title: Removal of infused water predominantly during insertion (water exchange) is consistently associated with a greater reduction of pain score - review of randomized controlled trials (RCTs) of water method colonoscopy.
abstract: INTRODUCTION: Variation in the outcomes in RcTs comparing water-related methods and air insufflation during the insertion phase of colonoscopy raises challenging questions regarding the approach. This report reviews the impact of water exchange on the variation in attenuation of pain during colonoscopy by water-related methods.  METHODS: Medline (2008 to 2011) searches, abstracts of the 2011 Digestive Disease Week (DDW) and personal communications were considered to identify RcTs that compared water-related methods and air insufflation to aid insertion of the colonoscope. Results: Since 2008 nine published and one submitted RcTs and five abstracts of RcTs presented at the 2011 DDW have been identified. Thirteen RcTs (nine published, one submitted and one abstract, n=1850) described reduction of pain score during or after colonoscopy (eleven reported statistical significance); the remaining reports described lower doses of medication used, or lower proportion of patients experiencing severe pain in colonoscopy performed with water-related methods compared with air insufflation (Tables 1 and 2). The water-related methods notably differ in the timing of removal of the infused water - predominantly during insertion (water exchange) versus predominantly during withdrawal (water immersion). Use of water exchange was consistently associated with a greater attenuation of pain score in patients who did not receive full sedation (Table 3).  CONCLUSION: The comparative data reveal that a greater attenuation of pain was associated with water exchange than water immersion during insertion. The intriguing results should be subjected to further evaluation by additional RcTs to elucidate the mechanism of the pain-alleviating impact of the water method.
authors.affiliation: Sepulveda ACC, VAGLAHS, North Hill, CA; USA.
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authors.lastname: Leung
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authors.lastname: Leung
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authors.lastname: Siao-Salera
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authors.lastname: Mann
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authors.lastname: Ramirez
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authors.lastname: Friedland
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authors.lastname: Amato
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authors.lastname: Paggi
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authors.lastname: Terruzzi
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authors.lastname: Hsieh