An effective bowel cleanse can improve the imaging quality of video capsule endoscopy (VCE). We aimed to further investigate the optimal small bowel cleanse method by comparing the efficacy of 4 L of ...clear liquids, 2 L of polyethylene glycol (PEG), and 4 L of PEG on the image quality of VCE.
A randomized controlled, non-inferiority trial was performed comparing 4 L of clear liquids (Group A), 2 L of PEG (Group B), and 4 L of PEG (Group C). The primary endpoint was image quality between the groups. The secondary endpoints included patient tolerability and side effects.
Eighty-one patients were analyzed in group A, 84 patients were analyzed in group B, and 80 patients were analyzed in group C. Image quality scores revealed 4 L of clear liquids to be non-inferior to 2 L of PEG, and 2 L of PEG to be non-inferior to 4 L of PEG (p < 0.0167). Group A had a lower difficulty of completion rate than Group B and Group C and a lower rate of side effects when compared to Group C (p < 0.0167).
Four liters of clear liquids should be considered a routine method for small bowel preparation prior to VCE.
Background An observational study in veterans showed that a novel water method (water infusion in lieu of air insufflation) enhanced cecal intubation and willingness to undergo a repeat scheduled ...unsedated colonoscopy. Objective To confirm these beneficial effects and significant attenuation of discomfort in a randomized, controlled trial (RCT). Design Prospective RCT, intent-to-treat analysis. Setting Veterans Affairs ambulatory care facility. Patients Veterans undergoing scheduled unsedated colonoscopy. Interventions During insertion, the water and traditional air methods were compared. Main Outcome Measurements Discomfort and procedure-related outcomes. Results Eighty-two veterans were randomized to the air (n = 40) or water (n = 42) method. Cecal intubation (78% vs 98%) and willingness to repeat (78% vs 93%) were significantly better with the water method ( P < .05; Fisher exact test). The mean (standard deviation) of maximum discomfort (0 = none, 10 = most severe) during colonoscopy was 5.5 (3.0) versus 3.6 (2.1) P = .002 (Student t test), and the median overall discomfort after colonoscopy was 3 versus 2, P = .052 (Mann-Whitney U test), respectively. The method, but not patient characteristics, was a predictor of discomfort ( t = −1.998, P = .049, R2 = 0.074). The odds ratio for failed cecal intubation was 2.09 (95% CI, 1.49-2.93) for the air group. Fair/poor previous experience increased the risk of failed cecal intubation in the air group only. The water method numerically increased adenoma yield. Limitations Single site, small number of elderly men, unblinded examiner, possibility of unblinded subjects, restricted generalizability. Conclusions The RCT data confirmed that the water method significantly enhanced cecal intubation and willingness to undergo a repeat colonoscopy. The decrease in maximum discomfort was significant; the decrease in overall discomfort approached significance. The method, but not patient characteristics, was a predictor of discomfort. (Clinical trial registration number NCT00747084 ).
Water-aided colonoscopy: a systematic review Leung, Felix W., MD; Amato, Arnaldo, MD; Ell, Christian, MD, PhD ...
Gastrointestinal endoscopy,
09/2012, Letnik:
76, Številka:
3
Journal Article
Recenzirano
Background Water-aided methods for colonoscopy are distinguished by the timing of removal of infused water, predominantly during withdrawal (water immersion) or during insertion (water exchange). ...Objective To discuss the impact of these approaches on colonoscopy pain and adenoma detection rate (ADR). Design Systematic review. Setting Randomized, controlled trial (RCT) that compared water-aided methods and air insufflation during colonoscope insertion. Patients Patients undergoing colonoscopy. Intervention Medline, PubMed, and Google searches (January 2008-December 2011) and personal communications of manuscripts in press were considered to identify appropriate RCTs. Main Outcome Measurements Pain during colonoscopy and ADR. RCTs were grouped according to whether water immersion or water exchange was used. Reported pain scores and ADR were tabulated based on group assignment. Results Pain during colonoscopy is significantly reduced by both water immersion and water exchange compared with traditional air insufflation. The reduction in pain scores was qualitatively greater with water exchange as compared with water immersion. A mixed pattern of increases and decreases in ADR was observed with water immersion. A higher ADR, especially proximal to the splenic flexure, was obtained when water exchange was implemented. Limitations Differences in the reports limit application of meta-analysis. The inability to blind the colonoscopists exposed the observations to uncertain bias. Conclusion Compared with air insufflation, both water immersion and water exchange significantly reduce colonoscopy pain. Water exchange may be superior to water immersion in minimizing colonoscopy discomfort and in increasing ADR. A head-to-head comparison of these 3 approaches is required.
Optimal small bowel (SB) preparation for video capsule endoscopy (VCE) is controversial. Our study aimed to support the use of a specified volume of 4 liters of clear liquids for bowel preparation ...for VCE.
A retrospective review of 284 patients who underwent SB preparation with 2 liters of polyethylene glycol (PEG) and 284 patients who had 4 liters of clear liquid preparation. We analyzed image quality, endoscopic findings, completion rate, and transit times.
The 4-liter clear liquid group had significantly higher mean image quality scores when compared to the PEG group (2.669±0.64 to 2.908±0.77, p<0.0001), as well as more studies with adequate preparation (72% to 64%, p=0.0214). Although the PEG group had more endoscopic findings on VCE (40% to 23%, p<0.0001), there was a significant difference in the indications for the procedure between the groups. There was no difference in the capsule completion rate or SB transit time.
Our data demonstrate significantly higher mean image quality scores when using a specified volume of 4 liters of clear liquid compared to 2 liters of PEG. This study supports the growing evidence of the effectiveness of a 4-liter clear liquid SB preparation as opposed to PEG for VCE.
Background Pilot studies using a novel water method to perform screening colonoscopy allowed patients to complete colonoscopy without sedation medications and also significantly increased the cecal ...intubation success rate. Objective To perform a randomized, controlled trial comparing air insufflation (conventional method) and water infusion in lieu of air insufflation(study method) colonoscopy in minimally sedated patients. Hypothesis Compared with the conventional method, patients examined by the study method had lower pain scores and required less medication but had a similar cecal intubation rate and willingness to undergo colonoscopy in the future. Setting Outpatient colonoscopy in a single Veterans Affairs hospital. Methods After informed consent and standard bowel preparation, patients received premedications administered as 0.5-increments of fentanyl (25 μg) and 0.5-increments of Versed (midazolam) (1 mg) plus 50 mg of diphenhydramine. The conventional and the study methods for colonoscopy were implemented as previously described. Additional pain medications were administered at the patients' request. Main Outcome Measurements Increments of medications, pain scores, cecal intubation, and willingness to repeat colonoscopy. Results Increments of medications used before reaching the cecum (1.6 ± 0.2 vs 2.4 ± 0.2, P < .0027), total increments used (1.8 ± 0.2 vs 2.5 ± 0.2, P < .014), and the maximum pain scores (1.3 ± 0.3 vs 4.1 ± 0.6, P < .0002) were significantly lower with the water method. Cecal intubation rate (100%) and willingness to undergo a repeat colonoscopy (96%) were similar. Limitations Single Veterans Affairs hospital, older male population. Conclusion Water infusion in lieu of air insufflation is superior to air insufflation during colonoscopy in the minimally sedated patients ( ClinicalTrials.gov Identifier NCT00785889 ).
The relationship between gut microbial community composition at the higher-taxonomic order level and local and systemic immunologic abnormalities in HIV disease may provide insight into how bacterial ...translocation impacts HIV disease.
Antiretroviral-naive patients with HIV underwent upper endoscopy before and 9 months after starting antiretroviral treatment. Duodenal tissue was paraffin-embedded for immunohistochemical analysis and digested for fluorescence activated cell sorting for T-cell subsets and immune activation (CD38+/HLA-DR+) enumeration. Stool samples were provided from patients and control subjects for comparison. Metagenomic microbial DNA was extracted from feces for optimized 16S ribosomal RNA gene (rDNA) real-time quantitative polymerase chain reaction assays designed to quantify panbacterial loads and the relative abundances of proinflammatory Enterobacteriales order and the dominant Bacteroidales and Clostridiales orders.
Samples from 10 HIV subjects before initiating and from six subjects receiving antiretroviral treatment were available for analysis. There was a trend for a greater proportion of Enterobacteriales in HIV-positive subjects compared with control subjects (P = 0.099). There were significant negative correlations between total bacterial load and duodenal CD4 and CD8 T-cell activation levels (r = -0.74, P = 0.004 and r = -0.67, P = 0.013, respectively). The proportions of Enterobacteriales and Bacteroidales were significantly correlated with duodenal CD4 T-cell depletion and peripheral CD8 T-cell activation, respectively.
These data represent the first report of quantitative molecular and cellular correlations between total/universal and order-level gut bacterial populations and gastrointestinal-associated lymphoid tissue levels of immune activation in HIV-infected subjects. The correlations between lower overall 16S rDNA levels and tissue immune activation suggest that the gut microbiome may contribute to immune activation and influence HIV progression.
Whether initiation of antiretroviral therapy (ART) regimens aimed at achieving greater concentrations within gut associated lymphoid tissue (GALT) impacts the level of mucosal immune reconstitution, ...inflammatory markers and the viral reservoir remains unknown. We included 12 HIV- controls and 32 ART-naïve HIV patients who were randomized to efavirenz, maraviroc or maraviroc+raltegravir, each with fixed-dose tenofovir disoproxil fumarate/emtricitabine. Rectal and duodenal biopsies were obtained at baseline and at 9 months of ART. We performed a comprehensive assay of T-cell subsets by flow cytometry, T-cell density in intestinal biopsies, plasma and tissue concentrations of antiretroviral drugs by high-performance liquid chromatography/mass spectroscopy, and plasma interleukin-6 (IL-6), lipoteichoic acid (LTA), soluble CD14 (sCD14) and zonulin-1 each measured by ELISA. Total cell-associated HIV DNA was measured in PBMC and rectal and duodenal mononuclear cells. Twenty-six HIV-infected patients completed the follow-up. In the duodenum, the quadruple regimen resulted in greater CD8+ T-cell density decline, greater normalization of mucosal CCR5+CD4+ T-cells and increase of the naïve/memory CD8+ T-cell ratio, and a greater decline of sCD14 levels and duodenal HIV DNA levels (P = 0.004 and P = 0.067, respectively), with no changes in HIV RNA in plasma or tissue. Maraviroc showed the highest drug distribution to the gut tissue, and duodenal concentrations correlated well with other T-cell markers in duodenum, i.e., the CD4/CD8 ratio, %CD4+ and %CD8+ HLA-DR+CD38+ T-cells. Maraviroc use elicited greater activation of the mucosal naïve CD8+ T-cell subset, ameliorated the distribution of the CD8+ T-cell maturational subsets and induced higher improvement of zonulin-1 levels. These data suggest that combined CCR5 and integrase inhibitor based combination therapy in ART treatment naïve patients might more effectively reconstitute duodenal immunity, decrease inflammatory markers and impact on HIV persistence by cell-dependent mechanisms, and show unique effects of MVC in duodenal immunity driven by higher drug tissue penetration and possibly by class-dependent effects.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Background Sedation for colonoscopy discomfort imposes a recovery-time burden on patients. The water method permitted 52% of patients accepting on-demand sedation to complete colonoscopy without ...sedation. On-site and at-home recovery times were not reported. Objective To confirm the beneficial effect of the water method and document the patient recovery-time burden. Design Randomized, controlled trial, with single-blinded, intent-to-treat analysis. Setting Veterans Affairs outpatient endoscopy unit. Patients This study involved veterans accepting on-demand sedation for screening and surveillance colonoscopy. Intervention Air versus water method for colonoscope insertion. Main Outcome Measurements Proportion of patients completing colonoscopy without sedation, cecal intubation rate, medication requirement, maximum discomfort (0 = none, 10 = severe), procedure-related and patient-related outcomes. Results One hundred veterans were randomized to the air (n = 50) or water (n = 50) method. The proportions of patients who could complete colonoscopy without sedation in the water group (78%) and the air group (54%) were significantly different ( P = .011, Fisher exact test), but the cecal intubation rate was similar (100% in both groups). Secondary analysis (data as Mean SD) shows that the water method produced a reduction in medication requirement: fentanyl, 12.5 (26.8) μg versus 24.0 (30.7) μg; midazolam, 0.5 (1.1) mg versus 0.94 (1.20) mg; maximum discomfort, 2.3 (1.7) versus 4.9 (2.0); recovery time on site, 8.4 (6.8) versus 12.3 (9.4) minutes; and recovery time at home, 4.5 (9.2) versus 10.9 (14.0) hours ( P = .049; P = .06; P = .0012; P = .0199; and P = .0048, respectively, t test). Limitations Single Veterans Affairs site, predominantly male population, unblinded examiners. Conclusion This randomized, controlled trial confirms the reported beneficial effects of the water method. The combination of the water method with on-demand sedation minimizes the patient recovery-time burden. (Clinical trial registration number: NCT00920751 .)
Background
Concerns over the hypothetical adverse effects of water absorption and the disturbance of serum sodium and potassium levels prompted a quality assurance evaluation of water exchange (WE) ...colonoscopy.
Aim
The purpose of this study was to evaluate the balance of water infused and suctioned in WE colonoscopy, and to quantify the acute impact on serum levels of sodium and potassium.
Methods
Prospectively collected quality monitoring data of patients undergoing screening and surveillance colonoscopy at the Sacramento Veterans Affairs Medical Center were analyzed. Measurements were made of volume infused and suctioned during, and blood samples drawn 10 min before the start of and 10 min after completion of WE colonoscopy. Outcome measures included volume of water infused and suctioned, and serum levels of sodium and potassium.
Results
A total of 140 patients (134M:6F), mean age of 59, underwent WE colonoscopy. Mean total volume of water infused was 1,839 mL. A negative balance of an average of 22 mL was documented. The mean (standard deviation) values (in meq/L) of serum levels of sodium 139.33 (2.27) and 139.28 (2.32), and potassium 3.86 (0.36) and 3.91 (0.39), before and after colonoscopy, respectively, showed no significant change.
Conclusion
The WE method allowed most of the water infused during colonoscopy to be recovered by suction at the completion of colonoscopy. Serum sodium and potassium levels did not change significantly within 10 min after completion. The WE method appears to be safe with minimal water retention and is devoid of acute fluctuations in serum levels of sodium and potassium.
PDF
