title: SAFETY OF MANNITOL USE IN BOWEL PREPARATION: a prospective assessment of intestinal methane (CH4) levels during colonoscopy after mannitol and sodium phosphate (NaP) bowel cleansing.
abstract: BACKGROUND
  - Adequate bowel preparation is critical for the quality of colonoscopy. Despite reported occurrence of colonic explosion due to methane and hydrogen production by bacterial fermentation during colonoscopy, gas exchange during the procedure is believed to be effective in lowering existing methane concentration, allowing for safe utilization of mannitol for bowel preparation. Thus, mannitol is widely used for bowel cleansing prior to colonoscopy, considering its low cost and effectiveness for bowel preparation.
  
  
  OBJECTIVE
  - The aim of this study was to assess the safety of mannitol for bowel preparation, when compared to sodium phosphate (NaP).
  
  
  METHODS
  - We conducted a prospective observational study in which 250 patients undergoing colonoscopy at Universidade Federal de São Paulo and Hospital Albert Einstein (São Paulo, Brazil) were approached for inclusion in the study. Patients received either mannitol (n=50) or NaP (n=200) for bowel preparation, based on physician indication. Study was conducted from August 2009 to December 2009. The main outcome of interest was presence of detectable levels of methane (CH4) during colonoscopy and reduction in such levels after gas exchange during the procedure. Methane concentrations were measured in three intestinal segments during scope introduction and withdrawal. Safety was assessed as the absence of high levels of methane, defined as 5%. Measurements were made using a multi-gas monitor (X-am 7000, Dräger Safety AG & Co. KGaA, Lübeck, Germany) connected to a plastic catheter introduced into the working channel of the colonoscope. Additional outcomes of interest included levels of O2. Methane and O2 levels are reported as ppm. Mean, difference and standard deviation of levels of gas measured in both moments were calculated and compared in both groups. Proportions of patients with detectable or high levels of methane in both groups were compared. Continuous variables were analyzed using t test and categorical variables using qui-square tests. The Ethics Committee in both study sites approved the study protocol.
  
  
  RESULTS
  - Patients in both groups were similar regarding demographics, colonoscopy indication, ASA status and quality of bowel preparation. Seven (3.5%) patients in the NaP group had methane detected during introduction of the endoscope. Methane levels became undetectable during withdrawal of the scope. None of the patients in the mannitol group had detectable levels of methane. O2 levels did not differ in the groups.
  
  
  CONCLUSIONS
  - This is the largest study to assess the safety of mannitol for bowel preparation, considering methane measurements. Our results indicate that mannitol use is as safe as NaP, and gas exchange was efficient in reducing methane concentrations.
authors.affiliation: Divisão de Gastroenterologia, Universidade Federal de São Paulo (UNIFESP - EPM), SP, Brasil.|Unidade de Endoscopia, Hospital Albert Einstein, São Paulo, SP; Brasil.
authors.forename: Gustavo Andrade de
authors.initials: GA
authors.lastname: Paulo
authors.affiliation: Divisão de Gastroenterologia, Universidade Federal de São Paulo (UNIFESP - EPM), SP, Brasil.|Unidade de Endoscopia, Hospital Albert Einstein, São Paulo, SP; Brasil.
authors.forename: Fernanda Prata Borges
authors.initials: FP
authors.lastname: Martins
authors.affiliation: Divisão de Gastroenterologia, Universidade Federal de São Paulo (UNIFESP - EPM), SP, Brasil.|Unidade de Endoscopia, Hospital Albert Einstein, São Paulo, SP; Brasil.
authors.forename: Erika Pereira de
authors.initials: EP
authors.lastname: Macedo
authors.affiliation: Unidade de Endoscopia, Hospital Albert Einstein, São Paulo, SP; Brasil.
authors.forename: Manoel Ernesto Peçanha
authors.initials: ME
authors.lastname: Gonçalves
authors.affiliation: Divisão de Gastroenterologia, Universidade Federal de São Paulo (UNIFESP - EPM), SP, Brasil.|Unidade de Endoscopia, Hospital Albert Einstein, São Paulo, SP; Brasil.
authors.forename: Angelo Paulo
authors.initials: AP
authors.lastname: Ferrari
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002400:Cathartics / Q000008:administration & dosage*; D003113:Colonoscopy / Q000379:methods*; D005260:Female; D005740:Gases / Q000032:analysis; D006801:Humans; D007422:Intestines / Q000502:physiology; D008297:Male; D008353:Mannitol / Q000008:administration & dosage*; D008697:Methane / Q000032:analysis*; D008875:Middle Aged; D010710:Phosphates / Q000008:administration & dosage*; D011300:Preoperative Care / Q000379:methods; D011446:Prospective Studies; D055815:Young Adult
chemical_list: D002400:Cathartics; D005740:Gases; D010710:Phosphates; D008353:Mannitol; D008697:Methane; C018279:sodium phosphate