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1 Department of Intestinal Imaging, Intestinal Imaging Centre, Level 4V, St.
Mark's Hospital, Watford Rd., Northwick Park, London HA1 3UJ, United
Kingdom.
2 Cancer Research UK Colorectal Cancer Unit, St. Mark's Hospital, Northwick
Park, London HA1 3UJ, United Kingdom.
3 Wolfson Institute of Endoscopy, St. Mark's Hospital, Northwick Park, London
HA1 3UJ, United Kingdom.
Received December 23, 2002;
accepted after revision April 18, 2003.
Supported by the Royal College of Radiologists Research Fellowship and the
Wexham Gastrointestinal Trust.
Abstract
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SUBJECTS AND METHODS. One hundred sixty-eight patients underwent CT colonography followed by either flexible sigmoidoscopy (n = 59) or colonoscopy (n = 109). A 25-point questionnaire with principal components relating to satisfaction, worry, and physical discomfort was administered after CT colonography and after endoscopy, and a follow-up questionnaire was administered 1 week after the procedures. Questionnaires were also completed by 140 patients undergoing double-contrast barium enema examinations. Responses were compared using Wilcoxon's matched pairs test and the Mann-Whitney test.
RESULTS. Overall satisfaction was greater with colonoscopy (p = 0.01), but CT colonography caused less discomfort (p = 0.002), was better tolerated (p = 0.005), and was the preferred follow-up investigation of those expressing a preference (p = 0.003). Compared with flexible sigmoidoscopy, CT colonography caused less pain (p = 0.004), was more acceptable (p = 0.04), and was preferred as the follow-up investigation (p < 0.001). Tolerance of colonoscopy was significantly less in women (p = 0.03), but such was not the case for CT colonography (p = 0.58). Patients undergoing CT colonography were less worried (p < 0.001), were more satisfied (p = 0.001), and suffered less discomfort (p < 0.001) than those having barium enema.
CONCLUSION. Patients' experiences with barium enema examinations were significantly worse than with any other test. Although patients were most satisfied with colonoscopy, they reported more pain during both colonoscopy and sigmoidoscopy than during CT colonography, and they also found CT more acceptable. In patients expressing a preference, CT colonography was the preferred follow-up investigation.
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CT colonography has been increasingly advocated as a safer, less invasive, and more acceptable whole-colon investigation than endoscopy [5, 9, 10] while retaining adequate sensitivity for clinically significant lesions [11–13]. It has been suggested that this improved acceptance will inevitably increase compliance if CT colonography were offered as part of a screening program. However, recent studies have been conflicting, with some finding CT more acceptable than endoscopy [14], whereas others have found it less so [15]. Furthermore, little work has compared CT colonography with flexible sigmoidoscopy, which has been shown to be potentially viable in a national screening program [16], or with barium enema, which also has its advocates [17]. We aimed to compare patient satisfaction for CT colonography, total colonoscopy, flexible sigmoidoscopy, and double-contrast barium enema to ascertain any overall patient preference for colonic investigation.
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CT Colonography
CT colonography in all 168 patients was performed before subsequent
endoscopy and was performed using a standard technique
[12,
14,
18]. All patients were
instructed to maintain a clear liquid diet 24 hr before their appointment and
underwent full bowel preparation with either two packets of sodium
picosulphate and magnesium citrate (Picolax, Ferring Pharmaceuticals,
Berkshire, United Kingdom [UK]) (if scheduled for flexible sigmoidoscopy) or
two packets of magnesium citrate (Citramag, Bioglan Laboratories,
Hertfordshire, UK) supplemented with one packet of senna granules (Reckitt
Benckiser Healthcare, Hull, UK) (if scheduled for colonoscopy). No tagging
agents were used. One hundred twenty-five patients received IV spasmolytic
(20–40 mg of hyoscine-N-butyl bromide [Buscopan, Boehringer
Ingelheim, Bracknell, UK]) before gas insufflation. Colonic insufflation was
performed using an enema bag (E-Z-EM enema bag, E-Z-EM, Westbury, NY) filled
with approximately 2500 mL of carbon dioxide. Distention was achieved by
gentle squeezing of the enema bag to maximal patient tolerance. Scanning with
the patient both prone and supine was performed using a multidetector CT
scanner (four detector rows) (LightSpeed Plus, General Electric Medical
Systems, Milwaukee, WI) and the following parameters: 1.25- to 2.5-mm
collimation; pitch of 6; 120 kVp; 50–100 mA; and 50% slice overlap.
Images were reconstructed at half the nominal slice thickness. Image analysis
was performed using a dedicated stand-alone workstation as is our usual
practice.
Endoscopy
After completion of CT colonography, patients were escorted to the
endoscopy suite to undergo either flexible sigmoidoscopy or colonoscopy,
depending on the source of referral. Flexible sigmoidoscopy was performed by a
single experienced practitioner using a standard 60-cm flexible sigmoidoscope
(200s, Olympus, Southall, UK). No patient received spasmolytic or sedation
during flexible sigmoidoscopy, although the endoscopist was free to use such
medication if deemed necessary. Carbon dioxide was used to distend the colon
during the procedure. All colonoscopies were performed using a standard
colonoscope (CFQ240AL, Olympus). One hundred of the 109 colonoscopies were
performed by a single experienced colonoscopist; the other nine were performed
by one of three other experienced endoscopists. IV sedation (midazolam,
Pheonix Pharma, Gloucester, UK), analgesia (pethidine, Pamergan P100,
Martindale Pharmaceuticals, Romford, UK), and spasmolytic (10–40 mg of
hyoscine-N-butyl bromide) were administered routinely before
colonoscopy as is our usual practice. Sixteen of 109 patients received no
sedation or analgesia because of personal preference, and of these, seven also
received no spasmolytic. In total, 42 patients received 25 mg of pethidine and
1.25 mg of midazolam; 30 patients received 50 mg of pethidine and 1.25 mg of
midazolam; 18 patients received 50 mg of pethidine and 2.5 mg of midazolam;
and one patient each received 100 mg and 1.25 mg, 100 mg and 2.5 mg, and 100
mg and 4 mg of pethidine and midazolam. Nasal oxygen (2 L/min) was given
routinely to all patients undergoing colonoscopy.
Barium Enema Examination
Barium enemas examinations were performed by one of three experienced
radiographers according to a standard protocol consisting of multiple digital
fluoroscopic spot images of the colon followed by two lateral decubitus
overcouch radiographs. All patients were instructed to maintain a clear liquid
diet 24 hr before their appointment and underwent full bowel preparation with
two packets of sodium picosulphate and magnesium citrate (Picolax, Ferring
Pharmaceuticals, Berkshire, UK). Twenty milligrams of IV
hyoscine-N-butyl bromide was administered routinely to all patients
unless contraindicated, in which case 1 mg of glucagon (Nova Nordisk
Pharmaceuticals, Crawley, UK) was administered (eight patients). Barium
preparation (94% w/w, PolibarTM, by weight, Polibar (barium sulphate) E-Z-EM,
Westbury, NY) was diluted with 500 mL of water and instilled via a rectal
catheter. Colonic distention was achieved with carbon dioxide introduced by
manual compression of the gas-filled enema bag.
Questionnaires
Patients undergoing both CT colonography and subsequent endoscopy received
a detailed written explanation of both procedures via the mail at least 1 week
before their appointment. When the patient arrived at the CT suite on the day
of the tests, the supervising radiologist also gave an oral explanation of
both tests as part of the consent procedure for CT colonography. After CT
colonography, the admitting nurse also gave an oral explanation when the
patient arrived in the endoscopy suite.
A questionnaire was administered to patients to determine their subjective experience of the individual procedures. The questionnaire used was previously validated and was based on the responses derived from detailed interviews of a cohort of patients who had undergone full colonoscopy [19]. The questionnaire consisted of 25 individual items presented with the opposite separated by a seven-point scale. Three separate components that underlay each of the 25 individual items were identified using the technique of principal component analysis: satisfaction, worry, and physical discomfort [19] (Table 1). Patients were instructed to place a cross in one of the seven boxes between each item and its opposite, depending on their rating for the particular item. The questionnaire was designed so that a higher score reflected a more positive patient response. The questionnaire also included a 10-cm visual analog scale drawn between "no bloating" and "severe bloating" and between "no discomfort" and "severe discomfort," both during and after the procedure. Patients were asked to place a mark on the analog scale for each item that reflected their experience.
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The CT radiographer gave two copies of the questionnaire (marked "CT" and "endoscopy," respectively) to patients after CT colonography was completed. Patients were instructed to complete the first questionnaire, pertaining to CT colonography, while they waited in the endoscopy suite and were asked to hand the completed questionnaire to the endoscopy staff before being admitted by the endoscopy nurse. Instructions and examples of how to complete the questionnaire were detailed on the form, and questionnaires were completed by patients in isolation so that their responses were not influenced by the presence of the radiographer. Patients were also reassured in advance that their completed responses would not be revealed to the CT or endoscopy staff. The second copy of the questionnaire, pertaining to endoscopy, was completed just before the patient left the department to go home, at which time any sedation given during the endoscopy was deemed sufficiently diminished to allow the patient to leave direct medical supervision and travel home safely. This second questionnaire was handed to the endoscopy receptionist as the patient departed.
Patients undergoing only barium enema examination were given a copy of the same questionnaire by a radiology nurse after completion of the examination. The patients completed this questionnaire before leaving the radiology department, under similar conditions to patients having endoscopy. The completed questionnaire was left with the radiology department receptionist.
A follow-up questionnaire was sent 1 week later to all patients who had undergone CT colonography and endoscopy. Patients were asked to circle one of several set responses to a series of questions about both CT colonography and endoscopy as follows: I felt I tolerated CT—well, fairly well, poorly, or very poorly. I felt I tolerated endoscopy—well, fairly well, poorly, or very poorly. Would you have the CT scan again?—yes, no, or maybe. Would you have endoscopy again?—yes, no, or maybe. If you had to have just one of the tests again, which would you prefer?—CT scan, endoscopy, or don't mind. Bearing in mind all you know about the risks and benefits of both tests, which do you feel is the most acceptable?—CT scan, endoscopy, or about the same.
Patients were also asked to indicate whether they had recovered from the CT colonography before the endoscopy started and how long they considered it took them to recover fully from endoscopy. A stamped and addressed envelope was included with the questionnaire to encourage patient response.
Statistical Analysis
Items were discarded from analysis if patients failed to mark a response or
made more than one response. Initial analysis of the seven-point questionnaire
indicated that responses were skewed toward the upper end of the distribution,
so nonparametric methods were applied. Wilcoxon's matched pairs test was used
to compare the responses to the questionnaires and the visual analog scales
among CT colonography, colonoscopy, and flexible sigmoidoscopy. The responses
from patients undergoing barium enema examination were compared separately
with the responses from all patients undergoing CT colonography, colonoscopy,
and flexible sigmoidoscopy using the Mann-Whitney test statistic. Any
influence caused by the following patient characteristics was also determined
using the Mann-Whitney test statistic: age (< 65 years, > 65 years),
sex, use of hyoscine-N-butyl bromide, and whether a biopsy was
performed or a polyp removed during endoscopy.
Few patients reported tolerating any procedure poorly or very poorly on the follow-up questionnaire, so those responses were combined with the group tolerating "fairly well" and were compared with the remaining "well" group using a paired exact test (binomial-based exact test). Similarly, few subjects indicated they would not have any procedure again, so these responses were combined with the group responding "maybe" and compared with the proportion who would have the test again. A comparison of which procedure was preferred and which was most acceptable was made using a one-sample test of proportions. Those who did not express a preference were not included in the analysis. The effect of patient characteristics (age, sex, and whether a biopsy sample was taken or polyp removed) on patient preference was assessed separately for each procedure using Fisher's exact test.
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Of the 140 patients undergoing barium enema examination, 126 (90%) completed the seven-point questionnaire, of whom 103 (74%) filled in the visual analog scale.
Seven-Point Questionnaire
The median and interquartile ranges of the sum of all the individual items
for each principal component are shown in
Figure 1 for those undergoing
CT colonography and colonoscopy and in
Figure 2 for those undergoing
CT colonography and flexible sigmoidoscopy. Patients reported statistically
greater satisfaction with colonoscopy than with CT colonography, although the
median scores for this principal component were identical. The only individual
item to reach significance for the satisfaction component was "staff
were interested in me," with patients responding more favorably toward
colonoscopy (p = 0.003). Again, median scores for this item were
identical (median, 7; interquartile range, 7–7 for CT colonography and
colonoscopy). No overall significant difference was seen between CT
colonography and colonoscopy for the worry principal component, although
patients were significantly more worried about what would be found during
colonoscopy (median, 4; interquartile range, 1.75–7) than during CT
colonography (median, 5; interquartile range, 2–7) (p = 0.02).
Concerning the principal component of physical discomfort, patients found
colonoscopy significantly worse than CT colonography (p = 0.002).
Patients found colonoscopy more painful (median, 5, interquartile range,
3–7 vs median, 6, interquartile range, 4–7; p = 0.02),
were more weary (median, 5.5, interquartile range, 3–7 vs median, 7,
interquartile range, 5–7, p < 0.001), were more afraid of
making a fool of themselves (median, 7; interquartile range, 6–7 for
both; p = 0.01), and were more relieved when colonoscopy was over
(median, 1, interquartile range, 1–2 vs median, 1, interquartile range,
1–4; p < 0.001).
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No difference was noted between the satisfaction or worry principal component when CT colonography was compared with flexible sigmoidoscopy, either overall or for any of the individual items examined (Fig. 2). The only item to have a median score of less than 6 was "worried what they would find," which had a median core of 5 for CT colonography. Although no significant difference was seen between sigmoidoscopy and CT colonography for the physical discomfort component, with respect to individual responses patients found sigmoidoscopy significantly more painful than CT (median, 5, interquartile range, 4–7 vs median, 6, interquartile range, 5–7; p = 0.004), would prefer to be less awake during sigmoidoscopy (median, 4, interquartile range, 4–5.25 vs median, 4, interquartile range, 4–6.25; p = 0.02), and reported more soreness after sigmoidoscopy (median, 6, interquartile range, 4–7 vs median, 7, interquartile range, 5–7; p = 0.02).
The comparison between individual item responses after barium enema examination and after endoscopy and CT colonography is shown in Table 2. The overall principal component analysis is shown in Figure 3. Patients undergoing barium enema were significantly less satisfied, more worried, and suffered more physical discomfort than patients undergoing either CT colonography, colonoscopy, or flexible sigmoidoscopy. In particular, patients found barium enema significantly less dignified, more confusing, more puzzling, and more worrying than any of the other procedures and were more afraid of making a fool of themselves.
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Visual Analog Scale
Patients recorded significantly more bloating during CT colonography
(median, 3; interquartile range, 1–6) than during colonoscopy (median,
2; interquartile range, 1–4; p = 0.002) but more discomfort
during colonoscopy (median, 3, interquartile range, 1–7 vs median, 2,
interquartile range, 0–5; p = 0.005). Patients also recorded
significantly more discomfort during flexible sigmoidoscopy (median, 4;
interquartile range, 2–5) than during CT colonography (p =
0.01). Patients reported significantly more bloating after barium enema
examination than after CT colonography (p = 0.01) and colonoscopy
(p = 0.003), and significantly more discomfort after barium enema
examination than after CT colonography (p = 0.005)
(Table 2).
Patient Characteristics
No significant effect of patient age was seen on the questionnaire
responses for CT colonography, colonoscopy, or barium enema, although patients
younger than 65 years scored significantly lower (i.e., worse) on the worry
component for flexible sigmoidoscopy than those older than 65 years (median,
45, interquartile range, 38.8–45 vs median, 50, interquartile range,
45.5–54; p = 0.04). Younger patients also reported more
bloating and discomfort on the visual analog scale after barium enema than did
older patients (median, 3, interquartile range, 1–6.75 vs median, 1,
interquartile range, 0–4; p = 0.008; and median, 2,
interquartile range, 1–5 vs median, 1, interquartile range, 0–3;
p = 0.02 respectively).
Women reported greater worry during CT colonography than did men (median, 46, interquartile range, 41–49 vs median, 48, interquartile range, 42.5–50; p = 0.03) and more discomfort during colonoscopy (median, 42, interquartile range, 36–49 vs median, 49, interquartile range, 41.5–55; p = 0.002). Women also reported more worry and discomfort during barium enema than did men (median, 38, interquartile range, 32.5–44 vs median, 45, interquartile range, 39–50; p = 0.001; and median, 39, interquartile range, 31–46 vs median, 47, interquartile range, 39–50; p = 0.01, respectively). No significant effect of spasmolytic or biopsy was seen on any of the three principal components or visual analogues for CT colonography, colonoscopy, or flexible sigmoidoscopy.
Follow-Up Questionnaires
Eight (6.2%) of the 129 responders indicated they had not recovered from
the CT colonography before endoscopy, and eight (21%) of the 38 patients
undergoing flexible sigmoidoscopy and 18 (19.8%) of the 91 patients undergoing
colonoscopy took more than 3 hr to recover from the endoscopy. The
distribution of responses to the questionnaire is shown in Figures
4 and
5. CT colonography was
significantly better tolerated than colonoscopy (p = 0.005), but no
significant difference was seen between CT and sigmoidoscopy (p =
0.18). However, significantly fewer patients were prepared to undergo
sigmoidoscopy again than to undergo CT colonography again (22 vs 29,
p = 0.02). When asked which test they would prefer to have in the
future, 55 patients (61.1%) who underwent colonoscopy expressed a preference,
and significantly more of those preferred CT colonography (40/55, p =
0.001). Significantly more of the 60 patients who found one test more
acceptable than the other favored CT colonography over colonoscopy (42/60,
p = 0.003). Similarly, when asked which test they would prefer to
have in the future, 22 (58%) of those who underwent sigmoidoscopy expressed a
preference, of whom significantly more again preferred CT colonography (19/22,
p < 0.001). Significantly more of the 20 patients who found one
test more acceptable than the other favored CT colonography (15/20, p
= 0.04).
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Patient Characteristics and Follow-Up Questionnaires
Colonoscopy was significantly less well tolerated by women than by men
(22/51 vs 27/40, p = 0.03), and significantly fewer women would have
the test again (32/51 vs 33/40, p = 0.03). Concerning sigmoidoscopy,
although sex did not appear to significantly interact with tolerance, more
women were significantly less willing to undergo the test again (4/14 vs
18/24, p = 0.02). Sex had no effect on patients' opinions of CT
colonography. Neither age nor a history of endoscopic intervention had any
significant effect on patient tolerance or willingness to undergo tests again
for any of the three procedures. Also, no significant effect of age, sex, or
endoscopic intervention was seen on patient test preference or assessment of
acceptance. Patients expressing an overall preference for CT colonography
reported that they were more satisfied (p = 0.007), less worried
(p = 0.007), and suffered less physical discomfort (p =
0.004) after CT than those who preferred colonoscopy, but no significant
difference was seen in questionnaire responses after colonoscopy for those
patients expressing a preference for either test over the other. Similarly,
questionnaire responses from those who underwent sigmoidoscopy were not
significantly associated with their subsequent test preference.
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We found that the barium enema was significantly less well tolerated than any other procedure in terms of overall patient satisfaction, worry, and physical discomfort. To our knowledge, ours is the first study that has shown that CT colonography is better tolerated than barium enema. This finding is compounded by the fact that CT is likely to be more sensitive and specific for the detection of colorectal neoplasia, although no direct comparison between CT colonography and barium enema has been published at the time of this writing. Indeed, we found more positive responses after colonoscopy than after barium enema, which is in keeping with other studies that have also reported greater discomfort during barium enema than during colonoscopy [25]. Interestingly, Steine [26] found patients reported more pain during colonoscopy, although we found no significant differences between barium enema and colonoscopy for either discomfort on the visual analog scale or response to the pain item on the seven-point questionnaire. This discrepancy may in part be explained by the medication administered to patients; patients recruited by Steine received intramuscular pethidine with no sedative, whereas patients in our study routinely received both IV pethidine and midazolam during colonoscopy.
Kim et al. [27], using a case control study design similar to our own, found that patients perceived barium enema as less dignified than sigmoidoscopy or colonoscopy; but unlike our results, those authors found sigmoidoscopy more painful than barium enema. Although data from case control studies may not be as valid as those from studies in which patients undergo both tests, the barium enema and CT colonography and endoscopy patient cohorts in our study were well matched in terms of demographics and were recruited from the same outpatient clinics. However, we cannot exclude that more subtle differences between the two groups induced by referral bias might have affected patients' responses to the questionnaires. This is an important consideration that may weaken our conclusions, although the frequency of significant differences between patient responses after barium enema compared with CT and endoscopy suggests a true difference in patient experience. Some divergence between the two groups also existed in bowel preparation regimes, although our questionnaires specifically referred to the tests themselves rather than to the experience of bowel purging.
With the exception of barium enema, patients were generally satisfied with all other modalities tested. However, satisfaction with colonoscopy was significantly greater than with CT colonography, albeit the actual difference was small overall. Perhaps not surprisingly, patients believed staff were more interested in them during colonoscopy than during CT colonography. By its very nature, CT colonography requires no sedation or continuous interaction with staff; the examination is performed by a machine rather than a doctor. Furthermore, rapid recovery eliminates the need for prolonged postprocedural observation, again possibly contributing to a sense of uninvolvement. Conversely, colonoscopy requires close patient monitoring combined with continuous staff–patient interaction both during and after the procedure, all likely to enhance perception of staff interest. Also, the ability to visualize the procedure in real time on a monitor increases patient satisfaction [28], an advantage that cannot easily be reproduced with CT colonography. Previous work has shown patient preference for endoscopy over a barium examination is largely related to staff interaction and the use of sedation [29].
However, patients did report significantly more physical discomfort during colonoscopy and sigmoidoscopy than during CT colonography. Both types of endoscopy were deemed more painful and resulted in higher discomfort scores on the visual analog scale. Patients would have preferred to be less awake during sigmoidoscopy than during CT colonography despite the fact that sedation was not used for either procedure, implying greater pain during sigmoidoscopy. Although previous researchers have found greater discomfort during colonoscopy [14, 30], this is not a universal finding: Akerkar et al. [15] found CT colonography more painful than colonoscopy. Air was used for colonic distention in the study by Akerkar et al. as opposed to carbon dioxide as was used in this study, and compelling evidence exists that the latter is less painful [31]. However, Svensson et al. [14] also used air, suggesting that the distention agent alone does not explain discrepancy. For example, male sex is related to increased tolerance, and most patients recruited by Akerkar et al. were men.
When asked to express a preference as to which test would be most
acceptable in the future, our patients found significantly in favor of CT
colonography. However, a significant minority (
40%) had no preference as
to which test they would have in the future. Overall, our findings mirror
those of Svensson et al., [14]
who found CT colonography strongly favored by the 71% of their cohort who
expressed a preference; pain was more strongly associated with test preference
than other psychologic factors were. Patients who preferred CT on follow-up
recorded significantly better questionnaire responses after CT than those
preferring colonoscopy, although the scores after endoscopy were no different
between the two groups. This implies that a patient's experience of CT
colonography rather than endoscopy was the more important factor in
determining test preference, perhaps because of greater familiarity with
conventional endoscopy than with a novel radiology technique.
Surprisingly, we found some evidence that younger patients tolerated procedures less well, particularly flexible sigmoidoscopy and barium enema. However, the most consistent finding was that of poorer female tolerance. Women found both colonoscopy and barium enema more uncomfortable than men did and were less likely to have either colonoscopy or sigmoidoscopy again. Reduced female tolerance of endoscopy is well described [32], and women are less likely to express an interest in undergoing screening flexible sigmoidoscopy [20]. Such differences may be partly psychologic in origin; women find endoscopy more embarrassing than men. However, anatomic differences also contribute; for example, posthysterectomy adhesions impede sigmoid intubation [33]. We found no sex difference regarding tolerance or discomfort during CT colonography, with women just as willing to undergo CT again, suggesting that screening using CT colonography may help diminish differences in compliance between the sexes.
Although hyoscine-N-butyl bromide has been reported to decrease patient discomfort during barium enema examinations [34], we found no evidence that patients who received a spasmolytic before CT colonography suffered any less discomfort or were any more tolerant of the test. One of the major advantages of endoscopy is that it permits the performance of biopsy and polyp removal, but perhaps surprisingly, like Svensson et al. [14], we found no evidence that endoscopic intervention had any influence on patient preference or assessment of test acceptance.
Because of the nature of the procedures, it was not possible to randomize the order in which patients underwent each test, so the experience of colonoscopy may have been altered by the preceding CT colonography. This fact is a potential source of weakness, although only eight patients believed that they had not fully recovered from CT colonography before undergoing endoscopy. Furthermore, we used carbon dioxide for colonic distention, which is rapidly absorbed, and our endoscopists did not report undue difficulty after CT. Inexperienced endoscopists decrease patient satisfaction [32]. We attempted to minimize this potential confounder by ensuring that most endoscopies were performed by one of two experienced operators.
Although it is possible that patients remained under the influence of sedation when completing the postcolonoscopy questionnaire, all were deemed fit to leave the department, and responses made at that time correlate well with responses to the same questionnaire given 24 hr later [14]. Furthermore, our study included a follow-up questionnaire administered at least 1 week after the procedures, which allowed patients to give a more considered view. We attempted to keep the follow-up questions as open as possible but accept that differences in wording can have a significant effect on patient responses. Although most patients were told their CT and endoscopy results, they did not receive formal reports and may not have been fully aware of differences in test performances when filling in the follow-up questionnaires. We investigated symptomatic patients, and caution must be exercised when applying our findings to an asymptomatic screening population.
In conclusion, we have shown that multidetector CT colonography is more acceptable than barium enema examination, raising the possibility that it may be the radiologic investigation of choice in symptomatic patients. Levels of overall satisfaction are slightly greater with colonoscopy, but CT colonography causes less discomfort, is better tolerated, and is the preferred follow-up test for those expressing a preference. Compared with flexible sigmoidoscopy, CT colonography causes less pain, is more acceptable, and is preferred for follow-up. Decreased tolerance in women is not found with CT colonography.
Acknowledgments
We thank the Royal College of Radiologists Research Fellowship and the
Wexham Gastrointestinal Trust for funding.
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D. Burling, S. A. Taylor, S. Halligan, L. Gartner, M. Paliwalla, C. Peiris, L. Singh, P. Bassett, and C. Bartram Automated Insufflation of Carbon Dioxide for MDCT Colonography: Distension and Patient Experience Compared with Manual Insufflation Am. J. Roentgenol., January 1, 2006; 186(1): 96 - 103. [Abstract] [Full Text] [PDF]
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W. Ajaj, T. C. Lauenstein, G. Pelster, G. Holtmann, S. G. Ruehm, J. F. Debatin, and S. C. Goehde MR Colonography in Patients with Incomplete Conventional Colonoscopy Radiology, February 1, 2005; 234(2): 452 - 459. [Abstract] [Full Text] [PDF]
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M. Cohnen, C. Vogt, A. Beck, K. Andersen, W. Heinen, S. vom Dahl, V. Aurich, D. Haeussinger, and U. Moedder Feasibility of MDCT Colonography in Ultra-Low-Dose Technique in the Detection of Colorectal Lesions: Comparison with High-Resolution Video Colonoscopy Am. J. Roentgenol., November 1, 2004; 183(5): 1355 - 1359. [Abstract] [Full Text] [PDF]
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J. F. Bruzzi, H. M. Fenlon, S. Halligan, S. Taylor, P. Bassett, and C. Bartram Colonic Distention in Multi-Detector Row CT Colonography [letter] * Dr Halligan and colleagues respond: Radiology, April 1, 2004; 231(1): 282 - 283. [Full Text] [PDF]
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) and colonoscopy (
). Higher score reflects more positive patient
response. Patients reported statistically significant greater satisfaction but
more physical discomfort with colonoscopy than with CT colonography
(p < 0.01 [asterisks]).
). Higher score reflects more
positive patient response. No significant difference was seen in overall
responses between CT colonography and flexible sigmoidoscopy for each
principal component.
) compared
with those undergoing multidetector CT colonography (
), and flexible sigmoidoscopy (
