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Beneficial effects of sublingual hyocyamine during colonoscopy
CLINICAL ENDOSCOPIC PRACTICE
t97
~9
BENEFICIAL EFFECTS OF SUBLINGUAL HYOSCYAMINE DURING COLONOSCOPY N. Kazi J. Losurdo, A Livak, J Lcya. Loyola University Medical Center, Maywood, Illinois and V A Hines Medical Center, Hines~ Illinois Colonoscopy can be painful for the patient and often difficult for the endoscopist which can increase the complication rate Oceasionall~r intravenous g]ucagon is used as an antispasmodic agent in very difficult cases Both oral hyoseyamine, an anticholinergic agent, and intravenous glucagon used for barium enema decrease abdominal discomfort to the same degree, with less side effect in the hyoscyamine group In this study we evaluate the effects of sublingual hyoscyamine on colonoscopy. Methods: Sixteen subjects were enrolled in the study. Patients with history of abdominal surgery, inflammatory bowel disease, glaucoma or any neuromuscular disorders were excluded. Eight subjects received placebo and eight received 05 mg sublingual hyoscyamine 10-15 minutes before colonoscopy Each subject received midazolam 0005mg/kg and meperidine 0.15mg/kg immediately before colonoscopy Additional mepcridine and or midazolam was given as required during the procedure. Colonoscopy was performed by a second year gastroenterology fellow who was blinded regarding the group Time to reach cecum, requirement for additional sedative, and complications were recorded ARer one hour each subject was asked to grade his discomfort during the procedure using ' near scale of 1-10, with 1-3 being mild, 4-6 moderate and 7-10 severe Results: Time reqaired to reach cecum was significantly (p=0 02, Mann-Whimey rank
subjects in the placebo group required additional sedation and none in the hyoscyamine group In one subject in the placebo group colonoscopy was incomplete due to discomfort and hypotension Abdominal discomfort score was also significantly less (p:0.03) in the hyoscyarmne group. None of the subjects in the hyoscyamine group experienced any complications or drug related side effects. Conclusion: 1) Sublingnal hyoscyanune reduces time of the colonoscopy, 2) increases the patient tolerance of the procedure. 3) may decrease the requirement for sedation Hyoscyamine is a save and an inexpensive adjuvant to routine sedation for coionoscopy
E M E R G E N T E N D O S C O P Y IN H E M O D Y N A M I C A L L Y STABLE PATIENTS WITH UPPER GASTROINTESTINAL HEMORRHAGE (UGIH) DECREASES H O S P I T A L A D M I S S I O N R A T E . J Koch, DC Rockey, JP Cello, Division of Gastroenterology, Department of Medicine, San Francisco General Hospital, University of California, San Francisco. Patients with melena and/or hematemesis are generally hospitalized for observation and e s o p h a g o g a s t r o d u o d e n o s c o p y (EGD). Endoscopic stigmata of recent hemorrhage (SRH) are accepted as accurate predictors of rebleeding rate. We sought to determine whether emergent, outpatient EGD can be used safely to triage patients to discharge or hospital admission. Methods: Since February, 1993, patients presenting with evidence of UGIH and thought to require admission to a general medicine ward were eligible. Evidence of alcoholic liver disease or inadequate social support to allow discharge following conscious sedation were exclusions. EGD was performed in the endoscopy unit and patients without SRH (visible vessel adherent clot, and active bleeding) and a low likelihood of rebleeding were discharged home. All patients returned to GI clinic one week after discharge. Results: During the study period, 231 patients were admitted to the medical wards with UGIH, however, only 27 (I2%) were enrolled into the study. The mean age was 41 years (+ 13.5; SD) in the 16 men and seven women. Five patients used NSAIDS, 7 acknowledged occasional alcohol use, 8 reported prior peptic ulcer disease and 7 had a history of prior UGIH. The mean post resuscitation hematocrit was 31.6 (+ 4.9) percent. Thirteen of 27 patients (48%) were admitted, 9 with SRH- 7 (30%) treated endoscopically-, 2 with giant gastric ulcers, and two without an identified bleeding site. Of the 204 patients admitted outside the study (in w h o m EGD was performed on day two or three of hospitalization), the number (44) treated eudoscopically was not statistically significantly different (30% vs 22%, p=0.7). There were no study related complications; one patient discharged, returned to the Emergency Department with recurrent melena and was admitted. Conclusions: Emergent, "outpatient" endoscopy is feasible in a public urban teaching hospital, although social factors limit patients' eligibility. Emergent endoscopy reduced the admission rate for UGIH by nearly 50%, although, earlier endoscopy was associated with a slightly higher prevalence of SRH. The cost-savings of earlier endoscopy need to be compared to the added cost of additional personnel needed for emergent, "outpatient" endoscopy.
98
t/00
VARIABLES AFFECTING THE LENGTH OF PROCEDURE TIME FOR COLONOSCOPY Randy P. Kiewe and Suzanne Rose, Department of Medicine, University of P~ttsburgh, Pittsburgh, PA.
DO DIVERTICULAR DISEASE (DD) AND/OR PRIOR ABDOMINAL OR PELVIC SURGERY (PAPS) INFLUE N C E T H E A B I L I T Y T O P E R F O R M C O M P L E T E COLO N O S C O P Y (CC): A P R O S P E C T I V E S T U D Y . . M . L . Kozam,
In an attempt to consider improved utilization of the endoscopy lab, it is important to consider those factors which may affect the length of a procedure. AIM: To determine what variables affect procedure time for colonoseopy. METHODS: 95 colonoscopies from the first weeks of July and December 1994, March and June 1995 were retrospectively reviewed. Statistical analysis of age, sex, prior abdominal surgeries, indication for colonoscopy, final diagnosis, fellow participation, and academic vs. voluntary faculty physician was performed with respect to the time it took to complete the procedure. RESULTS:
l Variable [ Time (min)
[ Variable [ Time (min) [ [
Male pt. 44.5 Age~:70 41.4 [[Prior surg [39.8
Female pt. 40.0 IAse<70 142"9 INo sur~ [41.7
Indications for Time procedure (# pts.) [ (minutes)
p value
J. H. Lewis, D. E. Fleischer, M. Stark, F. AI-Kawas, G. M. Eisen, S. B. Benjamin, Division of Gastroenterology, Georgetown University, Washington, DC.
]l
I [ 0.20 I 10"70 [0.51
Final Diagnosis (# pts.)
Time
(minutes)
Rectal bleeding (16) 38.1 Diverticula (35) 37.7 IBD (10) 48.8 !Polyps (45) 48.5 Polyps (28) 143.5 Hemorrhoids (15) 41.5 Heme + stool (27) [ 44.9 IColonic mass (8) 45.5 Abdominal pain (15) [ 35.8 Normal (6) 29.3 nalysis of pre-test indication for cc nnoscopy ~' increased time for colonoscopy only for patients with inflammatory bowel disease vs. rectal bleeding (p<0.05). Evaluation of the final diagnosis uncovered a significantly increased procedure time for patients with colonic polyps vs. patients with diverticular disease (p=0.005) and normal colonoscopies (p=0.Ol). There was no difference in procedure time when performed by fellow, full-time faculty or private gastroenterologist nor was there a difference in time according to the month performed. Conclusion: 1) Age and gender of the patient and prior surgery did not affect procedure time. 2) Colonoscopies performed for inflammatory bowel disease or those with polypeetomy may require more time to complete. 3) There was no evidence that fellow participation or time of year impacted on the length of the procedure.
In a previous retrospective study at our center, the CC success rate in 1398 patients was found to be slightly lower among females (94.3%) compared to males (97.5%), p < 0.005. We therefore undertook a prospective evaluation to see whether this difference was maintained and to determine what factors might influence CC to the cecum. METHODS: We prospectively analyzed the presence of DD and/or a history of PAPS on the rate of CC performed by the GI faculty from January 1 through October 31, 1995. Of 922 colonoscopies, t01 were excluded due to partial colonic resection (70), inadequate prep (21), obstructing lesions (7), or sedation difficulties (2). X2 analysis was used to compare subgroups. RESULTS: In 821 exams, the rate of CC was not significantly lower in females as compared to males (96.4% vs. 98.0%, p = 0.25). Analysis by DD and/or PAPS is given below: PAPS 118/120 98.3% 227/236 96.1% 345/356 96.9%
NoPAPS 276/282 97.9% 177/183 96.7% 453/465 97.4%
TOTAL
DD 178/178 100.0% 153/159 96.2% 331/337 98.2%
No D D 216/224 96.4% 251/260 96.5% 467/484 96.5%
Males Females TOTAL
PAPS & DD 64/64 100.0% 96/101 95.0% 160/165 97.0%
Males Females TOTAL Males
Females
No P A S 162/168 t20/I25 282/293
or D D 96.4% 96.0% 96.2%
NS NS
NS < 0.05 NS NS
p NS NS NS
CONCLUSIONS: Neither DD, PAPS, nor gender, alone or in combination, appear to adversely affect the rate of CC as determined by this prospective study.
VOLUME 43, NO. 4, 1996
GASTROINTESTINAL ENDOSCOPY 315
t97
~9
BENEFICIAL EFFECTS OF SUBLINGUAL HYOSCYAMINE DURING COLONOSCOPY N. Kazi J. Losurdo, A Livak, J Lcya. Loyola University Medical Center, Maywood, Illinois and V A Hines Medical Center, Hines~ Illinois Colonoscopy can be painful for the patient and often difficult for the endoscopist which can increase the complication rate Oceasionall~r intravenous g]ucagon is used as an antispasmodic agent in very difficult cases Both oral hyoseyamine, an anticholinergic agent, and intravenous glucagon used for barium enema decrease abdominal discomfort to the same degree, with less side effect in the hyoscyamine group In this study we evaluate the effects of sublingual hyoscyamine on colonoscopy. Methods: Sixteen subjects were enrolled in the study. Patients with history of abdominal surgery, inflammatory bowel disease, glaucoma or any neuromuscular disorders were excluded. Eight subjects received placebo and eight received 05 mg sublingual hyoscyamine 10-15 minutes before colonoscopy Each subject received midazolam 0005mg/kg and meperidine 0.15mg/kg immediately before colonoscopy Additional mepcridine and or midazolam was given as required during the procedure. Colonoscopy was performed by a second year gastroenterology fellow who was blinded regarding the group Time to reach cecum, requirement for additional sedative, and complications were recorded ARer one hour each subject was asked to grade his discomfort during the procedure using ' near scale of 1-10, with 1-3 being mild, 4-6 moderate and 7-10 severe Results: Time reqaired to reach cecum was significantly (p=0 02, Mann-Whimey rank
subjects in the placebo group required additional sedation and none in the hyoscyamine group In one subject in the placebo group colonoscopy was incomplete due to discomfort and hypotension Abdominal discomfort score was also significantly less (p:0.03) in the hyoscyarmne group. None of the subjects in the hyoscyamine group experienced any complications or drug related side effects. Conclusion: 1) Sublingnal hyoscyanune reduces time of the colonoscopy, 2) increases the patient tolerance of the procedure. 3) may decrease the requirement for sedation Hyoscyamine is a save and an inexpensive adjuvant to routine sedation for coionoscopy
E M E R G E N T E N D O S C O P Y IN H E M O D Y N A M I C A L L Y STABLE PATIENTS WITH UPPER GASTROINTESTINAL HEMORRHAGE (UGIH) DECREASES H O S P I T A L A D M I S S I O N R A T E . J Koch, DC Rockey, JP Cello, Division of Gastroenterology, Department of Medicine, San Francisco General Hospital, University of California, San Francisco. Patients with melena and/or hematemesis are generally hospitalized for observation and e s o p h a g o g a s t r o d u o d e n o s c o p y (EGD). Endoscopic stigmata of recent hemorrhage (SRH) are accepted as accurate predictors of rebleeding rate. We sought to determine whether emergent, outpatient EGD can be used safely to triage patients to discharge or hospital admission. Methods: Since February, 1993, patients presenting with evidence of UGIH and thought to require admission to a general medicine ward were eligible. Evidence of alcoholic liver disease or inadequate social support to allow discharge following conscious sedation were exclusions. EGD was performed in the endoscopy unit and patients without SRH (visible vessel adherent clot, and active bleeding) and a low likelihood of rebleeding were discharged home. All patients returned to GI clinic one week after discharge. Results: During the study period, 231 patients were admitted to the medical wards with UGIH, however, only 27 (I2%) were enrolled into the study. The mean age was 41 years (+ 13.5; SD) in the 16 men and seven women. Five patients used NSAIDS, 7 acknowledged occasional alcohol use, 8 reported prior peptic ulcer disease and 7 had a history of prior UGIH. The mean post resuscitation hematocrit was 31.6 (+ 4.9) percent. Thirteen of 27 patients (48%) were admitted, 9 with SRH- 7 (30%) treated endoscopically-, 2 with giant gastric ulcers, and two without an identified bleeding site. Of the 204 patients admitted outside the study (in w h o m EGD was performed on day two or three of hospitalization), the number (44) treated eudoscopically was not statistically significantly different (30% vs 22%, p=0.7). There were no study related complications; one patient discharged, returned to the Emergency Department with recurrent melena and was admitted. Conclusions: Emergent, "outpatient" endoscopy is feasible in a public urban teaching hospital, although social factors limit patients' eligibility. Emergent endoscopy reduced the admission rate for UGIH by nearly 50%, although, earlier endoscopy was associated with a slightly higher prevalence of SRH. The cost-savings of earlier endoscopy need to be compared to the added cost of additional personnel needed for emergent, "outpatient" endoscopy.
98
t/00
VARIABLES AFFECTING THE LENGTH OF PROCEDURE TIME FOR COLONOSCOPY Randy P. Kiewe and Suzanne Rose, Department of Medicine, University of P~ttsburgh, Pittsburgh, PA.
DO DIVERTICULAR DISEASE (DD) AND/OR PRIOR ABDOMINAL OR PELVIC SURGERY (PAPS) INFLUE N C E T H E A B I L I T Y T O P E R F O R M C O M P L E T E COLO N O S C O P Y (CC): A P R O S P E C T I V E S T U D Y . . M . L . Kozam,
In an attempt to consider improved utilization of the endoscopy lab, it is important to consider those factors which may affect the length of a procedure. AIM: To determine what variables affect procedure time for colonoseopy. METHODS: 95 colonoscopies from the first weeks of July and December 1994, March and June 1995 were retrospectively reviewed. Statistical analysis of age, sex, prior abdominal surgeries, indication for colonoscopy, final diagnosis, fellow participation, and academic vs. voluntary faculty physician was performed with respect to the time it took to complete the procedure. RESULTS:
l Variable [ Time (min)
[ Variable [ Time (min) [ [
Male pt. 44.5 Age~:70 41.4 [[Prior surg [39.8
Female pt. 40.0 IAse<70 142"9 INo sur~ [41.7
Indications for Time procedure (# pts.) [ (minutes)
p value
J. H. Lewis, D. E. Fleischer, M. Stark, F. AI-Kawas, G. M. Eisen, S. B. Benjamin, Division of Gastroenterology, Georgetown University, Washington, DC.
]l
I [ 0.20 I 10"70 [0.51
Final Diagnosis (# pts.)
Time
(minutes)
Rectal bleeding (16) 38.1 Diverticula (35) 37.7 IBD (10) 48.8 !Polyps (45) 48.5 Polyps (28) 143.5 Hemorrhoids (15) 41.5 Heme + stool (27) [ 44.9 IColonic mass (8) 45.5 Abdominal pain (15) [ 35.8 Normal (6) 29.3 nalysis of pre-test indication for cc nnoscopy ~' increased time for colonoscopy only for patients with inflammatory bowel disease vs. rectal bleeding (p<0.05). Evaluation of the final diagnosis uncovered a significantly increased procedure time for patients with colonic polyps vs. patients with diverticular disease (p=0.005) and normal colonoscopies (p=0.Ol). There was no difference in procedure time when performed by fellow, full-time faculty or private gastroenterologist nor was there a difference in time according to the month performed. Conclusion: 1) Age and gender of the patient and prior surgery did not affect procedure time. 2) Colonoscopies performed for inflammatory bowel disease or those with polypeetomy may require more time to complete. 3) There was no evidence that fellow participation or time of year impacted on the length of the procedure.
In a previous retrospective study at our center, the CC success rate in 1398 patients was found to be slightly lower among females (94.3%) compared to males (97.5%), p < 0.005. We therefore undertook a prospective evaluation to see whether this difference was maintained and to determine what factors might influence CC to the cecum. METHODS: We prospectively analyzed the presence of DD and/or a history of PAPS on the rate of CC performed by the GI faculty from January 1 through October 31, 1995. Of 922 colonoscopies, t01 were excluded due to partial colonic resection (70), inadequate prep (21), obstructing lesions (7), or sedation difficulties (2). X2 analysis was used to compare subgroups. RESULTS: In 821 exams, the rate of CC was not significantly lower in females as compared to males (96.4% vs. 98.0%, p = 0.25). Analysis by DD and/or PAPS is given below: PAPS 118/120 98.3% 227/236 96.1% 345/356 96.9%
NoPAPS 276/282 97.9% 177/183 96.7% 453/465 97.4%
TOTAL
DD 178/178 100.0% 153/159 96.2% 331/337 98.2%
No D D 216/224 96.4% 251/260 96.5% 467/484 96.5%
Males Females TOTAL
PAPS & DD 64/64 100.0% 96/101 95.0% 160/165 97.0%
Males Females TOTAL Males
Females
No P A S 162/168 t20/I25 282/293
or D D 96.4% 96.0% 96.2%
NS NS
NS < 0.05 NS NS
p NS NS NS
CONCLUSIONS: Neither DD, PAPS, nor gender, alone or in combination, appear to adversely affect the rate of CC as determined by this prospective study.
VOLUME 43, NO. 4, 1996
GASTROINTESTINAL ENDOSCOPY 315