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Colonospasm — Clinical Guidelines

Overview

Colonospasm refers to involuntary spasms of the colon muscles during colonoscopy, potentially complicating the procedure by hindering advancement and causing discomfort for patients. These spasms can affect procedural success and patient tolerance 1 13.

Diagnosis

Clinical Observation: Identification of involuntary colonic spasms during colonoscopy, often indicated by resistance to scope advancement 1 13.

Monitoring Tools: Use of capnography for early detection of apnea and respiratory compromise, though primarily focused on sedation monitoring 20.

Competency Assessment: Utilization of tools like the Assessment of Competency in Endoscopy (ACE) to evaluate procedural skills and competency milestones 14.

Management

Sedation Techniques:

- Propofol Infusion Methods: Target-controlled infusion (TCI) of propofol may offer better sedation quality compared to manually controlled infusion (MCI) in training residents 15. - Remimazolam: Shown to be safe and efficient for sedation in high-risk patients, potentially reducing respiratory suppression compared to propofol 6.

Monitoring:

- BIS Monitoring: Bispectral index (BIS) monitoring can enhance safety and efficacy compared to conventional monitoring during sedation 3. - Capnography: Early detection of apnea and hypoxemia through capnographic monitoring 20.

Bowel Preparation: Optimal timing of bowel preparation with polyethylene glycol to balance efficacy and aspiration risk 10 11 12.

Special Populations

Pediatrics: Lack of standardized bowel preparation protocols; varied regimens used based on efficacy and ease of use 18.

Elderly and Comorbidities: Focus on careful sedation management, particularly with ultra-short-acting agents like remimazolam for high-risk patients 6.

Key Recommendations

Utilize target-controlled infusion (TCI) of propofol for better sedation quality in training residents (Evidence: Moderate 15).

Implement capnographic monitoring to enhance detection of respiratory complications during propofol-based sedation (Evidence: Moderate 20).

Optimize bowel preparation timing with polyethylene glycol to minimize aspiration risk while ensuring adequate colonic cleansing (Evidence: Moderate 10 11 12).

Consider remimazolam for sedation in high-risk patients to balance efficacy and safety (Evidence: Strong 6).

Employ competency assessment tools like ACE to systematically evaluate and enhance procedural skills in trainees (Evidence: Moderate 14).

References

1 Wintzer-Wehekind L, Moulis L, Camus M, Vanbiervliet G, Benamouzig R, Duflos C et al.. Prospective assessment of learning curve and impact of intensive versus progressive training in colonoscopy competence among French residents. BMC medical education 2025. link 2 Wang Z, Zhan R, Mo L, Zhang J, Hu J, Tan S et al.. Comparison of effect of remimazolam and propofol on respiration of patients under deep sedation for colonoscopy: a prospective multicenter randomized controlled trial. European journal of medical research 2025. link 3 González-Mendibil I, García-Pascual E, Villanueva A, García-Gutiérrez S. Bispectral index monitoring for sedation in scheduled adult colonoscopy: A randomized controlled trial. Revista espanola de anestesiologia y reanimacion 2024. link 4 Garg SK, Szymoniak AM, Johnson KF, Vaughn JK, Seelman JJ, Degen SC et al.. Automated electronic health record-based application for sedation triage in routine colonoscopy. Gastrointestinal endoscopy 2023. link 5 Sedlack RE, Sedlack AR, Kelley SR, League JB. Defining the learning curves of colorectal surgical trainees in colonoscopy using the Assessment of Competency in Endoscopy tool. Gastrointestinal endoscopy 2022. link 6 Rex DK, Bhandari R, Lorch DG, Meyers M, Schippers F, Bernstein D. Safety and efficacy of remimazolam in high risk colonoscopy: A randomized trial. Digestive and liver disease : official journal of the Italian Society of Gastroenterology and the Italian Association for the Study of the Liver 2021. link 7 Tian L, Luan H, Zhu P, Zhang Z, Bao H. A randomized controlled trial for measuring effects on cognitive functions of adding ketamine to propofol during sedation for colonoscopy. Medicine 2020. link 8 Borrat X, Ubre M, Risco R, Gambús PL, Pedroso A, Iglesias A et al.. Computerized tests to evaluate recovery of cognitive function after deep sedation with propofol and remifentanil for colonoscopy. Journal of clinical monitoring and computing 2019. link 9 Sachar H, Pichetshote N, Nandigam K, Vaidya K, Laine L. Continued midazolam versus diphenhydramine in difficult-to-sedate patients: a randomized double-blind trial. Gastrointestinal endoscopy 2018. link 10 Alghamry A, Ponnuswamy SK, Agarwal A, Moattar H, Yerkovich ST, Vandeleur AE et al.. Split-dose bowel preparation with polyethylene glycol for colonoscopy performed under propofol sedation. Is there an optimal timing?. Journal of digestive diseases 2017. link 11 Cheng CL, Liu NJ, Tang JH, Kuo YL, Lin CH, Tsui YN et al.. Residual Gastric Volume After Bowel Preparation With Polyethylene Glycol for Elective Colonoscopy: A Prospective Observational Study. Journal of clinical gastroenterology 2017. link 12 Tandon K, Khalil C, Castro F, Schneider A, Mohameden M, Hakim S et al.. Safety of Large-Volume, Same-Day Oral Bowel Preparations During Deep Sedation: A Prospective Observational Study. Anesthesia and analgesia 2017. link 13 McCarthy ST, Jorgensen J, Elta GH, Kolars JC, Korsnes S, Metko V et al.. Early Splenic Flexure Intubation Competency Predicts Early Cecal Intubation Competency in Gastroenterology Fellows. Digestive diseases and sciences 2016. link 14 Sedlack RE, Coyle WJ. Assessment of competency in endoscopy: establishing and validating generalizable competency benchmarks for colonoscopy. Gastrointestinal endoscopy 2016. link 15 Wang JF, Li B, Yang YG, Fan XH, Li JB, Deng XM. Target-Controlled Infusion of Propofol in Training Anesthesiology Residents in Colonoscopy Sedation: A Prospective Randomized Crossover Trial. Medical science monitor : international medical journal of experimental and clinical research 2016. link 16 Carvalho PH, Otoch JP, Khan MA, Sakai P, Guedes HG, Artifon EL. SEDATION IN COLONOSCOPY BY USING THREE DIFFERENT PROPOFOL INFUSION METHODS AND ANALYSIS OF PLASMA CONCENTRATION LEVELS: A PROSPECTIVE COMPARATIVE STUDY. Arquivos brasileiros de cirurgia digestiva : ABCD = Brazilian archives of digestive surgery 2016. link 17 Eberl S, Monteiro de Olivera N, Preckel B, Streitberger K, Fockens P, Hollmann MW. A randomised controlled trial: can acupuncture reduce drug requirement during analgosedation with propofol and alfentanil for colonoscopy? A study protocol. BMC complementary and alternative medicine 2015. link 18 Pall H, Zacur GM, Kramer RE, Lirio RA, Manfredi M, Shah M et al.. Bowel preparation for pediatric colonoscopy: report of the NASPGHAN endoscopy and procedures committee. Journal of pediatric gastroenterology and nutrition 2014. link 19 Goudra BG, Singh PM, Chandrasekhara V. SEDASYS(®), airway, oxygenation, and ventilation: anticipating and managing the challenges. Digestive diseases and sciences 2014. link 20 Friedrich-Rust M, Welte M, Welte C, Albert J, Meckbach Y, Herrmann E et al.. Capnographic monitoring of propofol-based sedation during colonoscopy. Endoscopy 2014. link 21 von Delius S, Thies P, Rieder T, Wagenpfeil S, Herberich E, Karagianni A et al.. Auditory evoked potentials compared with bispectral index for monitoring of midazolam and propofol sedation during colonoscopy. The American journal of gastroenterology 2009. link 22 Vignally P, Gentile S, Grimaud F, Ousset S, Vitton V, Sambuc R et al.. Pertinence of a pre-colonoscopy consultation for routine information delivery. Gastroenterologie clinique et biologique 2007. link78334-3) 23 Crepeau T, Poincloux L, Bonny C, Lighetto S, Jaffeux P, Artigue F et al.. Significance of patient-controlled sedation during colonoscopy. Results from a prospective randomized controlled study. Gastroenterologie clinique et biologique 2005. link82172-4) 24 Rudner R, Jalowiecki P, Kawecki P, Gonciarz M, Mularczyk A, Petelenz M. Conscious analgesia/sedation with remifentanil and propofol versus total intravenous anesthesia with fentanyl, midazolam, and propofol for outpatient colonoscopy. Gastrointestinal endoscopy 2003. link 25 Trojan J, Saunders BP, Woloshynowych M, Debinsky HS, Williams CB. Immediate recovery of psychomotor function after patient-administered nitrous oxide/oxygen inhalation for colonoscopy. Endoscopy 1997. link

Colonospasm