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Gastro Flash 2018 › Gastro Flash Vol-4, No-1, 2018

Bowel Preparation For Colonoscopy & Flexible Sigmoidoscopy: Focus On The Role Of Drotaverine

Introduction

Both sigmoidoscopy and colonoscopy are being used since 19th century for the detection and treatment of colorectal cancer. With the further advancement in technology, their use has been substantially increased for both diagnostic and screening purposes.1Brenner H, Stock C, Hoffmeister M. Effect of screening sigmoidoscopy and screening colonoscopy on colorectal cancer incidence and mortality: systematic review and meta-analysis of randomised controlled trials and observational studies. The BMJ.2014;348:g2467.    Colorectal cancer is one of the top 3 neoplasms affecting the global patient population. A considerable improvement in the colorectal cancer mortality is dependent on prevention and diagnosis at an early stage. Even though various other noninvasive tests are available including fecal immunochemical test, fecal occult blood test and CT colonography; colonoscopy has the advantage of being a diagnostic and therapeutic tool at the same time. For this reason, colonoscopy is the current gold standard for diagnostic imaging of the colon. It has the ability to visualize the entire colon and if polyps are found they can be removed at the same procedure.2Bechtold ML, Mir F, Puli SR, Nguyen DL. Optimizing bowel preparation for colonoscopy:a guide to enhance quality of visualization. Annals of Gastroenterology: Quarterly Publication of the Hellenic Society of Gastroenterology. 2016;29(2):137-146.    3Nicholson FB, Korman MG. Acceptance of flexible sigmoidoscopy and colonoscopy for screening and surveillance in colorectal cancer prevention. J Med Screen. 2005;12(2):89-95.     Sigmoidoscopy also represents a cost-effective option for colorectal cancer screening, based on the recent findings of a study showing a long-lasting and substantial reduction of its incidence and mortality.4Senore C, Ederle A, Fantin A, Andreoni B, Bisanti L, Grazzini G, Zappa M, Ferrero F, Marutti A, Giuliani O, Armaroli P, Segnan N. Acceptability and side-effects of colonoscopy and sigmoidoscopy in a screening setting. J Med Screen.2011;18(3):128-34.   Various other studies have also shown that both colonoscopy and sigmoidoscopy are effective in reducing colorectal cancer and mortality.5Chen C, Läcke E, Stock C, Hoffmeister M, Brenner H. Colonoscopy and sigmoidoscopy use among older adults in different countries: A systematic review. Prev Med. 2017 Oct;103:33-42.   However, in an effort to further reduce the mortality of colorectal cancer, many approaches to quality improvement in colonoscopy have been proposed. The quality of colonoscopy practice is highly erratic and there is increasing public awareness of missed cancers, incomplete procedures and of adverse events related to colonoscopy which are potentially preventable.

The administration of important, measurable quality indicators and minimum quality standards is therefore mandatory to define and shape a quality colonoscopy service. The common approaches to quality improvement include adequate withdrawal time, optimal withdrawal technique, cecal intubation rate, optical enhancement and measurement of adenoma detection rate. In addition to these aproaches, the success of colonoscopy further depends on the quality of bowel preparation. A suboptimal bowel preparation may lead to a longer cecal intubation time, a lower cecal intubation rate, and a lower polyp detection rate. In can also result in increased costs associated with colonoscopy, since suboptimal colonoscopy often necessitates more frequent, shorter screening and surveillance intervals than recommended. An ideal bowel preparation should be small in volume, satisfactory and tolerable, reliable in cleansing efficacy, and safe for the patients.6Lee H-S, Byeon J-S. Bowel Preparation, the First Step for a Good Quality Colonoscopy. Intestinal Research. 2014;12(1):1-2.   7Bourikas LA, Tsiamoulos ZP, Haycock A, Thomas-Gibson S, Saunders BP. How we can measure quality in colonoscopy? World Journal of Gastrointestinal Endoscopy. 2013;5(10):468-475.

Need for bowel preparation before colonoscopy

As aforementioned bowel preparation is a central issue related to the quality of the procedure.8Parra-Blanco A, Ruiz A, Alvarez-Lobos M, et al. Achieving the best bowel preparation for colonoscopy. World Journal of Gastroenterology: WJG. 2014;20(47):17709-17726.    It is crucial to have a good bowel preparation with minimal fecal contamination, for an optimal assessment of large bowel with colonoscopy. Poor bowel preparation is a leading cause of failed colonoscopy examinations.9Gardezi SA, Tibbatts C. Improving bowel preparation for colonoscopy in a cost effective manner. BMJ Quality Improvement Reports. 2017;6(1):u204560.w5376.    It is widely accepted that quality of bowel preparation should be excellent to facilitate detecting neoplastic lesions.8Parra-Blanco A, Ruiz A, Alvarez-Lobos M, et al. Achieving the best bowel preparation for colonoscopy. World Journal of Gastroenterology: WJG. 2014;20(47):17709-17726.   Precolonoscopy bowel preparation is adequate to diagnose lesions of more than 5 mm in about 70% to 75% of the cases. The use of high-quality agents with established efficacy rates of 90% or more, identification of patients who are at increased risk of an inadequate preparation, in addition to patient education and motivation to be invested in the process further improves the success of bowel preparation.10 Cohen LB. Advances in bowel preparation for colonoscopy. Gastrointest Endosc Clin N Am. 2015 Apr;25(2):183-97.     The quality of bowel preparation can be estimated with the help of a grading scale (Table 1).11. Singhal S, Nigar S, Paleti V, Lane D, Duddempudi S. Bowel preparation regimens for colon capsule endoscopy: A review. Therapeutic Advances in Gastroenterology. 2014;7(3): 115-122.     Although many other scales are evident in the literature, out of which three validated bowel preparation scoring or grading systems are most commonly used. These include Aronchick, Ottawa, and the Boston Bowel Preparation scales (Table 2).2Bechtold ML, Mir F, Puli SR, Nguyen DL. Optimizing bowel preparation for colonoscopy:a guide to enhance quality of visualization. Annals of Gastroenterology: Quarterly Publication of the Hellenic Society of Gastroenterology. 2016;29(2):137-146.

A suboptimal bowel preparation may lead to small or flat lesions being missed, shortened surveillance times, considerable obstruction in progression of colonoscope, increased likelihood of complications, and more sedatives and analgesics being required. Consequently, a huge research has been performed on improving bowel preparations prior to colonoscopy. According to a joint statement by the American Society of Colon and Rectal Cancer (ASCRS), American Society of Gastrointestinal Endoscopy (ASGE), and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) in 2006, a colonoscopy preparation should have properties of being inexpensive; cleanse the bowels rapidly; and not cause significant patient discomfort or electrolyte imbalances. This is in line with the guidelines published by the European Society of Gastrointestinal Endoscopy. There are basically three factors which are essential for a good bowel preparation i.e. safe, palatable, and efficacious. An adequate bowel preparation is a combination of multiple factors including description of bowel preparation agents, grading scales for bowel preparations, factors that may influence the efficacy of the bowel preparation, impact of restrictive diets on preparation, and timing of preparation with colonoscopy.2Bechtold ML, Mir F, Puli SR, Nguyen DL. Optimizing bowel preparation for colonoscopy:a guide to enhance quality of visualization. Annals of Gastroenterology: Quarterly Publication of the Hellenic Society of Gastroenterology. 2016;29(2):137-146.    Thus, addressing the safety, tolerability, and effective administration of colon-cleansing regimens may enhance patient compliance, lead to a higher quality bowel preparation, and improve polyp detection.10 Cohen LB. Advances in bowel preparation for colonoscopy. Gastrointest Endosc Clin N Am. 2015 Apr;25(2):183-97.

Types of bowel preparation agents available

An ideal bowel preparation agent should be efficient, safe and well tolerated by the patient. A variety of agents have become commercially available overtime. The currently available agents can be classified according to their tonicity, as being isotonic or hypertonic.12Martens P, Bisschops R. Bowel preparation for colonoscopy: Efficacy, tolerability and safety. Acta Gastroenterol Belg. 2014 Jun;77(2):249-55.   These agents are described in Table 3.2Bechtold ML, Mir F, Puli SR, Nguyen DL. Optimizing bowel preparation for colonoscopy:a guide to enhance quality of visualization. Annals of Gastroenterology: Quarterly Publication of the Hellenic Society of Gastroenterology. 2016;29(2):137-146.

Role of drotaverine for premedication during colonoscopy procedure

Antispasmodic drugs are generally economical, effective and safe. They may improve outcomes in colonoscopy by easing bowel preparation procedure.13. Sanagapalli S, Agnihotri K, Leong R, Corte CJ. Antispasmodic drugs in colonoscopy: A review of their pharmacology, safety and efficacy in improving polyp detection and related outcomes. Therapeutic Advances in Gastroenterology. 2017;10(1):101-113.     In this context drotaverine has emerged as an effective antispasmodic agent in colonoscopy procedure. Several studies have reported its efficacy in various endoscopic procedures. One such study has suggested it to be a reasonable alternative as antimotility agent before endoscopic retrograde cholangiopancreatography (ERCP) procedure. The study aimed to evaluate the effects of drotaverine hydrochloride and scopolamine in reducing duodenal motility and in facilitating cannulation during ERCP. It was a randomized controlled trial of 650 participants from 4 endoscopic centers assigned to receive scopolamine 20 mg or drotaverine hydrochloride 40 mg intravenously 15 minutes before ERCP. The recorded parameters included duodenal motility grades, success rates of deep cannulation, ERCP-related complications and adverse effects. Results reported that there were no significant differences in duodenal motility grades (1.17 ± 0. 82 vs. 1.13 ± 0.89), success rate of deep cannulation (90. 9% vs. 91.8%) and incidence of ERCP-related complications (11.3% vs. 11.0%) between the two groups. Nevertheless, the incidence of tachycardia (heart rate > 120 bpm) during ERCP was lower in drotaverine group than in scopolamine group (2. 2% vs. 6. 9%).14Peng W, Feng L, Jian-feng Y, Chao-ying F, Xiu-fen T, Chun-lan Z, Xiao Z, Li-ping H, Xu R, Zhao-shen L. Pretreatment with Drotaverine Hydrochloride before endoscopic retrograde cholangiopanc reatogra-phy: A prospective multicenter randomized controlled trial. Chinese Journal of Digestive Endoscopy. 2009; 26(8) : 397-401.

These results were corroborated by another study15. Hong-min X, Xin-kui Y, Jia-xuan LI. Research of drotaverine applied before 48 ERCP case.China Practice Medicine. May 2016, Volume 11, Number 14.     which compared the effect by drotaverine hydrochloride in suppression of duodenal motility, and to investigate effectiveness and safety of drug application before ERCP. A total of 48 patients were randomized into two groups namely experimental and control group, with 34 cases in each group. The control group was conventional therapy, while the experimental group received additional 40 mg drotaverine hydrochloride in 30 min. Results revealed that oral administration of drotaverine hydrochloride before ERCP shows good spasmolysis effect and reduces intubation and operation time. It can be taken as common drug before operation.15. Hong-min X, Xin-kui Y, Jia-xuan LI. Research of drotaverine applied before 48 ERCP case.China Practice Medicine. May 2016, Volume 11, Number 14.    Colonoscopy procedure performed with drotaverine hydrochloride can effectively mitigate the sufferings of patients, forget the bad memories, and shorten the operation duration. This is a safe and effective method of bowel preparation during colonoscopy. In order to evaluate the efficacy of drotaverine hydrochloride in colonoscopy procedure a randomized controlled study was carried out including 100 patients undergoing colonoscopy. All the patients were randomly divided into the observation group (n=50) and the control group (n=50). The colonoscopy was conducted in the observation group after the intravenous injection of midazolam and drotaverine hydrochloride; whereas the control group underwent routine colonoscopy. Results divulged the success rate of colonoscopy to be 98 and 92% in the observation group and the control group, respectively (Figure 1). Additionally, the observation group had no complains of pains and the operation duration was 7.2 minutes in comparis on to 10.6 in control group.16Wei-xiang L, Hui-ping WU, Hui-ming Z, Li-sheng W. Investigation and nursing on colonoscopy with midazolam and drotaverine hydrochloride. Modern Nursing 2006-12.

Drotaverine is thus considered as safe and effective premedication treatment before any endoscopic procedure.

Conclusion

Healthcare professionals nowadays are increasingly individualizing bowel preparations to achieve an efficient, tolerable, and safe bowel preparation. An optimal bowel preparation leads to reduced total colonoscopy procedure time, increased cecal intubation, and decrease costs by preventing cancelled procedures and increasing intervals between screening and surveillance colonoscopies. Use of antispasmodic agents may improve outcomes in colonoscopy by easing bowel preparation procedure.

References

  1. Brenner H, Stock C, Hoffmeister M. Effect of screening sigmoidoscopy and screening colonoscopy on colorectal cancer incidence and mortality: systematic review and meta-analysis of randomised controlled trials and observational studies.The BMJ. 2014;348:g2467.
  2. Bechtold ML, Mir F, Puli SR, Nguyen DL. Optimizing bowel preparation for colonoscopy: a guide to enhance quality of visualization.Annals of Gastroenterology: Quarterly Publication of the Hellenic Society of Gastroenterology. 2016;29(2):137-146.
  3. Nicholson FB, Korman MG. Acceptance of flexible sigmoidoscopy and colonoscopy for screening and surveillance in colorectal cancer prevention.J Med Screen.2005;12(2):89-95.
  4. Senore C, Ederle A, Fantin A, Andreoni B, Bisanti L, Grazzini G, Zappa M, Ferrero F, Marutti A, Giuliani O, Armaroli P, Segnan N. Acceptability and side-effects of colonoscopy and sigmoidoscopy in a screening setting.J Med Screen. 2011;18(3):128-34.
  5. Chen C, Läcke E, Stock C, Hoffmeister M, Brenner H. Colonoscopy and sigmoidoscopy use among older adults in different countries: A systematic review.Prev Med. 2017 Oct;103:33-42.
  6. Lee H-S, Byeon J-S. Bowel Preparation, the First Step for a Good Quality Colonoscopy.Intestinal Research. 2014;12(1):1-2.
  7. Bourikas LA, Tsiamoulos ZP, Haycock A, Thomas-Gibson S, Saunders BP. How we can measure quality in colonoscopy?World Journal of Gastrointestinal Endoscopy. 2013;5(10):468-475.
  8. Parra-Blanco A, Ruiz A, Alvarez-Lobos M,et al. Achieving the best bowel preparation for colonoscopy.World Journal of Gastroenterology: WJG. 2014;20(47):17709-17726.
  9. Gardezi SA, Tibbatts C. Improving bowel preparation for colonoscopy in a cost effective manner.BMJ Quality Improvement Reports. 2017;6(1):u204560.w5376.
  10. Cohen LB. Advances in bowel preparation for colonoscopy.Gastrointest Endosc Clin N Am. 2015 Apr;25(2):183-97.
  11. Singhal S, Nigar S, Paleti V, Lane D, Duddempudi S. Bowel preparation regimens for colon capsule endoscopy: A review.Therapeutic Advances in Gastroenterology. 2014;7(3):115-122.
  12. Martens P, Bisschops R. Bowel preparation for colonoscopy: Efficacy, tolerability and safety.Acta Gastroenterol Belg.2014 Jun;77(2):249-55.
  13. Sanagapalli S, Agnihotri K, Leong R, Corte CJ. Antispasmodic drugs in colonoscopy: A review of their pharmacology, safety and efficacy in improving polyp detection and related outcomes.Therapeutic Advances in Gastroenterology. 2017;10(1):101-113.
  14. Peng W, Feng L, Jian-feng Y, Chao-ying F, Xiu-fen T, Chun-lan Z, Xiao Z, Li-ping H, Xu R, Zhao-shen L. Pretreatment with Drotaverine Hydrochloride before endoscopic retrograde cholangiopanc reatogra-phy: A prospective multicenter randomized controlled trial.Chinese Journal of Digestive Endoscopy. 2009; 26(8) : 397-401.
  15. Hong-min X, Xin-kui Y, Jia-xuan LI. Research of drotaverine applied before 48 ERCP case.China Practice Medicine. May 2016, Volume 11, Number 14.
  16. Wei-xiang L, Hui-ping WU, Hui-ming Z, Li-sheng W. Investigation and nursing on colonoscopy with midazolam and drotaverine hydrochloride.Modern Nursing 2006-12.
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