Reducing faecal incontinence following colonoscopy - Document (2023)

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Author: Felix W. Leung

Date: June 2012

From: (Vol. 9, Issue 6)

Publisher: Nature Publishing Group

Document Type: Article

Length: 1,436 words

Lexile Measure: 1770L

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Faecal incontinence can occur in patients who have undergone acolonoscopy. The incidence of postexamination faecal incontinence in a largeNorwegian cohort has now been reported, and the risk of faecal incontinencefound to be reduced if C[O.sub.2] is used instead of air to insufflate thecolon.

Faecal incontinence is the inability to control bowel movements;the resulting leakage of stool can cause considerable embarrassment. (1)Faecal incontinence might be caused by deficits in the function of internalor external anal sphincter or pelvic floor muscles. Other potentialcontributing factors to faecal incontinence include the loss of endovascularcushions as a result of disruption of the haemorrhoidal plexus, impairedanorectal sensation associated with chronic constipation, poor rectalcompliance and compromised accommodation of stool resulting from aging, IBD,radiation enteritis or pelvic surgery, and neuropathy affecting the pudendal,sacral, spinal or central nervous system. In some patients, incompleteevacuation of stool, large stool volume, liquid stool and the irritant effectof bile salts in the rectum might also contribute to faecal incontinence.1 Inone randomized, controlled trial comparing sodium phosphate and polyethyleneglycol bowel preparation for colonoscopy in a predominantly elderlypopulation, up to 25% of the patients experienced at least one episode offaecal incontinence. (2) The results led the authors to recommend that olderpatients (those >65 years of age) undergoing bowel preparation forcolonoscopy should be warned of the risk of faecal incontinence. (2)

Faecal incontinence after colonoscopy was not recognized asimportant before January 2009, when Hoff et al. (3) took the laudable step tointegrate a specific question about faecal incontinence after colonoscopy,defined as fluid leakage from the back passage (soiling), into the Norwegianprospective multicentre Gastronet study. They have now reported their initialfindings. (3) Patients mostly received polyethylene glycol for bowelpreparation and the colonoscopist attempted to remove by suction any residualfluid found during colonoscopy. In this data-mining study, 5,015 patientsunderwent colonoscopy performed using air insufflation and 2,797 patientsunderwent colonoscopy using C[O.sub.2] insufflation. (3) The two groups weresimilar in age, sex, indication for colonoscopy and use of sedation. Of thepatients examined with air insufflation, 50% experienced some degree ofabdominal distension after colonoscopy, versus 28% of the patients examinedwith C[O.sub.2] insufflation; the pain experienced during examination wassimilar in the two groups. The authors found that patient-reported faecalincontinence up to 24 h after colonoscopy was recorded by 336 of 7,812patients (4.3%). Incontinence was significantly less frequent in theC[O.sub.2] group than in the air group (2.1% versus 5.5%; adjusted OR 0.38;95% CI 0.28-0.50; P <0.001). Female patients had a higher risk ofincontinence than male patients (adjusted OR 1.77; 95% CI 1.39-2.24; P<0.001). The authors concluded that approximately every twentieth patientundergoing colonoscopy using standard air insufflation experiencesincontinence after the procedure. This proportion can be reduced by 60% byconverting from air insufflation to insufflation with absorbable C[O.sub.2.]In the discussion, the authors noted that although not part of their practicethey were aware that insufflation with water might ease the insertion of thecolonoscope. (4) They astutely speculated that the risk of residualpostcolonoscopy fluid might be expected to increase after water insufflationand the patient might face greater problems with faecal incontinence aftercolonoscopy. They went on to recommend appropriately that it might be worthconsidering conversion to C[O.sub.2] insufflation where water insufflationwas practiced.

Faecal incontinence after colonoscopy might be attributable toperformance of colonoscopy in individuals with the predisposing factorsoutlined above. (1) The finding that use of C[O.sub.2] instead of air toinsufflate the colon during colonoscopy produced a significant reduction inthe incidence of faecal incontinence after colonoscopy (3) is instructive andimportant. The result highlights a plausible link between colonic distensionand faecal incontinence. The theoretical basis for using C[O.sub.2] is itsabsorption by the gut wall, which should minimize colonic distension aftercolonoscopy. Reduced colonic distension and lower patient-reported painscores after colonoscopy have been repeatedly demonstrated with the use ofC[O.sub.2] during colonoscopy, compared with the use of air duringcolonoscopy. (5) The evidence supplied by Hoff et al. (3) provides animportant contribution to the understanding of the pathophysiology of faecalincontinence. Colonic distension can now be added to the list of factors1that predispose patients to the development of faecal incontinence.

The advantages of C[O.sub.2] insufflation in reducing pain aftercolonoscopy have previously been summarized. (5) If reduced patient-reportedpain and decreased abdominal distension associated with the use of C[O.sub.2]are accurate predictors of the amelioration of faecal incontinence aftercolonoscopy, as suggested by the data reported by Hoff et al., (3) othermodalities with similar capabilities deserve evaluation. One such approach isthe use of water-aided methods such as water immersion (6) or water exchange.(7) Both methods favourably effect patient-reported colonoscopy pain; withwater exchange being more effective than water immersion. (8) In contrast toC[O.sub.2] insufflation, which decreases pain predominantly aftercolonoscopy, (5) water exchange decreases pain both during and aftercolonoscopy. (4) Indeed, this distinction (reduction of pain duringcolonoscopy by water and not C[O.sub.2)] was the sole reason why waterimmersion was modified to develop a less painful method of water exchange tofacilitate completion of an unsedated colonoscopy. (7) Nonetheless,practitioners of water-aided methods should heed the admonition of Hoff etal. (3) and take precautions to avoid the risk of excessive residual fluidafter colonoscopy.

Water exchange also seems to enhance the detection of adenomas,(9) which has not been described with the use of C[O.sub.2]. The explanationfor this phenomenon might in part be related to salvage cleansing of thecolonic lumen during insertion that is provided by water exchange, (4,7) butnot by use of C[O.sub.2]. Compared with C[O.sub.2] insufflation, waterexchange requires less time devoted to cleaning the colonic lumen aftersalvage cleansing (which can be a distraction) and enables more time to befocused on lesion detection during withdrawal, which might be an additionalplausible explanation. (9)

Conversion from air to C[O.sub.2] insufflation does not requireany change in classic colonoscopy techniques. The use of water exchangerequires acquisition of a new set of skills and considerable practice in theearly stage of the transition in the absence of direct coaching. (10) Takentogether, the comparisons of water exchange and use of C[O.sub.2] duringinsertion or a combination of water exchange during insertion and use ofC[O.sub.2] during withdrawal deserve to be evaluated to determine the bestway to perform colonoscopy in the future.

doi: 10.1038/nrgastro.2012.93


The report is supported in part by Veterans Affairs MedicalResearch Funds at Veterans Affairs Greater Los Angeles Healthcare System andan American College of Gastroenterology Clinical Research Award.

Competing interests

The author declares no competing interests.

(1.) Leung, F. W., Schnelle, J. & Rao, S. S. C. in TheEncyclopedia of Elder Care (eds Capezuti, E. A., Siegler, E. L. & Mezey,M. D) 303-305 (Springer Publishing Co., New York, 2008).

(2.) Thomson, A., Naidoo, P. & Crotty, B. Bowel preparationfor colonoscopy: a randomized prospective trial comparing sodium phosphateand polyethylene glycol in a predominantly elderly population. J.Gastroenterol. Hepatol. 11, 103-107 (1996).

(3.) Hoff, G. et al. Incontinence after colonoscopy--anunrecognized and preventable problem. A cross-sectional study from theGastronet quality assurance program. Endoscopy 44, 349-353 (2012).

(4.) Leung, F. W. et al. A proof-of-principle, prospective,randomized controlled trial demonstrating improved outcomes in scheduledunsedated colonoscopy by the water method. Gastrointest. Endosc. 72, 693-700(2010).

(5.) Wu, J. & Hu, B. The role of carbon dioxide insufflationin colonoscopy: a systematic review and meta-analysis. Endoscopy 44, 128-136(2012).

(6.) Friedland, S. The water immersion technique for colonoscopyinsertion. Gastroenterol. Hepatol. (NY) 6, 555-556 (2010).

(7.) Leung, F. W., Leung, J. W., Mann, S. K., Friedland, S. &Ramirez, F. C. The water method significantly enhances patient-centeredoutcomes in sedated and unsedated colonoscopy. Endoscopy 43, 816-821 (2011).

Reducing faecal incontinence following colonoscopy - Document (1)

(Video) Digestive health: Successful prep for colonoscopy

(8.) Leung, F. W. et al. Removal of infused water predominantlyduring insertion (water exchange) is consistently associated with a greaterreduction of pain score--review of randomized controlled trials (RCTs) ofwater method colonoscopy. J. Interv. Gastroenterol. 1, 114-120 (2011).

(9.) Ramirez, F. C. & Leung, F. W. A head-to-head comparisonof the water vs. air method in patients undergoing screening colonoscopy. J.Interv. Gastroenterol. 1, 135-140 (2011).

(10.) Ramirez, F. C. & Leung, F. W. The water method foraiding colonoscope insertion: the learning curve of an experiencedcolonoscopist. J. Interv. Gastroenterol. 1, 97-101 (2011).

Section of Gastroenterology, 111G, Sepulveda Ambulatory CareCenter, Veterans Affairs Greater Los Angeles Healthcare System, 16111 PlummerStreet, North Hill, CA 91343, USA.

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