Assessment of patients' perceptions of bowel preparation quality at colonoscopy

Optimizing bowel preparation quality for colonoscopy: consensus recommendations by the US Multi-Society Task Force on Colorectal Cancer

This document is an update to the 2014 recommendations for optimizing the adequacy of bowel cleansing for colonoscopy from the US Multi-Society Task Force on Colorectal Cancer, which represents the American College of Gastroenterology, the American Gastroenterological Association, and the American Society for Gastrointestinal Endoscopy. The US Multi-Society Task Force developed consensus statements and key clinical concepts addressing important aspects of bowel preparation for colonoscopy. The majority of consensus statements focus on individuals at average risk for inadequate bowel preparation. However, statements addressing individuals at risk for inadequate bowel preparation quality are also provided. The quality of a bowel preparation is defined as adequate when standard screening or surveillance intervals can be assigned based on the findings of the colonoscopy. We recommend the use of a split-dose bowel preparation regimen and suggest that a 2 L regimen may be sufficient. A same-day regimen is recommended as an acceptable alternative for individuals undergoing afternoon colonoscopy, but we suggest that a same-day regimen is an inferior alternative for individuals undergoing morning colonoscopy. We recommend limiting dietary restrictions to the day before a colonoscopy, relying on either clear liquids or low-fiber/low-residue diets for the early and midday meals. We suggest the adjunctive use of oral simethicone for bowel preparation before colonoscopy. Routine tracking of the rate of adequate bowel preparations at the level of individual endoscopists and at the level of the endoscopy unit is also recommended, with a target of >90% for both rates.

Optimizing Bowel Preparation Quality for Colonoscopy: Consensus Recommendations by the US Multi-Society Task Force on Colorectal Cancer

This document is an update to the 2014 recommendations for optimizing the adequacy of bowel cleansing for colonoscopy from the US Multi-Society Task Force on Colorectal Cancer, which represents the American College of Gastroenterology, the American Gastroenterological Association, and the American Society for Gastrointestinal Endoscopy. The US Multi-Society Task Force developed consensus statements and key clinical concepts addressing important aspects of bowel preparation for colonoscopy. The majority of consensus statements focus on individuals at average risk for inadequate bowel preparation. However, statements addressing individuals at risk for inadequate bowel preparation quality are also provided. The quality of a bowel preparation is defined as adequate when standard screening or surveillance intervals can be assigned based on the findings of the colonoscopy. We recommend the use of a split-dose bowel preparation regimen and suggest that a 2 L regimen may be sufficient. A same-day regimen is recommended as an acceptable alternative for individuals undergoing afternoon colonoscopy, but we suggest that a same-day regimen is an inferior alternative for individuals undergoing morning colonoscopy. We recommend limiting dietary restrictions to the day before a colonoscopy, relying on either clear liquids or low-fiber/low-residue diets for the early and midday meals. We suggest the adjunctive use of oral simethicone for bowel preparation before colonoscopy. Routine tracking of the rate of adequate bowel preparations at the level of individual endoscopists and at the level of the endoscopy unit is also recommended, with a target of >90% for both rates.

Optimizing Bowel Preparation Quality for Colonoscopy: Consensus Recommendations by the US Multi-Society Task Force on Colorectal Cancer

This document is an update to the 2014 recommendations for optimizing the adequacy of bowel cleansing for colonoscopy from the US Multi-Society Task Force on Colorectal Cancer, which represents the American College of Gastroenterology and the American Society for Gastrointestinal Endoscopy. The US Multi-Society Task Force developed consensus statements and key clinical concepts addressing important aspects of bowel preparation for colonoscopy. The majority of consensus statements focus on individuals at average risk for inadequate bowel preparation. However, statements addressing individuals at risk for inadequate bowel preparation quality are also provided. The quality of a bowel preparation is defined as adequate when standard screening or surveillance intervals can be assigned based on the findings of the colonoscopy. We recommend the use of a split-dose bowel preparation regimen and suggest that a 2 L regimen may be sufficient. A same-day regimen is recommended as an acceptable alternative for individuals undergoing afternoon colonoscopy, but we suggest that a same-day regimen is an inferior alternative for individuals undergoing morning colonoscopy. We recommend limiting dietary restrictions to the day before a colonoscopy, relying on either clear liquids or low-fiber/low-residue diets for the early and midday meals. We suggest the adjunctive use of oral simethicone for bowel preparation before colonoscopy. Routine tracking of the rate of adequate bowel preparations at the level of individual endoscopists and at the level of the endoscopy unit is also recommended, with a target of >90% for both rates.

Interventions to improve bowel cleansing in colonoscopy

INTRODUCTION

Suboptimal bowel preparation adversely affects colonoscopy quality, increases healthcare costs, and prolongs waiting time. The primary contributing factors include poor tolerance to the preparation solutions, noncompliance with prescribed instructions, and suboptimal efficacy of the bowel cleansing solution itself.

AREAS COVERED

This review examined the predictive factors associated with suboptimal bowel preparation and discussed interventions aimed at improving bowel cleansing. It also provides evidence-based practical algorithms supplemented by insights from our own clinical experience. Relevant topics were reviewed using resources from the PubMed database.

EXPERT OPINION

Although current bowel preparation protocols are effective for the majority of patients, a significant proportion still present challenges for optimal preparation. These patients may benefit from personalized strategies tailored to the specific causes of preparation failure. Conducting a thorough interview is crucial for identifying the reasons for failure, particularly in patients who have previously experienced suboptimal preparation during colonoscopy. In colonoscopy-naïve patients, it is essential to assess the risk of suboptimal preparation. In both cases, interventions should be customized to either address the identified causes in the former group or employ preventive strategies to reduce the likelihood of failure in the latter.

Online Educational Module Improves Knowledge of Nurses on Bowel Preparation for Colonoscopy

The effectiveness of colonoscopy is limited by the adequacy of bowel preparation. Nurses are essential in providing bowel cleansing agents and instructions for hospitalized patients before colonoscopy. This study aims to assess and improve the knowledge of nurses on bowel preparation for inpatient colonoscopy. Participants were asked to complete the survey before and after completing an educational module. The module and survey questions were placed in the NetLearning environment of the hospital intranet. A minimum post-test score of 80% was required to pass the course. A total of 1,107 nurses participated in the survey. Overall, the average score improved from 87% to 93% after the module (p < .0495). Knowledge of the different ways of consuming bowel cleansing agents improved from 54.3% to 83.6% (p = .0001). Only 56.2% of nurses knew how to carry out a split-dose bowel preparation regimen, which increased to 80.1% after the educational module (p = .0001). Nurses' knowledge about the different ways of consuming bowel cleansing agents before colonoscopy and the split-dose regimen is inadequate. A simple online educational module significantly improved the knowledge of nurses on bowel preparation for colonoscopy.

Design and validation of an artificial intelligence system to detect the quality of colon cleansing before colonoscopy

BACKGROUND AND AIMS

Patients' perception of their bowel cleansing quality may guide rescue cleansing strategies before colonoscopy. The main aim of this study was to train and validate a convolutional neural network (CNN) for classifying rectal effluent during bowel preparation intake as "adequate" or "inadequate" cleansing before colonoscopy.

PATIENTS AND METHODS

Patients referred for outpatient colonoscopy were asked to provide images of their rectal effluent during the bowel preparation process. The images were categorized as adequate or inadequate cleansing based on a predefined 4-picture quality scale. A total of 1203 images were collected from 660 patients. The initial dataset (799 images), was split into a training set (80%) and a validation set (20%). The second dataset (404 images) was used to develop a second test of the CNN accuracy. Afterward, CNN prediction was prospectively compared with the Boston Bowel Preparation Scale (BBPS) in 200 additional patients who provided a picture of their last rectal effluent.

RESULTS

On the initial dataset, a global accuracy of 97.49%, a sensitivity of 98.17% and a specificity of 96.66% were obtained using the CNN model. On the second dataset, an accuracy of 95%, a sensitivity of 99.60% and a specificity of 87.41% were obtained. The results from the CNN model were significantly associated with those from the BBPS (P<0.001), and 77.78% of the patients with poor bowel preparation were correctly classified.

CONCLUSION

The designed CNN is capable of classifying "adequate cleansing" and "inadequate cleansing" images with high accuracy.

Agreement between the perception of colon cleansing reported by patients and colon cleansing assessed by a validated colon cleansing scale

AIMS

Patients' perception of their cleansing quality can guide strategies to improve cleansing during colonoscopy. There are no studies assessing the agreement between the quality of cleansing perceived by patients and cleansing quality assessed during colonoscopy using validated bowel preparation scales. The main aim of this study was to compare the cleansing quality reported by patients with the quality during colonoscopy using the Boston Bowel Preparation Scale (BBPS).

PATIENTS AND METHODS

Consecutive patients referred to an outpatient colonoscopy were included. Four drawings representing different degrees of cleansing were designed. Patients chose the drawing that most resembled the last stool. The predictive ability of the patient's perception and agreement between the patient's perception and the BBPS were calculated. A BBPS score of <2 points in any segment was considered inadequate.

RESULTS

Six hundred and thirty-three patients were included (age: 62.8±13.7 years, male: 53.4%). Overall, 107 patients (16.9%) had inadequate cleansing during colonoscopy, and in 12.2% of cases, the patient's perception was poor. The patient's perception compared to the quality of cleanliness during colonoscopy presented a positive and negative predictive value of 54.6% and 88.3%, respectively. The agreement between patient perception and the BBPS was significant (P<0.001), although fair (k=0.37). The results were similar in a validation cohort of 378 patients (k=0.41).

CONCLUSIONS

The cleanliness perceived by the patient and the quality of cleanliness using a validated scale were correlated, although fair. However, this measure satisfactorily identified patients with adequate preparation. Cleansing rescue strategies may target patients who self-report improper cleaning. Registration number of the trial: NCT03830489.

A Novel Model to Predict Inadequate Bowel Preparation Prior to Colonoscopy Incorporating Patients' Reactions to Drinking the Laxative

BACKGROUND AND AIMS

Prior studies have identified predictors of inadequate preparation with limited success. We aimed to build a model that could predict the likelihood of inadequate preparation by also including factors related to the patient's reaction to drinking the laxative preparation.

METHODS

Demographic, clinical, and preparation-related data were prospectively collected on patients undergoing colonoscopy. An inadequate preparation was defined as a Boston Bowel Preparation Scale < 6. Statistical analyses were performed to identify predictors of inadequate preparation and create a predictive model.

RESULTS

324 patients were included (age 67 +/- 14 years, 52% male). 77 (23.7%) had inadequate preparations. Diabetes (p < 0.001), cerebrovascular accident (CVA) (p < 0.001), incomplete prep consumption (p = 0.007), high school level education and above (p < 0.001), use of Bisacodyl (p = 0.005), >10 bowel movements (p = 0.02), and use of Sodium Picosulfate or low-volume polyethylene glycol (PEG) solution (2L) compared to PEG 3L (p < 0.001) were significant variables. In a multivariate analysis, prior CVA increased the risk for inadequate preparation (OR = 4.8, CI 1.6-14.5), whereas high school level education and above (OR = 0.4, CI 0.2-0.8), consumption of Bisacodyl (OR = 0.4, CI 0.2-0.8), >10 bowel movements (OR = 0.5, CI 0.3-0.9), and use of Sodium Picosulfate (OR = 0.5, CI 0.3-0.9) decreased the risk for inadequate prep. Using these, a predictive model for patients likely to have an inadequate colon preparation was created with an area under the curve of 0.74 (35% sensitivity, 90% specificity at a cutoff point of 39%).

CONCLUSION

Given the low sensitivity, this predictive model does not appear ready for clinical use. However, due to its high specificity, it may be helpful in high-risk, sicker populations by preventing inadequately prepped procedures.

Effectiveness of using a patient education mobile application to improve the quality of bowel preparation: a randomised controlled trial

AIMS

To determine the effectiveness of a mobile application (app) in improving the quality of bowel preparation for colonoscopy.

METHOD

An endoscopist-blinded randomised controlled trial enrolled patients who were undergoing a colonoscopy on the same day of bowel preparation. The intervention used a Vietnamese mobile app that provides instructions on bowel preparation while patients in the comparison group received conventional instructions. Outcomes included the Boston Bowel Preparation Scale (BBPS) to assess the quality of bowel preparation and the polyp detection rate (PDR) and adenoma detection rate (ADR).

RESULTS

The study recruited 515 patients (256 in the intervention group). The median age was 42 years, 50.9% were females, 69.1% high school graduates and higher, and 45.2% from urban area. Patients in the intervention group had higher adherence to instructions (60.9% vs 52.4%, p=0.05) and longer length of taking laxatives (mean difference 0.17 hours, 95% CI 0.06 to 0.27). The intervention did not reduce the risk of poor bowel cleansing (total BBPS<6) in both overall (7.4% vs 7.7%; risk ratio 0.96, 95% CI 0.53 to 1.76) and subgroup analysis. PDR and ADR were similar between the two groups.

CONCLUSIONS

The mobile app providing instructions on proper bowel preparation improved the practice during bowel preparation but did not improve the quality of bowel cleansing or PDR.

Hydrogen Breath Testing Predicts Bowel Preparation Quality Prior to Colonoscopy: A Systematic Review

Background

This systematic review aims to assess the accuracy of hydrogen breath testing as a predictor of bowel preparation.

Methods

Studies were identified from MEDLINE, Embase, Web of Science, Cochrane Library and clinicaltrials.gov. Two investigators evaluated abstracts for inclusion criteria - report of correlation between hydrogen breath levels and bowel preparation quality, prospective design and non-emergent colonoscopy in adults. Included studies underwent duplicate data extraction using a standardized approach. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool assessed quality of the studies.

Results

One hundred fifty-nine publications were identified, and six unique studies met inclusion criteria. The number of patients analyzed ranged from 61 to 127. Three studies were performed in the USA, one in Japan and two in Italy. Three studies used a prebiotic in addition to a purgative, with the intention of enhancing the discriminating ability of hydrogen breath levels. Three studies assessed baseline hydrogen levels. In five of the six studies, hydrogen breath levels were predictive of inadequate bowel preparation. Suggested absolute hydrogen levels to distinguish adequate from inadequate bowel preparation ranged from 3 to 10 parts per million. Depending on the cutoff value, sensitivity ranged from 71% to 100% and specificity from 87% to 100%. There was significant heterogeneity among studies in breath testing protocol and breath analyzer used. Full-text studies had low risk of bias in most assessed domains.

Conclusion

Hydrogen breath levels predict bowel preparation adequacy but existing studies have significant limitations. Further studies should use standardized methods and consider the real-world practicality of self-administered home breath testing.

Patient Characteristics Associated With Quality of Colonoscopy Preparation: A Systematic Review and Meta-analysis

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.

Comparison of rectal suction versus rectal tube insertion for reducing abdominal symptoms immediately after unsedated colonoscopy

BACKGROUND AND STUDY AIMS

Abdominal discomfort and bloating are common symptoms after colonoscopy. We aimed to compare the effects of direct rectal suction with insertion of a rectal tube on reducing abdominal symptoms after unsedated colonoscopy.

PATIENTS AND METHODS

Consecutive patients undergoing colonoscopy were randomized to have direct rectal suction or placement of a rectal tube immediately after colonoscopy. Post-procedure abdominal pain and bloating were measured with a 0 - 100 visual analogue scale. All participants ranked their satisfaction with either direct rectal suction or insertion of a rectal tube.

RESULTS

Abdominal pain and bloating were significantly reduced by direct rectal suction and placement of a rectal tube at 1 minute (both P < 0.05) and 3 minutes (both P < 0.05) after the colonoscopy. Direct rectal suction significantly reduced abdominal pain at 1 minute (P = 0.001) and 3 minutes (P = 0.005) after colonoscopy compared with rectal tube insertion. Bloating was significantly lower in patients with direct rectal suction compared to those with rectal tube insertion at 1 minute (P = 0.03) after colonoscopy. Greater satisfaction was found in patients with direct rectal suction compared to those with rectal tube insertion (P = 0.009).

CONCLUSION

Direct rectal suction is more effective than rectal tube placement in reducing abdominal symptoms immediately after colonoscopy. Our study suggests that direct rectal suction is useful in providing relief of symptoms when patients are having difficulty expelling air or are experiencing abdominal symptoms following colonoscopy.

Total Colonic Decompression After Colonoscopy Decreases Postcolonoscopy Abdominal Pain: A Randomized Double-Blind Controlled Trial

GOALS

The purpose of this study was to determine whether total colonic decompression after colonoscopy decreased postcolonoscopy abdominal pain.

BACKGROUND

Abdominal pain that occurs after a colonoscopy may cause significant discomfort in some patients, and residual bowel gas is thought to be a key contributor to this abdominal pain.

STUDY

Asymptomatic 300 patients who underwent colonoscopy under sedation were randomized to either the decompression group or the control group. Initial colonoscopic procedure was performed uniformly in both the groups. After the colonoscopy examination was completed, the colonoscope was reinserted into the cecum, and the intraluminal air was aspirated during withdrawal in the decompression group. Abdominal pain was assessed before discharge and 24 to 48 hours after colonoscopy using a 10-point visual analogue scale (VAS).

RESULTS

The 2 groups were similar with regard to clinical, demographic, and procedural factors. Among 288 patients, the incidence of abdominal pain (VAS≥1) after colonoscopy was 38 (26.6%) of 143 patients in the decompression group and 95 (65.5%) of 145 patients in the control group (VAS 0.68±1.35 vs. 2.14±2.15, P<0.001). There was an 86.1% reduction rate of abdominal pain by colonic decompression, based on multivariate analysis (odds ratio 0.139 [95% confidence interval, 0.077-0.250], P<0.001). Furthermore, independent factors for abdominal pain included female gender and total duration of procedure >800 seconds. There were no reinsertion-related complications in the decompression group.

CONCLUSION

Total colonic decompression after colonoscopy has a beneficial effect and can reduce postcolonoscopy abdominal pain without additional complications.

Patient descriptions of rectal effluents may help to predict the quality of bowel preparation with photographic examples

Background/Aims

Previous studies have suggested a weak correlation between self-reported rectal effluent status and bowel preparation quality. We aim to evaluate whether photographic examples of rectal effluents could improve the correlation between patient descriptions of rectal effluents and bowel preparation quality.

Methods

Before colonoscopy, patients were asked to describe the nature of their last three rectal effluents. Photographic examples of rectal effluents were provided as a reference for scoring. Bowel preparation was subsequently assessed by a single endoscopist using a global preparation assessment scale. Preparation outcomes were grouped into two levels (excellent to good vs. fair to inadequate). Both univariate and multivariate logistic regression models were used to find any association between bowel preparation quality and patient characteristics.

Results

A total of 138 patients completed the questionnaires. The mean age was 56.5±10.4 years. The mean sum of the last three rectal effluent scores was 5.9±2.0. Higher rectal effluent scores (odds ratio [OR], 0.82; P=0.043) and the presence of diverticula (OR, 0.16; P<0.001) were risk factors for suboptimal preparation.

Conclusions

Photographic example-guided patient descriptions of rectal effluents showed a statistically significant association with bowel preparation quality. However, clinical significance seemed to be low. The presence of diverticula was an independent predictive factor for suboptimal bowel preparation quality.

Effect of midazolam on cardiopulmonary function during colonoscopy with conscious sedation

BACKGROUND AND AIM

Conscious sedation of patients with midazolam reduces anxiety and pain and improves colonoscopy success rates. However, it may lead to adverse effects such as hypoxia and hypotension. The present study investigated the effects of midazolam on cardiopulmonary function during colonoscopy with conscious sedation.

METHODS

Between January 2011 and September 2011, 126 consecutive patients undergoing colonoscopy were enrolled and divided into two groups: (i) sedation with midazolam (midazolam group, n=65); and (ii) no sedation (control group, n=61). Systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), and peripheral oxygen saturation (SpO(2) ), were recorded before, during and after the endoscopic procedure.

RESULTS

In the midazolam group, SBP and DBP decreased more during colonoscopy than in the control group. However, the frequency of a significant change in SBP was similar in both groups. During colonoscopy, HR and SpO(2) decreased significantly in the midazolam group compared to those in the control group. SpO(2) levels returned to normal after the procedure.

CONCLUSIONS

Midazolam induced decreases in SBP, DBP, HR and SpO(2) during colonoscopy. Clinically significant changes in SBP, HR, and SpO(2) , however, were similar in the midazolam and control groups. These results suggest that midazolam has a tolerable effect on cardiopulmonary function and may be safely used during colonoscopy.

The modern bowel preparation in colonoscopy

Adequate bowel preparation is essential for optimal colonoscopy. Suboptimal bowel preparation occurs in 25% to 40% of cases and is associated with canceled procedures, prolonged procedure time, incomplete examination, increased cost, and missed pathology. There are several effective formulations for colon cleansing with a good safety profile. Split dosing should be implemented whenever possible in an effort to enhance tolerance and adherence, and improve mucosal visibility and overall quality of the examination. In this review, modern bowel preparations are discussed including their mechanism of action, mode of use, safety, and how to optimize outcomes.

Safety, patient's tolerance, and efficacy of a 2-liter vitamin C-enriched macrogol bowel preparation: a randomized, endoscopist-blinded prospective comparison with a 4-liter macrogol solution

BACKGROUND

Optimal bowel preparation is associated with lower polyp miss rates, but patients have difficulties in complying with the usual 4-L bowel preparation.

OBJECTIVE

This study aimed to compare the safety, acceptance, and efficacy of 2-L polyethylene glycol electrolyte solution enriched in vitamin C with 4-L polyethylene glycol electrolyte solution.

DESIGN

This study is an endoscopist-blinded randomized controlled trial.

SETTINGS

The study was conducted at a tertiary referral hospital.

PATIENTS

Consecutive outpatients were randomly assigned to receive 4-L polyethylene glycol electrolyte solution or 2-L polyethylene glycol electrolyte solution enriched in vitamin C with 2 L of clear fluids in a single-dose or a split-dose regime.

MAIN OUTCOME MEASURES

Safety was assessed by blood sampling before and after the preparation and by a 30-day postcolonoscopy chart and complication database review. Acceptance was investigated by questionnaires, and the adequacy of bowel preparation was assessed by the Aronchick and Ottawa scales.

RESULTS

One hundred eighty-eight patients, 98 in the polyethylene glycol electrolyte solution enriched in vitamin C group and 90 in the polyethylene glycol electrolyte solution group, participated. Although changes in bicarbonate blood concentrations with polyethylene glycol electrolyte solution enriched in vitamin C were seen to such an extent that the blinded investigator correctly guessed the preparation in 75.6%, no unsafe values were observed. A 30-day chart and complication database review revealed 1 severe adverse event of a myocardial infarction in the polyethylene glycol electrolyte solution enriched in vitamin C group. Patient acceptance and compliance were significantly higher with the polyethylene glycol electrolyte solution enriched in vitamin C group. The impact on sleep, daily activities, and physical complaints were similar in both groups. Polyethylene glycol electrolyte solution enriched in vitamin C was noninferior to polyethylene glycol electrolyte solution in cleansing efficacy, but the segmental rating of excellent and good preparation in right and transverse colon was significantly better for polyethylene glycol electrolyte solution, especially when taken as a split dose.

LIMITATIONS

The results cannot be extrapolated to immobile inpatients with comorbidities. Another limitation of our study was the inability to determine plasma vitamin C concentrations and to assess the quality of colonoscopy performance.

CONCLUSIONS

Two-liter polyethylene glycol electrolyte solution enriched in vitamin C is a safe and patient-friendly alternative to the 4-L polyethylene glycol electrolyte solution. Endoscopists slightly preferred the 4-L polyethylene glycol electrolyte solution.

Impact of patient education with cartoon visual aids on the quality of bowel preparation for colonoscopy

BACKGROUND

High-quality bowel preparation is a prerequisite for colonoscopy. Few studies have evaluated visual aids as a means of improving the quality of bowel preparation.

OBJECTIVE

To assess the effect of patient education by using cartoon visual aids on the quality of bowel preparation.

DESIGN

An endoscopist-blinded, randomized, controlled trial.

SETTING

Tertiary referral center.

SUBJECTS

Patients scheduled for screening colonoscopy in a health examination center.

INTERVENTIONS

Patients were assigned to receive the existing verbal and written instructions (group A) or a new cartoon visual educational instruction (group B) for colonoscopy.

MAIN OUTCOME MEASUREMENTS

The primary endpoint was the quality of bowel preparation, assessed by using the Boston Bowel Preparation Scale (BBPS). Secondary endpoints were the quality of bowel preparation assessed by using the Universal Preparation Assessment Scale; insertion, withdrawal, and workup times; and polyp detection rates in the 2 groups. Logistic regression analysis was performed to determine the factors associated with poor bowel preparation according to a BBPS score less than 5.

RESULTS

Group B exhibited better bowel preparation than group A according to BBPS scores (mean BBPS score, 6.12 ± 2.19 vs 7.44 ± 1.87, P ≤ .01; median BBPS score, 6.00 ± 0.00 vs 9.00 ± 0.00, P ≤ .01; good bowel preparation for colonoscopy, BBPS score ≥5, 81.6% vs 93.1%, P = .02). Multivariate analysis revealed that older age (odds ratio 1.07, P ≤ .01) and no use of visual aids (odds ratio 3.08, P = .02) were independent factors associated with poor bowel preparation.

LIMITATIONS

Single-center study.

CONCLUSIONS

Patient education with cartoons effectively improved bowel preparation for colonoscopy.

Low-volume plus ascorbic acid vs high-volume plus simethicone bowel preparation before colonoscopy

AIM: To investigate the effectiveness of low-volume plus ascorbic acid [polyethylene glycol plus ascorbic acid (PEG + Asc)] and high-volume plus simethicone [polyethylene glycol plus simethicone (PEG + Sim)] bowel preparations.

METHODS: A total of one hundred and forty-four outpatients (76 males), aged from 20 to 84 years (median age 59.5 years), who attended our Department, were divided into two groups, age and sex matched, and underwent colonoscopy. Two questionnaires, one for patients reporting acceptability and the other for endoscopists evaluating bowel cleansing effectiveness according to validated scales, were completed. Indications, timing of examination and endoscopical findings were recorded. Biopsy forceps were used as a measuring tool in order to determine polyp endoscopic size estimation. Difficulty in completing the preparation was rated in a 5-point Likert scale (1 = easy to 5 = unable). Adverse experiences (fullness, cramps, nausea, vomiting, abdominal pain, headache and insomnia), number of evacuations and types of activities performed during preparation (walking or resting in bed) were also investigated.

RESULTS: Seventy-two patients were selected for each group. The two groups were age and sex matched as well as being comparable in terms of medical history and drug therapies taken. Fourteen patients dropped out from the trial because they did not complete the preparation procedure. Ratings of global bowel cleansing examinations were considered to be adequate in 91% of PEG + Asc and 88% of PEG + Sim patients. Residual Stool Score indicated similar levels of amount and consistency of residual stool; there was a significant difference in the percentage of bowel wall visualization in favour of PEG + Sim patients. In the PEG + Sim group, 12 adenomas ≤ 10 mm diameter (5/left colon + 7/right colon) vs 9 (8/left colon + 1/right colon) in the PEG + Asc group were diagnosed. Visualization of small lesions seems to be one of the primary advantages of the PEG + Sim preparation.

CONCLUSION: PEG + Asc is a good alternative solution as a bowel preparation but more improvements are necessary in order to achieve the target of a perfect preparation.

Patients' description of rectal effluent and quality of bowel preparation at colonoscopy

BACKGROUND

There are few data evaluating how accurately patients can predict the quality of their colonoscopy preparation.

OBJECTIVE

The aim of this study was to assess whether patients' description of rectal effluent predicts preparation quality as assessed per endoscopist.

DESIGN

Prospective, cross-sectional.

SETTING

Three outpatient endoscopy units at Indiana University Medical Center.

PATIENTS

Patients undergoing colonoscopy were enrolled.

INTERVENTIONS

Patients were given a questionnaire assessing their preparation based on the description of their last rectal effluent. This was compared with endoscopists assessment of preparation.

MAIN OUTCOME MEASUREMENTS

Correlation between the patient's description of the last effluent and endoscopist's assessment of preparation.

RESULTS

Of the total 429 patients, 59% were male and 75% were white. There was only slight agreement between the patients' description of effluent and the endoscopists' description of preparation (Cohen kappa statistic, 0.067). However, patients reporting brown liquid or solid had a 54% chance of having fair or poor preparation. Ingestion of <90% of the preparation, male gender, use of medications associated with constipation, and comorbid conditions were independent predictors of fair or poor preparation.

LIMITATIONS

No validated system to assess the quality of the bowel preparation or for patients to assess their preparation.

CONCLUSION

Patients' description of last rectal effluent is not a reliable predictor of quality of preparation per the endoscopist, but patients reporting their last effluent as brown liquid or solid have a substantial likelihood of inadequate preparation. These patients may benefit from additional preparation, which may be particularly useful if it can be administered in the endoscopy unit followed by colonoscopy on the same day.

Systematic review: oral bowel preparation for colonoscopy

BACKGROUND

There are many published trials of colon cleansing regimens for colonoscopy but no clear consensus regarding relative performance.

AIM

To identify high quality controlled trials comparing two or more bowel preparation regimens and to compare efficacy and tolerability.

METHODS

A comprehensive systematic review was carried out to identify candidate studies. Quality appraisal was carried out on all identified studies. Results were meta-analysed where possible and qualitatively compared if not.

RESULTS

Eighty-two studies qualified for analysis. Polyethylene glycol and sodium phosphate were the most frequently investigated preparations. There was no significant efficacy difference between the two, but sodium phosphate was better tolerated. Sodium picosulphate/magnesium citrate, a commonly prescribed preparation, was investigated in four studies, with no clear benefit over other regimens demonstrated. Safety was not recognized as a problem in the randomized controlled trials. Published case series demonstrate that sodium phosphate is associated with the highest risk of clinically significant electrolyte disturbances.

CONCLUSION

Shortcomings in study design limit the value of many of the studies. Based on these results, no single bowel preparation emerges as consistently superior. New preparations are required that combine better efficacy and tolerability, in addition to rigorous new validated study designs, allowing unequivocal comparisons to be made.

Factors determining post-colonoscopy abdominal pain: prospective study of screening colonoscopy in 1000 subjects

BACKGROUND

Factors determining post-colonoscopy abdominal pain remain poorly understood. Accordingly, a prospective study was conducted to reveal the key determinants.

METHODS

One thousand consecutive and asymptomatic patients (569 men, 431 women; mean age 51 years, range 19-84 years) undergoing total colonoscopy were evaluated to assess their abdominal pain. Their demographic data, psychological profiles (determined on the Brief Symptom Rating Scale and Maudsley Personality Inventory), and endoscopic findings were treated as independent variables in polytomous logistic regression in which pain severities were treated as outcome variables. Factors affecting the duration of pain were evaluated on multivariate linear regression.

RESULTS

Colonoscopy duration (s; odds ratio [OR]: 1.001, 95% confidence interval [CI]: 1-1.002, P<0.01) and female sex (OR: 1.368, 95%CI: 1.02-1.853, P=0.03) were significantly associated with abdominal pain, but age, body mass index, psychological traits, conscious sedation, use of i.v. hyoscine butylbromide, and colonic preparation were not. Duration of the colonoscopy was longer in female than male subjects (P=0.04). On stepwise linear regression, irritable bowel syndrome (regression coefficient: 27.47, 95%CI: 6.99-47.67, P<0.01) and conscious sedation (regression coefficient: -22.17, 95%CI: -42.52 to -1.42, P = 0.036) were the best predictors of prolonged pain in 485 patients who had pain.

CONCLUSIONS

Female sex and duration of colonoscopy increased the likelihood of post-procedural abdominal pain. Conscious sedation temporarily suppressed the pain but had no effect on its occurrence. Irritable bowel syndrome may have prolonged the discomfort.