Complete colonoscopy for cancer screening requires cecal intubation. Failure to reach and examine the cecum may result in missed right colon pathology. We developed and validated a novel classification scheme for the endoscopic appearance of the normal appendiceal orifice (AO). We analyzed 1,456 AO images and grouped them into four categories based on distinguishing features: "diverticuloid," "umbilicoid," "crescent," and "linear." An expert panel classified the images and modified these categories, combining crescent and linear categories into "curvilinear." A 100-image subset was classified twice by a validation cohort consisting of gastroenterology faculty and fellows. Inter-observer agreement among the expert panel, and intra- and inter-observer agreement among the validation cohort were analyzed using Fleiss' kappa statistic. The distribution of AO images was 67% curvilinear, 19% umbilicoid, and 10% diverticuloid; 85 images (4%) were not classifiable. There was substantial inter-observer agreement among the expert panel (κ, 0.72). Inter-observer agreement among the validation cohort was moderate (κ, 0.53 and 0.55 for the first and second viewing, respectively). Intra-observer κ values among the validation cohort were 0.69 for the overall classification, 0.65 for diverticuloid, 0.70 for umbilicoid, and 0.70 for curvilinear, indicating substantial agreement. This simple, validated classification scheme for the endoscopic appearance of the normal AO can be used both as a research and clinical tool to measure endoscopic quality, improve cecal examination, and document successful cecal intubation.

Nausea and vomiting are commonly seen in the critically ill patient. While these symptoms are not often the cause for admission to critical care, they complicate and may extend the length of stay as well as the patient’s feelings about his or her hospitalization. As with all care provided in critical care, we should strive to implement interventions supported by evidence whenever possible. The article includes definitions, a general description, and the pathophysiology of nausea and vomiting. As well, an evidence-based plan of care for the assessment, planning, intervention, and evaluation of the patient with nausea and vomiting is outlined, using levels of recommendation based on the strength of available evidence. A case study is presented to allow for clinical application: case study commentary reviews the salient points of care.

Nausea and vomiting are commonly seen in the critically ill patient. While these symptoms are not often the cause for admission to critical care, they complicate and may extend the length of stay as well as the patient's feelings about his or her hospitalization. As with all care provided in critical care, we should strive to implement interventions supported by evidence whenever possible. The article includes definitions, a general description, and the pathophysiology of nausea and vomiting. As well, an evidence-based plan of care for the assessment, planning, intervention, and evaluation of the patient with nausea and vomiting is outlined, using levels of recommendation based on the strength of available evidence. A case study is presented to allow for clinical application: case study commentary reviews the salient points of care.

BACKGROUND:Despite increased emphasis on endoscopic performance indicators, e.g., cecal intubation rates, limited data from actual clinical practice have been published.OBJECTIVES:Retrospective database review to determine the rate and documentation of cecal intubation during colonoscopy at the University of Maryland Medical Center.METHODS:We reviewed 5,477 consecutive colonoscopies performed by 10 faculty gastroenterologists at a University hospital over a 6-yr period (March 1, 1999 to February 28, 2005). Unadjusted cecal intubation rates were analyzed as were rates that were adjusted based on the U.S. Multi-Society Task Force on Colorectal Cancer recommendations. We analyzed trends in overall and individual cecal intubation rates, circumstances that impact these rates, and the quality of documentation of cecal intubation.RESULTS:The overall adjusted cecal intubation rate for the entire 6 yr was 90.3%, and increased over the study period with the highest adjusted rate (93.7%) in the most recent year studied. There was no correlation between cecal intubation rate and patient age, gastroenterology fellow involvement, or endoscopist experience and number of procedures/year. In contrast, colon cancer screening, male gender, outpatient colonoscopy, and adequate bowel preparation predicted a higher cecal intubation rate. Written and photographic documentation of cecal intubation improved significantly after 2002.CONCLUSIONS:Our analysis revealed cecal intubation and documentation rates that meet current guidelines, and identified factors that may cause substantial variance in these rates depending on the nature of the practice. The present analysis confirms that computerized databases can be used to assess individual and group cecal intubation and documentation rates on an annual basis, and to make these data available to the public.

TO THE EDITOR: In the paper by Aslinia et al. (1), Table 1 shows a significant increase in the use of thinner colonoscopes during the 6-yr period. This may be due to their greater use on female patients whose distal colons can be difficult to navigate. Use of thinner colonoscopes, which can help navigate these difficult distal colons, may also explain the increasing completion rate over the study period. However, a new problem proximally may be encountered. Our study examining predictors of difficult colonoscopies performed with an adult colonoscope observed that predictive factors for female patients included older age, diverticulosis, and a low body mass index (BMI) (2). We also retrospectively studied 2,000 patients, and observed that when using the adult scope, female patients were more likely to have incomplete colonoscopies arrested in the distal colon (3). This was especially pronounced in thinner female patients (BMI <25). Marshall et al. compared the adult versus pediatric colonoscope in women with hysterectomies (4). They observed that while the use of the adult colonoscope was associated with incomplete colonoscopies halted in the distal colons of female patients, the pediatric colonoscope was associated with a higher rate of completion. Unfortunately the greater flexibility of a thinner colonoscope is associated with greater looping due to the loss of column strength compared with a thicker colonoscope (5). Aslinia et al. observed that women were more likely than men to have the incomplete colonoscopy terminated in the sigmoid colon, but there are no data regarding 6-yr trends. We suspect that due to the greater use of thinner colonoscopes, the percentage of procedures terminated in the distal versus the proximal colon decreased in their female patients during the 6-yr period. Our clinical experience is that women who are thin, older, have diverticular disease, or a combination of these factors, can be difficult to perform colonoscopy with an adult colonoscope. A thinner scope is beneficial in the distal colon, but a redundant colon can cause problems proximally. Whereas the watershed area for colonoscopy in female patients in the past has been the distal colon, the new challenging portion of the colon is the proximal portion. Olympus (Tokyo, Japan) has developed a tapered, prototype colonoscope that combines the distal flexibility of a pediatric colonoscope with the proximal column strength of the adult colonoscope. Our recent data demonstrate a decrease in looping as well as a diminished time required for cecal intubation when using this prototype as compared with the pediatric variable stiffness colonoscope (6).

TO THE EDITOR: In the paper by Aslinia et al. (1), Table 1 shows a significant increase in the use of thinner colonoscopes during the 6-yr period. This may be due to their greater use on female patients whose distal colons can be difficult to navigate. Use of thinner colonoscopes, which can help navigate these difficult distal colons, may also explain the increasing completion rate over the study period. However, a new problem proximally may be encountered. Our study examining predictors of difficult colonoscopies performed with an adult colonoscope observed that predictive factors for female patients included older age, diverticulosis, and a low body mass index (BMI) (2). We also retrospectively studied 2,000 patients, and observed that when using the adult scope, female patients were more likely to have incomplete colonoscopies arrested in the distal colon (3). This was especially pronounced in thinner female patients (BMI <25). Marshall et al. compared the adult versus pediatric colonoscope in women with hysterectomies (4). They observed that while the use of the adult colonoscope was associated with incomplete colonoscopies halted in the distal colons of female patients, the pediatric colonoscope was associated with a higher rate of completion. Unfortunately the greater flexibility of a thinner colonoscope is associated with greater looping due to the loss of column strength compared with a thicker colonoscope (5). Aslinia et al. observed that women were more likely than men to have the incomplete colonoscopy terminated in the sigmoid colon, but there are no data regarding 6-yr trends. We suspect that due to the greater use of thinner colonoscopes, the percentage of procedures terminated in the distal versus the proximal colon decreased in their female patients during the 6-yr period. Our clinical experience is that women who are thin, older, have diverticular disease, or a combination of these factors, can be difficult to perform colonoscopy with an adult colonoscope. A thinner scope is beneficial in the distal colon, but a redundant colon can cause problems proximally. Whereas the watershed area for colonoscopy in female patients in the past has been the distal colon, the new challenging portion of the colon is the proximal portion. Olympus (Tokyo, Japan) has developed a tapered, prototype colonoscope that combines the distal flexibility of a pediatric colonoscope with the proximal column strength of the adult colonoscope. Our recent data demonstrate a decrease in looping as well as a diminished time required for cecal intubation when using this prototype as compared with the pediatric variable stiffness colonoscope (6).