Effect of conscious sedation with midazolam and fentanyl on the overall quality of colonoscopy: a prospective and randomized study.

INTRODUCTION: a prospective, randomized study was performed to assess the influence of conscious sedation on the overall quality of colonoscopy, simultaneously quantifying its effect on the scientific quality, perceived quality and patient safety. METHODS: patients referred for a colonoscopy were included in the study and were randomized to receive or not receive sedation. Demographic data, indication for colonoscopy, cecal intubation, introduction and withdrawal time, resected adenomas and complications during the exploration were collected. Thirty days later, a satisfaction questionnaire was performed (GHAA 9-me) and patients were asked about complications after the examination. RESULTS: a total of 5,328 patients were included, the average age was 62 ± 15.22 years, 47% were male, 3,734 were sedated and 1,594 were not sedated. The sedated patients had a shorter endoscope insertion time (7'20 ± 2'15 min vs 6'15 ± 3'12 min, p < 0.019), a higher rate of cecal intubations (96% vs 88%, p < 0.05), longer withdrawal time (7'20 ± 2'15 min vs 6'15 ± 3'12 min, p < 0.01) and higher adenoma detection rates (22% vs 17%, p < 0.05). The use of sedation reduced discomfort during and after the exploration, without increasing the complications. The satisfaction questionnaire score was higher (23.6 ± 1.5 vs 16.6 ± 4.8, p < 0.001) in the sedated patients. CONCLUSIONS: superficial sedation not only reduces patient discomfort but also improves the overall quality of the colonoscopy. Therefore, we must consider the use of sedation as an essential part of colonoscopy.

[Subcapsular hepatic hematoma: an uncommon complication of endoscopic retrograde cholangiopancreatography]. / Hematoma hepático subcapsular. Una rara complicación de la CPRE.

This report describes the case of a patient who developed a subcapsular hepatic hematoma 48 hours after endoscopic retrograde cholangiopancreatography. She was treated by embolizing the sites of bleeding and by surgically resecting the area. We review the literature and discuss the potential mechanisms that cause this complication.

[Development and validation of quality standards for colonoscopy]. / Desarrollo y validación de indicadores y estándares de calidad en colonoscopia.

BACKGROUND AND OBJECTIVES: Before starting programs for colorectal cancer screening it is necessary to evaluate the quality of colonoscopy. Our objectives were to develop a group of quality indicators of colonoscopy easily applicable and to determine the variability of their achievement. PATIENTS AND METHODS: After reviewing the bibliography we prepared 21 potential indicators of quality that were submitted to a process of selection in which we measured their facial validity, content validity, reliability and viability of their measurement. We estimated the variability of their achievement by means of the coefficient of variability (CV) and the variability of the achievement of the standards by means of chi(2). RESULTS: Six indicators overcome the selection process: informed consent, medication administered, completed colonoscopy, complications, every polyp removed and recovered, and adenoma detection rate in patients older than 50 years. 1928 colonoscopies were included from eight endoscopy units. Every unit included the same number of colonoscopies selected by means of simple random sampling with substitution. There was an important variability in the achievement of some indicators and standards: medication administered (CV 43%, p<0.01), complications registered (CV 37%, p<0.01), every polyp removed and recovered (CV 12%, p<0.01) and adenoma detection rate in older than fifty years (CV 2%, p<0.01). CONCLUSIONS: We have validated six quality indicators for colonoscopy which are easily measurable. An important variability exists in the achievement of some indicators and standards. Our data highlight the importance of the development of continuous quality improvement programmes for colonoscopy before starting colorectal cancer screening.

[Long-term follow-up of patients with gastric antral vascular ectasia treated with argon plasma coagulation]. / Seguimiento a largo plazo de pacientes con ectasia vascular del antro gástrico tratados mediante coagulación con argón plasma.

BACKGROUND AND OBJECTIVE: Due to its easy use and low complication rates, argon plasma coagulation (APC) it is most common method of endoscopic treatment for gastric antral vascular ectasia (GAVE). We analyze both the long term effectiveness of APC for the treatment of GAVE and its side effects. MATERIAL AND METHODS: A retrospective review of GAVE patients treated with APC and followed up for a minimum of 24 months was done. RESULTS: Eighteen patients (mean age 67,16+/-13,53; 11 women) were included. Five initially presented with acute bleeding and 13 with anemia. GAVE eradication was achieved over 3.38+/-1,4 sessions per patient. There were no major complications. Five patients had mild bleeding and 11 complained of abdominal pain, that was self-limited during treatment. Seven patients relapsed (39%); 3 of them with melenae and 4 with anemia. Two patients with hypergastrinemia developed hyperplastic polyps. No differences were found between relapsers and non-relapsers. CONCLUSIONS: APC is a safe and effective technique for the treatment of GAVE. The recurrence rates increase gradually over time. Early action on recurrence would require improved clinical follow-up and blood test monitoring.

[Irritable bowel syndrome and cardiac right-to-left shunt through a patent foramen ovale]. / Síndrome del intestino irritable y cortocircuito cardíaco derecha-izquierda por foramen oval permeable.

BACKGROUND AND OBJECTIVE: Both irritable bowel syndrome (IBS) and patent foramen ovale (PFO) have a similar prevalence in the general population, affect more commonly women and are related to comorbidities such as migraine. In IBS there are alterations in the metabolism of certain substances like serotonin. In the presence of PFO with a right- to left-shunt (RLS), a percentage of venous blood bypasses the lung filter and may increase these substances in blood. PATIENTS AND METHOD: A phone interview was done to determine the presence of IBS in patients previously attended for detection of RLS with transcranial Doppler ultrasound. The presence and grade of RLS was analyzed and compared with subjects without gastrointestinal symptoms (NoGI). Rome II criteria were used to diagnose IBS or other functional gastrointestinal disorder (FGD) and Venice 1999 consensus were used for the diagnosis of RLS. RESULTS: Thirthy-three (18.3%) of 180 interviewed patients had IBS and 62 (34.4%) other FGD. RLS was found in 41% of NoGI patients, 64% of patients with IBS and 68% of patients with other FGD (odds ratio [OR] = 2.56; p < 0.05 for SII, and OR = 3.06; p < 0.01 for other FGD). RLS with a massive pattern was registered in en 27% of NoGI patients, 39% of patients with IBS and 45% of patients with other FGD (OR = 1.73; p = 1 for IBS, and OR = 2.21; p < 0.05 for other FGD). CONCLUSIONS: We found a higher prevalence of cardiac RLS through a PFO in patients with IBS and other FGD. A possible etiopathogenic relationship must be considered in future studies.

Evaluation of patient satisfaction in gastrointestinal endoscopy.

OBJECTIVE: Patient satisfaction questionnaires are a useful method for detecting opportunities for improvement on the basis of patient opinion. The aim of this study was to identify by means of a satisfaction questionnaire the main reasons for dissatisfaction in patients undergoing gastrointestinal endoscopy. PATIENTS AND METHODS: Five hundred and thirty-seven patients (age 49+/-15 years, 53% women) who attended a gastrointestinal endoscopy unit were interviewed 3 weeks after undergoing upper endoscopy or colonoscopy, using a previously translated and validated GHAA-9 questionnaire modified for use in gastrointestinal endoscopy. In each case, the overall score median and the percentage of patients who gave negative (poor or fair) appraisals on each of the seven main questions were estimated. These data were used to perform a Pareto analysis. RESULTS: The overall questionnaire score median was 29 (interquartiles 25 and 75 over 26 and 32, respectively). Negative appraisal percentages for each of the seven questions were: waiting time until the appointment, 9.3%; waiting time on the day of examination, 3.5%; explanations, 3.9%; personal manner of staff, 0.5%; personal manner of the physician, 0.6%; discomfort, 3.5%; overall rating, 1.9%. The vital few found by Pareto analysis were questions regarding waiting time for appointment and adequacy of explanations regarding procedure. These questions accounted for 61% of the total number of problems encountered by patients. CONCLUSION: Questionnaires on satisfaction or quality perceived by patients allow the most frequent causes for dissatisfaction to be identified. The main problems patients encountered were waiting time until the appointment and explanations.

[Heterotopic gastric mucosa in the upper esophagus. An unknown cause of dysphagia]. / Mucosa gástrica heterotópica en el esófago proximal. Una causa desconocida de disfagia.

Heterotopic gastric mucosa in the proximal third of the esophagus is an embryological lesion that has been described in between 1.1% and 10% of gastroscopies. Although most of these lesions are asymptomatic, they can sometimes be accompanied by upper esophageal symptoms due to acid secretion. We present a case of heterotopic gastric mucosa in the proximal third of the esophagus with dysphagia. pH-metry demonstrated acid secretion by these lesions, which was resolved by treatment with proton pump inhibitors.

The sedation increases the acceptance of repeat colonoscopies.

AIM: The aim of this research was to assess how the use of sedation during colonoscopy influences patient anxiety, fear, satisfaction, and acceptance of repeat examinations. MATERIALS AND METHODS: A prospective case-control study quantifying the anxiety and fears of patients appointed for colonoscopy, comparing patients who had undergone previous colonoscopies with sedation (cases) with patients who had undergone previous colonoscopies without sedation and patients who had never had a colonoscopy before (controls). Following the examination, patients answered a satisfaction survey and were asked whether they would be willing to undergo future colonoscopies. RESULTS: The study included 2016 patients (average age 50.05 ± 14.44 years; 47% men). Of these, 1270 patients (63%) were undergoing colonoscopy for the first time and 746 (37%) had undergone the procedure before; in the latter group, 313 patients (42%) had been provided sedation, whereas 433 (58%) had not. Patients who had been sedated for prior colonoscopies assigned significantly lower scores than patients who had undergone previous colonoscopies without sedation and those undergoing the procedure for the first time both in the anxiety survey (3.3 ± 2.5 vs. 7.5 ± 2.8 vs. 10.3 ± 3.5; P<0.01) and in the fears survey (7.1 ± 3.0 vs. 14 ± 2.8 vs. 20.3 ± 4.5; P<0.01). Satisfaction survey scores were significantly higher among sedated patients than among nonsedated patients (22.8 ± 2.7 vs. 18.6 ± 2.3). The percentage of sedated patients who would be willing to undergo colonoscopy again was significantly higher than that of nonsedated patients (70 vs. 25%; P<0.001). CONCLUSION: Sedation reduces the anxiety and fear of undergoing a repeat colonoscopy and improves both patient satisfaction and the acceptability of future procedures.

Minor adverse events of colonoscopy on ambulatory patients: the impact of moderate sedation.

BACKGROUND: Minor complications in colonoscopy, such as pain, distension, headache, dizziness, etc. are an important cause for the rejection of colonoscopy procedure. Their incidence, however, has not been established. OBJECTIVE: To determine minor complication rates in outpatient colonoscopy procedures and the effect of sedation on these complications. PATIENTS: A prospective randomized cohort study was performed on 1250 adults selected randomly among patients referred to our endoscopy unit. Complications and undesirable affects related to the colonoscopy were reordered during the patients' stay in the endoscopy unit (early complications) and 30 days postprocedure (late complications). RESULTS: One thousand one hundred and twenty-six patients were enrolled (mean age 50.43+/-13.7 years; 54.5% female), of which 875 (78%) were sedated and 251 (22%) were not. No difference between groups was observed. Thirty-one percent of the patients had early minor complications (25% among sedated patients; 52% of nonsedated patients; P<0.001 chi2); 23% had late minor complications (16% of sedated patients vs. 51% nonsedated patients; P<0.001 chi2). The most common undesirable effects were pain and abdominal distension. The risk of experiencing complications - odds ratio - was 1.013 times higher per year of age [confidence interval (CI) 95%: 1.004-1.022]; 1.953 times higher per increase in American Society of Anesthesiologists classification (95% CI: 1.524-2.504); and 0.116 times lower when sedation was used (95% CI: 0.079-0.170). CONCLUSION: Minor complications of colonoscopy are common. Their incidence increases with age and American Society of Anesthesiologists class and decreases with the use of sedation.

Use of sedation in gastrointestinal endoscopy: a nationwide survey in Spain.

INTRODUCTION: Gastrointestinal endoscopy causes discomfort and pain in patients. Sedation reduces anxiety and pain. Its use, however, continues to be a controversial issue and it varies greatly from one country to another. The use of sedation in Spanish gastrointestinal endoscopy (GIE) units is unknown. AIM: To determine the use of sedation in Spanish GIE units. MATERIALS AND METHODS: A 24-question survey on the use of sedation was distributed among 300 Spanish GIE units. RESULTS: Surveys were answered by 197 GIE units (65%), which had performed 588,326 endoscopies over the past 12 months. Sedation was used in more than 20% of gastroscopies performed at 55% of the GIE units, and more than 20% of colonoscopies were sedated at 71% of the units; endoscopic retrograde cholangiopancreatography (ERCP) is almost always performed under sedation. The most common drugs were midazolam for gastroscopy and midazolam and pethidine for colonoscopy and ERCP; propofol is used by anesthetists; pulse oximetry is used at 77% of GIE units; 42% of the GIE units fill in a nursing record; 52% of GIE units have recovery rooms and 91% have a cardiac arrest trolley. CONCLUSION: The use of sedation in endoscopy varies greatly in Spain. It is seldom used in gastroscopy; it is more frequent in colonoscopy, and in ERCP it is the norm. In most GIE units sedation is controlled by the endoscopist with pulse oximetry. The most commonly used drugs are benzodiazepines, on their own for gastroscopy and combined with opioids for colonoscopy and ERCP.

Sedación en endoscopia digestiva. Guía de práctica clínica de la Sociedad Española de Endoscopia Digestiva / Sedation for gastrointestinal endoscopy. Clinical practice guidelines of the Sociedad Española de Endoscopia Digestiva

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Heterotopic gastric mucosa: a significant clinical entity.

OBJECTIVE: Despite the apparent lack of clinical interest in the inlet patches of heterotopic gastric mucosa (HGM) in the upper esophagus, the literature contains reports of complications associated with HGM. The aim of this study was to determine the prevalence and clinical importance of HGM in patients referred for upper gastrointestinal endoscopy (UGE). MATERIAL AND METHODS: A total of 1033 consecutive outpatients referred for UGE were prospectively evaluated. Clinical, endoscopic and histologic findings were analyzed and 24-h double-channel pH-metry was performed on 20 patients with HGM. RESULTS: Fifty-three patients (5.1%) had HGM lesions. Dysphagia was significantly more frequent in HGM patients (21% versus 4%; p<0.001). Five of the 20 patients who underwent pH-metry presented with acid secretion from HGMs. These five patients had inlet patches of greater size. CONCLUSIONS: HGMs of the upper esophagus are not infrequent, although generally small and asymptomatic. In cases of large HGMs, acid secretion capacity may cause upper esophageal disorders.

Hematoma hepático subcapsular. Una rara complicación de la CPRE / Subcapsular hepatic hematoma: an uncommon complication of endoscopic retrograde cholangiopancreatography

Resumen Se presenta una paciente que desarrolló un hematoma hepático a las 48 horas de una CPRE. Para su tratamiento se realizó una embolización de los puntos sangrantes y posteriormente una resección quirúrgica de la zona. Se revisa la bibliografía y se discute sus posibles mecanismos de producción (AU)

Abstract This report describes the case of a patient who developed a subcapsular hepatic hematoma 48 hours after endoscopic retrograde cholangiopancreatography. She was treated by embolizing the sites of bleeding and by surgically resecting the area. We review the literature and discuss the potential mechanisms that cause this complication (AU)

Seguimiento a largo plazo de pacientes con ectasia vascular del antro gástrico tratados mediante coagulación con argón plasma / Long-term follow-up of patients with gastric antral vascular ectasia treated with argon plasma coagulation

Fundamento y objetivo: La APC (argon plasma coagulation coagulación con argón plasma ) es actualmente el método más utilizado para tratamiento endoscópico de la GAVE (gastric antral vascular ectasia ectasia vascular antral gástrica ) por su fácil uso y sus bajas tasas de complicaciones. El objetivo de este trabajo fue analizar la efectividad y la seguridad de la APC en el tratamiento de la GAVE. Material y método: Se revisaron retrospectivamente los pacientes con GAVE tratados con APC y con seguimiento superior a 24 meses. Resultados: Se incluyó a 18 pacientes (edad media de 67,16 DE: 13,53 años), 11 de éstos eran mujeres. Cinco pacientes se presentaron como hemorragias agudas y 13 como anemia crónica. La eliminación de la GAVE se consiguió en una media de 3,38 de 1 a 4 sesiones por paciente. No hubo complicaciones mayores. Hubo 5 hemorragias leves y 11 epigastralgias autolimitadas durante el tratamiento. En 2 pacientes con hipergastrinemia basal se desarrollaron pólipos hiperplásicos. Siete pacientes (39%) recidivaron: 3 hemorragias antes de 12 meses y 4 anemias después de 12 meses. No se encontraron diferencias entre los pacientes que presentaron recidivas y los que no presentaron recidivas. Conclusión: La APC es una técnica efectiva y segura en el tratamiento de la GAVE. Las recidivas clínicas y endoscópicas aumentan con el paso del tiempo, por lo que es necesaria la monitorización clínica y analítica de estos pacientes (AU)

Background and objective. Due to its easy use and low complication rates, argon plasma coagulation (APC) it is most common method of endoscopic treatment for gastric antral vascular ectasia (GAVE). We analyze both the long term effectiveness of APC for the treatment of GAVE and its side effects. Material and methods: A retrospective review of GAVE patients treated with APC and followed up for a minimum of 24 months was done. Results: Eighteen patients (mean age 67,16±13,53; 11 women) were included. Five initially presented with acute bleeding and 13 with anemia. GAVE eradication was achieved over 3.38±1,4 sessions per patient. There were no major complications. Five patients had mild bleeding and 11 complained of abdominal pain, that was self-limited during treatment. Seven patients relapsed (39%); 3 of them with melenae and 4 with anemia. Two patients with hypergastrinemia developed hyperplastic polyps. No differences were found between relapsers and non-relapsers. Conclusions: APC is a safe and effective technique for the treatment of GAVE. The recurrence rates increase gradually over time. Early action on recurrence would require improved clinical follow-up and blood test monitoring (AU)

Síndrome del intestino irritable y cortocircuito cardíaco derecha-izquierda por foramen oval permeable / Irritable bowel syndrome and cardiac right-to-left shunt through a patent foramen oval

FUNDAMENTO Y OBJETIVO: El síndrome de intestino irritable (SII) y el foramen oval permeable(FOP) tienen una prevalencia similar en la población general, afectan más a mujeres y se relacionancon otras enfermedades como la migraña. La presencia de FOP con cortocircuito (shunt) derecha izquierda (CDI) podría alterar el metabolismo de ciertas sustancias como la serotonina, muy relacionadas con el SII. Sin embargo, hasta la fecha no se ha estudiado la posibleasociación entre ambas entidades.PACIENTES Y MÉTODO: Se ha realizado una encuesta telefónica para determinar la presencia de SII enpacientes atendidos previamente para detección de CDI mediante ultrasonografía Doppler transcraneal.Se analizó la presencia y el grado de CDI y se los comparó con los de sujetos sin síntomas gastrointestinales (NoGI). Se utilizaron los criterios de Roma II para el diagnóstico de SII u otra enfermedad funcional gastrointestinal (EFGI), y el consenso de Venecia-1999 para el CDI.RESULTADOS: De 180 pacientes encuestados, 33 (18,3%) tenían SII y 62 (34,4%), otra EFGI.Tenían CDI un 41% de los NoGI, un 64% de los pacientes con SII y un 68% de los pacientes con otra EFGI (odds ratio [OR] = 2,56; p < 0,05 para SII, y OR = 3,06; p < 0,01 para otra EFGI). Los patrones masivos de CDI se registraron en el 27% de los NoGI, en el 39% de lospacientes con SII y en el 45% de los afectados por otra EFGI (OR = 1,73; p = 1 para SII, y OR = 2,21; p < 0,05 para otra EFGI).CONCLUSIONES: Se encontró mayor prevalencia de CDI cardíaco por FOP en pacientes con SII y otros trastornos funcionales digestivos. Su posible relación etiopatogénica debería considerarse en futuros estudios

BACKGROUND AND OBJECTIVE: Both irritable bowel syndrome (IBS) and patent foramen ovale (PFO) have a similar prevalence in the general population, affect more commonly women and are related to comorbidities such as migraine. In IBS there are alterations in the metabolism of certain substances like serotonin. In the presence of PFO with a right- to left-shunt (RLS), a percentageof venous blood bypasses the lung filter and may increase these substances in blood.PATIENTS AND METHOD: A phone interview was done to determine the presence of IBS in patientspreviously attended for detection of RLS with transcranial Doppler ultrasound. The presenceand grade of RLS was analyzed and compared with subjects without gastrointestinal symptoms (NoGI). Rome II criteria were used to diagnose IBS or other functional gastrointestinal disorder (FGD) and Venice 1999 consensus were used for the diagnosis of RLS.RESULTS: Thirthy-three (18.3%) of 180 interviewed patients had IBS and 62 (34.4%) other FGD. RLS was found in 41% of NoGI patients, 64% of patients with IBS and 68% of patients with other FGD (odds ratio [OR] = 2.56; p < 0.05 for SII, and OR = 3.06; p < 0.01 for otherFGD). RLS with a massive pattern was registered in en 27% of NoGI patients, 39% of patients with IBS and 45% of patients with other FGD (OR = 1.73; p = 1 for IBS, and OR = 2.21; p <0.05 for other FGD).CONCLUSIONS: We found a higher prevalence of cardiac RLS through a PFO in patients with IBS and other FGD. A possible etiopathogenic relationship must be considered in future studies