Luminary Learning Gastrointestinal Disorder- Issue 1

Current Guidelines for Colonoscopy •  39 Abdominal Pain or Discomfort Up to one-third of patients report at least one minor, transient gastrointestinal symptom after colonoscopy. The most commonly reported adverse effects of colonoscopy include bloating (25%) and abdominal pain or discomfort in 5% to 11% [24]. Avoidance of endoscope looping and mini- mized air insufflation help to reduce these symptoms during and after the procedure. Carbon dioxide compared with standard air insufflation accelerates the postinsufflation recovery [24]. Postpolypectomy Syndrome After interventional colonoscopy with submucosal or transmural injection (e.g., endoscopic mucosal resection, tattooing) and/or application of electrocautery (e.g., hot-snare polypectomy), patients may develop localized abdominal pain and tenderness, occasionally associated with an increase in inflammatory parameters (WBC, CRP), but show no evidence for a perforation. Postpolypectomy electrocoagulation syndrome (PPES) is poorly quantitated with a wide range of reported incidences from 3 per 100,000 (0.003%) to 1 in 1000 (0.1%) [21]. It is thought to be the result of collateral transmural energy spread through the bowel wall which leads to a localized peritoneal reaction. Treatment is conservative and ranges from watch and wait to administration of antibiotics, which results in resolution of symptoms within a few days. Gas Explosion Explosive complications related to the use of cautery during colonoscopy are uncommon but can have dramatic consequences. A 2007 review reported 9 cases, each resulting in colonic perforation and, in one case, death [25]. The combination of hydrogen or methane gas at combustible levels, oxygen, and electrosurgical energy form the risk triangle for explosions. The lack of an adequate anterograde cleansing, use of nonabsorbable or incompletely absorbable carbohydrate prepara- tions (such as mannitol, lactulose, or sorbitol), or the use of enemas-only cleansing (e.g., for flex- ible sigmoidoscopy) has been associated with an increased risk [26]. Electrocautery should not be performed during routine flexible sigmoidoscopy after enema preparation [26]. Management of Anticoagulants and Platelet Inhibitors An increasing number of patients presenting for colonoscopy are being treated with antithrom- botic agents (anticoagulants, platelet inhibitors) for a variety of conditions. The American Society of Gastrointestinal Endoscopy (ASGE) recently released extensive updated guide- lines for the management of antithrombotic agents for patients undergoing endoscopy [27]. In essence, the individual circumstances have to be analyzed to determine (a) the indication, the urgency, and the bleeding risk of the procedure (screening only = low risk, intervention including polypectomy=high risk), (b) the type of antithrombotic treatment and medications, and (c) the risk of thromboembolic events if one or all of these medications were paused. For example, when