AJG October, 2000
8. Agreus L, Talley N, Svardsudd K, et al. Identifying dyspepsia
and irritable bowel syndrome: The value of pain or discomfort,
and bowel habit descriptors. Scand J Gastroenterol 2000;35:
14251.
9. Bommelaer G, Dorval E, Denis P, et al. Prevalence of irritable
bowel syndrome according to the Rome criteria in the French
population. Gastroenterology 2000;118 (suppl 2):A760.
10. Saito A, Locke GR, Talley NJ, et al. The effect of new
diagnostic criteria for irritable bowel syndrome on community
prevalence estimates. Gastroenterology 2000;118(suppl 2):A
402.
11. Talley NJ, Phillips SF, Melton LJ, et al. Diagnostic value of
the Manning criteria in irritable bowel syndrome. Gut 1990;
31:77 81.
12. Whitehead WE. Patient subgroups in irritable bowel syndrome
that can be defined by symptom evaluation and physical ex-
amination. Am J Med 1999;107:33S 40S.
13. Vanner SJ, Depew WT, Paterson WG, et al. Predictive value
of the Rome criteria for diagnosing the irritable bowel syn-
drome [see comments]. Am J Gastroenterol 1999;94:29127.
14. Hamm LR, Sorrells SC, Harding JP, et al. Additional inves-
tigations fail to alter the diagnosis of irritable bowel syndrome
in subjects fulfilling the Rome criteria. Am J Gastroenterol
1999;94:1279 82.
15. Thompson WG, Heaton KW, Smyth GT, et al. Irritable bowel
syndrome in general practice: Prevalence, characteristics, and
referral. Gut 2000;46:78 82.
16. Drossman DA, McKee DC, Sandler RS, et al. Psychosocial
factors in the irritable bowel syndrome. A multivariate study
of patients and nonpatients with irritable bowel syndrome.
Gastroenterology 1988;95:701 8.
17. Berg L. Data on file. The Research Unit in Primary Care,
Tibro, Sweden.
18. Thompson WG, Heaton KW, Smyth GT, et al. Irritable bowel
syndrome: The view from general practice. Eur J Gastroen-
terol Hepatol 1997;9:689 92.
19. Britt H, Miles DA, Bridges-Webb C, et al. A comparison of
country and metropolitan general practice. Aust Fam Physi-
cian 1994;23:1116 21, 24 5.
20. Jones R. Self-care and primary care of dyspepsia: A review.
Fam Pract 1987;4:68 77.
21. Loof L, Adami HO, Agenas I, et al. The Diagnosis and
Therapy Survey October 1978 March 1983, health care con-
sumption and current drug therapy in Sweden with respect to
the clinical diagnosis of gastritis. Scand J Gastroenterol 1985;
20(suppl 109):359.
22. Kruis W, Thieme C, Weinzierl M, et al. A diagnostic score for
the irritable bowel syndrome. Its value in the exclusion of
organic disease. Gastroenterology 1984;87:17.
23. Doggan UB, Unal S. Kruis scoring system and Mannings
criteria in diagnosis of irritable bowel syndrome: Is it better to
use combined? Acta Gastroenterol Belg 1996;59:225 8.
24. Agreus L. The abdominal symptom study. An epidemiological
survey of gastrointestinal and other abdominal symptoms in
the adult population of Osthammar, Sweden. Thesis, Uppsala
University, Uppsala, Sweden 1993.
25. Ragnarsson G, Bodemar G. Pain is temporally related to eating
but not to defecation in the irritable bowel syndrome (IBS).
Patients description of diarrhea, constipation and symptom
variation during a prospective 6-week study. Eur J Gastroen-
terol Hepatol 1998;10:41521.
26. Agreus L, Svardsudd K, Nyren O, et al. Reproducibility and
validity of a postal questionnaire. The abdominal symptom
study. Scand J Prim Health Care 1993;11:252 62.
Editorials 2681
Reprint requests and correspondence: Lars Agreus, M.D.,
Ph.D., Family Medicine Stockholm, Novum, SE-141 57 Stock-
holm, Sweden.
Received June 14, 2000; accepted June 14, 2000.
Completing Colonoscopy
Whenever a colonoscopic examination is indicated or de-
termined to be necessary, a total examination of the entire
colon is required. The trained endoscopist should be able to
reach the cecum in 95% of cases with no excuses for gender,
prior surgery, body habitus, or pain tolerance. The authors
of the article in this issue, Anderson et al. (1) have found
that, in women, the persons size is inversely correlated with
the degree of difficulty in performing colonoscopy: the
smaller the body mass index, the more difficult is the
colonoscopy. The St. Marks group also attempted to ex-
plain the difference in the degree of colonoscopic difficulty
in women (as opposed to men) and found that, when mea-
suring the length of the colon on barium enema examina-
tion, the average female colon was longer than that of a male
patient despite the smaller abdominal cavity in women (2).
The authors have also demonstrated that the presence of
diverticular disease does not adversely impact on the com-
pletion rate of colonoscopy, nor does a previous hysterec-
tomy (1).
By personal observation, I have found that colonoscopic
examinations are much more difficult in younger patients
than in older patients, in slender patients compared to obese
patients, and in women. Colonoscopy is also difficult in tall,
fat men and in patients with severe diverticular disease. I
believe that the difficulty encountered with diverticular dis-
ease is related to fixation, tortuosity, and acute angulations
of the colon. However, in the absence of massive divertic-
ulosis, the mere presence of diverticulosis is not a limiting
factor for colonoscopy. The difficulty with colonoscopy in
the younger patient is that the mesocolon is relatively tight
in younger patients and is intolerant to being stretched.
Pulling or stretch on the mesocolon accounts for most of
the discomfort during colonoscopy. As the instrument is
passed through the sigmoid colon, the loop that forms pulls
on the root of the mesentery and stretches the mesocolon. In
older patients, the mesocolon is quite elastic, rendering it
possible to make a large loop in the sigmoid colon without
the perception of pain, whereas a smaller loop in younger
persons can be quite painful.
An additional factor rendering the colonoscopic exami-
nation somewhat more difficult in slender women is related
to the relatively longer colon being folded into a smaller
abdominal cavity. This alone accounts for a considerable
amount of tortuosity throughout the colon, especially evi-
dent in the sigmoid region. Another consideration that is
rarely mentioned is the acute angle of the mid-sigmoid/
descending colon junction as the sigmoid colon ascends
from the pelvis over the uterus and then dips into the left
2682 Editorials
lower quadrant, causing a sharp angulation with the de-
scending colon. In slender young women, all of these factors
tend to coalesce, rendering the colonoscopic examination
difficult. The young woman is difficult because of the taut-
ness of the mesocolon, resisting stretch. The slender woman
has a smaller abdominal cavity volume than a heavy person,
causing more folds and twists of the colon. (It is my im-
pression that fat in the abdominal cavity tends to blunt the
acute angulation in the left lower quadrant, making it more
of a U turn than an abrupt V turn.) The heavier the colon so that the cecum may be reached with the short
patient, the easier is the intubation of the sigmoid colon. On
the other hand, the sigmoid is not especially difficult to
intubate in the tall, obese man; but, because of the long,
mobile mesentery and long colon, the colonoscope may get
hung up near the hepatic flexure and, despite all efforts to
straighten the instrument, pull it back, use torque and ab-
dominal pressure, there may not be enough instrument left
to complete the colonoscopic examination.
What tricks are available to help in total colonoscopic
examination in these two groups of patients, young slender
women and tall, heavy men? Each requires their own set of
maneuvers. For women, an instrument with a tighter bend-
ing radius and a shorter tip will markedly help to intubate
the acute angles encountered in the sigmoid colon. This can
usually be accomplished with a pediatric colonoscope,
which has the above two characteristics but which is also
more slender and able to pass through a tortuous colon. A
problem with the pediatric colonoscope is that it may be
floppy and not stiff enough to achieve total intubation
when used in the normal colon. I have found that the
recently introduced variable stiffness colonoscope (3) aids
immeasurably in the ability to pass a pediatric-style colono-
scope to the cecum, as the shaft can be stiffened to permit
total colonoscopic examination once the scope has passed
beyond the sigmoid colon in soft mode. In the absence of the
variable stiffness colonoscope, or even a pediatric colono-
scope, it has been my custom to revert to a gastroscope to
intubate the difficult sigmoid colon. A gastroscope is not
only slender but has a much smaller radius of tip deflection
than a colonoscope and has a shorter nose, making it the
ideal instrument for intubating a tortuous and fixed sigmoid.
However, the use of a gastroscope for colonoscopy has its
own set of problems, as it is considerably shorter and has the
tendency to run out of length when reaching the right colon.
For the tall, fat male patient, the problem is not passage
through the sigmoid colon, but that the length of the colono-
scope is taken up by the tendency to form and re-form loops
in the sigmoid and transverse colon. In this group of pa-
tients, it is often probable that nothing short of an entero-
scope will allow a total colonoscopic examination. I have
successfully used an enteroscope in this circumstance on
several occasions.
A new imager has been developed by groups in Britain
that uses magnetic fields to ascertain the position and con-
figuration of the flexible instrument (4). This nonfluoro-
scopic tool may be useful in knowing where and when loops
AJG Vol. 95, No. 10, 2000
are forming and can accurately locate the place to apply
pressure when needed to keep the instrument shaft straight.
The suggestions of the authors that more time be set aside
for the colonoscopic examination in young, slender women
is worthwhile. In these women, I often will request a vari-
able stiffness pediatric colonoscope to begin the examina-
tion or use a gastroscope. If using a gastroscope, multiple
attempts at straightening the instrument are necessary to try
to keep the instrument as straight as possible in the sigmoid
instrument. The same straightening maneuvers are neces-
sary when using a standard colonoscope in a tall, obese male
patient. There should be no reluctance to use an upper
endoscope in the colon, provided that it is cleaned in stan-
dard fashion. After all, a properly cleaned and disinfected
endoscope is a clean and disinfected endoscope, whether it
was used in the colon or in the upper tract. The problem is
not sterility nor practicality, but only one of esthetics. With
the use of the appropriate equipment, the right maneuvers,
and enough time, more patients will have the protection
against cancer that a more complete colonoscopic examina-
tion will afford.
Jerome D. Waye, M.D.
Mt. Sinai Hospital
New York, New York
REFERENCES
1. Anderson JC, Gonzalez JD, Messina CR, et al. Factors that
predict incomplete colonoscopy: Thinner is not always better.
Am J Gastroenterol 2000;95:2784 7.
2. Saunders BP, Fukumoto M, Halligan S, et al. Why is colonos-
copy more difficult in women? Gastrointest Endosc 1996;43:
124 6.
3. Brooker JC, Saunders BP, Shah SG, et al. A new variable
stiffness colonoscope makes colonoscopy easier: A randomized
controlled trial. Gut 2000;46:8015.
4. Williams CG, Saunders BP, Bell GD, et al. Real-time magnetic
three-dimensional imaging of flexible endoscopy. Gastrointest
Endosc Clin North Am 1997;7:469 75.
Reprint requests and correspondence: Jerome D. Waye, M.D.,
650 Park Avenue, New York, NY 10021-6115.
Received June 14, 2000; accepted June 14, 2000.
Portal Hypertensive Gastropathy:
Much Ado About Nothing?
Portal hypertensive gastropathy (PHG) is often encountered
during endoscopy of the portal hypertensive patient, because
of bleeding or nonbleeding problems. Subtle findings or the
more distinctive mosaic pattern, with or without erythema-
tous lesions and enlarged folds, may more often be regarded
as incidental. PHG becomes a concern with acute or chronic
bleeding in the absence of varices or ulceration, especially