NHS research radiographer, Ziyad Al-Dibouni, summarises his systematic literature review which explored the factors that contribute to pre-lower gastrointestinal endoscopic anxiety while reviewing anxiety-lowering interventions.
Inflammatory bowel disease (IBD) is a lifelong condition that is characterised by the chronic inflammation of the gastrointestinal (GI) tract . It is estimated that the two main forms of IBD, Crohn’s disease and ulcerative colitis, affect more than 300 000 people in the UK and even more worldwide.
Crohn’s disease can affect any site within the GI tract, whereas ulcerative colitis only affects the colon, and both are diagnosed, treated, and monitored in similar ways, with minor variations. One of the ways that are used to diagnose, assess, and survey disease progression is by lower GI endoscopic investigations more commonly known as colonoscopies and flexible sigmoidoscopies. These methods are the best way to get a definitive diagnosis of IBD and involves the insertion of a thin flexible tube with a camera attached to it, up through the rectum to allow visualisation of the intestines.
Patients will continue to have these procedures as part of their follow-up care which also includes regular screening for colorectal cancer after 8 years of living with IBD. Despite these procedures being commonly used worldwide they can be uncomfortable, despite the use of sedation to improve comfort, patients still have negative experiences and perceptions of the procedures .
Although it is widely documented and known that patients experience anxiety before medical procedures, there have been no studies that have specifically explored the prevalence and severity of pre-lower GI endoscopic investigations anxiety in IBD patients (as far as the author(s) are aware).
Why is this an important area of research?
Despite lower GI endoscopy being widely used and not just for IBD investigations, there remains a negative stigma attached to it which seems to stem from the embarrassing nature of the procedure. The presence of this stigma can lead to patients missing appointments, which could be harmful to their health due to potential conditions going undiagnosed or not being followed up. It also has knock-on financial implications on healthcare organisations caused by non-attendance; this occurs directly from the cost of the missed appointment but also indirectly from the complications that may arise as a result of not attending appointments when necessary.
A systematic literature review  was conducted to identify the factors that contribute to pre-lower GI endoscopic anxiety. This was to allow the prevalence and severity of this anxiety to be assessed and to identify possible predictors of anxiety as well as anxiety-lowering interventions in IBD patients.
The results of this review showed that while no study (as far as the author(s) are aware) specifically looked at pre-procedure anxiety in IBD patients, there were study groups that did contain IBD patients among others. The results showed that there were high levels of anxiety seen in patients awaiting pre-lower GI investigations with the cause of the anxiety being due to bowel preparation, potential discomfort, and the stigma of embarrassment.
The results also show that patients awaiting pre-lower GI endoscopic investigations commonly experienced feelings of fear, vulnerability, and embarrassment, as well as pain and the inconvenience of bowel preparation. The impact of the concerns highlighted above were often seen in those who experienced the highest levels of anxiety about their procedure. This has a negative impact on the procedure by either or a combination of increasing the time it took to sufficiently visualise the bowel, an increased dose of sedatives used and a greater risk of complications occurring during the procedure.
What are the implications?
As highlighted previously, anxiety about the procedure leads to missed and/or delayed appointments with consequences financially for the healthcare system and for patients themselves. Greater anxiety about the investigations could also complicate procedures and add to stress experienced by patients. As these areas have been identified as contributors to anxiety in patients, addressing these factors should be of priority to help ease the emotional difficulty associated with such a procedure and to lower the overall impact anxiety has on patients, in the hopes of improving the overall patient experience.
How does it fit in with other research?
This literature review sought to expand on that previously conducted by Yang et al , who looked at anxiety associated with colonoscopy and flexible sigmoidoscopy in those received screening for colorectal cancer, to include IBD patients. Yang et al. (2018) concluded that most patients in their study reported pre-procedural anxiety which warranted an investigation into the methods used to reduce experienced anxiety. Their study showed that improving the way information is provided to patients prior to their procedure is an appropriate method of reducing anxiety experienced. This was mirrored in the literature review that was conducted highlighting that despite there being other methods to reduce anxiety such as multimedia/audio-visual tools, music therapy and aroma therapy, the greater emphasis should be on how the information is presented to the patient rather than the amount of information provided.
You can find Ziyad on Instagram at:
@thegrumblinggut - for IBD awareness:
@theresearchrad - for Radiology Research:
1. Bessissow T, Van Keerberghen CA, Van Oudenhove L, Ferrante M, Vermeire S, Rutgeerts P, Van Assche G. Anxiety is associated with impaired tolerance of colonoscopy preparation in inflammatory bowel disease and controls. J Crohns Colitis. 2013 Dec;7(11): e580-7. doi: 10.1016/j.crohns.2013.04.011. Epub 2013 May 9. PMID: 23664621.
2. Ersöz F, Toros AB, Aydoğan G, Bektaş H, Ozcan O, Arikan S. Assessment of anxiety levels in patients during elective upper gastrointestinal endoscopy and colonoscopy. Turk J Gastroenterol. 2010 Mar;21(1):29-33. doi: 10.4318/tjg.2010.0044. PMID: 20533109.
3. Ziyad Al-Dibouni, Andrew Poullis, and Marcus Jackson. Factors associated with anxiety in pre-lower gastrointestinal endoscopy in inflammatory bowel disease patients: a systematic literature review Gastrointestinal Nursing 2020 18: Sup8, S26-S35
4. Yang C, Sriranjan V, Abou-Setta AM, Poluha W, Walker JR, Singh H. Anxiety Associated with Colonoscopy and Flexible Sigmoidoscopy: A Systematic Review. Am J Gastroenterol. 2018 Dec;113(12):1810-1818. doi: 10.1038/s41395-018-0398-8. Epub 2018 Nov 1. PMID: 30385831; PMCID: PMC6768596.