Intravenous antispasmodic and patient-controlled analgesia are of benefit for screening flexible sigmoidoscopy

doi:10.1016/S0016-5107(95)70067-6

Gastrointestinal Endoscopy

Volume 42, Issue 2, August 1995, Pages 123-127

https://doi.org/10.1016/S0016-5107(95)70067-6 Get rights and content

Abstract

The possible benefits of premedication with the antispasmodic hyoscine n-butyl bromide (hyoscine) and analgesia with inhaled nitrous oxide/oxygen mixture (nitrous oxide) were assessed in a double-blinded, placebo-controlled trial. Consecutive patients at normal risk for cancer undergoing screening flexible sigmoidoscopy were randomly allocated to receive either (1) intravenous hyoscine 20 mg plus inhaled oxygen on demand (n = 40), (2) sterile water injection plus inhaled nitrous oxide on demand (n = 48), or (3) sterile water injection plus inhaled oxygen on demand (n = 43). One recently trained primary care physician performed all procedures. Duration of the procedure, endoscopic findings, and depth of insertion were recorded. After the examination, screenees rated their degree of pain during the procedure using a visual analogue scale. Depth of insertion did not differ between the three study groups, but the duration of the procedure was significantly less in the hyoscine group (median, 12.5 minutes) as compared with placebo (median, 18 minutes; p = .0008). Fifty-four percent of screenees chose to use the on-demand gas. Pain scores were significantly lower in those individuals who inhaled nitrous oxide as compared with placebo (p = .045). Premedication with antispasmodic shortens total procedure time for flexible sigmoidoscopy by a moderately experienced endoscopist as compared with placebo. In this study, a significant number of screenees experienced discomfort during flexible sigmoidoscopy, which appeared to be reduced by offering nitrous oxide inhalation (Gastrointest Endosc 1995;42:123-7.)

Section snippets

METHODS

In a double-blinded, placebo-controlled study, asymptomatic patients, ages 55 to 75 years, at average risk for cancer and undergoing screening flexible sigmoidoscopy, were randomly allocated to one of three treatment arms: (1) hyoscine (hyoscine n-butyl-bromide 20 mg i.v. plus inhaled oxygen on demand), (2) nitrous oxide (sterile water injection plus a mixture of 50% nitrous oxide and 50% oxygen inhaled on demand), or (3) placebo (sterile water injection plus inhaled oxygen on demand).

RESULTS

A total of 131 screenees who met the entry criteria were entered consecutively into the trial. Forty patients received hyoscine, 48 nitrous oxide, and 43 placebo. There were no significant differences between the profiles of the screenees in the three study groups. Subject details and endoscopic findings are displayed in Table 1.

No difference was observed between the study groups with regard to the maximum depth of insertion: for hyoscine, median depth was 60 cm and range 25 to 100 cm; for

DISCUSSION

Flexible sigmoidoscopy is a safe and relatively inexpensive procedure, performed by primary health care physicians and hospital gastroenterologists alike.1, 11 The American Cancer Society currently recommends screening by flexible sigmoidoscopy every 3 to 5 years after age 50.¹² To maintain compliance with repeated screening, it is essential that the procedure be acceptable to the patient, involve a minimum of discomfort, if any, and be quick and accurate. In this study, we have assessed the

Acknowledgements

The authors would like to thank Sergeant Bernard Winter and Corporal Garath Herbert of the 2nd Parachute Regiment for their help with this study.

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Cited by (36)

Colonoscopy and flexible sigmoidoscopy
2013, Colorectal Surgery, Fifth Edition
Nitrous oxide for analgesia in colonoscopy without sedation
2011, Gastrointestinal Endoscopy
Citation Excerpt :
Regarding colonoscopy, little difference was seen between the nitrous oxide groups and the control groups in the studies included.5-10 The study by Saunders et al13 was placebo controlled. Both intravenous sedation/analgesia and nitrous oxide proved favorable to placebo regarding patient-reported pain.
Colonoscopy is associated with pain and discomfort, and intravenous analgesics and sedatives are widely used. There are several disadvantages regarding this practice, including risk of complications, resources demanded, and amnesia after sedation. In spite of promising results in previous studies, nitrous oxide is rarely used at endoscopy centers around the world.
To investigate the efficiency of nitrous oxide versus placebo as an analgesic during colonoscopy without sedation.
A double-blind, randomized, placebo-controlled trial.
The endoscopy unit at Oslo University Hospital Rikshospitalet, Oslo, Norway, between June 2006 and May 2008.
This study involved patients undergoing elective colonoscopy.
Patients inhaled nitrous oxide or placebo on demand.
The participants filled in a questionnaire regarding their experiences with the examination. Pain was graded from 1 (no pain) to 4 (severe pain).
We recruited 199 patients. We randomized 97 patients to the nitrous oxide group and 102 to the control group. The groups were comparable regarding demographic factors. Median patient-reported pain was 2 in both the nitrous oxide group and the control group (interquartile range 2-3 in both groups). Additional sedatives and analgesics were given equally often and in similar doses in both groups. No side effects related to administration of nitrous oxide were reported.
The questionnaire was returned by 76% of the patients. The study gas was given on demand, not continuously.
Nitrous oxide given intermittently is not an effective substitution for intravenous on-demand sedation and analgesics in the setting of colonoscopy without sedation. (Clinical trial registration number: NCT00318825.)
Sublingual hyoscyamine spray as premedication for colonoscopy: a randomized double-blinded placebo-controlled trial
2008, American Journal of Surgery
Citation Excerpt :
There was no difference in terms of speed of procedure, medications required, or patient discomfort.7 In contrast to earlier studies, Saunders and Williams8 and Saunders et al9 showed benefit in 2 studies from hyoscine n-butylbromide, another antispasmodic given as premedication for colonoscopy. In the first study, 56 patients were randomly assigned to receive intravenous hyoscine or placebo before colonoscopy.
Colonic motility and spasm during colonoscopy may affect duration and quality of the examination as well as patient comfort during and after the procedure. Previous studies assessing the utility of antispasmodic agents in colonoscopy demonstrated conflicting results. The aim of this study was to determine the effect of sublingual hyoscyamine spray (IB-Stat, Inkine Pharmaceutical) on the performance of colonoscopy.
One hundred patients undergoing elective colonoscopy were randomized in a double-blind study to receive .25 mg sublingual hyoscyamine spray (n = 50: 25 men and 25 women, mean age 60) or placebo spray (n = 50: 23 men and 27 women, mean age 56) 15 to 30 minutes before the procedure. Parameters measured included time required to reach the cecum, total procedure time, endoscopist perception of colonic motility and difficulty of the procedure, and patient assessment of discomfort after the procedure. The latter parameters were measured using a 100-mm visual analog scale. A single endoscopist performed all of the procedures.
After adjustment for age, procedural difficulty scores and colonic motility scores were significantly lower in the hyoscyamine group compared with placebo (differences of 5.589 mm [P = .047] and 5.685 mm [P = .040], respectively). Mean time to cecal intubation and percentage of patients with discomfort were slightly lower in the hyoscyamine group (5.68 minutes/48%) compared with placebo (5.92 minutes/57.1%), although the differences were not statistically significant (P = .57 and P = .36, respectively).
Procedural difficulty and colonic motility scores were significantly lower in subjects who received sublingual hyoscyamine before colonoscopy.
Randomized, double-blinded, placebo-controlled trial of intravenously administered hyoscine N-butyl bromide in patients undergoing colonoscopy with patient-controlled sedation
2004, Gastrointestinal Endoscopy
A prospective, double-blinded, placebo-controlled randomized trial was conducted to investigate the effect of the antispasmodic hyoscine N-butyl bromide (Buscopan) during colonoscopy.
A total of 120 patients undergoing colonoscopy were randomized to receive either 40 mg of hyoscine N-butyl bromide (n = 60) or normal saline solution (n = 60) intravenously as premedication. Colonoscopy was performed under patient-controlled sedation. Outcome measures included cecal intubation and total procedure time, demanded and administered doses of patient-controlled sedation, spasm score, pain score, endoscopist satisfaction score, patient willingness to repeat colonoscopy, and vital signs (blood pressure, pulse rate) during colonoscopy.
Mean cecal intubation time in the hyoscine N-butyl bromide group was significantly longer than the control group (12.20 vs. 9.74 minutes; p = 0.04; but correction for multiple testing of data removed this significance). The use of hyoscine N-butyl bromide was associated with a significantly lower endoscopist mean satisfaction score (6.47 vs. 7.30; p = 0.04; but correction for multiple testing of data removed this significance), higher demanded and administered mean doses of patient-controlled sedation (respectively, 34.80 and 7.25 vs. 24.20 and 5.87; p = 0.045; p = 0.04, respectively; but correction for multiple testing of data removed these findings of significance), fewer patients willing to repeat colonoscopy (60% vs. 83.9%; p = 0.005), and more hemodynamic instability (p<0.001) when compared with the control group. No significant difference was found in the total procedure time, spasm score, or pain score.
Premedication with intravenously administered hyoscine N-butyl bromide impedes colonoscope insertion and causes greater patient discomfort, as well as hemodynamic instability.
Effect of hysterectomy status on polyp detection rates at screening flexible sigmoidoscopy
2003, Gastrointestinal Endoscopy
Background: Flexible sigmoidoscopy with polypectomy reduces the incidence of colorectal cancer by removal of premalignant lesions. Factors that reduce the area examined by flexible sigmoidoscopy may reduce its benefit. The aim of this study was to determine whether hysterectomy affects completion and polyp detection rates at flexible sigmoidoscopy. Methods: Within the setting of a multicenter, prospective, controlled trial of screening flexible sigmoidoscopy, patient and examination variables were compared by appropriate statistical methods for women between the ages of 55 and 64 years with and without a history of a hysterectomy. Results: One quarter of women participants had undergone a hysterectomy. These women were more likely to have incomplete examinations (risk ratio [RR] of incomplete examination, 1.53; 95% CI [1.4, 1.6]). Flexible sigmoidoscopy was more difficult (p < 0.001), more painful (p < 0.001), and less extensive (46 cm vs. 48 cm insertion on average; p < 0.0001) in women who had undergone a hysterectomy. There was a significant trend toward lower relative detection rates of polyps and adenomas at more proximal sites (rectum, sigmoid colon, and proximal to sigmoid; respectively, p = 0.008, p = 0.009) in this group. Conclusions: Women who have undergone a hysterectomy have less extensive flexible sigmoidoscopy examinations, which are more difficult and more painful, than women without a hysterectomy. Hysterectomy is associated with a reduction in polyp detection rate in the sigmoid colon. This modality of screening may be less effective in women who have undergone a hysterectomy. (Gastrointest Endosc 2003;57:848-53.)
Inhaled patient-administered nitrous oxide/oxygen mixture does not impair driving ability when used as analgesia during screening flexible sigmoidoscopy
2000, Gastrointestinal Endoscopy
Background: Entonox (nitrous oxide/oxygen mixture) has an analgesic effect, but its use is currently contraindicated in patients who plan to drive after its administration. We assessed the effect on driving ability of Entonox used as analgesia in patients undergoing screening flexible sigmoidoscopy. Methods: Forty men and 40 women scheduled for screening flexible sigmoidoscopy who had not driven to the examination site were recruited together with a matched control subject from the same list. Before the examination complex motor skills were assessed in both groups using an adaptive tracking task, previously demonstrated to be the most sensitive test for detecting impairment of driving ability due to drugs. During the examination Entonox analgesia was available to the study group only, and after the screening examination complex motor function was retested on the same computer. Results: Both groups improved their computer score on repeat testing, by 0.53 (range –1.9 to 4.6) in the study group and by 0.44 (range –0.6 to 2.5) in the control group. Conclusions: These data strongly support the view that Entonox analgesia does not impair driving ability. In the context of screening flexible sigmoidoscopy its use may lead to an increase in compliance. (Gastrointest Endosc 2000;51:701-3.)

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^☆: From the Department of Endoscopy and the Imperial Cancer Research Foundation, St. Mark's Hospital, London, United Kingdom; and the King Edward VII Memorial Hospital, Port Stanley, Falkland Islands.

^☆☆: Reprint requests: Brian P. Saunders, MRCP, Department of Endoscopy, St. Mark's Hosptial, City Road, London, EC1V 2PS.

^★: Reprint requests: Brian P. Saundes, MRCP, Department of Endoscopy, St. Mark's Hospital, City Road, London, EC1V 2PS.

^★★: 37/1/60791

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Intravenous antispasmodic and patient-controlled analgesia are of benefit for screening flexible sigmoidoscopy☆,☆☆,★,★★

Abstract

Section snippets

METHODS

RESULTS

DISCUSSION

Acknowledgements

Gastroenterology

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Am J Emerg Med

Ann Emerg Med

Flexible fibreoptic sigmoidoscopy—the Monroe clinic experience. A prospective study of 5000 examinations

Dis Colon Rectum

The yield of flexible fiberoptic sigmoidoscopy in the detection of asymptomatic colorectal neoplasia

Surg Endosc

Sigmoidoscopic examinations with rigid and flexible fiberoptic sigmoidoscopes in the surgeon's office: a comparative prospective study of effectiveness in 1012 cases

Dis Colon Rectum

Patient response to sigmoidoscopy. A randomized, controlled trial of rigid and flexible sigmoidoscopy

Cancer

Sensitivity and accuracy of the visual analogue scale and the analysis of analgesic action

Eur J Clin Pharmacol

Visual analogue scale and the analysis of analgesic action

Eur J Clin Pharmacol

Oral sedation for diagnostic upper endoscopy

Endoscopy