BACKGROUND: This study determines the pattern of fluoroscopy use during colonoscopy among a group of gastroenterologists and colon and rectal surgeons who have it readily available for each patient. METHODS: One thousand three hundred fifty-seven consecutive patients undergoing colonoscopic examination were studied over a 16-month period. RESULTS: Fluoroscopy was used during 34% of colonoscopic examinations. The frequency of fluoroscopy use was significantly higher for women (41% vs 28%, p < 0.001). Fluoroscopy was most commonly used to precisely locate the colonoscope tip (45%) or during manipulation of troublesome loops of colon (42%), thus accounting for 87% of 677 fluoroscopic checks. The most common location of the colonoscope tip during these fluoroscopic checks was the hepatic flexure (23%) followed by the cecum (20%); 51% involved the right colon. The selective use of fluoroscopy during the more difficult cases was substantiated by the longer procedure time (36 vs 26 min) and significantly lower cecal intubation rate (74% vs 96%, p < 0.002) when fluoroscopy was required. Fluoroscopy also proved to be valuable when precisely locating pathology and teaching colonoscope intubation techniques. CONCLUSIONS: Endoscopists who have fluoroscopy readily available often use it during difficult colonoscopic examinations. Fluoroscopy is most commonly used to maneuver troublesome loops of colon or to precisely locate colonoscope tip position, especially when negotiating the right colon. Although this technology is more frequently required for women, fluoroscopic capability for all colonoscopic examinations is advantageous.

Adolescent↗

PubMed1995

Effect of catheter diameter on resting pressures in anal fissure patients.

PURPOSE: Controversy exists as to whether fissure patients have elevated resting pressures when compared with control patients. The diameter of manometry catheters used in past studies varies widely (1.5-25 mm) and may have contributed to differences observed in resting pressures. A prospective study was undertaken to determine the influence of manometry catheter diameter on maximum resting pressure in patients with idiopathic chronic anal fissures. METHODS: A total of 28 fissure patients and 28 control patients had manometry performed with both a 1.8-mm and a 4.8-mm (external diameter) water-perfused catheter. RESULTS: Mean maximum resting pressure (RP) for fissure patients as measured with the 1.8-mm catheter was 86 (range, 65-115) mmHg and 83 (range, 47-117) mmHg with the 4.8-mm catheter (P = 0.65). Mean maximum RP for control patients with the 1.8-mm catheter was 70 (range, 30-108) mmHg and 72 (range, 35-109) mmHg with the 4.8-mm catheter (P = 0.07). When fissure and control patients were compared, a significantly higher mean RP was observed in the fissure group for both the 1.8-mm catheter (86 vs. 70 mmHg, respectively; P = 0.01) and the 4.8-mm catheter (83 vs. 72 mmHg, respectively; P = 0.03). There was no significant difference in length of the high-pressure zone within each group or when the fissure group and controls were compared, regardless of catheter used. For both groups of patients, there was a significantly higher incidence of ultraslow waves (USWs) observed with the 4.8-mm catheter when compared with the 1.8-mm catheter. The USW frequency was not significantly different when fissure and control groups were compared with either catheter type. CONCLUSIONS: Catheter size did not influence measured maximum RP in fissure patients. The maximum RP was significantly greater for fissure patients overall when compared with the control group, regardless of catheter used. There was an increased frequency of USWs noted with the larger catheter size in all patients; however, these USWs only became apparent when catheter was left at each station until a true baseline RP was obtained.

Adult↗

PubMed1995

Factors that predict incomplete colonoscopy.

PURPOSE AND METHODS: Certain factors in a patient's history, such as prior abdominal surgery or complicated diverticular disease, have been reported to hinder cecal intubation during colonoscopy. Over a 16-month period, 1,047 consecutive colonoscopies were prospectively evaluated to determine whether these factors were indeed clinically relevant. RESULTS: Of the 90 patients (9 percent) who had incomplete intubation of the colon, there were significantly more women (66 percent) than men (34 percent) (P < 0.001). Women with a history of abdominal hysterectomy had a significantly lower cecal intubation rate (P < 0.01). A history of diverticulitis did not alter the cecal intubation rate. In patients with incomplete colonic intubation, the most proximal extent of intubation was the sigmoid colon in women (31 percent) and the right colon in men (68 percent). Sixty-seven percent of patients with incomplete intubation of the colon had a prior colonoscopy completed to the cecum (67 percent women, 67 percent men), whereas 50 percent had a follow-up colonoscopy completed to the cecum (56 percent women, 40 percent men). CONCLUSIONS: Women, especially those with a history of abdominal hysterectomy, had a significantly lower cecal intubation rate usually because of an impassable sigmoid colon. Prior inability to complete colonoscopy to the cecum does not necessarily forecast future failure.

Abdomen↗

PubMed1995

Life-threatening hemorrhage and exsanguination from Crohn's disease. Report of four cases.

PURPOSE AND METHODS: From 1979 through 1991, four patients of 631 admissions (0.6 percent) for Crohn's disease in Erie, Pennsylvania, presented with life-threatening gastrointestinal hemorrhage. These and 34 similar cases from the medical literature were reviewed to provide a composite of those at risk and elucidate appropriate diagnostic and therapeutic maneuvers. RESULTS: The study revealed a preponderance of young men (2:1 ratio) with an average age of 35 (range, 14-89) years, the majority of whom had known Crohn's disease (60 percent) for an average of 4.6 (range, 0-18) years. The site of bleeding resembled the general distribution for Crohn's disease, with small bowel disease predominating (66 percent involved the ileum). The five cases of exsanguination (13 percent of the total) were all men with known Crohn's disease (average, 5.8 years) involving the ileum alone or in part. Mesenteric arteriography was positive in 17 patients, providing precise preoperative localization resulting in no mortality in this group. Excluding those who presented with exsanguination, surgery was necessary to cease hemorrhage in 91 percent (30/33) of patients. Ileocolectomy was the most frequently performed procedure (53 percent). In follow-up, only one patient required further surgical resection for recurrent bleeding (3.5 percent), and two other patients (7 percent) required further therapy for nonhemorrhagic recurrence. CONCLUSION: Crohn's disease may be responsible for life-threatening gastrointestinal hemorrhage and even exsanguination. Many of the characteristics of these patients resemble the general Crohn's disease population. Surgical resection provides excellent palliation. A long-term benign course can be expected in this subgroup of Crohn's disease patients.

Adolescent↗

PubMed1995

Confirmation of cecal intubation during colonoscopy.

PURPOSE: Establishing intubation of the cecum can be a laborious, frustrating, and sometimes erroneous endeavor. Following confirmed colonoscopic intubation of the cecum, the presence of three anatomic landmarks (alone and in combination) were evaluated to precisely define their reliability. METHODS: Between February 1991 and January 1992, 771 of 904 consecutive colonoscopic examinations were completed to the cecum as confirmed by fluoroscopy. RESULTS: All three cecal landmarks studied (ileocecal valve, appendiceal orifice, and transillumination) were present in 64 percent of patients, and two landmarks were seen in 32 percent (96 percent of patients had multiple landmarks). The ileocecal valve was the most reliable cecal landmark (98 percent), followed by the appendiceal orifice (87 percent) and transillumination through the abdominal wall (75 percent). CONCLUSIONS: The ileocecal valve is the most reliable cecal landmark and is invariably visualized, even when all other cecal landmarks are obscure. Although other cecal landmarks are usually identifiable, they are most valuable when found in association with the ileocecal valve.

Abdominal Muscles↗

PubMed1995

Local epinephrine injection as treatment for delayed hemorrhage after hemorrhoidectomy.

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Epinephrine↗