Postcolonoscopy Abdominal Pain Research Articles

Efficacy and safety of cold versus hot snare polypectomy for small (5–9 mm) colorectal polyps: a multicenter randomized controlled trial

Resection techniques for small polyps include cold snare polypectomy (CSP) and hot snare polypectomy (HSP). This study compared CSP and HSP in 5-9 mm polyps in terms of complete resection and adverse events. This was a multicenter, randomized trial conducted in seven Spanish centers between February and November 2019. Patients with ≥ 1 5-9 mm polyp were randomized to CSP or HSP, regardless of morphology or pit pattern. After polypectomy, two marginal biopsies were submitted to a pathologist who was blinded to polyp histology. Complete resection was defined as normal mucosa or burn artifacts in the biopsies. Abdominal pain was only assessed in patients without < 5 mm or > 9 mm polyps. 496 patients were randomized: 237 (394 polyps) to CSP and 259 (397 polyps) to HSP. Complete polypectomy rates were 92.5 % with CSP and 94.0 % with HSP (difference 1.5 %, 95 % confidence interval -1.9 % to 4.9 %). Intraprocedural bleeding occurred during three CSPs (0.8 %) and seven HSPs (1.8 %) (P = 0.34). One lesion per group (0.4 %) presented delayed hemorrhage. Post-colonoscopy abdominal pain presented similarly in both groups 1 hour after the procedure (CSP 18.8 % vs. HSP 18.4 %) but was higher in the HSP group after 5 hours (5.9 % vs. 16.5 %; P = 0.02). A higher proportion of patients were asymptomatic 24 hours after CSP than after HSP (97 % vs. 86.4 %; P = 0.01). We observed no differences in complete resection and bleeding rates between CSP and HSP. CSP reduced the intensity and duration of post-colonoscopy abdominal pain.

Carbon dioxide insufflation during colonoscopy can significantly decrease post-interventional abdominal discomfort in deeply sedated patients: A prospective, randomized, double-blinded, controlled trial.

CO2 has been reported to be absorbed from the bowel more rapidly than air, resulting in a discomfort reduction after colonoscopy. Its role in deeply sedated patients is limited. This study was designed to investigate the efficacy and safety of CO2 insufflation during colonoscopy in patients deeply sedated with propofol. A total of 125 continuous patients were randomly assigned to receive either CO2 (n = 63) or air (n = 62) insufflation during propofol-sedated colonoscopy. Postcolonoscopy abdominal pain, distention, and satisfaction were assessed at 1, 3, and 24 h after the procedure, and the proportions of pain-free and distention-free patients were compared. Residual bowel gas in the colon and small bowel was evaluated at 1 h after colonoscopy. End-tidal CO2 and O2 saturation was measured for safety analysis. There was a significant difference between the two groups regarding the postcolonoscopy abdominal pain, distention, and subjective satisfaction at 1 h (P < 0.001) and 3 h (P < 0.01) after the procedure. Patients' pain and distention at 1 and 3 h after the procedure were significantly lower in the CO2 group (P < 0.01). Residual bowel gas in the colon and small bowel was significantly less in the CO2 group (P < 0.001). There was no significant difference in end-tidal CO2 levels between two groups before, during, and after the procedure. Compared with air, CO2 insufflation during colonoscopy reduced postcolonoscopy abdominal discomfort and improved patients' satisfaction. It was safe to use CO2 insufflation in deeply sedated colonoscopy.

Total Colonic Decompression After Colonoscopy Decreases Postcolonoscopy Abdominal Pain: A Randomized Double-Blind Controlled Trial.

The purpose of this study was to determine whether total colonic decompression after colonoscopy decreased postcolonoscopy abdominal pain. Abdominal pain that occurs after a colonoscopy may cause significant discomfort in some patients, and residual bowel gas is thought to be a key contributor to this abdominal pain. Asymptomatic 300 patients who underwent colonoscopy under sedation were randomized to either the decompression group or the control group. Initial colonoscopic procedure was performed uniformly in both the groups. After the colonoscopy examination was completed, the colonoscope was reinserted into the cecum, and the intraluminal air was aspirated during withdrawal in the decompression group. Abdominal pain was assessed before discharge and 24 to 48 hours after colonoscopy using a 10-point visual analogue scale (VAS). The 2 groups were similar with regard to clinical, demographic, and procedural factors. Among 288 patients, the incidence of abdominal pain (VAS≥1) after colonoscopy was 38 (26.6%) of 143 patients in the decompression group and 95 (65.5%) of 145 patients in the control group (VAS 0.68±1.35 vs. 2.14±2.15, P<0.001). There was an 86.1% reduction rate of abdominal pain by colonic decompression, based on multivariate analysis (odds ratio 0.139 [95% confidence interval, 0.077-0.250], P<0.001). Furthermore, independent factors for abdominal pain included female gender and total duration of procedure >800 seconds. There were no reinsertion-related complications in the decompression group. Total colonic decompression after colonoscopy has a beneficial effect and can reduce postcolonoscopy abdominal pain without additional complications.

P-049: Reproducibility of serologic antibody activity at diagnosis and after treatment in pediatric ulcerative colitis and Crohn’s disease

P-049: Reproducibility of serologic antibody activity at diagnosis and after treatment in pediatric ulcerative colitis and Crohn’s disease

Splenic Rupture after Colonoscopy

Colonoscopy is the gold standard in diagnosis of colorectal diseases. It is generally a safe procedure with low complication rate. Splenic rupture is a very rare complication of colonoscopy. The case presented here, is a 57 years old male patient with complaint of hematochesia. He had colonoscopy and diagnosed as sigmoid colon tumor. After colonoscopy he had the findings of acute abdomen. At the operation splenic rupture was detected and he had undergone splenectomy with subtotal colectomy for the sigmoidal tumor. Splenic rupture is very rare but fatal complication of colonoscopy. In the management of patients with post-colonoscopy abdominal pain splenic injury should be kept in mind.

Minor Adverse Events Postcolonoscopy

Minor Adverse Events Postcolonoscopy

An unusual cause of postcolonoscopy abdominal pain

Colonoscopy is a common procedure used for screening, diagnosis, and treatment of gastrointestinal disease. Life-threatening complications are uncommon (28/10 000 procedures) but include perforation, hemorrhage, diverticulitis, and postpolypectomy syndrome. Although previously reported, the association between appendicitis and colonoscopy is not widely known. This case report highlights the underlying pathophysiology, clinical presentation, and diagnosis of postcolonoscopy appendicitis. A 52-year-old man presented to the emergency department with abdominal pain 8 hours after an uncomplicated routine screening colonoscopy. He initially reported mild generalized abdominal discomfort which 3 hours after the procedure intensified and localized to the periumbilical region. Computed tomography of the abdomen with oral and intravenous contrast revealed appendicitis as the cause of his abdominal pain. He underwent laparoscopic appendectomy and recovered uneventfully. Colonoscopy is a common procedure that rarely has life-threatening complications. Although establishing causality is difficult, there is an association between colonoscopy and appendicitis, which may be underreported with literature-based estimates as high as 3.8 appendicitis cases per 10 000 procedures. Timely diagnosis of postcolonoscopy appendicitis may prove challenging given limited knowledge of this association between colonoscopy and appendicitis and similarity of presentation with other more well-known complications. This case report demonstrates that a recent history of colonoscopy should not preclude consideration of a traditionally broad differential diagnosis for abdominal pain, including appendicitis.

603 Quality Indicators to Enhance Adenoma Detection Rate: Should There Be Reconsideration of the Current Standard?

603 Quality Indicators to Enhance Adenoma Detection Rate: Should There Be Reconsideration of the Current Standard?

Acute Appendicitis

Purpose: Acute appendicitis following colonoscopy is exceptionally rare with less than a dozen documented in current literature. We describe two cases of this rare complication. Methods: N/A Results: Case 1: A 46 year old male underwent a follow-up colonoscopy for a family history of colon cancer and history of polyps with no remarkable findings other than internal hemorrhoids. The prep for the procedure was excellent and the entire colon was visualized without difficulty. The patient returned to the hospital approximately three hours post procedure complaining of nausea, vomiting and 9 out of 10 sharp pain in the upper mid to left abdominal area. On admission patient had a temperature of 100.9 F and a WBC of 17.9. A CT of the abdomen revealed a distended appendix and significant stranding in the surrounding mesentery consistent with appendicitis. The following morning a laparoscopic appendectomy was performed with findings of a necrotic appendix. Case 2: A 53 year old male underwent colonoscopy for the evaluation of chronic constipation and possible narrowing of the colon as seen on barium enema. The colonoscopy was to the terminal ileum and revealed skipped areas of ulceration and granularity in the terminal ileum, right colon and sigmoid colon. Multiple biopsies were taken within these areas. The colonoscopy and biopsies were consistent with Crohn's colitis. Three days later the patient began to experience abdominal pain but did not seek medical attention until eight days post procedure. Upon presenting to the emergency room patient had peritoneal signs with hypotension and leukocytosis. An abdominal x-ray revealed free air below the diaphragm. During emergent laparotomy there was no evidence of colonic perforation and there was a great amount of foul smelling pus in the area of the appendix and the tip of the appendix was perforated. Conclusion: Diagnosis of appendicitis can be quite challenging following colonoscopy since the early symptoms may mimic other, more frequently encountered complications such as post-polypectomy syndrome and other non specific causes of abdominal pain. While rare, appendicitis is an important complication to keep in mind when treating patients with post colonoscopy abdominal pain.

Upper Endoscope for Colonoscopy: Evidence Is Still Too Sparse to Utilize

TO THE EDITOR: We read with interest the article by Park et al. in the November issue of this journal (1). We applaud their efforts to highlight the possibility of implementing a small-caliber scope to achieve individualized and successful colonoscopy, especially with the current global need for screening for colorectal cancer. However, we would like to add constructive comments on this study. In this single-operator study, the colonoscopy withdrawal time was not mentioned. Adequate withdrawal time has been suggested to decrease the adenoma miss rate (2, 3), and at least 6 min of withdrawal time is recommended (3). In addition, the authors did not clarify whether a one-man maneuver or two-man maneuver was adopted in colonoscopic insertion, since a two-man maneuver is still popular in many Asian countries. Comparison of the use of a two-man maneuver with a standard colonoscope and the use of a one-man maneuver with an upper endoscope may exaggerate the advantage of the upper endoscope. Likewise, the question of whether a small-caliber upper endoscope (9.2 mm) can be inadvertently withdrawn faster than a large-caliber standard colonoscope (12.2 mm) remains to be answered. Another question concerns patients with past histories of abdominal or pelvic surgery. Kozarek et al. have reported the usefulness of a small-caliber endoscope after unsuccessful standard colonoscopy because of stenosis or angulation (4). It would be interesting to see the comparative performance in these specific subgroups to test a potentially beneficial role of an upper endoscope in these patients. In this study, multivariate logistic regression analysis revealed three independent predictors of painful colonoscopy: using an upper endoscope, female gender, and lower BMI. Our previous work has similarities and dissimilarities with this study (5, 6). Patient characteristics are similar and so is the number of polyps detected in each examinee (1.7 per examinee in our study) (5). In our previous prospective study on the factors determining postcolonoscopy abdominal pain (6), female gender similarly increased the likelihood of postcolonoscopy abdominal pain, as did the duration of colonoscopy. However, BMI (23.76 ± 3.29 kg/m2 in our participants) did not contribute significantly to pain in our study. A major dissimilarity is that up to 88% of our colonoscopies were under conscious sedation in a screening setting. Application of this study to all colonoscopists might have some limitations since only one operator was included (1). As cases of colorectal cancers are increasing worldwide, more studies and discussions on high-quality colonoscopy for individualized patients are certainly needed. Yet, the evidence for routine use of an upper endoscope in colonoscopy may still be too sparse to utilize. Tsung-Chun Lee, M.D.1 Han-Mo Chiu, M.D.2 Yi-Chia Lee, M.D.2 Hsiu-Po Wang, M.D.3 Shih-Pei Huang, M.D., Ph.D.2 Ming-Shiang Wu, M.D., Ph.D.2 Jaw-Town Lin, M.D., Ph.D.2 1Department of Internal Medicine National Taiwan University Hospital Yun-Lin Branch, Yun-Lin, Taiwan Departments of 2Internal Medicine and 3Emergency Medicine, National Taiwan University Hospital and College of Medicine National Taiwan University Taipei, Taiwan

Acute Appendicitis Caused by Colonoscopy

A 48-year-old woman who was without any abnormal past medical history underwent colonoscopy as a screening procedure for colorectal disease. The procedure was uneventful and there was no sign of inflammation around the appendicular orifice or the luminal surface of the cecum. The patient did not complain of pain or significant discomfort throughout the procedure. She then developed pain in the right lower quadrant of the abdomen that evening and this persisted for four days. She visited the outpatient department and underwent abdominal ultrasonography, which showed a swollen appendix with a collection of pericecal fluid. Surgical exploration and appendectomy were performed; the final diagnosis was acute suppurative appendicitis. Colonoscopists should be aware of this rare complication and consider it when making the differential diagnosis of post-colonoscopy abdominal pain.

Factors determining post‐colonoscopy abdominal pain: Prospective study of screening colonoscopy in 1000 subjects

Factors determining post-colonoscopy abdominal pain remain poorly understood. Accordingly, a prospective study was conducted to reveal the key determinants. One thousand consecutive and asymptomatic patients (569 men, 431 women; mean age 51 years, range 19-84 years) undergoing total colonoscopy were evaluated to assess their abdominal pain. Their demographic data, psychological profiles (determined on the Brief Symptom Rating Scale and Maudsley Personality Inventory), and endoscopic findings were treated as independent variables in polytomous logistic regression in which pain severities were treated as outcome variables. Factors affecting the duration of pain were evaluated on multivariate linear regression. Colonoscopy duration (s; odds ratio [OR]: 1.001, 95% confidence interval [CI]: 1-1.002, P<0.01) and female sex (OR: 1.368, 95%CI: 1.02-1.853, P=0.03) were significantly associated with abdominal pain, but age, body mass index, psychological traits, conscious sedation, use of i.v. hyoscine butylbromide, and colonic preparation were not. Duration of the colonoscopy was longer in female than male subjects (P=0.04). On stepwise linear regression, irritable bowel syndrome (regression coefficient: 27.47, 95%CI: 6.99-47.67, P<0.01) and conscious sedation (regression coefficient: -22.17, 95%CI: -42.52 to -1.42, P = 0.036) were the best predictors of prolonged pain in 485 patients who had pain. Female sex and duration of colonoscopy increased the likelihood of post-procedural abdominal pain. Conscious sedation temporarily suppressed the pain but had no effect on its occurrence. Irritable bowel syndrome may have prolonged the discomfort.

Minimizing postcolonoscopy abdominal pain by using CO 2 insufflation: A prospective, randomized, double blind, controlled trial evaluating a new commercially available CO 2 delivery system

Background: Abdominal pain after colonoscopy is a common, distressing symptom resulting from bowel distension by insufflated gas. CO 2, unlike air, is rapidly cleared from the colon by passive absorption. A commercially available CO 2 delivery system has only recently become available. The effects of CO 2 and air insufflation on residual bowel gas and postprocedure pain were compared. Methods: One hundred patients were randomized to undergo colonoscopy with insufflation of air (n = 51) or CO 2 (n = 49) by means of a regulator; 97 patients completed the study. Patients with active GI bleeding, inflammatory bowel disease, or previous colectomy were excluded. Pain scores (ordinal scale: 0 = none, to 5 = extreme) were recorded immediately after colonoscopy and at 1, 6, and 24 hours. Residual colonic gas was evaluated on abdominal radiographs at 1 hour. Results: Residual colonic gas and postprocedural pain at 1 and 6 hours were significantly less in the CO 2 group. 71% of patients insufflated with room air had colonic distension in excess of 6 cm versus 4% for those in the CO 2 group. 94% of patients insufflated with CO 2 had minimal colonic gas versus 2% in whom air was used ( p < 0.0001). Of patients insufflated with air, 45% and 31% had pain at, respectively, 1 hour and 6 hours, versus 7% and 9%, respectively, for those insufflated with CO 2 (respectively, p < 0.0001 and p < O.02). No complications resulted from use of the CO 2 delivery system. Conclusions: Insufflation of CO 2 rather than air significantly reduces abdominal pain and bowel distension after colonoscopy. CO 2 may be insufflated safely and effectively with the new CO 2 delivery system. (Gastrointest Endosc 2002;56:190-4.)

Minimizing postcolonoscopy abdominal pain by using CO insufflation: A prospective, randomized, double blind, controlled trial evaluating a new commercially available CO delivery system

Minimizing postcolonoscopy abdominal pain by using CO insufflation: A prospective, randomized, double blind, controlled trial evaluating a new commercially available CO delivery system