Hyoscine N-butylbromide for adenoma detection during colonoscopy: a randomized, double-blind, placebo-controlled study

Provider-reported use of butylscopolamine in gastrointestinal endoscopy in Germany

Introduction The anti-cholinergic agent hyoscine-N-butylbromide (HBB) is used in gastrointestinal (GI) endoscopy to decrease motility and facilitate endoscopic procedures. Data from clinical studies to support this practice is limited especially for therapeutic procedures. Likewise, patterns of use among endoscopist are largely unclear. This study sought to assess usage of HBB among German-speaking endoscopists. Material and Methods We conducted an anonymous online survey among endoscopists in German-speaking countries. Results A total of 207 physicians participated in the survey. The majority (76.9%) were experienced endoscopists and 92.3% of respondents use HBB at least occasionally during procedures. The reported median stated frequency of HBB use varied greatly between different types of procedures and increased with the complexity of the procedure being performed. HBB was rarely used in diagnostic esophagogastroduodenoscopies (EGD) (median stated frequency 1% of procedures), while use frequency was significantly higher in EGD with endoscopic mucosal resection (EMR) (10%; p=0.002) and EGD with endoscopic submucosal dissection (ESD) (20%; p<0.001). Similarly, use frequency during diagnostic colonoscopy was lower (5%) compared to colonoscopy with EMR (20%, p=0.005) or ESD (42.5%, p<0.001). The highest use frequency was reported for ERCP (50%). The most frequently stated reason to use HBB was facilitation of the procedure (80.6%) followed by increasing diagnostic yield (58.3%). Conclusion German-speaking endoscopists commonly use HBB, most frequently to facilitate complex therapeutic procedures. Given there is almost no data supporting HBB use in therapeutic endoscopy, we suggest that more research is needed to evaluate benefits and risks of this practice.

Canadian Association of Gastroenterology (CAG) Position Statement on the Use of Hyoscine-n-butylbromide (Buscopan) During Gastrointestinal Endoscopy

Hyoscine butylbromide, also known as hyoscyamine or scopolamine, and sold under the trade name Buscopan, is an antimuscarinic agent commonly used to induce smooth muscle relaxation and reduce spasmodic activity of the gastrointestinal (GI) tract during endoscopic procedures. However, the balance between desirable and undesirable (adverse) effects is not clear when used during GI endoscopy. The Clinical Affairs Committee of the Canadian Association of Gastroenterology (CAG) conducted systematic reviews and applied the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to develop recommendations for the use of Buscopan during GI endoscopy. To summarize, we recommend against the use of Buscopan before or during colonoscopy (strong recommendation, high certainty of evidence). We suggest against the use of Buscopan before or during gastroscopy (conditional recommendation, very low certainty of evidence). We suggest the use of Buscopan before or during ERCP (conditional recommendation, very low certainty of evidence). More research is needed to determine whether patients undergoing advanced procedures such as endoscopic mucosal resection or endoscopic submucosal dissection benefit from its use. Buscopan should be used with caution in patients with cardiac comorbidities. According to its product monograph, Buscopan is contraindicated in patients with tachycardia, angina, and cardiac failure. Thus, Buscopan should be used very cautiously in patients with these conditions, and only when the potential benefits of its use outweigh the potential risks in a particular case. Such patients require careful cardiac monitoring in an environment where resuscitation equipment and appropriately trained staff to use it are readily available. According to its product monograph, Buscopan is also contraindicated in patients with prostatic hypertrophy with urinary retention, and therefore, should be used very cautiously in such patients as well, and only when the potential benefits of its use outweigh the potential risks in a particular case. Obtaining a preprocedural history of glaucoma is unlikely to be of value when considering Buscopan use. However, in cases where Buscopan has been used, patients should be counselled postprocedurally and told to present to an emergency facility should they experience eye pain, redness, decreased vision, nausea and vomiting or headache.

Does Hyoscine improve polyp detection rate during colonoscopy? Systematic Review & meta-analysis of randomized clinical trials

BACKGROUND/OBJECTIVE

Published studies have shown conflicting results regarding the benefit of Hyoscine Butylbrmoide use during colonoscopy in polyp and adenoma detection rates. This meta-analysis was conducted with the aim to summarize all available evidence.

METHODS

A literature search was carried out using PubMed, Ovid MEDLINE and the Cochrane Library database from inception to December 2017. Studies that compared the use of Hyoscine Butylbrmoide compared to placebo during colonoscopy were included. Pooled odds ratio and 95% confidence interval were calculated using Mantel-Haenszel fixed-effects model when there was no heterogeneity identified.

RESULTS

Of the 423 retrieved studies, eight met the eligibility criteria and were included in the analysis. There was no significant difference between the groups in terms of polyp and adenoma detection rates.There was no significant difference between the Hyoscine and placebo groups in polyp detection rate (49.3% vs 48%, OR = 1.06, 95% CI: 0.90-1.23, P = 0.50). Adenoma detection rate was also not significantly different between the 2 groups 33.7% vs, 31%; OR = 1.13; 95%CI: 0.95-1.35; P = 0.16). No heterogeneity was observed (P = 0.65, I² = 0%).

CONCLUSION

This meta-analysis found no significant impact of Hyoscine on polyp and adenoma detection when used during colonoscopy.

Impact of Hyoscine Bromide Use on Polyp Detection Rate During Colonoscopy: A Systematic Review and Meta-Analysis

Background

Colorectal cancer (CRC) is a leading cause of death worldwide. Polyp detection rate (PDR) and adenoma detection rate (ADR) are key focus in endoscopic research for CRC screening and prevention. Use of anti-spasmodic agents during colonoscopy to help identify adenomas and polyps has remained a controversial topic. Hyoscine butyl bromide (HBB) is the most commonly used anti-spasmodic agent in patients undergoing colonoscopy. Some randomized controlled trials (RCTs) have questioned the clinical efficacy and safety of routine use of HBB for polyp and adenoma detection rates.

Methods

We conducted a systematic search in PubMed and MEDLINE from inception until February 10, 2018, for studies which compared HBB with placebo. We used RevMan version 5.3 for analysis. Procedural end-points were polyps, adenomas, and advanced adenoma detection rates, mean number of polyps detected and cecal intubation time.

Results

We included seven RCTs with 2,588 patients in our analysis. A total of 1,301 patients were randomized to HBB arm and 1,287 to the placebo arm. There was no significant difference in the primary outcome of polyp detection rate, 654 in HBB group vs. 616 in the placebo group, (odds ratio (OR) = 1.11, confidence interval (CI) = 0.93 - 1.34, P = 0.25). There was no difference in secondary outcomes of adenoma detection rate, 430 in HBB group vs. 396 in the placebo group, (OR = 1.06, CI = 0.89 - 1.26, P = 0.51), advanced adenoma detection rate, 92 in HBB vs. 95 in placebo group (OR = 0.95, CI = 0.70 - 1.30, P = 0.76), mean number of polyps detected (point estimate = 0.12, CI = 0.00 - 0.23, P = 0.05), adenomatous polyps (OR = 0.84, CI = 0.39 - 1.81, P = 0.65) and cecal intubation time (point estimate = 0.73, CI = -1.98 - 0.52, P = 0.25) between the two groups.

Conclusions

The use of HBB in patients undergoing colonoscopy does not appear to improve polyp or adenoma detection rates. It showed a non-significant trend of increased mean number of polyps detected with HBB.

Use of warm carbon dioxide insufflators does not affect intra-colonic gas temperature and has no effect on polyp detection rate during colonoscopy - a randomized controlled trial

BACKGROUND AND STUDY AIMS

Methods to improve polyp detection during colonoscopy have been investigated, with conflicting results for warm water irrigation. Carbon Dioxide (CO ₂₎ warmed to 37 °C may have similar or more pronounced effects on bowel motility. This study aimed to assess whether warmed CO ₂ would improve polyp detection compared to room temperature air insufflation.

PATIENTS AND METHODS

 This was a double-blind, randomized controlled trial that enrolled 204 patients undergoing screening or surveillance outpatient colonoscopy. The primary outcome was polyp per patient detection rate. Secondary outcomes included adenoma per patient detection rates, bowel spasm, and patient comfort.

RESULTS

 The trial was terminated after an interim analysis determined futility. Between the warmed CO ₂ and room air groups, no significant differences were found in the per-colonoscopy polyp detection rate ( P  = 0.57); overall polyp detection rate ( P  = 0.69); or adenoma detection rates ( P  = 0.74). More patients in the room temperature group had lower spasm scores (p = 0.02); however, there was a trend towards greater patient comfort in the warmed CO ₂ group ( P  = 0.054). An ex-vivo study showed a significant difference between exiting CO ₂ temperature at the insufflator end vs. delivered CO ₂ temperature at the colonoscope tip end. The temperature of insufflation at the tip of the colonoscope was not different when using warmed vs. unwarmed insufflation ( P  = 0.62).

CONCLUSION

 When compared with room air insufflation, warmed CO ₂ insufflation did not affect polyp detection rates.

Hyoscine butylbromide for colorectal polyp detection: prospective, randomized, placebo-controlled trial

OBJECTIVES:

The removal of pre-malignant colorectal lesions prevents cancer. Hyoscine has been proposed as a means of improving diagnosis by reducing colonic movements. The aim of this study was to analyze whether this anti-spasmodic enhances the detection of pre-malignant colorectal lesions.

METHODS:

In a randomized, double-blinded fashion patients received hyoscine or a saline solution in all consecutive colonoscopies in which the cecum was reached. Lesions were analysed with respect to number, size, location, histology and capillary pattern.

RESULTS:

A total of 440 colonoscopies were randomized. The overall polyp detection rate (PDR) and the adenoma detection rate (ADR) were 65.2% and 49.3%, respectively. In the hyoscine group, non-polypoid lesions were detected significantly more often (p=0.01). In the placebo group 281 lesions were diagnosed (202 adenomas) and in the hyoscine group 282 lesions were detected (189 adenomas) (p=0.23). The PDR and ADR were similar between the placebo and hyoscine groups (64% vs 66% and 50% vs 47%, respectively). No differences were observed between the two groups in the advanced-ADR or advanced neoplasia detection rate, as well the mean numbers of polyps, adenomas, advanced adenomas and advanced neoplasias detected per patient. The administration of hyoscine also did not improve the diagnostic accuracy of digital chromoendoscopy. The presence of adenomatous polyps in the right colon was detected significantly more frequently in the hyoscine group (OR 5.41 95% CI 2.7 - 11; p<0.01 vs OR 2.3 95% CI 1.1 - 4.6; p=0.02).

CONCLUSION:

The use of hyoscine before beginning the withdrawal of the colonoscope does not seem to enhance the PDR and the ADR.

Antispasmodic drugs in colonoscopy: a review of their pharmacology, safety and efficacy in improving polyp detection and related outcomes

Antispasmodic drugs are cheap, effective and generally safe. They may improve outcomes in colonoscopy, however their use has not been consistent or widespread. This manuscript reviews the three most commonly used antispasmodics in colonoscopy, namely, hyoscine butylbromide (and related ammonium compounds), glucagon and peppermint oil. The pharmacology, action and safety of the agents, as well as the evidence for them improving colonoscopic outcomes will be discussed. In addition to polyp detection, other colonoscopic outcome endpoints of interest include cecal and ileal intubation, and patient comfort. The drugs studied were all found to be effective gastrointestinal antispasmodics with good safety profiles. There is insufficient evidence to conclude whether antispasmodics improve cecal intubation rate, predominantly because the baseline rates are already high. Antispasmodics probably have efficacy in reducing cecal intubation time especially in those with marked colonic spasm. Antispasmodics do not offer significant benefit in polyp detection or improving patient comfort during colonoscopy. Future studies should focus on inexperienced colonoscopists as well as those with marked colonic spasm, in whom the greatest benefit seems to lie.

Technical interventions to increase adenoma detection rate in colonoscopy

Adenoma detection rate (ADR) is the most robust colonoscopy quality metric and clinical studies have adopted it as the ideal method to assess the impact of technical interventions. Areas covered: We reviewed papers focusing on the impact of colonoscopy technical issues on ADR, including withdrawal time and technique, second evaluation of the right colon, patient positional changes, gastrointestinal assistant participation during colonoscopy, water-aided technique, optimization of bowel preparation and antispasmodic administration. Expert commentary: Overall, technical interventions are inexpensive, available worldwide and easy to implement. Some of them, such as the adoption of split dose regimen and slow scope withdrawal to allow a careful inspection, have been demonstrated to significantly improve ADR. Emerging data support the use of water-exchange colonoscopy. According to published studies, other technical interventions seem to provide only marginal benefit to ADR. Unfortunately, the available evidence has methodological limitations, such as small sample sizes, the inclusion of expert endoscopists only and the evaluation of single technical interventions. Additionally, larger studies are needed to clarify whether these interventions might have a higher benefit on low adenoma detectors and whether the implementation of a bundle of them, instead of a single technical maneuver, might have a greater impact on ADR.

Improving the utility of colonoscopy: Recent advances in practice

Colonoscopy is a frequently performed diagnostic and therapeutic test and the primary screening tool in several nationalized bowel cancer screening programs. There has been a considerable focus on maximizing the utility of colonoscopy. This has occurred in four key areas: Optimizing patient selection to reduce unnecessary or low yield colonoscopy has offered cost-benefit improvements in population screening. Improving quality assurance, through the development of widely accepted quality metrics for use in individual practice and the research setting, has offered measurable improvements in colonoscopic yield. Significant improvements have been demonstrated in colonoscopic technique, from the administration of preparation to the techniques employed during withdrawal of the colonoscope. Improved techniques to avoid post-procedural complications have also been developed-further maximizing the utility of colonoscopy. The aim of this review is to summarize the recent evidence-based advances in colonoscopic practice that contribute to the optimal practice of colonoscopy.

Techniques and technologies to maximize mucosal exposure

Performing high-quality colonoscopy is one of the important goals of gastroenterology practices and requires achieving a high level of bowel cleansing, performing good and safe polypectomy, and detecting all polyps present in the colon. This article summarizes currently available techniques and technologies to maximize mucosal visualization. Several maneuvers can be applied during insertion and withdrawal of the colonoscope to optimize mucosal visualization and decrease the number of missed polyps. Newly developed technologies support the endoscopist in the detection of polyps. Each technique is reviewed, with emphasis on the impact on colorectal polyp detection.

Can I improve my adenoma detection rate?

Adenoma detection rate (ADR) has emerged as a key quality metric for colonoscopy. Despite limitations, its major strength is based on its proven correlation with interval colorectal cancer. This has prompted extensive efforts to identify factors and interventions that improve ADR. Potentially modifiable factors that may influence ADR can be patient related (eg, bowel preparation), endoscopist related (eg, withdrawal time, quality of mucosal inspection, additional observers), or procedure related (eg, water infusion, additional examination of right colon, change in position, antispasmodics, colonoscopic equipment, and accessories). Providing endoscopists with educational material and/or feedback also seems to improve ADR.

Effect of hyoscine N-butylbromide on adenoma detection rate: meta-analysis of randomized clinical trials

BACKGROUND AND AIM

Anti-spasmodic drugs may facilitate mucosal inspection during colonoscopy. The impact of hyoscine N-butylbromide (HBB) on polyp detection rate (PDR) and adenoma detection rate (ADR) is unclear.

METHODS

We conducted a reproducible literature search of multiple databases. Two reviewers independently compared manuscripts for PDR, ADR, advanced adenoma detection rate (AADR), and rates of complications. Pooling was conducted by fixed-effects and random-effects models. Relative risk (RR) estimates were calculated (95% confidence interval). I(2) index assessed heterogeneity.

RESULTS

Patient demographics were comparable. The pooled analysis showed a trend toward improving PDR and ADR among the HBB group compared with the placebo group but failed to reach statistical significance, (46% vs 43%, RR = 1.08 [0.94, 1.25], P = 0.27), (31% vs 28%, RR = 1.12 [0.97, 1.29], P = 0.11) respectively.

CONCLUSION

HBB during colonoscopy may provide marginal improvements in ADR and PDR. However, heterogeneity in the available data precludes firm conclusions at this time.

Carbon dioxide insufflation vs conventional air insufflation for colonoscopy: a systematic review and meta-analysis of published randomized controlled trials

AIM

Conventional air insufflation (AI) may cause prolonged abdominal bloating, excessive abdominal pain and discomfort during colonoscopy. Carbon dioxide may be an acceptable alternative to avoid these complications. The object of this study was to evaluate systematically the effectiveness of carbon dioxide insufflation (CI) for colonoscopy compared with AI.

METHOD

Randomized controlled trials (RCTs) comparing the effectiveness of CI with that of AI during colonoscopy were retrieved from medical electronic databases and combined analysis was performed using the RevMan statistical package. The combined outcome of dichotomous and continuous variables was expressed as an odds ratio (OR) and standardized mean difference (SMD).

RESULTS

Twenty-one RCTs comprising 3607 patients were included in the study. There was statistically significant heterogeneity among included studies. CI showed a significant trend towards reduced procedural pain [SMD -1.34; 95% confidence interval (95% CI) -2.23 to -0.45; z = 2.96; P < 0.003] and also postprocedural pain at 1 h (SMD -1.11; 95% CI -1.83 to -0.38; z = 2.97; P < 0.003), 6 and 24 h (OR 0.44; 95% CI 0.23-0.85; z = 2.44; P < 0.01). CI was associated with faster caecal intubation (SMD -0.20; 95% CI -0.37 to -0.02; z = 2.23; P < 0.03) but the caecal intubation rate was similar (P = 0.59) in both colonic insufflation techniques .

CONCLUSION

CI seems to have clinical advantages over AI for colonoscopy with regard to pain during and after the procedure.

The impact of hyoscine-N-butylbromide on adenoma detection during colonoscopy: meta-analysis of randomized, controlled studies

BACKGROUND

Hyoscine-N-butylbromide (HBB) can induce flattening of colon folds through inhibition of smooth muscle activity, which improves mucosal visualization. Whether this affects polyp detection is controversial.

OBJECTIVE

To evaluate whether HBB, administered during colonoscopy, improves polyp and adenoma detection.

DESIGN

We performed a comprehensive search in MEDLINE and EMBASE databases to identify randomized, placebo-controlled trials (RCTs) in which HBB was administered during colonoscopy and which also reported the detection rate for polyps and/or adenomas (PDR and/or ADR, respectively).

SETTING

Meta-analysis of 5 RCTs.

PATIENTS

A total of 1998 patients (1006 receiving HBB) were included in the study.

INTERVENTIONS

Intravenous administration of 20 mg (2 mL) HBB or 2 mL saline solution at the time of cecal intubation.

MAIN OUTCOME MEASUREMENTS

The PDR was the primary outcome variable. Secondary outcomes included the ADR, the advanced adenoma detection rate (adv-ADR), and the mean number of polyps and adenomas per patient (PPP and APP, respectively).

RESULTS

The PDR, ADR, and adv-ADR did not differ significantly between the 2 groups. The odds ratios (95% confidence interval [CI]) for PDR, ADR, and adv-ADR were 1.09, 95% CI, 0.91-1.31; 1.13, 95% CI, 0.92-1.38; and 0.9, 95% CI, 0.63-1.30, respectively. In addition, no significant differences were observed in PPP and APP between the 2 groups.

LIMITATIONS

Small number of studies included. Limited data about secondary outcomes and safety.

CONCLUSION

Our meta-analysis does not provide evidence that routine HBB administration at cecal intubation improves PDR or ADR. More studies are needed for final conclusions, particularly on HBB's effect on PPP and APP.

Does hyoscine butylbromide really improve polyp detection during colonoscopy? A meta-analysis of randomized controlled trials

AIM: To investigate the benefits of hyoscine butylbromide in polyp detection during colonoscopy by a meta-analysis of available randomized controlled trials (RCTs).

METHODS: Databases, including PubMed, EMBASE, the Cochrane Library, and the Science Citation Index up to September 2013, were searched. The primary outcome was polyp detection rate, and the secondary outcome was adenoma detection rate. The meta-analysis was performed using the free software Review Manager. Differences observed between the treated and the control groups were expressed as odds ratio (OR) with a 95% confidence interval (CI). A fixed-effects model was used to pool data when statistical heterogeneity was absent. If statistical heterogeneity was present (P < 0.05), a random-effects model was used.

RESULTS: The initial search identified nine articles. After screening, five RCTs with a total of 1998 patients were included in this meta-analysis. Of the five studies, all described a comparison of baseline patient characteristics and showed that there was no statistically significant difference between the two groups. Among the 1998 patients, 1006 received hyoscine butylbromide and 992 were allocated to the control group, and the polyp detection rate was reported. There were no significant differences between the treated and the control group (OR = 1.09, 95%CI: 0.91-1.31, P = 0.33). Four RCTs included 1882 patients, of whom 948 received hyoscine butylbromide, and the adenoma detection rate was reported. There were no significant differences between the treated and the control group (OR = 1.13, 95%CI: 0.92-1.38, P = 0.24).

CONCLUSION: The use of hyoscine butylbromide did not significantly improve the polyp detection rate during colonoscopy.