our unit. Methods: Retrospective chart review of all colonoscopies performed in our endoscopy unit from November 2003 to October 2004 at MetroHealth Medical Center, Cleveland, Ohio. Colonoscopies are performed by either gastroenterology trainees under attending supervision or by attending physicians. There are a total of 12 endoscopy nurses who assist in colonoscopies, of which 5 are registered nurses (RN) and 7 are licensed practical nurses (LPN). Patient demographics, indications for procedure and colonoscopic findings were reviewed. Patients who had incomplete colonoscopy due to poor bowel preparation and colonic pathology precluding completion were excluded. Results: A total of 1896 colonoscopies were included in the analysis, of which 62 were incomplete (3.3%). Mean number of colonoscopies assisted by each individual endoscopy nurse was 158 (range 86-392). Mean endoscopy work experience of the nurses was 4.5 years (range 0.5-15 years). Incompletion rate of colonoscopies was similar among the individual nurses and ranged from 1.0% to 5.8% (p O 0.05). Incompletion rate did not correlate with either nurse’s work experience or the level of education, LPN versus RN (p O 0.05). Conclusions: The endoscopy nurse assisting in colonoscopy does not impact colonoscopy completion rate. Also, there is no correlation between the nurse’s work experience or the level of education (LPN versus RN) on colonoscopy completion rates. W1150 Colonic Polyps and Malignant Potential – Does Size Matter? Uwe Seitz, Tiing Leong Ang, Frederick Dy, Theerapong Sookpaisal, Johannes Sadikin, Indra Marki, Frank Thonke, Stefan Seewald, Sabine Bohnacker, Andreas De Weerth, Nib Soehendra Background: When colonic polyps are encountered during colonoscopy, polypectomy is the standard of care. Malignant potential was correlated with larger adenoma size, villous histology, and more severe dysplasia. Adenomas have classically been categorized into three size groups: !1 cm, 1-2 cm, and O2 cm. Whether the malignant potential differs among polyps O2 cm is not well defined. Aim: To correlate the size of colonic polyps with severity of dysplasia, occurrence of malignancy and histological subtype. Methods: The clinical data of all patients who underwent colonoscopy and polypectomy during the period from October 1997 to October 2004 was reviewed retrospectively. Only patients with resected polyps and histology were included. Polypectomy was performed using a monofilament snare. For large sessile polyps, piecemeal resection was preferred. None of these patients had endoscopic suspicion of malignancy such as induration, ulceration and friability. The size of the polyps was correlated with the histological findings. Results: A total of 12164 colonoscopies were performed during the review period and 2681 patients (mean age 63 years, range 18 to 94; male 61%) were eligible, yielding a total of 6453 polyps. The size of the polyps ranged from !0.5 to 20 cm. The number of polyps larger than 2 cm was 409. Distribution of polyps based on dysplasia: high grade dysplasia (H) 3.6%, low grade dysplasia (L) 72.1% and carcinoma (C) 0.8%. Histological subtype: tubular adenoma (T) 73.8%, tubulovillous adenoma (TV) 25.4% and villous adenoma (V) 1.3%. Correlation of polyp size with severity of dysplasia: !0.5 cm: C 0.1%, H 0.7%; 0.5-1 cm: C 0.8%, H 3.6%; 1-2 cm: C 3.7%, H 8.6%; 2-3 cm: C 5.2%, H 15.7%; 3-4 cm: C 2.3%, H 34.5%; O4 cm: C 2.9%, H 46.4% (p ! 0.01). Correlation of polyp size with histological subtype: !0.5 cm: TV 13.2%, V 0.4%; 0.5-1 cm: TV 19.5%, V 0.7%; 1-2 cm: TV 38.3%, V 1.7%; 2-3 cm: TV 51.4%, V 4.9%; 3-4 cm: TV 67.9% V 9.5%; O4 cm: TV 68.7%, V 11.9% (p ! 0.01). Three polyps measured 10 cm (C 1; H 2) while 1 polyp measured 20 cm (H). Conclusion: A larger polyp size was significantly associated with increased severity of dysplasia and villous histology. Beyond 4 cm size, although the tendency for HGD continued to rise, the risk for invasive cancer appears to plateau off. Thus, in the context of large colonic polyps without obvious endoscopic features of malignancy, endoscopic resection should be attempted first if technically feasible and the expertise is available.

Effects of vaginal distension on urethral anatomy and function.

To determine the effect of repeated and prolonged vaginal distension on the leak-point pressure (LPP) and urethral anatomy in the female rat, as prolonged vaginal distension has been clinically correlated with signs of stress urinary incontinence (SUI). Sixty female rats were placed into one of five groups; four groups underwent one of four vaginal distension protocols using a modified 10 F Foley catheter, i.e. prolonged (1 h), brief (0.5 h), intermittent (cycling inflated/deflated for 0.5 h) or sham distension. All animals had a suprapubic bladder catheter implanted 2 days after and were assessed urodynamically 4 days after vaginal distension. The fifth group of rats acted as controls and did not undergo vaginal distension, but did have a suprapubic bladder catheter placed and urodynamics assessed. To measure LPP the rats were anaesthetized with urethane, placed supine and the bladder filled with saline (5 mL/h) while bladder pressure was measured via the bladder catheter. LPPs were measured three times in each animal by manually increasing the abdominal pressure until leakage at the urethral meatus, when the external abdominal pressure was rapidly released. Peak bladder pressure was taken as the LPP and a mean value calculated for each animal. Immediately after measuring LPP the urethra was removed and processed routinely for histology (5 micro m sections, stained with haematoxylin/eosin and trichrome). The means (sem) were compared using a Kruskal-Wallis one-way anova on ranks, followed by a Dunn's test, with P < 0.05 indicating a significant difference. Both LPP and the external increase in abdominal pressure were significantly lower after prolonged distension, at 31.4 (1.7) and 19.8 (1.2) cmH2O, than in the sham group, at 41.1 (3.2) and 32.0 (4.7) cmH2O, respectively. There were no significant differences in LPP or in the increase in abdominal pressure between the brief, intermittent and sham groups. Qualitative histology showed that prolonged distension resulted in extensive disruption and marked thinning of urethral skeletal muscle fibres. Brief and intermittent distension showed mild and focal disruptions, respectively. As observed clinically, prolonged vaginal distension results in a lower LPP, greater anatomical injury and increased severity of SUI. These results suggest that ischaemia is important in the development of SUI after prolonged vaginal distension.