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Asgari A, Ziamanesh F, Aliasgari A, Sohrabpour AA. Incidence and predicting factors of inadequate bowel preparation for colonoscopy: A cross-sectional study. JGH Open 2024; 8:e13116. [PMID: 39170058 PMCID: PMC11336044 DOI: 10.1002/jgh3.13116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 06/07/2024] [Accepted: 06/21/2024] [Indexed: 08/23/2024]
Abstract
Background and Aim Adequate bowel preparation is necessary for optimal colonoscopy. Inadequate bowel preparation results in increased costs and imprecise colonoscopy results. This study aims to determine the incidence and risk factors of inadequate bowel preparation. Methods In this study, 604 consecutive patients were observed prospectively who underwent colonoscopy examination. The patient's clinical and demographic data were obtained on the day of the procedure. Bowel preparation was evaluated by Boston Bowel Preparation Scale (BBPS) and was divided into two groups; adequate and inadequate. Univariate and multivariate analyses were performed. Results Inadequate bowel preparation incidence was 17.9%. In the univariate analysis, education level (P value = 0.009), body mass index (P value = 0.03), admission type (P value = 0.038), previous history of colonoscopy (P value = 0.03), color and consistency of the last feces (P value = 0.03), diabetes (P value = 0.004), and smoking (P value = 0.03) were significantly related with the incidence of inadequate bowel preparation. While ischemic heart disease (IHD) decreased the level of inadequate bowel preparation (P value = 0.047). Multivariate analysis showed that diabetes mellitus (odds ratio [OR] = 2.18), smoking (OR = 2.10), inpatient status of admission type (OR = 3.32), last stool that was non-watery (OR = 1.60), and ischemic heart disease (OR = 0.032) were independent factors associated with inadequate bowel preparation. Conclusion Diabetic patients, smokers, inpatients and who defecated a non-watery and colory stool as the last defecation are at risk of inadequate bowel preparation and need more potent regimens. It is important to inform patients about preventable factors that affect bowel preparation to improve their preparation outcomes.
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Affiliation(s)
- Alireza Asgari
- Digestive Disease Research InstituteTehran University of Medical SciencesTehranIran
| | - Fateme Ziamanesh
- Digestive Disease Research InstituteTehran University of Medical SciencesTehranIran
| | - Ali Aliasgari
- Digestive Disease Research InstituteTehran University of Medical SciencesTehranIran
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2
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Chen L, Ren G, Luo H, Zhang L, Wang L, Zhao J, Zhang R, Zhang X, Kang X, Pan Y. Superiority of a preparation-related model for predicting inadequate bowel preparation in patients undergoing colonoscopy: A multicenter prospective study. J Gastroenterol Hepatol 2022; 37:2297-2305. [PMID: 36181263 DOI: 10.1111/jgh.16010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 07/15/2022] [Accepted: 09/17/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Three models based on patient-related factors have been developed to predict inadequate bowel preparation (BP). However, the performance of the models seems suboptimal. This study aimed to develop a novel preparation-related model and compare it with the available patient-related models. METHODS Patients receiving standard BP were prospectively enrolled from five endoscopic centers. Patient-related and preparation-related factors for inadequate BP (defined by segmental Boston Bowel Preparation Scale score < 2) were identified by logistic regression. A preparation-related model was derived and internally validated in 906 patients. The comparisons of models were assessed by discrimination and calibration. The preparation-related model was also externally validated. RESULTS Several patient-related factors (male and American Society of Anesthesiologists Physical Status Classification System score ≥ 3) and preparation-related factors (drinking-to-stool interval ≥ 3 h, preparation-to-colonoscopy interval ≥ 6 h, and poor rectal effluent) were found to be independently associated with inadequate BP (all P < 0.05). C-statistics was 0.81 for the preparation-related model in the training cohort (n = 604), significantly higher than three available patient-based models (0.58-0.61). Similar results were observed in the validation cohort (n = 302). Calibration curves showed close agreement in the preparation-related model (R2 = 0.315 in the training cohort and 0.279 in the validation cohort). The preparation-related model was externally validated in another 606 patients with C-index of 0.80. CONCLUSIONS A new preparation-related model (consisting of drinking-to-stool interval ≥ 3 h, preparation-to-colonoscopy interval ≥ 6 h, and poor last rectal effluent) was developed and performed better than three available patient-related models. This easy-to-use model may be a useful decision-support tool on individualized plans in patients undergoing BP.
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Affiliation(s)
- Long Chen
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Gui Ren
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Hui Luo
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Linhui Zhang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Limei Wang
- Department of Gastroenterology, Shaanxi Second People's Hospital, Xi'an, Shaanxi, China
| | - Jianghai Zhao
- Department of Gastroenterology, Huaihe Hospital of Henan University, Kaifeng, Henan, China
| | - Rongchun Zhang
- Department of Gastroenterology, Hongai Hospital, Xiamen, Fujian, China
| | - Xiaoying Zhang
- Department of Gastroenterology, Shenzhen Hospital of Southern Medical University, Shenzhen, Guangdong, China
| | - Xiaoyu Kang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Yanglin Pan
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
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Kurlander JE, Waljee AK, Menees SB, Lipson R, Kokaly AN, Read AJ, Shehadeh KS, Cohn A, Saini SD. Regression and Random Forest Machine Learning Have Limited Performance in Predicting Bowel Preparation in Veteran Population. Dig Dis Sci 2022; 67:2827-2841. [PMID: 34169434 DOI: 10.1007/s10620-021-07113-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 06/12/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND Inadequate bowel preparation undermines the quality of colonoscopy, but patients likely to be affected are difficult to identify beforehand. AIMS This study aimed to develop, validate, and compare prediction models for bowel preparation inadequacy using conventional logistic regression (LR) and random forest machine learning (RFML). METHODS We created a retrospective cohort of patients who underwent outpatient colonoscopy at a single VA medical center between January 2012 and October 2015. Candidate predictor variables were chosen after a literature review. We extracted all available predictor variables from the electronic medical record, and bowel preparation from the endoscopy database. The data were split into 70% training and 30% validation sets. Multivariable LR and RFML were used to predict preparation inadequacy as a dichotomous outcome. RESULTS The cohort included 6,885 Veterans, of whom 964 (14%) had inadequate preparation. Using LR, the area under the receiver operating characteristic curve (AUC) for the validation cohort was 0.66 (95% CI 0.62, 0.69) and the Brier score, in which a lower score indicates better performance, was 0.11. Using RFML, the AUC for the validation cohort was 0.61 (95% CI 0.58, 0.65) and the Brier score was 0.12. CONCLUSIONS LR and RFML had similar performance in predicting bowel preparation, which was modest and likely insufficient for use in practice. Future research is needed to identify additional predictor variables and to test other machine learning algorithms. At present, endoscopy units should focus on universal strategies to enhance preparation adequacy.
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Affiliation(s)
- Jacob E Kurlander
- Department of Internal Medicine, University of Michigan, 3912 Taubman Center, 1500 E. Medical Center Dr., SPC 5362, Ann Arbor, MI, 48109-5362, USA. .,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA. .,Veterans Affairs Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA.
| | - Akbar K Waljee
- Department of Internal Medicine, University of Michigan, 3912 Taubman Center, 1500 E. Medical Center Dr., SPC 5362, Ann Arbor, MI, 48109-5362, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,Veterans Affairs Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Stacy B Menees
- Department of Internal Medicine, University of Michigan, 3912 Taubman Center, 1500 E. Medical Center Dr., SPC 5362, Ann Arbor, MI, 48109-5362, USA.,VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, USA
| | - Rachel Lipson
- Veterans Affairs Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Alex N Kokaly
- Department of Medicine, UCLA Health, 200 UCLA Medical Plaza, Suite 420, Los Angeles, 90095-1685, CA, USA
| | - Andrew J Read
- Department of Internal Medicine, University of Michigan, 3912 Taubman Center, 1500 E. Medical Center Dr., SPC 5362, Ann Arbor, MI, 48109-5362, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Karmel S Shehadeh
- Department of Industrial and Systems Engineering, Lehigh University, 200 West Packer Ave, Bethlehem, PA, 18015, USA
| | - Amy Cohn
- Department of Industrial and Operations Engineering, University of Michigan, 2015 Beal Ave, Ann Arbor, MI, 4819-2117, USA
| | - Sameer D Saini
- Department of Internal Medicine, University of Michigan, 3912 Taubman Center, 1500 E. Medical Center Dr., SPC 5362, Ann Arbor, MI, 48109-5362, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,Veterans Affairs Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
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Comparative Effectiveness of Commercial Bowel Preparations in Ambulatory Patients Presenting for Screening or Surveillance Colonoscopy. Dig Dis Sci 2021; 66:2059-2068. [PMID: 32691384 PMCID: PMC8794767 DOI: 10.1007/s10620-020-06492-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 07/11/2020] [Indexed: 12/09/2022]
Abstract
BACKGROUND Inadequate bowel preparation (IBP) is associated with reduced adenoma detection. However, limited research has examined the impact of different commercial bowel preparations (CBPs) on IBP and adenoma detection. We aim to determine whether type of CBP used is associated with IBP or adenoma detection. METHODS We retrospectively evaluated outpatient, screening or surveillance colonoscopies performed in the Cleveland Clinic health system between January 2011 and June 2017. IBP was defined by the Aronchick scale. Multilevel mixed-effects logistic regression was performed to assess the association between CBP type and IBP and adenoma detection. Fixed effects were defined as demographics, comorbidities, medication use, and colonoscopy factors. Random effect of individual endoscopist was considered. RESULTS Of 153,639 colonoscopies, 75,874 records met inclusion criteria. Median age was 54; 50% were female; 17.7% had IBP, and adenoma detection rate was 32.6%. In adjusted analyses, compared to GoLYTELY, only NuLYTELY [OR 0.66 (95% CI 0.60, 0.72)] and SuPREP [OR 0.53 (95% CI 0.40, 0.69)] were associated with reduced IBP. Adenoma detection did not vary based on the type of bowel preparation used. CONCLUSIONS Among patients referred for screening or surveillance colonoscopy, choice of CBP was not associated with adenoma detection. Decisions about CBP should be based on other factors, such as tolerability, cost, or safety.
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Cavett CL, Tonero M, Marks SL, Winston JA, Gilor C, Rudinsky AJ. Consistency of faecal scoring using two canine faecal scoring systems. J Small Anim Pract 2021; 62:167-173. [PMID: 33491796 DOI: 10.1111/jsap.13283] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 10/28/2020] [Accepted: 11/26/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To determine the agreement of canine faecal scoring between individuals with different levels of experience using two available faecal scoring systems. MATERIALS AND METHODS Naturally-voided, undisturbed bowel movements from 126 dogs were evaluated by veterinarians (n = 3) and members of the lay public (n = 126) within 15 minutes of defecation. Each participant was provided a copy of the Purina and Waltham faecal scoring charts in order to characterise the faeces. Agreement between veterinarians and lay people was assessed with kappa statistics, Bland-Altman analysis and visualised with Bland-Altman plots. RESULTS Variable levels of consistency were observed in assessing faecal form among individuals with varying degrees of experience. Fair to substantial agreement existed between individual veterinarians scoring the same bowel movement (kappa statistic ranging from 0.40 to 0.77 on the Purina Scale and 0.54 to 0.61 on the Waltham Scale), while the agreement scores between the veterinarian and the lay public was fair (kappa statistic of 0.38 on the Purina Scale and 0.34 on the Waltham Scale). Disagreement in faecal scores occurred more frequently with lay people versus veterinarians. CLINICAL SIGNIFICANCE The consistency of faecal scoring improved based on the level of experience with the highest agreement consistently noted between veterinarians. In all comparisons, there was inconsistency in faecal scoring which might have implications for veterinarians managing diarrhoeic canine patients. Further studies are needed to better investigate how faecal scoring can be optimised for use in clinical and research settings.
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Affiliation(s)
- C L Cavett
- Department of Veterinary Clinical Medicine (Cavett, Tonero), College of Veterinary Medicine, University of Illinois, Urbana, Illinois, 61820, USA
| | - M Tonero
- Department of Veterinary Clinical Medicine (Cavett, Tonero), College of Veterinary Medicine, University of Illinois, Urbana, Illinois, 61820, USA
| | - S L Marks
- Department of Veterinary Medicine and Epidemiology (Marks), School of Veterinary Medicine, University of California, Davis, Davis, California, 95616, USA
| | - J A Winston
- Department of Veterinary Clinical Sciences (Winston, Rudinsky), College of Veterinary Medicine, The Ohio State University, Columbus, Ohio, 43210, USA.,Comparative Hepatobiliary and Intestinal Research Program (CHIRP) (Winston, Rudinsky), College of Veterinary Medicine, The Ohio State University, Columbus, Ohio, 43210, USA
| | - C Gilor
- Department of Small Animal Clinical Sciences (Gilor), College of Veterinary Medicine, University of Florida, Gainesville, Florida, 32608, USA
| | - A J Rudinsky
- Department of Veterinary Clinical Sciences (Winston, Rudinsky), College of Veterinary Medicine, The Ohio State University, Columbus, Ohio, 43210, USA.,Comparative Hepatobiliary and Intestinal Research Program (CHIRP) (Winston, Rudinsky), College of Veterinary Medicine, The Ohio State University, Columbus, Ohio, 43210, USA
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An Evidence-based Approach Towards Targeted Patient Education to Improve Bowel Preparation for Colonoscopy. J Clin Gastroenterol 2020; 54:707-713. [PMID: 31764487 DOI: 10.1097/mcg.0000000000001286] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
GOALS AND BACKGROUND Quality of bowel preparation is an important factor influencing adenoma detection. Patient education is believed to improve the quality of bowel preparation but might be resource-intensive. We aimed to (a) identify risk factors for failed bowel preparations and (b) develop and test the efficacy of a screening tool that allows to prospectively identify and target patients at increased risk. STUDY Part 1: 76 consecutive outpatients with poor bowel preparation were compared with 76 age-matched and gender-matched outpatients with good preparation from the same procedure lists. Sociodemographic and clinical data were obtained from centralized databases. Univariate analysis and multivariate logistic regression was used to identify risk factors for poor bowel preparation. Part 2: on the basis of results of part 1, a screening tool for prospectively identifying patients at high risk was developed, and targeted education tested. RESULTS We identified the use of opioids or other constipating agents and low socioeconomic status as risk factors for poor bowel preparation [odds ratio (OR)=2.88; 95% confidence interval (CI): 1.22-6.80 and OR=2.43; 95% CI: 1.25-4.72]. Diabetes, hypothyroidism, age, and gender were found to have no effect on quality. When education was provided only to patients at increased risk, the targeted approach did not negatively affect the proportion of poor preparation (OR=6.12%; 95% CI: 4.79%-7.78% vs. OR=5.73%; 95% CI: 4.61%-7.10%). CONCLUSIONS Poor bowel preparation is associated with specific risk factors. Identifying and specifically targeting education at patients with these risk factors appears to facilitate more efficient use of education resources in endoscopy.
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7
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Kutyla MJ, Gray MA, von Hippel C, Hourigan LF, Kendall BJ, Whaley AJ, O'Connor S, Holtmann GJ. Improving the Quality of Bowel Preparation: Rewarding Patients for Success or Intensive Patient Education? Dig Dis 2020; 39:113-118. [PMID: 32720916 DOI: 10.1159/000510461] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 07/22/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION AND OBJECTIVES The quality of the bowel preparation is a critical parameter for the outcome of colonoscopies. It is well established that the bowel preparation modality (e.g., split or larger volume preparation) significantly improves the quality of the bowel preparation. Patient compliance is another important factor impacting on the quality of bowel preparations that receives relatively little research attention. We aimed to explore if intensified education or a lottery ticket as reward for good bowel preparation could improve outcomes. METHODS After informed consent, all patients received a standardized printed information booklet. In a randomized fashion, patients were offered (a) a lottery scratchy ticket with an opportunity to win $25,000 as "reward" for good bowel preparation, (b) an education session delivered over the phone by a trained nurse, or (c) no additional measure. RESULTS Overall, the quality of the bowel preparation was rated good or very good in 69.1% (95% CI 61.7-75.7%) of patients. Reward intervention did not influence the quality of bowel preparation (OR 0.42, 95% CI 0.09-1.91, p = 0.260); however, bowel preparation quality decreased in patients randomized to receive the additional education (OR 0.28, 95% CI 0.08-0.96, p = 0.042). Neither intervention significantly impacted on polyp detection rates. CONCLUSIONS Contrasting general beliefs, additional interventions (e.g., incentives or phone consultation) did not improve the quality of the bowel preparation. The unexpected result shows that utilizing extra resources must be balanced against real-world outcomes and may not always provide the expected result.
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Affiliation(s)
- Marguerite J Kutyla
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia.,School of Pharmacy, Faculty of Health and Behavioural Sciences, University of Queensland, Brisbane, Queensland, Australia
| | - Marcus A Gray
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia.,School of Psychology, Faculty of Health and Behavioural Sciences, University of Queensland, Brisbane, Queensland, Australia.,Translational Research Institute, Brisbane, Queensland, Australia
| | - Courtney von Hippel
- School of Psychology, Faculty of Health and Behavioural Sciences, University of Queensland, Brisbane, Queensland, Australia
| | - Luke F Hourigan
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Bradley J Kendall
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Amanda J Whaley
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Sam O'Connor
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Gerald J Holtmann
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia, .,Translational Research Institute, Brisbane, Queensland, Australia, .,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia, .,Faculty of Health and Behavioural Sciences, University of Queensland, Brisbane, Queensland, Australia,
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8
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Effect of the High-FODMAP Diet on Bowel Preparation for Colonoscopy: A Multicenter, Prospective Cohort Study. Gastroenterol Res Pract 2020; 2020:1612040. [PMID: 32676102 PMCID: PMC7327609 DOI: 10.1155/2020/1612040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 05/19/2020] [Accepted: 06/02/2020] [Indexed: 12/16/2022] Open
Abstract
Background Optimal bowel preparation for colonoscopy is fundamental to a successful examination. The FODMAP diet can increase the content of intestinal water and gas, but its impact on bowel cleanliness and bubbles has not been reported. This study was therefore aimed at evaluating the effect of the FODMAP diet on the quality of bowel preparation and the adenoma detection rate (ADR). Methods This was a multicenter, prospective cohort study involving consecutive patients who underwent colonoscopy in two centers in China. Patients were assigned to one of two groups: high-FODMAP or nonhigh-FODMAP diet. ODMP Software was used for the identification of FODMAP diet types. The primary outcome was ADR; secondary outcomes were the quality of bowel preparation, measured by the Boston bowel preparation scale and bubble scores. Results There were 365 patients included. Patients in the high-FODMAP-diet group showed poor bowel cleansing efficacy: BBPS ≥ 6 in 76.8% vs. 90.3% (P < 0.01) and bubble scores of 2.42 ± 1.69 vs. 1.32 ± 1.63 (P < 0.001). The intubation time was significantly longer in the high-FODMAP-diet group (7.07 ± 5.18 vs. 5.46 ± 3.05 min; P = 0.002). The High-FODMAP diet was an independent risk predictor for inadequate bowel preparation. There were no statistically significant differences in ADR between the two dietary groups. Conclusion The high-FODMAP diet significantly reduced the quality of bowel preparation. We recommend the consumption of nonhigh-FODMAP diet in bowel preparation as a reference standard for dietary regimen. This method was effective, flexible, referable, and well tolerated, which could help to provide patients a valuable dietary guidance in bowel preparation.
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Shin SY, Ga KS, Kim IY, Park YM, Jung DH, Kim JH, Youn YH, Park H, Park JJ. Predictive factors for inadequate bowel preparation using low-volume polyethylene glycol (PEG) plus ascorbic acid for an outpatient colonoscopy. Sci Rep 2019; 9:19715. [PMID: 31873135 PMCID: PMC6928254 DOI: 10.1038/s41598-019-56107-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 11/04/2019] [Indexed: 02/08/2023] Open
Abstract
Low-volume polyethylene glycol (PEG) plus ascorbic acid solutions are widely used for bowel cleansing before colonoscopy. This study aimed to investigate the pre-endoscopic predictive factors for inadequate preparation in subjects receiving low-volume PEG plus ascorbic acid. A prospective study was performed at Gangnam Severance Hospital, Korea, from June 2016 to December 2016. All participants received low-volume PEG plus ascorbic acid solutions for outpatient colonoscopy. The split-dose bowel preparation was administered in subject with morning colonoscopy while same day bowel preparation was used for afternoon colonoscopy. 715 patients were enrolled (mean age 56.1 years, 54.4% male), of which 138 (19.3%) had an inadequate bowel preparation. In multivariable analysis, cirrhosis (OR 4.943, 95% CI 1.191–20.515), low (less than 70%) compliance for three-day low-residual diet (OR 2.165, 95% CI 1.333–3.515), brown liquid rectal effluent (compared with clear or semi-clear effluent) (OR 7.604, 95% CI, 1.760–32.857), and longer time interval (≥2 hours) between last defecation and colonoscopic examination (OR 1.841, 95% CI, 1.190–2.849) were found as an independent predictors for inadequate preparation. These predictive factors may be useful in guiding additional intervention to improve quality of bowel preparation.
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Affiliation(s)
- Seung Yong Shin
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Kyeong Seon Ga
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - In Young Kim
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yoo Mi Park
- Health Promotion Center, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Da Hyun Jung
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jie-Hyun Kim
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young Hoon Youn
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyojin Park
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Jun Park
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
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10
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Hyun JH, Kim SJ, Park JH, Wie GA, Kim JS, Han KS, Kim BC, Hong CW, Sohn DK. Lifestyle Factors and Bowel Preparation for Screening Colonoscopy. Ann Coloproctol 2018; 34:197-205. [PMID: 30208683 PMCID: PMC6140368 DOI: 10.3393/ac.2018.03.13] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 03/13/2018] [Indexed: 01/10/2023] Open
Abstract
Purpose The quality of bowel preparation is a major determinant of the quality of colonoscopy. This study evaluated lifestyle factors, including usual dietary style, associated with bowel preparation. Methods This retrospective study evaluated 1,079 consecutive subjects who underwent complete colonoscopy from December 2012 to April 2014 at National Cancer Center of Korea. Questionnaires on bowel preparation were completed by the subjects, with the quality of bowel preparation categorized as optimal (excellent or good) or suboptimal (fair, poor or inadequate). Lifestyle factors associated with bowel preparation were analyzed. Results The 1,079 subjects included 680 male (63.0%) and 399 female patietns (37.0%), with a mean age of 49.6 ± 8.32 years. Bowel preparation was categorized as optimal in 657 subjects (60.9%) and as suboptimal in 422 (39.1%). Univariate analyses showed no differences between groups in lifestyle factors, such as regular exercise, alcohol intake, smoking, and dietary factor. Body mass index (BMI) > 25 kg/m2 was the only factor associated with suboptimal bowel preparation on both the univariate (P = 0.007) and the multivariate (odds ratio, 1.437; 95% confidence interval, 1.104–1.871; P = 0.007) analyses. Conclusion Most lifestyle factors, including dietary patterns, exercise, alcohol intake and smoking, were not associated with suboptimal bowel preparation in Koreans. However, BMI > 25 kg/m2 was independently associated with suboptimal bowel preparation. More intense preparation regimens before colonoscopy can be helpful in subjects with BMI > 25 kg/m2.
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Affiliation(s)
- Jong Hee Hyun
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Sang Jin Kim
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Jung Hun Park
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Gyung Ah Wie
- Department of Clinical Nutrition, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Jeong-Seon Kim
- Division of Cancer Epidemiology and Prevention, Research Institute, National Cancer Center, Goyang, Korea
| | - Kyung Su Han
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Byung Chang Kim
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Chang Won Hong
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Dae Kyung Sohn
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
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Predictors of inadequate bowel preparation for colonoscopy: a systematic review and meta-analysis. Eur J Gastroenterol Hepatol 2018; 30:819-826. [PMID: 29847488 DOI: 10.1097/meg.0000000000001175] [Citation(s) in RCA: 128] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The aim of this study was to investigate factors contributing to poor bowel preparation in patients undergoing colonoscopy procedures. We used a reproducible search strategy to identify studies, searching 10 medical databases, including PubMed, Ovid, Medline, and Cochrane Library Database for reports published between 2000 and 2016. Fully published studies, evaluating risk factors for inadequate bowel preparation, were included. Two reviewers independently scored the identified studies for methodology and abstracted pertinent data. Pooling was conducted with both fixed-effects and random-effects models; results were presented from the random effects model when heterogeneity was significant. Odds ratios (OR) estimates with 95% confidence interval were calculated. Heterogeneity was assessed by I statistics. Twenty-four studies with a total of 49 868 patients met the inclusion criteria. Age (OR: -1.20), male sex (OR: 0.85), inpatient status (OR: 0.57), diabetes mellitus (OR: 0.58), hypertension (OR: 0.58), cirrhosis (OR: 0.49), narcotic use (OR: 0.59), constipation (OR: 0.61), stroke (OR; 0.51), and tricyclic antidepressant (TCA) use (0.51), were associated with inadequate bowel preparation. In our sensitivity analysis comparing Western and Asian countries, we found that diabetes, cirrhosis, male sex, history of stroke and TCA use were stronger risk factors for inadequate bowel preparation in Western countries than in Asian countries. We also found that history of stroke, TCA use, and race were risk factors for inadequate bowel preparation in patients receiving conventional bowel preparation compared with those receiving split-dose bowel preparation. Multiple risk factors affect the quality of bowel preparation and specific risk factors can be intervened upon, in different populations, to optimize preparation.
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Woo DH, Kim KO, Jeong DE, Nam YJ, Lee SH, Jang BI, Kim TN. Prospective analysis of factors associated with inadequate bowel preparation for colonoscopy in actual clinical practice. Intest Res 2018; 16:293-298. [PMID: 29743843 PMCID: PMC5934603 DOI: 10.5217/ir.2018.16.2.293] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 10/17/2017] [Accepted: 10/20/2017] [Indexed: 12/13/2022] Open
Abstract
Background/Aims Inadequate bowel preparation can result in prolonged procedure time and increased missed lesion and complication rates. This prospective study aimed to evaluate bowel preparation quality and identify the predictive factors for inadequate bowel preparation in actual clinical practice. Methods We included 399 patients who underwent colonoscopy between June 2015 and July 2016. Using the Aronchick bowel preparation scale, we defined a score ≤2 as adequate preparation and a score >2 as inadequate preparation. Results Mean patient age was 58.38±12.97 years; 60.6% were male. Indications for colonoscopy included screening (69.7%) and surveillance after polyp removal (21.3%). A split-dose regimen was prescribed to 55.4% of patients. The inadequate bowel preparation rate was 28.1%. Overall, the median time between the last bowel preparation agent dose and start of colonoscopy was 5.0 hours (range, 1.5-16.0 hours); that of the adequate group was 5.0 hours (range, 1.5-16.0 hours); and that of the inadequate group was 5 hours (range, 2-23 hours). The mean bowel preparation scale score of the ascending colon (1.94±0.25) was significantly higher than that of other colon segments. On multivariate analysis, elderly age, history of cerebrovascular disease, history of gastrectomy or appendectomy, and total preparation solution uptake <2 L were the independent predictors of inadequate bowel preparation. Conclusions The inadequate bowel preparation rate was 28.1%. Risk factors included elderly age and history of cerebrovascular disease or abdominal surgery. Patients with these risk factors require special care and education.
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Affiliation(s)
- Dae Hyung Woo
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Kyeong Ok Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Da Eun Jeong
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Yoon Jeong Nam
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Si Hyung Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Byung Ik Jang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Tae Nyeun Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
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Patient Characteristics Associated With Quality of Colonoscopy Preparation: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2018; 16:357-369.e10. [PMID: 28826680 DOI: 10.1016/j.cgh.2017.08.016] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 08/03/2017] [Accepted: 08/08/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Some features of patients are associated with inadequate bowel preparation, which reduces the effectiveness of colonoscopy examination. We performed a systematic review and meta-analysis of the association between patients' sociodemographic characteristics, health conditions, and medications with inadequate bowel preparation. METHODS We searched the PubMed, Scopus, and Cochrane Review databases for randomized controlled trials cohort (prospective and retrospective), case-control, and cross-sectional studies published through March 2016. We collected information on study design, study population, and bowel preparation. For each factor, we obtained the odds ratio (OR) for inadequate bowel preparation. We conducted the meta-analyses using the random-effects approach and investigated any identified heterogeneity and publication bias via graphical methods, stratification, and meta-regression. RESULTS We performed a meta-analysis of 67 studies, comprising 75,818 patients. The estimated pooled OR for inadequate bowel preparation was small for sociodemographic characteristics: 1.14 for age, and 1.23 for male sex (excluding studies in Asia, which had substantial heterogeneity and publication bias), and 1.49 for low education. The effect of high body mass index differed significantly in studies with mostly female patients (OR, 1.05) vs those with mostly male patients (OR, 1.30) (P = .013 for the difference). ORs for constipation and cirrhosis were heterogeneous; adjusted ORs were larger than unadjusted ORs (1.97 vs 1.29 for constipation and 3.41 vs 1.36 for cirrhosis). Diabetes (OR, 1.79), hypertension (OR, 1.25), stroke or dementia (OR, 2.09), and opioid use (OR, 1.70) were associated with inadequate bowel preparation. History of abdominal surgery (OR, 0.99) did not associate with inadequate bowel preparation. Use of tricyclic antidepressants had a larger effect on risk of inadequate bowel preparation in studies of mostly female patients (OR, 2.62) than studies of mostly male patients (OR, 1.42) (P = .085 for the difference). CONCLUSIONS In a systematic review and meta-analysis, we found no single patient-related factor to be solely associated with inadequate bowel preparation. Health conditions and use of some medications appear to be stronger predictors than sociodemographic characteristics.
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Zhang YY, Niu M, Wu ZY, Wang XY, Zhao YY, Gu J. The incidence of and risk factors for inadequate bowel preparation in elderly patients: A prospective observational study. Saudi J Gastroenterol 2018; 24:87-92. [PMID: 29637915 PMCID: PMC5900479 DOI: 10.4103/sjg.sjg_426_17] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND/AIM : We conducted a prospective observational study to identify the incidence of and risk factors for inadequate bowel preparation in elderly Chinese patients. PATIENTS AND METHODS We enrolled 240 outpatients over 60 years of age scheduled for elective colonoscopy at our university hospital between November 2016 and April 2017. We recorded patient demographics, bowel preparation data, and clinical characteristics. Factors associated with inadequate bowel preparation were identified by multivariate logistical regression analysis. RESULTS The rate of inadequate bowel preparation was 34.6%. Factors associated with inadequate bowel preparation were a history of abdominal surgery (OR, 2.617; CI, 1.324-5.174; P = 0.006), chronic constipation (OR, 3.307; CI, 1.551-7.054; P = 0.002), non-compliance with dietary instructions (OR, 2.239; CI, 1.122-4.471; P = 0.022), non-compliance with polyethylene glycol (PEG) dosage (OR, 4.576; CI, 1.855-11.287; P = 0.001), walking <30 minutes during preparation (OR, 2.474; CI, 1.261-4.855; P = 0.008), interval between PEG ingestion and the onset of bowel activity (OR, 1.025; CI, 1.010-1.040; P = 0.001), and a last stool that was not clear and watery (OR, 4.191; CI, 1.529-11.485; P = 0.005). CONCLUSION The incidence of adequate bowel preparation in elderly patients is not optimal. Walking <30 minutes during the PEG ingestion period may be a surrogate for bowel preparation failure. Future studies should identify elderly patients at risk for poor bowel preparation and develop interventions to improve outcomes in this population.
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Affiliation(s)
- Yuan-Yuan Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Soochow University, Suzhou, China,Department of Medicine, School of Nursing, Soochow University, Suzhou, China
| | - Mei'e Niu
- Department of Nursing, The First Affiliated Hospital of Soochow University, Suzhou, China,Address for correspondence: Mei'e Niu, Department of Nursing, The First Affiliated Hospital of Soochow University, Suzhou 215006, China. E-mail:
| | - Zhen-Yun Wu
- Department of Medicine, School of Nursing, Soochow University, Suzhou, China
| | - Xi-Ya Wang
- Department of Gastroenterology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Yuan-Yuan Zhao
- Department of Medicine, School of Nursing, Soochow University, Suzhou, China
| | - Jie Gu
- Department of Gastroenterology, The First Affiliated Hospital of Soochow University, Suzhou, China
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Mandolesi D, Frazzoni L, Bazzoli F, Fuccio L. The management of 'hard-to-prepare' colonoscopy patients. Expert Rev Gastroenterol Hepatol 2017; 11:731-740. [PMID: 28594580 DOI: 10.1080/17474124.2017.1338947] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Effective bowel cleansing is crucial for high quality colonoscopy. A notable portion of patients still present with low quality bowel preparation prior to their colonoscopy, compromising the overall quality of their colonoscopy. Areas covered: This review focuses on the main strategies that can improve the cleansing quality with a special interest on those clinical conditions that have been associated with a poor bowel preparation quality, such as patients with chronic constipation, history of bowel resection, liver cirrhosis, diabetes mellitus and chronic kidney disease. The review provides a practical and evidence-based approach to help clinicians in the management of 'hard-to-prepare' patients. Expert commentary: In the past few years, the quality of colonoscopy has become a hot topic and bowel cleansing is a crucial part of it; however, the approach to patients with an increased risk of poor bowel preparation quality is still not always supported by high-quality evidence, since most of these patients are routinely excluded from the clinical studies. Trials focused on this subgroup of patients are recommended to provide tailored bowel preparation regimens and guarantee high-quality procedures.
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Affiliation(s)
- Daniele Mandolesi
- a Gastroenterology Unit, Department of Medical and Surgical Sciences , University of Bologna, S.Orsola-Malpighi Hospital , Bologna , Italy
| | - Leonardo Frazzoni
- a Gastroenterology Unit, Department of Medical and Surgical Sciences , University of Bologna, S.Orsola-Malpighi Hospital , Bologna , Italy
| | - Franco Bazzoli
- a Gastroenterology Unit, Department of Medical and Surgical Sciences , University of Bologna, S.Orsola-Malpighi Hospital , Bologna , Italy
| | - Lorenzo Fuccio
- a Gastroenterology Unit, Department of Medical and Surgical Sciences , University of Bologna, S.Orsola-Malpighi Hospital , Bologna , Italy
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Kawasato R, Hashimoto S, Shirasawa T, Goto A, Okamoto T, Nishikawa J, Sakaida I. Correlation between obesity and metabolic syndrome-related factors and cecal intubation time during colonoscopy. Clin Exp Gastroenterol 2017; 10:1-7. [PMID: 28115863 PMCID: PMC5221549 DOI: 10.2147/ceg.s120544] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Purpose To investigate which colonoscopy (CS) cases should be presided over by endoscopists in training, using factors including obesity and metabolic syndrome. Patients and methods Items investigated were sex, age, body mass index (BMI), waist circumference, hypertension, diabetes, hyperlipidemia, history of abdominal surgery (excluding colectomy), colon diverticulosis, prescription of antithrombotic agents, and quality of bowel preparation. Expert physicians were defined as those with at least 9 years of endoscopy experience; all other physicians were defined as being in training. In a retrospective analysis, cases in which a physician in training reached the cecum within 15 minutes without requiring the involvement of the supervising physician were defined as eligible cases over which a physician in training should preside, while other cases were defined as non-eligible. Results Overall, 813 CS cases were analyzed. Males (P<0.0001), cases started by an expert physician (P<0.0001), cases of no fellow physician involvement (P<0.0001), and cases with good bowel preparation (P<0.0001) had significantly shorter cecal intubation times. Of the 562 cases presided over by a physician in training, 194 were deemed eligible and 368 non-eligible. The eligible cases had a higher proportion of males (P=0.017), younger age (P=0.033), higher BMI (P=0.034), and higher rates of hypertension (P=0.001) and good bowel preparation (P=0.001). In analysis by sex, males demonstrated significantly more eligible cases among younger patients (P=0.009) and those with good bowel preparation (P=0.008), while there were significantly more eligible cases among females with hypertension (P=0.004). Conclusion It may be useful to select CS cases for physicians considering sex, age, BMI, hypertension, and bowel preparation.
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Affiliation(s)
| | | | | | | | | | - Jun Nishikawa
- Department of Laboratory Science, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
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Fang J, Fu HY, Ma D, Wang D, Liu YP, Wang YF, Zhu CP, Qian W, Bai Y, Li ZS. Constipation, fiber intake and non-compliance contribute to inadequate colonoscopy bowel preparation: a prospective cohort study. J Dig Dis 2016; 17:458-63. [PMID: 27356275 DOI: 10.1111/1751-2980.12376] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 06/14/2016] [Accepted: 06/22/2016] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Adequate bowel preparation is important for colonoscopy. Currently available evidence on the determinants of poor bowel preparation is largely derived from studies in Western countries. We aimed to identify the risk factors for inadequate bowel preparation for colonoscopy in the Chinese population. METHODS In this single-center study, patients admitted to the Outpatient Department between March 2013 and December 2015 and had indications for colonoscopy were prospectively enrolled. Questionnaires were administered to the patients. Their characteristics and procedure-related parameters such as procedure time were recorded. Bowel preparation was assessed using Boston bowel preparation scale score. RESULTS A total of 409 patients with a mean age of 48.8 ± 12.9 years were enrolled in the study, 60.9% of whom were men. On univariate analysis, poor educational level (P = 0.020), chronic constipation (P = 0.001), taking no physical exercise after medication (P < 0.001), a high-fiber diet during the 24-h period immediately preceding the colonoscopy (P < 0.001), incomplete intake of medication (P < 0.001), the passage of yellow or dark stools before colonoscopy (P < 0.001), waiting time (P = 0.001) and stool frequency after medication (P = 0.048) were significantly associated with inadequate bowel preparation. On multivariate analysis, chronic constipation [odds ratio (OR) 2.05, 95% confidence interval (CI) 1.31-3.23, P = 0.002], incomplete intake of the medication (OR 2.77, 95% CI 1.47-5.21, P = 0.002) and a high-fiber diet within 24 h before colonoscopy (OR 2.15, 95% CI 1.40-3.28, P < 0.001) were independent risk factors for inadequate bowel preparation. CONCLUSIONS Chronic constipation, poor compliance with treatment and high-fiber diet were predictors of poor bowel preparation. Patients with these risk factors require more effective strategies for bowel preparation.
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Affiliation(s)
- Jun Fang
- Department of Gastroenterology, Shanghai, China
| | - Hong Yu Fu
- Digestive Endoscopy Center, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Dan Ma
- Department of Gastroenterology, Shanghai, China
| | - Dong Wang
- Department of Gastroenterology, Shanghai, China
| | - Ya Ping Liu
- Department of Gastroenterology, Shanghai, China
| | | | | | - Wei Qian
- Department of Gastroenterology, Shanghai, China
| | - Yu Bai
- Department of Gastroenterology, Shanghai, China.
| | - Zhao Shen Li
- Department of Gastroenterology, Shanghai, China.
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