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CT colonography with limited bowel preparation: prospective assessment of patient experience and preference in comparison to optical colonoscopy with cathartic bowel preparation.
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MedLine Citation:
PMID:  19626326     Owner:  NLM     Status:  MEDLINE    
Abstract/OtherAbstract:
The purpose of this study was to prospectively compare participant experience and preference of limited preparation computed tomography colonography (CTC) with full-preparation colonoscopy in a consecutive series of patients at increased risk of colorectal cancer. CTC preparation comprised 180 ml diatrizoate meglumine, 80 ml barium and 30 mg bisacodyl. For the colonoscopy preparation 4 l of polyethylene glycol solution was used. Participants' experience and preference were compared using the Wilcoxon signed rank test and the chi-squared test, respectively. Associations between preference and experience parameters for the 173 participants were determined by logistic regression. Diarrhoea occurred in 94% of participants during CTC preparation. This side effect was perceived as severely or extremely burdensome by 29%. Nonetheless, the total burden was significantly lower for the CTC preparation than for colonoscopy (9% rated the CTC preparation as severely or extremely burdensome compared with 59% for colonoscopy; p < 0.001). Participants experienced significantly more pain, discomfort and total burden with the colonoscopy procedure than with CTC (p < 0.001). After 5 weeks, 69% preferred CTC, 8% were indifferent and 23% preferred colonoscopy (p < 0.001). A burdensome colonoscopy preparation and pain at colonoscopy were associated with CTC preference (p < 0.04). In conclusion, participants' experience and preference were rated in favour of CTC with limited bowel preparation compared with full-preparation colonoscopy.
Authors:
Sebastiaan Jensch; Shandra Bipat; Jan Peringa; Ayso H de Vries; Anneke Heutinck; Evelien Dekker; Lubbertus C Baak; Alexander D Montauban van Swijndregt; Jaap Stoker
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Publication Detail:
Type:  Controlled Clinical Trial; Journal Article; Research Support, Non-U.S. Gov't     Date:  2009-07-23
Journal Detail:
Title:  European radiology     Volume:  20     ISSN:  1432-1084     ISO Abbreviation:  Eur Radiol     Publication Date:  2010 Jan 
Date Detail:
Created Date:  2010-01-11     Completed Date:  2010-03-30     Revised Date:  2013-06-02    
Medline Journal Info:
Nlm Unique ID:  9114774     Medline TA:  Eur Radiol     Country:  Germany    
Other Details:
Languages:  eng     Pagination:  146-56     Citation Subset:  IM    
Affiliation:
Department of Radiology, University of Amsterdam, Meibergdreef 9, 1100 DD Amsterdam, The Netherlands. s.jensch@amc.uva.nl
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MeSH Terms
Descriptor/Qualifier:
Cathartics / administration & dosage,  diagnostic use*
Colonography, Computed Tomographic / methods,  utilization*
Colonoscopy / utilization*
Colorectal Neoplasms / diagnosis*,  epidemiology*
Female
Humans
Male
Middle Aged
Netherlands / epidemiology
Patient Preference / statistics & numerical data*
Prevalence
Questionnaires
Reproducibility of Results
Risk Assessment
Risk Factors
Sensitivity and Specificity
Chemical
Reg. No./Substance:
0/Cathartics
Comments/Corrections

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

Full Text
Journal Information
Journal ID (nlm-ta): Eur Radiol
ISSN: 0938-7994
ISSN: 1432-1084
Publisher: Springer-Verlag, Berlin/Heidelberg
Article Information
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© The Author(s) 2009
Received Day: 11 Month: 2 Year: 2009
Revision Received Day: 5 Month: 5 Year: 2009
Accepted Day: 14 Month: 5 Year: 2009
Electronic publication date: Day: 23 Month: 7 Year: 2009
pmc-release publication date: Day: 23 Month: 7 Year: 2009
Print publication date: Month: 1 Year: 2010
Volume: 20 Issue: 1
First Page: 146 Last Page: 156
ID: 2803752
PubMed Id: 19626326
Publisher Id: 1517
DOI: 10.1007/s00330-009-1517-0

CT colonography with limited bowel preparation: prospective assessment of patient experience and preference in comparison to optical colonoscopy with cathartic bowel preparation
Sebastiaan Jensch125 Address: +31-20-5666495 +31-20-566119 s.jensch@amc.uva.nl
Shandra Bipat1
Jan Peringa2
Ayso H. de Vries1
Anneke Heutinck1
Evelien Dekker3
Lubbertus C. Baak4
Alexander D. Montauban van Swijndregt2
Jaap Stoker1
1Department of Radiology, University of Amsterdam, Meibergdreef 9, 1100 DD Amsterdam, The Netherlands
2Department of Radiology, Onze Lieve Vrouwe Gasthuis, Oosterparkstraat 9, 1090 HM Amsterdam, The Netherlands
3Department of Gastroenterology and Hepatology, University of Amsterdam, Meibergdreef 9, 1100 DD Amsterdam, The Netherlands
4Department of Gastroenterology, Onze Lieve Vrouwe Gasthuis, Oosterparkstraat 9, 1090 HM Amsterdam, The Netherlands
5Department of Radiology, Academic Medical Center, Meibergdreef 9, Postbus 22660, 1100 DD Amsterdam, The Netherlands

Introduction

Computed tomography (CT) colonography is an established and widely used imaging technique in patients with symptoms of colorectal cancer. In addition, it has been identified as an effective instrument for screening average-risk individuals [14]. However, CT colonography requires a cathartic bowel preparation that is burdensome and often considered the most unpleasant part of the examination [57].

Several studies have reported promising results for CT colonography with regard to image quality and accuracy after a less extensive bowel preparation [812]. Data on acceptance of these limited bowel preparation schemes are however sparse. To our knowledge, three feasibility studies and one accuracy study have investigated patient acceptance of a limited preparation with favourable results [1316]. To date, no comprehensive data on patient acceptance and preference in a larger cohort have been published.

Therefore, the purpose of our study was to assess intraindividual experience and preference for CT colonography with a limited preparation in comparison to optical colonoscopy with a cathartic preparation in a population at increased risk of colorectal cancer.


Materials and methods
Study population

Patients with a personal or family history of colorectal polyps or cancer were invited to participate in our study [17]. All patients were scheduled for a routine optical colonoscopy at the endoscopy departments of the Academic Medical Center (AMC) or the Onze Lieve Vrouwe Gasthuis (OLVG). Exclusion criteria were: age under 18 years, previous reaction to iodine-containing contrast agent, inflammatory bowel disease, familial adenomatous polyposis or previous participation in a research project that involved ionising radiation within 12 months preceding the CT colonography examination. The institutional review board of both hospitals approved the study. All patients gave written informed consent.

Questionnaires

Participants filled out six questionnaires at different time points with regard to (Appendix, Table 4):

  1. Pretest appraisal and post-test experience with the preparation for CT colonography and the preparation for optical colonoscopy.
  2. Pretest appraisal and post-test experience with the CT colonography and optical colonoscopy procedures.
  3. Preference for their future examinations.

Participants’ pretest appraisal was based on previous knowledge of the examinations and on information provided by us (in writing and by phone) and was filled out 2 weeks before CT colonography.

Participants’ experience with the preparation and the procedure was rated using a five-point scale (none, mild, moderate, severe, extreme) and filled out on the day of the examination. Furthermore, after completing both tests participants indicated which event was most burdensome to undergo (CT colonography preparation, the CT colonography procedure, optical colonoscopy preparation, or the optical colonoscopy procedure).

Participants’ preference for CT colonography or optical colonoscopy was rated using a seven-point scale (definitely, probably, possibly CT colonography; indifferent; possibly, probably, definitely optical colonoscopy) and based on the presumption that in 20% of CT colonography examinations a significant lesion would be found that would result in optical colonoscopy referral for polyp removal. Because adverse reactions to tests tend to temper in time and the attitude at that later time point will better reflect the attitude towards future screening, the preference was again assessed 5 weeks later at home. The questionnaires were designed by the Department of Social Medicine [6, 18]

Limited bowel preparation for CT colonography

Participants were prepared with a low-fibre diet 2 days before CT colonography. A combination of 80 ml barium sulphate suspension (Tagitol V, E-Z-EM Inc., Westbury, USA) and 180 ml diatrizoate meglumine (200 mg/ml, hospital pharmacy) was prescribed for faecal tagging. Bisacodyl (hospital pharmacy) was given the day before and on the day of the examination to reduce the amount of faeces in the colon (Fig. 1).

CT colonography procedure

CT colonography was performed 1–4 weeks (mean 25 days) before optical colonoscopy. Participants were imaged in the AMC by a dedicated CT colonography technician or research fellow [S.J.]. Through a thin flexible rectal tube the colon was distended automatically with CO2 (ProtocO2l, E-Z-EM, Westbury, NY, USA). Butylscopolamine bromide (20 mg, Buscopan; Boehringer Ingelheim, Ingelheim, Germany) or, if contraindicated, glucagon hydrochloride (1 mg, Glucagon; Novo Nordisk A/S, Bagsvaerd, Denmark) was given intravenously immediately before the imaging. Examinations were performed within a 22-s breath hold on a Philips Mx8000 CT system in the supine and prone positions. The time that patients spent in the CT room and the amount of insufflated CO2 were recorded [A.H.].

Cathartic bowel preparation for optical colonoscopy

Bowel preparation for optical colonoscopy consisted of 4 l of polyethylene glycol electrolyte solution (Klean Prep, Helsinn Birex Pharmaceuticals, Dublin, Ireland). After starting the catharsis participants were not allowed to eat.

Optical colonoscopy procedure

An experienced staff member (gastroenterologist or a gastrointestinal surgeon with average experience of 11 years, range 1–26 years) or a gastroenterology fellow under direct supervision performed the optical colonoscopy in the AMC or the OLVG. Participants received sedatives (5 mg midazolam; Dormicum, Roche, Basel, Switzerland), or analgesics (0.05 mg fentanyl, Janssen Pharmaceuticals, Beerse, Belgium or 0.5 mg Rapifen; hospital pharmacy) on request. The endoscopist increased the dose until sedation or pain control was sufficient. Butylscopolamine bromide was administered intravenously. After the examination participants were admitted to the recovery ward for 2 h.

Statistical analysis

Data from participants who completed both examinations were included for analysis.

Pretest appraisal differences between CT colonography and optical colonoscopy and post-test experience differences between the two examinations were tested for statistical significance using the Wilcoxon signed rank test. Differences in preference were tested for significance using the chi-squared test after dichotomisation (preference for CT colonography versus preference for optical colonoscopy); participants who were indifferent were not included. The chi-squared test was also used to analyse differences in preference between the first and the second measurement (immediately post-test versus 5-weeks post-test); p < 0.05 was considered statistically significant.

Univariate logistic regression analysis was used to investigate associations between participants’ preferences for CT colonography or optical colonoscopy (first and second measurement) and patient-related factors: age ≥ 65 years, sex, completion of academic or higher vocational education, income with respect to 27,000 euros (the mean net Dutch annual income per household) or greater, recent symptoms of colorectal cancer, indication for surveillance (personal or familial history of colorectal carcinoma or polyps), difficult or painful defecation habits in daily life, use of sedatives or analgesics during optical colonoscopy, above average duration of the optical colonoscopy examination, presence of polyps at optical colonoscopy, above average duration of the CT colonography examination, above average amount of CO2 used for colonic distension at CT colonography, and experience parameters on the day of the examination (burdensome bowel preparation for CT colonography or for optical colonoscopy; and pain, embarrassment or discomfort during CT colonography or optical colonoscopy [no, mild and moderate versus severe and extreme burden]). Subsequently, covariates with a p value of 0.10 or lower were included in the multivariate logistic regression model. A stepwise backward selection strategy was used. An odds ratio less than 1 indicates a positive association with a preference for CT colonography; an odds ratio greater than 1 indicates a positive association with a preference for optical colonoscopy.


Results
Study population

Of 468 eligible individuals scheduled to undergo optical colonoscopy during the inclusion period, 173 participants were included for analysis (Fig. 2, Table 1).

Bowel preparation, CT colonography and optical colonoscopy procedures

For CT colonography, all participants used the prescribed preparation. Participants rated the use of bisacodyl as the most burdensome factor of the CT colonography preparation (Fig. 3). Side effects such as abdominal pain, diarrhoea and flatulence were reported by 46% (78/171), 94% (158/168) and 42% (72/170) of participants, respectively, and were perceived as severely or extremely burdensome by 23% (18/78), 29% (46/158) and 18% (13/72) (Table 2). Diarrhoea was more burdensome compared with abdominal pain (p = 0.015) and flatulence (p < 0.001), while abdominal pain was more burdensome than flatulence (p = 0.049).

The average time that participants spent in the CT examination room was 21 min (range 13–48). Buscopan was administered to 84% of participants (143/170) and glucagon to 13% (22/170). The average amount of insufflated CO2 was 3.9 l (range 2–8). Most participants (56%; 89/159) found CO2 insufflation the most burdensome aspect of the CT colonography procedure, followed by the breath hold (25%; 39/159).

For optical colonoscopy, an average of 4 l of polyethylene glycol electrolyte solution (PEG) was used (range 2.5–6). The average duration of the optical colonoscopy examination was 40 min (range 12–90). Sedation and/or analgesics were administered to 82% of participants (139/169). In 73% of participants (127/173) a polyp was detected at optical colonoscopy (17). The movement of the scope was the most burdensome aspect of optical colonoscopy (50%; 81/162) followed by the CO2 insufflation (30%; 48/162).

Experience of bowel preparation and procedure (CT colonography versus optical colonoscopy)

The total burden of the CT colonography preparation was significantly lower than that of the optical colonoscopy preparation (p < 0.001); the CT colonography preparation was considered severe or extreme by 9% (15/171) of participants versus 59% (97/165) for optical colonoscopy (Fig. 4a).

The total burden of the procedure was also significantly lower for CT colonography (Fig. 4b) because participants experienced significantly more pain and discomfort during the optical colonoscopy procedure (all p values < 0.001) (Fig. 5). Embarrassment was rated as none or mild by 97% (166/172) for CT colonography and 93% (154/166) for optical colonoscopy with no statistically significant difference (p = 0.19).

Pre- and post-test appraisal of bowel preparation and procedure

In the pretest (2 weeks earlier at home) and post-test (5 weeks after the examinations at home) appraisals, 94% (152/162) and 87% (144/165) of participants, respectively, indicated that the optical colonoscopy preparation would be or was more burdensome to undergo than the CT colonography preparation. With regard to the examination, 94% (149/159) and 87% (142/164) of participants indicated pre- and post-test that optical colonoscopy was more burdensome than CT colonography. The small shift in the post-test appraisal in favour of optical colonoscopy preparation and procedure was significant (p = 0.003 and p = 0.005, respectively). This is in line with the fact that 18% (30/165) thought CT colonography was more burdensome than anticipated.

Pretest, 57% of participants (90/159) were more reluctant to undergo the optical colonoscopy procedure than the cathartic preparation; post-test, 67% (111/165) actually considered the optical colonoscopy preparation more burdensome than optical colonoscopy itself (p < 0.001). Immediately post-test, the optical colonoscopy preparation was considered the most burdensome event by 57% of participants (84/147); followed by the optical colonoscopy procedure by 35% (52/147), the CTC procedure by 5% (8/147) and last the CTC preparation by 2% (3/147). No significant changes were observed after 5 weeks.

Participants’ preference and determinants of preference

In the recovery room after optical colonoscopy as well as 5 weeks later at home most participants indicated a preference for CT colonography as their next examination (p < 0.001); 76% (124/164) and 69% of participants (115/166), respectively, preferred CT colonography versus 16% (27/164) and 22% of participants (37/166) who preferred optical colonoscopy (Fig. 6). The small shift after 5 weeks towards optical colonoscopy was significant (p = 0.03). Table 3 displays the different reasons the participants gave for their preference.

With regard to associations between preference and patient-related factors, recent symptoms of colorectal cancer was a positive determinant of a preference for optical colonoscopy directly after optical colonoscopy (odds ratio 1.70; p = 0.03), but 5 weeks later at home this association was no longer present (Appendix, Table 5). With regard to participants’ experience parameters, a burdensome bowel preparation for CT colonography (odds ratio 6.06; p = 0.01) and a painful CT colonography procedure (odds ratio 6.34; p = 0.03) were independent determinants of optical colonoscopy preference. Likewise, a burdensome optical colonoscopy preparation (odds ratio 0.40; p = 0.05) and pain at optical colonoscopy (odds ratio 0.10; p = 0.01) were associated with a preference for CT colonography. After 5 weeks, the same determinants of experience were still associated (all p values ≤ 0.04) with the same preference outcome (Appendix, Table 6).


Discussion

In our 5-week follow-up study, most participants (115/166) indicated a preference for CT colonography as their next examination despite the fact that in 20% of CT colonography examinations a referral for optical colonoscopy would still be required for removal of polyps. The cathartic bowel preparation and pain and discomfort experienced during optical colonoscopy were such that optical colonoscopy was considered a more burdensome test than CT colonography with limited preparation.

In accordance with previous studies, we found a better patient tolerance for the limited preparation versus the cathartic preparation [1316]. However, in our study, almost all participants (158/168) experienced diarrhoea during the CT colonography preparation and this side effect was considered very unpleasant. Although Taylor et al. reported increased defecation frequency in their study [15], in the other studies the occurrence of diarrhoea was not reported or only a few patients experienced diarrhoea [13, 14, 16]. For example, Iannaccone et al. reported that diarrhoea occurred in just 6% of participants (13/203) [16]. This is worth mentioning, because the use of iodinated contrast agents and/or added laxatives is generally associated with diarrhoea [19]. In the study by Iannaccone a higher dose of diatrizoate meglumine (200 ml with a concentration of 370 mg/ml) was used than in our study (180 ml with a concentration of 200 mg/ml), but no additional laxative was applied [16]. At present, we no longer add laxatives to the preparation and we have reduced the dose of iodinated contrast. Patients still experience diarrhoea, but the burden of diarrhoea is significantly improved and image quality has not been impaired [unpublished data]. Despite the occurrence of side effects in our study, the preparation for CT colonography was nonetheless significantly better tolerated than the preparation for optical colonoscopy.

With regard to the CT colonography examination, the insufflation of the colon with CO2 was considered the most burdensome part. This is in line with a previous study that showed that insufflation of air and the insertion of the inflexible rectal tube were the most burdensome aspects [13]. Insertion of a rectal tube was not considered burdensome because we used a thin flexible catheter. Although in our study several aspects of the CTC examination were rated severely or extremely burdensome by some participants, the complete procedure was considered severely burdensome by only 2% (4/173) and none of the participants considered the examination extremely burdensome. In comparison, significantly more participants, 23% (38/166), perceived the optical colonoscopy examination as severely or extremely burdensome (p < 0.001).

Five weeks after completing both tests, 69% of participants preferred CT colonography and 22% preferred optical colonoscopy. In an earlier acceptance study comparing cathartic CT colonography with optical colonoscopy, 61% of participants preferred CT colonography [6]. The observed increase of 8% was not as large as we had anticipated, probably because most participants had diarrhoea as a side effect. This is underlined by the fact that a burdensome CT colonography preparation was associated with a preference for optical colonoscopy (p = 0.01). However, the decisive factor for most participants in preferring optical colonoscopy was the therapeutic aspect. As this is an important benefit of optical colonoscopy, it is a detriment of limited CT colonography (in comparison to cathartic CT colonography) because same-day referral for therapeutic optical colonoscopy is not possible.

Some limitations of our study should be discussed. First, the bowel preparation for optical colonoscopy comprised the standard 4 l of polyethylene glycol solution (PEG) (KleanPrep; Norgine Ltd; Harfield, UK) [20, 21]. However, 2 l of PEG (Moviprep; Norgine Ltd; Harfield, UK) or sodium phosphate can prepare the colon as effectively [2224], although the latter cannot be used in patients with heart and kidney failure [25, 26]. Preference outcome might have shifted towards optical colonoscopy if a milder preparation had been used for optical colonoscopy. A second potential limitation is that participants were told that the accuracy of CT colonography and optical colonoscopy with limited preparation were comparable [16]. It is likely that better accuracy for optical colonoscopy might move the preference pattern towards optical colonoscopy [27]. Third, the fact that only participants were included who were willing to undergo CT colonography in addition to their scheduled optical colonoscopy might have influenced our results in favour of CT colonography. Fourth, a surveillance population of individuals at increased risk was investigated and therefore we cannot be certain if our data are applicable to a screening population at average risk. However, as the referral rate for optical colonoscopy in a screening setting would probably be lower than the indicated 20% in our study, we believe that the reported preference for CT colonography could be an underestimation. Finally, no randomised comparison was made between noncathartic and cathartic CT colonography. However, as the PEG preparation for optical colonoscopy is also widely used for cathartic CT colonography, we believe that a limited preparation will be preferred above a PEG preparation for CT colonography.


Conclusion

This prospective study investigated individual experience of and preference for CT colonography with a limited preparation more stringently than previous studies. Our results demonstrated that the occurrence of diarrhoea was frequent and considered a burdensome side effect of the CT colonography preparation. To optimise patient acceptance, further efforts should be made to reduce this side effect. CT colonography, however, was better tolerated by participants than optical colonoscopy with regard to both preparation and procedure. As such, an apparent preference for CT colonography was observed in this population of individuals at increased risk of colorectal cancer. Therefore, we believe that CT colonography with a limited bowel preparation can be of value in increasing participation rates in screening programmes for colorectal cancer.


Acknowledgements

We would like to thank Marjolein Liedenbaum and Christina Lavini for their critical review of this manuscript. This research was supported by a grant from the Commission on Applied Clinical Research of the Dutch Cancer Society (KWF).

Open Access This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.


References
1.. Johnson CD,Chen MH,Toledano AY,et al. Accuracy of CT colonography for detection of large adenomas and cancersN Engl J MedYear: 20083591207121710.1056/NEJMoa080099618799557
2.. Kim DH,Pickhardt PJ,Taylor AJ,et al. CT colonography versus colonoscopy for the detection of advanced neoplasiaN Engl J MedYear: 20073571403141210.1056/NEJMoa07054317914041
3.. Smith RA,Cokkinides V,Brawley OW. Cancer screening in the United States, 2009: a review of current American Cancer Society guidelines and issues in cancer screeningCA Cancer J ClinYear: 200959274110.3322/caac.2000819147867
4.. Nelson N. Virtual colonoscopy accepted as primary colon cancer screening TestJNCIYear: 20081001492149418957683
5.. Ristvedt SL,McFarland EG,Weinstock LB,Thyssen EP. Patient preferences for CT colonography, conventional colonoscopy, and bowel preparationAm J GastroenterolYear: 20039857858510.1111/j.1572-0241.2003.07302.x12650790
6.. Gelder RE,Birnie E,Florie J,et al. CT colonography and colonoscopy: assessment of patient preference in a 5-week follow-up studyRadiologyYear: 200423332833710.1148/radiol.233103120815358854
7.. Beebe TJ,Johnson CD,Stoner SM,Anderson KJ,Limburg PJ. Assessing attitudes toward laxative preparation in colorectal cancer screening and effects on future testing: potential receptivity to computed tomographic colonographyMayo Clin ProcYear: 20078266667110.4065/82.6.66617550745
8.. Callstrom MR,Johnson CD,Fletcher JG,et al. CT colonography without cathartic group: feasibility studyRadiologyYear: 200121969369811376256
9.. Lefere P,Gryspeerdt S,Marrannes J,et al. CT colonography after fecal tagging with a reduced cathartic cleansing and a reduced volume of bariumAJR Am J RoentgenolYear: 20051841836184215908539
10.. Thomeer M,Carbone I,Bosmans H,et al. Stool tagging applied in thin-slice multidetector computed tomography colonographyJ Comput Assist TomogrYear: 20032713213910.1097/00004728-200303000-0000512703001
11.. Bielen D,Thomeer M,Vanbeckevoort D,et al. Dry group for virtual CT colonography with fecal tagging using water-soluble contrast medium initial resultsEur RadiolYear: 20031345345812594546
12.. Jensch S,Vries AH,Pot D,et al. Image quality and patient acceptance of four regimens with different amounts of mild laxatives for CT colonographyAJR Am J RoentgenolYear: 200819115816710.2214/AJR.07.312818562740
13.. Lefere PA,Gryspeerdt SS,Dewyspelaere J,et al. Dietary fecal tagging as a cleansing method before CT colonography: initial results polyp detection and patient acceptanceRadiologyYear: 200222439340310.1148/radiol.224101122212147834
14.. Zalis ME,Perumpillichira JJ,Magee C,Kohlberg G,Hahn PF. Tagging-based, electronically cleansed CT colonography: evaluation of patient comfort and image readabilityRadiologyYear: 200623914915910.1148/radiol.238304130816567485
15.. Taylor SA,Slater A,Burling DN,et al. CT colonography: optimisation, diagnostic performance and patient acceptability of reduced-laxative regimens using barium-based faecal taggingEur RadiolYear: 200818324210.1007/s00330-007-0631-017404739
16.. Iannaccone R,Laghi A,Catalano C,et al. Computed tomographic colonography without cathartic group for the detection of colorectal polypsGastroenterologyYear: 2004127300131110.1053/j.gastro.2004.08.02515236195
17.. Jensch S,Vries AH,Peringa J,et al. CT colonography with limited bowel preparation: performance characteristics in an increased-risk populationRadiologyYear: 200824712213210.1148/radiol.247107043918292475
18.. Florie J,Jensch S,Nievelstein RA,et al. MR colonography with limited bowel preparation compared with optical colonoscopy in patients at increased risk for colorectal cancerRadiologyYear: 200724312213110.1148/radiol.243105208817329686
19.. Pickhardt PJ. CT Colonography without catharsis: the ultimate study or useful additional option?GastroenterologyYear: 200512852152210.1053/j.gastro.2004.12.02015685576
20.. Davis GS,Santa Ana CA,Morawski SG,Fordtran JS. Development of a lavage solution associated with minimal water and electrolyte absorption or secretionGastroenterologyYear: 1980789919957380204
21.. Ell C,Fischbach W,Keller R,et al. A randomized, blinded, prospective trial to compare the safety and efficacy of three bowel-cleansing solutions for colonoscopyEndoscopyYear: 20033530030410.1055/s-2003-3815012664385
22.. Bitoun A,Ponchon T,Barthet M,et al. Results of a prospective randomised multicentre controlled trial comparing a new 2-L ascorbic acid plus polyethylene glycol and electrolyte solution vs. sodium phosphate solution in patients undergoing elective colonoscopy Aliment Pharmacol TherYear: 2006241631164210.1111/j.1365-2036.2006.03167.x17094774
23.. Poon CM,Lee DW,Mak SK,et al. Two liters of polyethylene glycol-electrolyte lavage solution versus sodium phosphate as bowel cleansing regimen for colonoscopy: a prospective randomized controlled trialEndoscopyYear: 20023456056310.1055/s-2002-3320712170410
24.. Ginnerup Pedersen B,Møller Christiansen TE,Viborg Mortensen F,Christensen H,Laurberg S. Bowel cleansing methods prior to CT colonographyActa RadiolYear: 20024330631110.1034/j.1600-0455.2002.430312.x12100328
25.. Curran MP,Plosker GL. Oral sodium phosphate solution: a review of its use as a colorectal cleanserDrugsYear: 2004641697171410.2165/00003495-200464150-0000915257632
26.. Tan HL,Liew QY,Loo S,Hawkins R. Severe hyperphosphataemia and associated electrolyte and metabolic derangement following the administration of sodium phosphate for bowel preparationAnaesthesiaYear: 20025747848310.1046/j.0003-2409.2001.02519.x11966559
27.. Wagner C,Halligan S,Atkin WS,et al. Choosing between CT colonography and colonoscopy in the diagnostic context: a qualitative study of influences on patient preferencesHealth ExpectYear: 200912182610.1111/j.1369-7625.2008.00520.x19250149
Appendix


Figures

[Figure ID: Fig1]
Fig. 1 

Limited bowel preparation for CT colonography



[Figure ID: Fig2]
Fig. 2 

Flowchart shows participation of the study population



[Figure ID: Fig3]
Fig. 3 

Participants’ ratings of the degree of burden for the four different parts of the CT colonography bowel preparation. Tagitol was considered the least burdensome aspect compared with all the others (p < 0.001). Bisacodyl was considered the most burdensome aspect (bisacodyl versus low-fibre diet, p < 0.001; bisacodyl versus diatrizoate meglumine, p = 0.07; bisacodyl versus tagitol V, p < 0.001). Values represent percentages



[Figure ID: Fig4]
Fig. 4 

Total burden of the bowel preparation (a) and procedure (b). Bowel preparation for optical colonoscopy was considered more burdensome than the bowel preparation for CT colonography (p < 0.001). Optical colonoscopy procedure was more burdensome than the CTC procedure (p < 0.001)



[Figure ID: Fig5]
Fig. 5 

Pain and discomfort associated with the examination. Participants experienced more pain and discomfort during the optical colonoscopy examination compared with the CT colonography examination (p < 0.001)



[Figure ID: Fig6]
Fig. 6 

Participant preference directly post-test and 5-weeks post-test. Participants preferred CT colonography above optical colonoscopy as their next examination of choice; as indicated by participants directly after optical colonoscopy (76%) and 5 weeks later at home (69%) (p < 0.001). Values represent percentages



Tables
[TableWrap ID: Tab1] Table 1 

Participant characteristics


Gender Men 107
Women 66
Age (years) 56
Hospital AMC/OLVG 122/51
Cultural background Western 154
Nonwestern 14
Not provided 5
Education Higher vocational/academic 59
Other 101
Not provided 13
Income Above 27,000 € 56
Below 27,000 € 77
Not provided 40
Normal bowel habits At least one defecation per day 141
At least one defecation per 3 days 25
Less than one defecation per 3 days 3
Not provided 4
Symptoms of CRC Abdominal pain 33
Altered bowel habits 18
Haematochezia 10
Personal history of Colorectal polyps 82
Colorectal cancer 14
Colorectal polyps and cancer 22
Previous optical colonoscopy Yes 117
No 54
Not provided 3

AMC Academic Medical Center, OLVG Onze Lieve Vrouwe Gasthuis


[TableWrap ID: Tab2] Table 2 

Side effects of the bowel preparation for CT colonography


  Symptoms reported None Mild Moderate Severe Extreme
Abdominal pain Yes n = 78 4/78 (5) 31/78 (40) 25/78 (32) 9/78 (12) 9/78 (12)
No n = 93
Diarrhoea Yes n = 158 15/158 (10) 52/158 (33) 45/158 (29) 26/158 (17) 20/158 (13)
No n = 0
Flatulence Yes n = 72 14/72 (19) 34/72 (47) 11/72 (15) 7/72 (10) 6/72 (8)
No n = 98

Participants indicated whether they experienced side effects of the bowel preparation for CT colonography. If side effects were present, the burden of the side effect was rated using a five-point scale. Values in parenthesis are percentages


[TableWrap ID: Tab3] Table 3 

Reasons why participants preferred either CT colonography or optical colonoscopy (5-weeks post-test)


Preference for CT colonography (n = 115) Preference for optical colonoscopy (n = 37)
PEG was burdensome 43 (37%) OC is therapeutic 20 (54%)
Complete CTC examination (preparation and procedure) less burdensome 17 (15%) CTC preparation was burdensome 6 (16%)
CTC preparation less burdensome 16 (15%) In the case of a positive CTC then follow-up with OC (2 examinations) 4 (11%)
No sedation for CTC 7 (6%) OC is more accurate 3 (8%)
No pain during CTC 6 (5%) Discomfort during CTC examination 1 (3%)
Less burden during CTC 5 (4%) Sedatives for OC 1 (3%)
Pain during OC 4 (3%) Ability to watch screen during OC 1 (3%)
If not necessary no (therapeutic) OC 3 (3%) No particular reason 1 (3%)
Simpler preparation for OC 2 (2%)
Evaluation of extracolonic condition 2 (2%)
No particular reason 10 (9%)

Participants wrote down on the questionnaire why they preferred CT colonography or optical colonoscopy as their future examination. No list of possible reasons was provided

PEG polyethylene glycol (4 l), CTC computed tomography colonography, OC optical colonoscopy


[TableWrap ID: Tab4] Table 4 

Content of questionnaires and number of responses per question


Parameter Questionnaire 1 Questionnaire 2 Questionnaire 3 Questionnaire 4 Questionnaire 5 Questionnaire 6
Where and when completed? By mail 2 weeks before CTC In waiting room before CTC In waiting room after CTC In waiting room before OC In recovery room after OC At home by mail 5 weeks after OC
Number of returned questionnaires 173/173 (100) 173/173 (100) 173/173 (100) 169/173 (98) 167/173 (97) 166/173 (96)
Baseline characteristics (±) + +
Most reluctant factor of the examination 173/173 (100) 161/173 (93)
How burdensome was low-fibre diet? 173/173 (100)
How burdensome was bisacodyl? 169/173 (98)
How burdensome were contrast agents 173/173 (100)
Side effects of the CTC bowel preparation 168/173 (97)
Total burden of entire bowel preparation 171/173 (99) 165/171 (95)
How painful was procedure? 171/173 (99) 167/173 (97)
How embarrassing was procedure? 172/173 (99) 166/173 (96)
How uncomfortable was procedure? 173/173 (100) 164/173 (95)
Total burden of entire procedure 173/173 (100) 167/173 (97)
Most burdensome aspect of procedure 159/173 (92) 162/173 (94)
Most burdensome preparation; CTC or OC 162/173 (94)a 160/173 (92) 165/173 (95)
Most burdensome procedure; CTC or OC 159/173 (92)a 159/173 (92) 164/173 (95)
Preference for examination; CTC or OC 164/173 (95) 166/173 (96)

Burdensome refers to the extent of burden (e.g. the degree of unpleasantness) that was associated with a particular aspect and rated on a five-point scale: 1, not burdensome; 2, mildly burdensome; 3, moderately burdensome; 4, severely burdensome; 5, extremely burdensome

aParticipants were asked to rate both the individual aspects of the preparation and procedure as well as the entire preparation and procedure as a whole (i.e.=total burden)


[TableWrap ID: Tab5] Table 5 

Patient-related determinants of participants’ preference for CTC or OC


  Direct post-test 5-weeks post-test
Univariate analysis Multivariate analysis Univariate analysis Multivariate analysis
Age ≥ 65 years 0.13 (0.02–0.97) p = 0.05 0.14 (0.02–1.18) p = 0.07 1.10 (0.45–2.73) p = 0.83 NA
Female 0.93 (0.39–2.20) p = 0.87 NA 1.28 (0.60–2.71) p = 0.53 NA
High level of education 2.34 (1.00–5.49) p = 0.05 1.92 (0.75–4.90) p = 0.17 1.48 (0.69–3.16) p = 0.32 NA
Income ≥ 27,000 euros 1.02 (0.37–2.80) p = 0.97 NA 0.93 (0.40–2.18) p = 0.87 NA
Symptoms of colorectal cancer at present 1.70 (0.70–4.10) p = 0.03 1.02 (1.00–1.04) p = 0.03 1.02 (1.00–1.04) p = 0.08 NA
Personal history of colorectal polyps 0.51 (0.22–1.21) p = 0.13 NA 0.67 (0.31–1.43) p = 0.30 NA
Personal history of colorectal cancer 0.89 (0.30–2.59) p = 0.82 NA 0.89 (0.34–2.28) p = 0.80 NA
Family history of colorectal polyps or cancer 2.52 (0.80–7.92) p = 0.11 NA 0.91 (0.40–2.06) p = 0.82 NA
Difficult or painful defecation in daily life 0.27 (0.61–1.23) p = 0.09 0.30 (0.07–1.41) p = 0.13 0.42 (0.13–1.29) p = 0.13 NA
Use of sedatives or analgesics at optical colonoscopy 1.20 (0.37–3.82) p = 0.76 NA 2.83 (0.67–8.52) p = 0.18 NA
Duration of optical colonoscopy >40 min 1.02 (0.99–1.05) p = 0.26 NA 2.42 (1.12–5.25) p = 0.03 NA
Depiction of polyps at optical colonoscopy 1.27 (0.47–3.42) p = 0.64 NA 0.91 (0.40–2.06) p = 0.82 NA
Duration of CT colonography >20 min 1.56 (0.66–3.66) p = 0.31 NA 1.58 (0.74–3.35) p = 0.24 NA
Insufflation of CO2 at CT colonography (>4 l) 1.08 (0.46–2.57) p = 0.86 NA 0.63 (0.28–1.42) p = 0.26 NA

An odds ratio less than 1 indicates a positive association with a preference for CT colonography; an odds ratio greater than 1 indicates a positive association with a preference for optical colonoscopy

NA not applicable


[TableWrap ID: Tab6] Table 6 

Experience determinants of participants’ preference for CTC or OC


  Direct post-test 5-weeks post-test
Univariate analysis Multivariate analysis Univariate analysis Multivariate analysis
Burdensome bowel preparation for CT colonography 3.59 (1.16–11.14) p = 0.03 6.06 (1.61–22.87) p = 0.01 3.533 (1.15–10.87) p = 0.03 5.69 (1.51–21.51) p = 0.01
Painful CT colonography examination 5.13 (1.20–22.01) p = 0.03 6.34 (1.23–32.60) p = 0.03 12.95 (2.56–65.60) p = 0.01 9.80 (1.74–55.08) p = 0.01
Embarrassment experienced during CT colonography 0.00 (0.00–) p = 1.00 NA 0.00 (0.00–) p = 1.00 NA
Discomfort experienced during CT colonography 0.94 (0.92–8.17) p = 0.94 NA 3.29 (0.64–17.08) p = 0.16 NA
Burdensome bowel preparation for optical colonoscopy 0.42 (0.18–0.98) p = 0.05 0.40 (0.16–1.02) p = 0.05 0.32 (0.15–0.71) p = 0.01 0.31 (0.13–0.77) p = 0.01
Painful optical colonoscopy examination 0.17 (0.04–0.74) p = 0.02 0.10 (0.02–0.58) p = 0.01 0.32 (0.12–0.89) p = 0.03 0.28 (0.08–0.94) p = 0.04
Embarrassment experienced during optical colonoscopy 0.00 (0.00–) p = 1.00 NA 0.00 (0.00–) p = 0.99 NA
Discomfort experienced during CT optical colonoscopy 0.18 (0.24–1.43) p = 0.11 NA 0.15 (0.02–1.52) p = 0.07 0.32 (0.03–3.06) p = 0.32

An odds ratio less than 1 indicates a positive association with a preference for CT colonography; an odds ratio greater than 1 indicates a positive association with a preference for optical colonoscopy

NA not applicable



Article Categories:
  • Gastrointestinal

Keywords: Keywords CT colonography, Gastrointestinal, Colon, Bowel preparation, Patient acceptance, Side effects, Contrast, Faecal tagging.

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