Secrets of success in a difficult colonoscopy

Letters to the Editor

REFERENCES 1. Pais WP, Duerksen DR, Pettigrew NM, et al. How many duodenal biopsy specimens are required to make a diagnosis of CD? Gastrointest Endosc 2008;67:1082-7. 2. Hopper AD, Cross SS, Sanders DS. Patchy villous atrophy in adult patients with suspected gluten-sensitive enteropathy: is a multiple duodenal biopsy strategy appropriate? Endoscopy 2008;40:219-24. 3. Green PH. Celiac disease: how many biopsies for diagnosis? Gastrointest Endosc 2008;67:1088-90. 4. Sanders DS, Hurlstone DP, Stokes RO, et al. The changing face of coeliac disease: experience of a single university hospital in South Yorkshire. Postgrad Med J 2002;78:31-3. doi:10.1016/j.gie.2008.06.041

Response: We appreciate the interest of Drs Hopper and Sanders and Dr Mangiavillano et al in our article exploring the optimal number of duodenal biopsy specimens necessary to clinch a diagnosis of celiac disease. These investigators, as well as Dr Green,1 in his editorial, have introduced the concept of duodenal bulb biopsies as requisite to clinch a diagnosis because in occasional cases in the submitted letters and in reports cited from elsewhere,2-6 duodenal bulb biopsies had some degree of villous atrophy when descending duodenum biopsies did not. In all cases that reported the bulb biopsies were important, the pretest probability of celiac disease was high on the basis of positive serology. Hence, if duodenal bulb biopsies had been omitted, the occasional subject with positive serology would not have had celiac disease proven by biopsy but might have been considered to have subclinical disease. If histological confirmation of definite celiac disease was to have been required, at some later time a repeat upper endoscopy with duodenal biopsy might have been undertaken, or, if the subject were symptomatic in some way, a gluten-free diet might have been initiated anyway based on the serology. But what about the biopsy approach in subjects with some indication for duodenal biopsy and consideration of celiac disease with either negative serology or no serology? None of the reports touting duodenal bulb biopsies included control groups of patients without celiac disease to remind us about the presence of villous blunting in the bulb in health. If we incorporate bulb biopsies into our biopsy algorithm, how often will we erroneously label someone as having celiac disease and commit them to a gluten-free diet when no other features of the disease are found? It is known that the presence of Brunner’s glands can be one cause of blunted-appearing villi in the bulb. Hence, most endoscopists have been encouraged to avoid biopsying the bulb. In our opinion, it is better to occasionally miss a diagnosis of celiac disease on biopsy (and likely repeat the biopsies at a later date if histologically clinching the diagnosis is critical) than to overdiagnose celiac disease in persons who only have ‘‘normal’’ partial-villous blunting in the bulb. If an endoscopist has accessed the duodenal bulb, then almost 390 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 2 : 2009

certainly the descending duodenum can be reachedd that is where the biopsy specimens should be taken. Charles N. Bernstein, MD Section of Gastroenterology University of Manitoba Winnipeg, Manitoba, Canada REFERENCES 1. Green PH. Celiac disease: how many biopsies for diagnosis? Gastrointest Endosc 2008;67:1088-90. 2. Vogelsang H, Honel S, Steiner B, et al. Diagnostic duodenal bulb biopsy in celiac disease. Endoscopy 2001;33:336-40. 3. Bonamico M, Mariani P, Thanasi E, et al. Patchy villous atrophy of the duodenum in childhood celiac disease. J Pediatr Gastroenterol Nutr 2004;38:204-7. 4. Ravelli A, Bolognini S, Gambarotti M, et al. Variability of histologic lesions in relation to biopsy site in gluten-sensitive enteropathy. Am J Gastroenterol 2005;100:177-85. 5. Brocchi E, Tomassetti P, Volta U, et al. Adult celiac disease diagnosed by endoscopic biopsies in the duodenal bulb. Eur J Gastroenterol Hepatol 2005;17:1413-5. 6. Hopper AD, Cross SS, Sanders DS. Patchy villous atrophy in adult patients with suspected gluten-sensitive enteropathy: is a multiple duodenal biopsy strategy appropriate? Endoscopy 2008;40:219-24. doi:10.1016/j.gie.2008.07.001

Secrets of success in a difficult colonoscopy To the Editor: I read with great interest the review article by Dr Rex, ‘‘Achieving cecal intubation in the very difficult colon,’’1 in the May issue of the journal. He gracefully described various techniques and equipment that are helpful in such cases. In day-to-day practice, after excluding poor bowel–preparation cases, the reason for an incomplete colonoscopy is usually multifactorial: a combination of patient intolerance with or without associated difficult anatomy, inadequate sedation or inability to sedate safely by conscious sedation, and, in some cases, poor endoscopic technique. The majority of these cases (80%-90%) could be completed by repeating the colonoscopy using a pediatric colonoscope with variable stiffness device (PC-VSD) and providing adequate sedation (generous conscious sedation, or, in some cases, propofol sedation) along with meticulous technique throughout the procedure. Generous use of position changes, abdominal pressure, and instillation of water, preferably warm water, helps in navigating the difficult colons in such cases. A PC-VSD has the 2-fold advantage of having a smaller diameter that helps to navigate through acute angulations or turns and VSD that helps to prevent loop formation. In most of the remaining cases (10%-15%), use of a gastroscope (in smaller patients) or a thin-caliber longer endoscope, such as balloon enteroscope (in larger patients), is useful to complete the colonoscopy. In the remaining small www.giejournal.org

Letters to the Editor

minority of cases, other techniques and equipment described in the review might be useful. However, there might be up to 5% of prior incomplete colonoscopies that might remain incomplete despite the use of various maneuvers and devices available today. Madhusudhan R. Sanaka, MD Department of Gastroenterology and Hepatology Cleveland Clinic Cleveland, Ohio, USA REFERENCE 1. Rex DK. Achieving cecal intubation in the very difficult colon. Gastrointest Endosc 2008;67:938-44. doi:10.1016/j.gie.2008.05.038

Warm water and oil for the difficult colon

REFERENCES 1. Rex KD. Achieving cecal intubation in the very difficult colon. Gastrointest Endosc 2008;67:938-44. 2. Church JM. Warm water irrigation for dealing with spasm during colonoscopy: simple, inexpensive, and effective. Gastrointest Endosc 2002; 56:672-4. 3. Leung JW, Mann S, Leung FW. Option for screening colonoscopy without sedationda pilot study in US veterans. Aliment Pharmacol Ther 2007;26:627-31. 4. Brocchi E, Pezzilli R, Tomassetti P, et al. Warm water or oil assisted colonoscopy: toward simpler examinations? Am J Gastroenterol 2008; 103:581-7. 5. Brocchi E, Pezzilli R, Bonora M, et al. Oil-lubricated colonoscopy: easier and less painful? Endoscopy 2005;37:340-5. 6. Falchuk ZM, Griffin PH. A technique to facilitate colonoscopy in areas of severe diverticular disease. N Engl J Med 1984;310:598. 7. Baumann UA. Water intubation of the sigmoid colon: water instillation speeds up left-sided colonoscopy. Endoscopy 1999;31:314-7. 8. Hamamoto N, Nakanishi Y, Morimoto N, et al. A new water instillation method for colonoscopy without sedation as performed by endoscopists-in-training. Gastrointest Endosc 2002;56:825-8. 9. Leung FW. Water-related techniques for performance of colonoscopy. Dig Dis Sci 2008 May 7 [Epub ahead of print]. doi:10.1016/j.gie.2008.06.040

To the Editor: We read with great interest and particular attention the review by Douglas Rex,1 dealing with the goal of achieving cecal intubation in the very difficult colon. We appreciated very much his precious advice, as well as the broad review of the techniques and equipment that could be helpful for successful intubation of difficult cases. We would add 2 simple, inexpensive, and quick additional methods that may be of help, particularly in the angulated or narrowed sigmoid colon: the injection of warm water2-4 or corn seed oil4,5 through the biopsy channel. Although these techniques mainly were proven to minimize patient discomfort and shorten cecal intubation time, we have found them very useful in navigating an angulated, narrowed, or ‘‘fixed’’ sigmoid colon. In a previous study,5 we tested the oil technique in a subgroup of patients in which cecal intubation was not achieved with the standard method and found that in 6 of 17 patients (35.2%), the addition of oil allowed us to reach the cecum. While the addition of oil acts only to decrease the friction between the colonoscope and the mucosa,4,5 warm water minimizes spasm and produces a local distension that facilitates passage, besides decreasing friction.2-4,6-9 We think that these methods should be kept in mind when dealing with a difficult sigmoid colon because their application is simple, quick, and does not preclude the use of other approaches. Emilio Brocchi, MD Paola Tomassetti, MD Davide Campana, MD Roberto Corinaldesi, MD Department of Internal Medicine and Gastroenterology University of Bologna Bologna, Italy www.giejournal.org

The importance of ‘‘timing’’ when attempting to achieve cecal intubation of the ‘‘difficult colon’’ To the Editor: I thoroughly enjoyed reading Dr Rex’s insightful technical review entitled, ‘‘Achieving cecal intubation in the very difficult colon.’’1 In addition to many critically important factors relating to endoscopic technique, Dr Rex mentions that it is important to allot sufficient time in the schedule when attempting to complete the examination in a patient with a history of incomplete colonoscopy. In this regard, I have a couple of additional comments to make. I have found it useful to schedule such procedures when I have no on-call responsibilities, so that I have less ‘‘time-pressure’’ and am less likely to be distracted and interrupted with emergent situations, which might require my immediate attention. Further, I make an effort to schedule such challenging cases early in the day because I have found that successfully intubating difficult colons is less tedious when I am better rested, as opposed to later in the day after I may have performed numerous other endoscopic procedures. I understand that making such allowances might not be possible in all practice settings. Nonetheless, making such scheduling allowances when faced with the very difficult colon has, anecdotally, been quite helpful.

Josph C. Yarze, MD, FACP, FACG, FASGE, AGAF Gastroenterology Associates of Northern New York Glens Falls, New York, USA Volume 69, No. 2 : 2009 GASTROINTESTINAL ENDOSCOPY 391