Letters to the Editor
Variable Use of Sedation During Colonoscopy and Impact on Outcome I. Shaikh, MBBS, MS, MRCS, MD, FRCS1, N. Iqbal, MBBS, MRCS1, A. Khan, MBBS1 and S. Doughan, FRCS1 doi:10.1038/ajg.2013.33
To the Editor: We read the paper published by Bannert et al. (1), with interest. Congratulations for the large data of screening colonoscopies. We agree with you that there is no difference in polyp detection between sedated and nonsedated patients. However, no sedation may reduce procedure related complications and may aid in engaging the patient during the procedure. In addition the nursing staff may find it easy to change the position of patient during the procedure and talk to the patient. We performed a search in our database of colonoscopies and analyzed the results with respect to sedation and nonsedation. This showed no statistical difference in polyp detection in those groups. Our experience showed that about 11% (194/1694) of patients underwent colonoscopy with no sedation. We find that the initial patient anxiety and negotiating the sigmoid loop is the time where most patients demand some sedation to be given. We believe that adenoma detection may not be an issue if an acceptable cecal intubation could be achieved as most of the pathologies can be detected during withdrawal (2). The withdrawal time is possibly one of the confounding factors and unfortunately not available from Bannert et al., study. However, we would like to know from Bannert et al., what were the discomfort levels experienced by these patients. As colonoscopy is an invasive procedure, it, therefore, requires patients to have a high level of motivation to have it performed without sedation. Our study (manuscript under preparation) showed no difference in discomfort levels between both groups of patients. We think the best surrogate maker would be a patient coming back for repeat colonoscopy and having it
© 2013 by the American College of Gastroenterology
performed under no sedation again. Is it possible to share the data of how many of these patients underwent repeat unsedated colonoscopy? The main factor for failed cecal intubation was pain in both the groups. We wonder if any of those patients who failed cecal intubation in the nonsedated group were offered sedation. In our experience, if the patient starts with no premedication and before abandoning the procedure, we offer them sedation for any discomfort. Even if the completion of the procedure has failed, it would be more likely due to the fixed angulation of colon or an unresolved loop. Could Bannert et al., clarify in the analysis whether the patients who were given sedation during procedure were included in the sedation group, because that would then increase the relative cecal intubation rate of that group. It was interesting to note though that there was no difference in other causes of failed cecal intubation, which is possibly due to unresolved loops or fixed angulation etc. We think there has to be separate calculation of cecal intubation for nonsedated, sedated, and patients who had sedation intra procedure. Then a direct comparison can be made between sedated and nonsedated cecal intubation. Lastly, is there any particular age group in your study that is more likely to accept colonoscopy under no sedation? CONFLICT OF INTEREST Specific author contributions: Manuscript preparation: I.S.; data collection: N.I.; Manuscript preparation: A.K.; critical review of manuscript and supervision: S.D. Potential competing interests: None. REFERENCES 1. Bannert C, Reinhart K, Dinkler D et al. Sedation in screening colonoscopy - impact on quality indicators and complications. Am J Gastroenterol 2012;107:1837–48. 2. Lee TJ, Blanks RG, Rees CJ et al. Longer mean colonoscopy withdrawal time is associated with increased adenoma detection: evidence from the Bowel Cancer Screening Programme in England. Endoscopy 2013;45:20–6. 1
Department of Surgery, QEQM Hospital, Margate, UK. Correspondence: S. Doughan, FRCS, Department of Surgery, QEQM Hospital, Margate CT94AN, UK. E-mail:
[email protected]
Response to Shaikh et al. Monika Ferlitsch, MD1, Christina Bannert, MD1 and Arnulf Ferlitsch, MD1 doi:10.1038/ajg.2013.35
To the Editor: We are thankful to Shaikh et al. (1) for their interest in our work and for sharing their data with us. Unfortunately, although withdrawal time is an important quality parameter, we do not have data on withdrawal time in our database. As our database started at the end of 2007 we also cannot tell you how many of these patients underwent repeated unsedated colonoscopy. However, we also think that it is an important issue that has to be addressed in future trials. Many patients in rural areas approach endoscopy units by car and prefer unsedated screening colonoscopy. In these cases, patients’ motivation to change from unsedated to sedated colonoscopy will be low, despite possible unpleasant memories of their previous colonoscopy. In our study, patients who received sedation during the procedure were included in the sedation group, and, unfortunately, cannot be analyzed separately (2). We do agree that changing from unsedated colonoscopy to sedated colonoscopy may increase the relative CIR in the sedation group, although we think that there is no need to discriminate if sedation is started at the beginning of the procedure or later to pass the fixed angulation of the colon. The median age in sedated and unsedated patients was the same (sedated 60.6 years (interquartile range: 54.3–67.5), unsedated 60.7 years (interquartile range: 54.4–67.9)). CONFLICT OF INTEREST The authors declare no conflict of interest. REFERENCES 1. Shaikh I, Iqbal N, Khan A et al. Variable use of sedation during colonoscopy and impact on outcome. Am J Gastroenterol 2013;108:853 (this issue). 2. Bannert C, Reinhart K, Dunkler D et al. Sedation in screening colonoscopy: impact on quality indicators and complications. Am J Gastroenterol 2012;107:1837–48. 1 Quality Assurance Working Group of the Austrian Society of Gastroenterology and
The American Journal of GASTROENTEROLOGY
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Letters to the Editor
Hepatology and Department of Internal Medicine III, Division of Gastroenterology & Hepatology, Medical University Vienna, Vienna, Austria. Correspondence: Monika Ferlitsch, MD, Quality Assurance Working Group of the Austrian Society of Gastroenterology and Hepatology and Department of Internal Medicine III, Division of Gastroenterology & Hepatology, Medical University Vienna, Waehringer Guertel 18-20, Vienna, Austria. E-mail:
[email protected]
An Electrocardiograph Should be Examined in Patients With a Hypersensitive Esophagus Before a Trial of Citalopram Tae Hee Lee, MD1 and Joon Seong Lee, MD1 doi: 10.1038/ajg.2013.25
To the Editor: We read with great interest the study by Viazis et al. (1) regarding the role of citalopram in a hypersensitive esophagus, which is defined as a state of significant symptom/reflux correlations with normal esophageal acid exposure. They reported a significantly higher remission rate for reflux-related symptoms in the citalopram group, compared with a placebo group (61.5 vs. 33.3%, P = 0.021). According to their results, citalopram seems to be a justifiable, beneficial drug for patients with a hypersensitive esophagus. However, we would like to raise one concern regarding a trial of citalopram in patients with a hypersensitive esophagus. Citalopram can induce torsade de pointes, especially in patients with congenital long QT syndrome or known pre-existing QT interval prolongation (2–4). Therefore, in patients with cardiac disease or electrolyte imbalance (e.g., hypokalemia or hypomagnesemia), an electrocardiograph should be examined before citalopram is administered. The coadministration of citalopram with medications that prolong the QT interval is also contraindicated. These medications include some antiarrhythmics, antipsychotics, antimicrobials, antihistamines, and antiretrovirals. Esophageal hypersensitivity can occur in The American Journal of GASTROENTEROLOGY
patients with gastroesophageal reflux disease with increased esophageal acid exposure. This is why the coadministration of a proton pump inhibitor (PPI) seems to be justifiable in patients with a suspected hypersensitive esophagus. Long-term PPI therapy can cause hypomagnesemia, especially in elderly patients (5). Therefore, in patients on a PPI, serum magnesium should be monitored during citalopram therapy. Gastroenterologists should be aware of this potential complication when citalopram is administered to patients with a hypersensitive esophagus. CONFLICT OF INTEREST The authors declare no conflict of interest. REFERENCES 1. Viazis N, Keyoglou A, Kanellopoulos AK et al. Selective serotonin reuptake inhibitors for the treatment of hypersensitive esophagus: a randomized, double-blind, placebo-controlled study. Am J Gastroenterol 2012;107:1662–7. 2. de Gregorio C, Morabito G, Cerrito M et al. Citalopram-induced long QT syndrome and torsade de pointes: role for concomitant therapy and disease. Int J Cardiol 2011;148:226–8. 3. Fayssoil A, Issi J, Guerbaa M et al. Torsade de pointes induced by citalopram and amiodarone. Ann Cardiol Angeiol (Paris) 2011;60:165–8. 4. Kanjanauthai S, Kanluen T, Chareonthaitawee P. Citalopram induced torsade de pointes, a rare life threatening side effect. Int J Cardiol 2008;131:e33–4. 5. Mackay JD, Bladon PT. Hypomagnesaemia due to proton-pump inhibitor therapy: a clinical case series. QJM 2010;103:387–95. 1
Institute for Digestive Research, Digestive Disease Center, Soonchunhyang University Hospital, College of Medicine, Seoul, South Korea. Correspondence: Joon Seong Lee, MD, Institute for Digestive Research, Digestive Disease Center, Soonchunhyang University Hospital, College of Medicine, Daesagwan-gil 22, Yongsan-gu, Seoul, South Korea. E-mail:
[email protected]
When Cure Becomes Worse Than the Disease Amnon Sonnenberg, MD, MSc1,2 and Charles R. Boardman, DNP, MS1,2 doi: 10.1038/ajg.2013.18
To the Editor: Gastroenterologists see many patients who complain of pain, bloating, nausea, and other vague symptoms of
the abdomen. A large fraction of these complaints are transient, self-limited, benign, or referred. The symptoms may relate to functional bowel disorders, somatization, or non-gastrointestinal pain radiating to the abdomen. Any ensuing diagnostic workup often unearths a new layer of nonspecific abnormalities that invariably engender subsidiary workups of their own: radiographic thickening of bowel segments, gall bladder sludge, mild fibrosis of the colonic lamina propria, slightly elevated liver enzymes, or mild anemia. Patients with functional bowel disorders undergo substantially more unnecessary abdominal and pelvic surgery than the general population (1,2). Such patients are also more likely to undergo fruitless endoscopic retrograde cholangiopancreatography, endoscopic ultrasound, and optical endoscopy (3,4). After such interventions, an appreciable fraction of patients enter the vicious cycle, wherein postoperative ileuses, adhesions, or infections lead to future stress, pain, and anxiety, which lead to further diagnostic and therapeutic interventions, initiating a lamentable fractal outgrowth of cost and pain (2). Such vicious cycles are also set in motion with incautious medical management using polypharmacy where many medicines now are prescribed simply to counteract the side effects of other medications. Thus, any physician managing nonspecific complaints has to ask herself whether the benefit of a given therapy outweighs its potential side effects. Figure 1 uses a simple decision tree to illustrate the underlying problem. A planned therapy can result in healing with a probability p1 and no healing with a probability 1–p1. In both outcomes, the therapy can also result in side effects with a probability p3. If no therapy is initiated, as shown in the lower main branch, spontaneous healing or symptom resolution can occur with a probability of p2. For therapy to be the preferred choice, the outcomes of the upper branch must supersede those of the lower branch: p1· heal − p3 · side effects > p2 · heal
(1)
or, after some minor re-arrangements: (p1 − p2) · heal > p3 · side effects
(2)
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