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Volume 76 - 2013 - Fasc.2 - Original articles

Carbon dioxide insufflation reduces the discomfort due to colonoscopy as objectively analyzed by salivary stress markers

Background : Carbon dioxide (CO2) insufflation has been shown to reduce the procedure-related pain and discomfort during colo- noscopy. However, the effects of CO2 insufflation on the improve- ment of participant's stress had not been objectively analyzed. Methods : Using a randomized, double-blinded design, 100 con- secutive patients undergoing colonoscopy were assigned to have their examination performed with either CO2 or air insufflation. Patients completed a questionnaire to grade their discomfort using a visual analogue scale (VAS). The salivary alpha-amylase (SAA) level was also measured at these times as a marker of stress. Results : The total VAS score did not show any statistically sig- nificant differences between the CO2 and air insufflation groups. However, the VAS score for abdominal fullness significantly decreased in the CO2 insufflation group in comparison to the air insufflation group in the patients who had a longer examination. The titer of the maximum SAA was significantly increased by colo- noscopy (P < 0.01). CO2 insufflation significantly reduced the total SAA after the colonoscopy in comparison with air insufflation (P < 0.05). The examination time and SAA tended to have a posi- tive relationship in the air insufflation group. However, no such relationship was observed in the CO2 insufflation group. Conclusions : CO2 insufflation significantly reduced the post- examination discomfort, as indicated by a salivary stress marker. The use of CO2 rather than air insufflation reduced the patients' stress and may contribute to better acceptance of colonoscopy. The usefulness of CO2 insufflation was more prominent when a longer examination was necessary. (Acta gastroenterol. belg., 2013, 76, 219- 224).


Endoscopic mucosal resection of large colorectal polyps : prospective evaluation of recurrence and complications

Background : Endoscopic mucosal resection (EMR) is a major therapeutic advance in the treatment of sessile and flat colorectal polyps. The aim of the study was to prospectively evaluate the success, complications and recurrence with EMR in colon. Methods : From Jun/2008 to Jan/2012, patients referred for EMR of polyps = 20 mm were included. Inject and cut EMR tech- nique was used. Rates of complications and recurrence were as- sessed at 3, 12 and 36 months. Results : From 78 referred polyps, 73 EMR were performed in 71 patients (54% men, 65.8 ± 10.6 years). Median polyp size was 30 (20 ; 35) mm, 64.4% sessile and 37% in rectum. Piecemeal re- moval performed in 86.3%. Median follow-up time was 12 (7 ; 15) months. Histological analysis revealed low-grade dysplasia in 51%, high-grade dysplasia in 37%, intramucosal carcinoma in 11% and invasive carcinoma in 1%. The case of invasive carcinoma was re- ferred for surgery. There were 6 complications (8.2%) resolved without surgery : 5.5% of delayed bleeding, 1.4% of post-polypec- tomy syndrome and 1.4% of perforation. Recurrence was observed in 22.2% at 3 months, 11.1% at 12 months and 0% at 36 months. By logistic regression, a location near the pectinate line (OR 26.13) and a previous history of polypectomy (OR 7.70) became indepen- dent factors related to recurrence. Conclusions : In our experience, EMR was a relatively safe procedure with all complications managed conservatively. We had an acceptable percentage of local recurrence and all cases of recur- rence were treated endoscopically. (Acta gastroenterol. belg., 2013, 76, 225-230).


Early quality of life outcomes following Doppler guided transanal haemorrhoidal dearterialisation : a prospective observational study

Background and aims : There are few studies examining the quality of life (QOL) of patients with haemorrhoidal disease. Transanal heamorrhoidal dearterialization (THD) is a treatment modality for heamorrhoidal disease in which a Doppler transducer is used to locate the supplying arteries that are subsequently ligat- ed. The aim of this study was to assess symptoms and QOL changes following THD. Patients and methods : This was a prospective evaluation of QOL and symptom changes following THD. Patient symptoms, demo- graphics and QOL were recorded preoperatively and 1-month post-operatively following THD using the medical outcomes study short-form-36 (SF-36). Results : Thirteen patients undergoing THD were evaluated. One month following THD symptoms of haemorrhoid protrusion, bleeding, anal pain, painful defaecation, constipation and tenes- mus, had all significantly reduced (P < 0.05). Limitations in usual role activities because of physical health problems (53.8 ± 10.5 Vs 90.4±4.5, P=0.004), vitality, energy and fatigue (45±6.9 Vs 73.5 ± 5.0, P = 0.003), general mental health, psychologic distress and wellbeing (60.9 ± 6.9 Vs 83.1 ± 5.9, P = 0.023), limitations in social activities because of physical or emotional problems (58.7 ± 8.8 Vs 84 ± 5.9, P = 0.025), and physical pain (52.9 ± 7.9 Vs 84.6 ± 6.4, P = 0.005) scores had all improved 1-month following THD. Conclusions : THD significantly reduces symptoms of haemor- rhoidal disease and improves specific aspects of QOL 1-month following surgery. (Acta gastroenterol. belg., 2013, 76, 231-234).


Is early enteral nutrition dangerous in acute non surgical complicated diverticu- litis ? About 25 patients fed with oral fiber free energetic liquid diet

Background and study aims : Complicated Acute Colonic Diver- ticulitis (ACD) is usually treated by parenteral way thus keeping the bowel at rest. To date there are no clear recommendations re- garding the route of nutrition administration. We study the safety of early feeding by oral energetic fiber-free liquid diet in non-surgi- cal complicated ACD patients. Patients and methods : From February 2008 to October 2011, 25 patients were admitted with complicated ACD and took part in this prospective study. Surgical and medical assessments were per- formed at admission. Initial treatment was given with perfusion, intravenous antibiotics and hydric diet. Within 72 hours of admis- sion, antibiotic therapy was switched to oral administration for 5 up to 15 days depending on the progression of the disease. At the same time the patient received oral liquid fiber-free feeding. Solid but fiber-free diet was introduced 24h hours before discharge. Results : 25 cases of ACD were complicated with covered perfo- ration and/or abscess. Mean hospitalisation time was 10.4 days. 23 cases had good recovery and discharged, while 1 case progressed to colonic stenosis during hospitalisation, requiring a sigmoidectomy with a one-time anastomosis with good recovery. One patient re- lapsed his abscess during hospitalisation despite CT guided drain- age and required sigmoidectomy with transient ileostomy. The mean daily treatment and nutrition cost for the non-surgical 23 patients was 30 euros. Conclusions : Early enteral nutrition in complicated ACD is fea- sible, not harmful, and reduce both, mean hospitalization time and treatment cost. Further studies comparing enteral with parenteral nutrition are necessary to confirm our hypothesis. (Acta gastro- enterol. belg., 2013, 76, 235-240).


Novel predictors of intrapulmonary vascular dilatations in cirrhosis : extending the role of pulse oximetry and echocardiography

Background and study aims : Intrapulmonary vascular dilata- tions (IPVDs) are a criterion for the diagnosis of hepatopulmonary syndrome in patients with liver cirrhosis. We aimed to show that IPVDs are more common than suspected in a heterogenous cir- rhotic population and to identify new diagnostic parameters. Patients and methods : Forty-three consecutive patients with cir- rhosis admitted to our Gastroenterology department were included in this prospective study. History, physical examination, ECG and, when warranted, pulmonary function tests and chest radiograph were used to exclude patients with significant cardiac or pulmo- nary disease. Contrast enhanced transthoracic echocardiography (CEE) was used to determine the presence of IPVDs. Pulse oxime- try readings were taken in the supine and standing positions. Results : We found 12 patients with IPVDs. Statistical analysis proved the correlation between IPVDs and systolic pulmonary ar- tery pressure (sPAP) (p = .049), right ventricle wall width (RVW) (p = .013) and E/A ratio (p = .034) but not left atrial or ventricular diameter. Orthodeoxia was also present more frequently in patients with positive CEE. The difference between supine and standing oxygen saturation (?Sat) proved a fair diagnostic test for detecting IPVDs, with an area under the receiver operated curve (AUROC) of 0.823. Conclusions : Our study shows that RVW, sPAP, E/A and ortho- deoxia determined by pulse oximetry are valuable novel predictors of IPVDs, encouraging the routine use of pulse oximetry and echo- cardiography in cirrhotic patients. (Acta gastroenterol. belg., 2013, 76, 241-245).


Increased liver stiffness values in patients with heart failure

Background : Liver stiffness has been claimed to be increased in patients with heart failure. Aims : To determine the magnitude of this increase in liver stiff- ness, and to clarify whether it is related to the degree of heart fail- ure or not. Methods : Twenty-six patients were prospectively collected, and divided in groups CHF (those with compensated chronic heart failure) and AHF (those with acute decompensated heart failure). Patients underwent routine blood chemistries, pro-BNP determi- nation, echocardiography and transient elastography during out- patient care (group CHF) or at hospital admission (group AHF). Blood chemistries, pro-BNP and transient elastography were re- peated in patients in group AHF before being discharged. Results : Correlation between liver stiffness and pro-BNP levels was statistically significant (Rho = 0.747, p = 0.001). Patients in group CHF had lower values of liver stiffness and pro-BNP when compared with patients in group AHF at admission. Median liver stiffness and pro-BNP values were 6.5 vs 14.4 kPa (p = 0.009) and 1511 vs 3535 pg/ml (p = 0.025) respectively. After clinical com- pensation, liver stiffness decreased in all patients in group AHF. Liver stiffness was 14.4 kPa at admission and 8.2 kPa at discharge (p=0.008). Pro-BNP values also decreased from a median of 3535 pg/ml to a median of 1098 pg/ml (p = 0.025). Conclusions : Patients with heart failure have increased liver stiffness, that appears to be related with the severity of heart fail- ure. (Acta gastroenterol. belg., 2013, 76, 246-250).