Peppermint Oil to Improve Visualization in Screening Colonoscopy: A Randomized Controlled Clinical Trial.

BACKGROUND: Screening colonoscopy has been associated with reduced mortality from colorectal cancer by means of early detection and timely treatment. However, visualization during colonoscopy is often impaired since the colon is naturally prone to peristalsis and spasm. There is evidence to suggest benefit of topical peppermint oil in causing smooth muscle relaxation, thereby decreasing peristalsis. The aim of our study was to determine if peppermint oil helps reduce colonic spasticity so as to allow for better visualization during screening colonoscopy. METHODS: We performed a randomized controlled, double-blinded, clinical trial where patients undergoing screening colonoscopy were assigned to receive either peppermint oil or placebo. Once cecum was reached, 50 mL of either solution was directly injected via the working channel of the colonoscope. Colonic peristalsis, spasticity and bowel visibility were documented. Bowel preparation quality, withdrawal time and adenoma detection rate (ADR) were also assessed. Continuous variables were analyzed using t-test or Wilcoxon rank-sum test while categorical variables were compared using the two-way Chi-square test. RESULTS: Forty-eight patients were included, of whom 24 patients received peppermint oil and 24 received placebo. Mean Boston bowel preparation score (BBPS) was excellent for both groups (8 points vs. 7.9 points; P = 0.98). Both mean total colonoscopy time (17.8 min vs. 21.9 min; P = 0.07) and mean cecal intubation time (7.2 min vs. 10.3 min; P = 0.04) were shorter with peppermint oil as compared to placebo. Complete absence of bowel spasticity was observed among 58.3% patients in the peppermint oil group as compared to 45.8% patients in the placebo group (P = 0.05). More than 75% of bowel was visualized in 83% of patients in both groups (P = 0.56). Mean ADR was higher in the peppermint group as compared to the placebo group (45.8% vs. 37.5%; P = 0.56). CONCLUSION: Our study suggests that topical peppermint oil reduces bowel wall spasticity, which could lead to better visualization of the bowel during screening colonoscopy. Although use of peppermint oil was associated with better ADRs, these results did not achieve statistical significance. Larger sample size and use of alternative methods of peppermint oil administration allowing for more absorption time may establish stronger results.

Is the level of cleanliness using segmental Boston bowel preparation scale associated with a higher adenoma detection rate?

BACKGROUND: The impact of Boston bowel preparation scale (BBPS) scores on the adenoma detection rate (ADR) in each segment has not been adequately addressed. The aim of this study was to determine the association between segmental or overall ADR and serrated polyp detection rate (SDR) with segmental and total BBPS scores. METHODS: All outpatient screening colonoscopies with documented BBPS scores were retrospectively reviewed at a tertiary institution from January to December 2013. Chi-square tests and logistic regression were used to analyze the detection rates of adenomas and serrated polyps with bowel prep scores. Odds ratios were calculated using logistic regression that controlled for withdrawal time, age, body mass index, diabetes status and sex. RESULTS: We analyzed 1991 colonoscopies. The overall ADR was 37.5% (95% confidence interval [CI], 35.3-39.6). There was a significant difference in the overall ADR, and in SDR across all bowel category groups, with total BBPS scores of 8 and 9 having lower detection rates than scores of 5, 6 and 7. As the quality of bowel preparation increased, there was a statistical decrease in the ADR (odds ratio [OR] 0.79 [CI 0.66-0.94], P=0.04) of the right colon, while in the left colon, there was a statistical decrease in SDR (OR 0.78, [CI 0.65-0.92] P=0.019). CONCLUSION: Segmental ADR and SDR both decreased as prep scores increased, decreasing notably in patients with excellent prep scores of 8 and 9. A possible explanation for this unexpected discrepancy may be related to longer and better visualization of the mucosa when cleansing and suctioning is necessary.

A Mysterious DRESS Case: Autoimmune Enteropathy Associated with DRESS Syndrome.

Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) is a rare but potentially life-threatening cutaneous hypersensitivity reaction characterized by extensive mucocutaneous eruption, fever, hematologic abnormalities, and extensive organ involvement. Here, we present a case of a young woman with DRESS syndrome following exposure to vancomycin with renal, cutaneous, and gastrointestinal involvement. To the best of our knowledge, this is the first case description in the literature of DRESS of the gastrointestinal tract with autoimmune enteropathy.

Kinematic analysis of wrist motion during simulated colonoscopy in first-year gastroenterology fellows.

BACKGROUND AND STUDY AIMS: Gastroenterology trainees acquire skill and proficiency in performing colonoscopies at different rates. The cause for heterogeneous competency among the trainees is unclear. Kinematic analysis of the wrist joint while performing colonoscopy can objectively assess the variation in wrist motion. Our objective was to test the hypothesis that the time spent by the trainees in extreme ranges of wrist motion will decrease as the trainees advance through the fellowship year. SUBJECTS AND METHODS: Five first-year gastroenterology fellows were prospectively studied at four intervals while performing simulated colonoscopies. The setting was an endoscopy simulation laboratory at a tertiary care center. Kinematic assessment of wrist motion was done using a magnetic position/orientation tracker held in place by a custom-made arm sleeve and hand glove. The main outcome measure was time spent performing each of four ranges of wrist motion (mid, center, extreme, and out) for each wrist degree of freedom (pronation/supination, flexion/extension, and adduction/abduction). RESULTS: There were no statistically significant differences in the time spent for wrist movements across the three degrees of freedom throughout the study period. However, fellows spent significantly less time in extreme range (1.47 ±â€Š0.34 min vs. 2.44 ±â€Š0.34 min, P = 0.004) and center range (1.02 ±â€Š0.34 min vs 1.9 ±â€Š0.34 min, P = 0.01) at the end of the study compared to the baseline evaluation. The study was limited by the small number of subjects and performance of colonoscopies on a simulator rather than live patients. CONCLUSIONS: Gastroenterology trainees alter the time spent at the extreme range of wrist motion as they advance through training. Endoscopy training during the first 10 months of fellowship may have beneficial effects on learning ergonomically correct motion patterns.

Cronkhite-Canada syndrome diagnosis in the absence of gastrointestinal polyps: a case report.

A 66-year-old male patient presented with nausea, abdominal pain, occasional rectal bleeding, progressive dysgeusia, onicodystrophy, and alopecia. Endoscopic exam and biopsies revealed severe atrophy and diffuse marked edema of mucosa of stomach and duodenum. No evidence of polyps was found in any portion of the gastrointestinal tract. The diagnosis of Cronkhite-Canada syndrome (CCS) was rendered. The patient symptoms resolved completely after initiation of steroid treatment. This additional case of CCS illustrates how the diagnosis of CCS does not require the presence of polyps but is defined by the appreciation of the diffuse marked edema and atrophy of the gastrointestinal mucosa.