The management of 'hard-to-prepare' colonoscopy patients

2L polyethylene glycol combined with castor oil versus 4L polyethylene glycol for bowel preparation before colonoscopy among inpatients

Inpatients are more likely to have inadequate bowel preparation compared to outpatients. Although experts recommend 4L split polyethylene glycol (PEG) preparation, bowel preparation with castor oil (CaO) was recently found to reduce the volume of solution required. The aim of the study was to evaluate the cleansing effect and safety of 2L-PEG with Cao in bowel preparation among inpatients. Our study retrospectively analyzed the medical records and colonoscopy reports of inpatients (n = 1251) who underwent colonoscopy in the Affiliated Changzhou No.2 People Hospital of Nanjing Medical University, and the inpatients were divided into 2L-PEG-CaO and 4L-PEG group according to different bowel preparation protocols. Boston Bowel Preparation Scale (BBPS) is used to assess bowel preparation efficacy before colonoscopy. Furthermore, we also calculated other outcomes, such as polyp or adenoma detection rates and adverse events. A total of 1251 patients undergoing colonoscopy were included in this study, 738 were taken 4L-PEG and 513 2L-PEG-CaO. Both inpatients groups were matched for baseline characteristics. The 2L-PEG-CaO group was significantly higher than the 4L-PEG group on both BBPS (7.26 ± 1.75 vs 7.06 ± 1.58, P = .043) and adequate bowel cleansing rates (83.2% vs 77.4%, P = .011). Regarding adverse events, the 4L-PEG group was significantly higher than the 2L-PEG-CaO group on the incidence of abdominal fullness (6.4% vs 9.6%, P = .045) and adverse events (33.7% vs 28.5%, P = .048). The 2L split PEG with CaO preparation increased quality of bowel cleansing and improved tolerance in inpatients. Bowel preparation with 2L-PEG-CaO is suitable alternative to traditional 4L split PEG bowel preparation for colonoscopy of inpatients.

Future challenges in gastroenterology and hepatology, between innovations and unmet needs: A SIGE Young Editorial Board's perspective

Gastroenterology, Digestive Endoscopy and Hepatology have faced significant improvements in terms of diagnosis and therapy in the last decades. However, many fields still remain poorly explored, and many questions unanswered. Moreover, basic-science, as well as translational and clinical discoveries, together with technology advancement will determine further steps toward a better, refined care for many gastroenterological disorders in the future. Therefore, the Young Investigators of the Italian Society of Gastroenterology (SIGE) joined together, offering a perspective on major future innovations in some hot clinical topics in Gastroenterology, Endoscopy, and Hepatology, as well as the current pitfalls and the grey zones.

Novel frontiers of agents for bowel cleansing for colonoscopy

The incidence of colorectal cancer (CRC) is characterized by rapid declines in the wake of widespread screening. Colonoscopy is the gold standard for CRC screening, but its accuracy is related to high quality of bowel preparation (BP). In this review, we aimed to summarized the current strategy to increase bowel cleansing before colonoscopy. Newly bowel cleansing agents were developed with the same efficacy of previous agent but requiring less amount of liquid to improve patients' acceptability. The role of the diet before colonoscopy was also changed, as well the contribution of educational intervention and the use of adjunctive drugs to improve patients' tolerance and/or quality of BP. The review also described BP in special situations, as lower gastrointestinal bleeding, elderly people, patients with chronic kidney disease, patients with inflammatory bowel disease, patients with congestive heart failure, inpatient, patient with previous bowel resection, pregnant/lactating patients. The review underlined the quality of BP should be described using a validate scale in colonoscopy report and it explored the available scales. Finally, the review explored the possible contribution of bowel cleansing in post-colonoscopy syndrome that can be related by a transient alteration of gut microbiota. Moreover, the study underlined several points needed to further investigations.

1L- vs. 4L-Polyethylene glycol for bowel preparation before colonoscopy among inpatients: A propensity score-matching analysis

BACKGROUND

Inpatients are at risk for inadequate colon cleansing. Experts recommend 4L-polyethylene-glycol (PEG) solution. A higher colon cleansing adequacy rate for a hyperosmolar 1L-PEG plus ascorbate prep has been recently reported.

AIMS

We aimed to determine whether 1L-PEG outperforms 4L-PEG among inpatients.

METHODS

post-hoc analysis of a large Italian multicenter prospective observational study among inpatients (QIPS study). We performed a propensity score matching between 1L-PEG and 4L-PEG group. The primary outcome was the rate of adequate colon cleansing as assessed by unblinded endoscopists through Boston scale. Secondary outcome was the safety profile.

RESULTS

Among 1,004 patients undergoing colonoscopy, 724 (72%) were prescribed 4L-PEG and 280 (28%) 1L-PEG. The overall adequate colon cleansing rate was 69.2% (n = 695). We matched 274 pairs of patients with similar distribution of confounders. The rate of patients with adequate colon cleansing was higher in 1L-PEG than in 4L-PEG group (84.3% vs. 77.4%, p = 0.039). No different shift in serum concentration of electrolytes (namely Na⁺, K⁺, Ca²⁺), creatinine and hematocrit were observed for both preparations.

CONCLUSION

We found a higher rate of adequate colon cleansing for colonoscopy with the 1L-PEG bowel prep vs. 4L-PEG, with apparent similar safety profile, among inpatients. A confirmatory randomized trial is needed. (ClinicalTrials.gov no: NCT04310332).

Same-Day Single Dose of 2 Liter Polyethylene Glycol is Not Inferior to The Standard Bowel Preparation Regimen in Low-Risk Patients: A Randomized, Controlled Trial

OBJECTIVES

Split dose of 4 l polyethylene glycol (PEG) is currently the standard regimen for bowel preparation (BP). However, it may be unnecessary for patients without high risks (e.g., old age, constipation, and diabetes, and so on) for inadequate BP. The study aimed to compare the efficacy of bowel cleansing between low-risk patients receiving same-day, single dose of low-volume (SSL) PEG vs. standard regimen.

METHODS

This prospective, randomized, observer-blinded, non-inferiority study enrolled low-risk patients in three centers. Patients undergoing colonoscopy were randomized (1:1) to the SSL or standard group. The primary outcome was adequate BP, defined by Boston Bowel Preparation Score (BBPS) ≥6 and each segmental score ≥2. Secondary outcomes included adverse events, cecal intubation rate, and patient willingness to repeat BP, and so on.

RESULTS

Among 2,532 patients eligible for the study, 940 (37.1%) were at low risk and 792 (31.3%) at high risk for inadequate BP. The low-risk patients were randomly allocated to the SSL (n=470) or standard group (n=470). The baseline characteristics of the two groups were similar. Intention-to-treat analysis showed that adequate BP was achieved in 88.1% in the SSL group and 87.0% in the standard group (relative risk (RR) 1.10, 95% confidence interval (CI): 0.75-1.63, P=0.621). The overall BBPS was 7.3±1.2 and 7.3±1.3, respectively (P=0.948). No significant differences were found between the two groups with regards to the right, transverse, and left-segmental colon BBPS (all P>0.05). However, in terms of adverse events, patients in the SSL group reported less nausea (19.6% vs. 29.9%), vomiting (5.3% vs. 11.4%), and abdominal discomfort (2.2% vs. 6.0%) compared with those in the standard group. More patients in the SSL group were willing to repeat BP (94.0% vs. 89.5%, P=0.015).

CONCLUSIONS

For low-risk patients, the SSL regimen was not inferior to the split dose of 4 l PEG for adequacy of BP. Single dose of low-volume regimen had significantly fewer adverse events. This simplified regimen may be preferable in the "easy-to prepare" population.

Diabetes Mellitus and the Colon

OPINION STATEMENT

Diabetes mellitus (DM) can affect the structure and function of the colon promoting commonly encountered lower gastrointestinal symptoms such as constipation, diarrhea, abdominal distention, bloating, and abdominal pain. Specific colonic disorders for which adults with DM are at greater risk include chronic constipation, enteropathic diarrhea, colorectal cancer (CRC), inflammatory bowel disease, microscopic colitis, and Clostridium difficile colitis. Smooth muscle structure and function, density of the interstitial cells of Cajal, and the health and function of the autonomic and enteric nerves of the colon are all potential affected by DM. These effects can in turn lead to alterations in colon motility, visceral sensation, immune function, endothelial function, and the colonic microbiome. The evaluation and treatment for slow transit constipation as well as pelvic floor dysfunction should be considered when constipation symptoms are refractory to initial treatment measures. DM-related medications and small bowel conditions such as celiac disease and small intestinal bowel overgrowth should be considered and excluded before a diagnosis of enteropathic diarrhea is made. Given the higher risk of CRC, adults with DM should be appropriately screened and may require a longer bowel preparation to ensure an adequate evaluation.