STRESS MEDICINE, VOL. 3: 301-305 (1987)

RESEARCH REPORTS

STRESS RESPONSES TO TWO INVASIVE

COLONOSCOPY AND SIGMOIDOSCOPY MEDICAL INVESTIGATIONS: LEFT-SIDED

ELAINE FOX. B A ' Research Department, Eastern Health Board, Garden Hill, E H B Box 41a, 1 James St, Dublin 8

AND

CIARAN A. O'BOYLE, BSc. PhD Research Department, Eastern Health Board, Garden Hill, E H B B O X 4/a, I James St, Dublin 8

and

Department of' Psychology, Royal College of Surgeons in Irelurid. St Stevens Green. Dribliti 2

AND

JOHN LENNON. MD, FRCPI Gastrointestinal Unit, Muter Misericordiue Hospital, Dublin 7

SUMMARY Invasive medical investigations constitute significant stressful events for many patients. Data are presented from 60 adult patients undergoing either left-sided colonoscopy (N=47) or sigmoidoscopy ( N = 13). Stress responses were measured by means of objective and subjective ratings and by indices of cardiovascular arousal. Eighty- five per cent of patients rated the procedure as painful, 68 per cent reported anxiety about undergoing the procedure again, and heart-rate was significantly elevated during the test. Experienced pain was the determining factor in the patients' perception of the stressfulness of the procedure. The colonoscopist tended to underestimate the degree of patient discomfort, and also the need for drug intervention. The results suggest that some form of premedication would help patients cope with these stressful investigations. It is clear that analgesic rather than anxiolytic premedication would be most appropriate in this population.

KEY worms-stress, medical investigations, left-sided colonoscopy, sigmoidoscopy.

Modern stress research is increasingly concerned with investigating stress responses to naturalistic situations and events.' Invasive medical examinations constitute such events, being unpleasant experiences for most patients.2 In a descriptive survey of medical ward patients, Wilson-Barnett and Carrigy-' found that 90 per cent of patients undergoing an invasive test described the experience in negative terms. Hawkins4 reported that over half of the patients

Correspondence to Elaine Fox

074~8386/87/040301-05$05 .00 0 1987 by John Wiley RC Son, Ltd.

undergoing invasive tests (angiography, gastro- scopy, myelogram) suffered pain and discomfort, and intense emotional responses have been observed in patients undergoing cardiac catheter- ization,h gastro~copy,"~~ sigrnoidoscopyX and blood donation.'

There is a paucity of information regarding diagnostic examinations of the bowel and colon such as sigmoidoscopy (SIG), which is a common diagnostic examination of the mucosa of the bowel and anal cavity. While this test is not believed to be particularly painful, it is

Received 12 December 1986

302 ELAINE FOX, CIARAN A. O’BOYLE AND JOHN LENNON

uncomfortable and causes stress in a significant number of patients.x Left-sided colonoscopy (LS) is a more extensive examination of the bowel and colon with a fibre-optic instrument which can extend to the caecum. This test usually lasts about 10 minutes and often causes severe cramp-like pain since air is inserted into the colon to aid visualization of the lumen. The aim of the present study was to determine the stressfulness of SIG and LS in a group of unmedicated patients.

METHODS

Sixty unmedicated patients (33 female, 27 male), ranging in age from 19 to 78 years (mean=46 years), presenting for routine signoidoscopy ( N = 13) or left-sided colonoscopy (N=47) took part in the study. Because of the multidimen- sional nature of the stress response, self-report measures and objective ratings, as well as indices of cardiovascular arousal, were used.

Patient assessment The Spielberger State-Trait Anxiety Inventory

(STAI: 10) was used as a self-report measure of anxiety. A specially designed patient question- naire evaluated patients’ opinions of the pro- cedure (tolerable, unpleasant, very unpleasant), whether the test was ‘better’ or ‘worse’ than expected, whether they would be worried about a repeat examination (not at all, a little, very), whether the test was painful (not at all, a little, very), whether they would have liked sedation, and finally, how anxious they were about the test (not at all, somewhat, moderately so, very much so).

Colonoscopist and nurse assessment The colonoscopist questionnaire required

ratings of the adequacy of the examination (excel- lent, good, poor), patient pain and anxiety (mild, moderate, severe) and requirement for sedation (strongly indicated, indicated, not indicated). The nurse questionnaire involved assessment of (1) patient anxiety and (2) patient discomfort during scoping (mild, moderate, severe).

Cardiovascular measurement Systolic and diastolic blood pressure (SBP,

DBP: mmHg) and heart-rate (HR: bpm) were

measured with a Dinamap 845 automatic moni- tor: (2) before the examination (baseline), (b) at insertion of the sigmoidoscope, and (c) during scoping.

Procedure Patients were interviewed by a psychologist

approximately 30 minutes before their test and the nature of the study was explained to them. Both trait and state scales of the STAI were then administered and SBP, DBP and HR were measured. Ten minutes following their test each patient again completed the state-anxiety scale and the patient questionnaire. The colonoscopist and the attending nurse independently completed their respective questionnaires immediately fol- lowing examination of each patient.

RESULTS

Patient ratings Patients were significantly more anxious as

rated on the state-anxiety scale of the STAI before than after the procedure (X,,, = 45.8; Xpl,ht=40.0; p<0.001). The majority found the procedure unpleasant and painful and would be concerned about having it repeated (Table 1). Of those experiencing pain,.94.7 per cent would have liked sedation (p<O.Ol) , and all rated the procedure as ‘unpleasant’ or ‘very unpleasant’. In contrast 80 per cent of patients reporting ‘no pain’ rated the procedure as ‘tolerable’ (p<0.001). A multiple regression analysis was conducted to determine the major variables influencing the patients’ opinion of the test. The only variable explaining a significant amount of the variance was subjectively experienced pain (R2=0.44, p<0.0001). Other variables in the regression included age, sex, trait and state anx- iety and previous experience; these variables combined accounted for only 4 per cent of the variance.

Patients found LS more traumatic than SIG. Less than half (46.2 per cent) of the SIG patients would have liked sedation, compared to 82.6 per cent of LS patients (p<0.05). 84.6 per cent of the SIG patients rated the test as ‘better’ than expected, while only 50 per cent of the LS pati- ents felt that it was ‘better’ than they had expected ( ’ ~ ~ 0 . 0 5 ) .

STRESS AND ENDOSCOPY 303

Table 1 - Patients’ assessment of the procedure. (Data were missing for one patient, N=59)

Patient rating

Opinion of procedure

Was test better than expected

Would you be worried about repeat examination

Would you like sedation

Was the procedure painful

Tolerable Unpleasant Very unpleasant

Better Worse

Not at all A little Very

Yes No

Not at all A little Very

N %

19 32.2 23 39.0 17 28.8

34 57.6 25 42.4 18 30.5 30 50.8 11 18.6 44 74.6 15 25.4

8 13.6 36 61.0 15 25.4

~ ~~ .- -. ~

Table 2 - Colonoscopist and nurse’s assessment of patients undergoing the procedure

Colonoscopist rating”

Adequacy of examination

Patient anxiety

Patient pain

Indication for sedation

Nurse’s rating Patient anxiety

Poor Good Excellent Mild Moderate Severe

Mild Moderate Severe

~~ ~ ~

N Yo

4 6.9 11 19.0 43 74.1 38 65.5 14 24.1 6 10.3

38 65.5 16 27.6 4 6.9

Not indicated 41 70.7 Indicated 15 25.9 Strongly indicated 2 3.4

Mild Moderate Severe

36 60.0 16 26.7 8 13.3

Patient discomfort Mild 29 48.3 Moderate 19 31.7 Severe 12 20.0

* Data missing for two patients (N=58).

Colonoscopist and nurse assessment pain, and sedation was indicated in just 17 pati- ents (28 per cent). The colonoscopist’s rec- ommendation for sedation was clearly based on hidher perception of patients’ pain. All patients rated as experiencing ‘severe’ pain, and 56.3 per cent of those rated as experiencing ‘moderate’

The majority of patients were rated as experi- encing ‘mild’ anxiety by both the colonoscopist and the nurse (Table 2). The colonoscopist felt that the majority of patients experienced ‘mild’

304 ELAINE FOX, CIARAN A. O’BOYLE AND JOHN LENNON

pain, were judged to require sedation, whereas sedation was not recommended for any patient rated as having ‘mild’ pain @<0.001).

Both the colonoscopist and the nurse’s assess- ment indicated more distress during LS than dur- ing SIG. Sedation was recommended only in LS patients @<0.05), and more ‘discomfort’ was observed in LS patients by the attending nurse ( ’ ~ ~ 0 . 0 5 ) .

Cardiovascular data Cardiovascular monitoring was instituted half-

way through the trial. SIG was considered too brief to obtain accurate measurements, therefore cardiovascular parameters were recorded in 32 patients underoing LS. SBP and DBP remained relatively constant from baseline to intraoperative pgriods, whereas HR increased significantly (XHR at scoping=93 bpm, x HR at baseline=84 bpm: pC0.05). Patients showing high preoperat- ive anxiety had significantly higher HR at base- line, insertion and during scoping (Table 3).

Table 3 - Pearson correlations of preoperative state anxiety with cardiovascular function at baseline,

insertion and scoping

Baseline Insertion Scoping - -

Heart-rate 048* 059” 0 54k

Diastolic BP -0.14 -005 -0 04 Systolic BP -0 17 -006 -0 22

* p<O.Ol. *li p<O.OOI.

Concordance between assessments Significant agreement was found between the

colonoscopist and nurse’s assessment of both anx- iety and pain (Table 4). As shown, the nurses’ and patients’ ratings of anxiety and painldis- comfort were in agreement. However, the col- onoscopist and patient ratings were significantly related for pain but not for anxiety.

Although the colonoscopist and patient ratings of pain were significantly related, the correlation was not very strong. Of the 15 patients who rated the procedure as ‘very painful’, 14 (93.3 per cent) were rated by the colonoscopist as experiencing either ‘mild’ (33.3 per cent) or ‘moderate’ (60 per cent) pain. In contrast, seven of these patients

(46.7 per cent) were rated by the nurse as experi- encing ‘severe’ discomfort.

DISCUSSION

The stressfulness of left-sided colonoscopy (LS) and lower sigmoidoscopy (SIG) was assessed by means of objective and subjective assessments in 60 adult outpatients. Findings indicated that these diagnostic examinations are highly unpleasant and painful experiences for the majority of pati- ents, particularly for those undergoing LS. Given that patients may be required to undergo repeat procedures, the subjective stress of these tests is a cause for concern.

Both the clinician and the attending nurse tended to underestimate the distress and pain experienced by patients. In general, the nurse’s rating was a more accurate assessment of the patient‘s emotional state, possibly because the colonoscopist is concerned with the internal examination while the nurse is in constant attend- ance to the patient. The divergence between the physicians’ and the patients’ perception of the procedure has considerable implications given that the physicians base their judgement of the requirement for medication on their own percep- tion of patient pain. It should also be noted that many investigations have utilized only physicians’ impression of patient so that pati- ents’ actual tolerance of many invasive pro- cedures may be overestimated.

It has been suggested that drug intervention (e.g. benzodiazepine sedation) helps patients to cope with stressful medical investigations. l 3 In the present study, the majority of patients would have liked some form of premedication. Since experienced pain was the major factor in deter- mining patients’ perception of the procedure, it would appear that analgesia is more appropriate for this population than anxiolytic medication. While the colonoscopists based their recommen- dation for premedication on their perception of patients’ pain, this rating of pain was an under- estimation of subjectively experienced pain.

Research is clearly needed to determine whether psychological stress reduction tech- n i q u e ~ ’ ~ or pharmacologocal techniques, I s which have been effective with other types of invasive procedures, would be successful in helping pati- ents cope with colonoscopic examinations. Given that subjectively experienced pain emerged as a

STRESS AND ENDOSCOPY 305

Table 4 - Spearman rank-order correlations between colonoscopist, nurse and patients' perception of the procedure

Colonoscopist rating Nurse rating Patient rating

Anxiety Indication for sedation Discomfort Anxiety Anxiety Pain

- . _. ~ - _ _ _ ~ _ ~ - ~ ~~ _ _ _ _ -

~ ~~ ~ _ _ _ _ - _ _ - ~

Pain 0.25" 0.62*** Anxiety 0.28"" Sedation

Discomfort Anxiety

0.49""" 0.07 0.14 0.27" 0.44' a :@ 0.30:' 0.21 0.25'E

0.28" * 0.14 0.31""

0.09 0.37"" 037'? :L

0.38" " * 0.56 * 2% *

-0.06

Anxiety 0.13

* p<0.05. * * p<o.01. * * * p<o.001

major variable in the present study, intervention techniques designed to reduce pain rather than anxiety would appear to be most appropriate.

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