Patient pain during colonoscopy: An analysis using real-time magnetic endoscope imaging

Background and Study Aims: Colonoscopy is generally perceived as being a painful procedure. Contributory factors are: stretching of the colonic wall and mesenteric attachments from looping of the instrument shaft, overinsufflation, the degree of torque or force applied to the colonoscope shaft, and patient pain threshold. The aim of this study was to determine the frequency of pain episodes experienced during diagnostic colonoscopy and the corresponding colonoscope configuration, utilizing real-time magnetic endoscope imaging (MEI). Patients and Methods: Consecutive outpatients undergoing colonoscopy were studied. Patients with previous colonic resections were excluded. Procedures were commenced with anti-spasmodics only, and patient sedation was self-administered whenever significant discomfort was experienced, using a patient-controlled analgesia (PCA) syringe pump. All "demands" were correlated with the MEI record, which was subsequently analysed. Results: A total of 650 demands were recorded in 102 patients. Seventy-seven percent of all demands occurred with the colonoscope tip in the sigmoid colon, 7% in the descending colon, 6% at the splenic flexure, 5% in the transverse colon, and 4% in the proximal colon. Ninety percent of all pain episodes coincided with either looping (79%) or straightening of the colonoscope shaft (11%); presumed overinsufflation being an infrequent cause of pain (9%). Of the loops encountered during colonoscopy, the N-sigmoid spiral loop was associated with the majority of pain episodes (56%). Looping was both more frequent (P = 0.0002) and less well tolerated in women than in men (P = 0.0140). Conclusions: This study is the first to document pain at colonoscopy accurately. Looping, particularly in the variable anatomy of the sigmoid colon, is the major cause of pain, especially in women. Use of MEI may improve pain control by facilitating the straightening of loops within the sigmoid colon, and by enabling the endoscopist to target patient analgesia.