The present review examines four current issues related to the efficacy, patient tolerance and safety of the following bowel cleansing agents: oral sodium phosphate (NaP), polyethylene glycol (PEG) and magnesium citrate (Pico-Salax, Ferring Pharmaceuticals Inc, Canada), an agent recently made available in Canada. MedLine and PubMed databases were systematically searched to identify studies related to the efficacy of altered PEG solutions combined with adjunct treatments; the efficacy, tolerability and safety of Pico-Salax; the association between nephrocalcinosis, and chronic renal failure and oral NaP use; and the role of diet. Although lower volume PEG solutions combined with adjuvant agents were generally associated with better patient tolerance, their efficacy was varied and interpretation of this end point is complicated by study design issues. There are very few reported studies of Pico-Salax, and as a result, there are insufficient data to draw conclusions about the efficacy of this agent. The available data suggest that Pico-Salax may be better tolerated by patients, than oral NaP and PEG solutions. There is a paucity of hemodynamic monitoring data pre- and postadministration, but the available data suggests that this small-volume osmotic agent could cause subclinical contraction of the intravascular space. Recent case reports suggest an association between nephrocalcinosis and oral NaP ingestion, but to date, these reports have been confined to a single centre. Preliminary studies suggest that this is not a widespread problem, but more studies are needed. There are only a few studies examining diet and patient tolerability, but they do suggest that diet may be liberalized with some cleansing regimens to enhance tolerability without decreasing efficacy. The present review highlights current controversies and advances in colon cleansing before colonoscopy, and also identifies areas for further study.
Delayed postpolypectomy bleeding (DPPB) is a relatively common adverse event. Evidence is conflicting on the efficacy of prophylactic clipping to prevent DPPB, and real-world effectiveness data are lacking. We aimed to determine the effectiveness of prophylactic clipping in preventing DPPB in a large screening-related cohort.We manually reviewed records of patients who underwent polypectomy from 2008 to 2014 at a screening facility. Endoscopist-, patient- and polyp-related data were collected. The primary outcome was DPPB within 30 days. All unplanned healthcare visits were reviewed; DPPB cases were adjudicated by committee using a criterion-based lexicon. Multivariable logistic regression was performed, yielding adjusted odds ratios (AORs) for the association between clipping and DPPB. Secondary analyses were performed on procedures where one polyp was removed, in addition to propensity score-matched and subgroup analyses.In total, 8,366 colonoscopies involving polypectomy were analyzed, yielding 95 DPPB events. Prophylactic clipping was not associated with reduced DPPB (AOR 1.27; 0.83-1.96). These findings were similar in the single-polyp cohort (n = 3,369, AOR 1.07; 0.50-2.31). In patients with one proximal polyp ≥20 mm removed, there was a nonsignificant AOR with clipping of 0.55 (0.10-2.66). Clipping was not associated with a protective benefit in the propensity score-matched or other subgroup analyses.In this large cohort study, prophylactic clipping was not associated with lower DPPB rates. Endoscopists should not routinely use prophylactic clipping in most patients. Additional effectiveness and cost-effectiveness studies are required in patients with proximal lesions ≥20 mm, in whom there may be a role for prophylactic clipping.
An important mandate of the Canadian Association of Gastroenterology (CAG), as documented in the Association's governance policies, is to optimize the care of patients with digestive disorders. Clinical practice guidelines are one means of achieving this goal. The benefits of timely, high-quality and evidenced-based recommendations include: Enhancing the professional development of clinical members through education and dissemination of synthesized clinical research; Improving patient care provided by members by providing focus on quality and evidence; Creating legislative environments that favour effective clinical practice; Enhancing the clinical care provided to patients with digestive disease by nongastroenterologists; and Identifying areas that require further information or research to improve clinical care. The present document provides the foundation required to ensure that clinical practice guidelines produced by the CAG are necessary, appropriate, credible and applicable. These recommendations should be adhered to as closely as possible to obtain CAG endorsement.
Introduction: With increasing demand for endoscopic procedures in the context of limited resources, it is imperative to identify factors that can be optimized to influence efficiency of the endoscopy unit. Methods: A prospective study from December 2013 to March 2014 was undertaken in the endoscopy unit at the Hotel-Dieu Hospital, Kingston, Ontario. Time elapsed for all components from patient registration to exit from the endoscopy unit was recorded. The data was collected in three components: individual endoscopy room utilization, pre-procedure room, and overall endoscopy unit room usage. Mean times were analyzed to identify if maximal time consumption was attributed to patient related, endoscopist related, equipment or process related causes. Results: Data were collected for 137 procedures in the endoscopy room, 139 procedures in the preprocedure room, and 143 procedures for overall room usage. The mean time for patient registration was 39.22 minutes ahead (95% CI: -44.76 to -33.68) of their scheduled starting time. The mean time spent in the pre-procedure room was 50.15 minutes (95% CI: 45.84 - 54.47). The mean time delay from the scheduled start time to the actual time the patient was transferred into the endoscopy room was 18.51 minutes (95% CI: 13.44 - 23.58). Whilst, the mean time delay between scheduled starting time to that of endoscopist arrival into the endoscopy suite was 27.05 minutes (95% CI: 20.93 - 33.18). Overall, the mean time spent by the patient in the endoscopy room was found to be 27.15 minutes (95% CI: 24.60 - 29.69) for an EGD, 57.95 minutes (95% CI: 50.38 - 65.53) for a colonoscopy, 71.29 minutes (95% CI: 49.36 - 93.22) for a double procedure, and 29.15 minutes (95% CI: 16.16 - 42.13) for a flexible sigmoidoscopy. The average room turnover time was found to be 7.42 minutes (95% CI: 6.85 - 8.00). Conclusion: There is limited literature on the range of efficiencies or validated methodology for evaluating the endoscopy unit. Nevertheless these findings are consistent with the recognition that individual units have unique operational characteristics and that identifying bottlenecks can lead to optimization of resources appropriately. The patient arrival to the endoscopy unit was ahead of their scheduled registration time. However their entry into the endoscopy suite was much delayed, independent of further delay contributed by endoscopist unavailability. This suggests that delays cannot be attributed to patient related causes and are either endoscopist or process related. Endoscopy efficiency to improve patient throughput is imperative for quality of care. Hence, the next phase underway entails staff interviews to further characterize the impediments and facilitate implementation of targeted quality improvement initiatives.
INTRODUCTION: Clinically significant post-endoscopic retrograde cholangiopancreatography (ERCP) bleeding (CSPEB) is common. Contemporary estimates of risk are lacking. We aimed to identify risk factors of and outcomes after CSPEB. METHODS: We analyzed multicenter prospective ERCP data between 2018 and 2024 with 30-day follow-up. The primary outcome was CSPEB, defined as hematemesis, melena, or hematochezia resulting in (i) hemoglobin drop ≥ 20 g/L or transfusion and/or (ii) endoscopy to evaluate suspected bleeding and/or (iii) unplanned healthcare visitation and/or prolongation of existing admission. Firth logistic regression was used. P values <0.05 were significant, with odds ratios (ORs) and 95% confidence intervals reported. RESULTS: CSPEB occurred after 129 (1.5%) of 8,517 ERCPs (mean onset 3.2 days), with 110 of 4,849 events (2.3%) occurring after higher risk interventions (sphincterotomy, sphincteroplasty, precut sphincterotomy, and/or needle-knife access). Patients with CSPEB required endoscopy and transfusion in 86.0% and 53.5% of cases, respectively, with 3 cases (2.3%) being fatal. P2Y 12 inhibitors were held for a median of 4 days (interquartile range 4) before higher risk ERCP. After higher risk interventions, P2Y 12 inhibitors (OR 3.33, 1.26–7.74), warfarin (OR 8.54, 3.32–19.81), dabigatran (OR 13.40, 2.06–59.96), rivaroxaban (OR 7.42, 3.43–15.24), and apixaban (OR 4.16, 1.99–8.20) were associated with CSPEB. Significant intraprocedural bleeding after sphincterotomy (OR 2.32, 1.06–4.60), but not after sphincteroplasty, was also associated. Concomitant cardiorespiratory events occurred more frequently within 30 days after CSPEB (OR 12.71, 4.75–32.54). DISCUSSION: Risks of antiplatelet-related CSPEB may be underestimated by endoscopists based on observations of suboptimal holding before higher risk ERCP. Appropriate periprocedural antithrombotic management is essential and could represent novel quality initiative targets.
One of the issues I struggle with in gastroenterology is when, if and whom to screen for Barrett’s esophagus (BE). Although it is becoming common practice to screen patients with chronic reflux for BE, questions abound pertaining to whether screening is effective, as well as cost-effective, whom to screen and what to do when BE is found, not to mention the issues that arise when dysplasia is found. In light of the enormous clinical and economical implications of diagnosing patients with BE (1), some have questioned whether BE is a reasonable target for screening or whether resources would be better allocated to colon cancer prevention. Most patients agree to endoscopic screening when explained that the initial endoscopy is performed to search for an abnormal lining of the esophagus which, if present, has the potential to lead to esophageal cancer. What most of us do not explain, in any great detail at least, is what happens when and if dysplasia is found. Until recently, the finding of dysplasia led to anxiety on the part of the patient and physician. The potential therapeutic avenues included more intense surveillance or referral for esophagectomy, with its inherent risks and complications. It is possible that if these risks and complications were explained to patients in the beginning, a higher proportion would opt out of a surveillance program. On the other hand, there is evidence that suggests that the majority of patients overestimate the risk of developing adenocarcinoma of the esophagus, and this is worsened in patients who research their condition on the Internet (2), thus making our role as physicians and patient educators even more important. With the advent of more advanced and efficacious endoscopic therapy for dysplasia in BE, one hopes that the transition from diagnosis of BE to therapy of dysplasia will be smoother. DEFINITION AND EPIDEMIOLOGY The definition of BE has gone through several renditions to arrive at its current form: the presence of columnar-lined esophagus with specialized intestinal epithelium confirmed on biopsy. In the literature, the length of BE has been classified into long segment BE (3 cm or greater) and short segment BE (less than 3 cm). Although, when first described, short segment BE was thought to be associated with a much lower risk of esophageal adenocarcinoma, current evidence suggests that this risk is still significant and one cannot treat these patients differently than those with long segment BE (3,4). The risk estimation of esophageal adenocarcinoma in patients with BE varies widely, ranging from one per 99 patient years to one per 300 patient years (3-8).
