Hyoscine butylbromide administered at the cecum increases polyp detection: a randomized double-blind placebo-controlled trial

Background and study aims: Removal of colonic polyps prevents progression of colonic neoplasia. Miss rates of polyps range from 5 % to 32 %. The effect of colonic contractility on polyp detection has not been studied adequately. Hyoscine butylbromide results in colonic spasmolysis and may improve polyp detection.

Patients and methods: Patients undergoing colonoscopy for standard indications were included and randomized to receive either 20 mg hyoscine butylbromide or placebo at cecal intubation. Operators were blind to the intervention. Data on indication, preparation, sedation, colonoscope type, times of insertion/withdrawal, polyps, and failure were recorded. The primary end point was the number of polyps detected per patient. Secondary endpoints were adenoma detection rate and polyp detection rate.

Results: A total of 303 patients received hyoscine butylbromide and 298 received placebo. More polyps per patient were identified in the hyoscine group than in the placebo group (0.91 vs. 0.70; P = 0.044). Adenoma detection rate and polyp detection rate were higher in the hyoscine arm but not significantly different (27.1 % vs. 21.8 % [P = 0.13] and 43.6 % vs. 36.6 % [P = 0.08], respectively). After adjusting for confounding variables, the odds of detecting any polyp were 1.56 higher in the hyoscine than the placebo group (95 % confidence interval [CI] 1.09 – 2.21, P = 0.014). The adjusted odds of detecting any adenoma were 1.62 higher in the hyoscine group compared with the placebo group (95 %CI 1.09 – 2.42, P = 0.017). There were no differences in baseline characteristics between the groups. No adverse colonoscopy-related events were recorded. One patient experienced transient tachycardia without sequelae.

Conclusions: Hyoscine butylbromide administered at the cecum aids polyp detection. Further studies are required to determine the contribution of colonic spasm to polyp miss rates.

• References

• 1 Ferlay J, Shin HR, Bray F et al. Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008. Int J Cancer 2010; 127: 2893-2917
• 2 Jemal A, Center MM, De Santis C, Ward EM. Global patterns of cancer incidence and mortality rates and trends. Cancer Epidemiol Biomarkers Prev 2010; 19: 1893-1907
• 3 Jemal A, Siegel R, Ward E et al. Cancer statistics, 2006. CA: A Cancer Journal for Clinicians 2006; 56: 106-130
• 4 Winawer SJ, Zauber AG, Ho MN. The National Polyp Study Workgroup et al. Prevention of colorectal cancer by colonoscopic polypectomy. New Engl J Med 1993; 329: 1977
• 5 Winawer S, Fletcher R, Rex D et al. Colorectal cancer screening and surveillance: clinical guidelines and rationale-Update based on new evidence. Gastroenterology 2003; 124: 544-560
• 6 Winawer SJ, Fletcher RH, Miller L et al. Colorectal cancer screening: clinical guidelines and rationale. Gastroenterology 1997; 112: 594-642
• 7 ACN Colorectal Cancer (CRC) Working Party. Guidelines for the prevention, early detection and management of colorectal cancer. Sydney: The Cancer Council Australia and Australian Cancer Network; 2005
• 8 Levin B, Lieberman DA, McFarland B et al. Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. Gastroenterology 2008; 134: 1570-1595
• 9 Excellence NIfHaC. Improving outcomes in colorectal cancers. London: National Institute for Health and Clinical Excellence; 2004
• 10 van Rijn JC, Reitsma JB, Stoker J et al. Polyp miss rate determined by tandem colonoscopy: a systematic review. Am J Gastroenterol 2006; 101: 343-350
• 11 Hixson LJ, Fennerty MB, Sampliner RE, Garewal HS. Prospective blinded trial of the colonoscopic miss-rate of large colorectal polyps. Gastrointest Endosc 1991; 37: 125-127
• 12 Rex DK, Cutler CS, Lemmel GT et al. Colonoscopic miss rates of adenomas determined by back-to-back colonoscopies. Gastroenterology 1997; 112: 24-28
• 13 Matsushita M, Hajiro K, Okazaki K et al. Efficacy of total colonoscopy with a transparent cap in comparison with colonoscopy without the cap. Endoscopy 1998; 30: 444-447
• 14 Rex DK, Chadalawada V, Helper DJ. Wide angle colonoscopy with a prototype instrument: impact on miss rates and efficiency as determined by back-to-back colonoscopies. Am J Gastroenterol 2003; 98: 2000-2005
• 15 Harrison M, Singh N, Rex DK. Impact of proximal colon retroflexion on adenoma miss rates. Am J Gastroenterol 2004; 99: 519-522
• 16 Hixson LJ, Fennerty MB, Sampliner RE et al. Prospective study of the frequency and size distribution of polyps missed by colonoscopy. J Natl Cancer Inst 1990; 82: 1769-1772
• 17 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
• 18 Harewood GC, Sharma VK, de Garmo P. Impact of colonoscopy preparation quality on detection of suspected colonic neoplasia. Gastrointest Endosc 2003; 58: 76-79
• 19 Parra-Blanco A, Nicolas-Perez D, Gimeno-Garcia A et al. The timing of bowel preparation before colonoscopy determines the quality of cleansing, and is a significant factor contributing to the detection of flat lesions: a randomized study. World J Gastroenterol 2006; 12: 6161-6166
• 20 Rex DK. Colonoscopic withdrawal technique is associated with adenoma miss rates. Gastrointest Endosc 2000; 51: 33-36
• 21 Barclay RL, Vicari JJ, Doughty AS et al. Colonoscopic Withdrawal Times and Adenoma Detection during Screening Colonoscopy. New Engl J Med 2006; 355: 2533-2541
• 22 Simmons DT, Harewood GC, Baron TH et al. Impact of endoscopist withdrawal speed on polyp yield: implications for optimal colonoscopy withdrawal time. Aliment Pharmacol Ther 2006; 24: 965-971
• 23 Sanchez W, Harewood GC, Petersen BT. Evaluation of polyp detection in relation to procedure time of screening or surveillance colonoscopy. Am J Gastroenterol 2004; 99: 1941-1945
• 24 Corte CJ, Kim AH, Kaffes AJ. M1417: Objective measures of colonoscopic difficulty: correlation with polyp detection and operator perception. Gastrointest Endosc 2010; 71: AB215-AB216
• 25 Pickhardt PJ, Nugent PA, Mysliwiec PA et al. Location of adenomas missed by optical colonoscopy. Ann Intern Med 2004; 141: 352-359
• 26 Froehlich F. Colonoscopy: antispasmodics not only for premedication, but also during endoscope withdrawal?. Gastrointest Endosc 2000; 51: 379
• 27 Lee JM, Cheon JH, Park JJ et al. Effects of Hyosine N-butyl bromide on the detection of polyps during colonoscopy. Hepatogastroenterology 2010; 57: 90-94
• 28 Brown S, Baraza W, Hurlstone P. Chromoscopy versus conventional endoscopy for the detection of polyps in the colon and rectum. Cochrane Database Syst Rev 2007; (04) CD006439
• 29 Leufkens AM, DeMarco DC, Rastogi A et al. Effect of a retrograde-viewing device on adenoma detection rate during colonoscopy: the TERRACE study. Gastrointest Endosc 2011; 73: 480-489
• 30 Leung F, Harker J, Leung J et al. Removal of infused water predominantly during insertion (water exchange) is consistently associated with an increase in adenoma detection rate – review of data in randomized controlled trials (RCTs) of water-related methods. J Interv Gastroenterol 2011; 1: 121-126
• 31 Leung FW. Water exchange may be superior to water immersion for colonoscopy. Clin Gastroenterol Hepatol 2011; 9: 1012-1014
• 32 Tytgat GN. Hyoscine butylbromide – a review on its parenteral use in acute abdominal spasm and as an aid in abdominal diagnostic and therapeutic procedures. Curr Med Res Opin 2008; 24: 3159-3173
• 33 Grainger SL, Smith SE. Dose-response relationships of intravenous hyoscine butylbromide and atropine sulphate on heart rate in healthy volunteers. Br J Clin Pharmacol 1983; 16: 623-626
• 34 Gonzalez-Mendiola R, Sanchez Fernandez C, Prieto Montano P et al. Acute urticaria induced by hyoscine butylbromide. Allergy 2004; 59: 787-788
• 35 Treweeke P, Barrett NK. Allergic reaction to Buscopan. Br J Radiol 1987; 60: 417-418
• 36 Altintas E, Ucbilek E, Sezgin O, Sayici Y. Alverine citrate plus simethicone reduces cecal intubation time in colonoscopy – a randomized study. Turk J Gastroenterol 2008; 19: 174-179
• 37 Chaptini LA, Janec EM, Seltzer G et al. Sublingual hyoscyamine spray as premedication for colonoscopy: a randomized double-blinded placebo-controlled trial. Am J Surg 2008; 196: 51-55
• 38 Dumot JA, Verzola E, Nicol S et al. Sublingual hyoscyamine for patient comfort during screening sigmoidoscopy: a randomized, double-blind, placebo-controlled clinical trial. Gastrointest Endosc 1998; 48: 283-286
• 39 Marshall JB, Patel M, Mahajan RJ et al. Benefit of intravenous antispasmodic (hyoscyamine sulfate) as premedication for colonoscopy. Gastrointest Endosc 1999; 49: 720-726
• 40 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
• 41 Norfleet RG. Premedication for colonoscopy: Randomized, double-blind study of glucagon versus placebo. Gastrointest Endosc 1978; 24: 164-165
• 42 Norfleet RG, Saviage K. Atropine premedication for colonoscopy: a randomized double-blind study. Gastrointest Endosc 1983; 29: 157
• 43 Waxman I, Mathews J, Gallagher J et al. Limited benefit of atropine as premedication for colonoscopy. Gastrointest Endosc 1991; 37: 329-331
• 44 Yoong KY, Perkin D, Portal J et al. Intravenous hyoscine as a premedication for colonoscopy: a randomized double-blind controlled trial. Endoscopy 2004; 36: 720-722
• 45 Yoshikawa I, Yamasaki M, Taguchi M et al. Comparison of glucagon and scopolamine butylbromide as premedication for colonoscopy in unsedated patients. Dis Colon Rectum 2006; 49: 1393-1398
• 46 Cutler CS, Rex DK, Hawes RH, Lehman GA. Does routine intravenous glucagon administration facilitate colonoscopy? A randomized trial.. Gastrointest Endosc 1995; 42: 346-350
• 47 Bond JH, Chally CH, Blackwood WD. A controlled trial of premedication with dicyclomine hydrochloride (Bentyl) in colonoscopy. Gastrointest Endosc 1974; 21: 61
• 48 Elphick DA, Donnelly MT, Smith KS, Riley SA. Factors associated with abdominal discomfort during colonoscopy: a prospective analysis. Eur J Gastroenterol Hepatol 2009; 21: 1076-1082
• 49 Lee YC, Wang HP, Chiu HM et al. Factors determining post-colonoscopy abdominal pain: prospective study of screening colonoscopy in 1000 subjects. J Gastroenterol Hepatol 2006; 21: 1575-1580
• 50 Takahashi Y, Tanaka H, Kinjo M, Sakumoto K. Prospective evaluation of factors predicting difficulty and pain during sedation-free colonoscopy. Dis Colon Rectum 2005; 48: 1295-1300
• 51 Ansari A, Soon SY, Saunders BP, Sanderson JD. A prospective study of the technical feasibility of ileoscopy at colonoscopy. Scand J Gastroenterol 2003; 38: 1184-1186
• 52 Misra SP, Dwivedi M. Role of intravenously administered hyoscine butyl bromide in retrograde terminal ileoscopy: a randomized, double-blinded, placebo-controlled trial. World J Gastroenterol 2007; 13: 1820-1823
• 53 Tee HP, Corte C, Al-Ghamdi H et al. Prospective randomized controlled trial evaluating cap-assisted colonoscopy vs standard colonoscopy. World J Gastroenterol 2010; 16: 3905-3910
• 54 Ell C, Fischbach W, Bronisch HJ et al. Randomized trial of low-volume PEG solution versus standard PEG + electrolytes for bowel cleansing before colonoscopy. Am J Gastroenterol 2008; 103: 883-893
• 55 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
• 56 de Wijkerslooth TR, Stoop EM, Bossuyt PM et al. Adenoma detection with cap-assisted colonoscopy versus regular colonoscopy: a randomised controlled trial. Gut In press 2011 DOI: 10.1136/gutjnl-2011-301327.
• 57 Cooper GS, Chak A, Koroukian S. The polyp detection rate of colonoscopy: a national study of Medicare beneficiaries. Am J Med 2005; 118: 1413
• 58 Kaltenbach T, Friedland S, Soetikno R. A randomised tandem colonoscopy trial of narrow band imaging versus white light examination to compare neoplasia miss rates. Gut 2008; 57: 1406
• 59 DeMarco DC, Odstrcil E, Lara LF et al. Impact of experience with a retrograde-viewing device on adenoma detection rates and withdrawal times during colonoscopy: the Third Eye Retroscope study group. Gastrointest Endosc 2010; 71: 542-550
• 60 Munroe CA, Lee P, Copland A et al. A tandem colonoscopy study of adenoma miss rates during training: a venture into uncharted territory. Gastrointest Endosc 2012; 75: 561-567
• 61 Francis DL, Rodriguez-Correa DT, Buchner A et al. Application of a conversion factor to estimate the adenoma detection rate from the polyp detection rate. Gastrointest Endosc 2011; 73: 493-497