Reply to Letter to the Editor

In the letter entitled “Use of a prokinetic agent after double-balloon endoscopy reduces abdominal distension and discomfort, and shortens recovery time: potential adjunct or alternative to CO₂” Dr Mishkin reports on his experience with the administration of a prokinetic drug in patients undergoing balloon-assisted enteroscopy [1]. Because of the potential side-effects in such a long-lasting endoscopic intervention due to the broad use of gas insufflation, all included patients received metoclopramide after the procedure. According to the presented data, less abdominal distention and discomfort were experienced by these patients; furthermore, recovery time after enteroscopy seemed to be shortened. Although the use of a prokinetic drug appears to lead to some clinical improvement in the patient group undergoing balloon-assisted enteroscopy, there are several potential drawbacks in this report.

Dr Mishkin’s results must be considered as personal experiences because the study was a single-center study (all examinations were performed by the same endoscopists), which was performed in a nonrandomized fashion with only a small number of patients.

In his letter, Dr Mishkin refers to the data of our German–Norwegian study group, comparing carbon dioxide with air as insufflation gas [2]. In this trial, 112 consecutive patients who were scheduled for double-balloon enteroscopy (DBE) were randomly assigned to either CO₂ or air insufflation during DBE. The mean small-bowel intubation depth was significantly extended by 30 % in the CO₂ group compared with the air group. Furthermore, patient pain and discomfort were significantly reduced in the CO₂ group. According to our results, using CO₂ insufflation in balloon-assisted enteroscopy may eventually lead to a higher diagnostic and therapeutic yield of DBE, with reduced patient discomfort. In contrast to Dr Mishkin’s opinion, we do not expect an adjuvant effect of prokinetic agents with respect to the symptoms when used with carbon dioxide insufflation because the patients included in our trial were symptomatic to only a very low degree. In our opinion, however, the main reason for using carbon dioxide in balloon-assisted enteroscopy is the significant improvement in intubation depth.

Competing interests: None

Reference

• 1 Mishkin D S. Use of a prokinetic agent after double-balloon endoscopy reduces abdominal distension and discomfort, and shortens recovery time: potential adjunct or alternative to CO₂.  Endoscopy. 2009;  41 1064-1067
• 2 Domagk D, Bretthauer M, Lenz P, Aabakken L, Ullerich H, Maaser C, Domschke W, Kucharzik T. Carbon dioxide insufflation improves intubation depth in double-balloon enteroscopy: a randomized, controlled, double-blind trial.  Endoscopy. 2007;  39 1064-1067