Abstract
A thorough and complete colonoscopy is critically important in preventing colorectal cancer. Factors associated with difficult and incomplete colonoscopy include a poor bowel preparation, severe diverticulosis, redundant colon, looping, adhesions, young and female patients, patient discomfort, and the expertise of the endoscopist. For difficult colonoscopy, focusing on bowel preparation techniques, appropriate sedation and adjunct techniques such as water immersion, abdominal pressure techniques, and patient positioning can overcome many of these challenges. Occasionally, these fail and other alternatives to incomplete colonoscopy have to be considered. If patients have low risk of polyps, then noninvasive imaging options such as computed tomography (CT) or magnetic resonance (MR) colonography can be considered. Novel applications such as Colon Capsule™ and Check-Cap are also emerging. In patients in whom a clinically significant lesion is noted on a noninvasive imaging test or if they are at a higher risk of having polyps, balloon-assisted colonoscopy can be performed with either a single- or double-balloon enteroscope or colonoscope. The application of these techniques enables complete colonoscopic examination in the vast majority of patients.
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Edwards BK et al. Annual report to the nation on the status of cancer, 1975–2006, featuring colorectal cancer trends and impact of interventions (risk factors, screening, and treatment) to reduce future rates. Cancer. 2010;116(3):544–73.
Zauber AG, Winawer SJ, O’Brien MJ, et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med. 2012;366:687–96.
Zauber AG, Landsdorp-Vogelaar I, Knudson AB, et al. Evaluating test strategies for colorectal cancer screening: a decision analysis for the U.S. preventive services task force. Ann Int Med. 2008;14:659–69.
Rex DK, Shoenfeld PS, Cohen J. Quality indicators for colonoscopy. Am J Gastroenterol. 2015;110(1):72–90. Updated version of the quality indicators for colonoscopy.
Brenner H, Chang-Claude J, Jansen L, et al. Role of colonoscopy and polyp characteristics in colorectal cancer after colonoscopic polyp detection: a population-based case–control study. Ann Intern Med. 2012;157(4):225–32.
Imperiale TF, Wagner DR, Lin CY, et al. Risk of advanced proximal neoplasms in asymptomatic adults according to the distal colorectal findings. N Engl J Med. 2000;343:169–74.
Rex D, Bond J, 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 in colorectal cancer. Am J Gastroenterol. 2002;97:1296–308.
Rex DK, Petrini JL, Baron TH, et al. Quality indicators for colonoscopy. Am J Gastroenterol. 2006;101(4):873–85.
Bowles CJ, Leicester R, Romaya C, et al. A prospective study of colonoscopy in practice in the UK today: are we adequately prepared for national colorectal screening tomorrow? Gut. 2004;53:277–83.
Lieberman DA, Weiss DG, Bond JH, et al. Use of colonoscopy to screen asymptomatic adults for colorectal cancer. N Engl J Med. 2000;343:162–8.
Marshall JB, Barthel JS. The frequency of total colonoscopy and terminal ileal intubation in the 1990’s. Gastrointest Endosc. 1993;39:518–20.
Ridolfi T, Valente M, Church J. Achieving a complete colonic evaluation in patients with incomplete colonoscopy is worth the effort. Dis Col Rectum. 2013;56(4), e106.
Witte TN, Enns R. The difficult colonoscopy. Can J Gastroenterol. 2007;21(8):487–90.
Saunders BP, Fukumoto M, Hallingan S, et al. Why is colonoscopy more difficult in women? Gastrointest Endosc. 1996;43:124–6.
Anderson JC, Gonzales JD, Messina CR, et al. Factors that predict incomplete colonoscopy: thinner is not always better. Am J Gastroenterol. 2000;95:2784–7.
Waye JD. Completing colonoscopy. Am J Gastroenterol. 2000;95:2681–2.
Dik VK, Moons LM, Huyuk M, et al. Predicting inadequate bowel preparation for colonoscopy in participants receiving split-dose bowel preparation: development and validation of a prediction score. Gastrointest Endosc. 2015;81(3):665–72. This article shows a validated, easy-to-use prediction scale that can be used to identify subjects with an increased risk of inadequate bowel preparation who may benefit from an intensified bowel cleansing regimen.
Hendry PO, Jenkins JT, Diament RH. The impact of poor bowel preparation on colonoscopy: a prospective single center study of 10,571 colonoscopies. Colorectal Dis. 2007;9(8):745–8.
Lichtenstein DR, Jagannath S, Baron TH, et al. Sedation and anesthesia in GI endoscopy. Gastrointest Endosc. 2008;68(5):815–26.
Villa NA, Qureshi W. External pressure during colonoscopy: how and when to use it. In: Adler DG, editor. Core Concepts in Colonoscopy 1st ed. SLACK Incorporated; 2014. (A nice and thorough review of external pressure techniques in difficult colonoscopies).
Bourke MJ, Rex DK. Tips for better colonoscopy from two experts. Am J Gastroenterol. 2012;107(10):1467–72. 20 great tips from 2 well known experts to succeed in colonoscopy.
Leung FW, Mann SK, Leung JW, et al. The water method is effective in difficult colonoscopy—it enhances cecal intubation in unsedated patients with a history of abdominal surgery. J Interv Gastroenterol. 2011;1(4):172–6.
Vemulapalli KC, Rex DK. Water immersion simplifies cecal intubation in patients with redundant colons and previous incomplete colonoscopies. Gastrointest Endosc. 2012;76(4):812–7. Nice retrospective cohort showing that water immersion has good cecal intubation rates in addition to decreases in the need for external straightening devices and position change maneuvers in patients with redundant colons and previously incomplete colonoscopies.
Rex DK, Chen SC, Overhiser AJ. Colonoscopy technique in consecutive patients referred for prior incomplete colonoscopy. Clin Gastroenterol Hepatol. 2007;5(7):879–83.
Williams CB, Guy C, Gilles D, et al. Electronic three-dimensional imaging of intestinal endoscopy. Lancet. 1993;341:724–5.
Saunders BP, Bell GD, Williams CB. First clinical results with a real time electronic imager as an aid to colonoscopy. Gut. 1995;36:915–7.
Shah SG, Brooker JC, Williams CB, et al. Effect of magnetic endoscope imaging on colonoscopy performance: a randomized controlled trial. Lancet. 2000;356:1718–22.
Hoff G, Bretthauder M, Dahler S, et al. Improvement in cecal intubation rate and pain reduction by using 3-dimensional magnetic imaging for unsedated colonoscopy: a randomized trial of patients referred for colonoscopy. Scand J of Gastro. 2007;42:885–9.
Chen Y, Duan YT, Xie Q, et al. Magnetic endoscopic imaging vs standard colonoscopy: meta-analysis of randomized controlled trials. World J Gastroenterol. 2013;19(41):7197–204.
Yamamoto H. Double-balloon endoscopy. Clin Gastroenterol Hepatol. 2005;3(7 suppl 1):S27–9.
Yamamoto H, Yano T, Kita H, Sunada K, Ido K, Sugano K. New system of double-balloon enteroscopy for diagnosis and treatment of small intestinal disorders. Gastroenterology. 2003;125:1556. author reply 1556–1557.
Kaltenbach T, Soetikno R, Friedland S. Use of double balloon enteroscope facilitates cecal intubation after incomplete colonoscopy with a standard colonoscope. Dig Liver Dis. 2006;38(12):921–5.
Pasha SF, Harrison ME, Das A, et al. Utility of double-balloon colonoscopy for completion of colon examination after incomplete colonoscopy with conventional colonoscope. Gastrointest Endosc. 2007;65(6):848–53.
Monkemuller K, Knippig C, Rickes S, et al. Usefulness of the double-balloon enteroscope in colonoscopies performed in patients with previously failed colonoscopy. Scand J Gastroenterol. 2007;42(2):277–8.
Gay G, Delvaux M. Double-balloon colonoscopy after failed conventional colonoscopy: a pilot series with a new instrument. Endoscopy. 2007;39(9):788–92.
Moreels TG, Macken EJ, Roth B, et al. Cecal intubation rate with the double-balloon endoscope after incomplete conventional colonoscopy: a study in 45 patients. J Gastroenterol Hepatol. 2010;25(1):80–3.
Nemoto D, Isohata N, Utano K, et al. Double-balloon colonoscopy carried out by a trainee after incomplete conventional colonoscopy. Dig Endosc. 2014;26(3):392–5.
Kobayashi K, Katsumata T, Saigenji K. Clinical usefulness of single-balloon enteroscopy for the diagnosis and treatment of small-intestinal diseases. New challenges in gastrointestinal endoscopy. Tokyo: Springer; 2008. p. 243–50.
Kawamura T, Yasuda K, Tanaka K, et al. Clinical evaluation of a newly developed single-balloon enteroscope. Gastrointest Endosc. 2008;68:1112–6.
Tsujikawa T, Saitoh Y, Andoh A, et al. Novel single-balloon enteroscopy for diagnosis and treatment of the small intestine: preliminary experiences. Endoscopy. 2008;40:11–5.
May A, Nachbar L, Ell C. Push-and-pull enteroscopy using a single-balloon technique for difficult colonoscopy. Endoscopy. 2006;38(4):395–8.
Teshima CW, Aktas H, Haringsma J, et al. Single-balloon-assisted colonoscopy in patients with previously failed colonoscopy. Gastrointest Endosc. 2010;71(7):1319–23.
Keswani RN. Single-balloon colonoscopy versus repeat standard colonoscopy for previous incomplete colonoscopy: a randomized, controlled trial. Gastrointest Endosc. 2011;73(3):507–12.
Coppola F, Gaia S, Cosimato M, et al. Enteroscope without overtube for cecal intubation after an incomplete colonoscopy. Dig Liver Dis. 2011;43(6):474–7.
Grainek IM, Suissa A, Domanov S. Safety and efficacy of a novel balloon colonoscope: a prospective cohort study. Endoscopy. 2014;46(10):883–7.
Halpem Z, Adler SN, Santo EM. Challenging colonoscopy: safety and effectiveness of a new ON-demand balloon device for Facilitatin complete colonoscopy in challenging patient anatomy. Gastrointest Endosc. 2012;75, No.4S:AB340.
Dzeletovic I, Harrison ME, Pasha SF, et al. Comparison of single versus double balloon assisted colonoscopy for colon examination after previous incomplete standard colonoscopy. Dig Dis Sci. 2012;57(10):2680–6. Nice retrospective review comparing completion rates of SBE and DBE in patients with previous incomplete conventional colonoscopy and showing that both offer high cecal intubation rates.
Yamada A, Watabe H, Tokano N, et al. Utility of single and double balloon endoscopy in patients with difficult colonoscopy: a randomized controlled trial. World J Gastroenterol. 2013;19(29):4732–6. Randomized trial comparing SBE with DBE after previous incomplete colonoscopy and showing similar success rates.
Winawer SJ, Stewart ET, Zauber AG, et al. A comparison of colonoscopy and double-contrast barium enema for surveillance after polypectomy. National polyp study work group. N Engl Med. 2000;342(24):1766–72.
Gawron AJ, Veerappan A, McCarthy ST, et al. Impact of an incomplete colonoscopy referral program on recommendations after incomplete colonoscopy. Dig Dis Sci. 2013;58(7):1849–55.
McFarland EG, Fletcher JG, Pickhardt. ACR colon cancer committee white paper: status of CT colonography 2009. J Am Coll Rad. 2009;6:756–72.
Johnson CD, Chen MH, Toledano AY, et al. Accuracy of CT colnography for detection of large adenomas and cancers. N Engl J Med. 2008;359(26):2853.
Copel L, Sosna J, Kruskal JB, et al. CT colonography in 546 patients with incomplete colonoscopy. Radiology. 2007;244:471–8.
Sali L, Falchini M, Bonanomi AG, et al. CT colonography after incomplete colonoscopy in subjects with positive fecal occult blood test. World J Gastroenterol. 2008;14:1499–4504.
Graser A, Melzer A, Lindner E, et al. Magnetic resonance colonography for the detection of colorectal neoplasia in asymptomatic adults. Gastroenterology. 2013;144(4):743–50.
Ajaj W, Lavenstein TC, Pelster G, et al. MR colonography in patients with incomplete conventional colonoscopy. Radiology. 2005;234(2):452–9.
Rockey D, Barish M, Brill J, et al. Standards for gastroenterologists for performing and interpreting diagnostic computed tomographic colonography. Gastroenterology. 2007;133(3):1005–24.
Alarcon-Fernandez O, Ramos L, Adrian-de-Ganzo Z, et al. Effects of colon capsule endoscopy on medical decision making in patients with incomplete colonoscopies. Clin Gastroenterol Hepatol. 2013;11:534–40.
Spada C, Hassan C, Cesaro P, et al. Prospective Trial of PillCam Colon Capsule (CCE) vs CT-Colonography (CTC) in the Evaluation of patients with incomplete conventional colonoscopy (CC): an interim analysis. Gastrintest Endosc. 2013;77No5S;AB163.
Rondonotti E, Borghi C, Mandelli G, et al. Accuracy of capsule colonoscopy and computed tomographic colonography in individuals with positive results from the fecal occult blood test. Clin Gastroenterol Hepatol. 2014;12(8):1303–10.
Rex DK, Adler SN, Aisenberg J, et al. Accuracy of capsule colonoscopy in detecting colorectal polyps in a screening population. Gastroenterology 2015 (ahead of print). (Detailed prospective study measuring the accuracy of the capsule colonoscopy to detect polyps >6 mm and showing to be adequate for patients who cannot undergo colonoscopy or had incomplete colonoscopies).
Chatrath H, Rex DK. Potential screening benefit of a colorectal imaging capsule that does not require bowel preparation. J Clin Gastroenterol. 2014;48(1):52–4. New emerging non-invasive imaging study and bowel prep free as an alternative for screening or incomplete colonoscopy.
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Nicolas A. Villa declare that he has no conflict of interest.
Rahul Pannala has received research support from FujiFilm, USA unrelated to this article.
Jonathan A. Leighton has served as a consultant to Covidien, Olympus, unrelated to this article.
Shabana Pasha has received honoraria from Covidien and expense reimbursement from Capsovision, unrelated to this article. Dr. Pasha’s institution has received grants from Covidien and Capsovision, unrelated to this article.
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Villa, N.A., Pannala, R., Pasha, S.F. et al. Alternatives to Incomplete Colonoscopy. Curr Gastroenterol Rep 17, 43 (2015). https://doi.org/10.1007/s11894-015-0468-7
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DOI: https://doi.org/10.1007/s11894-015-0468-7