The optimum bowel preparation for flexible sigmoidoscopy

Effect of WeChat Messaging on Improving the Quality of Bowel Preparation for Outpatient Colonoscopy: A Randomized Controlled Study

With the most active users of any social media platform in China, WeChat has become the preferred platform for public announcements and is widely used in the fields of medicine and nursing (Hong, Zhou, Fang, & Shi, 2017; Zeng, Deng, Wang, & Liu, 2016). The aim of this study was to evaluate the effect of WeChat messaging on bowel preparation for outpatient colonoscopy. A total of 150 outpatients scheduled for colonoscopy in a Grade III level A hospital were randomly assigned to the experimental group (n = 73) or the control group (n = 72). Both groups received routine guidance from the day of the scheduling appointment through the day of colonoscopy. In addition, the experimental group received colonoscopy-related information and individualized guidance daily through WeChat from the day of the appointment. After the colonoscopy, the diet and medication compliance, satisfaction, anxiety, and bowel cleanliness were compared. Post-intervention, there were significant differences in bowel cleanliness, satisfaction, diet and medication compliance, and anxiety between the two groups. WeChat messaging can help improve diet and medication compliance, patient satisfaction, and the success rate and thoroughness of colonoscopy, as well as alleviate the anxiety of patients scheduled for outpatient colonoscopy.

Clinical trial: free fatty acid suppositories compared with enema as bowel preparation for flexible sigmoidoscopy

OBJECTIVES

The purpose of this trial was to evaluate the efficacy and safety of recently developed suppositories containing free fatty acids as a bowel-cleansing agent prior to flexible sigmoidoscopy and compare them with Klyx (docusate sodium/sorbitol).

DESIGN

A controlled, non-inferiority, single-blind, randomised study on outpatients undergoing flexible sigmoidoscopy.

SETTING

Department of Gastroenterology, Landspitali-University Hospital and endoscopic clinic.

PATIENTS

53 outpatients undergoing flexible sigmoidoscopy.

INTERVENTION

Participants were randomised to receive either free fatty acid suppositories (28) or a standard bowel preparation with Klyx enema (25). In the study group, two suppositories were administered the evening before as well as 2 h prior to the sigmoidoscopy. In the control group, Klyx enema (120 mL) was administered the evening before and repeated 2 h prior to the procedure.

MAIN OUTCOME MEASUREMENTS

Quality of the bowel cleansing, height of scope insertion and safety.

RESULTS

The mean height of scope insertion and bowel cleansing was 43 cm (SD=13.4) in the study group and 48 cm (SD=10.4) in the control group (NS). The investigating physicians were less satisfied with the bowel preparation in the study group compared with the control group with a difference of 20% (p<0.016). The amount of faeces noted in the rectum was similar in both groups with no significant difference (p<0.56). No serious side effects, toxic reaction or irritation were observed.

CONCLUSIONS

The suppositories are well tolerated with no significant side effects. The suppositories had distinct bowel emptying effect and as effective as Klyx in rectal cleansing. Although physician's satisfaction was slightly lower, the height of scope insertion was similar.

TRIAL REGISTRATION NUMBER

EudraCT nr.: 2010-018761-35.

Hyponatremia and sodium picosulfate bowel preparations in older adults

OBJECTIVES

Bowel preparations are commonly prescribed drugs. Case reports and our clinical experience suggest that sodium picosulfate bowel preparations can precipitate severe hyponatremia in some older adults. At present, this risk is poorly quantified. We investigated the association between sodium picosulfate use and the risk of hyponatremia in older adults.

METHODS

We conducted a population-based retrospective cohort study using six linked administrative databases in Ontario, Canada. All Ontario residents over the age of 65 years who filled an outpatient bowel preparation prescription before colonoscopy were eligible. We enrolled new users of either sodium picosulfate (n=99,237) or polyethylene glycol (n=48,595). The primary outcome was hospitalization with hyponatremia within 30 days of the bowel preparation assessed by database codes. The secondary outcomes were hospitalization with urgent head computed tomography (CT) (a proxy for acute central nervous system disturbance) and all-cause mortality.

RESULTS

The baseline characteristics of the two groups, including patient demographics, comorbid conditions, and concomitant medications, were nearly identical. Compared with polyethylene glycol, sodium picosulfate was associated with a higher risk of hospitalization with hyponatremia (absolute risk increase: 0.05%, 95% confidence interval (CI): 0.04-0.06%, relative risk (RR): 2.4, 95% CI: 1.5-3.9), but not hospitalization with urgent CT head (RR: 1.1, 95% CI: 0.7-1.4) or mortality (RR: 0.9, 95% CI: 0.7-1.3).

CONCLUSIONS

Sodium picosulfate bowel preparations lead to more hyponatremia than polyethylene glycol. There was no evidence of increased risk of acute neurologic symptoms or mortality. The absolute increase in risk of hospitalization with hyponatremia remains low but may be avoidable through appropriate fluid intake or preferential use of polyethylene glycol in some older adults.

A prospective randomized single blind trial of Fleet phosphate enema versus glycerin suppositories as preparation for flexible sigmoidoscopy

AIM

This study compared the efficacy and patient acceptability of two methods of bowel preparation for flexible sigmoidoscopy.

METHODS

Patients attending for outpatient flexible sigmoidoscopy were prospectively randomized to receive one Fleet ready-to-use enema or 2 x 4 g glycerin suppositories, 2 h preprocedure. Patient and endoscopist questionnaires were used to compare the outcomes.

RESULTS

From November 2000 to August 2001, 203 (male = 95; female = 108) patients were randomized. Patient data available for 163 patients (enema = 93; suppository = 70) revealed: ease of use (enema = 52; suppository = 25; P < 0.02, Fisher's exact); assistance required (enema = 19; suppository = 3; P < 0.005, Fisher's exact); grade of effectiveness (enema = 83; suppository = 44; P < 0.0001, Fisher's exact), and whether patients wished to try another preparation in future (enema = 16; suppository = 24; P = 0.016, Fisher's exact). Endoscopist data available for 151 patients (enema = 76; suppository = 75) revealed: average depth of insertion (enema = 53.6 +/- 11.6 cm; suppository 46.3 +/- 13.7 cm; P < 0.001, Student's t test); acceptable (excellent + good) quality of preparation [enema = 60 (78.9%); suppository = 34 (45.3%); P < 0.0001, Fisher's exact].

CONCLUSION

Bowel preparation for flexible sigmoidoscopy using a single Fleet enema is acceptable to patients and more effective than glycerin suppositories.

Sodium picosulfate/magnesium citrate: a review of its use as a colorectal cleanser

Oral sodium picosulfate/magnesium citrate (CitraFleet; Picolax), consisting of sodium picosulfate (a stimulant laxative) and magnesium citrate (an osmotic laxative), is approved for use in adults (CitraFleet; Picolax) and/or adolescents and children (Picolax) as a colorectal cleansing agent prior to any diagnostic procedure (e.g. colonoscopy or x-ray examination) requiring a clean bowel and/or surgery. It is dispensed in powder form (sodium picosulfate 0.01 g, magnesium oxide 3.5 g, citric acid 12.0 g per sachet), with the magnesium oxide and citric acid components forming magnesium citrate when the powder is dissolved in water. In adult patients, two sachets of sodium picosulfate/magnesium citrate was at least as effective and well tolerated as oral magnesium citrate 17.7 or 35.4 g, or oral polyethylene glycol 236 g in adult patients undergoing a double-contrast barium enema procedure in three large, randomized, comparative clinical studies. In contrast, sodium picosulfate/magnesium citrate was less effective than a sodium phosphate enema preparation in two studies in patients undergoing flexible sigmoidoscopy. A similar number of patients receiving two sachets of sodium picosulfate/magnesium citrate or two 45 mL doses of oral sodium phosphate the day before a double-contrast barium enema procedure achieved satisfactory barium coating and none/minimal faecal residue in one study. However, the data from three of these studies should be interpreted with caution because the administrative regimens used differed from that recommended. Sodium picosulfate/magnesium citrate is also an effective and generally well tolerated colorectal cleansing agent in children and adolescents; the preparation was more effective than oral bisacodyl 0.01 or 0.02 g plus a sodium phosphate enema preparation in this population. Further research is thus required to accurately position sodium picosulfate/magnesium citrate and fully establish its efficacy and tolerability prior to various exploratory or surgical procedures. Nevertheless, oral sodium picosulfate/magnesium citrate provides a useful option in the preparation of the colon and rectum in adults, adolescents and children undergoing any diagnostic procedure (e.g. colonoscopy or x-ray examination) requiring a clean bowel and/or surgery. Oral sodium picosulfate/magnesium citrate acts locally in the colon as both a stimulant laxative, by increasing the frequency and the force of peristalsis (sodium picosulfate component), and an osmotic laxative, by retaining fluids in the colon (magnesium citrate component), to clear the colon and rectum of faecal contents. It is not absorbed in any detectable quantities. Sodium picosulfate is a prodrug: it is hydrolyzed by bacteria in the colon to the active metabolite 4,4'-dihydroxydiphenyl-(2-pyridyl)methane. Sodium picosulfate/magnesium citrate may be associated with a dehydrating effect, as evidenced by a reduction in bodyweight and increased haemoglobin levels; some at-risk patients may experience postural hypotension and older patients may require additional electrolytes. In three large (n >100), randomized, single-blind clinical studies, two sachets of oral sodium picosulfate/magnesium citrate was at least as effective as oral magnesium citrate 17.7 or 35.4 g, or oral polyethylene glycol 236 g as a colorectal cleansing agent in adult patients undergoing a double-contrast barium enema procedure. In contrast, sodium picosulfate/magnesium citrate was less effective than a sodium phosphate enema preparation in two studies in patients undergoing flexible sigmoidoscopy. A similar number of patients receiving two sachets of sodium picosulfate/magnesium citrate or two 45 mL doses of oral sodium phosphate the day before a double-contrast barium enema procedure achieved satisfactory barium coating and none/minimal faecal residue in one study. However, the data from three of these studies should be interpreted with caution because the administrative regimens used differed from that recommended. In children and adolescents, sodium picosulfate/magnesium citrate was significantly more effective as a colorectal cleansing agent than oral bisacodyl 0.01 or 0.02 g plus a sodium phosphate enema preparation in a randomized, single-blind study; dosages were adjusted for age in this study. Oral sodium picosulfate/magnesium citrate is generally well tolerated in adult patients undergoing various investigational colorectal procedures. Adverse events were generally mild to moderate in intensity and mainly gastrointestinal in nature (e.g. abdominal cramps/pain, nausea); other common treatment-emergent adverse events included disturbance of daily activity, headache and sleep disturbance. This combination is at least as well tolerated as oral sodium phosphate or oral polyethylene glycol, with moderate/severe nausea and vomiting occurring less frequently in sodium picosulfate/magnesium citrate recipients than in those receiving oral sodium phosphate, and abdominal bloating/pain and nausea developing less often with sodium picosulfate/magnesium citrate than polyethylene glycol therapy. The incidence of abdominal pain and sleep disturbance in sodium picosulfate/magnesium citrate versus oral magnesium citrate recipients was similar in one study, but significantly lower with sodium picosulfate/magnesium citrate in another. While the incidence of most adverse events was similar in recipients of sodium picosulfate/magnesium citrate and a sodium phosphate enema preparation, more patients receiving sodium picosulfate/magnesium citrate reported moderate/severe flatulence, incontinence and sleep disturbance, and more patients receiving the enema preparation reported rectal soreness. The tolerability profile of sodium picosulfate/magnesium citrate in patients aged >70 years is reportedly similar to that in patients aged <70 years. Abdominal pain also occurred less frequently with sodium picosulfate/magnesium citrate than with oral bisacodyl plus a sodium phosphate enema preparation in children and adolescents.

A prospective randomized single-blind comparison of three methods of bowel preparation for outpatient flexible sigmoidoscopy

BACKGROUND

Preparation for outpatient flexible sigmoidoscopy using a self-administered phosphate enema is the standard practice in our unit, but it provides acceptable bowel preparation in only 80% of patients. This study compared two methods of bowel preparation with the current standard in an attempt to improve efficacy and acceptability.

METHODS

From January to September 2003, patients scheduled for out-patient flexible sigmoidoscopy were prospectively randomized to 3 groups: group 1: one Fleet enema 2 h pre-procedure; group 2: two Fleet enemas, one on the evening prior to sigmoidoscopy and one 2 h pre-procedure; group 3: lactulose 30 ml orally 48 and 24 h prior to sigmoidoscopy, plus a single Fleet enema 2 h pre-procedure. A patient questionnaire was used to assess side effects and tolerance. The endoscopists questionnaire assessed the indication for the procedure, quality of preparation, depth of insertion, and pathological findings identified. Power calculations were based on the 80% acceptable preparation rate obtained using a single enema.

RESULTS

For this study, 305 patients were randomized to the three groups. Patient data were available for 261 patients (group 1 = 105; group 2 = 81; group 3 = 75), and endoscopist data were available for 251 patients (group 1 = 97; group 2 = 79; group 3 = 75). No difference was noted between the groups with regard to age, gender, procedure indication, grade of endoscopist, or patient acceptability variables (ease of use: p = 0.09; assistance required: p = 0.11; cramps experienced: p = 0.84; alternative method: p = 0.25). There was no significant difference between the groups in terms of depth of insertion (p = 0.42-chi-squared test) or abnormalities noted (p = 0.34-chi-squared test). Nor was there any difference in the quality of preparation of patients in group 1 versus group 2 (p = 0.39-Fishers exact test) or group 1 versus group 3 (p = 0.13-Fishers exact). However, lactulose + Fleet resulted in significantly fewer patients with acceptable preparation compared with those who administered two Fleet enemas (p = 0.02- Fishers exact test).

CONCLUSIONS

The addition of a Fleet enema or oral lactulose over and above a single Fleet enema gives no significant improvement in the acceptability or efficacy of bowel preparation.

Evaluating the evidence for administering phosphate enemas

This article analyses the existing evidence surrounding the use of phosphate enemas in practice. Phosphate enemas are routinely used in a variety of clinical areas to relieve constipation or as a diagnostic bowel preparation. Yet, there is increasing uncertainty about both the medication's clinical effectiveness and its safety. There is limited evidence to suggest the product is more effective than other medications in the management of chronic constipation. However, phosphate enemas are an effective preparation for some diagnostic bowel investigations. There are also a variety of infrequently seen, but detrimental, complications specifically associated with the administration of phosphate enemas. The administration of phosphate enemas should be avoided if clients have certain underlying conditions.

Achieving quality in flexible sigmoidoscopy screening for colorectal cancer

BACKGROUND

Sigmoidoscopy screening, which can dramatically reduce colorectal cancer mortality, is supported increasingly by physicians and payers, and is likely to be performed more frequently in the future. As more physicians and nonphysician medical personnel learn how to perform this procedure, and with attention to quality standards, the overall impact of sigmoidoscopy screening may improve. This review describes elements that characterize high-quality examinations and identifies resources for in-depth information on performing flexible sigmoidoscopy.

METHODS

The domains of quality were identified from textbooks, articles, and the professional opinions of gastroenterologists and primary care physicians. Information was obtained from MEDLINE, bibliographies in recent articles, medical professional organizations, equipment manufacturers' representatives, and focus groups of primary care physicians.

RESULTS

Nine domains of quality are identified and discussed: training, logistical start-up, patient interaction, bowel preparation, examination technique, lesion recognition, complications, reporting, and processing (equipment cleaning and disinfection).

CONCLUSIONS

Persons learning how to perform and to implement flexible sigmoidoscopy may use this information to help ensure the quality of screening examinations.

CT colonography: data acquisition and patient preparation techniques

The success of a virtual endoscopy is essentially dependent on the image quality of the corresponding 3-dimensional reconstructions. Before loading image data on a post-processing computer, certain prerequisites concerning the source data must be met. To carry out a CT colonography, the source data must be of good quality. High spatial resolution in all geometrical directions, continuous data acquisition without gaps, and artefact-free images are pivotal factors influencing source data. A generally applicable rule is that the size of the smallest detectable polyp is limited by the nominal slice thickness, emphasizing the ultimate importance of the initially chosen primary slice collimation. Furthermore, calculation of an endoluminal view is impossible without sufficient distension of the bowels. Thorough patient preparation that accommodates the technical circumstances for post-processing is also required for attaining a high sensitivity in polyp detection.

Flexible sigmoidoscopy by nurses: state of the art 1999

Although screening flexible sigmoidoscopy is associated with a significant decrease in colorectal cancer mortality, less than 50% of eligible Americans have had a sigmoidoscopy. As the United States population ages, over 50 million Americans will be eligible for colorectal cancer screening with flexible sigmoidoscopy. The projected increase in a population eligible for screening is expected to increase demand for this procedure and may result in overwhelming currently available endoscopic resources. Gastroenterology nurses should actively seek training to perform flexible sigmoidoscopy to accommodate this increased demand. Current barriers to nurse-performed sigmoidoscopy are prohibitions by state Boards of Nursing and lack of procedural reimbursement for nurse endoscopists performing flexible sigmoidoscopy. The lack of research about the effectiveness of this practice is a contributing factor to the hindrances in the development of this nursing role. This review outlines research about the effectiveness of flexible sigmoidoscopy by nurses, legal and reimbursement issues, and details the scope of training programs used by institutions with nurse endoscopists.

Flexible sigmoidoscopy by paramedical personnel

Screening sigmoidoscopy is associated with a 45% to 80% reduction in colorectal cancer mortality. Although less than 50% of eligible Americans have been screened with flexible sigmoidoscopy (FS), the use of this procedure is rising rapidly. By the year 2000, as many as 10 million screening FS per year could be performed. To accommodate the increased demand, many medical centers have trained paramedical personnel (i.e. physician assistants, nurses, and gastroenterology technicians) to perform FS. However, as a result of the paucity of research about this practice, only physicians receive a professional fee for performing screening FS. Many state Boards of Nursing explicitly prohibit registered nurses (RNs) from performing this procedure. This review outlines research about the effectiveness of paramedical endoscopists, medico-legal and reimbursement issues, and outlines a training program in FS for paramedical personnel.