PATIENTS’ PERCEPTION OF COLONOSCOPY

T Fasih, MA Tabaqchali, JS Varma

Keywords: Colonoscopy, patient perception, sedation, bowel preparation

Short title: Experience of colonoscopy

SUMMARY

Background and study aims

There is very little information available in literature about the experience of patients undergoing colonoscopy.

The aim of this study was to audit patients’ perception of colonoscopy after appropriate counselling, focusing on their experience of bowel preparation, sedation provided and discomfort during the procedure.

Research design and methods

In a 12-month period all colonoscopies performed (n=202) under the care of one Consultant were recruited to the study. This study appraises the 174 patients in whom complete colonoscopy was achieved.

All patients received Picolax to prepare their bowel and completed a score-based questionnaire relating to the problems they experienced with this.

Conscious sedation was achieved with intravenous pethidine and midazolam and subsequently completed a score-based questionnaire to express their satisfaction with sedation, severity of discomfort and willingness to have a repeat colonoscopy.

Main findings

The median score for tolerance to the preparation, abdominal discomfort, sleep loss and nausea related to bowel preparation was 0.

The median scores for severity of discomfort, sedation satisfaction and overall satisfaction were 1,5,and 5 respectively.

The median acceptance score for the procedure was 1. Fourteen patients (8%) were unwilling to have the procedure repeated.

There was a difference in sedation satisfaction between procedures performed by consultant or trainee (p=0.06).

Conclusions

Patient undergoing full colonoscopy with appropriate preparation and counselling tolerate the bowel preparation and procedure well and express high satisfaction and acceptance rates.

INTRODUCTION

Colonoscopy remains the gold standard for the detection of colorectal pathology. 1 It is widely used in the diagnosis, prevention, follow-up and treatment of colorectal disease 2 . It is, however, invasive and patients undergoing the procedure are understandably apprehensive and anxious about their experience. Although there is much data about technique and training of colonoscopy, very little information is available about the patients’ perspective. In this study we have prospectively audited, based on scoring criteria, patients’ perception of their bowel preparation, sedation and experience of the procedure.

PATIENTS AND METHODS

In a 12 month period, 202 consecutive patients who underwent intended colonoscopy under the care of one consultant in a surgical coloproctology unit were recruited to this study. Of these, 174 patients underwent complete colonoscopy and are the subject of this study. There were 97 females and 77 males. The mean age was 57 years (range 14-90 years). Complete colonoscopy was not possible in the remaining 28 patients mainly due to obstructive lesions and poor bowel preparation. These patients were excluded from the present study. Consultants performed 50 colonoscopies; Specialist Registrar (SpR) performed 83 and other junior grades of endoscopists (Research fellows) labelled as ‘Others’ performed a total of 41 procedures.

Intubation of the caecum was confirmed by a combination of some or all of the following: identification of trivalvular folds, ileocaecal valve, appendicular aperture, transillumination test or entry of terminal ileum.

Counselling

Prior to the procedure all patients received a leaflet providing detailed information about the bowel preparation and its possible side effects including abdominal discomfort, nausea, vomiting and sleep disturbance. A brief description of the procedure and the likelihood of complications and success were also given. Conscious sedation was explained in that the patient would be aware of the procedure and would not be completely knocked out.

Bowel preparation

All patients received full bowel preparation in the form of Picolax in a dose of one sachet in the morning and one in the evening. Patients were instructed to drink copious amounts of clear fluids only the day before the test and to fast after midnight.

Patients completed a questionnaire stating acceptance and tolerance of the preparation using a scoring system the details of which are summarised in Table I.

Table I. Scoring of Patient’s perception of Full Bowel Preparation

Sedation

All 174 patients received sedation immediately prior to the procedure with intravenous pethidine and midazolam.

Post procedure questionnaire

Patients were given a questionnaire to fill, more than 24 hours after the procedure to assess the effect of sedation, severity of pain experienced during procedure, willingness for a repeat procedure and to evaluate their overall satisfaction. This is summarised in Table II.

Table II. Post-procedure questionnaire

RESULTS

Patients’ tolerance of bowel preparation

All 174 patients receiving full preparation answered the questionnaire regarding the preparation. Details are shown in Fig.1.

Figure 1 Experience with bowel preparation

Patients tolerated full bowel preparation easily with a median score of 0 in both groups. The median score for tolerance to the preparation, abdominal discomfort, sleep loss and nausea related to bowel preparation was 0.

Details of acceptance of repeat bowel preparation are shown in Figure 2.

Figure 2. Acceptance of repeat bowel preparation

Sedation

One hundred and sixty three patients (94%) returned the completed questionnaire. The mean dose of Hypnoval was 5 mgms (range 2-10 mgms) and that of Pethidine was 50 mgms (25-100 mgms). There appeared to be a difference in sedation satisfaction between procedures performed by Consultant and the trainee (p=0.06).

Severity of pain, sedation satisfaction & overall satisfaction

The median score for the severity of pain was 1. There was no significant difference between the incidences of discomfort between the different grades of endoscopists (p=0.56)

The median score with the sedation satisfaction was 5. Only 9% of the patients were unsatisfied with the sedation given.

The overall median satisfaction was scored as 5 but 7% of the patients were dissatisfied with the overall outcome.

These results are summarised in Tables III and IV.

Table III. Perception of pain

Table IV. Satisfaction Score

Acceptance of repeat colonoscopy

The median acceptance score for the procedure was 1 (1-5).

6% would not want a repeat of the test and 20% would only accept a repeat examination if necessary.

The causes for deferring another test were pain in 7 patients, unsatisfactory sedation in 2 patients and reluctance to repeat bowel preparation in 5 patients.

Details of acceptance of a repeat procedure are shown in figure 3.

Figure 3. Acceptance of repeat procedure

Much has been written to improve the outcome of colonoscopy by optimal bowel preparation, improving technique and conscious sedation. There is however scant literature on the expectations or experience of patients undergoing this procedure.

Although the outcomes have been enhanced by vast improvements in instrumentation 3 and sedation, most patients undergoing colonoscopy are apprehensive 4 and experience some pain and discomfort during the procedure. It is therefore important to reduce the anxiety of patients by counselling them about the procedure and the bowel preparation beforehand. Patients do like to receive specifically detailed information on the way the examination is performed and their teaching and information on medical procedures and care organisation is recognised as an important task. 5

Accurate colonoscopy requires adequate bowel preparation. The ideal method for colonoscopy preparation should be effective, safe, easily administered and well tolerated by the patient 6 . We had no major problem with tolerance and side effects of bowel preparation. In the literature, about 5-15% of patients experience difficulty with the preparation volume, especially with polyethylene glycol, resulting in inadequate preparation 7,8 . The acceptance of ingesting one solution versus another is difficult to compare, since acceptance is a subjective variable, perhaps reliably reported only by patients who have taken both solutions 6 .

Efforts to further improve patient acceptability of colonoscopy with conscious sedation are likely to require improved patient counselling and education 9 . In our study sedation was less adequate in the hands of juniors. Therefore trainees need training and education not to substitute strong sedation for technique. It is important to educate patients on the merits of conscious sedation, during which they are aware of the procedure and are able to co-operate with the endoscopist. The concept of completely putting the patient ‘out’ is a misconception and should be clearly explained.

We observed anxiety to be the clinical variable independently related to patient pain and tolerance during colonoscopy. Other authors have shared this view 10 . In our series, patients who were anxious about their test reported the most pain during colonoscopy, similar to reports from Europe 11,12

However, 74% patients would accept a repeat procedure in the same circumstances. This is comparable to a study where 78% patients accepted the procedure in the same enviroment ; the main factors associated with acceptance being good tolerance, old age, conscious sedation, male gender and ambulatory care. 13

Patient undergoing full colonoscopy with appropriate preparation and counselling tolerate the bowel preparation and procedure well and express high satisfaction and acceptance rates.