“Sub-10-minute High-quality Diagnostic Colonoscopy”

Like the last two days, this post addresses “high quality” colonoscopy…

A recent report (M Thomson et al. JPGN 2019: 69: 6-12) describes quicker pediatric colonoscopy times than previously reported and with 100% rate of ileal intubation.

In this report, there were 181 colonoscopies.

Time of colonoscopy:

  • The authors emphasize the fact that their mean time to the terminal ileum was 9.8 minutes.  Their good technical skill is probably related in part to experience: all 6 endoscopists had more than 10 years of experience (mean 19 years) and more than a thousand prior colonoscopies each.

Ileal Intubation Rate:

  • The 100% ileal intubation rate similarly indicates good technical skill.  It may indicate that their patient population was healthier as ileal structuring (which can prevent ileal intubation) can be noted in patients with Crohn’s disease.

Low Diagnostic Yield:

  • In my view, the study reports a low diagnostic yield.  They report 33% had abnormal histology (when excluding patients with IBD followup examinations)
  • 38% of their patients had colonoscopy due to abdominal pain. They reported a yield in this group of only 11.6% though this includes 4 patients with “TI lymphoid hyperplasia.”   Is this an abnormal finding?

My take: This study shows that with good technical skill colonoscopy can be done quickly with ileal intubation times averaging 10 minutes and with ileal intubation rates close to 100%.  In my view, another quality metric is diagnostic yield and their yield is lower than has been reported in most pediatric studies.

Related references:

  • K Siau et al. JPGN 2019; 69: 18-23.  This study describes “Direct Observation of Procedural Skills” (DOPS). Among 29 trainees, 81% of DOPS were rate competent after 125-140 procedures.
  • MT Barakat et al. JPGN 2019; 69: 24-31. This study noted that the vast majority of pediatric GI centers (>90%) were performing less than 25 ERCPs annually and that >70% “believe their institution’s current arrangement for performing pediatric therapeutic endoscopy is inadequate.”

Quality Metrics in Pediatric Colonoscopy

Continuing the theme from yesterday’s post…

Because of similar research in our group, I was interested in a recent study looking at pediatric colonoscopy quality indicators: CS Pasquarella et al.. JPGN 2019; 68: 648-54. (Editorial: CG Sauer, CM Walsh. JPGN 2019; 607-08.)

The authors analyzed 391 colonoscopies.

Key findings:

  • Ileal intubation rate of 91% (which is similar to our rate)
  • Ileal intubation rate was greater in their endoscopy suite where assistance was readily available.
  • Time for procedure: 34 minutes with staff alone compared to 42 minutes with a fellow trainee participant

To this point, we have not collected data on procedure duration at our institution –though 34 minutes seemed longer than I expected.

The authors also comment on cecal intubation.  I find this statistic to be less useful in pediatrics than adult medicine.  Reaching the cecum is important in cancer screening whereas reaching the ileum is important in identifying cases of inflammatory bowel disease.  The former is the main focus in adult gastroenterology and the latter is the main focus in pediatric gastroenterology.

My take: The editorial notes that “endoscopic providers and users can only know whether high-quality care is being delivered if it is being measured.”  I do think ileal intubation is important but other measures include good prep, low complication rate, appropriate patient selection (eg. good indication), and careful followup. Our work in this area will be presented at our upcoming NASPGHAN meeting–stay tuned.

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Sagrad Familia, Barcelona

 

Colonoscopy and Isolated Abdominal Pain = Low Value Care

A recent study (HK Singh, LC Ee. JPGN 2019; 68: 214-7) reviewed a single center’s colonoscopy data (n=652) from 2011-15 with a focus on patients who underwent this procedure for abdominal pain.

Key findings:

  • Only 15 patients had isolated abdominal pain as an indication. In total 68 patients had abdominal pain as an indication but the majority had other ‘red flags’ such as rectal bleeding, family history of IBD or polyposis, weight loss, anemia, food allergy, or altered bowel habits
  • None of these 15 patients with isolated abdominal pain had organic disease
  • Among 36 patients with a measured fecal calprotectin and abdominal pain, all with elevated levels had positive histologic findings.
  • The ileal intubation rate/biopsy rate was 92.4%

I was particularly interested in this study because our group has reviewed our clinical experience in a large cohort undergoing outpatient colonoscopy (findings will be presented this fall).  Our group has a similar ileal intubation rate and a low rate of organic disease in those with isolated abdominal pain.

My take: More efforts are needed to carefully select pediatric patients undergoing endoscopy to minimize low value procedures.

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Georgia Aquarium

Expansive View of Endoscopy from Porto IBD Group

The pediatric IBD Porto Group of ESPGHAN has updated endoscopy guidelines: S Oliva et al. JPGN 2018; 67: 414-430.   In total, the authors make 17 recommendations –here are a few of them:

A) In non-emergency situations, the diagnostic evaluation for suspected IBD in children should include a combination of EGD and colonoscopy.  Multiple biopsies from each segment are recommended even in the absence of macroscopic disease.

B) Endoscopic evaluation is recommended for the following:

  • before major treatment changes
  • in symptomatic patients when it is not clear whether the symptoms are inflammation-related
  • in Crohn’s disease(CD) to ensure mucosal healing during clinical remission
  • in Ulcerative colitis (UC) to ensure mucosal healing during clinical remission only if fecal calprotectin is elevated

C) 6-12 months after bowel resection to identify postoperative recurrence

D) Endoscopic surveillance in pediatric UC after 10 years from the onset of disease (as early as 8 years in older children (>16 years) with risk factors like extensive disease and strong family history

E) In patients with concurrent primary sclerosing cholangitis (PSC), surveillance colonoscopy may be considered every 1-2 years, starting from time of PSC diagnosis. However, in children <12 years of age, surveillance could be postponed based on individual risk factors.

In addition to discussions of conventional endoscopy, the authors favor evaluation of small bowel inflammation: “the choice to perform CE [capsule endoscopy], MRE or both, depends on local availability and expertise.”  The authors caution to consider strictures and the potential need for patency capsule prior to CE.

Conclusion of authors: “Endoscopy in pediatric IBD provides a more definitive diagnosis and disease extent evaluation, assesses therapeutic efficacy and leads to targeted therapy, which lessens complications and progression.”

My take: While I agree that endoscopy increases our understanding of disease extent and response to treatment, I do have some concerns about the recommendations (under section B above) regarding assessment of mucosal healing.  Part of the concern is that there is not a single accepted definition of mucosal healing.  Also, as a practical matter, there needs to be a discussion of the costs and more proof that frequent endoscopy will improve outcomes; it is possible that increased use of endoscopy will lead to some detrimental outcomes in some patients based on the interpretation of the results (eg. dropping a therapy that may be helping and replacing with a less effective treatment)..

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

Reassuring Study on Colonoscopy Safety in Adults

Full Abstract: Low Rates of Gastrointestinal and Non-Gastrointestinal Complicaitons for Screening or Surveillance Colonoscopies in a Population-Based Study

(L Wang, et al. Gastroenterol 2018; 154: 540-555https://doi.org/10.1053/j.gastro.2017.10.006)

Using California’s Ambulatory Services Databases, the authors identified 1.58 million surveillance/screening colonoscopies (2005-2011) and compared complications to patients who underwent other ambulatory procedures like joint aspiration, arthroscopy and cataract surgery.

Availlable online: graphical abstract

Key findings:

  • GI complications including perforation and GI bleeding were low but more common with colonoscopy than comparator procedures
  • Rates of serious non-GI complications including myocardial infarction, stroke, and serious pulmonary events were no higher than other low-risk comparator procedures.
  • Complication rates were higher with advancing age, particularly in those >70 years. see Figure 2 below

 

Image available online: Figure 2

 

Improving the Value of Pediatric Colonoscopy

Two recent studies examine the diagnostic utility of pediatric gastrointestinal endoscopy:

  • PS Kawada et al. JPGN 2017; 64: 898-902
  • M Thomson, S Sharma. JPGN 2017; 64: 903-06

Before looking at these studies more closely, I would say that I was struck by contrasting remarks in their discussions. The first study: “a negative colonoscopy has not been shown to improve outcomes in those with functional pain” and references: Bonilla S et a. Clin Pediatr (Phila) 2011; 50: 396-401.  The second study states that “a negative endoscopic finding, with effective reassurance, can prevent unnecessary medicalization of many children in whom other nonorganic causes may present with GI symptoms.” The latter study does not provide any data to support their claim.

In terms of the specifics, the first study is a retrospective examination of 999 colonoscopies.  The indications for colonoscopy were suspected IBD; in this circumstance, 143 of 449 (32%) were normal.  For isolated rectal bleeding, 141 of 197 (72%) were normal.  For recurrent abdominal pain, all 46 were normal.  The cecal or beyond completion rate was only 52%, potentially lowering diagnostic yield.  The perforation rate during the 10 year timeframe (2001-2010) was 0.2%. The authors conclude that the yield of colonoscopy for recurrent abdominal pain (without other features) is very low and that many children with isolated rectal bleeding “should have a trial of conservative management before undergoing endoscopy.”

The second study retrospectively examined 153 endoscopic cases from a database of 2471 children (2012-2014).  The median age was 9.58 years. The authors found a diagnostic yield of 18.9% for upper endoscopy alone, 32.6% for ileocolonoscopy alone, and 39.2% for combined upper endoscopy/ileocolonoscopy. The terminal ileum intubation rate was 98%.

My take: Both of these studies look at pediatric endoscopy and reach opposite conclusions. The first study suggests that many colonoscopies could be avoided and the latter suggests that whether normal or not, endoscopy contributes to improved management. What is your conclusion?

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Jean Hugues 1890, Edipe a Colone, Marbre taille d’apres le platre expose au Salon des Artistes fracaise. Musee d’Orsay

 

Turning Conventional Colonoscopy Positioning Upside Down

A recent article (The American Journal of Gastroenterology 110, 1576-1581 (November 2015) | doi:10.1038/ajg.2015.298) indicates that right-sided positioning rather than left-side down results in quicker and more comfortable colonoscopy.  While it is disconcerting to realize that I had been trained exactly opposite, if this technique works for me, it will be particularly helpful when patients undergo combination procedures since this means that the bed would not need to be rotated.  Thanks to Mike Hart for this reference.

Right Or Left in COLonoscopy (ROLCOL)? A Randomized Controlled Trial of Right- versus Left-Sided Starting Position in Colonoscopy

N VergisA K McGrathC H Stoddart and Jonathan M Hoare

OBJECTIVES:

Colonoscopy is technically challenging and can cause discomfort for patients. We aimed to test whether right-sided starting position for colonoscopy would result in shorter procedure time and greater patient comfort when compared with conventional left-sided starting position.

METHODS:

We conducted a randomized controlled trial in which patients were randomized to begin in either the right- (RL) or conventional left-lateral (LL) position. One hundred and sixty-three adult patients undergoing scheduled colonoscopy were stratified by age, gender, body mass index, and experience of the endoscopist. Patients were then randomized 1:1 in permuted blocks. The primary outcome measure was time to cecal intubation and secondary outcome measures included patient comfort that was evaluated by visual analog comfort scale.

RESULTS:

Median time to reach the cecum was quicker when colonoscopy began with patients positioned RL rather than LL (P=0.0078). Moreover, patients found RL more comfortable than LL (P=0.02). Multiple linear regression confirmed starting position in colonoscopy as an independent determinant of time to reach the cecum (P=0.007). Women and those who had previously undergone abdominal surgery gained the greatest benefit from right-sided positioning (RL vs. LL: 498 vs. 824s; P=0.03 and 498 vs. 797s; P=0.006, respectively).

CONCLUSIONS:

Our study reveals that right-sided positioning at the start of colonoscopy results in more comfortable and quicker procedures. Of the factors identified by multiple linear regression to independently have an impact on time to reach the cecum, only starting position is modifiable. Right-sided starting position may therefore be of benefit in colonoscopy, in particular for women and patients who have previously undergone abdominal surgery.

“Show Don’t Tell” –Colonoscopy Prep Instructions

A recent study, summarized in this link– Gastroenterology and Endoscopy News, indicates that providing an 11 minute video with colonoscopy prep instructions was more effective than written instructions.  Not only were the cleanouts better, but this resulted in better outcomes including higher adenoma detection rate and higher rates of completed colonosocpy.

Here’s an excerpt:

Dr. Bearelly and his colleagues randomized 298 individuals scheduled for screening colonoscopy to receive either the practice’s usual written instructions, or to receive the paper handout plus an instructional video (right). The 11-minute video—burned on a disk —covers the same instructions as the written materials, but in an interactive format that depicts a typical patient asking questions of one of the practice’s doctors.

The quality of bowel preparation between the two groups differed significantly (P=0.0098). Cecal intubation was 96% in the intervention group compared with 89% in the control group, and the adenoma detection rate was 53% and 42% in the two groups, respectively.

Patients in the intervention group had a Boston Bowel Preparation Score (BBPS) of 6.99±1.87, whereas those in the control group had a score of 6.43±2.54, although the difference was not statistically significant. A BBPS of 6, with a minimum of 2 in each segment, was considered adequate.

Take-home message:  Video instructions for colonoscopy are worthwhile.  In pediatrics, variability in cleanout regimens is a limiting factor.

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NASPGHAN “Best Practices Cleanout Regimens”

The authors of a recent report (JPGN 2014; 59: 409-16) acknowledge that “bowel regimens vary significantly” and “few clinical studies in pediatrics have evaluated the use of various bowel preparation regimens.” Furthermore, “pediatric studies did not have a common efficacy measure.”

Nevertheless, they provide a “NASPGHAN best practices cleanout regimens.”  According to Table 7:

  • Option 1: PEG-3350 (eg. Miralax) -1-day cleanout:  If less than 50 kg, then 4 g/kg/day + bisacodyl 5 mg.  If >50 kg, then 238 g in 1.5 L sports drink + bisacodyl 10 mg.   PEG-3350 administered over 4-6 hours.
  • Option 2: PEG-3350 -2-day cleanout: If <50 kg, then 2 g/kg/day + bisacodyl 5 mg; if >50 kg, then 2 g/kg/day + bisacodyl 10 mg.
  • Option 3: NG cleanout: PEG-ELS (eg. Nulytely) 25 mL/kg/h (max 450 mL/h).  NG cleanouts mainly in those with history of failed preps or other adherence problems (eg. vomiting).
  • Option 4: non-PEG cleanout: Magnesium citrate 4-6 mL/kg/day + bisacodyl 5-10 mg.

My personal opinion is that Table 7 could drop the words “best practices” since the report states “alternative dosing regimens may be entirely reasonable” and the data are quite limited.

With regard to split dosing preparations which are now recommended in adults, their role in pediatrics is a “potential area for future research.” For adults, the U.S. Multi-Society Task Force Consensus Statement on Adequate Bowel Cleansing for Colonoscopy (Johnson DA et al. Optimizing Adequacy of Bowel Cleansing for Colonoscopy: Recommendations from the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 2014; 147(4):903-924) recommends:

  • Use of a split-dose bowel cleansing regimen is strongly recommended for elective colonoscopy, meaning roughly half of the bowel cleansing dose is given the day of the colonoscopy.
  • The second dose of split preparation ideally should begin four to six hours before the time of colonoscopy with completion of the last dose at least two hours before the procedure time.
  • During a split-dose bowel cleansing regimen, diet recommendations can include either low-residue or full liquids until the evening on the day before colonoscopy. 

Take-home message: This NASPGHAN report summarizes the literature and provides recommendations for effective bowel preparations.

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