Brief Communications

A randornised blinded study in colonic lavage for colonoscopy Polyethylene glycol electrolyte lavage solution (PEGELS) has become the standard preparation used for colonic washout prior to colonoscopy in many units because it results in insignificant net water and electrolyte absorption and has proven to be safe and effective.’.’ However, 5-10% of patients tolerate PEGELS poorly because of its taste and attendant nausea, abdominal distension and cramps.’ It has been suggested4 that patient acceptability and side effect profile can be improved by a two stage lavage in which half the volume of PEG-ELS is drunk the evening before colonoscopy and the remaining half in the morning of the procedure. It has also been suggested that simethiconeS6 when added to PEG-ELS may improve visibility within the colon. T h e present study sought to determine the effect of two stage versus one stage lavage and the addition of simethicone on the quality of colonic washout and patient acceptance. Seventy-nine patients who attended the Gastroenterology Department for colonoscopy for routine indications (including iron deficiency anaemia, haematochezia, colonic polyposis and inflammatory bowel disease) were enrolled. The age, sex and weight distribution of the patients are shown in Table 1. ‘These patients were randomly allocated to four lavage groups: Group A received four litres of PEG-ELS (‘golytely’) taken the evening before colonoscopy. Group B were given four litres of PEG-ELS with 30 ml simethicone taken as in group A. Group C were asked to take two litres of‘PEG-ELS on the evening before colonoscopy and the remaining two litres on the morning of colonoscopy before the procedure. Group D were given the same PEG-ELS regimen as in group C with added simethicone. A questionnaire was administered to the patient prior to colonoscopy. Nausea was graded as ‘absent’, ‘unpleasant nausea’, and ‘vomiting’. Abdominal distension and anal irritation were likewise graded as ‘mild’, ‘moderate’ and ‘severe’. Presence or absence of faeces in the last bowel motion was graded. Questions were also directed to find out whether the patients had drunk the full prescribed volume of fluid and whether they were prepared to repeat the lavage if required.

T h e colonoscopies were perhrmed by one of three experienced colonoscopists blinded to the lavage regimens used. A questionnaire was completed following a colonoscopy. The colonic presence of residual faeces was graded from clear liquid to solid stool. Likewise the degree of bowel wall visualisation was graded from complete visualisation to varying degrees of inadequate visualisation. Presence of foam in the colon was graded from the absence of foam in the colon to large amount of foam requiring washing. Simethicone was obtained from Sigma. T h e trial was approved by the local Ethical Committee for medical research. The data were analysed using the statistical analysis system SAS. Continuous variables were investigated using a general linear models approach to analysis of variance with significant main effects further examined using the procedure of Tukey. Discrete variables were examined using a robust likelihood approach. A significance level of 5?70 was maintained throughout. T h e values are expressed as absolute patient numbers. There were no significant differences between the groups with regard to nausea, abdominal distension and anal irritation caused by different lavage regimens. However, a significant number of patients (seven out of 19) in group B (four litres PEG-ELS 30 ml simethicone) were unable to drink the entire volume of fluid prescribed (Table 2). Also, a significant number (four out of 19 and eight out of 21 respectively) of patients in both group B and group D (simethicone added groups) were unwilling to repeat the washout regimens (Table 3). There were no significant differences between the different lavage regimens with respect to body weight changes, consistency of the last bowel motion following washout and the presence or absence of residual faeces, degree of bowel wall visualisation and the amount of foam at colonoscopy. T h e lavage methods used in this study have been used previously. The dose (30 ml) of simethicone used was intermediate between 2.4 m15 and 75 m16 used previously. Although two earlier studies with small’ (2.4 ml) and larger’ (75 ml) doses of, simethicone have achieved decreased amount of foam in the colon, an

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Corrcspunderrre ro: Dr M. Lane, Gastruenterologist, Auckland Hospital, Park Road, Auckland I , New Zraland 4 STL’DY

Ih-COLON[(: I HVA(r1.

Aust NZ J M e d 1991; 21

769

TABLE 1 Age. Sex and Weight Distribution in the Four Lavage Groups Lavage groups (Gr)

Age yr median (range)

4 L + 3 0 rnl placebo

60 (39-76) 59 (19-71) 65 (31-80) 50 (23-75)

(Gr A) 4 L + 30 ml simethicone (Gr 8 ) 2 1 2 i + 3 0 ml placebo (Gr C ) 2 + 2 L + 30 ml sirnethicone (Gr D)

intermediate dose (30 ml) of simethicone used in this study failed to show any advantage over washouts with PEG-ELS alone. The large majority of our patients in all groups had minimal foam in their colon. This may be related to the fact that all of our trial uatients had at least half of their washout completed the evening prior to colonoscopy and it has been suggested6 that formation of foam is a transient phenomenon and an interval of seven to eight hours between lavage and colonoscopy, as in our study, may explain the lack of foam. The study of McNally et ai.’ did not record any advantage of simethicone in clearing faecal debris in accordance with our study in contradistinction to that of Shaver et aL6 It also appears from our study that addition of simethicone decreases patient acceptability. Since there were no differences between the lavage groups with regard to side effects like nausea, abdominal distension or anal irritation, the reason for the refusal to repeat washout regimens containing simethicone may lie with its taste. There was no difference between two stage and one stage lavage groups with regard to side effects, patient acceptability or the quality of colonic washout. This result differs from that of Rosch et al. This difference may be due to the fact that in our one stage lavage four litres of PEG-ELS were drunk the evening prior to colonoscopy rather than on the morning of the pro~cdure.~ Colonoscopists’assessment failed to show any difference between the groups in the quality of colonic washout as determined by the analysis of the data for residual faeces, degree of bowel wall visualisation and amount of foam. A recent study’ using oral sodium

Weight (kg) Total no. median (range) of patients

Male 11

9

8

11

8

11

9

12

75 (52-134) 70.5 (52-103.3) 68 (48.5- 100) 79 (51.5-96 5)

20

19 19 21

TABLE 3 Comparison of Treatment Groups in their Willingness to Repeat Lavage Lavage groups (Gr) 4 L + 30 mi placebo Gr (A) 4 L + 3 0 ml simethicone Gr (B) 2 L + 2 L+30 ml placebo Gr (C) 2 L + 2 L +30 ml simethicone Gr (0) *xZ=

No

Yes

1

19 15 17 13

4’

0

a*

14.513, p = 0.002.

phosphate, a potent osmotic agent, claimed superior patient acceptability and colon cleansing over PEGELS. However, significant elevation of haematocrit, serum Na + ,serum C1-, serum osmolality and serum phosphate and a fall in serum K + occurred. One patient had a syncope which was not adequately explained. In contrast, the safety of PEG-ELS is established and reaffirmed in our study. In our opinion, PEG-ELS will continue to be the lavage solution of choice for considerable time to come. We conclude that two stage lavage does not increase patient acceptability over one-stage lavage and the addition of sirnethicone seems to decrease patient acceptability. There is no difference in the quality of colonic washout between different PEG-ELS lavage regimens with or without the addition of 30 ml of simethicone. Acknowledgements We would like to thank Mr Greg Gamble for statistical analysis and Miss Alison MacKay for the preparation of the manuscript. B. J. CHAKRAVARTY Registrar, Gastroenterology Department, Auckland Hospital, New Zealand.

A. FRASER TABLE 2 Comparison of Groups in their Ability to Drink all the Lavage Fluid Lavage groups (Gr) 4 L+30 ml placebo Gr (A) 4 L + 3 0 mi simethicone Gr (B) 2 L + 2 L + 3 0 ml placebo Gr (C) 2 L + 2 L + 3 0 mi sirnethicone Gr (D) *xZ=13.857, p = 0.003.

770

No

Yes

1

19 12 19 19

7* 0

2

Registrar, Gastroenterology Department, Royal Free Hospital, London. I. HAMILTON Gastroenterology Department, Auckland Hospital, New Zealand. M . LANE Gastroenterology Department, Auckland Hospital, New Zealand. Date of Submission: 15 March 1991 CHAKRAVARTYETAL

References 1. Di Palma JA, Brady CE 111, Stewart DL er ai. (:omparison of colon cleansing methods in preparation for colonoscopy. Gastroenterology 1984; 86: 856-60. 2 . Goldman J, Rerchelderfir M. Evaluation of rapid colonoscopy preparation using a new gut lavage solution. Gastrointes Endos 1982; 28: 9-11. 3. Di Palma JA, Brady CE 111, Pierson WP. Colon cleansing. Acceptance by older patients. Am J Gastroenterol 1986; 81: 652-5. 4. Rosch T, Classen hl. Fractional cleansing of large bowel with ‘Golytely’for colonoscopic preparation. A controlled trial. Endosc 1987; 19: 198-200.

5. McNally PK, Maydonovitch CL, Wong R K H . The effect of simethicone on colonic visibility after night prior colonic lavage. J Clin Gastroenterol 1989; 1 I: 650-2. 6. Shaver WA, Stroms P, Peterson WI.. Improvement oforal colonic lavage with supplemental simethicone. Digest Dis and Sci 1988; 33: 185-8. 7. Vannes SJ, MacDonald PH, Paterson WG, Prentice RSA, Da Costa LR, Beck IT. A randomisrd prospectivc trial comparing oral sodium phosphate with standard polyethylene glycol-based lavage solution (Golytely) in the preparation of patients for colonoscopy. Am J Gasrroenterol 1990; 85: 422-7.

AUSTRALIAN GASTROENTEROLOGY INSTITUTE The Australian Gastroenterology Institute (AGI) is a voluntary, non-profit organisation established under the aegis of the Gastroenterological Society of Australia. It is an educational body committed to promoting better health in the Australian community by reducing illness and premature death from all forms of gastrointestinal and liver disease in Australia. This will be achieved through educational and community service programmes directed towards the medical profession and allied health professionals as well as towards the community as a whole. In addition, the AGI will have a role in working with governments and other health authorities to develop policies for health issues related to digestive diseases. The AGI has recently produced booklets for health care professionals covering two topics of major importance. These are: 1. Screening for Colorectal Cancer - This presents clear guidelines for who should be screened and the methods for doing so.

2. Hepatitis C - This outlines the most recently available information on this virus, including treatment. For copies of these booklets or more information on the Australian Gastroenterology lnstitute please contact: The Executive Officer Australian Gastroenterology Institute 145 Macquarie Street Sydney N S W 2000 Telephone: (02) 256 5455 Facsimile: (02) 231 3120 A YI‘UDY IN C D I D N I C LAVAGE

Xust N Z J Med 1991; 21

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A randomised blinded study in colonic lavage for colonoscopy.

Brief Communications A randornised blinded study in colonic lavage for colonoscopy Polyethylene glycol electrolyte lavage solution (PEGELS) has becom...
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