Achieving the best bowel preparation for colonoscopy

Effect of Cholecystectomy on Bubble Formation and Endoscopic Visualization: A Retrospective Cohort Study

PURPOSE

This study aimed to evaluate the association between cholecystectomy and colonic bubble formation during colonoscopy, METHODS: A single-center retrospective cohort study was conducted at Staten Island University Hospital. Researchers reviewed 348 colonoscopy reports, comparing patients with (n = 56) and without (n = 292) a history of cholecystectomy. Colonic bubble formation was assessed using a 0-3 scale (0 = no bubbles, 3 = severe bubbles). Secondary endpoints included polyp and adenoma detection, withdrawal and procedure times, bowel preparation quality, and repeat procedures. Statistical analysis included t-tests, Mann-Whitney U tests, and χ2 tests.

RESULTS

Patients with prior cholecystectomy had significantly higher incidence of severe bubble formation (score 3; 28.6% vs. 12%, p = 0.001), longer withdrawal times (18 ± 8 vs. 15 ± 5 min, p = 0.024), and increased need for repeat colonoscopies (10.7% vs. 2.1%, p = 0.001). No significant differences were found in adenoma detection, polyp detection, or bowel preparation quality between the two groups.

CONCLUSION

Cholecystectomy is associated with increased colonic bubble formation during colonoscopy, leading to longer withdrawal times and higher rates of repeat procedures. While this study did not find a difference in adenoma detection rates, the impaired visualization caused by bubbles may necessitate tailored bowel preparation strategies for patients with a history of cholecystectomy to optimize colonoscopy effectiveness.

Effects of Different Bowel Preparation Regimens and Age Factors on the Gut Microbiota: A Prospective Randomized Controlled Study

BACKGROUND

Opinions about the impact of bowel preparation on the gut microbiota are divided. This study investigated the effects of different regimens on the gut microbiota post-bowel preparation and the differences in responses across different age groups.

METHODS

This single-center, prospective, randomized, controlled clinical trial included 194 patients. Patients were categorized into two groups: one group receiving polyethylene glycol (n = 108) and one receiving sodium picosulfate (n = 86) for bowel preparation. Fecal samples were collected at baseline and on days 7 and 14 post-bowel preparation. The microbiota's diversity and composition were analyzed using 16S ribosomal RNA gene sequencing, followed by comparative analyses.

RESULTS

The gut microbiota's abundance and diversity in patients significantly decreased post-bowel preparation, which did not recover to the level of pre-bowel preparation on Day 14. When comparing different regimens, the polyethylene glycol and sodium picosulfate groups recovered faster in richness and diversity, respectively. Patients aged < 65 years had higher richness and diversity of the gut microbiota, whereas the microbiota structure in those aged ≥ 65 years returned to the baseline state faster. The structure of beta diversity is significantly altered and did not return in the short term. However, in the elderly population aged ≥ 65 years, it can rebound quickly. This study also identified a number of significantly altered bacterial genera.

CONCLUSIONS

Following the use of different bowel preparation regimens, the gut microbiota recovers in diverse ways, with older people over 65 experiencing a faster recovery of the microbial structure.

A prospective, single-blinded, non-inferiority, randomized controlled study comparing the effectiveness and safety of oral lactulose combined with carbohydrate-containing clear liquids versus 3-L polyethylene glycol electrolyte for colonoscopy bowel preparation

BACKGROUND

Polyethylene glycol electrolyte solution (PEG-ELS) is the standard for bowel preparation but often suffers from poor patient compliance and tolerability due to its high-volume requirement. This prospective, single-blinded, non-inferiority, randomized control trial aims to investigate the efficacy and safety of a lactulose-based regimen as an alternative for bowel preparation.

METHODS

Two hundred nine patients were randomly allocated to receive either a combination regimen consisting of 133.4 g lactulose in 200 mL, 800 mL carbohydrate-containing clear liquid, 2L additional water, and 5 g simethicone (n = 104) or 3L PEG-ELS with 5 g simethicone (n = 105), both administered in a split-dose format. The primary outcome was the rate of adequate bowel preparation, measured by the Boston bowel preparation score (BBPS). Adequate bowel preparation was defined as a BBPS score of 2 or 3 in all colon segments. Secondary outcomes included the percentage of high-quality bowel preparation (defining as a total BBPS score of 8 or 9), polyp detection rate (defining as the percentage of procedures where at least one polyp was detected), willingness to repeat the bowel preparation, adverse events, and changes in blood glucose and electrolyte levels.

RESULTS

The rate of adequate bowel preparation (96.2% vs. 97.1%, p = 0.691), the percentage of high-quality preparation (62.5% vs. 66.7%, p = 0.529), average total BBPS scores (p = 0.607), polyp detection rates (66.3% vs. 77.1%, p = 0.083), and tolerability and acceptability outcomes, including satisfaction (p = 0.729) and willingness to repeat preparation (p = 0.744), were not statistically different between the two arms. Adverse events and changes in blood glucose and electrolytes showed no significant differences (all p > 0.05).

CONCLUSION

The combination of oral lactulose and carbohydrate-containing clear fluids was non-inferior to 3L PEG-ELS for bowel preparation adequacy and polyp detection, without statistically significant differences in terms of tolerability and safety.

Development and validation of a novel scoring system based on a nomogram for predicting inadequate bowel preparation

BACKGROUND AND AIMS

Adequate bowel preparation (BP) is crucial for the diagnosis of colorectal diseases. Identifying patients at risk of inadequate BP allows for targeted interventions and improved outcomes. We aimed to develop a model for predicting inadequate BP based on preparation-related factors.

METHODS

Adult outpatients scheduled for colonoscopy between May 2022 and October 2022 were enrolled. One set (N = 913) was used to develop and internally validate the predictive model. The primary predictive model was displayed as a nomogram and then modified into a novel scoring system, which was externally validated in an independent set (N = 177). Inadequate BP was defined as a Boston Bowel Preparedness Scale (BBPS) score of less than 2 for any colonic segment. The model was evaluated by the receiver operating characteristic (ROC) curve, calibration plots, and decision curve analysis (DCA).

RESULTS

Independent factors included in the prediction model were stool frequency ≤ 5 (15 points), preparation-to-colonoscopy interval ≥ 5 h (15 points), incomplete dosage (100 points), non-split dose (90 points), unrestricted diet (88 points), no additional water intake (15 points), and last stool appearance as an opaque liquid (0-80 points). The training set exhibited the following performance metrics for identifying BP failure: area under the curve (AUC) of 0.818, accuracy (ACC) of 0.818, positive likelihood ratio (PLR) of 2.397, negative likelihood ratio (NLR) of 0.162, positive predictive value (PPV) of 0.850, and negative predictive value (NPV) of 0.723. In the internal validation set, these metrics were 0.747, 0.776, 2.099, 0.278, 0.866, and 0.538, respectively. The external validation set showed values of 0.728, 0.757, 2.10, 0.247, 0.782, and 0.704, respectively, indicating strong discriminative ability. Calibration curves demonstrated close agreement, and DCA indicated superior clinical benefits at a threshold probability of 0.73 in the training cohort and 0.75 in the validation cohort for this model.

CONCLUSIONS

This novel scoring system was developed from a prospective study and externally validated in an independent set based on 7 easily accessible variables, demonstrating robust performance in predicting inadequate BP.

Single-center experience with intraprocedural cleansing system to improve inadequate bowel preparation during colonoscopy

Inadequate bowel preparation is common despite various preprocedure interventions. There is a need for an intervention at the time of colonoscopy to combat poor preparation. In this retrospective, observational study of 46 patients, we evaluated the clinical efficacy and feasibility of implementing the third generation of the Pure-Vu EVS System, a US Food and Drug Administration-cleared over-the-scope-based intraprocedural cleansing device, into our practice at the Minneapolis VA Medical Center (Minneapolis, Minnesota, United States). To study clinical efficacy, we measured bowel preparation adequacy before and after using the device, as measured by the Boston Bowel Preparation Score, and reviewed colonoscopy surveillance interval recommendations. Technical success and feasibility of using the device were measured by procedure success rates and duration. We found that BBPS scores increased from 4.4 to 7.9 when using the device. Technical success was achieved 78.3% of the time (36/46 cases). Median colonoscopy duration was 46 minutes, although there was a trend toward shorter procedures over time. This is the first clinical evaluation of the third generation of an intraprocedural cleansing device. We found the device efficacious and easy to use with low procedure failure rates, but it does come with a learning curve. We suspect that adoption of this device mutually will benefit patients and health systems with the potential to improve resource utilization.

Deaths and cardiopulmonary events following colorectal cancer screening-A systematic review with meta-analyses

BACKGROUND

Colorectal cancer screening programmes (CRCSPs) are implemented worldwide despite recent evidence indicating more physical harm occurring during CRCSPs than previously thought. Therefore, we aimed to review the evidence on physical harms associated with endoscopic diagnostic procedures during CRCSPs and, when possible, to quantify the risk of the most serious types of physical harm during CRCSPs, i.e. deaths and cardiopulmonary events (CPEs).

METHODS

Systematic review with descriptive statistics and random-effects meta-analyses of studies investigating physical harms following CRCSPs. We conducted a systematic search in the literature and assessed the risk of bias and the certainty of the evidence.

RESULTS

We included 134 studies for review, reporting findings from 151 unique populations when accounting for multiple screening interventions per study. Physical harm can be categorized into 17 types of harm. The evidence was very heterogeneous with inadequate measurement and reporting of harms. The risk of bias was serious or critical in 95% of assessments of deaths and CPEs, and the certainty of the evidence was very low in all analyses. The risk of death was assessed for 57 populations with large variation across studies. Meta-analyses indicated that 3 to 23 deaths occur during CRCSPs per 100,000 people screened. Cardiopulmonary events were assessed for 55 populations. Despite our efforts to subcategorize CPEs into 17 distinct subtypes, 41% of CPE assessments were too poorly measured or reported to allow quantification. We found a tendency towards lower estimates of deaths and CPEs in studies with a critical risk of bias.

DISCUSSION

Deaths and CPEs during CRCSPs are rare, yet they do occur during CRCSPs. We believe that our findings are conservative due to the heterogeneity and low quality of the evidence. A standardized system for the measurement and reporting of the harms of screening is warranted.

TRIAL REGISTRATION

PROSPERO Registration number CRD42017058844.

Lactulose vs Polyethylene Glycol for Bowel Preparation: A Single-Center, Prospective, Randomized Controlled Study Based on BMI

INTRODUCTION

Colonoscopy is currently considered as one of the principal techniques to diagnose the colorectal diseases. Admittedly, qualified bowel preparation before colonoscopy is a premise for high-quality examination. Lower quality bowel preparation might seriously impede visualization of the intestinal mucosa, resulting in missed and misdiagnosed intestinal lesions. Therefore, it is necessary to choose the appropriate oral laxative based on the guarantee of safety and efficacy.

METHODS

This prospective randomized controlled study was conducted to compare lactulose oral solution and polyethylene glycol (PEG) electrolyte powder for bowel preparation using the following indicators: Boston Bowel Preparation Scale, Bowel Bubble Score, detection rate of adenoma and lesion, patients' satisfaction, and adverse effects. Our study investigated the suitability of 2 bowel preparation reagents for patients with different body mass indices mainly based on body mass index (BMI).

RESULTS

In the lactulose group, there was a significant improvement in the quality of bowel preparation compared with those in the PEG group ( P < 0.05), especially in people with normal BMI and higher BMI. Compared with the PEG group, individuals in the lactulose group had a significantly higher adenoma detection rate (50% vs 33.5%, P < 0.05) and taste scores (8.82 vs 6.69, P < 0.05), as well as significantly fewer adverse reactions (6.5% vs 32.5%, P < 0.05).

DISCUSSION

Lactulose oral solution is superior to PEG in bowel preparation quality and taste, especially in normal BMI and higher BMI groups. It can be used clinically as a potential and promising bowel preparation agent in the future. Clinical Trial registration number: ChiCTR2100054318.

Emerging space for non-polyethene-glycol bowel preparations in inflammatory bowel disease-related colonoscopy: Veering toward better adherence and palatability

Patients with inflammatory bowel diseases (IBDs) require repeated endoscopic evaluations over time by colonoscopy to weigh disease activity but also for different and additional indications (e.g., evaluation of postoperative recurrence, colorectal cancer surveillance). Colonoscopy, however, requires adequate bowel preparation to be of quality. The latter is achieved as long as the patient takes a certain amount of product to have a number of bowel movements suitable to clean the colon and allow optimal visualization of the mucosa during endoscopy. However, significant guidelines recommend preparations for patients with IBD not excelling in palatability. This recommendation originates from the fact that most of the studies conducted on bowel preparations in patients with IBD have been done with isosmolar preparations based on polyethylene glycol (PEG), for which, therefore, more safety data exist. As a result, the low-volume non-PEG preparations (e.g., magnesium citrate plus picosulphate, oral sulphate solutions) have been set aside for the whole range of warnings to be heeded because of their hyperosmolarity. New studies, however, are emerging, leaning in overall for a paradigm shift in this matter. Indeed, such non-PEG preparations seem to show a particularly encouraging and engaging safety profile when considering their broad potential for tolerability and patient preference. Indeed, such evidence is insufficient to indicate such preparations in all patients with IBD but may pave the way for those with remission or well-controlled disease. This article summarizes the central studies conducted in IBD settings using non-PEG preparations by discussing their results.

Pilot Study of Ondansetron in Improvement of Pediatric Colonoscopy Preparation Outcomes at an Urban Academic Center

Objectives

To gather initial data on the effectiveness and tolerability of the addition of Ondansetron to bowel preparation regimens to justify a funded, larger, placebo-controlled study.

Methods

Design, Setting, and Participants:: A total of 41 pediatric and young adult (age 2-22) patients participated in a single center, open label, parallel randomized trial, with simple randomization. All patients were recruited as outpatients, and all procedures occurred as outpatient procedures, with both recruitment and procedures occurring at a low-resource urban academic medical center in Brooklyn.Interventions and Outcome Measures:: The intervention studied was a single dose of oral-dissolving tablet Ondansetron provided before initiation of bowel preparation using a standardized prep of Polyethylene Glycol 3350 and Bisacodyl. There were 2 arms, a study arm using typical preparation (Polyethylene Glycol 3350 and Bisacodyl) and Ondansetron, and a control arm (Polyethylene Glycol 3350 and Bisacodyl). Patients received standard weight-based dosing. The primary outcome measure assessed was the Boston Bowel Preparation Scale (BBPS) to assess efficacy of preparation. Secondary objectives included evaluation of patient satisfaction via a survey answered by each patient. The questionnaire assessed the presence of the following symptoms during bowel prep: abdominal pain, nausea, bloating, vomiting, scale of ease/difficulty, and if the entire bowel prep was completed.

Results

No benefit to BBPS from the addition of Ondansetron to bowel preparation was observed. Statistically significant improvement in reports of abdominal pain (35% decrease in Ondansetron arm) was noted with a P = 0.019. No statistically significant improvement was noted in other symptoms although all domains showed nonsignificant improvement in the Ondansetron arm.

Conclusion

No benefit to efficacy of preparation as measured by the BBPS was observed. A single dose of Ondansetron before bowel preparation reduced reports of abdominal pain by 35%, with other symptomatic improvements suggesting possible improvements to be confirmed by a higher-powered study. Trial registration: NCT05439772.

Comparing Low Volume Versus Conventional Volume of Polyethylene Glycol for Bowel Preparation during Colonoscopy: A Randomised Controlled Trial

BACKGROUND

Polyethylene glycol (PEG) solution is widely used as a colonoscopic bowel cleaning agent, although some patients are intolerant due to the need for ingesting large solution volumes and unpleasant taste. A low-volume solution may enhance patient tolerability and compliance in bowel preparation. Accordingly, this study compared the effectiveness of two difference PEG volumes for bowel preparation before colonoscopy in terms of bowel cleanliness, completeness of colonoscopy, patient tolerability and colonoscopy duration.

METHODS

Using a prospective randomised controlled single-blinded study design, 164 patients scheduled for colonoscopy were allocated to two groups (n = 82 patients in each) to receive either the conventional PEG volume (3 L, control group) or the low volume (2 L, intervention group). The Boston Bowel Preparation Scale (BBPS), a validated scale for assessing bowel cleanliness during colonoscopy, was used to score bowel cleanliness in three colon segments. Secondarily, colonoscopy completeness, tolerability to drinking PEG and the duration of colonoscopy were compared between the groups.

RESULTS

There were no statistically significant differences between the two intervention groups in terms of bowel cleanliness (P = 0.119), colonoscopy completion (P = 0.535), tolerability (P = 0.190) or the amount of sedation/analgesia required (midazolam, P = 0.162; pethidine, P = 0.708). Only the duration of colonoscopy differed between the two groups (longer duration in the control group, P = 0.039).

CONCLUSION

Low-volume (2 L) PEG is as effective as the standard 3 L solution in bowel cleaning before colonoscopy; however, the superiority of either solution could not be established.

Mandatory vs. optional split-dose bowel preparation for morning colonoscopies: a pragmatic noninferiority randomized controlled trial

BACKGROUND : We compared the effectiveness of optional split-dose bowel preparation (SDBP) with mandatory SDBP for morning colonoscopies in usual clinical practice. METHODS : Adult patients undergoing outpatient early morning (8:00 AM-10:30 PM) and late morning (10:30 AM-12:00 PM) colonoscopies were included. Written bowel preparation instructions were provided based on randomization: one group were instructed to take their bowel preparation (4 L polyethylene glycol solution) as a split dose (mandatory), while the comparator group was allowed the choice of SDBP or single-dose bowel preparation administered entirely on the day before (optional). The primary end point, using noninferiority hypothesis testing with a 5 % margin, was adequate bowel cleanliness measured by the Boston Bowel Preparation Scale (BBPS) and defined by a BBPS score ≥ 6. RESULTS : Among 770 randomized patients with complete data, there were 267 mandatory SDBP and 265 optional SDBP patients for early morning colonoscopies, and 120 mandatory SDBP and 118 optional SDBP patients for late morning colonoscopies. Optional SDBP was inferior to mandatory SDBP, with a lower proportion of adequate BBPS cleanliness for early morning colonoscopies (78.9 % vs. 89.9 %; absolute risk difference [aRD] 11.0 %, 95 %CI 5.9 % to 16.1 %), but was not statistically different for late morning colonoscopies (76.3 % vs. 83.3 %; aRD 7.1 %, 95 %CI -1.5 % to 15.5 %). CONCLUSIONS : Optional SDBP is inferior to mandatory SDBP in providing adequate bowel preparation quality for early morning colonoscopies (8:00 AM-10:30 AM), and probably inferior for late morning colonoscopies (10:30 AM-12:00 PM).

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.

Quality of bowel preparation in patients with inflammatory bowel disease undergoing colonoscopy: What factors to consider?

An adequate bowel preparation in patients with inflammatory bowel disease (IBD) is a prerequisite for successful colonoscopy for screening, diagnosis, and surveillance. Several bowel preparation formulations are available, both high- and low-volume based on polyethylene glycol. Generally, low-volume formulations are also based on several compounds such as magnesium citrate preparations with sodium picosulphate, oral sulphate solution, and oral sodium phosphate-based solutions. Targeted studies on the quality of bowel preparation prior to colonoscopy in the IBD population are still required, with current evidence from existing studies being inconclusive. New frontiers are also moving towards the use of alternatives to anterograde ones, using preparations based on retrograde colonic lavage.

Advanced intestinal regulation improves bowel preparation quality in patients with constipation: A systematic review and network meta-analysis

Background: Inadequate bowel preparation (IBP) has a critical influence on the colonoscopy procedure and is associated with significantly lower rates of detection of colorectal lesions. Constipation is an important risk factor of IBP, and some studies have attempted to address the bowel cleansing for constipated patients. However, there is still lack of consensus to guide the clinical work of bowel preparation (BP) for patients with constipation. Therefore, we aimed to perform a network meta-analysis to compare the overall efficacy of various regimens for BP in constipated patients. Methods: We performed a comprehensive search of PubMed, MEDLINE, EMBASE, Cochrane, and Web of science to identify randomized controlled trials (RCTs) of bowel preparation regimens in constipated patients, update to January 2021. Two investigators independently evaluated articles and extracted data. The odds ratio (OR) with a 95% confidence interval (CI) was used to combine dichotomous data of the primary outcome which was defined as adequate bowel preparation (ABP). Rank probability was used to exhibit the outcome of the network meta-analysis. Results: Eleven studies that included 1891 constipated patients were identified as suitable for inclusion. The proportion of ABP was associated with the administration of intensive regimen (OR 2.19, 95% CI 1.16-4.17, p = .02, I2 = 84%). Moreover, an intensive regimen had a significant efficacy and light heterogeneity when the same basic laxative program was used (OR 4.06, 95% CI 3.04-5.43, p < .0001, I2 = 0%). In the network meta-analysis, the protocol of a normal regimen + A (normal regimen plus advanced intestinal regulation) had a significant effect for bowel preparation compared with a normal regimen + IR (normal regimen plus irritating laxative regimen) (OR 5.21, 95% CI 1.18-24.55), H PEG (4L- polyethylene glycol) (OR 8.70, 95% CI 1.75-52.56), and normal regimen (NR) (OR 7.37, 95% CI 2.33-26.39). In the remaining protocols, no significant difference was observed in any comparison. No significant severe adverse events (AEs) associated with bowel preparation were reported in included studies. Conclusion: Intensive regimens could improve bowel cleansing quality for patients with constipation, and advanced intestinal regulation regimens may be superior to others.

Oral mannitol for bowel preparation: a dose-finding phase II study

BACKGROUND

Successful bowel preparation (BP) for colonoscopy depends on the instructions, diet, the laxative product, and patient adherence, which all affect colonoscopy quality. Nevertheless, there are no laxatives which combine effectiveness, safety, easy self-administration, good patient acceptance, and low cost. However, mannitol, a sugar alcohol, could be an attractive candidate for use in clinical practice if it is shown to demonstrate adequate efficacy and safety.

AIMS

The present phase II dose-finding study compared three doses of mannitol (50, 100, and 150 g) to identify the best dose to be used in a subsequent phase III study.

METHODS

The Boston Bowel Preparation Scale, caecal intubation rate, adherence, acceptability, and safety profile, including measurement of potentially dangerous colonic gas concentrations (CH4, H2, O2), were considered in all patients. A weighted algorithm was used to identify the best mannitol dose for use in the subsequent study.

RESULTS

The per-protocol population included 60 patients in the 50 g group, 54 in the 100 g group, and 49 in the 150 g group. The 100 g dose was the best as it afforded optimal colon cleansing efficacy (94.4% of patients had adequate BP), adherence, acceptability, and safety, including negligible gas concentrations.

CONCLUSIONS

The present study demonstrated that the colon cleansing efficacy and safety of mannitol were dose dependent. Conversely, gas concentrations were not dose dependent and negligible in all patients. Combined evaluation of efficacy, tolerability, and safety, using a weighted algorithm, determined that mannitol 100 g was the best dose for the phase III study.

The Changes in Trends of Lower Gastrointestinal Endoscopy Conducted in Children and Adolescents after the COVID-19 Outbreak in Korea

Background and Objectives: The coronavirus disease 2019 (COVID-19) pandemic has affected medical practice in diverse ways. We aimed to investigate the change in trends of lower gastrointestinal (LGI) endoscopy conducted in children and adolescents after the COVID-19 outbreak in Korea. Material and Methods: This was a multicenter, retrospective study conducted in Korea. We included children and adolescents aged <19 years who had undergone their first LGI endoscopy between 2016 and 2020. We compared clinicodemographic and endoscopic factors between groups divided according to the pre- and postCOVID-19 era in Korea. Results: We included 1307 patients in this study. Colonoscopies, instead of sigmoidoscopies, were conducted in most patients in the postCOVID-19 era compared to those in the preCOVID-19 era (86.9% vs. 78.5%, p = 0.007). The diagnosis of inflammatory bowel disease (IBD) was also significantly higher in the postCOVID-19 era compared to the preCOVID-19 era (47.2% vs. 28.5%, p < 0.001). According to multivariate logistic regression analysis, age at LGI endoscopy, LGI bleeding indication, and IBD diagnosis were independently associated with the use of a colonoscopy over a sigmoidoscopy (odds ratio (OR) 1.19, 95% confidence interval (CI) 1.12−1.27, p < 0.001; OR 0.56, 95% CI 0.37−0.83, p = 0.005; OR 1.80, 95% CI 1.20−2.77, p = 0.006, respectively). Conclusions: The COVID-19 pandemic has changed LGI endoscopy practice trends of pediatric gastroenterologists in Korea, who tended to perform lesser LGI endoscopies compared to previous years while conducting significantly more colonoscopies than sigmoidoscopies in the postCOVID-19 era. Furthermore, these colonoscopies were significantly associated with the diagnosis of IBD, as well as a significant increase in IBD diagnosis in the postCOVID-19 era.

Oral sulfate solution benefits polyp and adenoma detection during colonoscopy: Meta-analysis of randomized controlled trials

OBJECTIVES

Although oral sulfate solution (OSS) has been revealed to be not only safe and efficacious but also noninferior to polyethylene glycol with ascorbic acid (PEG + ASC), it is unclear whether OSS can ultimately increase the polyp detection rate (PDR) and adenoma detection rate (ADR). We performed this meta-analysis to estimate the effect of OSS on PDR and ADR during colonoscopy.

METHODS

We searched PubMed, EMBASE, and the Cochrane Library to identify relevant randomized controlled trials (RCTs) investigating the comparative effect of OSS versus PEG + ASC on the PDR and ADR during colonoscopy. Cecal intubation time (CIT), cecal intubation rate (CIR), and bowel preparation score were also evaluated. Review Manager (RevMan) version 5.3.0 was used to perform statistical analysis.

RESULTS

Eight RCTs involving 2059 patients fulfilled the selection criteria. Meta-analysis suggested that OSS significantly increased the PDR (47.34% vs. 40.14%, risk ratio [RR] 1.13, 95% confidence interval [CI] 1.03-1.24, P = 0.01) and ADR (44.60% vs. 38.14%, RR 1.17, 95% CI 1.03-1.33, P = 0.01) during colonoscopy. Subgroup analysis showed that the beneficial effects of OSS on PDR and ADR were consistent among patients with mean age >55 years and with body mass index <25 kg/m² receiving outpatient colonoscopy, morning colonoscopy, and the 2-L bowel preparation protocol. Meanwhile, patients receiving OSS had a beneficial bowel preparation score.

CONCLUSION

Compared with polyethylene glycol-based regimens, the OSS bowel preparation regimen significantly increased the PDR and ADR in patients undergoing colonoscopy.

Pre-colonoscopy special guidance and education on intestinal cleaning and examination in older adult patients with constipation

BACKGROUND

The prevalence of constipation in the Chinese population over 60 years of age is 11.5%, and this prevalence increases with age, which seriously affects the quality of life in older adults. Therefore, reducing the incidence of constipation in older adults is necessary to promote a healthy lifestyle as well as biochemical health.

AIM

To explore the value of preoperative guidance and education to improve the effects of bowel cleaning in older adult patients undergoing colonoscopy.

METHODS

In this study, 160 older adult patients with constipation requiring colonoscopy at Shandong Provincial Hospital between January 2019 and March 2021 were selected and randomly divided into a study group and a control group, with 80 patients in each group. The study group received medication guidance and targeted educational guidance before the operation, while the control group received only medication and dietary guidance. The baseline data, colonoscopy duration, bowel preparation compliance, Boston bowel preparation (BBPS) assessment score, intestinal bubble score, the incidence of adverse reactions during bowel preparation, and nursing appointment satisfaction were compared between the two groups.

RESULTS

The colonoscopy duration times and intestinal bubble scores of the study group were shorter than those of the control group, with statistically significant differences. The BBPS scores for the right, left, and interrupted colon in the study group were also higher than those in the control group, and the difference was statistically significant. Additionally, the study group had a higher rate of liquid diet one day before the examination, higher rate of correct bowel-clearing agent dilution method, higher rate of accurate time of ingesting the bowel-clearing agent, and a higher proportion of patients ingesting bowel-clearing agent at the specified time than the control group, with statistically significant differences. The incidence of nausea and vomiting during bowel clearance in the study group was significantly lower than that in the control group. The incidence of abdominal pain, abdominal distension, dizziness, and fatigue was compared between the two groups, but the difference was not statistically significant. The scores of service attitude, detailed notification of dietary precautions, clear and easy-to-understand health educational content, and receiving care and comfort in the study group were significantly higher than those in the control group.

CONCLUSION

Preoperative special guidance and education were shown to significantly improve bowel clearance and compliance and reduce the incidence of adverse reactions in older adult patients with constipation undergoing colonoscopy. These factors are beneficial for improving patient satisfaction with nursing services.

Patient education by smartphones for bowel preparation before colonoscopy

BACKGROUND AND AIM

We aim to evaluate the effect of smartphone education on the bowel preparation quality of patients undergoing colonoscopy by meta-analysis.

METHODS

Randomized controlled trials using smartphones to educate patients on bowel preparation for colonoscopy were screened from the PubMed, Web of Science, Cochrane Library, and Embase databases from inception to August 31, 2021. After extracting the data, Review Manager software was used for meta-analysis.

RESULTS

A total of 12 randomized controlled trials with 4165 patients were included in the meta-analysis. There were 2060 patients in the smartphone group, including 1784 patients with adequate bowel preparation, with a rate of 86.6%, and 2105 patients in the control group, including 1614 patients with adequate bowel preparation, with a rate of 76.7%, and pooled risk ratio (RR) was 1.15 (95% confidence interval [CI]: 1.07-1.23, P < 0.01). Eight included studies reported the adenoma detection rate. The adenoma detection rate in the smartphone group was 26.2%, and the rate in the control group was 19.3%, with an RR of 1.29 (95% CI: 1.03-1.62, P < 0.05).

CONCLUSION

Using smartphones to educate patients on bowel preparation for colonoscopy improved the quality of bowel preparation and increased the adenoma detection rate.

Effects of bowel preparation on intestinal bacterial associated urine and faecal metabolites and the associated faecal microbiome

BACKGROUND

Urinary and faecal metabolic profiling have been extensively studied in gastrointestinal diseases as potential diagnostic markers, and to enhance our understanding of the intestinal microbiome in the pathogenesis these conditions. The impact of bowel cleansing on the microbiome has been investigated in several studies, but limited to just one study on the faecal metabolome.

AIM

To compare the effects of bowel cleansing on the composition of the faecal microbiome, and the urine and faecal metabolome.

METHODS

Urine and faecal samples were obtained from eleven patients undergoing colonoscopy at baseline, and then at day 3 and week 6 after colonoscopy. 16S rRNA gene sequencing was used to analyse changes in the microbiome, and metabonomic analysis was performed using proton nuclear magnetic resonance (1H NMR) spectroscopy.

RESULTS

Microbiomic analysis demonstrated a reduction in alpha diversity (Shannon index) between samples taken at baseline and three days following bowel cleansing (p = 0.002), and there was no significant difference between samples at baseline and six weeks post colonoscopy. Targeted and non-targeted analysis of urinary and faecal bacterial associated metabolites showed no significant impact following bowel cleansing.

CONCLUSIONS

Bowel cleansing causes a temporary disturbance in bacterial alpha diversity measured in faeces, but no significant changes in the faecal and urine metabolic profiles, suggesting that overall the faecal microbiome and its associated metabolome is resistant to the effects of an induced osmotic diarrhoea.

Comparative study between manitol and sodium picosulfate with magnesium oxide solutions in the preparation for colonoscopy

This prospective, randomized and double-blind study aims to compare two different protocols used for bowel preparation in patients scheduled for colonoscopy. The protocols were composed by solutions of Mannitol or sodium picosulfate combined with magnesium oxide. Patients from the proctology outpatient clinic of the General Surgery Unit of the Regional Hospital of Asa Norte (HRAN) comprised the sample of this study. Both the patients and the colonoscopist had no prior knowledge of the substance used to prepare bowel, which was randomly distributed among the participants. Both protocols demonstrated good and similar results regarding the efficiency of colon preparation, although the review of literature shows a difference in favor of preparation made with Mannitol solution regarding the colon neatness during the exam. In line with the literature, patients who used Mannitol solution had more side effects, highlighting the significant difference found for vomiting and sleep impairment. The preparation with Sodium Picosulfate with Magnesium Oxide was significantly superior in relation to the ease of ingestion perceived by the patients.

Colonoscopy: Preparation and Potential Complications

Colonoscopy is a fairly common test that serves both diagnostic and therapeutic purposes. It has been considered the gold standard in colorectal cancer screening for several years. Due to the nature of the examination, various types of complications may occur. The purpose of this analysis is to describe the various complications related to the period of preparation for colonoscopy among hospitalized patients, including life-threatening ones, in order to know how to avoid complications while preparing for a colonoscopy. We analyzed the nursing and medical reports of 9962 patients who were prepared for colonoscopy between 2005 and 2016. The frequency of various side effects associated with intensive bowel cleansing prior to colonoscopy was assessed. In justified cases, additional medical data were collected from patients, their families or from other doctors providing advice to patients after complications. Out of 9962 patients prepared for colonoscopy, 180 procedures were discontinued due to complications and side effects, and in these cases no colonoscopy was performed. The most common complications were: vomiting; epistaxis; loss of consciousness with head injury; abdominal pain; acute diarrhea; symptoms of choking; heart rhythm disturbances; dyspnea; fractures of limbs and hands; acute coronary syndrome; hypotension; hypertension; cerebral ischemia; severe blood glucose fluctuations; increased muscle contraction and allergic reactions. In addition to the documentation of our own research, several works of other research groups were also analyzed. Currently, the literature does not provide data on the frequency and type of complications in the preparation period for colonoscopy. The advantage of our work is the awareness of the possibility of serious complications and postulating the necessary identification of threats. Individualization of the recommended procedures and increased supervision of patients undergoing bowel cleansing procedure, we hope, will reduce the occurrence of complications and side effects.

Colonoscopy screening and surveillance guidelines

The Colonoscopy Screening and Surveillance Guidelines were developed by the Japan Gastroenterological Endoscopy Society as basic guidelines based on the scientific methods. The importance of endoscopic screening and surveillance for both detection and post-treatment follow-up of colorectal cancer has been recognized as essential to reduce disease mortality. There is limited high-level evidence in this field; therefore, we had to focus on the consensus of experts. These clinical practice guidelines consist of 20 clinical questions and eight background knowledge topics that have been determined as the current guiding principles.

Sex difference in bowel preparation quality and colonoscopy time

BACKGROUND/AIMS

The length of colon is known to be longer in females than in males. In addition, the morphology of colon cancer is different between males and females. The aim of this study was to investigate sex differences in Boston bowel preparation score (BBPS) and colonoscopy insertion time.

METHODS

This study retrospectively analyzed medical records and colonoscopy readings of subjects who underwent colonoscopy at Seoul National University Bundang Hospital from March 2015 to April 2018. BPPS was used to evaluate the degree of colon cleanness before colonoscopy. Statistical analysis was performed to compare demographic, clinical, and outcome variables between two groups.

RESULTS

The study group consisted of a total of 12,561 patients (6,148 females and 6,413 males). Mean age was 57.8 ± 13.5 years for females and 57.5 ± 13.8 years for males (p = 0.695). Females showed better bowel preparation than males (mean total score: 7.4 ± 1.8 vs. 7.2 ± 1.9, p = 0.001; total score ≥ 6: 5,340 [86.9%] vs. 5,437 [84.8%], p = 0.001; BBPS ≥ 2 for all segments: 5,048 [82.1%] vs. 5,097 [79.5%], p < 0.001). However, cecal intubation time (8.3 ± 6.2 minutes vs. 6.2 ± 6.1 minutes, p < 0.001) and withdrawal time (7.9 ± 3.5 minutes vs. 7.4 ± 3.1 minutes, p < 0.001) were longer in males.

CONCLUSION

There were sex differences in BBPS, cecal intubation time, and withdrawal time for subjects undergoing colonoscopy.

The Efficacy and Safety of Combined Senna and Probiotic-Based Bowel Preparation for Colonoscopy in Children

Background and objective

Bowel preparation (BP) is a major determinant of accurate and successful colonoscopy and its outcomes in children and adults. The present study aimed to evaluate the effectiveness and safety of a senna alkaloid and probiotic-based BP in children undergoing elective colonoscopy.

Methods

Children aged 2-15 years who underwent esophagogastroduodenoscopy (OGD) and colonoscopy for various indications from December 2018 to May 2019 at the Apollo Children’s Hospital who were prescribed a senna and probiotic-based [Bacillus coagulans (B. coagulans)] preparation before the procedure were included in the study. The effectiveness of the bowel preparation was assessed using the Boston Bowel Preparation Scale (BBPS). Safety assessment was performed by recording adverse events in the study.

Results

Successful bowel preparation was observed in all patients according to BBPS, and the mean BBPS score was 2.93 ±0.25, indicating good bowel clearance. About 29 (96.67%) patients showed accessible terminal ileum. There were no major side effects reported in the study. The formulation was found to be palatable and acceptable by 100% of patients.

Conclusion

The study revealed the administration of the novel BP to be effective and safe in children undergoing elective colonoscopy for various indications.

Dextran-Coated Cerium Oxide Nanoparticles: A Computed Tomography Contrast Agent for Imaging the Gastrointestinal Tract and Inflammatory Bowel Disease

Computed tomography (CT) is an X-ray-based medical imaging technique commonly used for noninvasive gastrointestinal tract (GIT) imaging. Iodine- and barium-based CT contrast agents are used in the clinic for GIT imaging; however, inflammatory bowel disease (IBD) imaging is challenging since iodinated and barium-based CT agents are not specific for sites of inflammation. Cerium oxide nanoparticles (CeNP) can produce strong X-ray attenuation due to cerium's k-edge at 40.4 keV but have not yet been explored for CT imaging. In addition, we hypothesized that the use of dextran as a coating material on cerium oxide nanoparticles would encourage accumulation in IBD inflammation sites in a similar fashion to other inflammatory diseases. In this study, therefore, we sought to develop a CT contrast agent, i.e., dextran-coated cerium oxide nanoparticles (Dex-CeNP) for GIT imaging with IBD. We synthesized Dex-CeNP, characterized them using various analytical tools, and examined their in vitro biocompatibility, CT contrast generation, and protective effect against oxidative stress. In vivo CT imaging was done with both healthy mice and a dextran sodium sulfate induced colitis mouse model. Dex-CeNP's CT contrast generation and accumulation in inflammation sites were compared with iopamidol, an FDA approved CT contrast agent. Dex-CeNP was found to be protective against oxidative damage. Dex-CeNP produced strong CT contrast and accumulated in the colitis area of large intestines. In addition, >97% of oral doses were cleared from the body within 24 h. Therefore, Dex-CeNP can be used as a potential CT contrast agent for imaging GIT with IBD while protecting against oxidative damage.

A prospective randomized clinical study evaluating the efficacy and compliance of oral sulfate solution and 2-L ascorbic acid plus polyethylene glycol

BACKGROUND/AIMS

Oral sulfate solution (OSS) is an emerging cleansing agent for bowel preparation. However, data comparing OSS to other conventional bowel preparations in Asian patients are limited. Therefore, the objective of this study was to compare the efficacy and tolerability of OSS to ascorbic acid plus polyethylene glycol (AA + PEG) in Asian patients.

METHODS

This was a prospective, randomized, parallel, investigator-blind study performed in two university hospitals in Korea. Bowel preparation efficacy was evaluated using both the Ottawa Bowel Preparation Scale (OBPS) and Boston Bowel Preparation Scale (BBPS).

RESULTS

Among 173 patients, 86 received OSS while 87 received AA + PEG for bowel preparation. Total OBPS score was 2.80 ± 2.48 in the OSS group and 4.49 ± 3.08 in the AA + PEG group, indicating significantly (p < 0.001) better efficacy with OSS. Total BBPS was higher in the OSS group (7.43 ± 1.49 vs. 6.51 ± 1.76, p < 0.001), indicating superior bowel preparation quality with OSS. Preparation-related adverse events were generally acceptable. Patients receiving OSS had more nausea (1.92 ± 0.94 vs. 1.54 ± 0.76, p = 0.004) and abdominal cramping (1.45 ± 0.78 vs. 1.17 ± 0.51, p = 0.006) than those receiving AA + PEG. However, overall satisfaction and taste were similar between the two groups.

CONCLUSION

OSS had a non-inferior bowel cleansing efficacy than AA + PEG regardless of colon segment.

Improving the quality of surveillance colonoscopy in inflammatory bowel disease

Several recommendations have addressed the topic of improving the quality of surveillance colonoscopy in inflammatory bowel disease. However, there is variation between these recommendations, in part due to the absence of well-defined quality indicators, suggesting that these quality indicators should be studied and developed. We did a systematic review of evidence related to surveillance colonoscopy in inflammatory bowel disease to look at the different variables in this practice and offer a critique of the quality control measures before, during, and after the procedure. We identified several key quality measures that could be adopted in clinical practice, including control of inflammation, optimal bowel preparation, ideal time allocation, training, sedation, detection and characterisation of lesions, therapeutic management of the lesions, and colonoscopic reports. However, further primary research and consensus reports are needed to continue developing roadmaps at a global level.

Oral Probiotics Alleviate Intestinal Dysbacteriosis for People Receiving Bowel Preparation

Background: Bowel preparation is necessary for successful colonoscopy, while it can seriously affect intestinal microbial composition and damage the intestinal mucosal barriers in humans.

Methods: To figure out whether probiotics can sustain intestinal homeostasis and guard people's health, the probiotic drug of Bifidobacterium Tetragenous viable Bacteria Tablets (P group, n = 16) or placebo (C group, n = 16) was used for volunteers receiving bowel preparation, and high-throughput sequencing method was applied to monitor their intestinal microbial changes.

Results: The present results suggested that bowel preparation obviously reduced the intestinal microbial diversity, while taking probiotics significantly restored it to normal level. In addition, probiotics sharply reduced the abundance of pathogenic Proteobacteria, and obviously lowered the ratio of Firmicutes/Bacteroidetes compared with control group at phylum level (P < 0.05). And probiotics markedly decreased the abundance of pathogenic Acinetobacter and Streptococcus, while greatly enriched the relative abundance of beneficial bacteria Bacteroides, Roseburia, Faecalibacterium, and Parabacteroides at genus level (P < 0.05).

Conclusion: Probiotic drugs, e.g., Bifidobacterium Tetragenous viable Bacteria Tablets, can be used to restore intestinal dysbacteriosis caused by bowel preparation, and reduce side effects during colonoscopy.

Predictive factors for inadequate bowel preparation using low-volume polyethylene glycol (PEG) plus ascorbic acid for an outpatient colonoscopy

Low-volume polyethylene glycol (PEG) plus ascorbic acid solutions are widely used for bowel cleansing before colonoscopy. This study aimed to investigate the pre-endoscopic predictive factors for inadequate preparation in subjects receiving low-volume PEG plus ascorbic acid. A prospective study was performed at Gangnam Severance Hospital, Korea, from June 2016 to December 2016. All participants received low-volume PEG plus ascorbic acid solutions for outpatient colonoscopy. The split-dose bowel preparation was administered in subject with morning colonoscopy while same day bowel preparation was used for afternoon colonoscopy. 715 patients were enrolled (mean age 56.1 years, 54.4% male), of which 138 (19.3%) had an inadequate bowel preparation. In multivariable analysis, cirrhosis (OR 4.943, 95% CI 1.191–20.515), low (less than 70%) compliance for three-day low-residual diet (OR 2.165, 95% CI 1.333–3.515), brown liquid rectal effluent (compared with clear or semi-clear effluent) (OR 7.604, 95% CI, 1.760–32.857), and longer time interval (≥2 hours) between last defecation and colonoscopic examination (OR 1.841, 95% CI, 1.190–2.849) were found as an independent predictors for inadequate preparation. These predictive factors may be useful in guiding additional intervention to improve quality of bowel preparation.

Augmentation with pre-emptive macrogol-based osmotic laxative does not significantly improve standard bowel preparation in unselected patients: A randomized trial

Background and Aim

The addition of a laxative prior to a standard bowel preparation (BP) has shown variable results in efficacy, safety, and tolerability of the BP. This study compared the efficacy and tolerability of a macrogol-augmented BP (M-BP) with standard BP for routine colonoscopy in unselected patients.

Methods

Adults undergoing outpatient colonoscopy were randomized to either M-BP (one sachet of macrogol-based osmotic laxative (MBOL) twice daily for eight doses prior to standard preparation) or BP (split-dose of polyethylene glycol and sodium picosulfate). Bowel cleansing was assessed using the Ottawa BP scale. Risk factors for poor BP, patient satisfaction, and tolerance were recorded.

Results

This randomized trial was stopped due to futility after 14 months; at that point, 92 subjects were randomized to the study arm and 102 to the control arm. M-BP had a success rate of 71.7% (95% CI: 58.5-82.7%), while the BP had a success rate of 67.7% (95% CI: 54.9-78.8%), with a Pearson χ ² test P-value of 0.639, which exceeded the cut-off for futility (0.313). In subgroup analyses, there were statistically significant decreases in the rates of successful BP in patients taking regular opioids and regular laxatives. Both preparations were well tolerated, with no difference between groups (BP - 5.3% and M-BP - 6.6% P = 0.66).

Conclusion

The addition of MBOL prior to a standard BP in unselected subjects does not significantly improve bowel cleanliness at routine colonoscopy. The role of this laxative in patients at high risk of poor preparation warrants further investigation.

Efficacy, Tolerability, and Safety of Low-Volume Bowel Preparations for Patients with Inflammatory Bowel Diseases: The French Multicentre CLEAN Study

BACKGROUND

Standard high-volume polyethylene glycol [PEG] bowel preparations [PEG-4L] are recommended for patients with inflammatory bowel disease [IBD] undergoing colonoscopy. However, low-volume preparations [≤2 L of active volume] are often used in clinical practice. The aim of this study was to evaluate the efficacy, tolerability, and safety of the various bowel preparations for patients with IBD, including low-volume preparations.

METHODS

We conducted a French prospective multicentre observational study over a period of 1 month. Patients aged 18-75 years with IBD with an indication of colonoscopy independent of the study were enrolled. The choice of the preparation was left to the investigators, as per their usual protocol. The patients' characteristics, disease, and colonoscopy characteristics were recorded, and they were given self-reported questionnaires.

RESULTS

Twenty-five public and private hospitals enrolled 278 patients. Among them, 46 had a disease flare and 41 had bowel stenoses. Bowel preparations for colonoscopy were as follows: 42% received PEG-2L, 29% received sodium picosulfate [Pico], 15% received PEG-4L, and 14% had other preparations. The preparation did not reach the Boston's score efficacy outcome in the PEG-4L group in 51.2% of the patients [p = 0.0011]. The preparation intake was complete for 59.5% in the PEG-4L group, compared with 82.9% in the PEG-2L group and 93.8% in the Pico group [p < 0.0001]. Tolerability, as assessed by the patients' VAS, was significantly better for both Pico and PEG-2L compared with PEG-4L, and better for Pico compared with PEG-2L [p = 0.008; p = 0.0003]. In multivariate analyses, low-volume preparations were independent factors of efficacy and tolerability. Adverse events occurred in 4.3% of the patients.

CONCLUSIONS

Preparations with PEG-2L and Pico were equally safe, with better efficacy and tolerability outcomes compared with PEG-4L preparations. The best efficacy/tolerance/safety profile was achieved with the Pico preparation.

Influence of preoperative enema application on the return of gastrointestinal function in elective Cesarean sections: a randomized controlled trial

AIM

There is an extensive literature on the mechanical bowel preparation by an enema in colorectal, abdominal, and gynecologic surgeries that provide evidence against the use of enema. There are, however, few studies investigating the effect of enema prior to elective Cesarean sections. The aim of this study is to investigate whether preoperative enema facilitates the return of gastrointestinal activity in pregnant women undergoing elective Cesarean section.

MATERIALS AND METHODS

The surgeon-blinded prospective randomized controlled study included 225 elective Cesarean patients between the ages of 18 and 44. The patients were randomized into two groups: those who had enema preoperatively (n = 114) and those who did not (n = 111). The outcome measures were first bowel sound time and first flatus time, the length of hospital stay, the rate of mid ileus symptoms, and additional analgesic and antiemetic need.

RESULTS

In the non-enema group, the time of the first bowel sound, flatus time, length of hospital stay, the rates of additional analgesic need, additional antiemetic need, and mild ileus symptoms were respectively 10.5 ± 5.8 hours, 16.0 ± 7.6 hours, 1.9 ± 0.3 days, 8.1%, 7.2%, and 2.7%. For the enema group, the same parameters were respectively 11.6 ± 4.7 hours, 17.5 ± 6.5 hours, 1.8 ± 0.3 days, 7%, 6.1% ,and 1.8%. For all parameters, the difference between the groups was not statistically significant (p values were respectively .09, .12, .8, .79, .68, and .26).

CONCLUSIONS

The study suggests that preoperative enema in elective cesarean sections does not prevent postoperative gastrointestinal complications and does not shorten the recovery of bowel movements or length of hospital stay.

Quality optimisation in colonoscopy: a function of time of colonoscopy or bowel preparation

To test the hypothesis claimed in recent studies that quality of bowel preparation for colonoscopy could be influenced by the time of the day colonoscopy is performed. Do patients in morning list have better bowel preparation than those on the afternoon list? Retrospective analysis of 736 consecutive patients who had colonoscopy from 1^st August to 31^st December 2012. Patients with poor bowel preparation (Boston Bowel Prep Score 6 or less) were identified (n = 242). Colonoscopy reports of these patients analysed. Patients were stratified into two groups (am and pm) and results compared. Mean patient age 63.9 years (range 19-89). Male to female ratio 1:1. 92% of patients were given Moviprep. for bowel preparation. 32.9% (242/736) of patients were identified as having inadequate bowel preparation. 37.7% of morning list patients had poor bowel preparation. 26.7% of afternoon list patients had poor bowel preparation. 14.7% (108/736) had incomplete colonoscopy, of which 26.9% (29/108) were due to poor bowel preparation. The commonest reasons for incomplete examination were patient discomfort & bowel looping. Our study demonstrates that morning session patients had poorer bowel preparation than the afternoon session patients in contrast to published evidence in recent literature. This implies that timing of bowel preparation is probably more important than timing of colonoscopy. Poor bowel preparation does not seem to have a significant impact on the colonoscopy failure rate in this series.

Clinical comparison of low-volume agents (oral sulfate solution and sodium picosulfate with magnesium citrate) for bowel preparation: the EASE study

BACKGROUND/AIMS

This study compared the efficacy, compliance, and safety of bowel preparation between sodium picosulfate with magnesium citrate (SPMC) and oral sulfate solution (OSS).

METHODS

A prospective randomized multicenter study was performed. Split preparation methods were performed in both groups; the SPMC group, 2 sachets on the day before, and 1 sachet on the day of the procedure, the OSS group, half of the OSS with 1 L of water on both the day before and the day of the procedure. The adenoma detection rate (ADR), adequacy of bowel preparation using the Boston Bowel Preparation Scale (BBPS) score, patient satisfaction on a visual analog scale (VAS), and safety were compared between the 2 groups.

RESULTS

This study analyzed 229 patients (121 in the SPMC group and 108 in the OSS group). ADR showed no differences between 2 groups (51.7% vs. 41.7%, P> 0.05). The mean total BBPS score (7.95 vs. 8.11, P> 0.05) and adequate bowel preparation rate (94.9% vs. 96.3%, P> 0.05) were similar between the 2 groups. The mean VAS score for taste (7.62 vs. 6.87, P=0.006) was significantly higher in the SPMC group than in the OSS group. There were no significant differences in any other safety variables between the 2 groups except nausea symptom (36.1% vs. 20.3%, P=0.008).

CONCLUSIONS

Bowel preparation for colonoscopy using low volume OSS and SPMC yielded similar ADRs and levels of efficacy. SPMC had higher levels of satisfaction for taste and feeling than did OSS.

Sodium picosulphate or polyethylene glycol before elective colonoscopy in outpatients? A systematic review and meta-analysis

AIM

To determine the best option for bowel preparation [sodium picosulphate or polyethylene glycol (PEG)] for elective colonoscopy in adult outpatients.

METHODS

A systematic review of the literature following the PRISMA guidelines was performed using Medline, Scopus, EMBASE, Central, Cinahl and Lilacs. No restrictions were placed for country, year of publication or language. The last search in the literature was performed on November 20th, 2017. Only randomized clinical trials with full texts published were included. The subjects included were adult outpatients who underwent bowel cleansing for elective colonoscopy. The included studies compared sodium picosulphate with magnesium citrate (SPMC) and PEG for bowel preparation. Exclusion criteria were the inclusion of inpatients or groups with specific conditions, failure to mention patient status (outpatient or inpatient) or dietary restrictions, and permission to have unrestricted diet on the day prior to the exam. Primary outcomes were bowel cleaning success and/or tolerability of colon preparation. Secondary outcomes were adverse events, polyp and adenoma detection rates. Data on intention-to-treat were extracted by two independent authors and risk of bias assessed through the Jadad scale. Funnel plots, Egger's test, Higgins' test (I 2) and sensitivity analyses were used to assess reporting bias and heterogeneity. The meta-analysis was performed by computing risk difference (RD) using Mantel-Haenszel (MH) method with fixed-effects (FE) and random-effects (RE) models. Review Manager 5 (RevMan 5) version 6.1 (The Cochrane Collaboration) was the software chosen to perform the meta-analysis.

RESULTS

662 records were identified but only 16 trials with 6200 subjects were included for the meta-analysis. High heterogeneity among studies was found and sensitivity analysis was needed and performed to interpret data. In the pooled analysis, SPMC was better for bowel cleaning [MH FE, RD 0.03, IC (0.01, 0.05), P = 0.003, I 2 = 33%, NNT 34], for tolerability [MH RE, RD 0.08, IC (0.03, 0.13), P = 0.002, I 2 = 88%, NNT 13] and for adverse events [MH RE, RD 0.13, IC (0.05, 0.22), P = 0.002, I 2 = 88%, NNT 7]. There was no difference in regard to polyp and adenoma detection rates. Additional analyses were made by subgroups (type of regimen, volume of PEG solution and dietary recommendations). SPMC demonstrated better tolerability levels when compared to PEG in the following subgroups: "day-before preparation" [MH FE, RD 0.17, IC (0.13, 0.21), P < 0.0001, I 2 = 0%, NNT 6], "preparation in accordance with time interval for colonoscopy" [MH RE, RD 0.08, IC (0.01, 0.15), P = 0.02, I 2 = 54%, NNT 13], when compared to "high-volume PEG solutions" [MH RE, RD 0.08, IC (0.01, 0.14), I 2 = 89%, P = 0.02, NNT 13] and in the subgroup "liquid diet on day before" [MH RE, RD 0.14, IC (0.06,0.22), P = 0.0006, I 2 = 81%, NNT 8]. SPMC was also found to cause fewer adverse events than PEG in the "high-volume PEG solutions" [MH RE, RD -0.18, IC (-0.30, -0.07), P = 0.002, I 2 = 79%, NNT 6] and PEG in the "low-residue diet" subgroup [MH RE, RD -0.17, IC (-0.27, 0.07), P = 0.0008, I 2 = 86%, NNT 6].

CONCLUSION

SPMC seems to be better than PEG for bowel preparation, with a similar bowel cleaning success rate, better tolerability and lower prevalence of adverse events.

Does Mechanical Bowel Preparation Reduce the Risk of Developing Infectious Complications in Pediatric Colorectal Surgery? A Systematic Review and Meta-Analysis

OBJECTIVES

To evaluate whether the application of mechanical bowel preparation (MBP) before colorectal surgery reduces the risk of developing infectious complications in children.

STUDY DESIGN

In this systematic review and meta-analysis, PubMed, Embase, and the Cochrane Library were systematically searched to identify all articles comparing pediatric patients receiving MBP with pediatric patients not receiving MBP before colorectal surgery. Results are presented with weighted risk differences based on the number of events and sample size per study.

RESULTS

Six original studies were included comparing MBP (n = 810) and no MBP (n = 1167). The overall risk of developing infectious complications was 10.1% in patients with MBP, compared with 9.1% in patients without MBP, resulting in a nonsignificant risk difference of -0.03% (95% CI, -0.09% to 0.03%). Concerning the number of wound infections and anastomotic leaks, we found nonsignificant risk differences of -0.03% (95% CI, -0.08% to 0.02%) and 0.01% (95% CI, -0.01% to 0.02%), respectively.

CONCLUSION

Based on the current literature, there is insufficient evidence to indicate that the use of MBP leads to a significant difference in the risk of developing infectious complications in pediatric colorectal surgery.

Effect and Tolerability of Same-Day Repeat Colonoscopy

Purpose/Aim of the study: The main purpose of the colonoscopy is screening for colorectal cancers and diagnosis of colorectal disease The cost-effectiveness of colonoscopy directly depend on the adequate bowel preparation. Inadequate colonoscopy is recommended to be re-scheduled within 1 year. Re-scheduling is an economic and patient burden. Thus instead of re-scheduling, another strategy may be attempted. The purpose of this study was to examine the usefulness and effect of the same day repeat colonoscopy after administration of an additional laxative dose. Materials and Methods: Patients with inadequate colonoscopy were enrolled in the study. The patients eligible for the enrollment were instructed to consume an additional laxative and scheduled in afternoon. The demographic data of the patient, the details of the index and repeat procedures were obtained by a questionnaire. Results: A total of 60 patients were enrolled in the study. The rate of adequate colonoscopy was 80%. Cecum intubation rate was 83.3%. There were no complications due to colonoscopy itself and additional laxatives. The polyp detection rate was 26.6%. The withdrawal time was 6.7 ± 1.34 min. Conclusion: The results of the present study showed that same day repeat colonoscopy with additional laxative dose can be a safe and effective method for repeat procedure of an inadequate colonoscopy. The patients tolerated and were satisfied with the same day protocol. Quality indicators of colonoscopy such as adenoma detection rate and cecum intubation rate were achieved. Same day bowel cleansing method may be considered as an alternative way rather than re-scheduling inadequate colonoscopy for a later time.

Management of Diverticular Bleeding: Evaluation, Stabilization, Intervention, and Recurrence of Bleeding and Indications for Resection after Control of Bleeding

Diverticular bleeding is the most common cause of lower gastrointestinal bleeding with nearly 200,000 admissions in the United States annually. Less than 5% of patients with diverticulosis present with diverticular bleeding and present usually as painless, intermittent, and large volume of lower gastrointestinal bleeding. Management algorithm for patients presenting with diverticular bleeding includes resuscitation followed by diagnostic evaluation. Colonoscopy is the recommended first-line investigation and helps in identifying the stigmata of recent hemorrhage and endoscopic management of the bleeding. Radionuclide scanning is the most sensitive but least accurate test due to low spatial resolution. Angiography is helpful when patients are actively bleeding and therapeutic interventions are performed with angioembolization. Surgery for diverticular bleeding is necessary when associated with hemodynamic instability and after failed endoscopic or angiographic interventions. When the bleeding site is localized preoperatively, partial colectomy is sufficient, but subtotal colectomy is necessary when localization is not possible preoperatively.

[Tolerance, safety and efficacy of the one-day preparation of PEG3350 + bisacodyl compared to 2 days of PEG3350 + bisacodyl in pediatric patients]

BACKGROUND

Multiple intestinal preparations have been used in children undergoing colonoscopy, with variable limitation due to acceptance, tolerance, and proper cleaning. The objective of this study was to compare the tolerability, safety and efficacy of the colonoscopy preparation with 1 day with PEG 3350 (poliethylenglycol) (4g/kg/day) + bisacodyl compared to 2 days of preparation with PEG 3350 (2g/kg/day) + bisacodyl in pediatric patients.

METHODS

A clinical, randomized, and blind trial was performed. Patients aged 2 to 18 years scheduled for colonoscopy were included. Patients were randomized into two groups: 1 day of preparation with PEG 3350 4g/kg/day + bisacodyl and 2 days of preparation with PEG 3350 2g/kg/day + bisacodyl. Through a questionnaire, physical examination and endoscopic evaluation (Boston scale), the tolerance, safety and efficacy of the 2 preparations to be evaluated were determined. Student's t test was performed for quantitative variables and χ² for qualitative variables.

RESULTS

There were no significant differences in compliance rates, adverse effects, and extent of colonoscopic evaluation.

CONCLUSIONS

Tolerance and safety between the intestinal preparation for 1-day colonoscopy with PEG 3350 (4g/kg/day) + bisacodyl and the 2-day preparation with PEG 3350 (2g/kg/day) + bisacodyl were similar. The quality of cleanliness was good in both groups, being partially more effective in the 1-day group with PEG 3350 (4g/kg/day).

Systematic review and meta-analysis of colon cleansing preparations in patients with inflammatory bowel disease

AIM

To performed a systematic review and meta-analysis to determine any possible differences in terms of effectiveness, safety and tolerability between existing colon-cleansing products in patients with inflammatory bowel disease.

METHODS

Systematic searches were performed (January 1980-September 2016) using MEDLINE, EMBASE, Scopus, CENTRAL and ISI Web of knowledge for randomized trials assessing preparations with or without adjuvants, given in split and non-split dosing, and in high (> 3 L) or low-volume (2 L or less) regimens. Bowel cleansing quality was the primary outcome. Secondary outcomes included patient willingness-to-repeat the procedure and side effects/complications.

RESULTS

Out of 439 citations, 4 trials fulfilled our inclusion criteria (n = 449 patients). One trial assessed the impact of adding simethicone to polyethylene glycol (PEG) 4 L with no effect on bowel cleansing quality, but a better tolerance. Another trial compared senna to castor oil, again without any differences in term of bowel cleansing. Two trials compared the efficacy of PEG high-volume vs PEG low-volume associated to an adjuvant in split-dose regimens: PEG low-dose efficacy was not different to PEG high-dose; OR = 0.84 (0.37-1.92). A higher proportion of patients were willing to repeat low-volume preparations vs high-volume; OR = 5.11 (1.31-20.0).

CONCLUSION

In inflammatory bowel disease population, PEG low-volume regimen seems not inferior to PEG high-volume to clean the colon, and yields improved willingness-to-repeat. Further additional research is urgently required to compare contemporary products in this population.

Bowel Preparation for a Better Colonoscopy Using Polyethylene Glycol or C-lax: A Double Blind Randomized Clinical Trial

BACKGROUND

Ideal bowel preparation regimen for a suitable colonoscopy should be safe, and well tolerated, and should rapidly clear gastrointestinal tract. Soluble polyethylene glycol (PEG) is the most common cleansing drug and Senna or C-Lax (Cassia angustifolia Vahl) is an alternative herbal one. This study was designed to compare the efficacy of PEG and C-lax in bowel preparation.

METHODS

In this randomized double blind trial (registry number in IRCT.ir: IRCT201601161264N7), 320 patients were randomly assigned in PEG or C-lax groups. PEG solution was prepared from 5×70 gr sachets in 20×250cc water (250 ml every 15 minutes), prescribed 24h before the colonoscopy. In the other group 3×60 ml C-lax syrup glasses (each containing 90 mg senozid B) was given in two divided doses (1.5 glasses of 250cc every 12 hours), 24h before the colonoscopy. Ottawa score was used to evaluate the quality of bowel preparation. Chi-square test, Student t test, MannWhitney test and multivariate analysis were used to analyze the data.

RESULTS

Of these patients with the mean (SD) age of 50 (15.16) years, 162 (50.8%) were men. Mean (SD) Ottawa score was 2.57 (0.2) and 3.15 (0.31) in the PEG and C-lax group, respectively (p value = 0.81). Multivariate analysis showed that less opium consumption (p < 0.001) and higher educational level (p =0.005) were associated with better bowel preparation.

CONCLUSION

C-Lax is non-inferior to PEG solution in cleansing colon. The quality of bowel preparation was lower in opium consumers and better in those with higher educational level.

Impact of gum chewing on the quality of bowel preparation for colonoscopy: an endoscopist-blinded, randomized controlled trial

BACKGROUND AND AIMS

Gum chewing can accelerate motility in the GI tract; clinical studies suggested gum chewing can reduce postoperative ileus. However, no trial has investigated the effect of gum chewing on bowel preparation for colonoscopy in addition to polyethylene glycol (PEG). The objective of this study was to investigate whether gum chewing before colonoscopy can increase the quality of bowel preparation.

METHODS

This was a single-center, randomized controlled trial. Consecutive patients undergoing colonoscopy were randomized to the gum group or the control group. Patients in the gum group chewed sugar-free gum every 2 hours for 20 minutes each time from the end of drinking 2 L of PEG to the beginning of colonoscopy. Patients in the control group only received 2 L of PEG before colonoscopy. The quality of bowel preparation, procedure time, adenoma detection rate, patients' tolerance, and adverse events were compared.

RESULTS

Three hundred patients were included in the study (150 in the control group, 150 in the gum group). More than 90% of patients in both groups were satisfied with the process of bowel preparation, and the incidence of adverse events was comparable in the 2 groups (41.3% vs 46.0%, P = .42). The mean Boston Bowel Preparation Scale score was 6.2 ± 1.4 and 6.1 ± 1.2 in the control group and the gum group, respectively, and the difference between the 2 groups was not significant (P = .51).

CONCLUSIONS

This study indicates that gum chewing does not improve the quality of bowel preparation for colonoscopy, but it can improve patients' satisfaction with the process of bowel preparation and does not have negative effects on cleanliness. (Clinical trials registration number: NCT02507037.).

Addition of Lubiprostone to polyethylene glycol(PEG) enhances the quality & efficacy of colonoscopy preparation: a randomized, double-blind, placebo controlled trial

Background

Adequate bowel preparation is an essential prerequisite for complete mucosal visualization during colonoscopy. Polyethylene glycol (PEG) solutions are commonly used. However the large volume of the solution is often poorly tolerated. Addition of Lubiprostone (LB) could improve the adequacy of standard PEG preparation & reduce requirement. The aims to assess adequacy of PEG preparation with addition of single dose LB (24mcg) vs placebo and efficacy of reduced dose PEG + LB compared with full dose PEG + LB.

Methods

Single center prospective double blind randomized controlled trial. Part I: 442 patients for colonoscopy randomized to receive placebo (GrA) or single dose of LB (GrB) prior to PEG preparation. Quality of bowel preparation graded 0–9 according to Boston Bowel Preparation Scale (BBPS). BBPS-9: excellent and BBPS 0–4: repeat procedure.

Part II: 146 patients randomized to receive LB + 1.5 L PEG (GrC; 75) or LB + 1 L PEG (GrD; 71). BBPS score compared with GrB (2 L PEG).

Results

Part I: 442 patients (221 GrA & 221 Gr B). LB resulted in significant improvement in total BBPS (7.44 + 0.14 vs. 6.36 + 0.16, p < 0.0001). 66.5 % Gr B vs 38 % Gr A had excellent prep; 42.5 % GrB vs 24 % GrA had adequate prep. Repeat procedure needed 9.5 % Gr B vs 16.7 % Gr A (P < 0.01).

Part II: No difference in BBPS scores with lower doses (Gr C&D) compared to standard (GrB) (Mean BBPS 7.44 + 0.14 GrA,7.30 + 0.25 GrC;7.25 + 0.26 GrD;p >0.05).

Conclusion

Single dose LB prior to PEG significantly enhanced bowel preparation compared to PEG alone. There was no significant difference in quality of preparation with lower doses of PEG when combined with LB.

Trial registration

The study protocol was approved by institutional review board and the trial was registered on March 22, 2011 with clinicaltrials.gov (NCT01324284).

Optimizing bowel preparation for colonoscopy: a guide to enhance quality of visualization

Colonoscopy is an important screening and therapeutic modality for colorectal cancer. Unlike other screening tests, colonoscopy is dependent on pre-procedure bowel preparation. If the bowel preparation is poor, significant pathology may be missed. Many factors are known to improve bowel preparation. This review will highlight those factors that may optimize the bowel preparation, including choice of bowel preparation, grading or scoring of the bowel preparation, special factors that influence preparation, and diet prior to colonoscopy that affects bowel preparation. The aim of the review is to offer suggestions and guide endoscopists on how to optimize the bowel preparation for the patients undergoing colonoscopy.

Combination could be another tool for bowel preparation?

Optimal bowel preparation increases the cecal intubation rate and detection of neoplastic lesions while decreasing the procedural time and procedural-related complications. Although high-volume polyethylene glycol (PEG) solution is the most frequently used preparation for bowel cleansing, patients are often unwilling to take PEG solution due to its large volume, poor palatability, and high incidence of adverse events, such as abdominal bloating and nausea. Other purgatives include osmotic agents (e.g., sodium phosphate, magnesium citrate, and sodium sulfate), stimulant agents (e.g., senna, bisacodyl, and sodium picosulfate), and prokinetic agents (e.g., cisapride, mosapride, and itopride). A combination of PEG with an osmotic, stimulant, or prokinetic agent could effectively reduce the PEG solution volume and increase patients’ adherence. Some such solutions have been found in several published studies to not be inferior to PEG alone in terms of bowel cleansing quality. Although combination methods showed similar efficacy and safety, the value of these studies is limited by shortcomings in study design. New effective and well-tolerated combination preparations are required, in addition to rigorous new validated studies.