Efficacy of Lukewarm Saline Water and Exercise as Colonoscopy Preparation – A Randomized,

Endoscopist Blinded Study(Presidential Award Recipient, ACG 2009)

Vijaypal Arya M.D, F.A.C.P, F.A.C.G, A.G.A.F. Clinical Asst Prof. of Medicine , Hofstra Northwell School of Medicine.

Director, Endoscopy UnitWyckoff Heights Medical Center.

President, Vikalp Inc.

Colon Polypectomy

DISCOVERY OF THE CENTURY

Polypectomy snare

Beth Israel Medical Center

1 Sivak et al., 2004, 2Winawer et al., 1993

Dr Hiromi Shinya1 and Dr William Wolf

1971 - First colonoscopic polypectomy

COLONOSCOPY

• Third most common cancer in USA- 131,607 new cases/year (2012) 67,700 men,

63907 women• Second Leading cause of cancer death in

men and women- 51,690 deaths (2012)

• Average patient CRC death- Losses 13 years of life

• A person at age of 50 has about - 5 % lifetime risk- 2.5% CRC death rate

CRC Facts

Average Risk Factors for Colorectal Cancer

• Male > Female

• AGE: 90% of cases occur at age 50 and above

Average Risk Factors for Colorectal Cancer

• Asymptomatic

Average Risk Factors for Colorectal Cancer

CRC Etiology • Environmental

– Stress– Activity– Diet

• Genetic – Sporadic 85-90% Avg risk• - HCCS 5-10% High risk

Consumption of red meat and

Saturated fat

Refined carbohydrates

Alcohol

Lack of regular physical activity.

Low fruit and vegetable intake.

A low-fiber and high-fat diet.

Overweight and obesity.

Tobacco use.

INCREASED RISK

Dietary factors implicated in colorectal carcinogenesis

North America has highest rate of Obesity-related cancers

• Colon

• Rectum

• Pancreas

• Esophagus

• Others

Dietary fiber

Vegetables

Fruits

Antioxidant/ vitamins

Calcium

folate (B Vitamin)

DECREASED RISK

Dietary factors implicated in colorectal carcinogenesis

Colonoscopy

Colonoscopy is considered the gold standard for colorectal cancer screening

Success of colonoscopy

Patient acceptance

Endoscopist skill

Colon preparation

PREP QUALITY

Bowel Preparation

• Dreaded more than procedure itself • Patient perspective

High volume

Unpalatable

Dietary restriction

Complex instructions

Day before v/s split dose

Impact on work or daily activity

Tolerability (side effects)

Consequences: More Pt. Discomfort

More Complications

Prolonged Procedure

Repeat Exams

Incomplete Exams

Missed lesions / Lost Polyps

Patient Dissatisfaction

Physician Dissatisfaction

POOR PREP

≈ 20-25%

CONVENTIONAL PREPS

Bowel Prep with Sitting & Watching TV: Is it good for colonoscopy outcome??

SHUDH INSPIRATION

A patient of Indian descent used “Shankh Prakshalana (BLS and exercise)” as a preparation for colonoscopy

The preparation was of such excellent quality that we were inspired to conduct our studies

Pilot Randomized -DVD

INSTRUCTIONS

Mindfulness: No Distractions

Make sure you have a designated bathroom

Drink continuously rather than sipping slowly 8 oz (240 ml) in less than one minute 16 oz (480 ml) in less than two minutes Alternate with Yoga Poses Use restroom as desired Continue until return is clear

INSTRUCTIONS

UPWARD STRETCH

Ready position While inhale While exhale

SIDE STRETCH

Ready Inhale and to right Inhale and to left

TWIST STRETCH

Ready position Inhale Inhale

Ready position Inhale Inhale

PUSH UP

Ready position Inhale Inhale

SQUATTING

How it Works

SHUDH SOLUTION

• 0.9% NS• Lukewarm• Isocaloric

BOLUS DRINKING

• First order kinetics -GE

• Gastro-colic reflex

YOGA

• Postures• Exercise • Breathing??• Gravity• ANS role

COMPONENTS OF SHUDH METHOD OF BOWEL PREPARATION

ROLE OF BOLUS DRINKING

• Rapid consumption (dumping) – Central role

• First order kinetics of Gastric emptying

- More volume empties into the intestines (maintains high flow rate)

• Prominent role of Gastro-colic cholinergic propulsive reflex ?

*8 oz. “Bolus” Minutes (SD)

16 oz. “Bolus” Minutes (SD) P-value

Total time spent 119.17 (39.30) 87.80 (38.60) <0.0310

Time to first bowel movement

57.42 (21.05) 25.80 (4.83) <0.0001

*Arya et al., JACM. 2010

EFFECT OF TEMPERATURE ON GARTRIC EMPTYING

• Lukewarm temperature:

– Relaxing effect on the cervical esophagus (enhances the effect of

bolus drinking)

– Adaptive relaxation of gastric muscle (allows greater volume to

be consumed)

• Cold liquids inhibits gastric emptying

EFFECT OF GRAVITY AND POSTURE ON GARTRIC EMPTYING

• Gravity and posture influence the intra-gastric

distribution of liquids:– Lying on right side improves gastric emptying of saline

– Result in more rapid emptying of non-nutrient inert liquids

• Duodenal feedback receptors are not stimulated

• Role of CCK? (Mg and Na salts cause CCK release)

EFFECT OF GRAVITY AND POSTURE ON GARTRIC EMPTYING

• Yoga poses involve:– Changes in gravity: Standing and Lying down

– Changes in posture: Right and left sided body movements & arms at various

positions

– Deep inhalation and exhalation can change the gastric configuration

– Vestibular fluid movements influence gastric emptying

• May have an accelerating effect on gastric emptying

EFFECT OF DEEP BREATHING ON GARTRIC EMPTYING

• Yoga poses start with deep inhalation and end with deep

exhalation

– Movements of diaphragm change the gastric

configuration and gastric emptying

– Deep breathing is a known parasympathetic

stimulator and it may accelerate gastric emptying

INHALATION

EXHALATION

STRETCHING

TO RIGHT SIDE

STRETCHING

TO LEFT SIDE

EFFECT OF EXERCISE ON GI MOTILITY

• Exercise improved colonoscopy preparation (Kim et al., Am J Gastro. 2005)

• We call Yoga poses as “Targeted Yoga Poses”:

– Poses 1-4: Improved gastric emptying

– Pose 5: Increased intra-abdominal pressure improving colonic motility

THE ROLE OF YOGA ITSELF

“Modern biomedical research identified mechanisms by

which mind and body interact”

“Advanced practitioners of Yoga regulate ANS”

ANS influences GI motility

• For the relaxed mind in a relaxed body - Thinking clean

may play a role in becoming so”

• Shankh Prakshalana began as purification process, after all

OTHER USES• Detoxification (every 3 to 4 months) • Irritable Bowel Syndrome

• Mild Constipation

CAUTION• Salt Sensitivity

• Chronic Heart, Liver, and Kidney Diseases

• Arthritis

• Pregnancy

• Diabetes; uncontrolled

• Gastrointestinal Obstruction

• Severe Constipation

The complete explanation of yoga cannot be put in words, it can only be experienced

-BKS Iyengar

Yoga is the only exercise on this planet from which you gain energy instead of burning energy.

-Bikram Choudhury

Thank you