Mechanisms of hyoscine butylbromide to improve adenoma detection: A case-control study of surface visualization at simulated colonoscope withdrawal

Background and study aims: Antispasmodics may improve mucosal visualization during colonoscope withdrawal, potentially improving polyp and adenoma detection. Meta-analysis and case-control studies suggest a 9 % to 13 % relative increase in adenoma and polyp detection. We aimed to assess the impact of hyoscine butylbromide on the expected visualization during colonoscope withdrawal using a CT colonography (CTC) simulation.

Patients and methods: Datasets from a previous CTC study examining the effect of antispasmodic were re-analyzed with customised CTC software, adjusted to simulate a standard colonoscopic view. Eighty-six patients received intravenous (IV) hyoscine butylbromide 20 mg, 40 mg or no antispasmodic. Main outcome measurements at unidirectional flythrough, simulating colonoscope withdrawal, were percentage colonic surface visualization, numbers and sizes of unseen areas, and colonic length.

Results: Use of antispasmodic was associated with a significant relative increase in percentage surface visualization of 2.6 % to 3.9 %, compared with no antispasmodic, P < 0.006. Total numbers of missed areas and intermediate sized (300 – 1000 mm²) missed areas were significantly decreased, by approximately 20 %. There were no differences between the 20-mg and 40-mg doses. Mean colonic length (161 – 169 cm) was unchanged by antispasmodic.

Conclusions: IV hyoscine butylbromide at simulated colonoscope withdrawal was associated with significant increases in surface visualization, which might explain up to half the improvement in adenoma detection seen in clinical studies.

• References

• 1 Barclay RL, Vicari JJ, Doughty AS et al. Colonoscopic withdrawal times and adenoma detection during screening colonoscopy. N Engl J Med 2006; 355: 2533-2541
• 2 East JE, Suzuki N, Arebi N et al. Position changes improve visibility during colonoscope withdrawal: a randomized, blinded, crossover trial. Gastrointest Endosc 2007; 65: 263-269
• 3 Froehlich F, Wietlisbach V, Gonvers JJ et al. Impact of colonic cleansing on quality and diagnostic yield of colonoscopy: the European Panel of Appropriateness of Gastrointestinal Endoscopy European multicenter study. Gastrointest Endosc 2005; 61: 378-384
• 4 Rex D. Colonoscopic withdrawal technique is associated with adenoma miss rates. Gastrointest Endosc 2000; 51: 33-36
• 5 Saunders B, Williams C. Premedication with intravenous antispasmodic speeds colonoscope insertion. Gastrointest Endosc 1996; 43: 209-211
• 6 Mui LM, Ng EK, Chan KC et al. Randomized, double-blinded, placebo-controlled trial of intravenously administered hyoscine N-butyl bromide in patients undergoing colonoscopy with patient-controlled sedation. Gastrointest Endosc 2004; 59: 22-27
• 7 Takahashi Y, Tanaka H, Kinjo M et al. Prospective evaluation of factors predicting difficulty and pain during sedation-free colonoscopy. Dis Colon Rectum 2005; 48: 1295-1300
• 8 Shaheen NJ, Robertson DJ, Crosby MA et al. Hyoscyamine as a pharmacological adjunct in colonoscopy: a randomized, double blinded, placebo-controlled trial. Am Journal Gastroenterol 1999; 94: 2905-2908
• 9 Asao T, Mochiki E, Suzuki H et al. An easy method for the intraluminal administration of peppermint oil before colonoscopy and its effectiveness in reducing colonic spasm. Gastrointest Endosc 2001; 53: 172-177
• 10 Bond JH, Chally CH, Blackwood WD. A controlled trial of premedication with dicyclomine hydrochloride (Bentyl) in colonoscopy. Gastrointest Endosc 1974; 21: 61
• 11 Cutler CS, Rex DK, Hawes RH et al. Does routine intravenous glucagon administration facilitate colonoscopy? A randomized trial. Gastrointest Endosc 1995; 42: 346-350
• 12 Norfleet RG. Premedication for colonoscopy: randomized, double-blind study of glucagon versus placebo. Gastrointest Endosc 1978; 24: 164-165
• 13 Waxman I, Mathews J, Gallagher J et al. Limited benefit of atropine as premedication for colonoscopy. Gastrointest Endosc 1991; 37: 329-331
• 14 Church JM. Warm water irrigation for dealing with spasm during colonoscopy: Simple, inexpensive, and effective. Gastrointest Endosc 2002; 56: 672-674
• 15 Pickhardt PJ, Nugent PA, Mysliwiec PA et al. Location of adenomas missed by optical colonoscopy. Ann Intern Med 2004; 141: 352-359
• 16 Rondonotti E, Zolk O, Amato A et al. The impact of hyoscine-N-butylbromide on adenoma detection during colonoscopy: meta-analysis of randomized, controlled studies. Gastrointest Endosc 2014; 80: 1103-1112
• 17 Lee TJ, Rees CJ, Blanks RG et al. Colonoscopic factors associated with adenoma detection in a national colorectal cancer screening program. Endoscopy 2014; 46: 203-211
• 18 Bowles CJA, Leicester R, Romaya C et al. A prospective study of colonoscopy practice in the UK today: are we adequately prepared for national colorectal cancer screening tomorrow?. Gut 2004; 53: 277-283
• 19 Rex DK, Bond JH, Winawer S et al. Quality in the technical performance of colonoscopy and the continuous quality improvement process for colonoscopy: recommendations of the U.S. Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol 2002; 97: 1296-1308
• 20 Rogalla P, Lembcke A, Ruckert JC et al. Spasmolysis at CT colonography: Butyl scopolamine versus glucagon. Radiology 2005; 236: 184-188
• 21 Taylor SA, Halligan S, Goh V et al. Optimizing colonic distention for multi-detector row CT colonography: Effect of hyoscine butylbromide and rectal balloon catheter. Radiology 2003; 229: 99-108
• 22 Goei R, Nix M, Kessels AH et al. Use of antispasmodic drugs in double contrast barium enema examination: glucagon or buscopan?. Clin Radiol 1995; 50: 553-557
• 23 East JE, Saunders BP, Burling D et al. Surface visualisation at CT colonography simulated colonoscopy: Effect of varying field of view and retrograde view. Am J Gastroenterol 2007; 102: 2529-2535
• 24 Pickhardt PJ, Taylor AJ, Gopal DV. Surface visualization at 3D endoluminal CT colonography: Degree of coverage and implications for polyp detection. Gastroenterology 2006; 130: 1582-1587
• 25 Saunders B, Fukumoto M, Halligan S et al. Why is colonoscopy more difficult in women?. Gastrointest Endosc 1996; 43: 124-126
• 26 Bressler B, Paszat LF, Chen Z et al. Rates of new or missed colorectal cancers after colonoscopy and their risk factors: A population-based analysis. Gastroenterology 2007; 132: 96-102
• 27 Baxter NN, Goldwasser MA, Paszat LF et al. Association of colonoscopy and death from colorectal cancer. Ann Intern Med 2009; 150: 1-8
• 28 Khashab MA, Pickhardt PJ, Kim DH et al. Colorectal anatomy in adults at computed tomography colonography: normal distribution and the effect of age, sex, and body mass index. Endoscopy 2009; 41: 674-678
• 29 Waye JD, Heigh RI, Fleischer DE et al. A retrograde-viewing device improves detection of adenomas in the colon: a prospective efficacy evaluation (with videos). Gastrointest Endosc 2010; 71: 551-556
• 30 Saunders BP, Halligan S, Jobling C et al. Can barium enema indicate when colonoscopy will be difficult?. Clin Radiol 1995; 50: 318-321