Split-dosed MiraLAX/Gatorade is an effective, safe, and tolerable option for bowel preparation in low-risk patients: a randomized controlled study

Dried lemon slices improve bowel cleansing quality of polyethylene glycol for colonoscopy preparation: randomized controlled trial

BACKGROUND

adequate bowel preparation is related to the quality of colonoscopy. Dried lemon slices can increase gastrointestinal peristalsis, which has shown potential as an adjuvant of bowel preparation. We hypothesized that the combination of dried lemon slices and polyethylene glycol (PEG) could improve the efficacy of bowel preparation and be more acceptable to participants.

AIM

to investigate the effectiveness of lemon slices combined with PEG for colonoscopy preparation.

METHODS

a prospective, single-center, randomized, controlled trial was performed of 521 patients randomly assigned to two groups. A total of 254 patients were given lemon slices based on conventional 4-L PEG treatment for the bowel, while 267 patients received only 4-L PEG treatment. Patients' basic information, procedure-related parameters, adverse effects, and subjective feelings were collected by questionnaires. Intestinal tract cleanliness was scored according to the Boston Bowel Preparation Scale (BBPS) by experienced endoscopists. Data were analyzed by the two-sample t-test or the Chi-squared test.

RESULTS

the BBPS scores were significantly higher in the PEG + lemon slice group (p < 0.05). The taste acceptability, satisfaction, and willingness to repeat bowel preparation were significantly higher in the PEG+ lemon slice group (p < 0.05). However, a larger proportion of patients from the PEG+ lemon slice group (30.7 %) suffered abdominal distension compared with the PEG group (20.6 %), while the incidence of other adverse effects was comparable between the two groups.

CONCLUSION

the addition of dried lemon slices to conventional PEG showed its superiority for bowel preparation.

Gut microbiota in children with split-dose bowel preparations revealed by metagenomics

Objective

Split-dose polyethylene glycol (PEG) is routinely used for bowel preparation before colonoscopy. This study aimed to investigate the composition of gut microbiota and its functions in pediatric patients undergoing split-dose PEG bowel preparation for colonoscopy to understand the stability and resilience of gut microbiota.

Material and methods

From September to December 2021, 19 pediatric patients were enrolled at Shenzhen Children's Hospital and 76 samples (4 time points) were analyzed using metagenomics. Time points included Time_1 (one day before bowel preparation), Time_2 (one day after colonoscopy), Time_3 (two weeks after bowel preparation), and Time_4 (four weeks after bowel preparation).

Result

Alpha diversity comparison at both the species and gene levels showed a decrease in community richness after colonoscopy, with little statistical significance. However, the Shannon diversity index significantly decreased (P<0.05) and gradually returned to pre-preparation levels at two weeks after bowel preparation. The genus level analysis showed six genera (Eubacterium, Escherichia, Intertinibacter, Veillonella, Ruminococcaceae unclassified, and Coprobacillus) significantly different across the four time periods. Additionally, at the species level, the abundance of Escherichia coli, Bacteroides fragilis, and Veillonella parvula significantly increased at one day after colonoscopy before gradually decreasing at two weeks after bowel preparation. In contrast, the abundance of Intertinibacter bartlettii decreased at one day after colonoscopy but then recovered at two weeks after bowel preparation, reaching the preoperative level at four weeks after bowel preparation. Furthermore, five functional pathways (base excision repair, biosynthesis of ansamycins, biosynthesis of siderophore group nonribosomal peptide, flavonoid biosynthesis, and biosynthesis of type II polyketide products) were significantly different across the four time periods, with recovery at two weeks after bowel preparation and reaching preoperative levels at four weeks after bowel preparation.

Conclusions

Gut microbiota at the genus level, species level, and functional pathways are impacted in pediatric patients undergoing split-dose PEG bowel preparation and colonoscopy, with recovery two weeks following bowel preparation. However, the phylum level was not impacted. Modifications in gut microbiota composition and function may be investigated in future studies of bowel preparation. This study highlights the stability and resilience of gut microbiota among pediatric patients during bowel preparation.

2021 Patient Perceptions Regarding Colonoscopy Experience

GOAL

We sought to document patient perceptions in 2021 regarding colonoscopy experience and potential deterrents to repeat colonoscopy.

BACKGROUND AND AIM

Bowel preparation has been previously considered by patients to be the worst part of a colonoscopy.

MATERIALS AND METHODS

We conducted a prospective survey of consecutive patients age 18 years and older who had just completed colonoscopy at 2 outpatient endoscopy centers at a tertiary academic hospital. The short survey was conducted in the recovery area. The main outcome measure was patient perceptions of the worst part of their colonoscopy experience and which factor would most deter them from a future colonoscopy.

RESULTS

Four hundred patients completed the survey of 405 approached. Average patient age was 64 years, and 48% were women. Seventy-five percent of patients used low-volume preparations. Bowel preparation was considered the worst part of colonoscopy by 71% of patients. Women were more likely to choose laxatives as the worst part of a colonoscopy. Bowel preparation was chosen most often (55%) as the most likely deterrent to a future colonoscopy. There were minimal differences in responses between those receiving low-volume versus high-volume (4 L) preparations.

CONCLUSION

Bowel preparation remains the worst part of the colonoscopy experience for patients, and the most likely deterrent to future colonoscopy.

The efficacy and tolerability of sports drink versus water in bowel preparations: a randomised controlled study

Background

An optimal bowel preparation can result in an improved colonoscopy. This study was to compare the effectiveness and safety of the use of a sports drink (Mizone) plus polyethylene glycol (PEG) solution with a water plus PEG solution in bowel preparations.

Methods

This was a randomised controlled study. All of the included patients were randomly divided into the following two groups: the PEG + Mizone group and the PEG + water group. The palatability of the solution was measured through the use of questionnaires. Additionally, bowel cleanliness was evaluated according to the Ottawa Bowel Preparation Scale (OBPS, 0–14, with higher values indicating worse cleanliness), as well as with the aid of colonoscopy videos.

Results

A total of 270 patients were enrolled. The rate of adequate bowel preparation was 74.8% in the PEG + Mizone group and 68.9% in the PEG + water group, with a risk difference of 5.9% (95% CI: − 4.8–16.6%), which indicated noninferiority (noninferiority margin: − 9.5% <  − 4.8%). However, patients rated the palatability (65.9% vs 44.4%, P < 0.001) and willingness to recommend or repeat (88.9% vs 75.6%, P = 0.004) the administration of the PEG + Mizone preparation as being better than those of the PEG + water preparation. The rates of adverse events during the bowel preparations were not significantly different between the two groups, except for bloating (PEG + Mizone vs PEG + water, 4.4% vs 13.3%, P = 0.010).

Conclusion

The concomitant use of PEG + Mizone was a well tolerated and effective bowel preparation, compared with the PEG + water treatment.

Trial registration

ClinicalTrials.gov NCT04247386. Registered on 30 Jan 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06658-2.

Surveillance of Colorectal Cancer (CRC) in Cystic Fibrosis (CF) Patients

Cystic Fibrosis (CF) is the commonest inherited genetic disorder in Caucasians due to a mutation in the gene CFTR (Cystic Fibrosis Transmembrane Conductance Regulator), and it should be considered as an Inherited Colorectal Cancer (CRC) Syndrome. In the United States, physicians of CF Foundation established the “Developing Innovative Gastroenterology Speciality Training Program” to increase the research on CF in gastrointestinal and hepatobiliary diseases. The risk to develop a CRC is 5–10 times higher in CF patients than in the general population and even greater in CF patients receiving immunosuppressive therapy due to organ transplantation (30-fold increased risk relative to the general population). Colonoscopy should be considered the best screening for CRC in CF patients. The screening colonoscopy should be started at the age of 40 in CF patients and, if negative, a new colonoscopy should be performed every 5 years and every 3 years if adenomas are detected. For transplanted CF patients, the screening colonoscopy could be started at the age of 35, in transplanted patients at the age of 30 and, if before, at the age of 30. CF transplanted patients, between the age of 35 and 55, must repeat colonoscopy every 3 years. Our review draws attention towards the clinically relevant development of CRC in CF patients, and it may pave the way for further screenings and studies.

Can adjuncts to bowel preparation for colonoscopy improve patient experience and result in superior bowel cleanliness? A systematic review and meta-analysis

BACKGROUND

Bowel preparation for colonoscopy is often poorly tolerated due to poor palatability and adverse effects. This can negatively impact on the patient experience and on the quality of bowel preparation. This systematic review and meta-analysis was carried out to assess whether adjuncts to bowel preparation affected palatability, tolerability and quality of bowel preparation (bowel cleanliness).

METHODS

A systematic search strategy was conducted on PubMed, MEDLINE, EMBASE and the Cochrane Database of Systematic Reviews to identify studies evaluating adjunct use for colonoscopic bowel preparation. Studies comparing different regimens and volumes were excluded. Specific outcomes studied included palatability (taste), willingness to repeat bowel preparation, gastrointestinal adverse events and the quality of bowel preparation. Data across studies were pooled using a random-effects model and heterogeneity assessed using I2-statistics.

RESULTS

Of 467 studies screened, six were included for analysis (all single-blind randomised trials; n = 1187 patients). Adjuncts comprised citrus reticulata peel, orange juice, menthol candy drops, simethicone, Coke Zero and sugar-free chewing gum. Overall, adjunct use was associated with improved palatability (mean difference 0.62, 95% confidence interval 0.29-0.96, p < 0.001) on a scale of 0-5, acceptability of taste (odds ratio 2.75, 95% confidence interval: 1.52-4.95, p < 0.001) and willingness to repeat bowel preparation (odds ratio 2.92, 95% confidence interval: 1.97-4.35, p < 0.001). Patients in the adjunct group reported lower rates of bloating (odds ratio 0.48, 95% confidence interval: 0.29-0.77, p = 0.003) and vomiting (odds ratio 0.47, 95% confidence interval 0.27-0.81, p = 0.007), but no difference in nausea (p = 0.10) or abdominal pain (p = 0.62). Adjunct use resulted in superior bowel cleanliness (odds ratio 2.52, 95% confidence interval: 1.31-4.85, p = 0.006). Heterogeneity varied across outcomes, ranging from 0% (vomiting) to 81% (palatability), without evidence of publication bias. The overall quality of evidence was rated moderate.

CONCLUSION

In this meta-analysis, the use of adjuncts was associated with better palatability, less vomiting and bloating, willingness to repeat bowel preparation and superior quality of bowel preparation. The addition of adjuncts to bowel preparation may improve outcomes of colonoscopy and the overall patient experience.

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.

Comparing the Real-World Effectiveness of Competing Colonoscopy Preparations: Results of a Prospective Trial

OBJECTIVES

National societies provide little guidance regarding which colonoscopy bowel preps are best tolerated and most effective; this reflects a lack of comparative effectiveness studies that directly evaluate the available preps in a "real-world" setting. To address this gap, we conducted a prospective, commercially unfunded comparative effectiveness study of currently available bowel preps and measured their impact on bowel cleansing.

METHODS

We included patients aged ≥18 years, who presented for an outpatient colonoscopy at a large medical center serving more than 70 academic and community-based endoscopists who are free to prescribe the bowel prep of their choice. The primary outcome was bowel cleansing quality as measured by the Boston Bowel Preparation Scale. We performed regression models with random effects on the outcomes to adjust for confounding.

RESULTS

Approximately 4,339 colonoscopies were performed by 75 endoscopists. Magnesium citrate, MiraLAX with Gatorade, MoviPrep, OsmoPrep, Prepopik/Clenpiq, and Suprep all had significantly higher prep tolerability compared with GoLYTELY (all P < 0.05). For bowel cleansing, Suprep (7.28 ± 1.66; P < 0.001), MoviPrep (7.11 ± 1.62; P = 0.004), and MiraLAX with Gatorade (7.09 ± 1.64; P < 0.001) had higher total Boston Bowel Preparation Scale scores compared with GoLYTELY (6.67 ± 1.87); there were no significant differences among the remaining preps. Split-prep dosing was associated with better cleansing; however, men, opioid and tricyclic antidepressent users, and patients with diabetes and cirrhosis had worse cleansing (all P < 0.05).

CONCLUSIONS

In this prospective, real-world comparative effectiveness study of available bowel preps, we found that MiraLAX with Gatorade, MoviPrep, and Suprep were prospectively associated with superior tolerability and bowel cleansing.

Bowel preparation for colonoscopy: what is best and necessary for quality?

PURPOSE OF REVIEW

Colonoscopy is recognizably, the best colon cancer prevention test, provided the quality of the preparation is adequate for detection of precancerous polyps but also allowing for accurate identification of margins, thereby facilitating complete endoscopic resection. As there are many aspects effecting colon prep outcomes, it is timely to review new standards for optimizing outcomes, including product selection based on patient demographics.

RECENT FINDINGS

New national guidelines have set a minimum quality threshold for adequacy and also defined a split day delivery for oral options as the "standard of care". Several new prep options have been recently released and these data are discussed.

SUMMARY

Optimizing the quality of colon preps has major implications for clinical practice. Clinicians must recognize new targets for standard of care, providing the best approach for each individual patient, considering variable factors which may otherwise compromise success.

Polyethylene glycol plus bisacodyl: A safe, cheap, and effective regimen for colonoscopy in the South Asian patients

Background and Aim

Data regarding the comparison of colonoscopic preparation regimens are still variable. We aimed to assess the adequacy and tolerability of two bowel preparation regimens for afternoon colonoscopy.

Methods

In a randomized, investigator‐blinded trial, two preparation regimens [4‐L split‐dose polyethylene glycol‐electrolytes (PEG‐ELS) and 2‐L PEG‐ELS plus bisacodyl) were compared in terms of bowel cleansing efficacy and adverse effects.

Results

The mean (±SD) age (years) of the 4‐L split‐dose PEG‐ELS group (N = 147) and the 2‐L PEG‐ELS plus bisacodyl (N = 155) were 44.09 (±15.62) (M:F : 2:1) and 44.12 years (±15.61) (M:F : 1.7:1), respectively. Percentage of patients with excellent and good preparation was higher in the 4‐L split‐dose PEG‐ELS regimen compared with the 2‐L PEG‐ELS plus bisacodyl regimen (22.44 vs 17.41 and 44.21% vs 36.12%). Percentage of patients with fair and poor preparation was lower in 4‐L split‐dose PEG‐ELS regimen compared with the 2‐L PEG‐ELS plus bisacodyl regimen (21.08% vs 27.74% and 12.24% vs 18.70%). In comparison with the 2‐L PEG‐ELS plus bisacodyl group, the incidences of abdominal pain (11% vs 15%), bloating (9% vs 12.24%), nausea/vomiting (8.38% vs 9.52%), and sleep disturbance (11% vs 12%) were slightly more common in the 4‐L split‐dose PEG‐ELS group. There were no statistically significant differences between the two regimens with regard to bowel cleansing efficacy and adverse events.

Conclusions

The 2‐L PEG‐ELS plus bisacodyl (10 mg) preparation is as efficacious as the 4‐L split‐dose PEG‐ELS regimen for afternoon colonoscopy. Optimal preparation for colonoscopy can be achieved with the 2‐L PEG‐ELS plus bisacodyl regimen with slightly fewer adverse events and lower cost compared to the 4‐L split‐dose PEG‐ELS regimen.

Bowel preparation quality scales for colonoscopy

Colorectal cancer (CRC) is the third most common cancer and second leading cause of cancer-related death in the United States. Colonoscopy is widely preferred for CRC screening and is the most commonly used method in the United States. Adequate bowel preparation is essential for successful colonoscopy CRC screening. However, up to one-quarter of colonoscopies are associated with inadequate bowel preparation, which may result in reduced polyp and adenoma detection rates, unsuccessful screens, and an increased likelihood of repeat procedure. In addition, standardized criteria and assessment scales for bowel preparation quality are lacking. While several bowel preparation quality scales are referred to in the literature, these differ greatly in grading methodology and categorization criteria. Published reliability and validity data are available for five bowel preparation quality assessment scales, which vary in several key attributes. However, clinicians and researchers continue to use a variety of bowel preparation quality measures, including nonvalidated scales, leading to potential confusion and difficulty when comparing quality results among clinicians and across clinical trials. Optimal clinical criteria for bowel preparation quality remain controversial. The use of validated bowel preparation quality scales with stringent but simple scoring criteria would help clarify clinical trial data as well as the performance of colonoscopy in clinical practice related to quality measurements.

Bowel preparation quality scales for colonoscopy

Colorectal cancer (CRC) is the third most common cancer and second leading cause of cancer-related death in the United States. Colonoscopy is widely preferred for CRC screening and is the most commonly used method in the United States. Adequate bowel preparation is essential for successful colonoscopy CRC screening. However, up to one-quarter of colonoscopies are associated with inadequate bowel preparation, which may result in reduced polyp and adenoma detection rates, unsuccessful screens, and an increased likelihood of repeat procedure. In addition, standardized criteria and assessment scales for bowel preparation quality are lacking. While several bowel preparation quality scales are referred to in the literature, these differ greatly in grading methodology and categorization criteria. Published reliability and validity data are available for five bowel preparation quality assessment scales, which vary in several key attributes. However, clinicians and researchers continue to use a variety of bowel preparation quality measures, including nonvalidated scales, leading to potential confusion and difficulty when comparing quality results among clinicians and across clinical trials. Optimal clinical criteria for bowel preparation quality remain controversial. The use of validated bowel preparation quality scales with stringent but simple scoring criteria would help clarify clinical trial data as well as the performance of colonoscopy in clinical practice related to quality measurements.

Shorter waiting times from education to colonoscopy can improve the quality of bowel preparation: A randomized controlled trial

BACKGROUND/AIMS

Adequate bowel preparation is essential for an effective and safe colonoscopy. This study aimed to evaluate the quality of bowel preparation according to waiting times from education to colonoscopy.

MATERIALS AND METHODS

A prospective, investigator-blinded, randomized study was performed from December 2016 to March 2017. Patients were divided into two groups: within 2 weeks (group A, n=64) or more than 2 weeks (group B, n=66) from education about bowel preparation to colonoscopy. The primary outcome was the quality of bowel preparation as assessed by the Boston Bowel Preparation Scale (BBPS). The secondary outcome was the polyp and adenoma detection rate.

RESULTS

A total of 130 patients were enrolled. The total BBPS score was significantly higher in group A (within 2 weeks from education to colonoscopy) than in group B (more than 2 weeks). Total BBPS scores were 8.25}0.97 in group A and 7.75}1.32 in group B (P=.017). The rate of good preparation (BBPS≥8) was higher in group A than in group B (78.1% vs. 59.1%, P=.020). The rates of polyp and adenoma detection were both slightly higher in group A (polyps, 42.2% vs. 38.5%, P=.667; adenoma, 31.2% vs. 22.7%, P=.275). A numerical trend was observed for the slightly superior polyp and adenoma detection rate in group A, but it was not statistically significant.

CONCLUSION

This study demonstrated that shorter waiting times from education to colonoscopy can improve the quality of bowel preparation. Ensuring sufficient staff and equipment for endoscopy is one approach to reducing waiting times to colonoscopy. If waiting times can not be reduced, more contact through telephone, e-mail, and text messaging could be used to remind patients about information regarding bowel preparation.

Polyethylene Glycol-3350 (Miralax®)+1.9-L sports drink (Gatorade®)+2 tablets of bisacodyl results in inferior bowel preparation for colonoscopy compared with Polyethylene Glycol-Ascorbic Acid (MoviPrep®)

BACKGROUND/AIMS

Polyethylene glycol (PEG)-3350, approved by Food and Drug Administration (FDA) only for constipation, combined with 1.9 L of sports drink (SD) (GatoradeR) and bisacodyl (B) is commonly used in outpatient practice for bowel preparation due to cited patient satisfaction and tolerability of this specific regimen. We aim to compare PEG-3350 (MiralaxR) with PEG-AA-based (MoviPrepR) in terms of efficacy, patient satisfaction, and the effects of these two regimen on serum electrolytes.

MATERIALS AND METHODS

This study is a prospective, single-blinded, block randomized trial comparing single-dose PEG-3350+SD+B to split-dose 2-L PEG-AA in the outpatient endoscopy unit in patients undergoing colonoscopy. Basic metabolic profiles were checked on the day of randomization and on the day of procedure. Patients completed a survey on the day of procedure. Bowel preparation quality was assessed using the Boston Bowel Preparation Scale (BBPS) by two endoscopists and a nurse present during the procedure.

RESULTS

We randomized 150 patients (74 PEG-3350+SD+B and 76 PEG-AA). The PEG-AA group had significantly higher BBPS scores in the right colon by Endoscopist 1, Nurse, and Endoscopist 2 (p 0.005, <0.000, 0.001) and in the left and transverse colon by Nurse and Endoscopist 2 (p 0.004, 0.26, 0.000, 0.006). There was no statistically significant difference in patient satisfaction or change in serum electrolytes between the two groups.

CONCLUSION

Use of single-dose PEG-3350+SD+B results in inferior bowel preparation for colonoscopy compared with split-dose PEGAA and does not provide any advantage in regards to patient satisfaction. We therefore recommend discontinuing the use of PEG 3350 for bowel preparation.

Cystic Fibrosis Colorectal Cancer Screening Consensus Recommendations

BACKGROUND & AIMS

Improved therapy has substantially increased survival of persons with cystic fibrosis (CF). But the risk of colorectal cancer (CRC) in adults with CF is 5-10 times greater compared to the general population, and 25-30 times greater in CF patients after an organ transplantation. To address this risk, the CF Foundation convened a multi-stakeholder task force to develop CRC screening recommendations.

METHODS

The 18-member task force consisted of experts including pulmonologists, gastroenterologists, a social worker, nurse coordinator, surgeon, epidemiologist, statistician, CF adult, and a parent. The committee comprised 3 workgroups: Cancer Risk, Transplant, and Procedure and Preparation. A guidelines specialist at the CF Foundation conducted an evidence synthesis February-March 2016 based on PubMed literature searches. Task force members conducted additional independent searches. A total of 1159 articles were retrieved. After initial screening, the committee read 198 articles in full and analyzed 123 articles to develop recommendation statements. An independent decision analysis evaluating the benefits of screening relative to harms and resources required was conducted by the Department of Public Health at Erasmus Medical Center, Netherlands using the Microsimulation Screening Analysis model from the Cancer Innervation and Surveillance Modeling Network. The task force included recommendation statements in the final guideline only if they reached an 80% acceptance threshold.

RESULTS

The task force makes 10 CRC screening recommendations that emphasize shared, individualized decision-making and familiarity with CF-specific gastrointestinal challenges. We recommend colonoscopy as the preferred screening method, initiation of screening at age 40 years, 5-year re-screening and 3-year surveillance intervals (unless shorter interval is indicated by individual findings), and a CF-specific intensive bowel preparation. Organ transplant recipients with CF should initiate CRC screening at age 30 years within 2 years of the transplantation because of the additional risk for colon cancer associated with immunosuppression.

CONCLUSIONS

These recommendations aim to help CF adults, families, primary care physicians, gastroenterologists, and CF and transplantation centers address the issue of CRC screening. They differ from guidelines developed for the general population with respect to the recommended age of screening initiation, screening method, preparation, and the interval for repeat screening and surveillance.

Clinical Trial of 1000 Subjects Randomized to 5 Low-Volume Bowel Preparations for Colonoscopy and Their Acceptance of Split-Dose Bowel Preparations

BACKGROUND

We assessed the efficacy and tolerability of 5 low-volume bowel preparations for colonoscopy.

STUDY

We performed an investigator-blinded, randomized trial of 5 bowel preparations: 64 ounces of Gatorade and 306 or 357 g of PEG, both given the day prior; Gatorade and 306 g PEG, 2 L PEG-electrolyte solution with ascorbic acid, and sulfate solution, all 3 given as a split dose. One thousand outpatients consumed their preparation before a morning colonoscopy. The primary endpoint was colon cleanliness assessed by the Chicago Bowel Preparation Scale (BPS). Tolerability was assessed using a subject questionnaire. Another primary endpoint was patient acceptance of a split-dose bowel preparation assessed using a subject questionnaire.

RESULTS

No statistically significant differences in the modified Chicago BPS were found among Gatorade and 357 g of PEG given as a day-prior dose and the 3 split-dose arms with 98.5% of colons cleansed adequately. The Gatorade and 357 g of PEG had significantly lower Chicago BPS fluid scores and Chicago BPS total scores (indicating dryer colons that required more irrigation) than the 3 split-dose arms. The Gatorade and PEG preparations were better tolerated. Many subjects are unwilling to consume a split-dose preparation and the majority of subjects would prefer a day-prior preparation with this preference highly dependent on the type of preparation they just consumed.

CONCLUSIONS

The cleanliness of the colons was not significantly different among the 3 split-dose preparations. Day-prior dosing of Gatorade and 357 g of PEG allowed the mucosa to be visualized as well as did the split-dose preparations.

Subjective taste to polyethylene glycol is associated with efficacy of right colon preparation

AIM

A prospective observational trial with preparations using polyethylene glycol (PEG) to compare patient compliance and adverse events according to individual subjective taste.

METHODS

A total of 299 outpatients (mean ± standard deviation [SD] 56.5 ± 13.8 years, 172 males) were recruited for our study. We assessed the efficacy of bowel preparation, subjective taste to their regimens, compliance and adverse events during the preparation.

RESULTS

We achieved adequate preparation in 267 (89.3%). A total of 124 patients (41.5%) had 'unacceptable taste' to their regimens. The patients with acceptable taste had better compliance than the patients with unacceptable taste (p = .009). The patients with unacceptable taste had more frequent adverse events such as nausea, vomiting and abdominal bloating than the patients with acceptable taste (all p < .001, Table 2). Patients with unacceptable taste (16.1%) had more frequent inadequate preparation in overall colon than patients with acceptable taste (6.9%, p = .011). There was a significant difference in the efficacy of preparation of right colon between the two groups (p = .004).

CONCLUSION

Subjective taste to PEG is associated with efficacy of right colon preparation. In addition, subjective taste to PEG is associated with compliance and adverse events.

A prospective randomized trial on the use of Coca-Cola Zero(®) vs water for polyethylene glycol bowel preparation before colonoscopy

AIM

The study aimed to determine whether Coca-Cola (Coke) Zero is a safe and effective solvent for polyethylene glycol (PEG).

METHOD

Between December 2013 and April 2014, 209 healthy adults (115 men, 95 women) scheduled for elective colonoscopy were randomized to use either Coke Zero (n = 100) or drinking water (n = 109) with PEG as bowel preparation. Each patient received two sachets of PEG to dissolve in 2 l of solvent, to be completed 6 h before colonoscopy. Serum electrolytes were measured before and after preparation. Bowel cleanliness and colonoscopy findings were recorded. Palatability of solution, adverse effects, time taken to complete and willingness to repeat the preparation were documented via questionnaire.

RESULTS

Mean palatability scores in the Coke Zero group were significantly better compared with the control group (2.31 ± 0.61 vs 2.51 ± 0.63, P = 0.019), with a higher proportion willing to use the same preparation again (55% vs 43%). The mean time taken to complete the PEG + Coke Zero solution was significantly faster (74 ± 29 min vs 86 ± 31 min, P = 0.0035). The quality of bowel cleansing was also significantly better in the Coke Zero group (P = 0.0297). There was no difference in the frequency of adverse events (P = 0.759) or the polyp detection rate (32% vs 31.2%). Consumption of either preparation did not significantly affect electrolyte levels or hydration status.

CONCLUSION

Coke Zero is a useful alternative solvent for PEG. It is well tolerated, more palatable, leads to quicker consumption of the bowel preparation and results in better quality cleansing.

Bowel cleansing before colonoscopy: Balancing efficacy, safety, cost and patient tolerance

Effective colorectal cancer screening relies on reliable colonoscopy findings which are themselves dependent on adequate bowel cleansing. Research has consistently demonstrated that inadequate bowel preparation adversely affects the adenoma detection rate and leads gastroenterologists to recommend earlier follow up than is consistent with published guidelines. Poor preparation affects as many as 30% of colonoscopies and contributes to an increased cost of colonoscopies. Patient tolerability is strongly affected by the preparation chosen and manner in which it is administered. Poor tolerability is, in turn, associated with lower quality bowel preparations. Recently, several new developments in both agents being used for bowel preparation and in the timing of administration have brought endoscopists closer to achieving the goal of effective, reliable, safe, and tolerable regimens. Historically, large volume preparations given in a single dose were administered to patients in order to achieve adequate bowel cleansing. These were poorly tolerated, and the unpleasant taste of and significant side effects produced by these large volume regimens contributed significantly to patients’ inability to reliably complete the preparation and to a reluctance to repeat the procedure. Smaller volumes, including preparations that are administered as tablets to be consumed with water, given as split doses have significantly improved both the patient experience and efficacy, and an appreciation of the importance of the preparation to colonoscopy interval have produced additional cleansing.

Determinants of Bowel Preparation Quality and Its Association With Adenoma Detection: A Prospective Colonoscopy Study

The predictors of poor bowel preparation in colorectal cancer screening participants have not been adequately studied, and the association between the quality of bowel preparation and adenoma detection has not been firmly established. This study examined the determinants of poor bowel preparation, and evaluated its relationship with adenoma detection.We included subjects aged between 50 and 70 years who received colonoscopy between 2008 and 2014 in a colorectal cancer screening program in Hong Kong. The quality of the bowel preparation was assessed by colonoscopists, and the factors associated with poor bowel cleansing were evaluated by a binary logistic regression analysis. A multivariate regression model was constructed to evaluate if poor bowel preparation was associated with detection of colorectal neoplasia.From 5470 screening participants (average age 57.7 years, SD 4.9), 1891 (34.6%) had poor or fair bowel preparation. The average cecal intubation time was 7.0 minutes (SD 5.4; range 1.22-36.9 minutes) and the average colonoscopy withdrawal time was 10.8 minutes (SD 6.9; range 6.0-107.0 minutes). Among all, 26.5% had colorectal neoplasia and 5.5% had advanced neoplasia. Older age (≥60 years; adjusted odds ratio [AOR] = 1.19-1.38, P = 0.02-0.04), male sex (AOR = 1.38, 95% confidence interval [CI] 1.19-1.60, P < 0.001), and current smoking (AOR = 1.41, 95% CI 1.14-1.75, P = 0.002) were significantly associated with poor/fair bowel preparation. Poorer cleansing resulted in significantly lower detection rate of neoplasia (AOR = 0.35-0.62) and advanced neoplasia (AOR = 0.36-0.50) irrespective of polyp size.Steps to improve proper procedures of bowel preparation are warranted, especially among subjects at risk of poor bowel preparation. Strategies should be implemented to improve bowel cleansing, which is now demonstrated as a definite quality indicator.

A Comparative Study of Treatment-Emergent Adverse Events Following Use of Common Bowel Preparations Among a Colonoscopy Screening Population: Results from a Post-Marketing Observational Study

BACKGROUND

Colonoscopy may be one of the most frequent elective procedures in older adults and is associated with a low occurrence of complications. However, reduction of risks attributable to the bowel preparation may be achieved with the use of effective and safer products.

AIM

The aim of this study was to examine the incidence of treatment-emergent adverse events (TEAEs) associated with SUPREP(®) [oral sulfate solution (OSS)] and other common prescription bowel preparations (non-OSS).

METHODS

This real-world, observational study used de-identified health insurance claims and laboratory results to identify TEAEs in the 3 months following screening colonoscopy in adults with a prescription for a bowel preparation in the prior 60 days. The unadjusted and adjusted (controlling for patient risk factors) cumulative incidences of TEAEs were estimated using Kaplan-Meier and Poisson regression, respectively.

RESULTS

Among patients ≥45 years, the overall cumulative incidence was significantly lower (p < 0.001) in the OSS cohort than in the non-OSS cohort (unadjusted: 2.31 vs. 2.89 %; adjusted: 1.61 vs. 1.95 %), with significantly lower acute cardiac conditions (1.56 vs. 1.90 %; p < 0.001), renal failure/other serious renal diseases (OSS: 0.21 %, non-OSS: 0.32 %; p < 0.001), and serum electrolyte abnormalities (OSS: 0.39 %, non-OSS: 0.49 %; p = 0.017). There were no significant differences between cohorts in death, seizure disorders, aggravation of gout, and ischemic colitis. Results were similar in the adjusted cumulative incidences.

CONCLUSIONS

In actual use, the overall cumulative incidence of TEAEs was significantly lower in the OSS cohort, demonstrating that OSS is as safe as, or possibly safer than, non-OSS prescription bowel preparations.

Endoscopic Therapy in Crohn's Disease: Principle, Preparation, and Technique

Stricture and fistula are common complications of Crohn's disease. Endoscopic balloon dilation and needle-knife stricturotomy has become a valid treatment option for Crohn's disease-associated strictures. Endoscopic therapy is also increasingly used in Crohn's disease-associated fistula. Preprocedural preparations, including routine laboratory testing, imaging examination, anticoagulant management, bowel cleansing and proper sedation, are essential to ensure a successful and safe endoscopic therapy. Adverse events, such as perforation and excessive bleeding, may occur during endoscopic intervention. The endoscopist should be well trained, always be cautious, anticipate for possible procedure-associated complications, be prepared for damage control during endoscopy, and have surgical backup ready. In this review, we discuss the principle, preparation, techniques of endoscopic therapy, as well as the prevention and management of endoscopic procedure-associated complications. We propose that inflammatory bowel disease endoscopy may be a part of training for "super" gastroenterology fellows, i.e., those seeking a career in advanced endoscopy or in inflammatory bowel disease.

Split-Dose Preparations Are Superior to Day-Before Bowel Cleansing Regimens: A Meta-analysis

BACKGROUND & AIMS

There are different regimens of preparing the colon for colonoscopy, including polyethylene glycol (PEG), sodium phosphate, picosulfate, or oral sulfate solutions. We performed a meta-analysis to determine the efficacy of split-dose vs other colon preparation regimens, the optimal products for use, and the most effective preparation volumes.

METHODS

We performed systematic searches of MEDLINE, EMBASE, Scopus, CENTRAL, and ISI Web of knowledge databases, from January 1980 to March 2014, for published results from randomized trials that assessed split-dose regimens vs day-before colonoscopy preparation. We excluded studies that included pediatric or hospitalized patients, or patients with inflammatory bowel disease. The primary outcome was efficacy of bowel cleansing. Secondary outcomes included side effects or complications, outcomes of procedures, patients' willingness to repeat the procedure, and the amount of time required for patients to resume daily activities.

RESULTS

We identified 47 trials that fulfilled our inclusion criteria (n = 13,487 patients). Split-dose preparations provided significantly better colon cleansing than day-before preparations (odds ratio [OR], 2.51; 95% confidence interval, 1.86-3.39), as well as day-before preparations with PEG (OR, 2.60; 95% confidence interval, 1.46-4.63), sodium phosphate (OR, 9.34; 95% confidence interval, 2.12-41.11), or picosulfate (OR, 3.54; 95% confidence interval, 1.95-6.45). PEG split-dose preparations of 3 L or more yielded greater bowel cleanliness than lower-volume split-dose regimens (OR, 1.89; 95% confidence interval, 1.01-3.46), but only in intention-to-treat analysis. A higher proportion of patients were willing to repeat split-dose vs day-before cleansing (OR, 1.90; 95% confidence interval, 1.05-3.46), and low-volume split-dose preparations vs high-volume split-dose preparation (OR, 4.95; 95% confidence interval, 2.21-11.10). There were no differences between preparations in other secondary outcome measures. However, there was variation among studies in definitions and main and secondary outcomes.

CONCLUSIONS

Based on meta-analysis, split-dose regimens increase the quality of colon cleansing and are preferred by patients compared with day-before preparations. Additional research is required to evaluate oral sulfate solution-based and PEG low-volume regimens further.

Optimizing bowel cleansing for colonoscopy

Adequate bowel cleansing is essential for complete examination of the colon mucosa during colonoscopy. Suboptimal bowel preparation has potential adverse consequences, such as missed pathologic abnormalities, the need for repeated procedures, and increased procedure-related complications. Several factors can predict individuals at increased risk for inadequate bowel preparation. If predictors of inadequate bowel preparation are identified, then education should be intensified and a more aggressive bowel regimen recommended. On completion of this article, you should be able to (1) define the frequency of inadequate colon preparations, (2) identify predictors of poor bowel preparation, and (3) use a more aggressive bowel regimen when clinically indicated.

Optimal bowel cleansing for colonoscopy: split the dose! A series of meta-analyses of controlled studies

BACKGROUND

Colonoscopy is considered the criterion standard for detecting colorectal cancer; adequate preparation is crucial for an effective colonoscopy, but definitive data on the optimal preparation are lacking.

OBJECTIVE

Our aim was to assess the efficacy of split-dose versus non-split-dose preparations, the rate of adequate preparation according to type and dose of laxatives, the role of "runway time" (the interval time between the last drink of purgative and the beginning of colonoscopy), and to evaluate compliance as an additive risk factor for colon cleansing.

DESIGN

A series of meta-analyses of controlled studies.

SETTING

Randomized clinical trial of split dose regimen versus entire dose taken on the day preceding colonoscopy.

PATIENTS

Published trials (1960-2013) comparing split-dose versus non-split-dose preparations in adults undergoing colonoscopy were selected by using MEDLINE, the Cochrane Central Register of Controlled Trials, clinicaltrial.gov, ISI Web of Science, and Scopus.

INTERVENTIONS

Colonoscopy.

MAIN OUTCOME MEASUREMENTS

Rate difference of the degree of colon cleansing between split dose and whole dose was the primary measure of treatment effect.

RESULTS

We included 29 studies. Overall, an adequate preparation was obtained in 85% of patients in the split-dose group and in 63% of the non-split-dose group (rate difference 22%). The heterogeneity was caused by 5 factors: the runway time (the longer, the worse the cleansing), type of diet, male sex, use of polyethylene glycol 4 L, and the Jadad score. Compliance was significantly higher in the split-dose group.

LIMITATIONS

Average quality of the included studies and publication bias.

CONCLUSION

We provided further evidence of the superiority of a split-dose regimen over a non-split-dose regimen and showed that, regardless of type and dose, the superiority of split-dose regimens remains valid if the "golden 5 hours" rule is preserved.

Orange juice intake reduces patient discomfort and is effective for bowel cleansing with polyethylene glycol during bowel preparation

BACKGROUND

Many patients report discomfort because of the unpleasant taste of bowel preparation solutions.

OBJECTIVE

This study aimed to determine whether adding orange juice to 2 L of polyethylene glycol plus ascorbic acid is effective for reducing patient discomfort and improving palatability during bowel preparation.

DESIGN

This was a single-blinded, randomized controlled trial.

SETTINGS

The study was conducted at a tertiary referral hospital and a generalized hospital.

PATIENTS

Consecutive outpatients and inpatients were randomly allocated to drink 2 L of polyethylene glycol-ascorbic acid or 2 L of polyethylene glycol-ascorbic acid with orange juice in a single dose or a split dose.

MAIN OUTCOME MEASURES

Tolerability, palatability score, willingness, and related adverse events were investigated by questionnaires. Bowel cleansing was rated using the Aronchick scale. Each score was graded on a 5-point scale.

RESULTS

A total of 107 patients, 53 in the orange juice group and 54 in the polyethylene glycol-ascorbic acid group who underwent elective colonoscopy were enrolled. The palatability score (mean ± SD) was higher in the orange juice group than in the control group (2.36 ± 0.76 vs 1.78 ± 0.88; p = 0.005). Nausea was less frequent in the orange juice group (26.4% vs 59.3%; p = 0.001). Total amount of bowel preparation ingested was not significantly different between the groups (p = 0.44). The bowel preparation score (mean ± SD) was not significantly different (1.49 ± 0.80 vs 1.43 ± 0.77; p = 0.94). Willingness to repeat the same process was higher in the orange juice group (90.4% vs 66.7%; p = 0.003).

LIMITATIONS

This study is limited because only ambulatory patients were enrolled.

CONCLUSIONS

Orange juice intake before drinking 2 L of polyethylene glycol-ascorbic acid for colonoscopy can reduce patient discomfort, resulting in improved acceptability and patient compliance. This method is as effective for bowel cleansing as polyethylene glycol.

Miralax with gatorade for bowel preparation: a meta-analysis of randomized controlled trials

OBJECTIVES

Polyethylene glycol (PEG) is a very popular bowel preparation for colonoscopy. However, its large volume may reduce patient compliance, resulting in suboptimal preparation. Recently, a combination of Miralax and Gatorade has been studied in various randomized controlled trials (RCTs) as a lower volume and more palatable bowel preparation. However, results have varied. Therefore, we conducted a meta-analysis assessing the use of Miralax-Gatorade (M-G) vs. PEG for bowel preparation before colonoscopy.

METHODS

Multiple databases were searched (January 2014). RCTs on adults comparing M-G (238-255 g in 1.9 l that is 64 fl oz) vs. PEG (3.8-4 l) for bowel preparation before colonoscopy were included. The effects were analyzed by calculating pooled estimates of quality of bowel preparation (satisfactory, unsatisfactory, excellent), patient tolerance (nausea, cramping, bloating), and polyp detection by using odds ratio (OR) with fixed- and random-effects models.

RESULTS

Five studies met inclusion criteria (N=1,418), with mean age ranging from 53.8 to 61.3 years. M-G demonstrated statistically significantly fewer satisfactory bowel preparations as compared with PEG (OR 0.65; 95% confidence interval (CI): 0.43-0.98, P=0.04) but more willingness to repeat preparation (OR 7.32; 95% CI: 4.88-10.98, P<0.01). Furthermore, no statistically significant differences in polyp detection (P=0.65) or side effects were apparent between the two preparations for nausea (P=0.71), cramping (P=0.84), or bloating (P=0.50). Subgroup analysis revealed similar results for split-dose M-G vs. split-dose PEG.

CONCLUSIONS

M-G for bowel preparation before colonoscopy was inferior to PEG in bowel preparation quality while demonstrating no significant improvements in adverse effects or polyp detection. Therefore, PEG appears superior to M-G for bowel preparation before colonoscopy.

Randomised clinical trial: Polyethylene glycol 3350 with sports drink vs. polyethylene glycol with electrolyte solution as purgatives for colonoscopy--the incidence of hyponatraemia

BACKGROUND

Polyethylene glycol 3350 plus sports drink (PEG-SD) is a hypo-osmotic purgative commonly used for colonoscopy, though little safety data are available.

AIM

To evaluate the effect of PEG-SD on serum sodium (Na) and other electrolytes compared with PEG-electrolyte solution (PEG-ELS).

METHODS

We performed a single center, prospective, randomised, investigator-blind comparison of PEG-ELS to PEG-SD in out-patients undergoing colonoscopy. Laboratories were obtained at baseline and immediately before and after colonoscopy. The primary endpoint was development of hyponatraemia (Na <135 mmol/L) the day of colonoscopy. Changes in electrolyte levels were computed as the difference between the lowest value on the day of colonoscopy and baseline. Purgative tolerance and efficacy were assessed.

RESULTS

A total of 389 patients were randomised; 364 took purgative and had baseline and day of colonoscopy labs (180 PEG-SD, 184 PEG-ELS). The groups were well matched except for a higher fraction of women and Blacks in PEG-ELS. Seven patients (3.9%) in PEG-SD and four patients (2.2%) in PEG-ELS developed hyponatraemia (OR = 1.82, 95% CI: 0.45-8.62, P = 0.376). Changes in electrolytes from baseline were small but significantly worse with PEG-SD for sodium, potassium and chloride (P = 0.001, 0.012, 0.001, respectively). Preparation completion, adverse events, and overall colon cleansing were similar between the groups, but PEG-ELS had more excellent preparations (52% vs. 30%; P = 0.001).

CONCLUSIONS

Greater, but very modest, electrolyte changes occur with PEG-SD. Hyponatraemia is infrequent with both purgatives. A significant increase in hyponatraemia was not identified for PEG-SD vs. PEG-ELS, but the sample size may have been inadequate to identify a small, but clinically important difference. ClinicalTrials.gov identifier NCT01299779.

Boston Bowel Preparation Scale scores provide a standardized definition of adequate for describing bowel cleanliness

BACKGROUND

Establishing a threshold of bowel cleanliness below which colonoscopies should be repeated at accelerated intervals is important, yet there are no standardized definitions for an adequate preparation.

OBJECTIVE

To determine whether Boston Bowel Preparation Scale (BBPS) scores could serve as a standard definition of adequacy.

DESIGN

Cross-sectional observational analysis of colonoscopy data from 36 adult GI endoscopy practices and prospective survey showing 4 standardized colonoscopy videos with varying degrees of bowel cleanliness.

SETTING

The Clinical Outcomes Research Initiative.

PATIENTS

Average-risk patients attending screening colonoscopy.

INTERVENTIONS

Colonoscopy.

MAIN OUTCOME MEASUREMENTS

Recommended follow-up intervals among average-risk, screening colonoscopies without polyps stratified by BBPS scores.

RESULTS

We evaluated 2516 negative screening colonoscopies performed by 74 endoscopists. If the BBPS score was ≥2 in all 3 segments (N = 2295), follow-up was recommended in 10 years in 90% of cases. Examinations with total BBPS scores of 3 to 5 (N = 167) had variable recommendations. Follow-up within 1 year was recommended for 96% of examinations with total BBPS scores of 0 to 2 (N = 26). Similar results were noted among 167 participants in a video survey with pre-established BBPS scores.

LIMITATIONS

Retrospective study.

CONCLUSION

BBPS scores correlate with endoscopist behavior regarding follow-up intervals for colonoscopy. A total BBPS score ≥6 and/or all segment scores ≥2 provides a standardized definition of adequate for 10-year follow-up, whereas total scores ≤2 indicate that a procedure should be repeated within 1 year. Future work should focus on finding consensus for management of examinations with total scores of 3 to 5.

Low-volume morning-only polyethylene glycol with specially designed test meals versus standard-volume split-dose polyethylene glycol with standard diet for colonoscopy: a prospective, randomized trial

BACKGROUND/AIMS

Split-dose polyethylene glycol (PEG) is a standard bowel preparation regimen for colonoscopy, but the large volume is burdensome to ingest and the night dose causes sleep disturbance. This study was performed to evaluate the efficacy and tolerability of a bowel preparation protocol using low-volume morning-only PEG with specially designed low-residue test meals (LV-PEG with TM) compared to a standard-volume split-dose PEG bowel preparation with a standard diet (SV-PEG with SD).

METHODS

This was a single-center, prospective, randomized, investigator-blinded, noninferiority study. The primary end point was bowel preparation quality according to the Ottawa scale. Tolerability, compliance, adverse events, sleep quality and polyp/adenoma detection were also assessed.

RESULTS

Among 197 patients analyzed (mean age 54.6 years, 51.3% men), 97 received LV-PEG with TM and 100 received SV-PEG with SD. The Ottawa score for the total colon was 3.76 ± 2.07 in the LV-PEG with TM group and 3.67 ± 1.57 in the SV-PEG with SD group (p = 0.723; difference 0.09, 95% confidence interval -0.60 to 0.42). The compliance was high (more than 95%) in both groups (p = 0.621). PEG was easier to ingest for patients in the LV-PEG with TM group compared to the SV-PEG with SD group [visual analogue scale (VAS) for difficulty: 4.64 ± 2.46 vs. 5.97 ± 2.42, respectively; p < 0.001]. Diet instructions were also easier to comply with for patients in the LV-PEG with TM group compared to the SV-PEG with SD group (VAS for difficulty: 3.11 ± 2.25 vs. 4.00 ± 2.39, respectively; p = 0.008). Patients in the LV-PEG with TM group had a lower incidence of abdominal bloating (p = 0.012) and better sleep quality (p < 0.001). There was no difference between the groups regarding polyp and adenoma detection.

CONCLUSIONS

LV-PEG with TM and SV-PEG with SD have similar efficacy with regard to bowel preparation for colonoscopy. LV-PEG with TM provided easier PEG intake and diet compliance, less abdominal bloating and better sleep quality than SV-PEG with SD.

Adjuncts to colonic cleansing before colonoscopy

Pre-procedural cleansing of the bowel can maximize the effectiveness and efficiency of colonoscopy. Yet, efficacy of the current gold standard colonic preparation method - high-volume oral administration of purgative agents 12-24 h prior to the procedure - is limited by several factors, such as patient compliance (due to poor palatability and inconvenience of the dosing regimen) and risks of complications (due to drug interactions or intolerance). Attempts to resolve these limitations have included providing adjunctive agents and methods to promote the colonic cleansing ability of the principal purgative agent, with the aim of lessening unpleasant side effects (such as bloating) and reducing the large ingested volume requirement. Several promising adjunctive agents are bisacodyl, magnesium citrate, senna, simethicone, metoclopramide, and prokinetics, and each are being investigated for their potential. This review provides an up to date summary of the reported investigations into the potencies and weaknesses of the key adjuncts currently being applied in clinic as supplements to the traditional bowel preparation agents. While the comparative analysis of these adjuncts showed that no single agent or method has yet achieved the goal of completely overcoming the limitations of the current gold standard preparation method, they at least provide endoscopists with an array of alternatives to help improve the suboptimal efficacy of the main cleansing solutions when used alone. To aid in this clinical endeavor, a subjective grade was assigned to each adjunct to indicate its practical value. In addition, the systematic review of the currently available agents and methods provides insight into the features of each that may be overcome or exploited to create novel drugs and strategies that may become adopted as effective bowel cleansing adjuncts or alternatives.

Colon cleansing for colonoscopy 2013: current status

Colonoscopy requires adequate bowel cleansing to be safe and effective. There are a variety of options available. This review will focus on highlighting new products, administration techniques emphasizing the value of split-dose and same-day regimens, safety, and options for inadequate cleansing.

Validity of a Web-based educational program to disseminate a standardized bowel preparation rating scale

GOALS

Our goal was to assess the validity of a Web-based educational program on the Boston Bowel Preparation Scale (BBPS).

BACKGROUND

Data on Web-based education for improving the practice and quality of colonoscopy are limited.

STUDY

Endoscopists worldwide participated in the BBPS Educational Program. We assessed program completion rates, satisfaction, short-term (0 to 90 d) and long-term (91 to 180 d) uptake of the BBPS, and the validity of the program by measuring the reliability of the BBPS among participants.

RESULTS

A total of 207 endoscopists completed the program. Overall, 93% found the content relevant, 89% felt confident in using the BBPS, and 97% thought the quality was good or excellent. Uptake of the BBPS into clinical practice was robust with 91% and 98% of colonoscopy reports containing the BBPS at short-term and long-term follow-up, respectively. The interobserver and test-retest reliability of BBPS segment and total scores were both substantial.

CONCLUSIONS

A BBPS Web-based educational program facilitates adoption into clinical practice and teaches the BBPS to be used reliably by a diverse group of endoscopists worldwide.

A Korean experience of the use of Boston bowel preparation scale: a valid and reliable instrument for colonoscopy-oriented research

BACKGROUND/AIMS

Few bowel preparation scales have been validated. The Boston Bowel Preparation Scale (BBPS) is a novel bowel preparation scale in western countries. We validated the BBPS in Korean patients and assessed the relationship between the colon polyp detection rate and BBPS score.

PATIENTS AND METHODS

This study was a prospective, single-center trial. The BBPS is a 10-point scale that assesses bowel preparation after the completion of all cleansing maneuvers. We assessed three segment scores (the right side, transverse section, and left side) and total BBPS scores during screening colonoscopy. In addition, we compared the BBPS scores with clinically meaningful outcomes such as the polyp detection rate and colonoscope withdrawal times.

RESULTS

We enrolled 482 screening colonoscopies between January 2011 and January 2012. The mean (± standard deviation [SD]) BBPS score was 8.1 ± 1.1. Higher BBPS scores (≥8 vs <8) were associated with a higher polyp detection rate (44.9% vs. 33.0%, P = 0.042). The BBPS scores were inversely correlated with colonoscope withdrawal times (r = -0.167, P < 0.001).

CONCLUSIONS

The BBPS is a valid and reliable measure for assessing bowel preparation during colonoscopy in Korean patients. The polyp detection rate is higher in patients with higher BBPS scores than in those with lower BBPS scores during a colonoscopic procedure.

Sugar-free menthol candy drops improve the palatability and bowel cleansing effect of polyethylene glycol electrolyte solution

BACKGROUND

Colon preparations are generally poorly tolerated.

OBJECTIVE

To study the efficacy of sugar-free candy drops in improving palatability and tolerability of polyethylene glycol electrolyte solution (PEG-E).

DESIGN

Single-blind, randomized, controlled trial.

SETTING

University medical center.

PATIENTS

Ambulatory patients scheduled for elective colonoscopy.

INTERVENTION

Menthol candy drops. Patients were randomly assigned to split-dose, 4-L, PEG-E ± cough drops. Palatability was assessed on a linear scale of 1 to 5 (1 = disgusting; 5 = tasty). Quality of preparation, remaining unconsumed volume, and side effects were secondary outcomes.

MAIN OUTCOME MEASUREMENTS

Palatability and tolerability of PEG-E.

RESULTS

A total of 99 patients were enrolled (50 control group, 49 candy drops-added group). The mean (± standard deviation) palatability score was significantly better in candy drop users versus controls (3.9 ± 0.7 vs 2.8 ± 1.2, respectively; P < .001) as were the preparations scored as excellent (63.3% vs 34% of controls; P = .004). Side effects were similar except for nausea (24.5% candy drops vs 44% controls; P = .04). The amount of unconsumed PEG-E was not different between candy drop and control groups (128 [± 361 mL] versus 69 [± 194 mL], respectively; P = .32) but was significantly lower in excellent grade preparations versus other grades (31 [± 103 mL] versus 162 [± 384 mL], respectively; P = .024). On multivariate logistic regression, an excellent preparation was associated with candy drops (odds ratio [OR] 3.3, 95% confidence interval [CI], 1.4-7.8; P = .006) and smaller unconsumed volume of same-day PEG-E [OR 0.996, 95% CI, 0.992-1.000; P = .044).

LIMITATIONS

Single-center study.

CONCLUSION

Sugar-free menthol candy drops are a safe and effective addition to split-dose PEG-E, resulting in improved tolerability and patient compliance, which appears to translate into improved bowel cleansing. (

CLINICAL TRIAL REGISTRATION NUMBER

NCT01541683.).

The modern bowel preparation in colonoscopy

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

Effectiveness of a simplified "patient friendly" split dose polyethylene glycol colonoscopy prep in Veterans Health Administration patients

BACKGROUND AND OBJECTIVES

Adequate colon cleansing is an important factor in performing quality colonoscopy. Split dose Polyethylene Glycol (PEG) solutions have been shown to improve colon cleansing, but the effectiveness in a large clinical practice of elderly co-morbid patients has not been demonstrated. The aim of this study was to assess the efficacy of a simplified split PEG bowel prep in Veterans Health Administration (VHA) patients.

METHODS

Prospective pre-post study design of VHA patients undergoing routine colonoscopy. Bowel prep quality was assessed using a standardized semi-quantitative 5-point scale. "Standard" 4L PEG prep was consumed once the evening before the procedure. "Split" prep was consumed half in the early evening and half in the late evening or early morning depending on procedure time.

RESULTS

Right colon preps were Excellent/Good in 81.4% of split preps (n=199) vs. 63% of standard preps (n=447, p<0.001). Left colon preps were Excellent/Good in 85.9% of split preps vs. 71.6% of standard preps (p<0.001). Diabetics (n=133) had significantly more right colon preps rated fair or worse compared to non-diabetics irrespective of prep (39.9% vs. 29.0%, p=0.02). Split prep in diabetics resulted in fewer right colon preps rated fair or worse compared to diabetics using standard prep (28.3% vs. 45.9%, p=0.049). Average adenomas detected per colonoscopy were 1.04 for split prep vs. 0.85 for standard prep (p=NS). Patient satisfaction was higher for split preps.

CONCLUSION

System-wide implementation of a split PEG prep resulted in significantly improved bowel cleansing in VHA patients, particularly in the right colon. Improved bowel cleansing with split preps was associated with higher patient satisfaction.