Colonoscopy is high yield in spinal cord injury

Water exchange technique improves colonoscopy in patients with spinal cord injury: Results of a matched cohort study

Background and study aims Colonoscopies in patients with spinal cord injury (SCI) frequently remain incomplete. This study aimed to evaluate the feasibility and impact of water exchange colonoscopy (WE) in patients with SCI. Patients and methods Three matched groups, each of 31 patients (WE in SCI patients [WE-SCI]) and in the general population (WE-GP), carbon dioxide-based colonoscopy in SCI patients (CO 2 -SCI)) were analyzed retrospectively. Results Intubation of the cecum and the terminal ileum was achieved in every case in both WE groups. The intubations among the CO 2 -SCI patients succeeded in 29 cases (93.5 %, ns) and 20 cases (64.5 %, P <0.001), respectively. The cecal insertion time (23:17 ± 10:17 min vs. 22:12 ± 16:48 min) and bowel preparation during cecal insertion did not differ between WE-SCI groups. Insertion in the general population was faster (13:38 ± 07:00 min, P <.001) and cleanliness was better. Both WE-SCI groups showed significantly better cleansing results during drawback; the improvement in cleanliness was highest in the WE-SCI (based on the five-step scale 1.4 ± 0.8 vs. 0.8 ± 0.8, P = 0.001). Conclusions The WE in SCI patients is feasible and safe and has the potential to improve the quality of colonoscopies substantially.

Colorectal cancer mortality after spinal cord injury

Context: Colorectal cancer (CRC) is the second leading cause of cancer related deaths in the US. There is paucity of data regarding CRC and the spinal cord injury (SCI) community. Persons with SCI have suboptimal rates of colonoscopies and face extensive barriers to care. The aim of our study was to compare CRC mortality in persons with SCI to CRC mortality in the general population.Design: A prospective follow-up study.Setting: Analysis of the National SCI database.Participants: 54,965 persons with SCI.Interventions: Not applicable.Outcome Measures: Current survival status and causes of death were determined. The expected number of CRC deaths was calculated for the general US population, using ICD-10 codes. Standardized mortality ratios (SMR) were calculated as the ratio of observed to expected CRC deaths stratified by current age, sex, race, time post-injury and neurologic group.Results: The CRC mortality was 146 persons out of 54,965 persons with SCI. The overall SMR was determined to be 1.11 (95% CI [0.94, 1.31]). Among subgroups, one finding was significant and this was for patients with injury level C1-4 with an American Spinal Injury Association Impairment Scale Grade of A, B or C with an SMR of 1.68 ([95% CI [1.03-2.61]).Conclusion: Although persons with SCI receive suboptimal rates of preventative care screenings and report extensive barriers to care, overall, they are not at an increased risk of CRC mortality. The current recommendations for CRC screening should be continued for these individuals while reducing barriers to care.

A Primary Care Provider's Guide to Preventive Health After Spinal Cord Injury

Objective: Provide guidance for preventive health and health maintenance after spinal cord injury (SCI) for primary care providers (PCPs). Main message: Individuals with SCI may not receive the same preventive health care as the general population. Additionally, SCI-related secondary conditions may put their health at risk. SCI is considered a complex condition associated with many barriers to receiving quality primary care. Attention to routine preventive care and the unique health considerations of persons with SCI can improve health and quality of life and may prevent unnecessary health care utilization. Conclusion: PCPs are experts in preventive care and continuity of care, however individuals with SCI may not receive the same preventive care due to numerous barriers. This article serves as a quick reference for PCPs.

Barriers to colorectal cancer screening for people with spinal cord injuries and/or disorders: A qualitative study

BACKGROUND

Limited research has shown people with spinal cord injuries and/or disorders (SCID) are less likely to be up to date with colorectal cancer (CRC) screening and therefore more likely to be diagnosed with advanced stage CRC compared to people without SCID.

OBJECTIVE

The aims of this study were to assess knowledge about CRC, CRC screening, and self-reported barriers to CRC screening for people with SCID.

METHODS

Interviews with 30 individuals with SCID were conducted using a semi-structured interview guide, audio recorded, and transcribed. Coding was performed using a hybrid approach of inductive and deductive analysis. Thematic analysis was used to identify, review, and modify themes and sub-themes.

RESULTS

Themes identified included barriers to CRC screening, such as socioeconomic, health system, transportation, psychological, and environmental or accessibility barriers. While most respondents were able to describe one CRC screening method (usually colonoscopy), knowledge of other screening modalities was limited. Low CRC literacy and misinformation about CRC screening appeared to increase respondent association between CRC screening and colonoscopy. While most respondents associated CRC screening with colonoscopy, almost half reported the colonoscopy preparation was the most substantial barrier to screening.

CONCLUSIONS

In addition to addressing identified barriers such as accessibility and transportation, communication, and prevention interventions should be specifically targeted to ensure all people with SCID are informed about appropriate and various modalities and the benefits of screening. Specific, evidence-based guidelines on the use of stool specimens first with follow up direct visualization, if needed, should be developed for this population.

Similar Adenoma Detection Rates in Colonoscopic Procedures of Patients with Spinal Cord Injury Compared to Controls

BACKGROUND

Cancer is a major cause of death in patients with spinal cord injury (SCI). Preventive strategies, such as colonoscopy, deal with higher burdens that may lead to lower quality.

AIMS

The primary objective was to evaluate the adenoma detection rate. Secondary objectives were to investigate other quality indicators regarding bowel preparation, sedation, and endoscopy.

METHODS

Consecutive SCI patients who had undergone colonoscopy from 2003 to 2014 were assigned to a control group matched for age, gender, and year of procedure and reviewed retrospectively.

RESULTS

Bowel preparation lasted longer (3.6 ± 1.5 vs. 1.2 ± 0.6 days, p = 0.001), achieved unsatisfactory cleansing results more often (23.7 vs. 3.6%) and caused more adverse events in 236 SCI compared to 414 control patients. Colonoscopy needed a longer time (36.9 vs. 25.0 min) and remained incomplete more often (24.6 vs. 4.6%), resulting in more re-colonoscopies (14.8 vs. 4.3%). Endoscopy- and sedation-related adverse events were equal. However, neither overall nor size-dependent polyp (30.9 vs. 34.8%), adenoma (21.2 vs. 21.0%), advanced adenoma (6.8 vs. 7.2%), or cancer (1.7 vs. 2.0%) detection rates differed.

CONCLUSION

Despite intensified protocols, bowel preparation shows inferior results in SCI patients; colonoscopy needs more effort to succeed but achieves a comparable quality.

A safe and effective multi-day colonoscopy bowel preparation for individuals with spinal cord injuries

CONTEXT/OBJECTIVE

Colonoscopy with polypectomy is associated with a reduced risk of colorectal cancer (CRC), but poor bowel cleansing limits the diagnostic yield of the procedure. Patients with spinal cord injury (SCI) frequently have suboptimal bowel cleansing with standard pre-colonoscopy bowel preparation regimens. We aimed to assess the safety, tolerability, and efficacy of a multi-day inpatient bowel preparation regimen in a population of patients with SCI.

DESIGN

Retrospective case series.

SETTING

VA Puget Sound SCI Center.

PARTICIPANTS

All patients with SCI (n = 53) who underwent inpatient colonoscopy at the VA Puget Sound from July 12, 2013 to February 12, 2015.

OUTCOME MEASURES

Patient characteristics, tolerance of full bowel preparation, pre- and post-bowel preparation electrolyte values, adverse events, and adequacy of bowel cleansing were abstracted.

RESULTS

Sixty-eight percent of patients had a cervical level of injury and the majority were either American Spinal Injury Association Impairment Scale A (41%) or D (43%). The full bowel preparation was tolerated by 91% of inpatients. In those with pre- and post-bowel preparation laboratory testing, there were small, but statistically significant decreases in serum calcium and phosphate. No patient had symptoms associated with electrolyte abnormalities or required treatment. Five out of 53 inpatients experienced autonomic dysreflexia (AD) during bowel preparation. Eighty-nine percent of patients had adequate bowel cleansing at colonoscopy.

CONCLUSIONS

We demonstrate a safe and effective inpatient bowel preparation regimen in a SCI population. The regimen was associated with mild, asymptomatic hypophosphatemia and hypocalcemia. AD was an uncommon event, predominantly occurring in patients who experienced frequent AD episodes at baseline.

Complicated fecal microbiota transplantation in a tetraplegic patient with severe Clostridium difficile infection

A 65-year-old male suffering from acute spinal cord injury leading to incomplete tetraplegia presented with severe recurrent Clostridium difficile (C. difficile) infection subsequent to antibiotic treatment for pneumonia. After a history of ineffective antimicrobial therapies, including metronidazole, vancomycin, fidaxomicin, rifaximin and tigecycline, leading to several relapses, the patient underwent colonoscopic fecal microbiota transplantation from his healthy son. Four days subsequent to the procedure, the patient showed a systemic inflammation response syndrome. Without detecting an infectious cause, the patient received antimicrobial treatment, including tigecycline, metronidazole, vancomycin via polyethylene glycol and an additional enema for a period of seven days, leading to a prompt recovery and no reported C. difficile infection relapse during a 12 wk follow up.

Colonoscopy after spinal cord injury: a case-control study

DESIGN

An age- and gender-matched case-control study.

OBJECTIVE

To compare colonoscopy after spinal cord injury (SCI) with the general population in terms of indications, bowel preparation, technical success and disease detection.

SETTING

Victoria, Australia.

METHODS

Consecutive SCI colonoscopies between January 1998 and February 2013 were compared with a randomly selected age- and gender-matched control group. Injury level, indication for procedure and demographics were collected. Outcome measures included quality of bowel preparation, completion rates, procedural duration and benign and malignant disease detection.

RESULTS

A total of 440 colonoscopies were assessed, comprising 148 SCI patients and 292 age- and gender-matched controls. Both the groups were of similar age (54.7 years vs 54.5 years, P=0.906) and comprised predominantly males (87.1% vs 86.3%, P=0.919). SCI colonoscopies were more often performed to investigate abnormalities (85.1% vs 58.2%, P<0.001) than for screening or surveillance (18.2% vs 40.8%, P<0.001). Unsatisfactory bowel preparation was recorded more often in the SCI group (36.0% vs 13.0%, P<0.001) and completion rates were lower (75.7% vs 93.1%, P<0.001). Overall disease detection was lower in the SCI group (45.3% vs 59.6%, P<0.006). The polyp detection rate was lower for SCI (11.4% vs 25.3%, P=0.001). The rate of diagnosis of malignancy was equivalent (2.7% vs 3.0%, P=0.904).

CONCLUSION

SCI patients have the same risk of malignancy as the general population and are less likely to undergo screening colonoscopy. Colonoscopy is then limited by poor bowel preparation and lower completion rates with a subsequent lower polyp detection rate.