Endoscopic retrograde cholangiopancreatography (ERCP) is usually performed with the patient lying in the prone position, on the assumption that this position is optimal for cannulation of the papilla ...and for obtaining good-quality radiographic images. The supine position, however, may be more comfortable for the patient and may facilitate airway management, and this study aimed to compare the two positions in terms of procedure outcome, safety, and patient tolerance.
Consecutive patients who were undergoing ERCP were randomized to start the procedure in either the prone position or the supine position. Patients under the age of 18 years, intubated patients, and those who had already undergone endoscopic sphincterotomy were excluded. The difficulty of cannulation was assessed using the Freeman score (1=one to five attempts; 2=six to 15 attempts; 3=more than 15 attempts; 4=failure of cannulation). Total procedure time, patient tolerance, willingness to undergo ERCP in the future, and procedure-related adverse cardiorespiratory events (oxygen desaturation, tachycardia, bradycardia) were also recorded.
A total of 34 patients were evaluated (21 men, 13 women; mean age 68, range 20-96), 17 patients in each group. Demographic and clinical features, and the indications for the procedure were similar for the two patient groups. The median Freeman score was significantly lower in the prone group compared with the supine group (1 vs. 3, P=0.0047, rank sum test). Biliary cannulation was achieved in all patients in the prone group, but was not achieved in five patients (29%) in the supine group (P=0.052). In four of these five patients, biliary cannulation was successfully achieved after turning the patient into the prone position. The percentage of patients unwilling to repeat the ERCP procedure in the future was higher in the supine group (29% vs. 6%, P=0.087); the mean tolerance score and mean total procedure time were similar in the two groups. Seven patients in the supine group experienced at least one adverse cardiorespiratory event, compared with only one patient in the prone group (41% vs. 6%, P=0.039).
ERCP performed with the patient in the supine position is technically more demanding for operators used to working with patients in the prone position and carries a greater risk of adverse cardiorespiratory events in nonintubated patients.
Main Recommendations
1
ESGE recommends that the initial assessment of patients presenting with acute lower gastrointestinal bleeding should include: a history of co-morbidities and medications that ...promote bleeding; hemodynamic parameters; physical examination (including digital rectal examination); and laboratory markers. A risk score can be used to aid, but should not replace, clinician judgment.
Strong recommendation, low quality evidence.
2
ESGE recommends that, in patients presenting with a self-limited bleed and no adverse clinical features, an Oakland score of ≤ 8 points can be used to guide the clinician decision to discharge the patient for outpatient investigation.
Strong recommendation, moderate quality evidence.
3
ESGE recommends, in hemodynamically stable patients with acute lower gastrointestinal bleeding and no history of cardiovascular disease, a restrictive red blood cell transfusion strategy, with a hemoglobin threshold of ≤ 7 g/dL prompting red blood cell transfusion. A post-transfusion target hemoglobin concentration of 7–9 g/dL is desirable. Strong recommendation, low quality evidence.
4
ESGE recommends, in hemodynamically stable patients with acute lower gastrointestinal bleeding and a history of acute or chronic cardiovascular disease, a more liberal red blood cell transfusion strategy, with a hemoglobin threshold of ≤ 8 g/dL prompting red blood cell transfusion. A post-transfusion target hemoglobin concentration of ≥ 10 g/dL is desirable.
Strong recommendation, low quality evidence.
5
ESGE recommends that, in patients with major acute lower gastrointestinal bleeding, colonoscopy should be performed sometime during their hospital stay because there is no high quality evidence that early colonoscopy influences patient outcomes.
Strong recommendation, low quality of evidence.
6
ESGE recommends that patients with hemodynamic instability and suspected ongoing bleeding undergo computed tomography angiography before endoscopic or radiologic treatment to locate the site of bleeding.
Strong recommendation, low quality evidence.
7
ESGE recommends withholding vitamin K antagonists in patients with major lower gastrointestinal bleeding and correcting their coagulopathy according to the severity of bleeding and their thrombotic risk. In patients with hemodynamic instability, we recommend administering intravenous vitamin K and four-factor prothrombin complex concentrate (PCC), or fresh frozen plasma if PCC is not available.
Strong recommendation, low quality evidence.
8
ESGE recommends temporarily withholding direct oral anticoagulants at presentation in patients with major lower gastrointestinal bleeding.
Strong recommendation, low quality evidence.
9
ESGE does not recommend withholding aspirin in patients taking low dose aspirin for secondary cardiovascular prevention. If withheld, low dose aspirin should be resumed, preferably within 5 days or even earlier if hemostasis is achieved or there is no further evidence of bleeding.
Strong recommendation, moderate quality evidence.
10
ESGE does not recommend routinely discontinuing dual antiplatelet therapy (low dose aspirin and a P2Y12 receptor antagonist) before cardiology consultation. Continuation of the aspirin is recommended, whereas the P2Y12 receptor antagonist can be continued or temporarily interrupted according to the severity of bleeding and the ischemic risk. If interrupted, the P2Y12 receptor antagonist should be restarted within 5 days, if still indicated.
Strong recommendation, low quality evidence.
Background
Colonoscopy is a widely used diagnostic and therapeutic modality. A large proportion of the population is likely to undergo colonoscopy for diagnosis and treatment of colorectal diseases, ...or when participating in colorectal cancer screening programs. To reduce pain, water infusion instead of traditional air insufflation during the insertion phase of the colonoscopy has been proposed, thereby improving patients’ acceptance of the procedure. Moreover, the water infusion method may improve early detection of precancerous neoplasms.
Objectives
To compare water infusion techniques with standard air insufflation, specifically evaluating technical quality and screening efficacy, as well as patients’ acceptance of the water infusion procedure.
Search methods
We searched the Cochrane Colorectal Cancer Group Specialized Register (February 2014), the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 1), Ovid MEDLINE (1950 to February 2014), Ovid EMBASE (1974 to February 2014), and ClinicalTrials.gov (1999 to February 2014) for eligible randomised controlled trials.
Selection criteria
We included randomised controlled trials comparing water infusion (water exchange or water immersion methods) against standard air insufflation during the insertion phase of the colonoscopy.
Data collection and analysis
Two review authors independently assessed the studies for inclusion and extracted data from eligible studies. We performed analysis using Review Manager software (RevMan 5).
Main results
We included 16 randomised controlled trials consisting of 2933 colonoscopies. Primary outcome measures were cecal intubation rate and adenoma detection; secondary outcomes were time needed to reach the cecum, pain experienced by participants during the procedure, completion of cecal intubation without sedation/analgesia, and adverse events. Completeness of colonoscopy, that is cecal intubation rate, was similar between water infusion and standard air insufflation (risk ratio 1.00, 95% confidence interval (CI) 0.97 to 1.03, P = 0.93). Adenoma detection rate, that is number of participants with at least one detected adenoma, was slightly improved with water infusion (risk ratio 1.16, 95% CI 1.04 to 1.30, P = 0.007). Assuming the fraction of patients undergoing screening colonoscopy who had one or more adenomas detected was 20 per 100 with standard colonoscopy, the use of water colonoscopy may increase the fraction to 23 per 100 individuals. From our findings, it is possible that up to 68,000 more of the 1.7 million outpatient screening colonoscopies performed annually in the United States, could detect adenomas if water infusion colonoscopy was used. In addition, with water infusion participants experienced significantly less pain (mean difference in pain score on a 0 to 10 scale: ‐1.57, 95% CI ‐2.00 to ‐1.14, P < 0.00001) and a significantly lower proportion of participants requested on‐demand sedation or analgesia, or both (risk ratio 1.20, 95% CI 1.14 to 1.27, P < 0.00001). Qualitative analysis suggests that water infusion colonoscopy was not associated with a markedly increased rate of adverse events compared with the standard procedure.
Authors' conclusions
Completeness of colonoscopy, that is cecal intubation rate, was not improved by water infusion compared with standard air insufflation colonoscopy. However, adenoma detection, assessed with two different measures (that is adenoma detection rate and number of detected adenomas per procedure), was slightly augmented by the water infusion colonoscopy. Improved adenoma detection might be due to the cleansing effects of water infusions on the mucosa. Detection of premalignant lesions during standard colonoscopy is suboptimal, and so improvements in adenoma detection by water infusion colonoscopy, although small, may help to reduce the risk of interval colorectal carcinoma. The most obvious benefit of water infusion colonoscopy was reduction of procedure‐related abdominal pain, which may enhance the acceptance of screening/surveillance colonoscopy.
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