Morning-only one-gallon polyethylene glycol improves bowel cleansing for afternoon colonoscopies: a randomized endoscopist-blinded prospective study

Sleep Disturbances, Bowel Movement Kinetics, and Travel Interruption With Bowel Preparation: A Bowel CLEANsing National Initiative Substudy

INTRODUCTION

We investigated sleep disturbances, bowel movement (BM) kinetics, and travel experience with different bowel preparation regimens in a substudy of patients enrolled in a randomized multicenter Canadian clinical trial.

METHODS

Patients scheduled to have a colonoscopy between 7:30 am and 10:30 am (early morning) were randomized to (i) 4-L single-dose polyethylene glycol (PEG) given in the evening before, (ii) 2-L split-dose PEG (+bisacodyl 15 mg), or (iii) 4-L split-dose PEG. Patients scheduled to undergo a colonoscopy between 10:30 am and 4:30 pm (afternoon) were randomized to (iv) 2-L single-dose PEG (+bisacodyl 15 mg) in the morning, (v) 2-L split-dose PEG (+bisacodyl 15 mg), or (vi) 4-L split-dose PEG. Patients were asked to record information on BM kinetics, sleep, and travel to the endoscopy unit. Continuous and categorical variables were compared between groups using a Kruskal-Wallis test or χ 2 test, respectively. Intention-to-treat analyses were performed.

RESULTS

Overall, 641 patients were included in this substudy. Patients undergoing early morning colonoscopies reported the most awakenings in the night when assigned to 4-L single-dose day-before PEG and the highest reduction in sleep hours when assigned to 4-L split-dose PEG. There were no significant between-group differences in urgent BMs, fecal incontinence episodes, or travel interruptions. Overall, 17% of those traveling for more than an hour had to stop for a BM during travel, with no significant difference between groups.

DISCUSSION

Day-before and split-dose high-volume PEG regimens for colonoscopies scheduled before 10:30 am lead to the greatest sleep disturbance.

Efficacy and Tolerability of Two Different Low-Volume Split-Dose Polyethylene Glycol Electrolytes Solution Bowel Preparation for Morning Colonoscopy

METHODS

A total of 120 patients were randomized to receive either the control group (n = 64) or the experimental group (n = 65). Patients in the control group adopted the low-volume split-dose regimen one, and patients in the experimental group adopted the low-volume split-dose regimen two. Those randomized to regimen one were instructed to take 0.75 L PEG two hours after dinner the day before the colonoscopy and 1.5 L PEG 4 hours before the colonoscopy. Patients assigned to regimen two were invited to consume 1.5 L PEG two hours after dinner the day before the colonoscopy and 0.75 L PEG 4 hours before the colonoscopy. The quality of bowel preparation, rated according to a Boston Bowel Preparation Scale (BBPS), represented the primary outcome measure. Tolerability, satisfaction, and lesions detection rated were secondary outcomes.

RESULTS

There was no significant difference between the transverse colon and right colon scores between the two groups (P > 0.05). The low-volume split-dose regimen two showed a higher success rate for cleansing of the right colon and overall colon (P < 0.05). For the comparison of the patients' bowel tolerance, there were no statistical differences between the two groups regarding thirst, abdominal pain or abdominal discomfort, abdominal distension, dizziness or headache, anal discomfort, and sleep disturbance (P > 0.05). However, regimen two had significantly less nausea, vomiting, and fatigue than regimen one (24.62% vs. 42.19%, P=0.034; 10.77% vs. 25.00%, P=0.035; 6.15% vs. 21.88%, P=0.010, respectively). Patient-reported satisfaction and willingness to repeat the bowel preparation were significantly higher for low-volume split-dose regimen two than for low-volume split-dose regimen one (P=0.011; P=0.015).

CONCLUSIONS

In early morning colonoscopies, the bowel-cleansing efficacy and patient tolerability of low-volume split-dose regimen two were superior to low-volume split-dose regimen one.

Comparison Between Same-Day and Split-Dose Preparations with Sodium Picosulfate/Magnesium Citrate: A Randomized Noninferiority Study

BACKGROUND

Sodium picosulfate/magnesium citrate (SPMC) is a small-volume bowel cleansing agent with similar efficacy to and better tolerability than polyethylene glycol. However, we found no data on which SPMC preparation (same-day vs. split-dose) provides better bowel cleansing efficacy for afternoon colonoscopy.

AIMS

To compare bowel cleansing efficacy of different timing of the regimen.

METHODS

This randomized, single-center, endoscopist-blinded, noninferior study compared same-day and split-dose SPMC preparations for afternoon colonoscopy in 101 and 96 patients, respectively. We also included a prospective observation group of 100 patients receiving morning colonoscopy to compare bowel preparation between morning and afternoon colonoscopies. Bowel cleansing efficacy was then evaluated by the Aronchick Scale, Ottawa Bowel Preparation Scale (OBPS), Boston Bowel Preparation Scale (BBPS), and the Bubble Scale.

RESULTS

Same-day and split-dose preparations were similar in efficacy in all four scales. In the Aronchick Scale, the success rate (excellent and good cleanliness) was higher in same-day preparation than in split-dose preparation (100% vs. 92.8%). The same-day preparation also obtained a better OBPS score (1.4 vs. 2.1), but BBPS showed no difference between such groups (7.7 vs. 7.4).

CONCLUSION

Same-day preparation with SPMC is not inferior to split-dose preparation for afternoon colonoscopy.

Quality Indicators for the Detection and Removal of Colorectal Polyps and Interventions to Improve Them

Modifiable risk factors for postcolonoscopy colorectal cancer include suboptimal lesion detection (missed neoplasms) and inadequate lesion removal (incomplete polypectomy) during colonoscopy. Competent detection and removal of colorectal polyps are thus fundamental to ensuring adequate colonoscopy quality. Several well-researched quality metrics for polyp detection have been implemented into clinical practice, chief among these the adenoma detection rate. Less data are available on quality indicators for polyp removal, which currently include complete resection rates and skills assessment tools. This review summarizes the available literature on quality indicators for the detection and removal of colorectal polyps, as well as interventions to improve them.

Efficacy and safety of oral sulfate solution for bowel preparation in Japanese patients undergoing colonoscopy: Noninferiority-based, randomized, controlled study

OBJECTIVES

To compare the efficacy and safety of oral sulfate solution administered using the same-day dose and the split-dose regimens with those of polyethylene glycol plus ascorbate solution, used for bowel preparation in Japanese patients undergoing colonoscopy.

METHODS

This multicenter (n = 13), randomized, active-controlled, colonoscopist- and image evaluator-blinded, noninferiority study with parallel-group comparison recruited 632 patients from December 2018 to June 2019. Of these, 602 patients were divided into the oral sulfate solution same-day dose group (n = 200); oral sulfate solution split-dose group (n = 202); and polyethylene glycol plus ascorbate same-day dose group (n = 200). Differences in the efficacy rates between the polyethylene glycol plus ascorbate group and each oral sulfate solution group were calculated using the asymptotic method. The safety of the oral sulfate solution was evaluated, based on the occurrence of adverse events and reactions.

RESULTS

Both oral sulfate solution protocols were confirmed as noninferior to the polyethylene glycol plus ascorbate protocol for bowel-cleansing. The occurrence of adverse reactions was significantly lower in the oral sulfate solution same-day dose group than in the polyethylene glycol plus ascorbate group (P = 0.010). The occurrence of adverse reactions was not significantly different between the oral sulfate solution split-dose and the polyethylene glycol plus ascorbate group.

CONCLUSIONS

Oral sulfate solution is not only safe and efficacious but also not inferior to polyethylene glycol plus ascorbate solution (active control). It could be used for bowel preparation in Japanese patients scheduled for colonoscopy (Clinical trial registration number: NCT03794310).

Comparison of Bowel Cleansing Efficacy, Safety, Bowel Movement Kinetics, and Patient Tolerability of Same-Day and Split-Dose Bowel Preparation Using 4 L of Polyethylene Glycol: A Prospective Randomized Study

BACKGROUND

Split-dose bowel preparation is recommended for morning colonoscopy, although a same-day dose regimen is an alternative for afternoon colonoscopy. Same-day preparation for morning colonoscopy has rarely been evaluated.

OBJECTIVE

We compared the bowel cleansing efficacy, bowel movement kinetics, safety profile, and patient tolerability of split-dose and same-day preparation using 4-L polyethylene glycol.

DESIGN

This was a prospective, randomized, assessor-blinded study.

SETTINGS

This study was performed at a tertiary center in Korea.

PATIENTS

Study subjects were randomly assigned to the same-day or split-dose groups. For the same-day dose group, 4 L of polyethylene glycol were ingested on the day of colonoscopy starting at 5:00 AM for morning colonoscopy or 7:00 AM for afternoon colonoscopy. In the split-dose group, 2 L of polyethylene glycol were ingested at 9:00 PM the day before colonoscopy, and the remaining 2 L from 7:00 AM for morning colonoscopy or from 10:00 AM for afternoon colonoscopy. Colonoscopy was performed from 10:00 AM.

MAIN OUTCOME MEASURES

The efficacy of bowel cleansing was evaluated using the Boston bowel preparation scale. The participants completed questionnaires asking about adverse events, bowel movement kinetics, and tolerability of the preparation before colonoscopy.

RESULTS

A total of 339 subjects were included (same-day dose = 172; split dose = 167). One subject in each group did not undergo colonoscopy. The rate of successful cleansing did not differ between the groups (same-day dose = 98.8% vs split dose = 98.2%; p = 0.681). There were no instances of hemodynamic instability or aspiration in either group. Tolerability, including overall satisfaction and willingness to reuse, were comparable between the groups.

LIMITATIONS

This was a single-center study.

CONCLUSIONS

The bowel cleansing efficacy, safety profile, and tolerability of same-day dosing with polyethylene glycol were comparable with those of split dose. Therefore, same-day dosing with 4 L of polyethylene glycol is a feasible bowel preparation method. See Video Abstract at http://links.lww.com/DCR/B44. COMPARACIÓN DE LA EFICACIA DE LA LIMPIEZA INTESTINAL, LA SEGURIDAD, LA CINÉTICA DEL MOVIMIENTO INTESTINAL Y LA TOLERABILIDAD DEL PACIENTE DE LA PREPARACIÓN INTESTINAL EN EL MISMO DÍA Y EN DOSIS DIVIDIDAS UTILIZANDO 4 L DE POLIETILENGLICOL: UN ESTUDIO PROSPECTIVO ALEATORIZADO: Se recomienda la preparación del intestino en dosis divididas para la colonoscopia de la mañana, aunque un régimen de una sola dosis el mismo día es una alternativa para la colonoscopia en la tarde. La preparación de una sola dosis el mismo día para la colonoscopia matutina rara vez se ha evaluado.Comparamos la eficacia de la limpieza intestinal, la cinética del movimiento intestinal, el perfil de seguridad y la tolerabilidad del paciente de la dosis dividida y la preparación el mismo día utilizando 4 L de polietilenglicol.Este fue un estudio prospectivo, aleatorizado, cegado por el evaluador.Este estudio se realizó en un centro terciario en Corea.Los sujetos del estudio fueron asignados aleatoriamente a el grupo de una dosis en el mismo día o al grupo de dosis dividida. Para el grupo de dosis del mismo día, se ingirieron 4 L de polietilenglicol el día de la colonoscopia a partir de las 5 a.m. para la colonoscopia de la mañana o las 7 a.m. para la colonoscopia de la tarde. En el grupo de dosis dividida, se ingirieron 2 L de polietilenglicol a las 9 p.m. el día anterior a la colonoscopia, y los otros 2 L restantes a partir de las 7 a.m. para la colonoscopia de la mañana o desde las 10 a.m. para la colonoscopia de la tarde. La colonoscopia se realizó a partir de las 10 a.m.La eficacia de la limpieza intestinal se evaluó mediante la escala de preparación intestinal de Boston. Los participantes completaron cuestionarios preguntando sobre los eventos adversos, la cinética del movimiento intestinal y la tolerabilidad de la preparación antes de la colonoscopia.Se incluyeron un total de 339 sujetos (dosis el mismo día, 172; dosis dividida, 167). Un sujeto en cada grupo no se sometió a colonoscopia. La tasa de limpieza exitosa no difirió entre los grupos (dosis el mismo día, 98.8% versus dosis dividida, 98.2%; p = 0.681). No hubo casos de inestabilidad hemodinámica o aspiración en ninguno de los grupos. La tolerabilidad, incluida la satisfacción general y la voluntad de reutilización, fueron comparables entre los grupos.Este fue un estudio de centro único.La eficacia de la limpieza intestinal, el perfil de seguridad y la tolerabilidad de la dosificación en el mismo día con polietilenglicol fueron comparables con los de la dosis dividida. Por lo tanto, la dosificación en el mismo día con 4 L de polietilenglicol es un método factible de preparación intestinal. Vea el video del resumen en http://links.lww.com/DCR/B44.

ASGE review of adverse events in colonoscopy

Colonoscopy is the most commonly performed endoscopic procedure and overall is considered a low-risk procedure. However, adverse events (AEs) related to this routinely performed procedure for screening, diagnostic, or therapeutic purposes are an important clinical consideration. The purpose of this document from the American Society for Gastrointestinal Endoscopy's Standards of Practice Committee is to provide an update on estimates of AEs related to colonoscopy in an evidence-based fashion. A systematic review and meta-analysis of population-based studies was conducted for the 3 most common and important serious AEs (bleeding, perforation, and mortality). In addition, this document includes an updated systematic review and meta-analysis of serious AEs (bleeding and perforation) related to EMR and endoscopic submucosal dissection for large colon polyps. Finally, a narrative review of other colonoscopy-related serious AEs and those related to specific colonic interventions is included.

No Interval Cancers in Endoscopic Practice

Colonoscopy is long time the most preferred method for CRC screening along with diagnosis and treatment for a range of colon diseases. Based on its difficulty in visualizing precursor CRC lesions, mostly those located on the right colon, this method can be subject of improvement. The colonoscopy quality can be influenced by many factors such as colon preparation, retraction time, the colonoscopists medical training and knowledges as well as the performance of endoscopy equipment. The bad quality of colonoscopy will result in the emergence of interval cancers defined, based on the author, as cancers that appear at 3-5 years up to 10 years from the colonoscopy procedure. Interval cancers have predominantly incriminated both the colonoscopy quality and the clinician competences and less the tumor biology. Subsequently there were set quality indicators of colonoscopy in order to raise the quality of the exploration. Among the important indicators, proving their utility in studies, the ADR (adenoma detection rate) is most commonly used along with PDR (polyp detection rate) and APC (adenoma per colonoscopy). Following the purpose of obtaining a higher colonoscopy quality the medical units should keep in check all indicators. Furthermore, there should be an active involvement in an additional training of non-conforming medical personnel or even restrain of practice, given the medical legal actions that have interval cancers as a main cause.

Validation of same-day bowel preparation regimen using 4L polyethylene glycol: Comparison of morning and afternoon colonoscopy

A split-dose regimen is the recommended method of bowel preparation for colonoscopy. However, for colonoscopy performed in the afternoon, same-day preparation is recommended rather than a split-dose regimen. No study has compared the efficacy of same-day bowel-cleansing for morning colonoscopy (MC) and afternoon colonoscopy (AC). The aims of this study were to evaluate the bowel-cleansing efficacy, adverse events, and patient tolerability of same-day bowel preparation for colonoscopy using 4L polyethylene glycol (PEG).The medical records of consecutive patients who underwent colonoscopy at our healthcare center over 3 months were retrospectively reviewed. Colonoscopy was performed between 10:00 and 16:00. Study subjects were assigned to the MC or AC group according to their colonoscopy start time (MC group, before 12:00; AC group, after 12:00). Study subjects were instructed to drink 500-mL PEG every 15 minutes. In the MC group, bowel cleansing was started at 05:00 and finished at 07:00. For the AC group, 2L PEG was consumed from 07:00, and the remaining 2L PEG was started 3 hours before colonoscopy. The composite safety profile included vital signs, laboratory test results, and questionnaire findings. Laboratory testing of subjects and completion of the questionnaire were performed before colonoscopy. The questionnaire asked about adverse events and tolerability of the bowel cleansing regimen. Bowel-cleansing efficacy was assessed using the Boston bowel preparation scale (BBPS). Bowel-cleansing efficacy, tolerability, and safety profile were compared between the 2 groups.Two hundred and ninety-one subjects were included (MC group, 169; AC group, 122).The BBPS did not differ between the 2 groups (7.3 ± 0.8 vs. 7.3 ± 0.8, P = .68). There were no instances of electrolyte imbalance or hemodynamic instability in either group. The tolerability of the bowel-cleansing regimen did not differ between the 2 groups (P = .59).The bowel-cleansing efficacy, safety profile, and patient tolerability of MC and AC were comparable. A same-day dose of 4L PEG is a feasible bowel preparation method.

Bowel Preparations Administered the Morning of Colonoscopy Provide Similar Efficacy to a Split Dose Regimen: A Meta Analysis

BACKGROUND

Comparative efficacy of same-day bowel preparations for colonoscopy remains unclear.

AIMS

A meta-analysis of randomized controlled trials comparing the efficacy of same-day versus split dose bowel preparations for colonoscopy.

METHODS

A systematic search was conducted in MEDLINE, clinicaltrials.gov, Cochrane Registry, EMBASE, SCOPUS, Web of Science and CINAHL. Studies were gathered using keywords: "morning preparation", "morning bowel preparation", "same day bowel preparation", and "colonoscopy." Pooled estimates of bowel preparation quality were analyzed among studies with categorical and continuous outcomes according to relative risk (RR) or mean difference (MD). A random effects model was chosen a priori for all analyses.

RESULTS

A total of 1216 studies were retrieved with 15 trials meeting inclusion criteria. The categorical outcome of high quality bowel preparation for any same-day bowel preparation versus any split preparation was no different with a RR 0.95 [0.90;1.00] (P=0.62). Adenoma detection rate (ADR) was not different between groups, RR 0.97 [0.79;1.20] (P=0.81). Willingness to repeat and tolerability did not differ (RR 1.14 [0.96,1.36] (P=0.14) and RR 1.00 [0.96;1.04] (P=0.98), respectively. Adverse events were similar except for bloating, which was less frequent among the same-day preparation group, RR 0.68 [0.40;0.94] (P=0.02).

CONCLUSION

No clinically significant differences were noted among recipients of same day or split dose regimens. Adenoma detection rate, willingness to repeat and tolerability were similar, but bloating and interference with sleep favored the same-day preparations. Given lack of clinical differences, patient preference should dictate timing of colonoscopy preparation.

Safety of Large-Volume, Same-Day Oral Bowel Preparations During Deep Sedation: A Prospective Observational Study

BACKGROUND

Colonoscopy quality is directly related to the bowel preparation. It is well established that bowel preparations are improved when at least part of the laxative is ingested on the day of the procedure. However, there is concern that this can result in higher gastric residual volumes (GRV) and increase the risk of pulmonary aspiration. The aim of this study is to evaluate GRV and gastric pH in patients who received day-before bowel preparation versus those ingesting their laxative on the day of colonoscopy under anesthesiologist-directed propofol deep sedation.

METHODS

This is a prospective observational study for patients undergoing same-day upper endoscopy and colonoscopy. All included patients had large-volume polyethylene glycol lavage preparation and received propofol sedation. Gastric fluid was collected during the upper endoscopy for volume and pH measurement.

RESULTS

The study included 428 patients with 56% receiving same-day laxative preparation and the remainder evening-before preparation. Mean ± SD GRV was 18.1 ± 10.2 mL, 16.3 ± 16.5 mL in each of these preparation groups, respectively (P = .69). GRV ≥ 25 mL or higher than expected GRV adjusted by weight (0.4 mL/kg) were also not different among the study groups (P = .90 and P = .87, respectively). Evaluating GRV based on time since last ingestion of preparation (3-5, 5-7, >7 hours) did not result in any differences (P = .56). Gastric pH was also similar between the bowel preparation groups (P = .23), with mean ± SD of 2.5 ± 1.4 for evening-before and 2.5 ± 1.3 for the same-day preparation. There were more inadequate bowel preparations in day before bowel preparations (P = .001).

CONCLUSIONS

A large-volume bowel preparation regimen finished on the day of colonoscopy as close as 3 hours before the procedure results in no increase in GRV or decrease in gastric pH.

Systematic Review: Outcomes by Duration of NPO Status prior to Colonoscopy

Background/Aims

Variation exists among anesthesia providers as to acceptable timing of NPO (“nothing by mouth”) for elective colonoscopy procedures. There is a need to balance optimal colonic preparation, patient convenience, and scheduling efficiency with anesthesia safety concerns. We reviewed the evidence for the relationship between NPO timing and aspiration incidence and colonoscopy rescheduling.

Methods

We searched MEDLINE (1990–April 2015) for English language studies of any design and included them if at least one bowel preparation regimen was completed within 8 hours of colonoscopy. Study characteristics, patient characteristics, and outcomes were abstracted and verified by investigators. We determined risk of bias for each study and overall strength of evidence for primary and secondary outcomes.

Results

We included 28 randomized controlled trials (RCTs), 2 controlled clinical trials, and 10 observational reports. Six studies reported on aspiration; none found that shorter NPO status prior to colonoscopy increased aspiration risk, though studies were not designed to assess this outcome (low strength of evidence). One RCT found fewer rescheduled procedures following split-dose preparation but NPO status was not well-documented (insufficient evidence).

Conclusions

Aspiration incidence requiring hospitalization during colonoscopy with moderate or deep sedation is very low. No study found that shorter NPO status prior to colonoscopy increased aspiration risk. We did not find direct evidence of the effect of NPO status on colonoscopy rescheduling.

Colorectal Cancer: Genetics is Changing Everything

Cancer is fundamentally a genetic disease caused by mutational or epigenetic alterations in DNA. There has been a remarkable expansion of the molecular understanding of colonic carcinogenesis in the last 30 years and that understanding is changing many aspects of colorectal cancer care. It is becoming increasingly clear that there are genetic subsets of colorectal cancer that have different risk factors, prognosis, and response to treatment. This article provides a general update on colorectal cancer and highlights the ways that genetics is changing clinical care.

Bowel cleansing before colonoscopy: Balancing efficacy, safety, cost and patient tolerance

Effective colorectal cancer screening relies on reliable colonoscopy findings which are themselves dependent on adequate bowel cleansing. Research has consistently demonstrated that inadequate bowel preparation adversely affects the adenoma detection rate and leads gastroenterologists to recommend earlier follow up than is consistent with published guidelines. Poor preparation affects as many as 30% of colonoscopies and contributes to an increased cost of colonoscopies. Patient tolerability is strongly affected by the preparation chosen and manner in which it is administered. Poor tolerability is, in turn, associated with lower quality bowel preparations. Recently, several new developments in both agents being used for bowel preparation and in the timing of administration have brought endoscopists closer to achieving the goal of effective, reliable, safe, and tolerable regimens. Historically, large volume preparations given in a single dose were administered to patients in order to achieve adequate bowel cleansing. These were poorly tolerated, and the unpleasant taste of and significant side effects produced by these large volume regimens contributed significantly to patients’ inability to reliably complete the preparation and to a reluctance to repeat the procedure. Smaller volumes, including preparations that are administered as tablets to be consumed with water, given as split doses have significantly improved both the patient experience and efficacy, and an appreciation of the importance of the preparation to colonoscopy interval have produced additional cleansing.

Split-Dose Polyethylene Glycol Is Superior to Single Dose for Colonoscopy Preparation: Results of a Randomized Controlled Trial

Background. The efficacy of colonoscopy in detecting abnormalities within the colon is highly dependent on the adequacy of the bowel preparation. The objective of this study was to compare the efficacy, safety, and tolerability of PEG lavage and split-dose PEG lavage with specific emphasis on the cleanliness of the right colon. Methods. The study was a prospective, randomized, two-arm, controlled trial of 237 patients. Patients between the age of 50 and 75 years were referred to an outpatient university screening clinic for colonoscopy. Patients were allocated to receive either a single 4 L PEG lavage or a split-dose PEG lavage. Results. Overall, the bowel preparation was superior in the split-dose group compared with the single-dose group (mean Ottawa score 3.50 ± 2.89 versus 5.96 ± 3.53; P < 0.05) and resulted in less overall fluid in the colon. This effect was observed across all segments of the colon assessed. Conclusions. The current study supports use of a split-dose PEG lavage over a single large volume lavage for superior bowel cleanliness, which may improve polyp detection. This trial is registered with ClinicalTrials.gov identifier NCT01610856.

Improving the utility of colonoscopy: Recent advances in practice

Colonoscopy is a frequently performed diagnostic and therapeutic test and the primary screening tool in several nationalized bowel cancer screening programs. There has been a considerable focus on maximizing the utility of colonoscopy. This has occurred in four key areas: Optimizing patient selection to reduce unnecessary or low yield colonoscopy has offered cost-benefit improvements in population screening. Improving quality assurance, through the development of widely accepted quality metrics for use in individual practice and the research setting, has offered measurable improvements in colonoscopic yield. Significant improvements have been demonstrated in colonoscopic technique, from the administration of preparation to the techniques employed during withdrawal of the colonoscope. Improved techniques to avoid post-procedural complications have also been developed-further maximizing the utility of colonoscopy. The aim of this review is to summarize the recent evidence-based advances in colonoscopic practice that contribute to the optimal practice of colonoscopy.

A randomized trial to compare the efficacy and tolerability of sodium picosulfate-magnesium citrate solution vs. 4 L polyethylene glycol solution as a bowel preparation for colonoscopy

PURPOSE

The purpose of this study is to compare the efficacy and acceptability of an evening-before regimens of sodium picosulfate/magnesium citrate (SPMC) and polyethylene glycol (PEG) as bowel cleansers and to explore the results of a same-day regimen of SPMC.

METHODS

Multicenter, randomized, observer-blinded, parallel study carried out in subjects who were 18-80 years old and were undergoing diagnostic colonoscopy for the first time. The primary outcome was treatment success, which was a composite outcome defined by (1) the evaluation of the overall preparation quality as "excellent" or "good" by two blinded independent evaluators with the Fleet(®) Grading Scale for Bowel Cleansing and (2) a subject's acceptability rating of "easy to take" or "tolerable." The primary outcome was analyzed using a logistic regression with site, gender, and age group (age ≥65 years and <65 years) as factors.

RESULTS

Four hundred ninety subjects were included in the efficacy evaluation. Although treatment success was significantly higher in subjects assigned to the evening-before regimen of SPMC vs. subjects assigned to the evening-before PEG, when evaluating the two individual components for treatment success, there were significant differences in the ease of completion but not in the quality of preparation. The same-day SPMC regimen was superior to both the evening-before regimen of SPMC and PEG in terms of the quality of preparation, especially regarding the proximal colon.

CONCLUSIONS

An evening-before regimen of SPMC is superior to an evening-before regimen of PEG in terms of subject's acceptability. The same-day SPMC regimen provides better cleansing levels in the proximal colon.

Colonoscopy performance is stable during the course of an extended three-session working day

BACKGROUND

Three-session days were introduced in our endoscopy unit to accommodate the increased demand resulting from the introduction of the National Health Service Bowel Cancer Screening Programme (BCSP). Cecal intubation rate (CIR) and adenoma detection rate (ADR) may decline with time during a standard working day, but data are lacking for an extended three-session day. We assessed colonoscopy performance in an extended three-session day.

METHODS

Colonoscopies performed during the year 2011 were retrospectively analyzed. The CIR and ADR were analyzed according to the time of day when procedures were done: morning (AM), afternoon (PM), or evening (EVE). Because of an expected higher incidence of adenomas in the BCSP patients, ADR was analyzed according to indication (BCSP or non-BCSP).

RESULTS

Of the 2574 colonoscopies, 1328 (51.7 %) were in male patients and 1239 (48.3 %) in female patients with a median age of 63 years (interquartile range [IQR], 51 - 70). Of the 2574 colonoscopies, 1091 (42.4 %) were performed in AM lists, 994 (38.6 %) in PM lists, and 489 (19 %) in EVE lists. Time of day did not affect the CIRs for the AM, PM, and EVE lists (90.5 %, 90.1 %, and 89.9 %, respectively; χ (2) [2, N = 2540] = 0.15, P = 0.927). The CIR was reduced in female patients and those with poor bowel preparation (P < 0.05). After exclusion of the BCSP patients, the ADR was lower in the EVE lists than in the AM and PM lists on univariate analysis, but on multivariate analysis, this difference was not significant (P > 0.05). The ADR was significantly higher in patients older than 60 years and in men (P < 0.001). Queue position did not independently influence the CIR or ADR.

CONCLUSIONS

Colonoscopy quality does not appear to depend on time of day or queue position in an extended three-session day.

Prospective, randomized comparison of same-day dose of 2 different bowel cleanser for afternoon colonoscopy: picosulfate, magnesium oxide, and citric acid versus polyethylene glycol

For afternoon colonoscopy, same-day administration of sodium picosulfate, magnesium oxide, and citric acid (PM/Ca) is recommended. However, few studies have evaluated the bowel-cleansing efficacy and safety of this regimen. The aim of this study was to compare the bowel-cleansing efficacy, side effects, and patient's tolerability of a same-day split administration of PM/Ca with polyethylene glycol (PEG) for afternoon colonoscopy. Patients were randomly assigned to a PM/Ca group or a PEG group. The PM/Ca group consumed 1 sachet of PM/Ca at 06:00 and 1 sachet of PM/Ca 4 hours before the colonoscopy. They also took 2 tablets of bisacodyl before sleep on the night before. The PEG group consumed 2 L of PEG at 06:00 and 2 L of PEG 4 hours before the colonoscopy. All subjects were instructed to finish the bowel cleanser or fluid at least 2 hours before colonoscopy. All colonoscopic examinations were performed in the afternoon on the same day. The bowel-cleansing efficacy was scored using 2 scales: the Ottawa Bowel Preparation Scale (OBPS) and the Aronchick scale. Ease of using the bowel cleanser was rated from 1 (very easy) to 5 (very difficult). Two hundred nine patients underwent colonoscopy. The bowel-cleansing scores by OBPS did not differ between groups (5.0 vs 4.9, P = 0.63). Ease of using the bowel cleanser was superior in the PM/Ca group (P < 0.01). The cleansing efficacy of PM/Ca administered on the day of colonoscopy is comparable to that of PEG. Patients prefer PM/Ca.

Optimizing bowel preparation for colonoscopy: what are the predictors of an inadequate preparation?

BACKGROUND

This retrospective study evaluates factors that are associated with an inadequate bowel preparation.

METHODS

A chart review was performed on 2,101 patients who underwent colonoscopy. The quality of preparation was classified as adequate or inadequate. Univariate and multivariate regression analyses identified factors associated with inadequate preparations.

RESULTS

A total of 91.5% of preparations were adequate. Standard preparations using polyethylene glycol-electrolyte solution and sodium picosulfate alone were 91.1% adequate. Regimens with adjuncts were 91.9% adequate. Factors that predicted an inadequate preparation include the following: stroke/dementia (odds ratio [OR] 3.5, 95% confidence interval [CI] 1.6 to 7.7, P = .002), opioids (OR 2.3, 95% CI 1.1 to 4.6, P = .02), male sex (OR 2.0, 95% CI 1.4 to 2.9, P = .000), calcium channel blockers (OR 1.9, 95% CI 1.1 to 3.3, P = .03), and antidepressants (OR 1.7, 95% CI 1.1 to 2.7, P = .02).

CONCLUSIONS

Several factors are associated with inadequate preparations. Adjuncts do not improve preparation quality. The effect of patient education on preparation quality is an area for further research.

Achieving the best bowel preparation for colonoscopy

Bowel preparation is a core issue in colonoscopy, as it is closely related to the quality of the procedure. Patients often find that bowel preparation is the most unpleasant part of the examination. It is widely accepted that the quality of cleansing must be excellent to facilitate detecting neoplastic lesions. In spite of its importance and potential implications, until recently, bowel preparation has not been the subject of much study. The most commonly used agents are high-volume polyethylene glycol (PEG) electrolyte solution and sodium phosphate. There has been some confusion, even in published meta-analyses, regarding which of the two agents provides better cleansing. It is clear now that both PEG and sodium phosphate are effective when administered with proper timing. Consequently, the timing of administration is recognized as one of the central factors to the quality of cleansing. The bowel preparation agent should be administered, at least in part, a few hours in advance of the colonoscopy. Several low volume agents are available, and either new or modified schedules with PEG that usually improve tolerance. Certain adjuvants can also be used to reduce the volume of PEG, or to improve the efficacy of other agents. Other factors apart from the choice of agent can improve the quality of bowel cleansing. For instance, the effect of diet before colonoscopy has not been completely clarified, but an exclusively liquid diet is probably not required, and a low-fiber diet may be preferable because it improves patient satisfaction and the quality of the procedure. Some patients, such as diabetics and persons with heart or kidney disease, require modified procedures and certain precautions. Bowel preparation for pediatric patients is also reviewed here. In such cases, PEG remains the most commonly used agent. As detecting neoplasia is not the main objective with these patients, less intensive preparation may suffice. Special considerations must be made for patients with inflammatory bowel disease, including safety and diagnostic issues, so that the most adequate agent is chosen. Identifying neoplasia is one of the main objectives of colonoscopy with these patients, and the target lesions are often almost invisible with white light endoscopy. Therefore excellent quality preparation is required to find these lesions and to apply advanced methods such as chromoendoscopy. Bowel preparation for patients with lower gastrointestinal bleeding represents a challenge, and the strategies available are also reviewed here.

Same-day colonoscopy preparation with Senna alkaloids and bisacodyl tablets: A pilot study

AIM: To evaluate the efficacy of same-day bowel preparation with Senna alkaloids combined with bisacodyl tablets in routine colonoscopy procedures.

METHODS: Between March and June 2013, a same-day bowel preparation was implemented in our endoscopy unit. The preparation consisted of a semi-liquid, fiber-free diet one day prior to the procedure, with two bisacodyl tablets after lunch and dinner, and 250 mL of Senna alkaloid with 1.5 L of drinking water at 6 am the day of the procedure. The quality control parameters of colonoscopy were evaluated and implemented according to the guidelines of the American Society for Gastrointestinal Endoscopy. The pre-procedure, during-procedure and post-procedure patient data were collected and analyzed: (1) pre-procedure (age, gender, comorbid diseases, colonoscopy indications, complete lack of compliance with the bowel preparation protocol); (2) during-procedure (sedation dose, duration of colonoscopy, withdrawal time, cecal intubation rate, polyp detection rate, Boston Bowel Preparation Scores and presence of foam and clear liquid); and (3) post-procedure (visual analogue scale score, pain during the procedure, patient satisfaction and premature withdrawal due to the insufficient bowel preparation).

RESULTS: A total of 75 patients were included in this study with a mean age of 54.64 ± 13.29 years; 53.3% (40/75) were female and 46.7% (35/75) were male. A complete lack of compliance with the bowel preparation protocol was seen in 6.7% of patients (5/75). The mean total duration of colonoscopy was 16.12 ± 6.51 min, and the mean withdrawal time was 8.89 ± 4.07 min. The cecal intubation rate was 93.8% (61/64) and the polyp detection rate was 40% (30/75). The mean Boston Bowel Preparation Score was 7.38 ± 1.81, with the following distribution: right colon, 2.34 ± 0.89; transverse colon, 2.52 ± 0.67; left colon, 2.52 ± 0.63. The mean visual analogue scale score was 4.59 ± 1.57. Due to insufficient bowel preparation, seven patients (7/75; 9.3%) were asked to repeat the procedure. Of these, five patients had poor or modest compliance with the protocol, and two patients reported constipation. Premature withdrawal due to insufficient bowel preparation was 2.7% (2/75). The overall satisfaction with the protocol was 86.7% (65/75), with patients reporting they would prefer the same protocol in a repeat procedure.

CONCLUSION: The same-day administration of Senna alkaloids appears to be a safe and effective bowel cleansing protocol for colonoscopy procedures.

Efficacy of morning-only 4 liter sulfa free polyethylene glycol vs 2 liter polyethylene glycol with ascorbic acid for afternoon colonoscopy

AIM

To compare the bowel cleansing efficacy of same day ingestion of 4-L sulfa-free polyethylene glycol (4-L SF-PEG) vs 2-L polyethylene glycol solution with ascorbic acid (2-L PEG + Asc) in patients undergoing afternoon colonoscopy.

METHODS

206 patients (mean age 56.7 years, 61% male) undergoing outpatient screening or surveillance colonoscopies were prospectively randomized to receive either 4-L SF-PEG (n = 104) or 2-L PEG + Asc solution (n = 102). Colonoscopies were performed by two blinded endoscopists. Bowel preparation was graded using the Ottawa scale. Each participant completed a satisfaction and side effect survey.

RESULTS

There was no difference in patient demographics amongst groups. 4-L SF-PEG resulted in better Ottawa scores compared to 2-L PEG + Asc, 4.2 vs 4.9 (P = 0.0186); left colon: 1.33 vs 1.57 respectively (P = 0.0224), right colon: 1.38 vs 1.63 respectively (P = 0.0097). No difference in Ottawa scores was found for the mid colon or amount of fluid. Patient satisfaction was similar for both arms but those assigned to 4-L SF-PEG reported less bloating: 23.1% vs 11.5% (P = 0.0235). Overall polyp detection, adenomatous polyp and advanced adenoma detection rates were similar between the two groups.

CONCLUSION

Morning only 4-L SF-PEG provided superior cleansing with less bloating as compared to 2-L PEG + Asc bowel preparation for afternoon colonoscopy. Thus, future studies evaluating efficacy of morning only preparation for afternoon colonoscopy should use 4-L SF-PEG as the standard comparator.

A randomized, endoscopist-blinded, prospective trial to compare the preference and efficacy of four bowel-cleansing regimens for colonoscopy

OBJECTIVES

The superiority of conventional polyethylene glycol (PEG) solution over sodium picosulfate with magnesium citrate (SPMC) for bowel preparation remains controversial. Therefore, this study compared the efficacy, safety, and tolerability of different regimens of SPMC and PEG solution in Koreans, who consume a traditional high-fiber diet.

MATERIALS AND METHODS

A total of 200 outpatients undergoing elective colonoscopy were randomized into four groups receiving different bowel-preparation regimens in a prospective study: 4 L PEG in the morning on the day of colonoscopy, two 2 L split doses of PEG, split doses of 2 SPMC sachets, and split doses of 3 SPMC sachets. Bowel cleansing efficacy was assessed based on the Ottawa bowel preparation scale and the Aronchick scale by endoscopists blinded to treatment, and patients filled out a questionnaire to determine satisfaction.

RESULTS

There was no difference among groups with respect to bowel cleansing grade (Ottawa scale, p = 0.314). Patients in the SPMC groups were less likely to have abdominal fullness, pain, nausea, or vomiting than patients in the PEG groups (p < 0.05). Patients reported SPMC was more palatable than PEG. There were no significant differences among groups with respect to polyp detection rate.

CONCLUSION

SPMC is as effective as conventional high-volume PEG-electrolyte solution in Korean patients. SPMC groups reported superior palatability and tolerability compared to PEG groups.

Optimal bowel preparation--a practical guide for clinicians

High-quality bowel preparation is essential for effective colonoscopy. Bowel preparations are judged by their safety, efficacy and tolerability. Between efficacy and tolerability, efficacy is the clinical priority because inadequate preparations are disruptive and costly. Achieving high rates of adequate preparation depends first on using split-dose or same-day dosing. Patients who have medical predictors of inadequate preparation quality (for example chronic constipation) should be prescribed more aggressive preparations and patients who have factors that predict they are less likely to follow the instructions (such as English not being their first language) should receive intensified education. On the day of the procedure, patients with persistent brown effluent should be considered for large-volume enemas or additional oral preparation before proceeding with colonoscopy. During the procedure, preparation quality should be graded after the clean-up has been completed.

Low-volume morning-only polyethylene glycol with specially designed test meals versus standard-volume split-dose polyethylene glycol with standard diet for colonoscopy: a prospective, randomized trial

BACKGROUND/AIMS

Split-dose polyethylene glycol (PEG) is a standard bowel preparation regimen for colonoscopy, but the large volume is burdensome to ingest and the night dose causes sleep disturbance. This study was performed to evaluate the efficacy and tolerability of a bowel preparation protocol using low-volume morning-only PEG with specially designed low-residue test meals (LV-PEG with TM) compared to a standard-volume split-dose PEG bowel preparation with a standard diet (SV-PEG with SD).

METHODS

This was a single-center, prospective, randomized, investigator-blinded, noninferiority study. The primary end point was bowel preparation quality according to the Ottawa scale. Tolerability, compliance, adverse events, sleep quality and polyp/adenoma detection were also assessed.

RESULTS

Among 197 patients analyzed (mean age 54.6 years, 51.3% men), 97 received LV-PEG with TM and 100 received SV-PEG with SD. The Ottawa score for the total colon was 3.76 ± 2.07 in the LV-PEG with TM group and 3.67 ± 1.57 in the SV-PEG with SD group (p = 0.723; difference 0.09, 95% confidence interval -0.60 to 0.42). The compliance was high (more than 95%) in both groups (p = 0.621). PEG was easier to ingest for patients in the LV-PEG with TM group compared to the SV-PEG with SD group [visual analogue scale (VAS) for difficulty: 4.64 ± 2.46 vs. 5.97 ± 2.42, respectively; p < 0.001]. Diet instructions were also easier to comply with for patients in the LV-PEG with TM group compared to the SV-PEG with SD group (VAS for difficulty: 3.11 ± 2.25 vs. 4.00 ± 2.39, respectively; p = 0.008). Patients in the LV-PEG with TM group had a lower incidence of abdominal bloating (p = 0.012) and better sleep quality (p < 0.001). There was no difference between the groups regarding polyp and adenoma detection.

CONCLUSIONS

LV-PEG with TM and SV-PEG with SD have similar efficacy with regard to bowel preparation for colonoscopy. LV-PEG with TM provided easier PEG intake and diet compliance, less abdominal bloating and better sleep quality than SV-PEG with SD.

Clinical effects of compound polyethylene glycol electrolyte solution with simethicone given by different methods in bowel preparation before capsule endoscopy

AIM: To observe the clinical effects of compound polyethylene glycol electrolyte solution with simethicone given by different methods in the bowel preparation before capsule endoscopy.

METHODS: This was a prospective, investigator-blinded randomized study. Sixty patients treated at our hospital were randomly divided into two groups; group A (n = 30) received 3 L of compound polyethylene glycol electrolyte solution 4 h before and 30 mL of simethicone 30 min before the examination, and group B (n = 30) received 2 L of compound polyethylene glycol electrolyte solution 4 h before, 15 mL of simethicone 2 d before (3 times a day, each 5 mL) and 15 mL of simethicone 30 min before the examination. The image quality of endoscopy was graded according to air bubble size, digestive tract juice quantity and its clear degree. Gastric emptying time and small bowel transit time were recorded for each examination, and adverse reactions were also recorded.

RESULTS: The air bubble size was significantly in group B less than in group A (0.20 ± 0.12 vs 0.30 ± 0.21, P < 0.05). The clear degree of digestive tract juice was better in group B than in group A (0.36 ± 0.32 vs 0.64 ± 0.47, P < 0.05). There was no significant difference in digestive tract juice quantity (0.70 ± 0.30 vs 0.86 ± 0.46, P > 0.05), gastric emptying time, small bowel transit time or adverse reactions between the two groups (P > 0.05 for all).

CONCLUSION: Two liters of compound polyethylene glycol electrolyte could achieve the desired results in the bowel preparation before capsule endoscopy. Simethicone in divided doses had better effects in removing the bubbles.

One-day versus two-day cleansing for colon capsule endoscopy: a prospective randomized pilot study

BACKGROUND

Standard bowel cleansing for colon capsule endoscopy (CCE) requires a liquid diet and bowel laxatives for at least 2 days, which is a major drawback of this procedure and affects tolerance and acceptability.

OBJECTIVE

To compare the quality of colon cleanliness achieved with one-day versus two-day bowel preparation in outpatients undergoing CCE.

METHODS

Patients were randomly assigned to one of two groups: group I (one-day schedule, n=20) received a fiber-free diet and 3 L of polyethylene glycol (PEG) on day 0; group II (two-day schedule, n=20) received a liquid diet and 3 L of PEG in the evening of day -1, and 1L of PEG in the early morning of day 0. In both groups, the patients received 15 mg bisacodyl on day -1 and one or two additional sodium phosphate (NaP) boosters following capsule ingestion. Each colon segment was assessed for cleanliness using a four-point grading scale (excellent=1, good=2, fair=3, and poor=4). For the final analysis, colon cleanliness was rated as adequate (good or excellent) or inadequate (fair or poor).

RESULTS

Overall colon cleanliness was adequate in 94% (CI 91-97) of patients in group I versus 80% (CI 72-88) in group II (P=0.27). No significant differences were observed in the per-segment quality of colon cleansing between the two groups. CCE reached the rectum in 80% (CI 73-87) of patients in group I versus 75% (CI 67-83) in group II (p=0.59).

CONCLUSION

The quality of colon cleanliness achieved with one-day bowel preparation is equivalent to that of the standard two-day schedule in patients undergoing CCE.

Same-day 2-L PEG-citrate-simethicone plus bisacodyl vs split 4-L PEG: Bowel cleansing for late-morning colonoscopy

AIM

To evaluate the efficacy, tolerability, acceptability and feasibility of bisacodyl plus low volume polyethyleneglycol-citrate-simeticone (2-L PEG-CS) taken the same day as compared with conventional split-dose 4-L PEG for late morning colonoscopy.

METHODS

Randomised, observer-blind, parallel group, comparative trial carried out in 2 centres. Out patients of both sexes, aged between 18 and 85 years, undergoing colonoscopy for diagnostic investigation, colorectal cancer screening or follow-up were eligible. The PEG-CS group received 3 bisacodyl tablets (4 tablets for patients with constipation) at bedtime and 2-L PEG-CS in the morning starting 5 h before colonoscopy. The control group received a conventional 4-L PEG formulation given as split regimen; the morning dose was taken with the same schedule of the low volume preparation. The Ottawa Bowel Preparation Scale (OBPS) score was used as the main outcome measure.

RESULTS

A total of 164 subjects were enrolled and 154 completed the study; 78 in the PEG-CS group and 76 in the split 4-L PEG group. The two groups were comparable at baseline. The OBPS score in the PEG-CS group (3.09 ± 2.40) and in the PEG group (2.39 ± 2.55) were equivalent (difference +0.70; 95%CI: -0.09-1.48). This was confirmed by the rate of successful bowel cleansing in the PEG-CS group (89.7%) and in the PEG group (92.1%) (difference -2.4%; 95%CI: -11.40- 6.70). PEG-CS was superior in terms of mucosa visibility compared to PEG (85.7% vs 72.4%, P = 0.042). There were no significant differences in caecum intubation rate, time to reach the caecum and withdrawal time between the two groups. The adenoma detection rate was similar (PEG-CS 43.6% vs PEG 44.7%). No serious adverse events occurred. No difference was found in tolerability of the bowel preparations. Compliance was equal in both groups: more than 90% of subjects drunk the whole solution. Willingness to repeat the same bowel preparations was about 90% for both regimes.

CONCLUSION

Same-day PEG-CS is feasible, effective as split-dose 4-L PEG for late morning colonoscopy and does not interfere with work and daily activities the day before colonoscopy.

Same-day 2-L PEG-citrate-simethicone plus bisacodyl vs split 4-L PEG: Bowel cleansing for late-morning colonoscopy

AIM: To evaluate the efficacy, tolerability, acceptability and feasibility of bisacodyl plus low volume polyethyleneglycol-citrate-simeticone (2-L PEG-CS) taken the same day as compared with conventional split-dose 4-L PEG for late morning colonoscopy.

METHODS: Randomised, observer-blind, parallel group, comparative trial carried out in 2 centres. Out patients of both sexes, aged between 18 and 85 years, undergoing colonoscopy for diagnostic investigation, colorectal cancer screening or follow-up were eligible. The PEG-CS group received 3 bisacodyl tablets (4 tablets for patients with constipation) at bedtime and 2-L PEG-CS in the morning starting 5 h before colonoscopy. The control group received a conventional 4-L PEG formulation given as split regimen; the morning dose was taken with the same schedule of the low volume preparation. The Ottawa Bowel Preparation Scale (OBPS) score was used as the main outcome measure.

RESULTS: A total of 164 subjects were enrolled and 154 completed the study; 78 in the PEG-CS group and 76 in the split 4-L PEG group. The two groups were comparable at baseline. The OBPS score in the PEG-CS group (3.09 ± 2.40) and in the PEG group (2.39 ± 2.55) were equivalent (difference +0.70; 95%CI: -0.09-1.48). This was confirmed by the rate of successful bowel cleansing in the PEG-CS group (89.7%) and in the PEG group (92.1%) (difference -2.4%; 95%CI: -11.40- 6.70). PEG-CS was superior in terms of mucosa visibility compared to PEG (85.7% vs 72.4%, P = 0.042). There were no significant differences in caecum intubation rate, time to reach the caecum and withdrawal time between the two groups. The adenoma detection rate was similar (PEG-CS 43.6% vs PEG 44.7%). No serious adverse events occurred. No difference was found in tolerability of the bowel preparations. Compliance was equal in both groups: more than 90% of subjects drunk the whole solution. Willingness to repeat the same bowel preparations was about 90% for both regimes.

CONCLUSION: Same-day PEG-CS is feasible, effective as split-dose 4-L PEG for late morning colonoscopy and does not interfere with work and daily activities the day before colonoscopy.

Consensus guidelines for the use of bowel preparation prior to colonic diagnostic procedures: colonoscopy and small bowel video capsule endoscopy

BACKGROUND

Adequate bowel preparation prior to colonic diagnostic procedures is essential to ensure adequate visualisation.

SCOPE

This consensus aims to provide guidance as to the appropriate use of bowel preparation for a range of defined clinical circumstances. A consensus group from across Europe was convened and met to discuss appropriate bowel preparation. The use of polyethylene glycol (PEG), sodium picosulphate and sodium phosphate (NaP), together with other agents, prokinetics and simethicone, in colonoscopy and small bowel video capsule endoscopy were considered. A systematic review of the literature was carried out and additional unpublished data was obtained from the members of the consensus group where required. Recommendations were graded according to the level of evidence.

FINDINGS

PEG-based regimens are recommended first line for both procedures, since their use is supported by good efficacy and safety data. Sodium-picosulphate-based regimens are recommended second line as their cleansing efficacy appears less than PEG-based regimens. NaP is not recommended for bowel cleansing due to the potential for renal damage and other adverse events. However, the use of NaP is acceptable in patients in whom PEG or sodium picosulphate is ineffective or not tolerated. NaP should not be used in patients with chronic kidney disease, pre-existing electrolyte disturbances, congestive heart failure, cirrhosis or a history of hypertension. The timing of the dose, dietary restrictions, use in special patient groups and recording of the quality of bowel preparation are also considered for patients undergoing colonoscopy. During the development of the guidelines the European Society of Gastrointestinal Endoscopy (ESGE) issued guidance on bowel preparation for colonoscopy. The ESGE guidelines and these consensus guidelines share many recommendations; differences between the guidelines are reviewed.

CONCLUSION

The use of bowel preparation should be tailored to the individual patient and their specific clinical circumstances.

[Colonoscopy quality control as a requirement of colorectal cancer screening]

The strategies used in population-based colorectal screening strategies culminate in colonoscopy and consequently the success of these programs largely depends on the quality of this diagnostic test. The main factors to consider when evaluating quality are scientific-technical quality, safety, patient satisfaction, and accessibility. Quality indicators allow variability among hospitals, endoscopy units and endoscopists to be determined and can identify those not achieving recommended standards. In Spain, the working group for colonoscopy quality of the Spanish Society of Gastroenterology and the Spanish Society of Gastrointestinal Endoscopy have recently drawn up a Clinical Practice Guideline that contains the available evidence on the quality of screening colonoscopy, as well as the basic requirements that must be met by endoscopy units and endoscopists carrying out this procedure. The implementation of training programs and screening colonoscopy quality controls are strongly recommended to guarantee the success of population-based colorectal cancer screening.

Optimal and safe bowel preparation for colonoscopy

Effective colonoscopy requires an adequate level of cleansing as a basic component. This review will describe a compact review about general considerations in bowel preparation for colonoscopy and specific considerations for various patients. A low-fiber diet instead of a regular diet on the day before colonoscopy is an independent predictor of adequate bowel preparation. Improved bowel cleansing does not result from the routine use of enemas or prokinetics in addition to oral bowel preparation. For morning colonoscopy, a split method of 4 L polyethylene glycol on the day before and the day of colonoscopy is recommended, while patients scheduled for afternoon colonoscopy typically receive a full method of 4 L polyethylene glycol on the day of the procedure. Valid alternatives are 2 L polyethylene glycol plus ascorbic acid or 2 L sodium picosulphate plus magnesium citrate. Although there are no statistically significant differences between polyethylene glycol and oral sodium phosphate for colon cleansing, polyethylene glycol-based bowel preparation is advisable in most situations because of safety concerns.

Quality indicators for colorectal cancer screening for colonoscopy

The growing importance of colonoscopy in the prevention of colorectal cancer has stimulated an effort to identify and track quality indicators for this procedure. Several factors have been identified so far which are readily measurable and in many cases have been associated with improved patient outcomes. There is also ample evidence of variations in performance of this procedure. As a result, gathering data about quality indicators may play a vital role in the process of continuous quality improvement. Quality indicators for colonoscopy in colorectal cancer prevention are described along with the evidence that supports their use in benchmarking, quality reporting, and continuous quality improvement.

Shorter preparation to procedure interval for colonoscopy improves quality of bowel cleansing

BACKGROUND

The timing of bowel preparation for colonoscopy influences the quality of bowel cleansing and the success of the procedure.

AIM

We aimed to determine whether the interval between the end of bowel preparation and the start of colonoscopy influences preparation quality.

METHODS

We retrospectively analysed 1785 colonoscopies performed between January 2010 and January 2011. The quality of bowel cleansing was compared between those who had a less than 8-h interval between the end of bowel preparation to the start of the procedure versus those who had a greater than 8-h interval. Univariate and multivariate logistic regression analyses evaluated quality of bowel cleansing, preparation to procedure time, age, gender, hospital inpatient or outpatient status, indication for colonoscopy, caecal intubation rate, and segmental polyp detection.

RESULTS

Fifty-three per cent of the cohort was male. Eighty-nine per cent were outpatients. Bowel cleansing was reported as satisfactory/good in 87% and poor in 13%. A <8-h preparation to procedure time was associated with a higher rate of satisfactory/good cleansing than a >8-h interval (odds ratio (OR) 1.3, P = 0.04). In a multivariate analysis, female gender (OR 1.4, P = 0.02), outpatient status (OR 3.1 P = 0.001) and indication for procedure (P < 0.01) were significant predictors of adequate bowel preparation. Adequate bowel preparation was associated with a significant increase in caecal intubation rates (OR 5.3, P = 0.001).

CONCLUSIONS

A shorter (<8 h) interval between end of bowel preparation and start of colonoscopy yielded better bowel cleansing than a longer (>8 h) interval. Adequate bowel preparation led to improved caecal intubation rates.

A new low-volume isosmotic polyethylene glycol solution plus bisacodyl versus split-dose 4 L polyethylene glycol for bowel cleansing prior to colonoscopy: a randomised controlled trial

BACKGROUND

4-L polyethylene glycol preparations are effective for colon cleansing before colonoscopy. However, large volume and unpleasant taste reduce tolerability and acceptability limiting patient compliance. A new isosmotic low-volume polyethylene glycol preparation with citrates and simethicone plus bisacodyl has been developed to improve patient compliance and tolerability.

AIM

To compare the efficacy of 2 different regimens of preparation vs a split-dose of polyethylene glycol solution.

PATIENTS AND METHODS

In this randomised, blinded, comparative study, 153 patients were allocated to 3 arms. Arm 1 (n=52) received bisacodyl and 2-L polyethylene glycol with citrates and simethicone the day before the procedure. Arm 2 (n=50) received bisacodyl the day before and 2-L polyethylene glycol with citrates and simethicone on the day of colonoscopy. Control group (n=51) received a split-dose of 4-L polyethylene glycol. Cleansing was evaluated according to Ottawa scale.

RESULTS

The mean Ottawa score was not different in the 3 groups. Excellent cleansing was observed more frequently in arm 2 (70%) than in controls (49%) (p<0.05). No serious adverse events were observed in the 3 regimens. The willingness to repeat the same bowel preparation was superior in arms 1 and 2 than in controls (p<0.001).

CONCLUSIONS

New low-volume preparations seem to be as effective as the split 4-L polyethylene glycol regimen, showing a better tolerability and acceptability.

Colonoscopic enema as rescue for inadequate bowel preparation before colonoscopy: a prospective, observational study

AIM

Colonoscopy may need to be rescheduled because of inadequate bowel preparation. We evaluated the effectiveness of colonoscopic enema as rescue for an inadequate 1-day bowel preparation before colonoscopy.

METHOD

Patients referred for afternoon colonoscopy were prospectively enrolled in the study during a 1-year period. Patients took bowel preparation (polyethylene glycol) solution on the morning of the endoscopy. If during colonoscopy the bowel preparation was poor, an enema of polyethylene glycol solution (500 ml) was instilled into the colon at the level of the hepatic flexure via the biopsy channel of the colonoscope which was then removed. The patient was allowed to recover from the propofol sedation and used the bathroom to evacuate the enema. The colonoscope was then introduced and the examination continued.

RESULTS

Of 504 patients undergoing colonoscopy, 26 (4.9%) received an enema. The median age was 59 (29-79) years and 19 (73%) were female. A subsequent successful colonoscopy was achieved in 25/26 (96%). There were no complications. The mean time spent for the entire colonoscopy from the initial preparation to the end of the examination including the enema was 7.6± 1.1h (5.4 h preparation, 0.2h first colonoscopy+enema, 0.66h waiting in the lavatory, 0.33h second colonoscopy and 1 h for recovery).

CONCLUSION

Colonoscopic enema was highly successful as rescue for patients with inadequate bowel preparation and avoided postponement of the procedure.

Water-aided colonoscopy: a systematic review

BACKGROUND

Water-aided methods for colonoscopy are distinguished by the timing of removal of infused water, predominantly during withdrawal (water immersion) or during insertion (water exchange).

OBJECTIVE

To discuss the impact of these approaches on colonoscopy pain and adenoma detection rate (ADR).

DESIGN

Systematic review.

SETTING

Randomized, controlled trial (RCT) that compared water-aided methods and air insufflation during colonoscope insertion.

PATIENTS

Patients undergoing colonoscopy.

INTERVENTION

Medline, PubMed, and Google searches (January 2008-December 2011) and personal communications of manuscripts in press were considered to identify appropriate RCTs.

MAIN OUTCOME MEASUREMENTS

Pain during colonoscopy and ADR. RCTs were grouped according to whether water immersion or water exchange was used. Reported pain scores and ADR were tabulated based on group assignment.

RESULTS

Pain during colonoscopy is significantly reduced by both water immersion and water exchange compared with traditional air insufflation. The reduction in pain scores was qualitatively greater with water exchange as compared with water immersion. A mixed pattern of increases and decreases in ADR was observed with water immersion. A higher ADR, especially proximal to the splenic flexure, was obtained when water exchange was implemented.

LIMITATIONS

Differences in the reports limit application of meta-analysis. The inability to blind the colonoscopists exposed the observations to uncertain bias.

CONCLUSION

Compared with air insufflation, both water immersion and water exchange significantly reduce colonoscopy pain. Water exchange may be superior to water immersion in minimizing colonoscopy discomfort and in increasing ADR. A head-to-head comparison of these 3 approaches is required.