Trauma to the solid abdominal organs:The missed dark box of colonoscopy

Colonoscopy is an integral part of the lower bowel care and is generally considered a potentially safe diagnostic and therapeutic procedure performed as a daycare outpatient procedure.Colonoscopy is associated with different complications that are not limited to adverse events related to the bowel preparation solutions used,the sedatives used,but to the procedure related as well including bleeding and perforation.Injuries to the extra-luminal abdominal organs during colonoscopy are uncommon,however,serious complications related to the procedure have been reported infrequently in the literature.Life threatening injuries to the spleen,liver,pancreas,mesentery,and urinary bladder have been reported as early as in mid-1970s.These injuries should not be overlooked by clinicians and endoscopists.Steadily increasing abdominal pain,abdominal distension,and hemodynamic instability in absence of rectal bleeding should raise the possibility of severe organ injury.Splenic and hepatic injury following colonoscopy are usually serious and may be life threatening.Although conservative management may help,yet they usually need interventional radiology or surgical intervention.Acute pancreatitis following colonoscopy is usually mild and is mostly managed conservatively.The mechanism of abdominal organ injuries during colonoscopy is not fully understood,however many risk factors have been identified,which can be classified as-organ related,procedure related,and local abdominal factors.Difficult colonoscopy and prior intra-abdominal adhesions are probably the most relevant risk factors for these injuries.Left lateral position,avoidance of looping and excessive force during the procedure would probably reduce the risk of such injuries.

Importance of diet and intestinal microbiota in the prevention of colorectal cancer-colonoscopy early screening diagnosis

Colorectal cancer is a term used to describe colon and rectal cancer,which is the third most common type of cancer.A MEDLINE and PubMed search resulted in the inclusion of manuscripts written in the last 10 years,using keywords relevant to the topic of the manuscript.By analyzing the aim of the searched studies and manuscripts,adequate articles were included that described the stated problem.The frequency of colorectal cancer varies with climate,nutrition,and many other factors,primarily endogenous,hereditary,intestinal microbiome,as well as external factors,such as exposure of the individual to stress,and bad eating habits.Colon cancer and rectal cancer or colorectal cancer in general in the early stages of the disease,may not show symptoms or are barely noticeable.Colorectal cancer symptoms will most often not develop until the disease has progressed to stage 2 or beyond.Regular screening tests for colon or rectal cancer,especially colonoscopy,are recommended as part of a regular checkup for people aged 50 years or younger who are at high risk due to a family history of the disease or other cancers.Diet and colonoscopy as an early screening method play an important role in the prevention of colorectal cancer.

Colonoscopy plays an important role in detecting colorectal neoplasms in patients with gastric neoplasms

BACKGROUND Gastric cancer(GC)and colorectal cancer(CRC)are the fifth and third most common cancer worldwide,respectively.Nowadays,GC is reported to have a potential predictive value for CRC,especially for advanced CRC.AIM To evaluate the necessity of colonoscopy for gastric neoplasm(GN)patients.METHODS Four databases,including PubMed,EMBASE,the Cochrane Library,and Ovid,were used to perform the search strategy on May 2,2023.The prevalence of colorectal neoplasms(CRN)and baseline characteristics were compared between the neoplasm group and the control group.Continuous variables are expressed as the mean difference and standard deviation.Relationships of categorical variables in the two groups are expressed as odds ratios(OR)and 95%confidence intervals(95%CIs).Subgroup analysis according to different kinds of GNs was conducted for more in-depth analysis.The results of this study are represented by forest plots.Publication bias was evaluated by a funnel plot.All data analyses were performed by STATA SE 16.0 software.RESULTS A total of 3018 patients with GNs and 3905 healthy controls(age and sex matched)were enrolled for analysis.After comparing the prevalence of CRNs between the two groups,CRNs were detected significantly more frequently in GN patients than in controls(OR=1.69,95%CI=1.28 to 2.23,I^(2)=85.12%,P=0.00),especially in patients with GC(OR=1.80,95%CI=1.49 to 2.18,I^(2)=25.55%,P<0.1).Moreover,other risk factors including age(OR=1.08,95%CI=1.00 to 1.17,I^(2)=90.13%,P=0.00)and male sex(OR=2.31,95%CI=1.26 to 4.22,I^(2)=87.35%,P=0.00),were related to the prevalence of CRNs.For patients in the GN group,body mass index(BMI,OR=0.88,95%CI=0.80 to 0.98,I^(2)=0.00%,P=0.92)and smoking(OR=1.03,95%CI=1.01 to 1.05,I^(2)=0.00%,P=0.57)were protective and risk factors for CRNs,respectively.CONCLUSION Patients are recommended to undergo colonoscopy when diagnosed with GNs,especially GC patients with a low BMI and a history of smoking.

Trends in colorectal cancer incidence according to an increase in the number of colonoscopy cases in Korea

BACKGROUND The incidence of colorectal cancer(CRC)and preinvasive CRC(e.g.,early colon cancer and advanced adenoma)is gradually increasing in several countries.AIM To evaluate the trend in incidence of CRC and preinvasive CRC according to the increase in the number of colonoscopies performed in Korea.METHODS This retrospective cohort study enrolled Korean patients from 2002 to 2020 to evaluate the incidence of CRC and preinvasive CRC,and assess the numbers of diagnostic colonoscopies and colonoscopic polypectomies.Colonoscopy-related complications by age group were also determined.RESULTS The incidence of CRC showed a rapid increase,then decreased after 2012 in the 50-75 year-age group.During the study period,the rate of incidence of preinvasive CRC increased at a similar level in patients under 50 and 50-75 years of age.Since 2009,the increase has been rapid,showing a pattern similar to the increase in colonoscopies.The rate of colonoscopic polypectomy in patients aged under 50 was similar to the rate in patients over 75 years of age after 2007.The rate of complications after colonoscopy and related deaths within 3 mo was high for those over 75 years of age.CONCLUSION The diagnosis of preinvasive CRC increased with the increase in the number of colonoscopies performed.As the risk of colonoscopy-related hospitalization and death is high in the elderly,if early lesions at risk of developing CRC are diagnosed and treated under or at the age of 75,colonoscopy-related complications can be reduced for those aged 76 years or over.

Vomiting-induced pharyngeal perforation during bowel preparation for colonoscopy:A case report

BACKGROUND Effective bowel cleansing is essential for a successful colonoscopy.Laxatives,such as polyethylene glycol,are commonly used for bowel preparation.Vomiting is a frequent complication during bowel preparation,and forceful vomiting can potentially lead to esophageal perforation,as reported in several previous cases.However,pharyngeal perforation during bowel preparation has not been previously documented.Here,we present a case of pharyngeal perforation induced by forceful vomiting during bowel preparation.CASE SUMMARY A 38-year-old man with a history of hypertension,dyslipidemia,diabetes mellitus,and end-stage renal disease on hemodialysis was admitted for evaluation of recurrent abdominal pain.The patient complained of sudden pain in the neck,throat,and anterior chest following forceful vomiting during bowel preparation.Physical examination revealed crepitus under the skin of the neck and anterior chest on palpation,and upper gastrointestinal endoscopy revealed pharyngeal perforation.The perforation site was located above the upper esophageal sphincter,which distinguished it from Boerhaave’s syndrome.Conservative medical management was chosen after consultation with a thoracic surgeon and an otolaryngologist,considering the patient's mild symptoms,stable vital signs,and the small size of the lesion;the perforation resolved without endoscopic or surgical intervention.The patient was discharged from hospital two weeks after the perforation.CONCLUSION Despite its rarity,pharyngeal perforation should be considered a potential complication of bowel preparation for colonoscopy.

Colonoscopy-assisted removal of an impaction foreign body at the rectosigmoid junction: A case report

BACKGROUND When an anorectal foreign body is found,its composition and shape should be evaluated,and a timely and effective treatment plan should be developed based on the patient's symptoms to avoid serious complications such as intestinal perforation caused by displacement of the foreign body.CASE SUMMARY A 54-year-old male was admitted to our outpatient clinic on June 3,2023,due to a rectal foreign body that had been embedded for more than 24 h.The patient reported using a glass electrode tube to assist in the recovery of prolapsed hemorrhoids,however,the electrode tube was inadvertently inserted into the anus and could not be removed by the patient.During hospitalization,the patient underwent surgery,and the foreign body was dragged into the rectum with the aid of colonoscopy.The anus was dilated with a comb-type pulling hook and an anal fistula pulling hook to widen the anus and remove the foreign body,and the local anal symptoms were then relieved with topical drugs.The patient was allowed to eat and drink,and an entire abdominal Computed tomography(CT)and colonoscopy were reviewed 3 d after surgery.CT revealed no foreign body residue and colonoscopy showed no metal or other residues in the colon and rectum,and no apparent intestinal tract damage.CONCLUSION The timeliness and rationality of the surgical and therapeutic options for this patient were based on a literature review of the clinical signs and conceivable conditions in such cases.The type,material and the potential risks of rectal foreign bodies should be considered.

Previously undiagnosed Morgagni hernia with bowel perforation detected during repeat screening colonoscopy: A case report

BACKGROUND Morgagni hernia(MH)is a form of congenital diaphragmatic hernia(CDH)characterized by an incomplete formation of diaphragm,resulting in the protru-sion of abdominal organs into the thoracic cavity.The estimated incidence of CDH is between 1 in 2000 and 1 in 5000 live births,although the true incidence is unknown.MH typically presents in childhood and can be diagnosed either pre-natally or postnatally.However,it can also be asymptomatic and carry the risk of developing into a life-threatening condition in adulthood.CASE SUMMARY A 76-year-old female with no history of prior abdominal surgeries presented for an elective colonoscopy for polyp surveillance.During the procedure,when approaching the hepatic flexure,the scope could not be advanced further despite multiple attempts.The patient experienced mild abdominal discomfort,leading to the abortion of the procedure.While in the recovery area,she developed increa-sing abdominal pains and hypotension.Urgent abdominal imaging revealed her-niation of the proximal transverse colon through a MH into the chest with evi-dence of perforation.The patient underwent laparoscopic urgent colonic resection and primary hernia repair and was discharged uneventfully 2 d later.CONCLUSION A MH is a rare condition in adults that can present as a life-threatening compli-cation of colonoscopy,even in patients with a history of uneventful colonoscopies.This case highlights the importance of considering congenital and internal hernias when faced with sudden and unexplained difficulties during colonoscopy.If there is a suspicion of MH,the endoscopist should halt the procedure and immediately obtain abdominal imaging to confirm the diagnosis.

Constipation and colonoscopy

Constipation is a significant sociomedical problem,which can be caused by various reasons.In the diagnostic approach to patients with constipation,the following data are usually sufficient:History,complete physical examination(including rectal examination),and additional diagnostic tests.A colonoscopy is not a necessary diagnostic method for all patients with constipation.However,if patients have alarm symptoms/signs,that suggest an organic reason for constipation,a colonoscopy is necessary.The most important alarm symptoms/signs are age>50 years,gastrointestinal bleeding,new-onset constipation,a palpable mass in the abdomen and rectum,weight loss,anemia,inflammatory bowel disease,and family history positive for colorectal cancer.Most endoscopists do not like to deal with patients with constipation.There are two reasons for this,namely the difficulty of endoscopy and the adequacy of preparation.Both are adversely affected by constipation.To improve the quality of colonoscopy in these patients,good examination techniques and often more extensive preparation are necessary.Good colonoscopy technique implies adequate psychological preparation of the patient,careful insertion of the endoscope with minimal insufflation,and early detection and resolution of loops.Bowel preparation for colonoscopy often requires prolonged preparation and sometimes the addition of other laxatives.

Long-term impact of artificial intelligence on colorectal adenoma detection in high-risk colonoscopy

BACKGROUND Improved adenoma detection rate(ADR)has been demonstrated with artificial intelligence(AI)-assisted colonoscopy.However,data on the real-world appli-cation of AI and its effect on colorectal cancer(CRC)screening outcomes is limited.AIM To analyze the long-term impact of AI on a diverse at-risk patient population undergoing diagnostic colonoscopy for positive CRC screening tests or sympt-oms.METHODS AI software(GI Genius,Medtronic)was implemented into the standard proced-ure protocol in November 2022.Data was collected on patient demographics,procedure indication,polyp size,location,and pathology.CRC screening outcomes were evaluated before and at different intervals after AI introduction with one year of follow-up.RESULTS We evaluated 1008 colonoscopies(278 pre-AI,255 early post-AI,285 established post-AI,and 190 late post-AI).The ADR was 38.1%pre-AI,42.0%early post-AI(P=0.77),40.0%established post-AI(P=0.44),and 39.5%late post-AI(P=0.77).There were no significant differences in polyp detection rate(PDR,baseline 59.7%),advanced ADR(baseline 16.2%),and non-neoplastic PDR(baseline 30.0%)before and after AI introduction.CONCLUSION In patients with an increased pre-test probability of having an abnormal colonoscopy,the current generation of AI did not yield enhanced CRC screening metrics over high-quality colonoscopy.Although the potential of AI in colonoscopy is undisputed,current AI technology may not universally elevate screening metrics across all situations and patient populations.Future studies that analyze different AI systems across various patient populations are needed to determine the most effective role of AI in optimizing CRC screening in clinical practice.

Colonoscopy in the diagnosis and management of appendiceal disease

In this editorial,we comment on the article published in the recent issue of the World Journal of Gastrointestinal Endoscopy.We focused on the understanding of appendiceal disease,and the various options for diagnosis and treatment via endoscopy.Some factors affecting the diagnosis and management of appendiceal diseases are also discussed.The existence of any organ has its natural rationality,and the appendix is such a magical organ.A growing number of experts and scholars have gradually come to a consensus that the appendix is not a useless evolutionary relic.There are many lymphocytes and lymph nodes in the appendix wall,which has a strong immune function,and this function is particularly important for children and adolescents.Many intestinal probiotics in the appendix are very helpful for maintaining the balance of the intestinal flora.With the continuous progress of endoscopic technology,endoscopic treatment involving preservation of the appendix has shown great advantages over surgery.In the diagnosis of appendiceal inflammation and neoplasms,colonoscopy,endoscopic retrograde appendicography and choledochoscopy help assess conditions of the appendix.Endoscopic retrograde appendicitis therapy,abscess drainage under colonoscopy,fenestration of abscess under colonoscopy,and endoscopic or natural orifice transluminal endoscopic surgery resection of appendiceal neoplasms are safe and effective endoscopic treatments for appendiceal disease.New breakthroughs in the application of endoscopy in the appendix are expected to occur in the near future.

Research Progress of Bowel Preparation for Colonoscopy

Colorectal cancer ranks third in the global cancer data in 2020. Colorectal scope is the most effective method to diagnose colorectal diseases such as benign and malignant colorectal tumors. The poor quality of intestinal preparation causes an increased rate of missed diagnosis of colorectal tumors, reduces the rate of cecal intubation for colorectal examination, increases the discomfort, and reduces the compliance of re-examination. Therefore, we should try our best to improve the quality of intestinal preparation. This study reviewed the latest advances related to the preoperative preparation for colonoscopy. Recent research shows that smartphone apps can provide more detailed education and guidance on bowel preparation;Pre-packaged foods are more suitable as a way to eat before colonoscopy. The use of smaller doses, better taste of cathartic agents, and some auxiliary measures, combined with the patient’s situation to provide personalized intestinal preparation measures to improve the quality of intestinal preparation. Starting from the quality of colonoscopy bowel preparation, continuous improvement of patients’ tolerance to bowel preparation, continuous improvement of bowel preparation plan based on individual factors’ needs, and better communication with examined subjects by using existing scientific information technology, may be the hot spot of colonoscopy bowel preparation research in the next few years.

The applications and challenges of artificial intelligence in colonoscopy

It has been widely acknowledged that colonoscopy is the most effective method of preventing colorectal cancer because it can detect and remove precursor lesions,thereby reducing both incidence and mortality.Among these approaches,standardized colonoscopy stands out as the most efficacious method for early-stage colorectal cancer identification.Artificial intelligence is a rapidly expanding field in gastrointestinal endoscopy.This article presents a comprehensive review of the advantages and clinical evidence supporting the application of artificial intelligence in colonoscopy while also discussing prospects for utilizing artificial intelligence-assisted endoscopy in diagnosing colorectal cancer.

Research Progress of Bowel Preparation for Colonoscopy

Colorectal cancer ranks third in the global cancer data in 2020.Colorectal scope is the most effective method to diagnose colorectal diseases such as benign and malignant colorectal tumors.The poor quality of intestinal preparation causes an increased rate of missed diagnosis of colorectal tumors,reduces the rate of cecal intubation for colorectal examination,increases the discomfort,and reduces the compliance of re-examination.Therefore,we should try our best to improve the quality of intestinal preparation.This study reviewed the latest advances related to the preoperative preparation for colonoscopy.Recent research shows that smartphone apps can provide more detailed education and guidance on bowel preparation;Pre-packaged foods are more suitable as a way to eat before colonoscopy.The use of smaller doses,better taste of cathartic agents,and some auxiliary measures,combined with the patient’s situation to provide personalized intestinal preparation measures to improve the quality of intestinal preparation.Starting from the quality of colonoscopy bowel preparation,continuous improvement of patients’tolerance to bowel preparation,continuous improvement of bowel preparation plan based on individual factors’needs,and better communication with examined subjects by using existing scientific information technology,may be the hot spot of colonoscopy bowel preparation research in the next few years.

When and why a colonoscopist should discontinue colonoscopy by himself?

AIM: To investigate when and why a colonoscopist should discontinue incomplete colonoscopy by himself.METHODS: In this cross-sectional study, 517 difficult colonoscope insertions(Grade C, Kudo's difficulty classification) screened from 37800 colonoscopy insertions were collected from April 2004 to June 2014 by three 4th-level(Kudo's classification) colonoscopists. The following common factors for the incomplete insertion were excluded: structural obstruction of the colon or rectum, insufficient colon cleansing, discontinuation due to patient's discomfort or pain, severe colon disease with a perforation risk(e.g., severe ischemic colonopathy). All the excluded patients were re-scheduled if permission was obtained from the patients whose intubation had failed. If the repeat intubations were still a failure because of the difficult operative techniques, those patients were also included in this study. The patient's age, sex, anesthesia and colonoscope type were recorded before colonoscopy. During the colonoscopic examination, the influencing factors of fixation, tortuosity, laxity and redundancy of the colon were assessed, and the insertion time(> 10 min or ≤ 10 min) were registered. The insertion time was analyzed by t-test, and other factors were analyzed by univariate and multivariate logistic regression.RESULTS: Three hundred and twenty-two(62.3%) of the 517 insertions were complete in the colonoscope insertion into the ileocecum, but 195(37.7%) failed in the insertion. Fixation, tortuosity, laxity or redundancy occurred during the colonoscopic examination. Multivariate logistic regression analysis revealed that fixation(OR = 0.06, 95%CI: 0.03-0.16, P < 0.001) and tortuosity(OR = 0.04, 95%CI: 0.02-0.08, P < 0.001) were significantly related to the insertion into the ileocecum in the left hemicolon; multivariate logistic regression analysis also revealed that fixation(OR = 0.16, 95%CI: 0.06-0.39, P < 0.001), tortuosity(OR0.23, 95%CI: 0.13-0.43, P < 0.001), redundancy(OR = 0.12, 95%CI: 0.05-0.26, P < 0.001) and sex(OR = 0.35, 95%CI: 0.20-0.63, P < 0.001) were significantly related to the insertion into the ileocecum in the right hemicolon. Prolonged insertion time(> 10 min) was an unfavorable factor for the insertion into the ileocecum.CONCLUSION: Colonoscopy should be discontinued if freedom of the colonoscope body's insertion and rotation is completely lost, and the insertion time is prolonged over 30 min.

Factors affecting the quality of bowel preparation for colonoscopy in hard-to-prepare patients:Evidence from the literature

Adequate bowel cleansing is critical for a high-quality colonoscopy because it affects diagnostic accuracy and adenoma detection.Nevertheless,almost a quarter of procedures are still carried out with suboptimal preparation,resulting in longer procedure times,higher risk of complications,and higher likelihood of missing lesions.Current guidelines recommend high-volume or low-volume polyethylene glycol(PEG)/non-PEG-based split-dose regimens.In patients who have had insufficient bowel cleansing,the colonoscopy should be repeated the same day or the next day with additional bowel cleansing as a salvage option.A strategy that includes a prolonged low-fiber diet,a split preparation regimen,and a colonoscopy within 5 h of the end of preparation may increase cleansing success rates in the elderly.Furthermore,even though no specific product is specifically recommended in the other cases for difficult-to-prepare patients,clinical evidence suggests that 1-L PEG plus ascorbic acid preparation are associated with higher cleansing success in hospitalized and inflammatory bowel disease patients.Patients with severe renal insufficiency(creatinine clearance<30 mL/min)should be prepared with isotonic high volume PEG solutions.Few data on cirrhotic patients are currently available,and no trials have been conducted in this population.An accurate characterization of procedural and patient variables may lead to a more personalized approach to bowel preparation,especially in patients undergoing resection of left colon lesions,where intestinal preparation has a poor outcome.The purpose of this review was to summarize the evidence on the risk factors influencing the quality of bowel cleansing in difficult-to-prepare patients,as well as strategies to improve colonoscopy preparation in these patients.

Quality of bowel preparation in patients with inflammatory bowel disease undergoing colonoscopy:What factors to consider?

An adequate bowel preparation in patients with inflammatory bowel disease(IBD)is a prerequisite for successful colonoscopy for screening,diagnosis,and surveillance.Several bowel preparation formulations are available,both high-and low-volume based on polyethylene glycol.Generally,low-volume formulations are also based on several compounds such as magnesium citrate preparations with sodium picosulphate,oral sulphate solution,and oral sodium phosphatebased solutions.Targeted studies on the quality of bowel preparation prior to colonoscopy in the IBD population are still required,with current evidence from existing studies being inconclusive.New frontiers are also moving towards the use of alternatives to anterograde ones,using preparations based on retrograde colonic lavage.

Efficacy and safety of propofol target-controlled infusion combined with butorphanol for sedated colonoscopy

BACKGROUND Propofol is a short-acting,rapid-recovering anesthetic widely used in sedated colonoscopy for the early detection,diagnosis and treatment of colon diseases.However,the use of propofol alone may require high doses to achieve the induction of anesthesia in sedated colonoscopy,which has been associated with anesthesia-related adverse events(AEs),including hypoxemia,sinus bradycardia,and hypotension.Therefore,propofol co-administrated with other anesthetics has been proposed to reduce the required dose of propofol,enhance the efficacy,and improve the satisfaction of patients receiving colonoscopy under sedation.AIM To evaluate the efficacy and safety of propofol target-controlled infusion(TCI)in combination with butorphanol for sedation during colonoscopy.METHODS In this controlled clinical trial,a total of 106 patients,who were scheduled for sedated colonoscopy,were prospectively recruited and assigned into three groups to receive different doses of butorphanol before propofol TCI:Low-dose butorphanol group(5μg/kg,group B1),high-dose butorphanol group(10μg/kg,group B2),and control group(normal saline,group C).Anesthesia was achieved by propofol TCI.The primary outcome was the median effective concentration(EC50)of propofol TCI,which was measured using the up-and-down sequential method.The secondary outcomes included AEs in perianesthesia and recovery characteristics.RESULTS The EC50 of propofol for TCI was 3.03μg/mL[95%confidence interval(CI):2.83-3.23μg/mL]in group B2,3.41μg/mL(95%CI:3.20-3.62μg/mL)in group B1,and 4.05μg/mL(95%CI:3.78-4.34μg/mL)in group C.The amount of propofol necessary for anesthesia was 132 mg[interquartile range(IQR),125-144.75 mg]in group B2 and 142 mg(IQR,135-154 mg)in group B1.Furthermore,the awakening concentration was 1.1μg/mL(IQR,0.9-1.2μg/mL)in group B2 and 1.2μg/mL(IQR,1.025-1.5μg/mL)in group B1.Notably,the propofol TCI plus butorphanol groups(groups B1 and B2)had a lower incidence of anesthesia AEs,when compared to group C.Furthermore,no significant differences were observed in the rates of AEs in perianesthesia,including hypoxemia,sinus bradycardia,hypotension,nausea and vomiting,and vertigo,among group C,group B1 and group B2.CONCLUSION The combined use with butorphanol reduces the EC50 of propofol TCI for anesthesia.The decrease in propofol might contribute to the reduced anesthesia-related AEs in patients undergoing sedated colonoscopy.

Emerging space for non-polyethene-glycol bowel preparations in inflammatory bowel disease-related colonoscopy:Veering toward better adherence and palatability

Patients with inflammatory bowel diseases(IBDs)require repeated endoscopic evaluations over time by colonoscopy to weigh disease activity but also for different and additional indications(e.g.,evaluation of postoperative recurrence,colorectal cancer surveillance).Colonoscopy,however,requires adequate bowel preparation to be of quality.The latter is achieved as long as the patient takes a certain amount of product to have a number of bowel movements suitable to clean the colon and allow optimal visualization of the mucosa during endoscopy.However,significant guidelines recommend preparations for patients with IBD not excelling in palatability.This recommendation originates from the fact that most of the studies conducted on bowel preparations in patients with IBD have been done with isosmolar preparations based on polyethylene glycol(PEG),for which,therefore,more safety data exist.As a result,the low-volume non-PEG preparations(e.g.,magnesium citrate plus picosulphate,oral sulphate solutions)have been set aside for the whole range of warnings to be heeded because of their hyperosmolarity.New studies,however,are emerging,leaning in overall for a paradigm shift in this matter.Indeed,such non-PEG preparations seem to show a particularly encouraging and engaging safety profile when considering their broad potential for tolerability and patient preference.Indeed,such evidence is insufficient to indicate such preparations in all patients with IBD but may pave the way for those with remission or well-controlled disease.This article summarizes the central studies conducted in IBD settings using non-PEG preparations by discussing their results.

Strategies to manage the difficult colonoscopy

During endoscopy,an endoscopist is inevitably faced with the occasional“difficult colonoscopy,”in which the endoscopist finds it challenging to advance the endoscope to the cecum.Beyond optimization of technique,with minimized looping,minimal insufflation,sufficient sedation,and abdominal splinting when needed,sometimes additional tools may be needed.In this review,we cover available techniques and technologies to help navigate the difficult colonoscopy,including the ultrathin colonoscope,rigidizing overtube,balloon-assisted colonoscopy and the abdominal compression device.

Supply and quality of colonoscopy according to the characteristics of gastroenterologists in the French population-based colorectalcancer screening program

BACKGROUND Since its complete roll-out in 2009,the French colorectal cancer screening program(CRCSP)experienced 3 major constraints[use of a less efficient Guaiac-test(gFOBT),stopping the supply of Fecal-Immunochemical-Test kits(FIT),and suspension of the program due to the coronavirus disease 2019(COVID-19)]affecting its effectiveness.AIM To describe the impact of the constraints in terms of changes in the quality of screeningcolonoscopy(Quali-Colo).METHODS This retrospective cohort study included screening-colonoscopies performed by gastroenterologists between Jan-2010 and Dec-2020 in people aged 50-74 living in Ile-de-France(France).The changes in Quali-colo(Proportion of colonoscopies performed beyond 7 mo(Colo_7 mo),Frequency of serious adverse events(SAE)and Colonoscopy detection rate)were described in a cohort of Gastroenterologists who performed at least one colonoscopy over each of the four periods defined according to the chronology of the constraints[gFOBT:Normal progress of the CRCSP using gFOBT(2010-2014);FIT:Normal progress of the CRCSP using FIT(2015-2018);STOP-FIT:Year(2019)during which the CRCSP experienced the cessation of the supply of test kits;COVID:Program suspension due to the COVID-19 health crisis(2020)].The link between each dependent variable(Colo_7 mo;SAE occurrence,neoplasm detection rate)and the predictive factors was analyzed in a two-level multivariate hierarchical model.RESULTS The 533 gastroenterologists(cohort)achieved 21509 screening colonoscopies over gFOBT period,38352 over FIT,7342 over STOP-FIT and 7995 over COVID period.The frequency of SAE did not change between periods(gFOBT:0.3%;FIT:0.3%;STOP-FIT:0.3%;and COVID:0.2%;P=0.10).The risk of Colo_7 mo doubled between FIT[adjusted odds ratio(aOR):1.2(1.1;1.2)]and STOPFIT[aOR:2.4(2.1;2.6)];then,decreased by 40%between STOP-FIT and COVID[aOR:2.0(1.8;2.2)].Regardless of the period,this Colo_7 mo’s risk was twice as high for screening colonoscopy performed in a public hospital[aOR:2.1(1.3;3.6)]compared to screening-colonoscopy performed in a private clinic.The neoplasm detection,which increased by 60%between gFOBT and FIT[aOR:1.6(1.5;1.7)],decreased by 40%between FIT and COVID[aOR:1.1(1.0;1.3)].CONCLUSION The constraints likely affected the time-to-colonoscopy as well as the colonoscopy detection rate without impacting the SAE’s occurrence,highlighting the need for a respectable reference time-tocolonoscopy in CRCSP.