The appropriateness of colonoscopies at a teaching hospital: magnitude, associated factors, and comparison of EPAGE and EPAGE-II criteria

BACKGROUND

The growing demand for colonoscopies and inappropriate colonoscopies have become a significant problem for health care.

OBJECTIVES

To assess the appropriateness of colonoscopies and to analyze the association with some clinical and organizational factors. To compare the results of the European Panel of Appropriateness of Gastrointestinal Endoscopy (EPAGE) and the EPAGE-II criteria.

DESIGN

Cross-sectional study.

SETTING

Endoscopy unit of a teaching hospital in Spain.

PATIENTS

Patients referred for colonoscopy, excluding urgent, therapeutic indications, and poor cleansing.

MAIN OUTCOME MEASUREMENTS

Appropriateness of colonoscopies according to the EPAGE criteria.

RESULTS

From 749 colonoscopies, 619 were included. Most patients were referred by gastroenterologists (66.1%) in an outpatient setting (80.6%). Hematochezia was the most frequent indication (31.5%) followed by colorectal cancer-related indications (27.3%); a clinically relevant diagnosis was established in 41%. Inappropriate use was higher with EPAGE (27.0%) than EPAGE-II (17.4%) criteria. Surveillance after colonic polypectomy and uncomplicated lower abdominal pain were the indications exhibiting higher inadequacy. Inappropriate use was less with older age, in hospitalized patients, with referrals from internal medicine, and in colonoscopies with clinically relevant diagnoses. Agreement between EPAGE and EPAGE-II was fair (weighted κ = 0.31) but improved to moderate (simple κ = 0.60) after grouping appropriate and uncertain levels.

LIMITATIONS

The appropriateness criteria are based on panel opinions. Some patients (12%) could not be evaluated with the EPAGE criteria.

CONCLUSIONS

Our study identifies substantial colonoscopy overuse, especially in tumor disease surveillance. The EPAGE-II criteria decrease the inappropriate rate and the possibility of overlooking potentially severe lesions.

Variation among endoscopy units in the achievement of the standards of colonoscopic performance indicators

BACKGROUND/AIMS

To assess the achievement of quality standards of colonoscopy at six endoscopy units.

METHODOLOGY

Three indicators were used to assess the quality of 1056 colonoscopies performed at six hospitals: cecal intubation; adequate colon cleansing; and removal and recovery of all detected polyps. Analyses were performed on the total number of colonoscopies and on colonoscopies in which polyps were actually detected. The accomplishment of each indicator and a global compound index of all three indicators, named the Problem Rate, were analyzed. Results from each endoscopy unit were compared to previously established standards.

RESULTS

Adequate colon cleansing was the most frequent problem for quality in all centers; adequate colon preparation was 67% (range 50 to 84%). The cecum was reached in 84% of all colonoscopies (range 76 to 90%). 75% of all patients (range 28. 79%) had all polyps excised and recovered. All centers had rates below standard for one or several indicators (p<0.01, all cases). Two of the participant hospitals had an overall problem rate above the estimated standard (p<0.01).

CONCLUSIONS

There is a significant variation in the achievement of quality standards of colonoscopy between endoscopy units. Colon cleansing is the most frequent quality problem for colonoscopy.

Evaluation of postsurgical recurrence in Crohn's disease: a new indication for capsule endoscopy?

BACKGROUND

Recurrence after surgery to treat Crohn's disease is frequent and unpredictable. The efficacy of postsurgery capsule endoscopy in detecting recurrence in patients with Crohn's disease is yet to be confirmed.

OBJECTIVE

To assess the safety, accuracy, and therapeutic impact of capsule endoscopy in these patients.

DESIGN

Crohn's disease recurrence at the neoileum (Rutgeers score) was assessed in the patients by colonoscopy and capsule endoscopy. The M2A Patency Capsule (Given Imaging, Yoqneam, Israel) was administered 1 week before capsule endoscopy. Capsule endoscopy was performed within 2 weeks of colonoscopy. Investigators were blinded to the results of each technique. Patient comfort during the procedures was recorded.

PATIENTS

Twenty-four patients with Crohn's disease with ileocolonic anastomosis were prospectively included. All patients were asymptomatic and did not receive any prophylactic treatment.

MAIN OUTCOME MEASUREMENTS

Neoileum recurrence.

RESULTS

A colonoscopy was performed in all patients, although the neoileum could not be reached in 3 of them. M2A Patency Capsule excretion was delayed in 2 patients; thus capsule endoscopy was given only to 22 patients. Recurrence was visualized with colonoscopy in 6 patients and with capsule endoscopy in 5. Ten additional recurrences were visualized only with capsule endoscopy. Moreover, proximal involvement was detected in 13 patients. Therapeutic management was modified in 16 patients. All patients preferred capsule endoscopy.

CONCLUSIONS

Capsule endoscopy is more effective in the evaluation of recurrence after surgery for Crohn's disease and is better tolerated than colonoscopy. This is of significant therapeutic relevance.

Quantitative cholescintigraphy and bile abnormalities in patients with acalculous biliary pain

Acalculous biliary pain has been related to gallbladder dysfunction that produces a gallbladder emptying defect-a condition which favours the development of lithiasis. It is therefore probable that microlithiasis is present in patients with gallbladder dysfunction. The aims of this study were to measure gallbladder emptying and investigate bile abnormalities in patients with acalculous biliary pain. In 92 consecutive patients, gallbladder emptying was assessed by quantitative cholescintigraphy (abnormal ejection fraction < or =40%). In 64 patients, a microscopic study was performed on duodenal bile, defining abnormality as the presence of cholesterol crystals in any amount and/or calcium bilirubinate granules and/or microspheroliths at a rate of >10 per slide. The ejection fraction was abnormal in 45 patients (49%) (median 25.1%, range 6.8-39.3%) and normal in the remaining 47 cases (median 71.3%, range 41.0-96.1%). Bile was abnormal in 32 of 64 patients (50%), the most frequent finding being calcium bilirubinate granules. In the patients with bile abnormalities, abnormal ejection fraction was more frequent (20 of 32) and the median ejection fraction was lower (30.9%, range 12.0-94.1%) than in the patients with normal bile (16 of 32 with an abnormal ejection fraction; median ejection fraction 50.7%, range 6.8-96.1%). Abnormal bile was frequent (55.5%) in patients with reduced ejection fraction, but was not uncommon in patients with normal ejection fraction (33.3%). Fewer patients showed no alteration (25%). It is concluded that in most patients, acalculous biliary pain coexists with gallbladder dysfunction or abnormal bile, the combination of both alterations being common.

Diagnostic value of symptoms in patients with suspected upper digestive tract disease

OBJECTIVE

to develop a predictive model based on clinical data for patients with suspected upper digestive tract disease.

PATIENTS AND METHODS

forty-seven clinical data were obtained before endoscopy from 283 patients with suspected upper digestive disease (153 men; mean age 55 years, limits 17-92 years). A clinical prediction of diagnosis was made before endoscopy. On the basis of the endoscopic findings, the patients were divided into three diagnostic groups: absence of significant disease (group I), significant benign disease (group II) and malignant disease (group III). The probability rate of belonging to each one of the three groups was obtained for each patient by using Bayes' theorem.

RESULTS

the endoscopic findings were classified according to their clinical importance: 121 patients (43%) belonged to group I, 137 (48%) were included in group II; and 25 (9%) in group III. The clinical prediction correctly classified 61% of the patients (group I: 56%, group II: 62% and group III: 76%) The coincidence between prediction obtained using Bayes' theorem and the actual diagnosis was 61% (group I: 65%, group II: 51%, group III: 92%). The predictive model was useful to confirm or not the clinical prediction.

CONCLUSION

objective analysis of clinical data can be useful to support clinical judgment, mainly in patients with neoplasia. However, the model is not adequate to improve indication of upper endoscopy since many patients are misclassified.

[Endoscopic treatment of pancreatitis and its complications]

OBJECTIVES

To study the long- and short-term safety and efficacy of endoscopic treatment of pancreatitis and its complications in our environment.

PATIENTS AND METHODS

We performed a retrospective analysis of 43 patients with chronic pancreatitis, acute pancreatitis complicated with pseudocyst, and pancreatic fistula diagnosed by endoscopic retrograde cholangiopancreatography who were suitable for endoscopic treatment.

RESULTS

Endoscopic treatment was attempted in 35 patients. The indication for treatment was pain in 17 patients (48.5%), jaundice in 7 (20%), pseudocyst in 10 (28.5%) and suspected external fistula in 1 (3%). The technique was successfully performed in 28 (80%). Of the patients with pain, pancreatic prosthesis was inserted in 13 and extracorporeal lithotripsy was applied in 6. Sixty-five percent of the patients improved. Of the 7 patients with jaundice, all had secondary stenosis of the biliary tract. Treatment was applied in 2, who showed partial improvement. Of the 15 patients with pseudocyst, endoscopic treatment was indicated in 10; the technique was successfully performed in 8 and complete resolution was achieved in 7 (87.5%). The patient with external fistula was treated with transpapillary prosthesis and complete resolution of disruption of Wirsung's duct was achieved. Overall improvement in successfully treated patients was: complete in 19 (68%), partial in 3 (18%), no improvement in 4 (14%) and 2 patients were lost to treatment. There were 4 short-term complications. There were 4 deaths and one was related to the technique.

CONCLUSIONS

Endoscopic treatment of chronic pain in chronic pancreatitis, pseudocysts and fistulas was effective in our environment with a low rate of complications.

[Endoscopic treatment combined with extracorporeal shock wave lithotripsy of difficult bile duct stones]

OBJECTIVES

The aim of this study was to determine the safety and effectiveness of extracorporeal shock wave lithotripsy (ESWL) in difficult bile duct stones resistant to endoscopic extraction.

PATIENTS AND METHOD

From January 1997 to February 2002, combined treatment with endoscopy and ESWL was used in 19 patients who had undergone unsuccessful endoscopic bile duct stone extraction after sphincterotomy. The procedure was carried out using analgesic and sedative drugs or deep sedation, prophylactic antibiotic therapy, and monitoring of vital signs. Bile duct stone localization was performed by contrast injection through nasobiliary drainage and fluoroscopy. After each ESWL session, lavage was performed through drainage and stone fragments were extracted endoscopically.

RESULTS

The 19 patients presented high surgical risk due to advanced aged and/or concomitant diseases. All presented jaundice and pain and nine (47.3%) presented associated cholangitis. Thirty ESWL sessions were performed (1.57 sessions per patient), with a mean of 2,120 shock waves per session. In 16 of the 19 patients (84.2%), combined treatment with ESWL and subsequent instrumental endoscopic extraction achieved complete clearance of the biliary tract. The treatment failed in 3 patients who were referred for surgical treatment. No early or late complications were observed, except in one patient who presented a self-limiting febrile syndrome.

CONCLUSIONS

Therapeutic endoscopy combined with ESWL is safe and effective in patients with difficult bile duct stones. It represents a therapeutic alternative in patients at high surgical risk.

[Comparison of the efficacy of cleaning and disinfection of videoscopes: mechanized versus manual]

AIM

a) To analyze the effectiveness of the automated cleaning and disinfection of endoscopies (Olympus miniETD, not previously tested) versus the manual method; b) To evaluate the drying and storage procedures used in our unit.

MATERIAL AND METHODS

Prospective 10-day study. The endoscopies were randomized for automated or manual cleaning and disinfection. Endoscopic samples were collected for microbiology studies at three points during the process: a) after endoscopy (after manual cleaning with water), b) after cleaning with enzymatic detergent and disinfection (automated or manual) and c) at the first hour in the morning.

RESULTS

Sixty-five samples were collected after endoscopy: 26 from gastroscopy, 26 from colonoscopy and 13 from duodenoscopy (positive cultures were found in 22, 25 and 10, respectively). The 35 samples collected after automated disinfection were negative, as were 29 of the 30 collected after manual disinfection (p = 0.46). Sixty-four of the 65 samples were negative for hepatitis B and hepatitis C. The only sample positive for hepatitis C became negative after manual disinfection. Positive culture was found in 15% of the samples collected before beginning the session.

CONCLUSIONS

a) Automated cleaning and disinfection (Olympus miniETD) are as effective as manual cleaning. b) Drying and storage procedures should be improved and/or disinfection should be carried out again before the first endoscopy of each session.

Individual prediction of response to pneumatic dilation in patients with achalasia

During nine years, 157 consecutive patients with achalasia have been dilated in our unit. First, the long-term effect of dilation on clinical status was evaluated. The probability of being in clinical remission eight years after first dilation was 51%. The pressure of the LES measured after dilation was highly predictive of the long-term clinical evolution. Second, a predictive model of the individual response to pneumatic dilation was developed and simplified. Therapy was effective in 80% of the patients, after one to four dilations. Younger age was the only factor significantly associated with ineffective therapy. Depending on the prognosis of the outcome calculated with the predictive model, patients were classified in groups of risk that showed a different rate of ineffective, therapy. In the simplified model, age < or = 20 years, male gender, esophageal body diameter < or = 3 cm, esophageal body basal pressure > 15 mm Hg, and pressure of the lower esophageal sphincter > 30 mm Hg were predictors of a poor response to dilation. We conclude that pneumatic dilation is an effective therapy for achalasia. A predictive model was useful to classify the patients in groups with a different risk for ineffective dilation. A simplification of this model could be used to predict the response to dilation.

Endoscopic sclerotherapy versus oesophageal transection in the prevention of variceal rebleeding

OBJECTIVE

To compare sclerotherapy with oesophageal transection in the prevention of rebleeding in patients with oesophageal varices.

DESIGN

A prospective trial.

PATIENTS

Forty-one patients with cirrhosis and variceal bleeding.

METHODS

After recovering from an acute episode of oesophageal variceal bleeding patients were randomized into two groups. One patient was excluded. Twenty-two patients were treated with sclerotherapy (group 1) and 18 underwent an oesophageal transection (group 2), with a shorter elapsed time from randomization to treatment in group 1. Both groups were similar with regard to clinical and biochemical features and variceal size. Failure, defined in group 1 as rebleeding or incomplete eradication after four sclerotherapy sessions, occurred in five (22.7%) patients; in group 2, rebleeding occurred in two (11.1%) patients (no statistically significant difference).

CONCLUSION

Although the survival rate was similar in both groups, sclerotherapy is preferable to oesophageal transection because it requires a shorter duration of hospitalization and has fewer complications.

[Combined endoscopic treatment with extracorporeal lithotripsy in chronic calcifying pancreatitis]

In the management of severe chronic pancreatitis, a variety of new endoscopic methods have been proposed as an alternative to traditional surgery. The main goal of these procedures is the remission of pain. They include pancreatic endoscopic sphincterotomy with subsequent endoscopic extraction, which can be associated to extracorporeal shock-wave lithotripsy for stone desintegration before removal of large calculi, and to the insertion of a pancreatic stent in case of a pancreatic duct stricture. We present two cases of severe chronic pancreatitis managed successfully with this endoscopic treatment.

[Results of endoscopic dilatation treatment of benign esophageal stenosis]

The management of benign esophageal stenoses is based on endoscopic dilatation of the tight segment for the remission of dysphagia. Five hundred and twenty sessions of dilatation with Savary-Guilliard bougies have been performed in one hundred and twenty-nine patients with benign esophageal stenoses. Patients with peptic stenoses (n = 59) needed a lesser number of sessions (mean: 2.47) than patients with postsurgical (n = 44; mean: 4.86) or caustic (n = 18; mean: 7.77) stenoses. The treatment failed in 4 patients (3.2%) and severe complications were observed in 3 patients (2.4%). These results support the efficacy and safety of this technique.

[Endoscopic prosthesis insertion in the palliative treatment of malignant esophageal stenosis. (Endoscopic esophageal prosthesis)]

We report our experience with endoscopic esophageal prosthesis in the treatment of 82 patients with advanced malignant oesophageal stenosis. The cause of the stenosis was an esophageal or esophagogastric cancer in 75 cases and a bronchogenic cancer in 7 patients. In 18 cases a tracheobronchial fistula was also present. A silicone tube (Atkinson) was used in 58 patients, a polyvinyl tube (Wilson-Cook) in 22 cases and a self-expanding tube in the remaining 2 patients. There was no technical failure in the insertion of the prosthesis. A normal feeding was possible in 71 of the 82 patients (86%) within 48 after the intubation. Major complications occurred in 8 cases (9.7%), 4 patients with esophageal perforation and 4 cases with aspiration bronchopneumonia. Postoperative mortality rate was 7.3%, one patient with perforation, 3 cases with aspiration bronchopneumonia and 2 patients with sepsis. The prosthesis partially displaced in 9 cases, but could be endoscopically replaced in all of them. The displacement of the prosthesis was complete in 3 patients, one of which needed a surgical procedure to remove the tube. The prosthesis was bunged up by a solid meal bolus in 4 cases, but an endoscopic procedure was successful in removing the bolus. Therapy with laser was necessary in two cases with self-expanding prosthesis obstructed by tumoral growth. We conclude that, in malignant esophageal stenosis, the endoscopic implantation of esophageal endoprosthesis is an effective, cheap and relatively safe palliative therapeutic alternative with a low postoperative mortality rate.

[Prevalence of gastroesophageal reflux in patients with primary motor disorder of the esophagus treated with endoscopic pneumatic dilatation]

The prevalence of gastroesophageal reflux after successful pneumatic dilatation was investigated in 30 patients with primary esophageal motor disorder. After a median follow-up period of 377 days, three patients presented symptoms of acid reflux and five patients had endoscopic esophagitis (grade I, 3 patients; grade II, one patient; and grade III, one patient). Ambulatory 24 hr. esophageal pH monitoring was positive in 20% and 30% of the patients compared to our normal values and to those from other series from the literature, respectively. The concordance between pH results and symptoms and/or endoscopic esophagitis was very low. It is concluded that 24 hr. esophageal pH monitoring is frequently abnormal after pneumatic dilatation, but its clinical significance is low, because very few patients have symptoms and/or severe esophagitis.

Does endoscopy improve prediction of the prognosis in upper gastrointestinal bleeding?

To evaluate the prognostic value of the endoscopic examination, we included 189 consecutive patients with upper gastrointestinal bleeding, in a prospective study. Rebleeding was more frequent in patients with endoscopic stigmata of hemorrhage. The prognostic prediction given by the physician was slightly, but not significantly, improved after the result of the endoscopy was available. However, when the clinical data were evaluated by computer, using the Bayes' theorem, the endoscopic findings provided no additional prognostic value. We conclude that the endoscopic findings have intrinsic prognostic value, but add little to clinical data obtained on admission.

[Carcinoma of the esophagus. Palliative treatment with endoscopic prosthesis]

The efficacy and safety of endoscopically inserted esophageal prosthesis was evaluated in 33 patients with non-operable carcinoma involving the esophagus. In 30 cases, the origin of the tumor was esophageal, and in 3 cases, bronchopulmonary. Esophago-pulmonary fistula was present in 9 patients. Histologic exam of the tumors revealed 11 adenocarcinomas and 22 epidermoid carcinomas. In every case, Atkinson prosthesis was used and previous esophageal dilatation was needed in 21 patients. Normal oral feeding was achieved in 29 patients. Mean hospital stay after insertion of the prosthesis was 5 days. Survival rate was 84.8% at one month, 63.6% at 4-6 months, 42.4% survived more than 6 months, and 21.2% were still alive one year after the procedure. Complications occurred in 3 patients (9%) -esophageal perforation in two cases, and pneumonia in one case. One patient died. In conclusion, in patients with advanced carcinoma involving the esophagus, palliative therapy with endoscopically inserted esophageal prosthesis is effective, relatively safe and cheap.

Motor pattern of the sphincter of Oddi in patients with juxtapapillary diverticula

In 15 patients with duodenal diverticula close to the papilla of Vater we evaluated the motor activity of the sphincter of Oddi by endoscopic biliary manometry. Both basal pressure and phasic activity were similar to those in nine patients without biliopancreatic disease and in 60 patients with common bile duct stones. The anatomical relationship between the papilla and diverticula did not lead to any change in the motor pattern. If juxtapapillary diverticula are associated with a higher prevalence of biliopancreatic disease, dysfunction of the sphincter of Oddi does not seem to play a pathogenic role.

[Early complications of pneumatic dilatation in the treatment of primary motility disorders of the esophagus]

We analyze the incidence and evolution of the early complications of 96 consecutive patients with primary esophagus motor disorders, treated with pneumatic dilatation under endoscopic control (1.4 sessions per patient). In 4 (0.042/patient, 0.029/dilatation) patients the esophagus was perforated; the diagnosis was made in the first 24 hours; pneumomediastinum was a constant finding in the radiological exploration. In three cases the complication was suspected because of the apparition of sustained thoracic pain after the dilatation maneuver and in one case the presentation symptom was bleeding of cardial mucosa, larger than usual, at the end of the dilatation. The four patients evolved favorably with conservative treatment (avoidance of oral food intake, gastroesophageal aspiration, antibiotic therapy and parenteral nutrition).

[Hemobilia in patient with hemophilia]

A case is reported of minor hemobilia in a patient with hemophilia. The form of presentation of the clinical picture with abdominal pain, nausea, vomiting and jaundice suggested a biliary origin and echographic evidence of an anomalous content in the bile tract that was not of lithiasic nature suggested the diagnosis of hemobilia. This was confirmed by retrograde cholangiography, which showed the expulsion of a clot from the papilla and was followed by spontaneous remission of the clinical picture.

Endoscopic biliary manometry in patients with suspected sphincter of Oddi dysfunction and in patients with cystic dilatation of the bile ducts

We studied the motility of the sphincter of Oddi in 12 patients with suspected sphincter of Oddi dysfunction, in four patients with cystic dilatation of the bile ducts (two Caroli's cases and two fusiform choledochal cyst cases), and in 33 patients with retained common duct stones. In these last 33 patients, the motor activity of the sphincter of Oddi was similar to that recorded in nine control subjects without pancreatic or biliary diseases. In the suspected Oddi dysfunction cases, both the basal sphincteric pressure and the frequency of the phasic contractions were significantly elevated (P less than 0.001). Patients with biliary cystic dilatation showed an increased basal pressure, but the frequency of the contractions was elevated in only those with choledochal cysts and the amplitude in only one of the two patients with Caroli's disease. Motor disorders of the sphincter of Oddi provide a basis for an alternative etiopathogenesis of cystic disease of the biliary system and a possible explanation for pain and dilatation of the bile duct in patients with suspected sphincter of Oddi dysfunction.

Effect of intravenous glucagon and glucagon-(1-21)-peptide on motor activity of sphincter of Oddi in humans

Glucagon-(1-21)-peptide, the peptide containing the amino acid sequence (1-21) of glucagon, has the same spasmolytic effect as the complete molecule, without its metabolic action. The effect of glucagon and glucagon-(1-21)-peptide on sphincter of Oddi motor activity was evaluated in 20 patients undergoing ERCP and endoscopic biliary manometry. Glucagon produced a nonsignificant decrease in basal pressure, but significantly reduced both frequency and amplitude of phasic activity of the sphincter of Oddi. Glucagon-(1-21)-peptide showed no effect on basal pressure and amplitude of phasic activity, but provoked a significant reduction of frequency of phasic contraction.

Motor pattern of the sphincter of Oddi in patients with bilioenteric shunt: a manometric study

An endoscopic biliary manometry was performed on 11 patients with a surgical bilioenteric shunt--choledochoduodenostomy--and no pressure gradient between common bile duct and duodenum. Basal pressure and frequency of the phasic waves of the sphincter of Oddi were significantly higher in these patients than in controls or in patients with retained common bile duct stones. These results suggest a functional adaptation of the sphincter of Oddi in an attempt to recover the normal pressure in the biliary tract.

Effects of atropine and pirenzepine on sphincter of Oddi motility. A manometric study

We studied the Oddi sphincter motility by endoscopic manometry in 10 consecutive patients randomized in a double-blind fashion, after i.v. administration of two anticholinergic compounds (0.5 mg atropine sulfate and 10 mg pirenzepine). Pirenzepine significantly decreased the basal sphincteric pressure, as well as the amplitude and frequency of the phasic contractions. The only significant effect of atropine was the modification of the frequency of the phasic contractions, but only for a short period of time. Our results suggest that muscarinic innervation must be present for a normal sphincter of Oddi motility.

Manometric evaluation of sphincter of Oddi after endoscopic sphincterotomy, and in patients with previous surgical sphincterotomy

Pressures in the sphincter of Oddi and common bile duct were determined in eight patients with previous surgical sphincterotomy, and in 14 patients before and after endoscopic sphincterotomy. Motor activity in the sphincter of Oddi was seen during manometric examination in 6 out of 8 patients of the surgical group. These six patients had common bile duct stones after cholecystectomy. Endoscopic sphincterotomy equalized the choledochoduodenal gradient and reduced the sphincter pressure in all the patients except three. In two of them further extension of the length of the sphincterotomy permitted removal of the stones and substantial reduction of the motor activity of the sphincter of Oddi.

Ischemic colitis attributable to a cleansing enema

A 42-year-ole woman developed ischemic colitis shortly after the administration of a cleansing enema. As possible predisposing factor in out patient we assess treatment with contraceptives by parenteral route, started one year before her episode of bowel ischemia. To out knowledge, this is the first patient without underlying pathology with proven ischemic colitis secondary to a cleansing enema.