Effective bowel cleansing before colonoscopy: a randomized study of split-dosage versus non-split dosage regimens of high-volume versus low-volume polyethylene glycol solutions

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.

Efficacy and safety of 1 L polyethylene glycol plus ascorbic acid for bowel preparation in elderly: comparison with oral sulfate solution

BACKGROUND/AIMS

Recently, 1 L of polyethylene glycol (PEG) plus ascorbic acid (Asc) has been introduced in Korea as a colonoscopy preparation agent. Data on its efficacy and safety in older adults have been limited. We aimed to evaluate the safety and efficacy of 1 L PEG/Asc in older adults by comparing it with oral sulfate solution (OSS).

METHODS

A prospective multicenter randomized study was conducted with subjects aged ≥ 65 years who underwent colonoscopy. The participants were randomized to receive 1 L PEG/Asc or OSS. The primary endpoint was successful bowel preparation, defined as total Boston Bowel Preparation Scale ≥ 6, and ≥ 2 at each segment. Patient satisfaction, adverse events, and renal function changes were compared between the groups.

RESULTS

Among the 106 patients, 104 were finally included in the analysis. Overall, successful bowel preparation was achieved in 96.2% of both 1 L PEG/Asc and OSS groups. The satisfaction scores for taste, total amount ingested, overall feeling, and willingness to repeat the same regimen were not significantly different between the groups. Adverse events of moderate or higher severity occurred in 16 and 10 cases in the 1 L PEG/Asc and OSS group, respectively. There were no significant changes in electrolyte levels or renal function from baseline.

CONCLUSION

The successful bowel preparation rate was > 90% in both groups without severe adverse effects and significant changes in renal function. As a new low-dose preparation regimen for colonoscopy in older adults, 1 L PEG/Asc, is as effective and safe as OSS.

Polyethylene glycol combined with lactulose has better efficacy than polyethylene glycol alone in bowel preparation before colonoscopy: A meta-analysis

BACKGROUND

The accuracy of diagnosis and the safety of treatment in colonoscopy depends largely on the quality of bowel cleansing. This study aimed to compare the efficacy and adverse reactions of Polyethylene Glycol (PEG) combined with lactulose with that of PEG alone in bowel preparation before colonoscopy.

METHODS

The authors searched a number of databases including EMBASE, MEDLINE, Cochrane Library, and China Academic Journals Full-text Database. The authors screened according to literature inclusion and exclusion criteria, assessed the quality of the included literature, and extracted the data. The meta-analysis of included literature used RevMan 5.3 and Stata 14.0 software.

RESULTS

A total of 18 studies, including 2274 patients, were enrolled. The meta-analysis showed that PEG combined with lactulose had a better efficacy (OR = 3.87, 95% CI 3.07‒4.87, p = 0.000, and I² = 36.2% in the efficiency group; WMD = 0.86, 95% CI 0.69‒1.03, p = 0.032 and I² = 0% in the BBPS score group) in bowel preparation for patients with or without constipation. Moreover, PEG combined with lactulose had fewer adverse reactions, including abdominal pain (OR = 1.42, 95% CI 0.94‒2.14, p = 0.094), nausea (OR = 1.60, 95% CI 1.13‒2.28, p = 0.009) and vomiting (OR = 1.77, 95% CI 1.14‒2.74, p = 0.011), than PEG alone. No significant reduction in the incidence of abdominal distention was observed.

CONCLUSION

PEG combined with lactulose may be a better choice for bowel preparation before colonoscopy compared with PEG alone.

The Bowel CLEANsing National Initiative: High-Volume Split-Dose Vs Low-Volume Split-Dose Polyethylene Glycol Preparations: A Randomized Controlled Trial

BACKGROUND & AIMS

The aim of this study was to compare high-volume polyethylene glycol (PEG) with low-volume PEG with bisacodyl split-dosing regimens.

METHODS

Adult outpatients in 10 Canadian tertiary hospitals were randomized, stratified by morning or afternoon colonoscopy, to high-volume split-dose PEG (2 L + 2 L) (High-SD) or low volume (1 L + 1 L) + bisacodyl (15 mg) PEG (Low-SD), with a second randomization to liquid or low-residue diets. The primary end point, using noninferiority hypothesis testing, was adequate bowel cleansing (Boston Bowel Preparation Scale total score of ≥6, with each of 3 colonic segments subscores ≥2). Secondary objectives were willingness to repeat the preparation, withdrawal time, cecal intubation, and polyp detection rates.

RESULTS

Over 29 months, 2314 subjects were randomized to High-SD (N = 1157) or Low-SD (N = 1157) (mean age, 56.2 ± 13.4 y; 52.1% women). Colonoscopy indications were 38.2% diagnostic, 36.8% screening, and 25.0% surveillance, with no between-group imbalances in patient characteristics. Low-SD satisfied noninferiority criteria vs High-SD for adequate bowel cleanliness with only marginally inferior results (90.1% vs 88.1%; P = .02; difference, 2.0%; 95% CI [0.0%; 4.5%]). High-SD was associated with lower willingness to repeat (66.9% vs 91.9%; P < .01), was less well tolerated (7.3 ± 2.3 vs 8.1 ± 1.9; P < .01), causing more symptoms. No differences in procedural outcomes were noted except for more frequent cecal intubation rates after High-SD (97.4% vs 95.6%; P = .02). Among the High-SD group, adequate bowel preparation was greater after a clear liquid diet (93.6% vs 87.9%; P < .01), a finding not seen in the Low-SD group.

CONCLUSIONS

Low-SD is noninferior to High-SD in providing adequate bowel preparation. Low-SD results in fewer symptoms, with greater willingness to repeat and tolerability. The overall impact of diet was modest.The study was approved by the research ethic boards from all sites and was registered at ClinicalTrials.gov (NCT02547571).

The Effectiveness and Tolerability of a Very Low-Volume Bowel Preparation for Colonoscopy Compared to Low and High-Volume Polyethylene Glycol-Solutions in the Real-Life Setting

Adequate bowel cleansing is essential for high-quality colonoscopy. Recently, a new very low-volume 1 litre (1L) polyethylene glycol (PEG) plus ascorbate solution (ASC) has been introduced. Our aims were to assess the effectiveness and tolerability of this product compared to low-volume 2L PEG-ASC and high-volume 4L PEG solutions, in a real-life setting. In six endoscopy units in Sweden, outpatients undergoing colonoscopy were either prescribed solutions according to local routines, or the very low-volume solution in split dose regimen. Bowel cleansing effectiveness and patient experience was assessed using the Boston Bowel preparation scale (BBPS) and a patient questionnaire. A total of 1098 patients (mean age 58 years, 52% women) were included. All subsegment and the total BBPS scores were significantly greater for 1L PEG-ASC in comparison to other solutions (p < 0.05 for 1L PEG-ASC and 4L PEG for transverse and left colon, otherwise p < 0.001). Nausea was more frequent with 1L PEG-ASC compared to 2L PEG-ASC (p < 0.001) and vomiting were more often reported compared to both other solutions (p < 0.01 and p < 0.05 for 2L PEG-ASC and 4L PEG, respectively). Smell, taste, and total experience was better for 1L PEG-ASC compared to 4L PEG (p < 0.001), and similar compared to the 2L PEG-ASC. In conclusion, 1L PEG-ASC leads to better bowel cleansing compared to 2L PEG-ASC or 4L PEG products, with similar or greater patient satisfaction.

Serum electrolytes, osmolality, and cleansing quality after bowel prep for colonoscopy with a PEG solution containing ascorbic acid and electrolytes

BACKGROUND

The cleansing procedure with PEG 3350 + ascorbic acid (PEG + Asc; Moviprep®) requires the additional ingestion of clear liquids. We aimed to determine the effects on serum electrolytes, osmolality and cleansing quality, and in a prospective "real world" trial.

PATIENTS AND METHODS

Patients underwent a standardized split-dose bowel preparation for colonoscopy with PEG + Asc. Serum electrolytes and osmolality were measured before and after the prep procedure. The volume of prep solution (PA) and additional clear liquid (CL) was recorded. Prep quality was assessed using the Ottawa Bowel Prep Grading Scale (OBPS). The primary outcome measures were changes of serum electrolytes and osmolality during the cleansing procedure. A secondary end point was the OPBS.

RESULTS

One hundred ninety-one of 219 patients entered the per protocol analysis. Prep quality was considered excellent in 57.6%, moderate in 20.9%, and insufficient in 21.5%. The number of patients with hyponatremia increased from 12 (6.3%) before to 25 (13.2%) after the prep procedure. Mean sodium concentration did not change significantly. The volume of CL correlated inversely with Na⁺ concentration (r =  - 0.409, p < 0.01) and a worse OBPS (r = 0.198, p < 0.01).

CONCLUSIONS

Bowel preparation with PEG-Asc in clinical routine is generally safe, but patients should be advised not to drink more than 2 l of clear liquid because of imminent electrolyte disturbances. Additionally, the quality of cleansing either remains unchanged or may even worsen.

Split-dose low-volume polyethylene glycol is non-inferior but less preferred compared with same-day bowel preparation for afternoon colonoscopy

Currently, the same-day polyethylene glycol-electrolyte lavage solution (PEG-ELS) regimen is particularly recommended for afternoon colonoscopy as an alternative to the split-dose regimen in western countries. However, in Japan, the split-dose regimen has never been used as a standard colonoscopy preparation regimen. The aim of this study was to compare the efficacy and tolerability of split-dose PEG containing ascorbic acid (ASC) with same-day single dose PEG-ASC in Japan.This was a single-blinded, non-inferiority, two-center, randomized, controlled study. In-hospital patients were randomized to the same-day regimen or the split regimen using a web-based registry system. The same-day group was instructed to take 5 mL of sodium picosulfate in the evening, and on the day of the colonoscopy, they took 1.5 L of PEG-ASC. The split group was instructed to take 1 L of PEG-ASC before the day of colonoscopy, followed by another 1 L of PEG-ASC on the day of colonoscopy. Bowel cleansing was evaluated by the Boston Bowel Preparation Scale.A total of 153 patients were randomized to either the same-day group (n=78, males 60.0%, mean age 62.7 years) or the split group (n=75, 61.3%, 61.9 years). The rates of successful bowel cleansing were 83.3% in the same-day group vs. 92.0% (83.4%–97.0%) in the split group, P=0.10). No serious adverse events occurred in the study population. However, more patients in the same-day group were willing to repeat the same preparation regimen (P<0.001). The split-dose regimen was not inferior to the same-day regimen with respect to the efficacy of bowel preparation, but the patients preferred the same-day regimen.

Increased Driving Distance to Screening Colonoscopy Negatively Affects Bowel Preparation Quality: an Observational Study

BACKGROUND

To prepare for colonoscopy, patients must consume a bowel purgative and travel from their home to the site of their procedure. The timing of bowel purgative ingestion predicts bowel preparation quality. Currently, it is not known if driving distance impacts bowel preparation quality or adenoma detection.

OBJECTIVE

This study investigates the effect of driving distance on bowel preparation and adenoma detection.

DESIGN

This is a cross-sectional retrospective analysis of outpatient screening colonoscopy procedures that were completed at an academic medical center.

PARTICIPANTS

A total of 5089 patients who completed screening colonoscopy across 3 procedure units were analyzed.

MAIN MEASURES

Description of bowel preparation was dichotomized to either adequate or inadequate. Patient residential addresses were converted into geographic coordinates for geospatial analysis of driving distance to their colonoscopy site.

KEY RESULTS

Median driving distance was 13.1 miles. Eighty-nine percent of patients had an adequate bowel preparation. The rate of adenoma detection was 37%. On multivariable logistic regression adjusting for age, sex, race, insurance, endoscopist, and site, increasing driving distance (10-mile increments) was negatively associated with adequate bowel preparation (odds ratio = 0.91; 95% confidence interval 0.85 to 0.97), while adenoma detection was positively associated with adequate bowel preparation (odds ratio = 1.53; 95% confidence interval 1.24 to 1.88) but not with driving distance (odds ratio = 1.02; 95% confidence interval 0.98 to 1.06). Driving distances of 30 miles or less were associated with adequate bowel preparation (odds ratio = 1.37; 95% confidence interval 1.09 to 1.72).

CONCLUSIONS

Increasing driving distance to screening colonoscopy was negatively associated with adequate bowel preparation but not adenoma detection. Among an academic medical center population, the likelihood of adequate bowel preparation was highest in patients traveling 30 miles or less to their screening colonoscopy. Patient driving distance to colonoscopy is an important consideration in optimizing screening colonoscopy quality.

Split-Dose Regimen With Bisacodyl Increases the Quality of Bowel Preparation for Colonoscopy

The aim of the present study was to compare 2 different bowel preparations procedures (split-dose with PicoPrep and bisacodyl vs. same-day preparation with PicoPrep) in patients undergoing colonoscopy with regard to quality of bowel preparation, compliance, and willingness to repeat. A retrospective quasi-experimental investigation was conducted. Adults with outpatient diagnostic and surveillance colonoscopies were included. A total of 540 patients participated: group 'split-dose with bisacodyl' (n = 293) and group 'same-day' (n = 247). Patients in group 'split-dose with bisacodyl' had a higher chance for having an excellent quality of bowel preparation (21.2%; 95% CI [13.5, 28.9]) and a reduced risk of an incomplete colonoscopy (4.1%; 95% CI [1.2, 7.0]). Group 'split-dose with bisacodyl' drank more fluid, had more nightly visits to the bathroom, and had more bathroom stops on the way to the endoscopic site. No differences were found between groups regarding adenoma detection rate, withdrawal time, overall time of colonoscopy, well-being during cleansing, patient satisfaction, the professional's assessment of the patient's tolerability of colonoscopy, and willingness to repeat the bowel preparation process. The split-dose regimen with PicoPrep and bisacodyl is now the standard bowel preparation procedure for patients undergoing elective colonoscopy as it is superior to the same-day regimen with PicoPrep regarding colon cleansing and incomplete colonoscopy. Hence, the written and verbal information at our institution regarding the bowel preparation procedure was altered according to the split-dose regimen, emphasizing the importance of adequate oral fluid intake and complete intake of the solution in order to ensure a safe and effective procedure.

The Bowel CLEANsing National Initiative: A Low-Volume Same-Day Polyethylene Glycol (PEG) Preparation vs Low-Volume Split-Dose PEG With Bisacodyl or High-Volume Split-Dose PEG Preparations-A Randomized Controlled Trial

INTRODUCTION

Bowel cleanliness has been shown to be superior with split-dose vs nonsplit preparations; we aimed to directly assess the poorly characterized comparative efficacies of split-dose vs same-day polyethylene glycol (PEG) regimens.

METHODS

In this study, one of a series of randomized trials performed across 10 Canadian endoscopy units, patients undergoing colonoscopies between 10:30 and 16:30 were allocated to PEG low-volume same-day (15 mg bisacodyl the day before, 2 L the morning of the procedure), low-volume split-dose (15 mg bisacodyl the day before, 1 L + 1 L), or high-volume split-dose (2 L + 2 L). Coprimary endpoints were adequate bowel cleansing based on the Boston Bowel Preparation Scale using in turn different threshold cutoffs.

RESULTS

Overall, 1,750 subjects were randomized equally across the 3 groups, with no differences in adequate bowel cleanliness rates (low-volume same-day, 90.5%; high-volume split-dose, 92.2%; P = 0.34; and low-volume split-dose, 87.9%; P = 0.17) for the Boston Bowel Preparation Scale ≥6 and 2 for each segment. Willingness to repeat the preparation was not significantly different between low-volume same-day (91.0%) and low-volume split-dose (92.5%; P = 0.40) but was greater than the high-volume split-dose (68.9%; P < 0.01). No significant differences were noted for withdrawal time, cecal intubation, or polyp detection rates.

DISCUSSION

In this large randomized trial of PEG regimens, low-volume same-day resulted in similar bowel cleanliness compared with high-volume or low-volume split-dosing. Willingness to repeat and tolerability were superior with low-volume same-day compared with high-volume split-dose and similar to low-volume split-dose.

Efficacy and Tolerability of High- vs Low-Volume Split-Dose Bowel Cleansing Regimens for Colonoscopy: A Systematic Review and Meta-analysis

BACKGROUND & AIMS

Efficacy of bowel preparation is an important determinant of outcomes of colonoscopy. It is not clear whether approved low-volume polyethylene glycol (PEG) and non-PEG regimens are as effective as high-volume PEG regimens when taken in a split dose.

METHODS

In a systematic review of multiple electronic databases through January 31, 2019 with a registered protocol (PROSPERO: CRD42019128067), we identified randomized controlled trials that compared low- vs high-volume bowel cleansing regimens, administered in a split dose, for colonoscopy. The primary efficacy outcome was rate of adequate bowel cleansing, and the secondary efficacy outcome was adenoma detection rate. Primary tolerability outcomes were compliance, tolerability, and willingness to repeat. We calculated relative risk (RR) and 95% CI values and assessed heterogeneity among studies by using the I² statistic. The overall quality of evidence was assessed using the GRADE framework.

RESULTS

In an analysis of data from 17 randomized controlled trials, comprising 7528 patients, we found no significant differences in adequacy of bowel cleansing between the low- vs high-volume split-dose regimens (86.1% vs 87.4%; RR, 1.00; 95% CI, 0.98-1.02) and there was minimal heterogeneity (I² = 17%). There was no significant difference in adenoma detection rate (RR, 0.96; 95% CI, 0.87-1.08) among 4 randomized controlled trials. Compared with high-volume, split-dose regimens, low-volume split-dose regimens had higher odds for compliance or completion (RR, 1.06; 95% CI, 1.02-1.10), tolerability (RR, 1.39; 95% CI, 1.12-1.74), and willingness to repeat bowel preparation (RR, 1.41; 95% CI, 1.20-1.66). The overall quality of evidence was moderate.

CONCLUSIONS

Based on a systematic review of 17 randomized controlled trials, low-volume, split-dose regimens appear to be as effective as high-volume, split-dose regimens in bowel cleansing and are better tolerated, with superior compliance.

Does It work in Clinical Practice? A Comparison of Colonoscopy Cleansing Effectiveness in Clinical Practice Versus Efficacy from Selected Prospective Trials

Background

Adequate bowel preparation is essential for a high-quality colonoscopy. Many randomized controlled trials (RCTs) have investigated bowel preparation protocols, including split-dose and low-volume regimens. However, RCTs are conducted in an ideal, controlled setting, and translation of trial results to clinical practice is challenging. In this study, we compared the quality of bowel preparations of real-world patients from clinical practice with those enrolled in several prospective trials.

Methods

Bowel preparation quality, defined by the Ottawa Bowel Preparation Scale (OBPS), from four RCTs and one prospective trial were compared with two observational diary studies. Bowel preparations were polyethylene glycol preparation (PEG) or sodium picosulfate plus magnesium citrate (P/MC) taken via traditional or split-dose timing regimen. Age, sex, average number of bowel movements per day, comorbidities, colonoscopy indication and colonoscopy completion rates were also collected.

Results

Patients enrolled in prospective trials had a better OBPS by one point when compared with those in observational clinical practice studies (P<0.049), after controlling for age, sex, colonoscopy indication and type of bowel preparation used. We also found that each 10-year increase in age was associated with a 0.2 point increase in OBPS (P=0.008), and men were associated with a 0.5 increase in OBPS when compared with women P=0.014).

Conclusion

Patients from clinical practice have higher OBPS than prospective trial patients. Increased age and male sex were also associated with increased OBPS. We believe increased patient motivation and education around bowel preparation regimen plays an important role in the success of bowel preparations.

A European, multicentre, observational, post-authorisation safety study of oral sulphate solution: compliance and safety

Background and study aims  Oral sulphate solution (OSS) is a sulphate-based, low-volume bowel cleansing preparation taken in two doses of 500 mL, each followed by 1000mL of water or clear liquid. The primary objective of this observational study was to document compliance with the recommended hydration guidelines in a representative sample of the European population. Patients and methods  Prospective, non-interventional, multicentre study (NCT02630680, EUPAS9361) in patients prescribed OSS for colonoscopy preparation in routine clinical practice in Europe. Patients were included according to pre-agreed consecutive enrolment rules. Patients recorded the volume of OSS and water or clear liquid intake, and occurrence of adverse events (AEs). Compliance with hydration was calculated as a ratio of actual volume of water/clear liquid taken versus prescribed 2,000 mL, and non-compliance defined as < 75 % intake. Colon cleansing level was assessed on a 4-point scale. Results  Between October 2015 and January 2017, 1,281 patients were recruited in 16 centres in four European countries (safety population n = 1,206; registry population n = 1,177). Of patients, 94.5 % were ≥ 75 % and 86.8 % 100 % compliant with hydration guidelines. Patients took an average of 96.8 % of the recommended OSS volume; 46 patients (3.9 %) were non-compliant. Colon cleansing levels were good-to-excellent in 87.6 % of patients. Three hundred and twenty-nine patients (27.3 %) experienced 758 treatment-related AEs, mostly gastrointestinal (82.9 %), all were mild-to-moderate. Non-compliant patients had no AEs suggestive of dehydration. Conclusion  In this non-interventional study in a real-life setting, treatment compliance with hydration guidelines was good-to-excellent in 94.5 % of patients receiving OSS. The safety profile of OSS was similar to the prescribing information.

Efficacy of Single- Versus Split-dose Polyethylene Glycol for Colonic Preparation in Children: A Randomized Control Study

OBJECTIVES

Polyethylene glycol (PEG) is the most effective colon-cleansing agent but volume-related adverse effects are common. Though split-dose PEG is used in adults, no pediatric study so-far has compared split-dose with single-dose PEG. We aimed at comparing the efficacy and tolerability of split-dose versus single-dose PEG for bowel preparation in children.

METHODS

Consecutive children (1-18 years) were randomized into either single-dose or split-dose PEG. Single-dose group received 4000 mL/1.73 m PEG solution day before colonoscopy whereas split-dose group received half dose day before and the remaining half on the day of colonoscopy. Effectiveness of bowel preparation was assessed on Aronchik scale, by the endoscopist who was blinded to the type of preparation. Interobserver variability was analyzed by comparing with independent scoring by the blinded trained endoscopy-nurse. The trial was registered with Clinical Trials Registry of India (Trail number 2017/08/009303).

RESULTS

Of the 220 randomized children, 179 completed the study (split-dose: 93, single-dose: 86). The mean age of the study population was 11.51 (4.82) years (72.6% boys). The efficacy of bowel preparation was better with split-dose (satisfactory preparation:76.34% vs 43.02%, P < 0.001) with almost perfect inter-observer agreement (k = 0.803). Nausea, vomiting, and sleep disturbance were significantly less in split-dose than single-dose group (P < 0.05). Split-dose patients were able to drink PEG solution faster (P = 0.002). Total sleep duration and uninterrupted sleep duration was also better in split-dose group as compared with single-dose (P = 0.001).

CONCLUSIONS

Split-dose PEG is more effective than single-dose regimen for bowel preparation with better tolerability and improved sleep quality in pediatric population.

A low-residue diet before colonoscopy tends to improve tolerability by patients with no differences in preparation quality: a randomized trial

BACKGROUND

The pre-colonoscopy diet traditionally involves 24 h of a clear liquid diet (CLD) in combination with a lavage solution; however, this preparation is poorly tolerated.

AIM

To compare the impact on the quality of bowel cleansing and tolerability of a CLD versus a low-residue diet (LRD).

METHODS

We performed a randomized trial. Subjects were randomized to CLD or LRD the day before of elective colonoscopy. All subjects received a 4-L preparation of single-dose PEG beginning 16 h prior to colonoscopy. The Boston bowel preparation scale was used to evaluate bowel cleansing; an adequate-quality preparation was defined as a score ≥ 2 per segment.

RESULTS

A total of 205 subjects were included with a mean age (SD) of 55.6 (12.6) years; 133 (64.9%) of them were female. A total of 105 subjects were randomized to receive CLD and 100 to LRD. No significant differences in bowel preparation quality were observed between groups according to the section of colon: right colon (70% vs. 73%, p = 0.08), transverse colon (82% vs. 79%, p = 0.062), or left colon (80% vs. 78.7%, p = 0.28). There was a tendency toward less-frequent nausea (p = 0.08) and vomiting (p = 0.07) in patients with LRD. No differences between groups regarding ADR (12% vs. 10%) were noted.

CONCLUSIONS

An LRD before colonoscopy resulted in a tendency toward improved tolerability by patients, with no differences in the quality of bowel preparation.

Comparative Efficacy of 2 L Polyethylene Glycol Alone or With Ascorbic Acid vs. 4 L Polyethylene Glycol for Colonoscopy: A Systematic Review and Network Meta-Analysis of 12 Randomized Controlled Trials

Background: Colonoscopy remains an optimal approach for early detection and treatment of gastrointestinal lesions, however adequate bowel preparation is the critical contributor to effective and safe colonoscopy. Polyethylene glycol (PEG)-based bowel cleansing regime has been the first recommendation before colonoscopy, however it remains unknown which regime is the optimal option. Aim: The aim of our study is to determine the comparative efficacy of 2 L PEG alone or plus ascorbic acid (Asc) vs. 4 L PEG alone for bowel cleansing prior to colonoscopy. Methods: We assigned two independent investigators to search and screen potential records, extract essential information, and appraise the risk of bias of individual study accordingly. Then, we adopted RevMan 5.3, Stata 14.0, and WinBUGS 1.4 software to perform all statistical analyses. We also calculated the surface under the cumulative ranking curve (SCURA) in order to rank all regimes. Results: Twelve studies involving 4,106 patients were analyzed finally. Pooled results indicated an improved bowel preparation efficacy in 2 L PEG plus ascorbic acid with split-dose regime rather than in 2 L PEG plus ascorbic acid (OR, 0.25; 95% CI, 0.18-0.36), 4 L PEG with split dose (OR, 3.18; 95% CI, 2.17-4.66), and 4 L PEG (OR, 4.53; 95% CI, 3.07-6.67) regimes, which was confirmed by network meta-analyses; a better compliance in 2 L PEG plus Asc with split dose (OR, 3.08; 95% CI, 1.51-6.30) and 4 L PEG with split dose (OR, 0.43; 95% CI, 0.22-0.82) regime rather than in 4 L PEG regime, but network meta-analyses generated inconsistency results; a higher preference in 2 L PEG plus Asc with split dose regime rather than in 4 L PEG split dose (OR, 2.24; 95% CI, 1.02-4.90), which were not supported by network meta-analyses; no statistically significant difference when all regimes compared with each other in terms of adverse events. Conclusions: As for bowel preparation before colonoscopy, 2 L PEG ascorbic acid with split dose should be optimally prescribed. Further studies investigating the comparative efficacy of 2 L PEG related to 4 L PEG, 4 L PEG with split dose, and 2 L PEG plus ascorbic acid with split dose, respectively are needed.

A Randomized Trial of Split Dose 3 L Polyethylene Glycol Lavage Solution, 2 L Polyethylene Glycol Lavage Combined With Castor Oil, and 1 L of Polyethylene Glycol Lavage Solution Combined With Castor Oil and Ascorbic Acid for Preparation for Colonoscopy

Background: Castor oil (CaO) has the potential of halving the required volume of bowel preparation solution; however, no clinical trial investigated the efficacy of CaO on bowel preparation for colonoscopy in addition to polyethylene glycol (PEG).

Objectives: Our aim was to evaluate efficacy and safety of lower dose PEG together with 30 mL CaO alone or plus ascorbic acid (Asc) in bowel preparation before colonoscopy.

Methods: Two hundred and forty-six patients were allocated randomly to ingest 2 L PEG with 30 mL CaO, 1 L PEG with 30 mL CaO plus 5 g Asc, or 3 L PEG. We used Boston Bowel Preparation Scale (BBPS) to evaluate bowel preparation efficacy. We also determined other outcomes such as procedure time, polyp or adenoma detection rate, and adverse events (AEs).

Results: Of 282 patients recruited, 36 were excluded. Groups were matched for baseline characteristics except weight (P = 0.020) and body mass index (BMI) (P = 0.003). Patient's satisfaction was higher in 2 L PEG-CaO (P = 0.016) and 1 L PEG-CaO-Asc groups (P = 0·017). Patients' compliance was 67.5, 71.4, and 80.5% in 3 L PEG, 2 L PEG-CaO, and 1 L PEG-CaO-Asc groups (P = 0.014). Adequate bowel preparation rate was 75, 78.57, and 53.66% in 3 L PEG, 2 L PEG-CaO, and 1 L PEG-CaO-Asc groups (P = 0.021). There were no differences in terms of remaining outcomes.

Conclusions: Despite an increase in patients' satisfaction and compliance, 1 L PEG-CaO-Asc significantly decreased adequate bowel preparation rate. However, 2 L PEG-CaO improved the patients' satisfaction and compliance and increased adequate bowel preparation rate (Registration number, ChiCTR-IIR-17012418).

Low-Volume Polyethylene Glycol Improved Patient Attendance in Bowel Preparation Before Colonoscopy: A Meta-Analysis With Trial Sequential Analysis

Background: Polyethylene glycol (PEG) has been regarded as the primary recommendation for bowel preparation before colonoscopy. However, a conclusive conclusion has not yet been generated.

Aim: We performed this updated meta-analysis to further investigate the comparative efficacy and safety of low volume preparation based on PEG plus ascorbic acid related to 4L PEG.

Methods: A systematic search was conducted to retrieve potential randomized controlled trials (RCTs) in PubMed, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) from January 2000 to April 2018. Two independent searchers critically searched all potential citations, extracted data, and appraised risk of bias accordingly. Moreover, we used the STATA 12.0 and trial sequential analysis (TSA) 0.9 to complete all analyses.

Results: A total of 13 RCTs enrolling 3,910 patients met inclusion criteria. Meta-analysis based on PP analysis indicated that compared to standard volume PEG regime, low volume regime improved patient compliance RR = 1.01; 95% CIs = 1.00, 1.03; P = 0.143 (≥75% intake); RR = 1.07; 95% CIs = 1.00, 1.14; P = 0.046 (100% intake), the willingness to repeat the same regime (RR = 1.30; 95% CIs = 1.07, 157; P = 0.007), and patient acceptability (RR = 1.18; 95% CIs = 1.07, 1.29; P = 0.001), and decreased the overall adverse events (RR = 0.86; 95% CIs = 0.77, 0.96; P = 0.009). However, no difference was observed between these two different solutions for bowel preparation efficacy (RR = 0.98; 95% CIs = 0.95, 1.02; P = 0.340). These all results were further confirmed by TSA.

Conclusions: The effect of low volume regime was not inferior to the standard volume PEG regime, and low volume regime was associated with better compliance when subjects ingested all the solution, willingness to repeat the same regime, higher acceptability, and lower nausea in non-selected population.

Quality measures improving endoscopic screening of colorectal cancer: a review of the literature

INTRODUCTION

Colorectal cancer (CRC) is a major health-care problem all over the world and CRC screening is effective in reducing mortality and increasing the 5-year survival. Colonoscopy has a central role in CRC screening. It can be performed as a primary test, as a recall policy after a positive result of another screening test, and for surveillance. Since effectiveness of endoscopic screening depends on adequate detection and removal of colonic polyps, consistent quality measures, which are useful in enhancing the diagnostic yield of examination, are essential. Areas covered: The aim of this review is to analyze current evidence from literature supporting quality measures able to refine endoscopic screening of colorectal cancer. Expert commentary: Quality measures namely a) time slot allotted to colonoscopy, b) assessment of indication, c) bowel preparation, d) Cecal intubation, e) withdrawal time, f) adenoma detection rate, g) proper management of lesions (polypectomy technique, polyps retrieval rate and tattooing of resection sites), and h) adequate follow-up intervals play a key role in identifying malignant and at-risk lesions and improving the outcome of screening. Adherence to these quality measures is critical to maximize the effectiveness of CRC screening, as well as, a proper technique of colonoscopy and a quality report of the procedure. Among all recommended measures, adenoma detection rate is the most important and must be kept above the recommended quality threshold by all physicians practicing in the setting of screening.

Preparation for colonoscopy: Recommendations by an expert panel in Italy

BACKGROUND

Despite several guidelines on bowel preparation being available, their applicability in Italy is poorly investigated.

AIMS

(1) To create expert-based recommendations for the Italian setting based on available international guidelines on bowel preparation for colonoscopy; (2) to assess consensus across the Italian endoscopy community.

METHODS

The study was conducted in 2 phases: (a) statements formulation, (b) assessment of consensus. For the first phase, 6 topics related to bowel preparation were identified: (1) efficacy/tolerability; (2) timing; (3) assessment of quality of bowel preparation; (4) factors associated with inadequate preparation; (5) patient education and (6) impact of organisational factors. For each topic, statements were produced and voted by a panel of experts. For consensus assessment, the invited participants were asked to rate the statements. The statement achieved a good level of agreement when at least 70% of voters agreed with it.

RESULTS

25 statements were agreed in the first phase. Agreement was not achieved by the endoscopy community for 7 statements, mainly concerning practical aspects (i.e. strategies for management of patients with inadequate preparation, organisational factors).

CONCLUSION

A clinically relevant consensus was achieved on the main topics of bowel preparation, such as the choice of laxative and the time of administration, and it may help to homogenize the colonoscopy practice in Italy. Nevertheless, there are a few country-specific preparation-related issues that need to be addressed.

An Automated Inpatient Split-dose Bowel Preparation System Improves Colonoscopy Quality and Reduces Repeat Procedures

BACKGROUND/GOALS

Inpatient colonoscopy preparations are often inadequate, compromising patient safety and procedure quality, while resulting in greater hospital costs. The aims of this study were to: (1) design and implement an electronic inpatient split-dose bowel preparation order set; (2) assess the intervention's impact upon preparation adequacy, repeated colonoscopies, hospital days, and costs.

STUDY

We conducted a single center prospective pragmatic quasiexperimental study of hospitalized adults undergoing colonoscopy. The experimental intervention was designed using DMAIC (define, measure, analyze, improve, and control) methodology. Prospective data collected over 12 months were compared with data from a historical preintervention cohort. The primary outcome was bowel preparation quality and secondary outcomes included number of repeated procedures, hospital days, and costs.

RESULTS

On the basis of a Delphi method and DMAIC process, we created an electronic inpatient bowel preparation order set inclusive of a split-dose bowel preparation algorithm, automated orders for rescue medications, and nursing bowel preparation checks. The analysis data set included 969 patients, 445 (46%) in the postintervention group. The adequacy of bowel preparation significantly increased following intervention (86% vs. 43%; P<0.01) and proportion of repeated procedures decreased (2.0% vs. 4.6%; P=0.03). Mean hospital days from bowel preparation initiation to discharge decreased from 8.0 to 6.9 days (P=0.02). The intervention resulted in an estimated 1-year cost-savings of $46,076 based on a reduction in excess hospital days associated with repeated and delayed procedures.

CONCLUSIONS

Our interdisciplinary initiative targeting inpatient colonoscopy preparations significantly improved quality and reduced repeat procedures, and hospital days. Other institutions should consider utilizing this framework to improve inpatient colonoscopy value.

Effect of Sending Educational Video Clips via Smartphone Mobile Messenger on Bowel Preparation before Colonoscopy

Background/Aim

We aimed to evaluate the efficacy of sending educational video clips via smartphone mobile messenger (SMM) on enhancing bowel preparation before colonoscopy.

Methods

This was a prospective, endoscopist-blinded, randomized controlled study. Patients in the SMM group received two video clips sent via SMM that explained the diet and regimen for bowel preparation, whereas those in the control group did not receive any video clips. We compared the quality of bowel preparation between the two groups, which was assessed by an endoscopist using the Ottawa scale.

Results

Between August and November 2014, 140 patients in the SMM group and 141 patients in the control group underwent colonoscopic examination. The total Ottawa score of the SMM group was significantly lower than that of the control group (5.47±1.74 vs. 5.97±1.78, p=0.018). These results were particularly prominent in the younger age group; the total Ottawa score of patents in the SMM group aged <40 years was significantly lower than that of patients in the control group aged <40 years (5.10±1.55 vs. 6.22±2.33, p=0.034).

Conclusions

We demonstrated that sending educational video clips via SMM could result in better bowel preparation, especially in the younger age group.

Acute Myocardial Infarction Following Administration of Polyethylene Glycol Electrolyte Solution with Ascorbic Acid (MoviPrep®) at Home: A Case Report

A male individual aged 82 years with hypertension who had a smoking history, but no history of cardiovascular events, developed acute myocardial infarction immediately after he took oral polyethylene glycol electrolyte solution with ascorbic acid as a pretreatment for a colonoscopy to examine anemia. He took polyethylene glycol electrolyte solution with ascorbic acid at twice (2 L/h) the rate recommended in the package insert and by the physician. The patient showed impaired consciousness 2 h after taking polyethylene glycol electrolyte solution with ascorbic acid and his family called the emergency medical service. Upon arrival of the emergency medical service, his systolic blood pressure was 60 mmHg and heart rate was 50 bpm. Systolic blood pressure and impaired consciousness were slightly improved, but compensatory shock remained, at arrival at the emergency outpatient service at our hospital. No dyspnea or rash was apparent. The patient had no subjective chest pain; however, ST-segment elevation was detected in the electrocardiogram at II, III, aVF, V3R, and V4R. He was diagnosed with ST-segment elevation myocardial infarction and underwent a coronary catheter intervention for total occlusion of the right coronary artery. His shock state was abolished by this intervention. The patient was pretreated with polyethylene glycol electrolyte solution with ascorbic acid under close watch in the coronary care unit 4 days later, with no relapse of symptoms. Advanced cancer was found in the ileocecum by colonoscopy; consequently, the patient underwent a colectomy and was discharged from our hospital and transferred to another hospital for rehabilitation on hospital day 74. A Naranjo assessment score of 4 was obtained, indicating a possible relationship of acute myocardial infarction with misuse of the suspect drug, polyethylene glycol electrolyte solution with ascorbic acid.

Impact of Hyoscine Bromide Use on Polyp Detection Rate During Colonoscopy: A Systematic Review and Meta-Analysis

Background

Colorectal cancer (CRC) is a leading cause of death worldwide. Polyp detection rate (PDR) and adenoma detection rate (ADR) are key focus in endoscopic research for CRC screening and prevention. Use of anti-spasmodic agents during colonoscopy to help identify adenomas and polyps has remained a controversial topic. Hyoscine butyl bromide (HBB) is the most commonly used anti-spasmodic agent in patients undergoing colonoscopy. Some randomized controlled trials (RCTs) have questioned the clinical efficacy and safety of routine use of HBB for polyp and adenoma detection rates.

Methods

We conducted a systematic search in PubMed and MEDLINE from inception until February 10, 2018, for studies which compared HBB with placebo. We used RevMan version 5.3 for analysis. Procedural end-points were polyps, adenomas, and advanced adenoma detection rates, mean number of polyps detected and cecal intubation time.

Results

We included seven RCTs with 2,588 patients in our analysis. A total of 1,301 patients were randomized to HBB arm and 1,287 to the placebo arm. There was no significant difference in the primary outcome of polyp detection rate, 654 in HBB group vs. 616 in the placebo group, (odds ratio (OR) = 1.11, confidence interval (CI) = 0.93 - 1.34, P = 0.25). There was no difference in secondary outcomes of adenoma detection rate, 430 in HBB group vs. 396 in the placebo group, (OR = 1.06, CI = 0.89 - 1.26, P = 0.51), advanced adenoma detection rate, 92 in HBB vs. 95 in placebo group (OR = 0.95, CI = 0.70 - 1.30, P = 0.76), mean number of polyps detected (point estimate = 0.12, CI = 0.00 - 0.23, P = 0.05), adenomatous polyps (OR = 0.84, CI = 0.39 - 1.81, P = 0.65) and cecal intubation time (point estimate = 0.73, CI = -1.98 - 0.52, P = 0.25) between the two groups.

Conclusions

The use of HBB in patients undergoing colonoscopy does not appear to improve polyp or adenoma detection rates. It showed a non-significant trend of increased mean number of polyps detected with HBB.

Efficacy and tolerability of 2-L polyethylene glycol with ascorbic acid versus sodium picosulfate with magnesium citrate: a randomized controlled trial

BACKGROUND/AIM

Previous studies comparing 2-L polyethylene glycol (PEG)-based solution with ascorbic acid (PEG/Asc) with sodium picosulfate/magnesium citrate (SP/MC) drew inconclusive results. This study aimed to compare a 2-L-PEG/Asc with SP/MC by split method in bowel cleansing efficacy, tolerability, and safety and to identify factors influencing inadequate bowel preparation.

METHOD

We performed a prospective randomized, endoscopist-blinded, single-center, controlled trial. The Aronchick scale and Ottawa bowel preparation scale (OBPS) were used to evaluate the bowel cleansing efficacy, and patients' tolerability and preferences were assessed by questionnaire.

RESULTS

In total, 223 patients were randomized to receive 2-L-PEG/Asc (n = 109) or SP/MC (n = 114). There was no significant difference in overall bowel cleansing efficacy between the two groups; however, when analyzing by individual segment, mean bowel cleansing efficacy of right colon showed a trend in favor of SP/MC group than in PEG/Asc group (OBPS; 1.55 ± 0.66 vs. 1.74 ± 0.88, P = 0.08). Furthermore, SP/MC was better tolerated than PEG/Asc based on ease of consumption and preference to receive the agents again in the future. Total adverse events were significantly lower in SP/MC group than PEG/Asc group (47.4 vs. 62.4%, P = 0.031). In multivariate analysis, later colonoscopic starting time was the only independent factor predicting inadequate bowel preparation (OR 1.39, 95% CI 1.156-1.692, P = 0.001).

CONCLUSIONS

There was no significant difference in overall bowel cleansing efficacy between PEG/Asc and SP/MC; however, SP/MC showed better tolerability and safety profile than PEG/Asc. The independent factor for inadequate bowel preparation was later colonoscopic starting time when applied split method.

The optimal bowel preparation intervals before colonoscopy: A randomized study comparing polyethylene glycol and low-volume solutions

BACKGROUND & AIMS

The optimal duration of bowel preparation has only been assessed for polyethylene glycol (PEG). The aim of the study was to determine the intervals for achieving a satisfactory quality/tolerability of the preparation using PEG/ascorbic acid (PEGA) and sodium picosulphate/magnesium citrate (SPMC), and to compare them with 4L of PEG.

METHODS

A randomized, endoscopist-blinded, multicentre study. The 612 outpatients referred to a colonoscopy, were prepared using PEG, SPMC, PEGA. The quality, tolerability, duration of the preparation, and the interval from the end of the preparation to the colonoscopy was assessed.

RESULTS

Optimum duration of the preparation was similar for both PEG and SPMC (≥7.3 vs. ≥8.8 h, overall ≥8.4 h). Optimum interval to the colonoscopy was ≤11.8 h and did not differ between preparations (PEG, PEGA ≤ 11.8, SPMC ≤ 13.3 h). These times were the only predictors for a satisfactory preparation. The tolerability depends on the product type (SPMC) only. Timing of the preparation or the other factors had no impact on tolerability.

CONCLUSION

The optimum intervals for bowel preparation are identical for all preparations. Satisfactory preparation is achived at the preparation length ≥8.4 h and the time to colonoscopy ≤11.8 h.

Gastric Residual Volume after Split-Dose Bowel Preparation versus Conventional Single-Dose Regimen before Anesthetic Colonoscopy

The aim of this study was to compare gastric residual volume (GRV) in patients given a split-dose versus a conventional single-dose of polyethylene glycol (PEG) preparation before undergoing anesthetic colonoscopy. Methods. In a prospective observational study, we assessed GRV in outpatients undergoing same-day anesthetic gastroscopy and colonoscopy between October 8 and December 30 of 2016. Outpatients were assigned to the split-dose (1 L PEG in the prior evening and 1 L PEG 2-4 h before endoscopy) or single-dose (ingestion of 2 L PEG ≥ 6 h before endoscopy) regimen randomly. Bowel cleansing quality was assessed with the Boston Bowel Preparation Scale (BBPS). Results. The median GRV in the split-dose group (17 ml, with a range of 0-50 ml; N = 65) was significantly lower than that in the single-dose group (22 ml, with a range of 0-62 ml; N = 64; p = 0.005), with a better bowel cleansing quality (BBPS score 8.05 ± 0.82 versus 7.64 ± 1.21; p = 0.028). GRV was not associated with diabetes or the use of medications. Conclusions. GRV after a split-dose preparation and fasting for 2-4 hours is not larger than that after a conventional single-dose preparation and fasting for 6-8 hours. The data indicates that the split-dose bowel preparation might not increase the risk of aspiration.

Effects of polyethylene glycol 2 L alone or with ascorbic acid compared with polyethylene glycol 4 L alone for bowel preparation before colonoscopy: protocol for a systematic review and network meta-analysis

INTRODUCTION

Colonoscopy has been regarded as a standard method of detecting and removing gastrointestinal lesions early, while adequate bowel preparation is the prerequisite of determining the diagnostic accuracy and treatment safety of this process. Polyethylene glycol (PEG) based bowel preparation regimens remain the first recommendation, but the optimal option is still uncertain. The aim of this systematic review and network meta-analysis of randomised controlled trials (RCTs) is to determine the optimal PEG based bowel preparation regimen before colonoscopy.

METHODS AND ANALYSIS

We will assign two investigators to independently search all potential citations, screen records, abstract essential information and appraise the risk of bias accordingly. Then, random effects pairwise and network meta-analyses of RCTs comparing PEG 2 L alone or with ascorbic acid with PEG 4 L alone will be performed using RevMan 5.3 (Copenhagen, Denmark: The Nordic Cochrane Centre, The Cochrane Collaboration, 2013), Stata 14 (StataCorp, Texas, USA) and WinBUGS 1.4 (Imperial College School of Medicine, St Mary's, London, UK) from January 2000 to April 2017. The surface under the cumulative ranking curve will also be calculated in order to rank the regimens.

ETHICS AND DISSEMINATION

Ethics approval and patient written informed consent will not be required because all of the analyses in the present study will be performed based on data from published studies. We will submit our systematic review and network meta-analysis to a peer reviewed scientific journal for publication.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42017068957.

The Effectiveness of Personalized Bowel Preparation Using a Smartphone Camera Application: A Randomized Pilot Study

Background

We aimed to investigate the effectiveness of a smartphone application that analyzes and judges the optimal dosage of polyethylene glycol (PEG) for bowel preparation.

Methods

Patients were assigned to use the smartphone camera application (app group) or written instructions (non-app group). The smartphone camera application was programmed to analyze the bowel preparation quality and automatically determine the dosage of PEG from an analysis of stool images. In contrast, the non-app group consumed PEG solution according to the manual.

Results

The primary outcome was the quality of the bowel preparation based on blinded ratings using the Ottawa bowel preparation scale (OBPS). There was no statistically significant difference in the mean OBPS scores between the two groups (P = 0.950). However, the app group consumed a lower dose of PEG than the non-app group (mean dosage (mL): 3713.2 ± 405.8 versus 3979.2 ± 102.06, P = 0.001). The app group (5-point Likert scale; mean score 4.37 ± 0.895) had high acceptance of the application.

Conclusions

Although the app group consumed a lower PEG dose, the bowel preparation quality was similar in the two groups. Moreover, use of the smartphone camera application enhanced compliance with the bowel preparation.

White Diet with split-dose Picosalax is preferred, better tolerated, and non-inferior to day-before clear fluids with polyethylene glycol plus sodium picosulfate-magnesium citrate for morning colonoscopy: A randomized, non-inferiority trial

Background and Aim

Bowel preparations with polyethylene glycol (PEG) and clear fluids are often poorly tolerated. We compared an innovative low‐residue White Diet and low‐volume, split‐dose Picosalax with the standard preparation at our institution of day‐before clear fluids and combination PEG plus sodium picosulfate/magnesium citrate (SPMC).

Methods

Adults undergoing morning colonoscopy were randomized to either the White Diet and split‐dose, two sachets of Picosalax (WD/PICO) or day‐before clear fluids and 1‐L PEG plus two sachets of SPMC (CF/PEG + SPMC). The primary endpoint was successful bowel preparation defined by an Ottawa bowel preparation score ≤ 6. An intention‐to‐treat analysis with a predefined non‐inferiority margin of 15% was used to compare efficacy.

Results

A total of 250 patients were randomized (125 WD/PICO and 125 CF/PEG + SPMC). WD/PICO was non‐inferior to CF/PEG + SPMC for successful bowel preparation by intention‐to‐treat analysis (58% WD/PICO vs 62% CF/PEG + SPMC, 95%CI: −14.2 to 6.2%) and per‐protocol analysis (64% WD/PICO vs 65% CF/PEG + SPMC, 95%CI: −11.3 to 9.4%). Patients in the WD/PICO group reported greater satisfaction with the diet (P < 0.001), greater ease of following the diet (P < 0.001), and improved experience compared with prior colonoscopy (P < 0.0001), less bloating (P = 0.02), less weakness (P = 0.046), less hunger (P < 0.0001), and less interference with daily activities (P = 0.001). Procedure/withdrawal times and adenoma detection rates were similar between groups.

Conclusion

Bowel preparation with the White Diet and low‐volume, split‐dose Picosalax was preferred and better tolerated without detriment to bowel preparation success compared with clear fluids and combination PEG plus SPMC for morning colonoscopy.

Comparison of a split-dose bowel preparation with 2 liters of polyethylene glycol plus ascorbic acid and 1 liter of polyethylene glycol plus ascorbic acid and bisacodyl before colonoscopy

BACKGROUND AND AIMS

Recently, a low-volume polyethylene glycol formulation containing ascorbic acid (PEG-Asc) has proven as safe and effective as traditional 4-L PEG solutions for colonoscopy preparation. However, currently available aqueous purgative formulations are poorly tolerated. The aim of this study was to compare a split-dose 2-L PEG-Asc formulation and a 1-L PEG-Asc formulation with bisacodyl (10 mg) to determine the quality of bowel cleansing and patient tolerability.

METHODS

A single-center, randomized, observer-blinded study was performed between May 2015 and September 2015. Two hundred outpatients referred for colonoscopy were prospectively enrolled and assigned to either the split-dose 2-L PEG-Asc group or the 1-L PEG-Asc with bisacodyl 10-mg group. The Boston Bowel Preparation Scale (BBPS) and Aronchick Bowel Preparation Scale (ABPS) were used to evaluate bowel cleansing. The tolerability of the regimens and satisfaction of patients was determined based on a questionnaire.

RESULTS

Two hundred patients received either 2-L PEG-Asc or 1-L PEG-Asc with bisacodyl. Regarding colon cleansing outcome (BBPS and ABPS), the 1-L PEG-Asc with bisacodyl group showed similar but non-inferior results compared with the 2-L PEG-Asc group on both BBPS (6.92 ± 1.63 vs 6.57 ± 1.37; P = .103) and ABPS (96% vs 95%; P = 1.000) scales. Tolerability was similar for both 1-L PEG-Asc with bisacodyl and 2-L PEG-Asc.

CONCLUSIONS

1-L PEG-Asc is a suitable alternative to low-volume bowel preparation for colonoscopy. Our study showed that the 1-L PEG-Asc plus bisacodyl preparation has comparable tolerability and results in adequate colon cleansing. Bowel preparation with bisacodyl and 1-L PEG-Asc is a suitable alternative to low-volume bowel preparation for colonoscopy. (Clinical trial registration number: NCT02980562.).

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

Background/Aims

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

Methods

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

Results

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

Conclusions

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

Hyoscine butylbromide for colorectal polyp detection: prospective, randomized, placebo-controlled trial

OBJECTIVES:

The removal of pre-malignant colorectal lesions prevents cancer. Hyoscine has been proposed as a means of improving diagnosis by reducing colonic movements. The aim of this study was to analyze whether this anti-spasmodic enhances the detection of pre-malignant colorectal lesions.

METHODS:

In a randomized, double-blinded fashion patients received hyoscine or a saline solution in all consecutive colonoscopies in which the cecum was reached. Lesions were analysed with respect to number, size, location, histology and capillary pattern.

RESULTS:

A total of 440 colonoscopies were randomized. The overall polyp detection rate (PDR) and the adenoma detection rate (ADR) were 65.2% and 49.3%, respectively. In the hyoscine group, non-polypoid lesions were detected significantly more often (p=0.01). In the placebo group 281 lesions were diagnosed (202 adenomas) and in the hyoscine group 282 lesions were detected (189 adenomas) (p=0.23). The PDR and ADR were similar between the placebo and hyoscine groups (64% vs 66% and 50% vs 47%, respectively). No differences were observed between the two groups in the advanced-ADR or advanced neoplasia detection rate, as well the mean numbers of polyps, adenomas, advanced adenomas and advanced neoplasias detected per patient. The administration of hyoscine also did not improve the diagnostic accuracy of digital chromoendoscopy. The presence of adenomatous polyps in the right colon was detected significantly more frequently in the hyoscine group (OR 5.41 95% CI 2.7 - 11; p<0.01 vs OR 2.3 95% CI 1.1 - 4.6; p=0.02).

CONCLUSION:

The use of hyoscine before beginning the withdrawal of the colonoscope does not seem to enhance the PDR and the ADR.

Optimal intake of clear liquids during preparation for afternoon colonoscopy with low-volume polyethylene glycol plus ascorbic acid

BACKGROUND AND STUDY AIMS

The standard colonoscopy preparation regimen in Japan for afternoon procedures is sequential intake of 1 L of polyethylene glycol electrolyte lavage solution containing ascorbic acid (PEG-ASC), 0.5 L of clear liquid, 0.5 L of PEG-ASC, and finally 0.25 L of clear fluids (all at a rate of 0.25 L every 15 min). However, this regimen seems poorly tolerated and complicated for many patients compared to previous regimen of polyethylene glycol electrolyte lavage solution. The aim of this study was to evaluate an alternate regimen of 0.5 L of PEG-ASC followed by 0.25 L clear liquids, repeated 3 times.

PATIENTS AND METHODS

This was a single-blinded, non-inferiority, randomized controlled study. Subjects were randomized to the standard regimen or the alternate regimen using a web-based registry system. All patients were instructed to eat a pre-packaged, low residue diet and to take sodium picosulfate hydrate the day before colonoscopy. The Boston Bowel Preparation Scale was used to evaluate bowel cleansing, and a 3-point scale was used to assess mucosal visibility. The primary endpoint was successful bowel cleansing. The acceptability, tolerability, safety, and endoscopic findings of these two regimens were secondary endpoints.

RESULTS

 A total of 409 patients were randomized to either the standard regimen (n = 204, males 54.0 %, mean age 65.5 years) or the alternate regimen (n = 205, 54.6 %, 65.0 years). The rates of successful bowel cleansing were 71.1 % (64.3 - 77.2 %) with the standard regimen vs. 75.1 % (68.6 - 80.9 %) with the alternate regimen (95 % lower confidence limit, for the difference = - 4.6, non-inferiority P  < 0.05). No significant differences were found in tolerability, safety, and endoscopic findings.

CONCLUSION

 The alternate regimen and standard regimen are clinically equivalent with respect to cleansing efficacy and acceptability, tolerability, safety, and endoscopic findings. These results are good news for patients with difficulty drinking the first liter of PEG-ASC.

Comparison of Two Intensive Bowel Cleansing Regimens in Patients With Previous Poor Bowel Preparation: A Randomized Controlled Study

OBJECTIVES

Inadequate bowel cleansing is a major burden for endoscopy units. The aim of this study was to compare two intensive bowel cleansing regimens in patients with previous colonoscopy with inadequate bowel preparation.

METHODS

Patients with inadequate cleansing at index colonoscopy were randomized to 4-L split-dose polyethylene-glycol (PEG) regimen vs. 2-L split-dose PEG plus ascorbic acid (PEG+Asc) regimen. All individuals underwent a 3-day low-residue diet and received 10 mg of bisacodyl, the day before colonoscopy. Cleansing was considered to be adequate if the Boston Bowel Preparation Scale scored ≥2 at each colonic segment. A non-inferiority analysis was performed to demonstrate that colonic cleansing with 2-L PEG+Asc was not inferior to 4-l PEG, considering a non-inferiority margin of 10%.

RESULTS

Adequate bowel cleansing was significantly higher in patients assigned to 4-L PEG regimen (n=127) vs. those randomized to 2-L PEG+Asc regimen (n=129) by intention-to-treat analysis (81.1 vs. 67.4%, odds ratio (OR) 2.07, 95% confidence interval (CI) (1.163-3.689)) and by per-protocol analysis (86.6 vs. 71.7%, OR: 2.55, 95% CI: (1.316-4.922)). The study was terminated for futility after the interim analysis, because the 95% CI of the difference of proportions was 3.13-24.27% in the intention-to-treat analysis and 3.33-26.47% in the per-protocol analysis, confirming the superiority of 4-L PEG preparation.

CONCLUSIONS

After 3-day low-residue diet and oral bisacodyl before colonoscopy, colon cleansing with 4-L split-dose PEG was superior to 2-L split-dose PEG+Asc in patients with previous inadequate cleansing. (EUDRACT: 2013-002506-31, NCT02073552).

A low-volume polyethylene glycol solution was associated with an increased suboptimal bowel preparation rate but had similar recommendations for an early repeat colonoscopy, procedure times, and adenoma detection rates

Background/Aims

Low-volume polyethylene glycol (PEG) bowel preparations are better tolerated by patients than high-volume preparations and may achieve similar preparation quality. However, there is little data comparing their effects on a recommendation for an early repeat colonoscopy (because of a suboptimal preparation), procedure times, adenoma detection rate (ADR), and advanced adenoma detection rate (AADR).

Methods

This is a retrospective cohort study of outpatient colonoscopies performed during a one-year period at a single academic medical center in which low-volume MoviPrep^® (n = 1841) or high-volume Colyte^® (n = 1337) was used. All preparations were split-dosed. Appropriate covariates were included in regression models assessing suboptimal preparation quality (fair, poor, or inadequate), procedure times, recommendation for an early repeat colonoscopy, ADR, and AADR.

Results

MoviPrep^® was associated with an increase in having a suboptimal bowel preparation (OR 1.36; 95% CI: 1.06–1.76), but it was not associated with differences in insertion (p = 0.43), withdrawal (p = 0.22), or total procedure times (p = 0.10). The adjusted percentage with a suboptimal preparation was 11.7% for patients using MoviPrep^® and 8.8% for patients using Colyte^®. MoviPrep^® was not associated with a significant difference in overall ADR (OR 0.93; 95% CI: 0.78–1.11), AADR (OR 1.18; 95% CI: 0.87–1.62), or recommendation for early repeat colonoscopy (OR 1.16; 95% CI: 0.72–1.88).

Conclusions

MoviPrep^® was associated with a small absolute increase in having a suboptimal preparation, but did not affect recommendations for an early repeat colonoscopy, procedure times, or adenoma detection rates. Mechanisms to reduce financial barriers limiting low-volume preparations should be considered because of their favorable tolerability profile.

Feasibility and safety of bowel cleansing using low-volume polyethylene glycol with ascorbic acid before pediatric colonoscopy: A pilot study

BACKGROUND AND AIM

To assess the feasibility and safety of same-day regimen of low-volume polyethylene glycol solution with ascorbic acid for bowel cleansing before colonoscopy in children.

METHODS

Data on children who received polyethylene glycol solution with ascorbic acid for bowel cleansing in our department were retrospectively analyzed. On the day before the procedure, patients ate a low-residue diet and received sodium picosulfate in the evening. The following day, patients took polyethylene glycol solution with ascorbic acid in the morning; the procedure was carried out in the afternoon. Dosages of sodium picosulfate and polyethylene glycol solution with ascorbic acid were adjusted based on bodyweight. Bowel cleansing efficacy was rated on a scale of 1-5 by the colonoscopist.

RESULTS

Between July 2013 and November 2014, polyethylene glycol solution with ascorbic acid was used in 112 cases (96 patients; male : female 73:39; median age 10.9 years, range 4-19 years). Ninety-one cases (81%) were able to orally ingest the prescribed amount of polyethylene glycol solution with ascorbic acid. Satisfactory bowel cleansing (cleansing grade ≥3) was attained in 87% on intention-to-treat analysis and 85% on per-protocol analysis. Cleansing grade was significantly better in children who ingested polyethylene glycol solution with ascorbic acid within 60 min (P < 0.05). There were no serious adverse events.

CONCLUSION

Same-day regimen of polyethylene glycol solution with ascorbic acid is effective and safe for bowel cleansing in children.

Split-dose bowel preparation with polyethylene glycol for colonoscopy performed under propofol sedation. Is there an optimal timing?

OBJECTIVE

Aspiration risk, especially with propofol sedation, remains a concern after split-dose bowel preparation of up to 1 L polyethylene glycol for the procedure. We aimed to identify the ideal timing of bowel preparation to achieve optimal colon cleansing with no increased risk of aspiration.

METHODS

A total of 892 consecutive patients undergoing simultaneous esophagogastroduodenoscopy (EGD) and colonoscopy were prospectively recruited. Residual gastric volume (RGV) and pH of gastric contents were measured at EGD, and patients' characteristics, runway time (duration between completion of the final liter of bowel preparation and colonoscopy commencement), and cleansing quality were recorded.

RESULTS

A shorter runway time resulted in better colon cleansing (r = -0.124, P < 0.001). No correlation between runway time and RGV or pH was found (r = -0.017, P = 0.62 and r = -0.030, P = 0.47, respectively). RGV and pH did not differ significantly with runway time of 4 or 5 h. RGV with runway time ≤3 h was 35.9 ± 11.8 mL and 17.4 ± 0.6 mL after runway time >3 h (P < 0.001). No aspiration pneumonia occurred. The only factors independently related to higher RGV were younger age and male sex.

CONCLUSIONS

The consumption of bowel preparation agent within 3-4 h before propofol sedation resulted in a similar RGV and pH as those achieved by more prolonged fasting, with no increased risk of aspiration even in patients perceived to be at high risk.

Is a split-dose regimen of 2 L polyethylene glycol plus ascorbic acid tolerable for colonoscopy in an early morning visit to a comprehensive medical check-up?

AIM

To evaluate the effectiveness and tolerability of a split-dose 2 L polyethylene glycol (PEG)/ascorbic acid (AA) regimen for healthy examinees who visited for comprehensive medical check-up in the early morning.

METHODS

From February 2015 to March 2015, examinees of average risk who were scheduled for a colonoscopy in the morning were retrospectively enrolled.

RESULTS

The 189 examinees were divided into split-dose and non-split-dose groups. The adequacy of bowel preparation for the split-dose group vs the non-split-dose group was 96.8% vs 85.2%, respectively, P < 0.001, and the compliance of the last meal restriction was 74.6% vs 58.2%, respectively, P < 0.001. The sleep disturbance (P < 0.001) was more prevalent in the split-dose group, however the willingness to repeat the same preparation method (P = 0.243) was not different in both groups. The split-dose regimen was the most important factor influencing adequate bowel preparation in multivariate analysis (HR = 10.89, 95%CI: 6.53-18.17, P < 0.001).

CONCLUSION

A split-dose regimen of 2 L PEG/AA for an early morning colonoscopy was more effective and showed better compliance for diet restriction without any difference in satisfaction and discomfort. Introducing a split-dose regimen of 2 L PEG/AA to morning colonoscopy examinees is effective and tolerable in a comprehensive medical check-up setting.

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).

Differences between morning and afternoon colonoscopies for adenoma detection in female and male patients

BACKGROUND

Colonoscopies performed in the afternoon (PM) have been shown to have lower adenoma detection rates (ADR) compared to those in the morning (AM). Endoscopist fatigue has been suggested as a possible reason. Colonoscopies tend to be technically more challenging in female patients. Furthermore, women have a lower incidence of adenomas then men. The impact of the timing of colonoscopy based on sex has not been studied. We hypothesized that any decrease in ADR in PM colonoscopies would be more pronounced in female patients when compared to male patients.

METHODS

We retrospectively reviewed colonoscopies performed for screening or surveillance in our outpatient endoscopy center from January 2008 to December 2011. Complete colonoscopies with a documented cecal intubation were included. All patients with a history of colorectal cancer or colonic resection, inadequate bowel preparation, or incomplete data were excluded.

RESULTS

A total of 2305 patients (1207 female) were included. Overall, ADR was significantly higher in AM than in PM procedures. Multivariate analysis demonstrated that ADR for females was lower in PM than in AM colonoscopies (odds ratio [OR] 0.63, 95% confidence interval [CI] 0.44-0.91, P=0.015). There was a non-significant trend towards a lower ADR for males in PM (OR 0.84, 95% CI 0.62-1.15, P=0.28). Females had a prolonged intubation time and a longer procedure time.

CONCLUSION

The difference in ADR between AM and PM procedures seems to apply mainly to female patients. No significant change in ADR was noted in male patients in the afternoon.

Impact of Single- vs. Split-Dose Low-Volume Bowel Preparations on Bowel Movement Kinetics, Patient Inconvenience, and Polyp Detection: A Prospective Trial

OBJECTIVES

There are little data on bowel movement (BM) kinetics induced by bowel preparation. Whether single-dose (SID) or split-dose (SPD) regimens differ in terms of patient convenience is unclear. We compared BM kinetics, sleep and travel disruptions, and polyp detection rates in patients undergoing colonoscopy assigned to SID vs. SPDs.

METHODS

Patients were randomly assigned to 2-L SID or SPD (SPD1 and SPD2) bowel preparations. Surveys were completed querying the onset, duration, cessation, and intensity of BMs, along with sleep and travel disruption en route to the endoscopy center. Colon cleansing quality and polyp histology were recorded.

RESULTS

A total of 341 patients were enrolled, 51% in SPD and 49% in SID. Over half of patients had their first BM within 60 min of starting the preparation. After dosing, 92% of SID and 66% of SPD1 patients achieved clear effluent (P<0.001), whereas it was reported in 97% of SPD2 patients (P=0.028 vs. SID). Total duration (P=0.041) and intensity (P<0.001) of BMs were greater in SID. More patients in SID woke up for BMs (65.9 vs. 48.8%, P<0.003). No differences in the need to stop driving en route to colonoscopy were noted. Bowel prep quality was better in SPD (P<0.001). Although no difference in the adenoma detection rate was noted, the sessile-serrated polyp detection rate was greater in SPD than in SID (9.9 vs. 2.4%, P=0.004).

CONCLUSIONS

Our data demonstrate that SPD bowel preparation results in decreased intensity and duration of BMs, less patient inconvenience, improved bowel preparation, and increased sessile-serrated polyp detection rates.

Randomised clinical study comparing the effectiveness and physiological effects of hypertonic and isotonic polyethylene glycol solutions for bowel cleansing

Objectives

Bowel cleansing is necessary before colonoscopy, but is a burden to patients because of the long cleansing time and large dose volume. A low-volume (2 L) hypertonic polyethylene glycol-ascorbic acid solution (PEG-Asc) has been introduced, but its possible dehydration effects have not been quantitatively studied. We compared the efficacy and safety including the dehydration risk between hypertonic PEG-Asc and isotonic PEG regimens.

Design

This was an observer-blinded randomised study. Participants (n=310) were allocated to receive 1 of 3 regimens on the day of colonoscopy: PEG-Asc (1.5 L) and water (0.75 L) dosed with 1 split (PEG-Asc-S) or 4 splits (PEG-Asc-M), or PEG-electrolyte solution (PEG-ES; 2.25 L) dosed with no split. Dehydration was analysed by measuring haematocrit (Ht).

Results

The cleansing time using the hypertonic PEG-Asc-S (3.33±0.48 hours) was significantly longer than that with isotonic PEG-ES (3.05±0.56 hours; p<0.001). PEG-Asc-M (3.00±0.53 hours) did not have this same disadvantage. Successful cleansing was achieved in more than 94% of participants using each of the 3 regimens. The percentage changes in Ht from baseline (before dosing) to the end of dosing with PEG-Asc-S (3.53±3.32%) and PEG-Asc-M (4.11±3.07%) were significantly greater than that with PEG-ES (1.31±3.01%).

Conclusions

These 3 lower volume regimens were efficacious and had no serious adverse effects. Even patients cleansed with isotonic PEG-ES showed significant physiological dehydration at the end of dosing. The four-split PEG-Asc-M regimen is recommended because of its shorter cleansing time without causing serious nausea.

Trial registration number

UMIN000013103; Results.

Medicare Under Age 65 and Medicaid Patients Have Poorer Bowel Preparations: Implications for Recommendations for an Early Repeat Colonoscopy

Background/Aims

Colonoscopy is performed on patients across a broad spectrum of demographic characteristics. These characteristics may aggregate by patient insurance provider and influence bowel preparation quality and the prevalence of adenomas. The purpose of this study was to evaluate the association of insurance status and suboptimal bowel preparation, recommendation for an early repeat colonoscopy due to suboptimal bowel preparation, adenoma detection rate (ADR), and advanced ADR (AADR).

Methods

This is a cohort study of outpatient colonoscopies (n = 3113) at a single academic medical center. Patient insurance status was categorized into five groups: 1) Medicare < 65y; 2) Medicare ≥ 65y; 3) Tricare/VA; 4) Medicaid/Colorado Indigent Care Program (CICP); and 5) commercial insurance. We used multivariable logistic or linear regression modeling to estimate the risks for the association between patient insurance and suboptimal bowel preparation, recommendation for an early repeat colonoscopy due to suboptimal bowel preparation, ADR, and AADR. Models were adjusted for appropriate covariates.

Results

Medicare patients < 65y (OR 4.91; 95% CI: 3.25–7.43) and Medicaid/CICP patients (OR 4.23; 95% CI: 2.65–7.65) were more likely to have a suboptimal preparation compared to commercial insurance patients. Medicare patients < 65y (OR 5.58; 95% CI: 2.85–10.92) and Medicaid/CICP patients (OR 3.64; CI: 1.60–8.28) were more likely to receive a recommendation for an early repeat colonoscopy compared to commercial insurance patients. Medicare patients < 65y had a significantly higher adjusted ADR (OR 1.50; 95% CI: 1.03–2.18) and adjusted AADR (OR 1.99; 95% CI: 1.15–3.44) compared to commercial insurance patients.

Conclusions

Understanding the reasons for the higher rate of a suboptimal bowel preparation in Medicare < 65y and Medicaid/CICP patients and reducing this rate is critical to improving colonoscopy outcomes and reducing healthcare costs in these populations.

Split-dose sodium picosulfate-magnesium citrate colonoscopy preparation achieves lower residual gastric volume with higher cleansing effectiveness than a previous-day regimen

BACKGROUND AND AIMS

It is known that sodium picosulfate-magnesium citrate (SPMC) bowel preparations are effective, well tolerated and safe, and that split-dosing is more effective for colon cleansing than previous-day regimens. Anesthetic guidelines consider that residual gastric fluid is independent of clear liquid fasting times. However, reluctance to use split-dosing persists. This may be due to limited data on residual gastric fluid volumes (RGFVs) and split-dosing bowel preparations, and that these may not be perceived as standard clear liquids. Furthermore, no studies are available on RGFV/residual gastric fluid pH (RGFpH) and SPMC. We aimed to evaluate the cleansing effectiveness and the RGFV/RGFpH achieved after an SPMC split-dosing regimen compared with a SPMC previous-day regimen.

METHODS

This was a single-center observational study. A total of 328 outpatients scheduled for simultaneous EGD and colonoscopy and following a split-dosing or previous-day regimen of SPMC were included. We prospectively measured colon cleanliness by using the Ottawa Bowel Preparation Scale, RGFV, and RGFpH.

RESULTS

Ottawa Bowel Preparation Scale scores for overall, right, mid-colon, and colon fluid were significantly better in the split-dosing group. In the split-dosing group, the 3- to 4-hour fasting time consistently achieved the best cleansing quality. RGFV was significantly lower in the split-dosing group (11.09 vs 18.62, P < .001). No significant differences in RGFpH were detected.

CONCLUSIONS

Split-dosing SPMC provides higher colon cleansing quality with lower RGFVs than previous-day SPMC regimens. SPMC in split-dosing acts exactly as a standard clear liquid acts, and thus anesthetic guidelines on this issue may be applied with no concerns.

Does Polyethylene Glycol (PEG) Plus Ascorbic Acid Induce More Mucosal Injuries than Split-Dose 4-L PEG during Bowel Preparation?

BACKGROUND/AIMS

The aims of this study were to compare the bowel-cleansing efficacy, patient affinity for the preparation solution, and mucosal injury between a split dose of polyethylene glycol (SD-PEG) and low-volume PEG plus ascorbic acid (LV-PEG+Asc) in outpatient scheduled colonoscopies.

METHODS

Of the 319 patients, 160 were enrolled for SDPEG, and 159 for LV-PEG+Asc. The bowel-cleansing efficacy was rated according to the Ottawa bowel preparation scale. Patient affinity for the preparation solution was assessed using a questionnaire. All mucosal injuries observed during colonoscopy were biopsied and histopathologically reviewed.

RESULTS

There was no significant difference in bowel cleansing between the groups. The LV-PEG+Asc group reported better patient acceptance and preference. There were no significant differences in the incidence or characteristics of the mucosal injuries between the two groups.

CONCLUSIONS

Compared with SD-PEG, LV-PEG+Asc exhibited equivalent bowel-cleansing efficacy and resulted in improved patient acceptance and preference. There was no significant difference in mucosal injury between SD-PEG and LV-PEG+Asc. Thus, the LV-PEG+Asc preparation could be used more effectively and easily for routine colonoscopies without risking significant mucosal injury.